Hiding in Plain Sight: Gendered Dimensions of Health Worker Migration from ‘Source’ Country Perspectives

Background: Gender roles affect health worker migration and their migration experiences, but policy responses have rarely considered the gender dimensions of health worker migration. This invisibility and lack of attention can lead to social, health and labour market inequities. Methods: A Canadian-led research team with co-investigators in the Philippines, South Africa, and India studied the international migration of health workers from these ‘source’ countries through documentary, interview and survey data with workers and country-based stakeholder interviews. Our particular focus was to examine the causes, consequences and policy responses to health worker migration. Here we undertake an explicit gender-based analysis highlighting the gender-related inuences and implications that emerged from the literature, policy documents and empirical data. Results: Our data from nurses, physicians, and other health workers reveal that gender mediates health workers’ access and participation in health worker training, employment, and migration, and the impact of health worker migration is gendered, depending on country context. Female migrant health workers were “preferred” for “innate” personal characteristics and cultural reasons. Female nurse migration in particular is greatly inuenced and linked to personal relationships and social networks including friends in the diaspora. Remittances by female nurses to family back home may play a large role in the decision to migrate. Migration may improve social status of women nurses, but it also exposes them to deskilling, sexism and racialization. Regardless of these apparent differences in migration decision-making and experiences for women and men health workers, gender is rarely considered either as an important contextual inuence or analytic category in the policy responses. Conclusion: An explicit gender-based analysis on health worker migration offers useful insights for health workers considering migration and those that ultimately migrate, the workplaces and families they leave behind, and social and health policy of their countries. In this paper, we explicitly analyse these gendered aspects of health worker migration from the three key data sources – country-based documentation, health worker surveys, and interviews with key stakeholders carried out for the study. We highlight the gendered aspects of health worker migration from both the literature and the ndings from our country case studies of health worker migration. Theoretically, this paper’s analysis builds on the extant literature on gender-based analysis and employs the typical (although non-gendered) push/pull theories of international labour market mobility as an organizing framework. Second, we draw upon insights of the gendered impact of health worker migration on formal and informal sectors in source countries, with a particular focus on immigration and emigration policies.


Introduction
Who migrating health workers are, why they migrate and the consequences of their migration are important details for consideration in health workforce and migration policy design and planning. Although there has been a visible growth in knowledge that gender roles affect health workers' reasons for migrating and their migration experiences (George 2007;Piper 2005; Spitzer, 2016a, 2016b; Walton Roberts 2019; Yeoh, 2014), an acknowledgement that gender is an important consideration or factor, health worker migration-related policies and regulations show little in the way of systematic consideration or sensitivity to gender. Although gender differences are present, their invisibility and lack of attention to them can lead to social inequality, and labour market and health inequities.
In some ways, this trend of the issue being hidden but all the while in plain sight is not so surprising: classical theories of migration of the 1960s and 1970s were focused on the assumption and stereotypes that migration decisions were men's and migration experiences were universally male. Men's experiences were considered the standard: women and families who accompanied them were assumed to be passive and invisible (Piper 2005). More recently, there is evidence of the feminisation of migration (Camlin, et al, 2014;Ryan, 2002) where women constitute 44.3 percent of the estimated 244 million international migrants world-wide (McAuliffe and Ruhs, 2018). Although some countries have restricted women's migration as a result of patriarchal ideologies and policy (Kingma, 2006), women migrants are increasingly moving independently of partners or families (Kofman, 2004;Timur, 2000).
Migration is thus becoming better understood as highly gendered as gender impacts men's and women's roles and experiences of migration differently (Spitzer, 2020 suggestions that gender played an important yet unnoticed role for potential migrants and migrants, the workplaces and families left behind, and social and health policies. In this paper, we explicitly analyse these gendered aspects of health worker migration from the three key data sources -country-based documentation, health worker surveys, and interviews with key stakeholders carried out for the study. We highlight the gendered aspects of health worker migration from both the literature and the ndings from our country case studies of health worker migration. Theoretically, this paper's analysis builds on the extant literature on gender-based analysis and employs the typical (although non-gendered) push/pull theories of international labour market mobility as an organizing framework. Second, we draw upon insights of the gendered impact of health worker migration on formal and informal sectors in source countries, with a particular focus on immigration and emigration policies.

Gender And Health Worker Migration
Gendering push-pull factors in uencing health workers decision to migration There is a tendency in the health worker migration literature to focus on individual level factors emphasizing how certain 'push' and 'pull' factors in uence personal decisions to migrate by individuals and families (Bourgeault et al., 2016). Factors pushing health workers to migrate include poor wages, limited opportunities for professional development, heavy workloads, economic instability, poorly funded health care systems, the burdens and risks of HIV/AIDS and safety concerns (Labonte, Packer, and Klassen, 2006; PAHO, 2001; Robinson and Carey, 2000;WHO, 2006). Pull factors include better and more comfortable living and working conditions, higher wages and greater opportunities for advancement and promotion (Aiken et al., 2004;Buchan, 2002;WHO, 2006). Health workers such as doctors and nurses from source countries are considered to be highly skilled and experienced personnel (Stilwell et al., 2004). Further, migration is not necessarily a young person's game: One older study reported that more than 40% of migrant nurses from South Africa, India, Pakistan and Mauritius were aged 40 or older (Buchan et al., 2006).
The push and pull factors approach to migration is a popular approach and useful for a descriptive means of organizing and listing factors at the individual level. However, it provides little distinction of their relative importance, nor analytic attention to root causes at a more structural level, including the in uence of gender and its association with the broader political economy (Bourgeault et al., 2016, Kingma 2006; Walton-Roberts, 2015a). It can also be critiqued for neglecting the historical (and gendered) nature of colonial and post-colonial relations, and other social divisions in its analysis of the migration dynamic (Hagopian et al., 2005). Gender is intricately implicated in the migration decision of health workers through the gendered discrimination and inequality experienced at home and abroad, and perpetuated by traditional societal attitudes towards women and the care work they undertake (e.g., Adhikari, 2013;Byron, 1998;Ryan, 2008). Factors typically characterized as push, such as poor working conditions and low earnings, are often indicators of women migrants' labour market marginality (Piper, 2005). Moreover, the global demand for care-workers coupled with the expectation that women should earn for their families' well-being-discourse that is underscored by public declarations that migrant workers sustain the national family-help propel out-migration (Spitzer, 2016a).
The Public Services International's participatory research on migration and women health care workers conducted in a number of countries demonstrated that women health workers were besieged in several ways. Foremost, structural health sector reforms had negative effects on women health care workers, who are often subject to low and inequitable wages, and violence in the workplace, while they need to work to support their families, and hold full responsibility of care for them (Pillinger, 2011(Pillinger, , 2012. All these factors can converge to cause women to migrate sometimes leaving their families behind, and/or leave work in the health sector altogether. The gendered nature of transnational social networks, which increase female health workers' awareness of migration opportunities, also have a particular in uence on their decisions (Nair, 2012;Le Espiritu, 2005;Ryan, 2008;Hagan, 1998).
Ryan's (2008) work on Irish nurses who migrated to Britain in the postwar period reveals, for instance, that most of them were encouraged to migrate by female relatives, especially sisters, aunts and cousins. Adhikari (2013) similarly illustrates how female nurses in Nepal are encouraged to migrate by women in their families; their migration is seen as a collective family investment, the key return on their investment being remittances that are sent back. Scholars are increasingly recognizing how gender intersects with various push and pull factors to in uence migration decisions of health workers.

Emigration policies in source countries
Studies of labour migration have often treated sending states as "unimportant auxiliaries" (Paton, 1994), merely reacting to the demands of the more powerful receiving nation-states which consume their citizens' labour. This under-theorization of what the sending state does before the migrant leaves, and the impact of sending state policies on the skills composition, geographical reach and scale of international migration, remains an important research gap in the migration eld (Lee, 2017), and particularly as it relates to health workers.
Policy changes that have taken place in both source and destination countries are instrumental in precipitating and tempering women's migration (Bandita, 2015). Although International human rights' laws a rm that an individual has the right to leave and return to one's own country (United Nations General Assembly, 1948) Article 13 (2), some countries have placed gender-based limitations on emigration based on law or social norms (e.g. women from Iran are not allowed to emigrate without permission of a husband or male relative if single). As Examination of states' emigration and immigration policies, cultural norms that foster international migration in some cases and prevent it in others, and the extent of women's autonomy in making decisions to emigrate, provides additional evidence that gender is excluded in push/pull considerations in the wider literature. Restrictions or guidelines on women migrating are often quite speci c to their gender, whereas restrictions placed on men are most likely to be targeted at the job class/profession. Emigration restrictions on women from Asian countries include: the banning of the recruitment of certain sectors dominated by women e.g. domestic helpers; restrictions on age of female migrants; selective bans on employment depending on destination country; and requirements of educational quali cations before exit permission would be granted. These restrictions are not equally applied to men (Oishi, 2002).

Gendered impacts of health worker migration on source countries
Migration can have positive impacts both formally on healthcare and informally in other sectors. For individual health workers, migration can bring about gains in social and professional status, and these can be accentuated for women. Indian nurses who hold visas to work overseas, and therefore have the potential to migrate, become preferred as potential wives because they can supply their own dowry, earn a wage, and buy a ticket for their future husbands (Percot, 2006;Walton-Roberts, 2012). Families 'at home' can also bene t from the signi cant contribution that remittances make to source country household incomes. Philippines and India for example view health worker migration positively because of Migration may improve social status of some women nurses, but it exposes others to deskilling, sexism and racialization in destination countries (Pratt, 2004). Although likely to be migrating for their own economic purposes, female migrant health workers are vulnerable to certain experiences that male counterparts do not experience, including increasing risks to their own health. In addition to such vulnerabilities, according to the International Labour Organization (ILO) and Public Services  (2000), and applied to the case of nurses by Yeates (2004Yeates ( , 2009) recognizes the role of female migrants as carers abroad, the care de cit left to be lled by women back home to whom their care responsibilities are transferred.
In summary, the literature of health worker migration has begun to show and acknowledge that gender is an important determinant of migration affecting the decision to migrate, the experiences of migrants, and impacting the formal and informal sectors in source and in destination countries. The exploration of these issues is still relatively limited and remains evident in policies in which gender plays a signi cant role, for example codes of practice that implicate international health worker migration. ( Table 1). Gender Based Analysis The documentary data and stakeholder interviews were originally analyzed thematically with a common coding scheme developed in partnership between Canadian principal investigators and the country-based teams. Using a number of gender-related keywords and a framework of directed questions, we analyzed the documentary and interview data for any explicit comments or details that related to gender. To answer the research question as to whether and how gender in uenced the migration of highly skilled health personnel, we examined any differences that related to the in uence of gender on individual health workers and the predominant gendering of the select professions on the migration questions that were posed in stakeholder interviews and health worker surveys; this augmented a sex disaggregation of data, particularly to gender sensitive questions.
Health worker surveys included a binary demographic question for female/male which was used to categorize responses to content questions. (We note that contemporary work on sex and gender-based analysis includes diverse sex and gender identities, orientations and expressions, but these concepts are more widely known in (Western) destination countries, informing a decision to focus on the binary identi cation.) In each country these questions included reasons for considering migration both in terms of work and living conditions, the consequences of geographical or regional impacts in relation to health worker shortages and or adequacy, and policy responses to endemic health worker migration. The data analysed here are largely descriptive, reporting frequencies of responses of the push and pull factors in uencing male and female workers differently, as well as their views on impacts and possible policy responses. These analyses are complemented with the qualitative responses of workers from the interviews as well as those with stakeholders.

South Africa
The literature on health worker migration from South Africa reveals a number of gender trends. Hull (2010), for example, noted that the career decisions of female nurses are in uenced by their personal relationships and networks, and the "opportunities or constraints" that are created by these. In short, female nurses' choices to migrate or to migrate and return are often fraught with moral decision-making related family and community responsibilities (Brock,  Findings from the survey of South African health workers showed little in the way of difference by male and female health workers' working conditions that in uenced their decision to move to another country ( Table 2)  The stakeholder interviews emphasized gender as a factor which suffused aspects of career choice, professional development and migration. For example, one key South African informant suggested that women were preferred health workers because of their innate personal characteristics: "Women tend to be more level-headed and cool-headed you know, as opposed to some of the men. They do bring a fair amount of stability within the department." (SAKI 14) In addition to expressing personal preferences for women health workers, the same respondent related this to migration: women were reportedly interested in migration because of the stability that jobs elsewhere could offer them. "So they are busy being recruited and the majority of them, you know because I think also because they want stability because most of them are mothers and most of them are females." (SAKI 14).
Respondents recognized an intersection between gender and choice of profession. For example, one male respondent commented on the suitability of females (sic) for certain positions as registrar doctors (doctors training to become a specialist or sub-specialist), and pointed out how women either select or are selected) into certain positions: "(in) the surgical specialities only 1 specialist can take 3 registrars. So in terms of females it is also a bit of a problem because there are certain specialities that females don't feel comfortable with like surgical because they have to raise children. You know males are a bit different because I can be working every day in the night so it might not be a problem. So females they battles with those kind of things, so they rather … they prefer to do the soft things." (SAKI 5) Respondents con rmed the lower numbers of men who are involved in nursing, but also commented on the apparent equality of nursing as a profession: For gender -there is equity in nursing -equal pay for equal work, no discrimination in salary because you are a woman or man; and you know nursing remains female dominated, but as a profession nursing is very strong. (SAKI 4).
Gender discrimination was understood as a generator of inequality in the workplace, and efforts reportedly being made to address it: Basically, the Department of Health in South Africa as well as in the provinces are committed to achievement of targets in terms of employment equity act. So, gender discrimination …we are not supporting that. We are trying by all means to ensure that now we are dealing with those discrepancies accordingly. (SAKI 12) Despite some insight into the gender differences in the division of labour in the South African health care system, respondents did not consider that gender might in uence migration intention. As one stated: No. there is no difference about gender. Really, I have never heard that the ladies wanted to do it more than the gentlemen or the men or the women. There's no de nite difference between that. De nitely not so … I've got single ladies interested in going, I've got family people, I've got single guys…there's de nitely no one group more than other. (SAKI 6) However, another respondent disagreed: "since nursing is populated by ladies then mostly it is females. But way back I know that even males have migrated to other countries." SAKI 13.
One respondent said that the countries to which people migrate depended on their acceptance of male and/or female health workers, echoing the earlier respondent's re ections on women's care work. For example, "If it is the middle east females go to the middle east because the culture and the religious beliefs there accept females than males. But UK takes both…both females and males." (SAKI 15) Regardless of some recognition of the issue of gender, there was no mention of how policy responses to health worker migration might need to take gender into consideration.

India
Much of the literature in India that has palpable bearing on gender and migration is associated with nursing.   The ndings from the stakeholder interviews largely supported ndings in the literature, and provided more nuanced description with regard to the gender conditions and impacts on nurse migration from India. In the literature, social network factors appear to have played a critical role in Indian nurse migration, as diaspora family members in Western countries facilitate migration and retention of migrants. There is other evidence that migration can enhance single women's prospective marriage (Walton-Roberts, 2012; 2015b). One informant added that foreign-earned income, which is greater than what could be earned at home, could enhance the prospect of marriage for women. "One reason for Kerala girls migrating in large numbers is that in Kerala the bridegroom has to be paid a huge dowry and these girls need to collect these funds."(KIKI #1).
Many interview participants described how female nurses stated their intentions to migrate and return to India. These intentions may have been based on the types of opportunities (including opportunities for citizenship) that are available in the countries to which they are migrating, and the unemployment and underemployment of nurses in the domestic context acting as push factors. Countries such as Saudi Arabia and other Middle-Eastern countries nearby to India promise good wages and have become major destination countries for Indian health workers, but they do not offer permanent residence or citizenship to migrants (Babar 2020). However, good wages allow putative migrants to consider temporary migration, earning enough money to remit and help to ensure nancing for their own eventual return and retirement in India. The literature and our ndings strongly suggested that Indian nurses' migration to the Gulf states was always intended to be temporary, and timed to effectively intersect with and enhance life cycle events such as marriage and child birth (Percot and Rajan 2007).
Female nurses' intentions to migrate and actual migration is in part explained by the construction and production of Indian nurses: female nurses in India are raised, prepared and educated in a culture that increasingly supports their migration, and it is a culture which also discourages the inclusion of men: "For nursing, female nurses are preferred. In a vacancy of 20 posts they only want 4 male nurses, basically for Psychiatry ward. Furthermore, male nurses were reported as badly treated in the Indian health context, "nobody wants them." "None of the private colleges are appointing male nurses." The Philippines Female health care professionals, particularly nurses, have come to dominate migration ows (Brush & Sochalski,, 2007;Lorenzo et al., 2007). Therefore, gendered health workforce migration from the Philippines has typically referred to female nurse migration, with a majority (up to 75% depending on the year) of land-based migrants from the Philippines being educated women, resulting in a 'brain drain' for the Philippines (Ball, 2004). Le Espiritu (2005), for example, notes that while female nurses from the Philippines mentioned economic motives, "…many more cited desire to be liberated from gendered constraints: to see the world and experience untried ways of living" (p. 8), including a "…newfound freedom to make more independent choices about marriage" (p. 9).
In addition, there are some indications in the literature that seeing themselves as committed to sustainment and improvement of their family and community, which is re ected in their ability to send remittances plays an important role in women's decision to migrate from Philippines (Basa, Harcourt & Zaro, 2011). While this motive for migration might seem purely economic in nature, it seems to be partly rooted in cultural expectations and values related to gender roles. Indeed, Filipinas tend to be proud of being responsible for their families back home, as Filipino culture puts responsibility to care for their natal families on them (e.g., it prescribes that the eldest daughter should be providing for her parents and siblings (Basa et al., 2011)).
In response to an unprecedented global demand for nurses, the Philippines has experienced the phenomenon of trained male doctors retraining as nurses in order to obtain positions overseas (Choo, 2003). Although, these changes suggest a trend towards balancing female/male distribution in nurse training, and indeed our respondents across the Philippines re ected a dominance of nurses, male or female, a gender analysis of health worker migration in the Philippines tends to focus on women as nurse migrants. Certain incentive schemes to retain health workers in the country have been employed, some of which have been described, as 'gender sensitive considerations' (Henderson and Tulloch, 2008). In particular, it has been recognized that since women represent a large proportion of the health profession, the different needs of female health workers need to be considered and addressed when developing incentives to encourage workers to stay in the workforce (e.g. exible and/or part-time working hours, exible leave/vacation time, access to childcare and schools, etc.) (Henderson & Tulloch, 2008). Table 5   Our survey results suggest that social networks (family, friends and colleagues) may act as an important source of information for Filipino health workers who intend to migrate. While our study did not explore a gendered aspect of such networks and their impact on migration decision of Filipino health workers, some research suggests that gender-based transnational social networks shape migration opportunities for female nurses as they help them to move and integrate into labour market of the destination country (Le Espiritu, 2005) Policy stakeholders in the Philippines suggest that there are differing views on migration as well as on the causes or drivers of the phenomenon, and these views are often related to gender. Some of the respondents regarded migration as a natural phenomenon: others saw it as a result of global trends, and others -social circumstances. As one Philippines informant stated it, "migration is not just a program of the government to help address the unemployment problem in the country, but …is also a global phenomenon" (PKI 031813).
With regard to migration-related policy, one o cial reiterated that the goal of bilateral agreements should always be fairness and social justice to all health workers and professionals, which included an awareness of concerns related to gender: "…There should be the principle of non-discrimination in employment terms and conditions; even in the issue of sex and gender, it should always be observed in the deployment of workers … (PKI 081213).
Given the active nature of Philippines labour export policies, it is interesting that stakeholders rarely spoke speci cally of gender, suggesting in part that sex and gender-based analysis of social contributors to the Philippines' labour economy, and the impacts of women s contributions in the informal sector have yet to be undertaken.
Stakeholders also did not re ect on culture of migration which some consider one of the main push factors for migration of health workers at macro level (Dimaya et al., 2012). Philippine government's labour export policy that has been sustained over decades, has contributed to the development of a culture that comfortably accommodates the idea of migration: Filipino workers, majority of which are nurses now view foreign labour markets as natural extensions of the s a n d m e n domestic labour market (Engman, 2010). Clearly, the culture of migration in Philippines is gendered as women assume nancial responsibility and as such are expected to migrate and provide for the family from afar, while men-or their female surrogates-stay home and take care of children (Oishi, 2002;Parreñas, 2005).

Discussion
Our empirical documentary, survey and interview data from nurses, physicians and other health workers indicates that gender mediates health workers' access and their participation in migration. Some push factors might carry more weight dependent on the potential migrants's gender and it appears to also be inluenced by a country's cultural and policy contexts. Gender in uences the choices to become educated as a health worker as well as the decision to migrate. Female migrant health workers seemed "preferred" for "innate" personal characteristics and cultural reasons, whereas in some contexts we saw examples of male health workers also being directed away from these roles considered only for women.
Female nurse migration in particular is greatly in uenced and linked to personal relationships and social networks including friends in the diaspora. Remittances by female nurses to family back home may play a large role in the decision to migrate. The fact that many health professions are dominated by women might also explain inadequate remuneration levels and the generally low social status ascribed to the work of women health personnel overall (Shannon et al 2019). It is di cult, however, to tease apart the individual level gender differences that emerged from this examination from those related to the predominant gender of the profession.
Regardless of apparent differences and implications in migration decision-making and experiences for women and men health workers, gender has rarely been considered either as an important contextual in uence or analytic category in the policy responses. While hidden in plain sight, making gender visible to health worker migration and associated health and social policies is necessity. Policy makers need to receive evidence of the in uence of gender on health worker migration, and can then understand that gender analysis can be important tool for health workforce planning and health system sustainability. Raising awareness of gender differences and consequences is a preliminary step, but carrying out a systematic sex and gender-based analysis of health worker migration deserves attention and integration into policy responses.
Increased international recognition and policies to implement gender analysis in health-related research sides with the arguments for explicit consideration of gendering of health workforce policies at all levels. Gender analysis is an approach that is now widely accepted and promoted by a wide range of bodies, including at the WHO (2019) and spearheaded by the Gender Equity hub of the Global Health Workforce Network. The European Union has also adopted a 'gender mainstreaming' approach that calls for "the integration of a gender equality perspective into every stage of policy process… with a view to promoting equality between women and men" with all EU policies to take into account the different situations of women and men. In Canada, gender-based analysis is written into the mandate letters of each federal minister. Our own work plans and papers in progress will focus on developing tools that can aid researchers and decisionmakers in understanding and analyzing gender and how they might be applied to health worker migration (Runnels et al., 2014).
Our ndings, which initially prompted us to pursue analyzing health worker migration from a gender lens, also presents a su cient case for a review of theoretical approaches with respect to health worker migration and policy to include genderbased analysis. Assumptions about migration intentions and pathways tend to be premised on older migration theory and to a certain extent without a fulsome consideration of the in uence of gender and its gendered implications. Our ndings have raised a number of questions and challenges including how to encourage and assist researchers and decisionmakers, particularly those for whom gender is not a typical lens employed, to think about and call attention to both what is known and what is not known about health worker migration from a gender lens.

Limitations And Future Research Directions
Although it would have been instructive to be able to compare across countries and professions controlling for gender, the slight variations in survey questions adopted by the country-based teams and insu cient sample sizes made it di cult to more fully integrate the quantitative analyses. We were not, for example, able to tease apart whether the gender differences found in India were related to more male respondents being physicians and female respondents being nurses. Future research should attempt to advance an analysis that considers the gender of the professional, the gender of the profession, and the shifting gender dynamics of the professions, and how this may relate to the opportunities presented by international migration for example the feminisation of medicine and the masculinisation of nursing.

Conclusions
Our ndings raise a number of questions and challenges including how to encourage and assist researchers and decisionmakers, particularly those for whom gender is not a typical concern, to think about and call attention to both what is know and what is not known about gender in health worker migration. Policy makers need to receive evidence of the impacts of gender on skilled health worker migration, in order to understand that gender analysis is an important tool for health workforce planning and sustainability. Ethics approval and consent to participate The study was approved by the University of Ottawa (Ethics Approval Certi cate numbers H07-10-02H and H07-10-02C).

Consent for Publication
Not applicable Availability of data and materials The participating countries' dataset(s) supporting the conclusions of this article are not publicly available to ensure respondents' anonymity in reporting and con dentiality in participating in the study as per the study's ethical requirements.
Competing Interests