[Special Feature: Changing India and Japan] International Labor Migration of Indian Nurses and the Transformation of Indian Society

2019/11/05

This article examines the transforming Indian society through the international labor migration of Indian nurses.

The global demand for nurses and caregivers is rising. In addition to the continuous demand in Gulf countries, which have relied on overseas human resources for nurses since the oil boom of the 1970s, the background of further demand increases includes the declining birthrate and aging population in developed countries, labor shortages, and the development of medical tourism that combines tourism and medical care. India, the subject of this article, is known as one of the two major suppliers of nurses alongside the Philippines. Although based on slightly older estimates, the number of Indian nurses working abroad was 640,000 as of 2011 (estimated by Irudaya Rajan, S. and Nair, S.), and the number of Indian nurses working in OECD countries is the second largest after Filipinos. Indian nurses have now become an indispensable presence in medical and nursing care settings worldwide.

Despite their global activity, the social status of nurses within India has been low, and the profession has been viewed as one for Christians. This is closely related to constraints imposed by religious customs and the fact that modern nursing in India developed as an activity accompanying Christian missionary work during the British Raj. In Hinduism, where the concepts of purity and impurity are strong, nursing was seen as an impure profession because of the potential contact with filth and patients' bodily fluids. Among Muslims, it was positioned as an unpopular profession because, if the nurse is female, the job involves touching strange men who are patients. As a result, contrary to its social importance, nursing work was recognized as a job for those of low status and for Christians who value the spirit of service. According to literature, around World War II, 90% of nurses in British India were Christian, and 80% of nurses were recorded as having received their nursing training at Christian-affiliated hospitals (Nair 2012). Furthermore, during the British Raj, because there were few applicants for nursing, recruitment focused on widows, divorced women, and daughters from poor families, which further instilled the perception that nursing was a profession for those of low status. On the other hand, for these disadvantaged women at the time, becoming a nurse was a means of escaping poverty.

The trigger for a major change in this negative image of nurses was the oil shock of the 1970s. Triggered by two oil shocks, the economies of Gulf countries progressed significantly. Medical facilities such as hospitals were improved, and as a result, the demand for nurses increased, leading many nurses from South India, centered on Kerala State, to go abroad to work. This was the beginning of the large-scale overseas labor migration of Indian nurses. Nurses worked in Gulf countries for higher wages than in India and sent money back to their families, which greatly helped the household finances of the sending families. Subsequently, opportunities to work in Western countries such as the UK and the US, where there is a shortage of nurses, and developed countries such as Australia and New Zealand increased. Indian nurses with high English proficiency, like Filipinos, gained employment opportunities in these countries. Unlike the Gulf countries, the purpose of labor migration to developed countries is not only to earn high wages but also to obtain permanent residency and citizenship in those countries. International labor migration to these countries became an extremely important means for the nurses themselves and their families to possess passports from developed countries. While one might hesitate to generalize, for many people in developing countries, obtaining permanent residency or nationality in a developed country is an aspiration and means achieving a high standard of living. Furthermore, looking at many cases where the sons, daughters, or siblings of wealthy Indians live in developed countries and have acquired nationality there, it can be said that acquiring nationality in a developed country is one of the family survival strategies to secure a destination for travel in case of emergency.

As opportunities for Indian nurses to work abroad increased and it became known that there were many benefits, such as families prospering through remittances and gaining opportunities to obtain passports from developed countries, changes in the view of nurses began to sprout. What was once a means of escaping poverty became considered a profession where one could earn money through overseas labor and a ticket to success that allows for the acquisition of permanent residency and citizenship in developed countries. In other words, it can be said that the international labor migration of nurses reduced prejudice against nurses within India and, in turn, contributed to the improvement of their social status. This change is something that nurses themselves feel strongly. In a survey conducted by the author and co-researchers in Tamil Nadu, South India, in 2016, in interviews with 209 nurses with more than 10 years of experience, 199 (95.2%) responded that the social status of nurses had improved compared to 10 years ago, and 138 of them stated it had improved significantly (Oda et al. 2017).

There are also reports that international labor migration increases the value of nurses in the marriage market, allowing them to marry under more favorable conditions, such as marrying someone of a higher status than themselves (Nair 2012). From the perspective of the other party, it seems they are willing to make certain concessions in exchange for the benefits brought by the marriage. In a survey conducted by the author and co-researchers in New Zealand, several patterns were seen where single Indian female nurses migrated to New Zealand, obtained nursing jobs, and then married men living in India and brought their husbands to New Zealand. This is exactly an example where the husband and the husband's family (though the nurse is not necessarily female) gained the opportunity for access to a developed country through marriage.

As the social status of nurses improved, many Hindus and Muslims also began to participate in the nursing profession, which was once considered a Christian occupation. Furthermore, many nursing schools managed by Hindus and Muslims have opened. The change in perception and the increase in popularity of nurses can be seen from the change in the number of schools providing nursing education. Against the background of the introduction of policies to promote investment in the education sector, many nursing schools, mainly private, have been established since 2000. According to statistics from the Indian Nursing Council, the number of nursing schools (diploma) and nursing colleges (bachelor's), which were 285 and 30 respectively in 2000, reached 2,958 and 1,690 respectively in 2015, totaling 4,648. This represents a nearly 15-fold increase in total. These figures suggest how rapid the change has been in a short period of time.

It must be noted that the improvement in the status of nurses in Indian society is not due to the recognition of nursing as a profession, but rather brought about by the benefits of international labor migration. Prejudice against the nursing profession still exists, and views that remain unchanged from the past also persist. For example, people of the highest rank in the Hindu status system (caste) called Brahmins (it is said) never become nurses. Also, in interviews with Indian nurses, there were cases where parents permitted enrollment in nursing school on the condition that the student would work abroad. Clearly, the parents do not recognize the profession of nursing itself, but are seeking the status of a nurse working overseas. Although the social status of nurses has changed significantly through international labor migration, it will still take time for the perception of the essence of the nursing profession to change.

Does this not apply to other things as well? Although the economy has slowed down recently, it cannot be denied that economic and social changes have occurred in India, which has achieved significant economic growth over the past 20 years. Top Western brands have opened stores in shopping malls in large cities, streets are overflowing with cars, rural areas are electrified, and the spread of toilets is progressing rapidly. At first glance, it seems that major changes are occurring. However, like the fundamental awareness of the nursing profession, things may not have changed much at the core.

Finally, let me touch upon the relationship with Japan. For Japan, where the birthrate is declining and the population is aging, securing nurses and caregivers is an urgent issue. According to recent estimates by the Ministry of Health, Labour and Welfare, there will be a shortage of 60,000 to 270,000 nurses by 2025. The Japanese government has been providing intergovernmental agreements and private recruitment support to supplement part of this human resource shortage with talent from overseas. Based on Economic Partnership Agreements (EPA), Japan has been accepting nurse and caregiver candidates from Indonesia since 2008, the Philippines since 2009, and Vietnam since 2014. Due to language issues for candidates to obtain Japanese nursing and caregiving qualifications, sufficient results have not yet been achieved. However, since Japan also has an EPA with India, there is a possibility of accepting nursing and caregiving personnel from India under the EPA scheme in the future. Furthermore, at the private level, under the Technical Intern Training Program for caregiving that started in 2017, Indian nurses have already been dispatched to private nursing homes as caregiving interns. It is expected that opportunities to see Indians working in medical and caregiving settings in Japan will increase in the future.

On the other hand, accepting nurses and others from overseas is not necessarily a win-win relationship for both the receiving and sending sides. A shortage of nurses has been pointed out in India, and a 2010 World Health Organization (WHO) report estimated the number at 2.4 million. It can be said that labor migration abroad has a significant impact on this shortage. The shortage of nurses is particularly serious in rural areas, where nurses play a major role because access to medical institutions is limited, and this shortage is a serious issue for public health in rural India. Nurses working abroad and their sending families can achieve improvements in economic and social status, but when viewed at the macro level of the nation, there is a great sacrifice due to the shortage of nurses. In Japan, we tend to focus only on accepting human resources, but we also need to fully understand the circumstances of the sending side.