John Connell: Migration and the globalisation of health care: the health worker exodus?

This book addresses a major current topic and attempts to cover the trends, arguments and dilemmas. The author is eminently qualified to tackle such an exercise as he has a long history of migration and other research, especially in the Pacific region. The book provides a comprehensive overview of the major issues together with detailed analysis and debate. Chapter 2 on ‘the geography of need’ outlines the factors that influence disease patterns and the provision of health care services, at the global, national and regional levels. In this context, the provision of health workers is only one factor but it is a crucial one. Connell states that the presence of health workers is crucial to positive health outcomes, and the association between ‘health workforce density’ and health outcomes has been clearly demonstrated (p. 13). This chapter contains a good mix of developed and developing-country examples and demonstrates the complex interplay of factors (including the availability of finance, politics, culture) that are at work to determine shortages or surpluses of skilled health workers. In developing countries the disease burden is greatest and least well served by workers and facilities. The migration of skilled workers has grown in recent decades and the trends and patterns are outlined in Chap. 3, ‘Phases of globalisation’. Connell identifies three major periods: (1) Early Days, Colonial Years, (2) The First Brain Drain? and (3) Globalization. The first period is hardly ever written about so this provides a timely reminder of the early flows and the place of expatriates in establishing the first Western-style services, and training Indigenous workers. Connell reminds us of the role of these movements in setting the scene for later flows in the opposite direction. The second phase ‘accompanied the recognition of widespread brain drain’ (p. 63) and he provides plenty of evidence for the validity of the concept at that time, in