Education and training: privatized and export oriented

India is a major supplier of trained nurses for overseas markets, even as the country experiences an acute deficit of domestic nursing resources (WHO 2017). There appears to be clear interest in promoting the growth and increased privatization of nurse training institutions oriented towards servicing international demand (Walton-Roberts 2015). Indeed, Khadria (2007) notes a strategic aligning between hospitals, recruitment agents, licensing bodies, and other stakeholders that profit from preparing and recruiting nurses for international opportunities. Economic benefits accruing to the state through remittance transfers, and the private sector through returns on investment in training institutions, suggest some level of state interest in managing and sustaining export-oriented nurse labour production and recruitment (Walton-Roberts et al 2017). Despite such interest in the ‘export’ of nursing labour, in recent years the Government of India (GoI) has opted for protective regulatory interventions in Indian nurse migration routes. This policy shift has been presented as a response to recently recorded cases of recruitment fraud (Rajan et al 2011), human rights violations, and the resultant pressure from civil society and migrant groups to institutionalize migrant protections.

National migration framework

Given the salience of migration to India’s socio-economic development, there are two dedicated governmental Ministries (formerly three) that administer migration related processes. The Ministry of External Affairs (MEA) is the central authority responsible for the formulation and implementation of emigration policies and processes. It also houses the Passport Issuing Authority and coordinates with Indian Missions abroad that inform the government about migrant and bilateral issues. A recent merger of the Ministry of Overseas Indian Affairs (MOIA) with the MEA was undertaken to ensure streamlining in matters relating to overseas Indians. In addition, the Ministry of Home Affairs is tasked with overseeing the Airport and Immigration Authorities of the Bureau of Immigration (BoI) to monitor emigration clearances granted by the regional Protector of Emigrants (POE).

The primary legislative grid framing migration from India is the Emigration Act of 1983. The national and regional institutional structures supporting its administration include the Protector General of Emigrants (PGE) in New Delhi and the ten regional offices of the POE that are entrusted with the protection of Indian migrants and those seeking to migrate, facilitation of formal migration through the granting of Emigration Clearance, and registration of recruitment agents. The GoI introduced the e-Migrate system in 2015 to streamline the migration process and increase transparency and efficiency. This e-Governance tool offers an online registration portal for workers designated under the ECR category, recruiting agents, and foreign employers desiring to recruit Indian workers, including nurses. The electronic platform is integrated with the Passport Seva Project (PSP), for the validation of passport details of registered ECR category workers, as well as with the BoI of the Ministry of Home Affairs, used at Immigration Check Post (ICP) at airports for online validation of the emigration clearance granted by POEs. Integration with the BoI system allows the e-Migrate system to record departure and arrival information of workers in the ECR category and verify their emigration clearance status in real time (Standing Committee on Labour 2018). Recent government circulars detail the stringent terms and conditions applied to registered Foreign Employers permitted to recruit nurses through private recruiters, which have to be vetted by the GoI and approved through a ‘Country Specific Order’ (CSO).

Sectoral migration policy

With the stated objectives of restructuring recruitment and migration processes, and eliminating exploitative recruitment and employment of migrant nurses, the Indian Government, in 2015, elected to place controls on the mobility of nurses to the Gulf while promoting state-run recruitment agencies and direct government recruitment (Thompson and Walton-Roberts 2018). Following numerous reports of exploitation by private brokers connecting nurses to employment in Gulf states, a national ordinance, issued by the erstwhile MOIA, brought the emigration of nurses to 18 ECR countries under the purview of the Emigration Clearance Required category. This previously only applied to low-skilled labour migrants – defined as those with less than matriculate-level education (Monsy 2014).

Under the aegis of this new policy, recruitment of Indian nurses to the Gulf states (and other ECR countries) has shifted to the public sector; foreign employers are required to register electronically with the e-Migrate system prior to engaging in the recruitment of nurses, and private recruitment agents are no longer permitted to facilitate the migration of nurses to ECR countries. Nurses seeking employment in the Gulf are now required to apply for an emigration clearance in addition to overseas visas and job contracts. Furthermore, their recruitment is routed exclusively through the following six government-mandated public sector agencies – NORKA Roots of Kerala, Overseas Development and Employment Promotion Consultants (ODEPC) of Kerala, Overseas Manpower Corporation Ltd. (OMCL) of Tamil Nadu, Uttar Pradesh Financial Corporation (UPFC) of Uttar Pradesh, Overseas Manpower Company Andhra Pradesh Limited (OMCAP) of Andhra Pradesh, and Telangana Overseas Manpower Company Limited (TOMCOM) of Telangana state. Governance of these accredited agencies is undertaken by respective state governments in coordination with the GoI. It is assumed that the move to a government-to-government recruitment model will ensure the recruitment ecosystem is more effectively monitored, transparent, and free from corruption.

International instruments

A number of international standards and inter-governmental agreements serve as guidelines for the migration and recruitment of women, healthcare workers, and migrants in general. The World Health Organization (WHO) adopted a voluntary Code of Practice on the International Recruitment of Health Personnel in May 2010. The Code endeavours to foster ethical and fair international recruitment of health workers, taking into account the rights, obligations, and expectations of source and destination countries, as well as those of health workers themselves (WHO 2017). Placing restrictions on the recruitment and migration of nurses, and migrant women, goes against the spirit of the WHO Global Code of Practice on the International Recruitment of Health Personnel, which asserts the individual rights of health personnel to leave any country in accordance with applicable laws and the freedom of workers to migrate to countries that wish to admit and employ them (Article 3.4). Also relevant are the ILO Conventions on Migration for Employment and the Private Employment Agencies Convention, and the Sustainable Development Goals (SDGs) – particularly 10.7, which calls for greater national and global coordination in facilitating safe, orderly, and regular migration (Thompson and Walton-Roberts 2018; Kerr et al 2016). In addition, India has engaged in institutional dialogue with Gulf receiving states under the Joint Working Groups on labour and manpower cooperation, the Abu Dhabi Dialogue, and has entered into a number of bilateral agreements and signed MoUs with the Gulf countries to facilitate the mobility of migrants.

Review of the Emigration Clearance Required procedure and its policy objectives

Migration and recruitment policies exert considerable influence on skilled women’s capacity to migrate, their channels of mobility, and experiences of migration. This section considers how the extension of ECR to nurses structures and limits their migration from India to the Gulf. There has been substantial media and public attention highlighting the particular vulnerabilities faced by women migrating to the Gulf, including deception relating to salary or working conditions, confiscation of passports, extortion, trafficking, and physical and mental abuse. The GoI has undertaken a number of measures to protect the specific interests of women migrants, including setting up Pre-Departure Orientation, multi-lingual helplines, shelters, and Migrant Resource Centers, as well as assisting in the repatriation of migrants stranded in the Gulf. In 2014, under the leadership of the Minister of External Affairs Sushma Swaraj, the Indian Government facilitated a number of challenging rescue operations to evacuate and rehabilitate nurses from conflict zones in Iraq, Libya, and Yemen (Padanna 2015). These successive efforts prompted the government to install further safeguards to manage the emigration of nurses to ECR countries and curb the operation of fraudulent agents.

The GoI elected to control the emigration of nurses between India and the Middle East due to concerns about the unethical practices of labour brokers and the resultant vulnerabilities the mainly female nurses might face (Standing Committee on Labour 2018). Reports suggest that recruitment for nurse migration was rife with deception, manipulation, and extortion, leading to unsafe or unsuitable working conditions (Walton-Roberts and Rajan 2013: Oda et al 2018). Nurses often paid higher costs for migration through higher agent charges and visa processing, with agents charging job seekers up to 2 million rupees – 100 times the eligible service charge ceiling of 20,000 rupees – in some cases (Rejimon 2018). Gross neglect and ineffective enforcement of recruitment guidelines contributed to the cycle of indebtedness, cheating, and fraudulent practices that prompted the introduction of this policy change. This was brought into sharp relief with the 2015 arrest of a central figure in Indian emigration administration, the Protector of Emigrants, Kochi, who was prosecuted for collusion with private recruiters, financial fraud, and extortion in a high-profile nursing recruitment scam (Mathew 2015).

In formalizing the migration of nurses through the ECR channels and e-Migrate, the government has sought to consolidate control over certain streams of migration, protect nurses seeking employment in the Gulf, restrict recruitment fraud, and increase the transparency and efficiency of the migration process. Recent government success in a number of high-profile evacuations of stranded nurses in the Gulf regions following public outcry has galvanized support for more direct government intervention (Padanna 2015). Electronic filing of the EC application and Foreign Employer requests is expected to increase oversight over these movements and lay the ground for more effective coordination and streamlining of these flows. However, the inclusion of migrant nurses under the ECR category has increased the bureaucratic burden on nurse migration. Transitioning the migration approval process from a national network of Protector of Emigrant (POE) offices to a few public sector agencies (initially three, and later expanded to six) has resulted in backlogs and institutional overburdening (also see Akhil and Ganga, this volume).Site visits to several government-linked agencies have shown that much of the services can only be accessed in-person, thereby limiting the scope of their activities and reach (Rajan and Joseph 2018). In the past, recruitment agents were able to submit applications for emigration clearance for their clients to respective POE offices. The additional bottleneck has lengthened the migration and recruitment process and made formal migration to the Gulf increasingly onerous.

Migrants and recruiters have expressed strong reservations about restrictive emigration rules. Recruiters, many of whom were integral in linking migrants to Gulf migration opportunities, lost out on a profitable niche of labour brokerage. A number of agents have even taken the GoI to court over grievances around the updated ECR policy and elimination of private actors from nurse migration. The Delhi High Court is considering 37 cases and petitions (MEA 2017a), however, federal and judicial responses appear to stand by and even double-down on the new policy and its objectives.

Impact on spatial, numerical, and gender character of nurse migratory flows

This section considers whether the implementation of ECR for nurses heading to the Gulf has altered the spatial, numerical, and gender character of nurse migratory flows within and outside of India. Media reports suggest that these regulatory moves accompany a decline in nursing opportunities for Indian women in the region, with indications of a drop in the number of Indian nurses in the Middle East from 20,000 to 12,000 between 2013 and 2015. An ILO (2018) India labour migration update shows that data from the GoI e-Migrate portal indicated a steady decline in the number of women workers from the top 25 Indian sending districts since the ECR system was introduced for nurses – from 1,167 in 2015 to 950 in 2016 and 512 in 2017.

Former Kerala Chief Minister Oomen Chandy, in a 2015 letter to the Minister of External Affairs, lamented that migration of nurses to ECR countries had completely stalled since the introduction of the new ECR policy for nurses (The Hindu 2015). MEA data indicates that this was true for nurses intending to migrate to Bahrain, Jordan, Kuwait, Qatar, and Saudi Arabia for the rest of 2015. While nurse migration to Kuwait and Qatar marginally increased over the following year, formal migration of Indian nurses to Bahrain and Jordan remained at a standstill. From Table 2.2, it is clear that the ECR approvals in the second half of 2015 were less than 5 per cent that of subsequent years. As the policy change was further incorporated there was a marked recovery in ECR approvals. By 2017 the destination of nurses had fanned out to include all countries of the ECR, with 3,326 Indian nurses employed in Saudi Arabia as of December 19, 2017. This was followed by Qatar with 350 nurses and Kuwait with 118 workers –10 per cent or less of the outsized totals directed to Saudi Arabia.

Since the introduction of the new recruitment process for nurses, Saudi Arabia has largely taken advantage of the exemptions accorded to the nurse ECR approval process through state recruitment agents. In mid 2015, the Ministry of Health for Saudi Arabia initiated a Country Specific Order (CSO) to allow the continued deployment of nurses to government hospitals across Saudi Arabia through a few designated private recruiters. Since then, this approach has been adopted by a number of private and public sector hospitals and medical centres across the Middle East, including Sultan Qaboos Government University Hospital, Oman; Ministry of Health, Oman; Hamad Medical Corporation, Qatar; Red Crescent Society, Qatar; King Hussein Cancer Centre, Amman; and in private hospitals in the UAE (Ministry of External Affairs 2016, 2017a). In the initial stages, among ECR countries, only Kuwait initiated action to recruit nurses through the six state agencies while all other Gulf governments resorted to short-term arrangements through CSOs (Ministry of External Affairs 2017b, 2018). It is unclear whether nurses migrating under these exemptions were recorded on the e-Migrate system. Given that the MEA data does not show any migrant nurses to Saudi Arabia for 2015, at a time when it had several CSOs in place, it either points to a delay in the processing of nurses recruited under such programmes, leading to the numbers being captured under the subsequent year, or suggests that the number of nurses migrating through private recruiters under approved CSOs were not included in the e-Migrate system.

Table 2.3 suggests that women migrants continue to dominate nurse migration flows to the Gulf and ECR countries. Female nurses applying from Kerala comprised 87 per cent of ECR flows from the agency between 2015 and 2018. This trend is consistent with the high proportion of women in the nursing profession. The composition of male nurses varied between 3 and 25 per cent of ECR approvals between 2016 and 2019 (Table 2.4). Estimates of nurse migration from Kerala based on household surveys by Rajan et al (WHO 2017) indicate a decline in numbers. Between the Kerala Migration Survey periods of 2011, 2013, and 2016, the number of Kerala nurses working abroad decreased from 30,038 to 26,138 to 20,622. This points to a decline in the migration rate from 32.8 per cent in 2011, to 30.8 per cent in 2013, and 23.2 per cent in 2016, a reduction of nearly 10 per cent between 2011 and 2016. Nearly 57 per cent of all emigrant nurses resided in Gulf countries in 2016 (with Saudi Arabia being the most favoured destination). In the same year, the UAE and Kuwait were the second and third favoured destination countries respectively. The share of migrant nurses going to Saudi Arabia declined from 32 per cent in 2011 to 22 per cent in 2016 – a decrease of 10 per cent. The proportion of migrant nurses going to the United States declined from 12.2 per cent in 2011 to 6 per cent in 2016, while the share of nurses migrating to Canada slightly increased from 3.3 per cent in 2013 to 5.5 per cent in 2016. Nurse migrants to Australia also registered rises in this period. Overall, nurse migration levels from Kerala are falling, and there appears to be a decline in preference for Gulf destinations, including Saudi Arabia (WHO 2017). The decline in oil prices since the end of 2014 may also explain part of this decline, but the influence of the imposition of ECR regulations on nurse migration must also be assessed in more detail.

Impact on multi-state relations and the governance of nurse migration

The reverberating impacts of the sending country’s policy reform on nurse migration to the Gulf and local labour markets is a compelling illustration of the presence of the migration governance complex detailed by Ennis and Blarel in the opening chapter of this volume. The migration of nurses from India involves a multiplicity of stakeholders at various levels, and is facilitated at the multi-state level through regional collaborative efforts that reflect a form of global social policy making (Ennis and Walton-Roberts 2018). This includes the adoption of global guidelines on ethical recruitment, government-to-government labour mobility agreements, and the regulation, monitoring, and licensing of a host of recruitment actors and practices.

Policy consequences within India and in the GCC labour market

This section analyses the connections between state policy on nurse recruitment and attendant consequences for migrants’ experiences within India and Gulf labour markets. It foregrounds the role of the state in shaping and structuring the flows and experiences of migrant nurses (Bach 2010), and examines shifts in migration policy, paying particular attention to the extension of ECR protocols and public sector nursing recruitment. We also comment on how understanding the nature of this migration process, and as a corollary, its governance and regulation, is seriously undermined by a lack of effective data collection.

Increasing vulnerability through individualizing governance: Among the most pervasive outcomes of the policy change is that when faced with increasing controls to formal migration, migrants bypass the system and use other methods to get overseas and find employment. Despite government efforts to prevent nurses from being duped in the recruitment process, through mandatory ECR requirements and state-designated recruiters, reports suggest that the number of nurses migrating through unofficial channels and private agents remains high. The Ministry of External Affairs issued an advisory in November 2018 stating that it is aware of nursing graduates travelling to the Gulf on tourist visas and converting the same to employment visas via recruitment agents in an attempt to subvert ECR (MEA 2018). Officials note that such informal practices beget gross recruitment and employment rights violations, leaving said migrants untraceable and outside the scope of embassy/government assistance should the need arise. According to one account, in the wake of newer, more stringent stipulations, nurses opting to migrate to Kuwait are regularly charged between Rs. 1 and 1.5 million by unauthorized private agencies. Activists note that while some migrants may secure their intended job once abroad, in most cases they are deceived and defrauded, losing the money paid and denied basic rights and working conditions in the Gulf (Rejimon 2018). Therefore, in limiting migrants’ ease of migration, the state effectively conditions the incorporation of migrants into Gulf labour markets (Bach 2010), limits the parameters of their employment and migration status, and, to some degree, contributes to an increased sense of vulnerability and the ratcheting down of conditions of migration and work.

Regulatory restraints in this context construct women migrants as uniquely risk-prone and responsible for their own safety should they deviate from state systems of control. These deeply entrenched gendered arrangements cast women migrants, regardless of their skills and experience, as requiring state supervision and protection. Scholars have critiqued this approach of regulating women’s mobility in the case of domestic workers, and argued that the state is complicit in creating regulatory gaps that increase women’s vulnerability (Kodoth and Varghese 2012; Varghese and Rajan 2011). While nurses are generally attributed with agency and skills, the placement of nursing in proximity to precarious migration streams via ECR presents a case where the state chooses to perform its duty to protect by regulating the migrant, not the conditions of inequality that exist in India that create a pool of trained nurses willing to go overseas. This may lead to a further devaluation of the nursing profession within the healthcare system and speaks to the need for systemic changes to Indian nursing.

There are also other issues that appear related to what seems a contradictory policy outcome, namely that seemingly protective regulation leads to more unregulated migration and increased vulnerability. Drawing on the control gap literature (Bonjour 2011), we need to ask if the apparent failure of regulatory oversight (the continued migration of nurses outside of the ECR framing) is due to some kind of external constraint, or whether the failure is intended. While control gap literature in immigration policy focuses on receiving states and why they accept ‘unwanted’ migrants, the case of India is similar in that pronounced policy is stated to regulate emigration but it appears that migrants continue to move outside of this channel. Bonjour (2011) looks at family class migrants to the Netherlands and argues that the state is not ‘constrained’ in its migration policy making (that is, the courts do not prevent the state from closing down family immigration), rather the state draws on moral and rights-based arguments to allow it. Applying control gap arguments to India suggests that despite the moral protective arguments about containing migrants’ movements (for their own protection), the GoI has effectively positioned itself in a manner that permits it to oversee continued unregulated migration. Varghese (2018) has argued that the ECR policy allows for ‘controlled informality’, in that authorities know nurses migrate to the GCC outside of ECR routes, but the GoI is now a central part of this overall migration infrastructure through its imposition of ECR and other regulations. It may be possible that the guarantee of protection that partly operates in the ECR process acts as a form of marketing aimed at receiving nations, domestic audiences, and/or international institutions to signal some kind of GoI oversight and control.

Oversupply of domestic nurses: GoI efforts to manage nurse migration through the ECR approval process are underpinned by competing objectives of promotion and protection. While ostensibly aimed at protecting workers from widespread abusive practices and promoting formal migration flows, the policy has in fact curtailed the flow of nurses to the Gulf (outside of Saudi Arabia). Although not framed explicitly as a domestic nurse retention strategy, since it does little to encourage domestic employment or discourage the desire to migrate, the policy change has nevertheless contributed to a temporary glut of domestically trained nurses wishing to go abroad. After the initial rollout of the policy in 2015, there were considerable delays in GCC governments recognizing the new system, during which many migrants who had already received job contracts and approval to migrate were reportedly turned away by POEs, emigration authorities, and airport officials, with others being deemed ineligible for emigration clearance (Padanna 2015). This excess supply of nursing graduates is unlikely to be absorbed into the domestic healthcare system due to prevailing labour conditions, and in fact, it may contribute to a further reduction in salaries, propping up of ‘intern culture’, and the contractual hiring of nurses within India.

Impact on migrant destinations and routes: Many migrants consider employment in Gulf states as a stepping-stone to other, more desired destinations in the West, such as the US, the UK, Canada, or Ireland (Percot 2007; Thompson and Walton-Roberts 2018). It remains to be seen whether the introduction of ECR processes in this corridor have altered this pattern of step-migration, causing potential migrants to seek destinations outside the GCC as their first point of anchor. According to Rajan et al (WHO 2017), foreign employers were slow to adapt to the new emigration rules and requirements. A salient point raised by a key informant signals the decreasing prospects for employer’s financial gain caused by the introduction of the new system. It was common practice that employers received a commission from recruitment agents for nurses hired by them – as this financial kickback can no longer be received, some employers may turn to nurses from other countries to meet their demand. It was also discussed that increasing regulatory constraints on formal nurse migration may cause nurses to migrate via alternative channels, such as applying for a visa through Indian embassies in foreign countries or moving overseas under a different visa category (for example, a tourist visa, Hajj/Umrah visa etc) and later interviewing for a job.

Reinforcing gendered perception of nursing and the impact on male nursing patterns: The policy rests on the twin-gendered assumption that nurses are primarily women and that women are inherently vulnerable. This perspective feeds into the dominant discourse that women migrants are unskilled migrants, lacking in agency and not in control of their own actions and experiences. This supposition, in turn, rests on a flawed social ontology that conceives of an individual’s agency through interlocking prisms of gender, education, and skill. With respect to implications on the gendered patterns of nurse migration flows, the apparent sectoral gender bias in this occupation may be further accentuated due to its inclusion in the ECR category and association with unskilled labour and unsafe migration. Taken together, these policies serve to reinforce nursing as a gendered occupation subject to greater surveillance and monitoring, at a time when men have been enrolling in greater numbers (Walton-Roberts 2019). But, it is possible that creating a sense of gendered insecurity might actually benefit male nurses: ‘With women returning due to strife, more men, who are ready to work in a tougher working environment, are now willing to learn nursing’ (Barnagarwala 2016).

Data limitations

Available estimates of nursing production, stock, and migration are spread across disparate data sources and there is considerable divergence in their collection, categorization, and collation. To advance our analysis, fragmented data and statistics have been gathered from multiple sources, including media outlets, Right to Information requests, the GoI e-Migrate website, POE offices, and government-appointed agency websites. Aside from being difficult to access, many of these figures are incomplete, represent incongruous timelines or worker categories that do not immediately lend themselves to comparative study, and fail to present a coherent picture of the migration of nurses or the policies framing these movements. For instance, data on ECR approvals only captures recent patterns of nurse migration to the Gulf and other ECR countries, and does not include trends of Indian nurse migration more broadly. While data deficiencies and discrepancies may be linked to the recording of data at multiple migration stages and sources, and continued channelling of nurse migrants through alternate routes that are not captured in the system, it is also reflective of the lack of attention to the gendered nature of migratory flows by governments of the Gulf and India. Furthermore, sustained analysis is impeded because facts and figures are not made available in the public domain and need to be requested by raising Right to Information (RTI) petitions that are tedious and time-consuming. The paucity of updated and relevant data on these critical labour flows highlights the need for improved and systematic information collection on migrant and healthcare workers to generate evidence-led policy suggestions.