24 May 2022, by Azusa Sato, Helen Dempster, Dorothy Leab, Hang Nguyen, and Linh Hoang

Migration for long-term care (LTC) in Asia has increasingly gained attention due to rapidly aging populations and the ensuant increase in demand for care1. COVID-19 has had a unique impact on these dynamics. Migration patterns have shifted, as some countries initially suspended out-migration, including deployment of nurses and other medical workers, to ensure enough personnel remained at home. Our research explores the impact of aging and COVID-19 on current and future health and care worker migration for LTC in Asia. We largely focus on describing and analyzing migration from primary countries of origin (Indonesia, Malaysia, the Philippines, Sri Lanka, Thailand, and Vietnam) to countries of destination (China, Japan, Singapore, South Korea, and Taiwan).

Key Messages

• Fueled by increasing life expectancy and falling total fertility rates, the number of people in Asia aged 60 or over will triple to 1.3 billion by 2050
• Meeting this demand requires millions of new long-term care (LTC) workers, many of whom will need to be migrants
• Most migration for LTC occurs from poorer Southeast Asian countries to richer East Asian ones, though primary countries of origin are shifting as those countries age and develop
• COVID-19 has exposed many countries’ reliance on migrant workers, and promoted a ‘global scramble’ to expand immigration pathways
• Asian countries of destination should expand immigration pathways for LTC, but in ways that are both ethical and sustainable.

This note has been prepared by GaneshAID, in collaboration with the Center for Global Development (CGD). It is a summary of a longer paper, COVID-19, Long-Term Care, and Migration in Asia, released by CGD in late April 2022. For more details please see the report and get in touch (Helen Dempster, Policy Fellow, CGD: hdempster@cgdev.org).

The Demand for LTC

Our countries of destination are experiencing rapidly aging populations. Over the past seven decades, total fertility rates (TFR) have fallen steeply and life expectancy has jumped dramatically. Thanks to better healthcare and basic standards of living and sanitation, both men and women in these countries can now expect to live well into their 80s, if not 90s. These trends have led to a higher old-age dependency ratio (Figure 1), which puts more pressure on younger people to care and provide for older people.

Data shows large gaps in the provision of, and access to, LTC services in many low- and middle-income countries3. There are many reasons as to why someone may not be able to access LTC, including problems with affordability, acceptability, accessibility, and availability.

In 2012, a survey found that, on average, 50 percent of people in Asia experienced an ‘unmet need’ for care. Such gaps were greater for those living in rural areas. (especially in Indonesia, the Philippines, Thailand, and Vietnam) and for women (especially in Singapore, Japan, and South Korea). Those living in poverty are more likely to experience a significant unmet need for care, especially in our countries of origin (Indonesia, Malaysia, the Philippines, and Vietnam). Meeting this need will require more LTC workers in the years to come.

Figure 1. Old-age dependency ratio growth in China, Indonesia, Japan, malaysia, the Philippines, Singapore, South Korea, Sri Lanka, Taïwan, Thailand, and Vietnam, 1950-250.

The LTC workforce

LTC is delivered by a variety of people with different levels of skills and experience. The OECD usually classifies LTC workers into ‘formal’ and ‘informal’ workers. The tasks that these workers are called upon to perform vary, as do their minimum qualifications and training requirements.

• Formal LTC workers comprise two main categories—nurses and personal care workers—with the latter including people providing LTC services at home or in institutions (other than hospitals) who are generally not qualified or certified as nurses.

• Informal LTC workers are those who are not formally contracted or paid to provide services. Family, friends, and neighbors tend to fall within this informal category.

Overall, it is thought that the number of informal caregivers (especially family) is declining, their increase is at a slower pace than the number of dependent older people, and they are facing limitations in their capacity to provide adequate care.

There is a global shortage of formal LTC workers. Ideally, there should be 4.2 formal LTC workers per 100 individuals aged 65 or over7. The highest deficit, 8.2 million people, is in Asia and the Pacific. In Japan, it is estimated there are fewer than four LTC workers per 100 individuals aged 65 or over, while South Korea has fewer than two and China has 1.1 (Table 1). As a result, much of the LTC in these countries is unpaid and provided by family members, reducing their broader labor market participation8. This informal provision may be one reason why 40 percent of our survey respondents felt their country did not face supply constraints in the domestic workforce for LTC.

Table 1. Coverage gap in LTC supply for available countries

Migrant Workers and LTC

Whether due to the wages and working conditions offered, the perception of the sector, or absolute labor scarcity, the demand for LTC in Asia is not currently being met through local recruitment. As a result, many countries of destination have turned to migrant workers to fill the gap.

Most labor migration in Asia occurs regionally; in 2013, two thirds of the 10.2 million international migrants in the Asian region came from the region itself. Much of this movement is occurring from poorer Southeast Asian countries to richer East Asian ones, and migration for LTC follows these dynamics. In general, the main countries of destination for LTC workers are Japan, South Korea, Taiwan, Hong Kong, and Singapore, while the key countries of origin are the Philippines, Indonesia, and Vietnam.

Globally, very few countries of destination have created specific labor immigration channels to attract migrant LTC workers. Instead, many migrant LTC workers enter for non-economic reasons— humanitarian, family, or student migration—and end up working in the LTC sector12. The Asian region is slightly different, with some countries of destination creating specific immigration policies aimed at attracting LTC workers and domestic workers. The examples of Japan, Singapore, and Taiwan are briefly outlined below:

Table 2. Specific policies for migrant LTC workers in countries of destination

The increasing prevalence of immigration pathways to attract health workers (including LTC workers), and the general shortage of health workers globally, has led many in the international community to explore how such migration could be regulated and improved.

One angle being tackled is how to increase human resources ethically and sustainably for health and LTC across borders. The World Health Organization (WHO) is currently supporting countries to better regulate health worker migration and reduce ‘brain drain’. Their Global Code of Practice on the International Recruitment of Health Personnel argues that migration from countries with a critical shortage of health workers must take place through a government-to-government agreement to ensure the development benefits of migration are secured. Another angle focuses on how to improve the wages and working conditions of migrant LTC workers, something which the International Labor Organization (ILO) has long supported16. Instruments, such as the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families, aim to guarantee equality of treatment between migrants and nationals, including wages, working conditions, and rights.

Beyond these international organizations, there have been several efforts at the regional level to better understand and regulate migration for LTC. The Asian Development Bank (ADB) has supported knowledge sharing between countries of origin, destination, and multilateral and specialized institutions on LTC and aging, putting forward policies to fill human resource gaps to meet LTC needs.

Certainly, Asian countries have been quick to work with international bodies such as the WHO, ILO, and International Organization for Migration (IOM) to ratify conventions and legal instruments, and seek to incorporate their provisions into their national laws. The rights afforded to migrant LTC workers have improved in recent years thanks, in part, to these international efforts. Yet much remains to be done.

The Impact of COVID-19

While the introduction of border restrictions and lockdowns was largely able to curb the spread of the virus within Asia, the ILO estimates that people lost a vast number of working hours, and therefore full-time jobs, particularly in areas most economically impacted by the pandemic.23 Lockdowns prevented many migrant workers (including LTC workers) from physically sending money home, despite money transfer organizations being designated as essential services. Thankfully, remittances throughout the region largely remained strong (Figure 2).

Figure 2. Patterns of migration for long-term care

Migrant workers, including LTC workers, were more likely to have their freedom of movement restricted or be forced into unsafe living conditions during COVID-19. Many were unable to leave and forced to work on their rest day, often because they were seen as potential carriers of disease who would bring COVID-19 back into the house17. In Singapore, there were reports of Malaysian work permit holders sleeping in train stations as they were unable to head home, yet their employers refused to give them accommodation18. As a result, the highest rates of COVID-19 infections and deaths were among migrant workers living in crowded conditions.

Many migrant LTC workers, and migrants in general, either do not have access or are concerned about accessing the health systems of their countries of destination. The pandemic has exacerbated the exclusionary nature of health policies towards migrants. Especially in the early days of COVID-19, access to information, testing, and treatment was impeded for migrants.

COVID-19 pandemic also marked a reduction in the number of labor migrants moving throughout the world, largely due to four factors: border restrictions to control the spread of the virus; suspended deployment of migrant workers; business closures leading to reduced demand; and reduced commercial flight schedules.

As countries throughout the region kept their borders and labor markets closed, many migrants abroad sought to return to their countries of origin due to a fear of COVID-19, job losses or expected job losses, and the expiration of work permits22. Many countries did support their overseas workers with repatriation flights and other forms of assistance such as Vietnam, the Philippines, and Indonesia, though others did not.

Several countries, wary of the impact of border restrictions and changing employer demand on the rights of their migrant workers, made steps to shift their employment conditions in some countries. South Korea granted three-month extensions to those with expiring visas, and Singapore extended expired work visas for two months. Taiwan barred entry to new migrant care workers but implemented successive six-month extensions for existing workers23. Others focused on the rights of migrant workers, especially migrant domestic workers, to change employers. Some countries explored the opposite, enacting regularization, and legalization campaigns, recognizing the impact that undocumented workers could have on labor shortages during the pandemic.

Recommendations

The COVID-19 pandemic has highlighted the importance of migrant workers to LTC systems. If Asian countries, particularly countries of destination, are to reduce their ‘unmet need’ for care, expanding immigration for LTC in an ethical, sustainable, and rights-respecting way will be required. These efforts should be undertaken alongside reforms to the LTC system itself, focusing on how the system is financed, structured, and resourced. Finally, the pandemic has highlighted lessons learned for how migrant care workers should be supported, both during and beyond crises, lessons that must be kept in mind throughout any reform efforts.

Support migrants and their families during crisis

• Ensure remittances can flow.
• Provide social protection for migrant workers abroad.
• Ensure migrants can access health systems.
• Focus on accommodation for LTC migrants.
• Help critical workers deploy their skills.

Build sustainable LTC systems

• Take a systems approach which integrates the strengths of each sector.
• Implement policies which uplift the LTC sector and attract LTC workers.
• Develop robust insurance or _nancing mechanisms.

Build sustainable LTC systems

• Collect and analyze data to understand skills shortages, both in quantity and quality, and enhance workforce planning.
• Recognize the need for more migration to meet demand.
• Take meaningful steps to recognize the quali_cations of registered nurses, to prevent down-skilling.
• Provide LTC workers, including migrant LTC workers, with opportunities and
• training to advance their skills.
• Promote standardization of quali_cations to enhance migration opportunities for LTC workers.

Build sustainable LTC systems

• Countries of destination should create a multi-year visa for LTC work.
• Countries of origin should ensure mutual benefit from any legal migration pathways.
• Ensure such pathways are built with sustainability in mind.
• Enter into BLAs and MOUs which safeguard migrant rights to: 1) monitor recruitment agencies; (2) include minimum provisions for contracts, including wages and working conditions; (3) provide migrant workers with the same rights as locals; and (4) ensure migrants have the right to organize and collectively bargain.

• Ratify the Domestic Workers Convention and enact legislation to support domestic workers.
• Encourage regional collaboration.