What about the workers? The missing geographies of health care

Abstract

Geographies of health have neglected relevant consideration of health human resources. Five developments in the sub-discipline are examined to demonstrate how health labour has been neglected. Three research themes, circulation, regulation and distribution, are then presented to indicate the value of a greater focus on health workers for the geography of health, and we suggest that deeper analytical engagement with labour and feminist geographies can support this. Each theme points to the increasingly global organization of health care and the need for health geographers to seriously examine the role of health workers during a period of health transformation, globalization, and privatization.

Keywords

global health health geography human resources labour medical geography migration workers

I Introduction

The recent transition from medical geography to a more broadly based health geography (Kearns and Moon, 2002; Brown and Moon, 2012; Jackson and Neely, 2014) has been paralleled by the transnational reach of medicine, disease and health care services. Epitomized by Ebola, once local problems have become global, linked to issues of security, environmental change and growing inequalities. Health geography has taken relatively little note of the implications of globalization for the functioning of health systems, notably access to health care for the relatively disadvantaged and the distribution of skilled health workers. The central argument of this paper is that as health has become a global phenomenon, more attention must be given to health employment and workforce issues, particularly with reference to spatial distribution, regulation and global circulation of skilled health workers (SHWs).

Despite covering multiple themes, from disease distributions to emotions and embodiment, health geography has largely neglected serious consideration of the human resources central to health care. Even works with promising titles (e.g. Andrews and Evans, 2008; Collinson et al., 2009; Curtis and Riva, 2010b; Gatrell and Elliott, 2011; Rosenberg, 2014), or offering multiple health geographies (Andrews et al., 2012; Andrews, 2006; Milligan et al., 2007; Milligan and Wiles, 2010; Curtis and Riva, 2010a; Jackson and Neely, 2014), overlook workforce issues. A special issue of Health & Place (Davies et al., 2004) focusing on the ‘geography of health knowledge(s)’ referenced workforce in only two papers (Bondi, 2004; Williamson, 2004), while another from the Annals (Kwan, 2012) had little on workers, with one exception (England and Dyck, 2012). Likewise, it is a salutary experience to search indexes of standard texts for ‘doctor’, ‘physician’ or ‘nurse’ (e.g. Anthamatten and Hazen, 2011; Learmonth, 1988; Meade et al., 1988; Gesler and Kearns, 2002; Curtis, 2004). Authors may consider the provision of health services, but usually through the location and appropriate size of facilities, and, in rare instances, health worker shortages (Wang and Luo, 2005). Even when health geographers advocate moving the discipline into new domains, labour geography is rarely involved, as in recent calls to connect with music (Andrews et al., 2014a), relational performance and therapy (Andrews et al., 2013) and therapeutic mobility (Gatrell, 2013). When issues of worker organization are examined they are presented through other analytical lenses such as governance (Lovell et al., 2014) or career mapping (Milligan et al., 2011). Some earlier texts on the geography of health care have considered the mobility of SHWs, incentives to changing distributions and differences between specializations (e.g. Joseph and Phillips, 1984). Rather than being a precursor, though, this focus faded until quite recently, when Gatrell (2011) examined the international mobility of SHWs (and medical tourism) and Crooks and Andrews (2009) focused on primary health care. We seek to promote this tentative re-engagement with health workforce issues by advocating deeper engagement with feminist and labour geographies.

Challenges exist in ensuring access to, and planning of, health workforces to achieve optimal employment mixes. Such issues have become more acute as the global financial crisis, austerity, technological changes, aging populations, the rise of non-communicable diseases (NCDs) and communicable diseases have stretched the ability of health systems to effectively and equitably deliver services. Growing concern has emerged that migration of SHWs represents a ‘perverse subsidy’ from the least to the most developed nations (Mackintosh et al., 2006; Connell, 2010), while migration routes become more diverse in direction and duration as trade in health services accelerates. Such concerns align with other strands of geographical analysis devoted to the politics of feminized global care chains, which are one means of managing the delivery of care under neoliberalism (Dyck, 2005; England et al., 2007), and the role of labour in value chains and global production networks.

In this paper we offer a selective overview of five approaches to health geography that highlight the hesitant relationship the sub-discipline currently has with workforce issues. We then consider three analytical lenses that encourage a resurgent geography of health care where workers are central, calling upon strands of labour/economic and feminist geography. Our aim is for health geographers to explicitly recognize that the increasing global organization of health care demands greater focus on the geographies of the health care workforce.

II Health geography

Our categorization of health geography through five contemporary approaches focuses on work undertaken in the last decade, is indicative and far from comprehensive. It suggests that, while health geography has been expansive in its theoretical and methodological framings of most health issues, this has not been the case for workforce issues.

1 Space and epidemiology

Space has long been central to medical geography and disease transmission and mortality, famously linked to Snow’s mapping of cholera, and including diffusion classics (e.g. Smallman-Raynor et al., 1992) and the human ecology of disease at various, increasingly global, scales (May, 1959; Fuller et al., 2014). Spatial approaches have involved increasingly sophisticated analytical techniques in mapping, modelling, GIS analysis and genetics (e.g. Wan et al., 2013; Carrel and Emch, 2013). This quantitative analysis rarely includes information on the availability or competence of health workers, but focuses on such characteristics as disease incidence, distance and patient variables (although see Ali et al., 1999). A growing epidemiological focus centres on the impacts of climate change (e.g. Maantay and Becker, 2012; Bai et al., 2013). This shift towards environmental health and political ecology, while engaging political economy (Mayer, 1996), reveals negligible concern with labour and capital relations including workforce rights, regulation, status and training (cf. Barnett, 1993).

Spatial analysis cannot easily capture the contributions of health and allied workers. This is evident in Brown’s (1995) critique of AIDS diffusion research that presents gay bodies only as vectors of disease, rather than as activists preventing the spread of AIDS. Designing systems to address diseases without considering the health worker context decreases the effectiveness of health care initiatives (Nordfeldt and Roalkvam, 2010; Scott and Shanker, 2010). In the Global South, workforce issues are intimately tied to the crises in health care provision. Global initiatives, such as the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund (to fight AIDS, tuberculosis and malaria) are disease focused rather than systems focused, and have drawn SHWs away from other sectors. Restructuring of health care financing also influences the organization and spatial distribution of SHWs (Barnett et al., 1998). Understanding spatial strategies and differences in the regulation, allocation, mobility and transnational organization of SHWs across health systems is central to understanding health challenges. Such critical socio-political contextual issues are poorly assessed through spatial analysis alone.

2 Culture

Emphasis on cultural issues marked a shift in health geography from positivistic sciences (e.g. epidemiology, economics) towards post-positivist approaches, and an engagement with social theory (Gesler, 1992; Gesler and Kearns, 2002; Kearns, 1993, 1995), that extended into emotional geographies (Valentine, 2003; Andrews et al., 2014b), psychoanalysis and embodiment (e.g. Evans, 2006; Hall, 2000), alternative therapies (Anyinam, 1990, Andrews et al., 2014a), and an emphasis on emerging NCDs, such as obesity, and their relationship to urban design, inactivity and body image (Procter et al., 2008; Colls and Evans, 2014). Emotions and healing successes are linked to quality of care – and care workers – but studies focus on patients and locations.

Understanding the experiences of persons managing particular disabilities has resulted in greater attention to identity (e.g. Davidson and Henderson, 2010), and more concerted efforts to engage with health and intersectionality in terms of ageing, sexuality and pregnancy (Bornat et al., 2011; Lewis, 2009; DeLyser and Shaw, 2013), and gendered approaches to rurality, mobility, ethnicity and mental health (Meurk et al., 2013; Bondi and Burman, 2001). Geographers have considered the marginal health status of particular groups, including indigenous communities (Bourke et al., 2013, Leeuw et al., 2012), immigrants (Asanin and Wilson, 2008) and sexual minorities (Fish, 2008; MacDonnell and Andrews, 2006). Some analysis has been attached to the incorporation of minority groups into health care professions (e.g. Wang and Luo, 2005; Kyriakides and Virdee, 2003). Cultural approaches have only begun to emerge in health geography in terms of pluralistic health services in developing countries, despite early work on parallel and intersecting care systems (Good et al., 1979; Hamnett and Connell, 1981). These studies, however, tended to focus on patient attitudes rather than workers (King, 2012; cf. Hampshire and Owusu, 2013). Deeper engagement with social theory in health research has enhanced workforce analysis, but mainly by cultural geographers exploring health (e.g. Dyer et al., 2008; Raghuram et al., 2011). Recent critical discourse analysis of professional health worker hierarchies reveals how status and identity inform the perception and migration of SHWs (Walton-Roberts, 2012; Nair, 2012; Adhikari, 2013). The cultural representation of SHWs shapes the nature of professional organization and is materially consequential to health care systems, where SHWs hold an ambivalent position of power between patients and administrators.

3 Place

Spatial approaches created greater awareness of people-place interactions and their health effects (Cummins et al., 2007). Health consequences of inactivity and urban and building design have been examined in light of the quality of place (Day et al., 2013; Rainham et al., 2010). Philo (1987) examined the ‘medico-moral’ discourse that informed 19th-century institutional geography of asylum facilities and health specialists’ concerns about their occupational status. Such historical analysis of workplace-identity interaction can inform contemporary place-based health research, but recent literature focuses on nature, rural and remote spaces, urban health retreats and spas, beaches and mountains (Kearns, 1993; Kearns and Gesler, 1998). This is positioned within a longer tradition of examining ‘therapeutic’ places and landscapes (Andrews, 2004), including everyday spaces and non-therapeutic places with emotional value (Qian, 2013). Health workers are (usually) therapeutic, yet the landscapes of their training, professional regulation, workplace interactions and professional status are relatively unexamined in this literature.

Health geographers’ attention to place has developed few links to formal paid carers, their work environments or their mobility. Literature that does focus on the roles, significance and status of carers addresses particular segments of the labour market: mostly unskilled informal carers working with people with disabilities, children and the elderly. In rural areas some carers are a ‘hidden, silenced group’ despite their crucial role in providing care and reducing costs within an increasingly liberalized and privatized ‘audit culture’ (Jonson and Giertz, 2013). Care-giving by international workers has been associated with an almost literal ‘race to the bottom’ where migrant SHWs are deskilled and disempowered, experience racism, and are employed in dirty, demanding and demeaning work, thus acquiring a contradictory place in the labour force as well-educated but low-cost labour (McGregor, 2007). The focus on place has not tended to include higher-skilled carers such as nurses, doctors, and therapists – despite the fact that compensation, status and hierarchical organization of the health workforce is marked by spatial differences.

4 Institutions, governance, policy and biopolitics

Foucault’s work on governmentality and the related concept of biopower (e.g. Foucault et al., 1991) has informed interest in governance and institutions (such as asylums and hospitals), and a distinct approach to medicine and health (Bunton and Petersen, 2002). Biopolitical foci emerged from the idea of biopower: the state’s attempt to manage, control and shape biological processes through regulatory mechanisms that generate societal norms (Hinchliffe et al., 2012; Rutherford and Rutherford, 2013), exemplified in public health, family planning and disease control (Ingram, 2013). Biopolitics, together with governmentality, offer a theoretical lens to examine public and global health governance in contemporary and historical eras (Brown et al., 2012; Legg, 2013), which has also been employed with reference to the body, especially pregnant bodies (Mansfield, 2012), and ‘surplus’ vulnerable populations subjected to state neglect, such as refugees, asylum seekers and the impoverished (Tyner, 2013).

Institutional landscapes of health care have received considerable attention through sophisticated analyses of access to facilities (e.g. Delamater, 2013; Sanders et al., 2013). Health geographers have focused on the provision and governance of public and private health services, restructuring of hospitals and specialized facilities (Learmonth and Curtis, 2013), policies directed at smoking and alcoholism (Jayne et al., 2008; Pearce et al., 2012), and health and voluntarism (Milligan and Conradson, 2006). Governance through deinstitutionalization has also been explored in care for disabled (Milligan, 2000, Giesbrecht et al., 2010) and children (Boyer et al., 2013; England and Henry, 2013) under shifting welfare regimes. Nevertheless, in this literature health workers remain largely in the background, with institutions distinct from the people who manage and work in them. Institutional frameworks of health care systems imply workers (the ‘ghosts in the machine’ perhaps?), but little attention is paid to their training and role, other than perspectives from outside health geography (e.g. Batnitzky and McDowell, 2011; Bornat et al., 2011). While policy perspectives indicate an opening for workforce issues, recent debates (e.g. Andrews et al., 2012) have focused greater analysis on the labour of health geographers rather than the health workforce. This is despite health care, especially in OECD nations, having moved towards inter-professional practice models, which are themselves riven with professional hierarchy, status, gender, and age distinctions (McNeil et al., 2013). The governance focus suggests that workforces are central elements of health care management and delivery (e.g. Hossler, 2013). The transnational organization of health workflows has been examined through health services outsourcing and medical tourism (e.g. Prasad and Prasad, 2012; Connell, 2011b), but few have traced the implications of these workforce processes for broader health outcomes.

5 Mobility

Multiple mobilities are embedded in everyday life (Cresswell, 2006). Health geographers have encountered mobility primarily through patient access to health care facilities and services, including the circumstances of those who move for health reasons, especially the retired (Breivik, 2012; Hardill et al., 2005), the well-being of those left behind (e.g. Kuhn, 2005) and whether travel itself is harmful or constitutes therapy (Feng and Boyle, 2014; Gatrell, 2013). Medical tourism examines patient mobility across borders (e.g. Connell, 2011a, 2011b, 2013; Crooks et al., 2011; Ormond, 2013; Ormond and Sulianti, 2014). More recently ‘mobility’ has involved the ethics of mobile transplant organs and patients (Davies, 2006). While not explicitly engaging with new mobilities literature, research by health geographers highlights how mobility informs health care delivery and access, but focuses on the experiences of non-white males, notably migrants (Portes et al., 2012), leading to growing interest in lifestyles, generational shifts and patient access to health workers of relevant ethno-linguistic and cultural competence (Wang, 2007; Wrede and Nare, 2013).

Given the past, present and future importance of population migration and globalizing health systems, remarkably little work has been done in health geography on most facets of mobility, even in an ‘age of migration’ (cf. Williams and Baláž, 2008). Contemporary manifestations of health and migration relationships, such as HIV/AIDS, SARS and Ebola, have, however, incited global concern, and the mobility of diseases (and patients) has attracted considerable interest (e.g. Shannon and Willoughby, 2004; Sparke and Anguelov, 2012; Hugo, 2005; Connell and Negin, 2012, Aggleton et al., 2014). This has been partly summarized by Gatrell (2011), with one chapter on the mobility of care workers: a rare recognition of the labour component of health systems. It is to this missing dimension that we now turn.

III Towards geographies of the health care workforce

The role of health workers has been under-examined and under-theorized in health geography, which may partly be the outcome of a geographical focus on health care in high-income countries, where worker maldistribution is less problematic. Beyond medical tourism, where geographers have played a leading role, geographical approaches to health scarcely consider SHWs, yet they are particularly significant in this global context. Geographical interest in global approaches to health, and greater attentiveness to health system administration and practice, is only now emerging (Brown and Moon, 2012), despite classic early works (Prothero, 1965; Hunter, 1966). Health care has become deterritorialized, and patients, workers (and pharmaceuticals and scans) move considerable distances. Health care is highly labour intensive and the provision of appropriate health workers is critical to success. Contemporary hospitals and clinics are capital and labour intensive, involving complex workplaces and crucial issues of skill, status, experience and hierarchy, and gendered distinctions typify different occupations in various settings (Halford, 2003). This is paralleled by international health corporatization and marketization (Sparke, 2009), global public-private partnerships (Buse and Walt, 2000; Ruckert and Labonté, 2014), increased trade in health services (Crone, 2008; Smith et al., 2009; Gabriel, 2013), and global health systems staff management (Farndale et al., 2010).

Shortages of health workers, especially in the Global South, contribute to poor health status and weak provision of basic functions such as immunization or attendance at births (Léonard et al., 2009). Based on global assessments, the World Health Organization (WHO) has estimated that 57 countries have critical health workforce shortages: a global deficit of 4 million, including 2.4 million doctors, nurses and midwives (WHO, 2006). In most of these countries meeting the Millennium Development Goals (MDGs) on health by 2015 is unlikely, and the availability of SHWs is one component of that problem. By contrast, in the aging societies of more industrialized countries, increasing numbers of people requiring long-term care have fuelled demand and intensified the global market for SHWs. Circulation of SHWs links these Global North and South structural conditions, and requires both deeper and more subtle analysis. It is difficult to assess health care status without some understanding of workforce issues, such as professional organization, workplace status, labour regulation and relationships between workloads and patient ratios (Pallikadavath et al., 2013). The absent focus on health workers has disconnected health geography from the human resources debates taking place in global health and development policy circles (e.g. Stilwell et al., 2003; Kim et al., 2013).

We seek to redress this lacuna and stimulate a resurgent geography of health care where workers are central by using concepts informed by feminist and labour/economic geographies. We approach this through three broad interlocking research themes of circulation, regulation and distribution that illustrate the increasingly global organization of health care and the centrality of workers to its effective and equitable delivery.

1 Geographies of international SHW circulation: Care chains and global production networks

The term ‘brain drain’ was first applied to the migration of doctors within the Global North in the 1960s (Gish, 1971; Gish and Godfrey, 1979), but the concept was quickly adopted in other regions (e.g. Engels and Connell, 1983). India, Pakistan and Iran emerged as major sources of SHWs migrating to the Global North and subsequently to the Gulf states. Brain drain sometimes led to brain waste (when SHWs dropped out of, or were excluded from, health care) and brain circulation (when, less frequently, they returned home or moved onwards). In south India, the Philippines and small island states, migration of SHWs has occurred over more than one generation, resulting in a ‘culture of migration’ that becomes pervasive, normative, nurtured, and enhanced by the presence of overseas kin (Choy, 2003; Connell, 2014). Migration has resulted in significant unmet needs in sending regions, with Africa the main locus of the disease burden (Connell, 2010; Kalipeni et al., 2012). Demand for SHWs increased in relatively rich countries because of aging populations, high attrition rates (especially for nurses), greater specialization, growing demand for health care (evident in the rise of medical tourism) and greater ability to pay. The convergence of demographic and epidemiological factors (ageing and NCDs) suggests an imminent labour-demanding ‘silver tsunami’ (Bartels and Naslund, 2013) that will emphasize the global need for SHWs. The established means through which developed nations have resolved this is the import of already trained SHWs or allied health workers.

Emerging economic hierarchies characterize global SHW migration chains from relatively poor Asian, African and small island states to the Global North. Parallel hierarchies also link Eastern European countries to Western Europe, reflecting regionalization processes that incorporate SHW training and labour landscapes (Walton-Roberts, 2014). SHWs move primarily for economic reasons, and increasingly choose health careers because they offer migration prospects. Because of relatively high incomes in the health sector, migration partly follows strategic household investment in education, and in many source regions the majority of nursing and medical graduates intend to migrate overseas (Connell, 2014; Walton-Roberts and Rajan, 2013; Crush and Pendleton, 2011), with governments such as Nepal and the Philippines pursuing SHW migration as a development strategy (Ball, 2008). In light of these tendencies, geographical work on the migration of SHWs has recently increased (Connell, 2009, 2010; Raghuram, 2006, 2009; Walton-Roberts, 2012; England, 2014), but it is not fully integrated into health geography.

The global circulation of both SHWs and care workers intersects with structural processes that feminist researchers have identified as a global and gendered care crisis. As women have moved into paid labour markets, their care role in the private sphere has increasingly been ‘outsourced’ through global care chains (GCCs): intricate linkages of worker and remittance flows between regions (Parreñas, 2001). While much literature on global care chains focuses on semi-skilled or unskilled workers (Huang et al., 2012), it has paid less attention to SHWs. Nurses form the majority of SHWs and can transform care delivery in the North, while simultaneously producing a service vacuum in sending countries (Brush and Vasupuram, 2006). The incorporation of SHWs into care chain analysis challenges simplistic representations of migrant women as passive and unskilled (Kofman and Raghuram, 2006) and promotes a feminist political-economy reading of increasingly feminized global service industries (Yeates, 2009). Transition between labour markets is rarely smooth, and regulatory barriers exact costs through credential devaluation (Pratt, 1999; Cuban, 2010). Feminist geographers have tackled dynamic and exploitative dimensions of SHW migration through the lens of gender and inequality (e.g. Dyck and Dossa, 2007). Analysis of health workforce issues attuned to gendered, racialized, and class segmentation of labour processes, through care chain analysis or similar approaches, is vital to understanding how health care access and delivery are restructured through globalization. Global care chain analysis foregrounds geographical and sectoral connectivity and permits engagement with critical research on transnational migration and neoliberal health care restructuring. Nevertheless, the geography of SHW migration circuits demands further analysis at the regional scale, where border regions and emerging global health service centres have acquired significance (Bochaton, 2014; Glinos and Baeten, 2014). This regional focus also draws attention to the links between health system change and SHW training and migration circuits, which are constantly negotiated, especially in light of international migration opportunities (Walton-Roberts, 2015). Health geographers could make considerable research contributions in such areas.

Beyond feminist work on care chains, opportunities exist for engagement with other streams of geography, especially labour and economic geography. Possibilities for productive engagement are considerable, especially through the role of unions and professional associations (Mohan, 1988) and global staffing agencies (Ward, 2004; Coe, 2013; cf. Rogerson and Crush, 2008, Connell and Stilwell, 2006). More broadly, health care services (from medical tourism, to organ trade and fertility treatments and surrogacy) can be examined through the lens of global production networks (GPNs) (Coe et al., 2008; Coe and Hess, 2013), which are analogous to global care chains (Yeates, 2009). GPNs offer a heuristic framework that is time and space sensitive and goes beyond the linearity of global commodity chains by embracing the multi-level networked nature of production and value creation, while incorporating flexible and dynamic production, labour and consumer input (Coe et al., 2008). It bridges economic, labour and development geography, and incorporates multiple scales and sources of agency in socio-economic networks. The sensitivity of GPNs to labour input is particularly relevant to our argument, since internal workforce hierarchies distribute power unequally, the quality of labour can add value (concomitantly, poor quality can diminish it), and international migration can spatially and socially distort the locus of agency and value addition. Medical tourism is one context where GPNs are facilitated by the migration of patients rather than staff, but current health transformations go far beyond medical tourism to include deeper bi-lateral trade integration between South-South partners, resulting in broader health system and labour process transformations (Crone, 2008; Walton-Roberts, 2015).

GPN and GCC approaches enable a focus on the role and importance of SHWs to health equity and access. An explicit gendered analysis can also advance GPN research more broadly (Barrientos, 2001). In light of increased health care marketization, the applicability of the GPN approach is invaluable, being centred on the incorporation of SHWs into evolving geographically extended labour processes. Intersections of distinct national health systems are evident in medical tourism, but such intersections also inform the labour market integration of migrant SHWs, international health service agreements, and the growing area of eHealth (Li et al., 2013; Prasad and Prasad, 2012). GCC analysis would also benefit from the inclusion of SHWs and more geographically sensitive analysis of their circulation.

2 Regulating and governing health worker migration and training

By choice or misfortune, several countries devote inadequate resources to SHW training, and considerable variation exists in the proportion of national budgets devoted to health care (WHO, 2006). Source countries have sought to mitigate the effects of international migration of SHWs through processes of ‘recruit, train, retain’, and encouragement of return migration. Compensation by destination countries and institutions, and taxation of overseas migrants (a ‘Bhagwati tax’) are not feasible methods of regulating migration (Connell, 2010). Remittances from overseas SHWs to many source countries are generally greater than training costs, contributing substantially to national and household economies. Where remittances of SHWs can be distinguished from those of other workers, they are substantial and sustained over time (Chikanda and Dodson, 2013), which explains national support for SHW migration despite its negative effect on national health care systems.

Costs of migration, inability of countries to develop effective policies for retention and return, recruiting (and the institutionalization of migration), and the significance of health care – literally involving matters of life and death – have posed ethical issues and led to the eventual (and unique) establishment of regional and global codes for ethical recruitment. Many potential migrants have escaped regulation, and codes have proved impossible to enforce (Connell and Buchan, 2011; Young, 2013). Some source and destination countries have developed bilateral agreements including quotas, training and return migration protocols. As ‘trade in natural persons’ under the General Agreement on Trades in Services (GATS) Mode 4 increases in significance, new forms of mutuality and group dynamics structure international SHW migration through bilateral agreements.

In response to SHW shortages several countries have developed policies to recruit indigenous people as paraprofessionals and health workers to meet indigenous needs, especially in remote areas (Bell and MacDougall, 2013), and integrate the skills and knowledge of traditional medical practitioners, notably birth attendants (Byrne and Morgan, 2011). New employment categories, particularly nurse-practitioners and community health workers, have been widely introduced in part to meet the needs of underserved populations, despite resistance from medical practitioners (Sharma et al., 2013). The importance of ‘task shifting’ and ‘non-physician prescribing’ has contributed to increased availability and accessibility to health care in rural areas, and an empowered (often female) second line of authority, adding checks and balances to prestige-based hierarchies that tend to pervade this knowledge-intensive service. Common invocations by various governmental agencies and international organizations to consider and involve traditional cultural practices, including the use of traditional healers, contrast with professional biases in favour of ‘modern’ health care. Scaling up has even led to rare examples of reverse diffusion of care practice (Johnson et al., 2013). Complex gendered issues relate to the appropriate delivery of health care, and a staff mix where nurse practitioners (usually women) predominate may be more effective than one dominated by doctors (often men). Particular skill mixes are significant but rarely clear-cut, because of the variable roles of health workers (Kruk et al., 2009). Mid-level cadres are being used to address SHW shortages in many African contexts, but insufficient, intermittent and ineffective middle management can compromise performance (Bradley et al., 2013). The relationship between health outcomes and effective team-based health care delivery demonstrates how workforce dynamics and regulation (beyond mere numbers) are central to health outcomes; overcoming professional hierarchies and turf wars improves health access (Nichter, 1996). While technology and e-health can be effective tools in extending health care delivery and improving productivity (despite SHW shortage), theory has always exceeded practice (Li et al., 2013).

Human resource policies have often concentrated at the macroscale, especially where resources are scarce, and this reduces attention to regional and local-level dynamics that inform SHW decision-making. Though substantial aid funds have come from global donors, much of this ignores local primary health care, may increase workloads, compete with state systems for staff, and undermine staffing policies (Garrett, 2007; Brugha et al., 2010). Even health charities and diaspora philanthropy groups face endemic staffing and management challenges (Walton-Roberts, 2009; Kane, 2010; Foley and Babou, 2011). Investment in effective health care delivery must attach greater importance to workforce issues, otherwise good intentions wither. Problems of forecasting the future economy, population growth, the distribution of changing diseases and health needs make the governance and regulation of SHWs and health care unusually complex and difficult.

3 Revisiting rural/regional skill distribution

Geographical distribution of health care has frequently been linked to an inverse care law, where: ‘The availability of good medical care tends to vary inversely with the need for it in the population served … [especially] where medical care is most exposed to market forces’ (Hart, 1971: 405). Its intuitive logic has meant that few studies refer directly to the inverse care law, despite its operating at multiple scales, between and within countries. Economies of scale result in SHWs being concentrated in larger urban areas, especially with hospital-based systems of medical care, as skilled workers (and their partners) usually prefer urban life (Buykx et al., 2010; Stevenson, 1987). Rural and regional areas are consequently neglected. By the 1960s such disparities were greatest in poorer, larger and less densely populated countries. While the uneven distribution of doctors was extreme, the distribution of other SHWs, including nurses, was less evident (King, 1967). Urban bias and uneven distribution have increased, with over 75 per cent of all doctors and 60 per cent of nurses living in urban areas (especially capital cities), while just over half the global population (but fewer in developing countries) live in urban areas (Connell, 2010). Rural and regional areas tend to be victims of financial shortages, mismanagement, neglect and cost squeezes in their health sectors, with facilities moving away from areas of need, often conflicting with national health planning policies.

Internal migration, and attrition, of SHWs tends to be greatest where countries are fragmented and all services in the periphery are limited (Chomitz et al., 1998; Connell, 2009). Retaining workers in rural areas, or getting them there, is difficult, and reluctance to work and stay in regional areas is virtually universal (Kolstad, 2013; Barnett, 1991). Developed countries have become increasingly dependent on immigrant doctors to meet health needs in remote areas (Durey, 2005; Grant, 2006). Consequently, in the US, migrant doctors are in places distinguished by younger, poorer, more non-white populations (Miller et al., 1998: 263–4).

Geographical maldistribution emphasizes issues of distributive justice, quality of care, workplace mix and governance, yet limited attention is focused on labour force shifts in nations at different parts of the development spectrum, the type of workforces, and their role in the provision of care. The 1978 Declaration of Alma Ata, which reaffirmed that health is a human right and identified primary health care as the means of attaining ‘health for all’, has not necessarily meant equitable access. Better understanding of health workers, their skills, distribution, their social worlds, and their place in the governance of local, regional and international health systems, is crucial.

IV Conclusion

Health and medical geography have largely eschewed workforces, yet health care without workers is inconceivable. All the conventional components of the geography of health care can be enhanced through greater consideration of workforce issues. Spatial approaches have long wielded an influential role for medical/health geographers, but quantitative assessments of human resources preclude examination of the crucial roles undertaken by workers, while mobility has attached more significance to patients and organs, as in medical tourism, rather than increasingly mobile workers. The transformation of quantitative medical geography towards qualitatively informed health geography better represented the needs of vulnerable groups, yet health workers’ experiences have been overlooked relative to patients. Interest in health workers has been more prominent in the non-formal spaces of the home and at the lower end of the skill spectrum. Increased interest in governance is evident in medical geography, especially in terms of health policy, but has been less evident in the more critical area of biopolitical approaches that would place health workers as an extension of state interests and efforts to manage population health risk.

Workers require and deserve a more central presence. Five points highlight this. Firstly, a critical situation in many developing nations is an absolute shortage of SHWs, further emphasized by maldistribution. Secondly, the circulation and global migration of SHWs emerges from the first (both literally and figuratively), and partly explains why some countries continue to face critical labour shortages. Labour mobility is unusually critical for health care. Sophisticated and globally connected intermediaries have shaped migration flows, creating complex networks and care chains where: ‘no country is an island in workforce development’ (Chen et al., 2004: 1987). The global code emphasizes that SHWs are considered differently from other skilled migrants, but the debate on ‘exceptionalism’ is unresolved, due to the spatial, social and sectoral complexity of SHW migration (Skeldon, 2009). The complicated moral and ethical nature of health care, and thus SHW migration, suggests this is a substantial research area that might draw on parallel work by cultural, feminist and labour geographers. Thirdly, global care chains link many of these concerns about health care restructuring. Feminist geographers have stressed the uneven global and gendered circulation of care labour, and linked it to structural dimensions of neoliberal market changes in both formal and informal workplaces. These extend into a fourth point: the utility of understanding the roles and occupational place of SHWs in health systems through the lens of GPNs. More than in other ‘service economies’ the quality of service is critical and the regulation, location, knowledge, attitude, role and relevance of workers (skilled or unskilled, traditional or modern) is crucial for patients. Technology has largely failed to replace SHWs: people remain crucial even as elements of their workplace organization, location, training and deployment undergo transformation. The fifth and final theme, centred on the inverse care law and the geographical imbalance of SHWs relative to disease burdens, recognizes that distributional complexity is more evident following marketization and globalization of health care, and the inclusion of multiple actors, whether public, private or philanthropic, at several scales. Private sector and NGO incentives affect public health workforces and play a critical role in changing distribution structures, posing questions about the evolving relationships between public and private health sectors.

Health care is constantly changing, and bound up in a complex and contested political economy (as ‘Obamacare’ in the US demonstrates), where the place, role, skills, aptitudes and mobility of health workers are central to health delivery, access, inequality, utilization and outcomes. The urgency of this has long been evident to medical researchers (Chen et al., 2004). The future of health care may involve new health care delivery systems featuring ‘diagonal’ approaches, teams and private–public partnerships, and greater collaboration between countries to achieve more efficient and equitable access to SHWs – all pre-requisites to achieving universal health care and the achievement and elaboration of the MDGs and their successors. Ubiquitously, workers are crucial. Their inclusion adds a valuable, vital and essential dimension to a more multi-disciplinary global health geography.

Footnotes

Acknowledgements

We thank the two editors and four referees for their valuable comments on an earlier version, and Robin Kearns and Tony Gatrell for their encouragement and support.

References

Adhikari

(2013) Empowered wives and frustrated husbands: Nursing, gender and migrant Nepali in the UK, International Migration 51: 168–179.

Aggleton

Bell

Kelly-Hanku

(2014) ‘Mobile men with money’: HIV prevention and the erasure of difference. Global Public Health 9(3): 257–270.

Ali

de Francisco

Khan

Chakraborty

Myaux

(1999). Factors affecting the performance of family planning workers: importance of geographical information systems in empirical analysis. International Journal of Population Geography 5(1): 19–29.

Andrews

(2004) (Re)thinking the dynamics between healthcare and place: therapeutic geographies in treatment and care practices. Area 36: 307–318.

Andrews

(2006) Geographies of health in nursing. Health & Place 12: 110–118.

Andrews

Evans

(2008) Understanding the reproduction of health care: Towards geographies in health care work. Progress in Human Geography 32: 759–780.

Andrews

Evans

Dunn

Masuda

(2012) Arguments in health geography: On sub-disciplinary progress, observation, translation. Geography Compass 6(6): 351–383.

Andrews

Evans

McAlister

(2013) ‘Creating the right therapy vibe’: Relational performances in holistic medicine, Social Science and Medicine 83: 99–109.

Andrews

Kingsbury

Kearns

(2014a) Soundscapes of Wellbeing in Popular Music. Farnham: Ashgate.

10.

Andrews

Chen

Myers

(2014b) The ‘taking place’ of health and wellbeing: Towards non-representational theory. Social Science and Medicine 108: 210–222.

11.

Anthamatten

Hazen

(2011) An Introduction to the Geography of Health. London: Routledge.

12.

Anyinam

(1990) Alternative medicine in western industrialized countries: An agenda for medical geography. Canadian Geographer 34: 69–76.

13.

Asanin

Wilson

(2008) “I spent nine years looking for a doctor”: Exploring access to health care among immigrants in Mississauga, Ontario, Canada. Social Science and Medicine, 66(6): 1271–1283.

14.

Bai

Morton

Liu

(2013) Climate change and mosquito-borne diseases in China: A review. Globalization and Health 9: 10.

15.

Ball

(2008) Globalised labour markets and the trade of Filipino nurses. In: Connell

(ed.) The International Migration of Health Workers. New York: Routledge, 30–46.

16.

Barnett

(1991) Geographical implications of restricting foreign medical immigration: A New Zealand case study, 1976–87. Social Science and Medicine 33: 459–470.

17.

Barnett

(1993) Does the geographic distribution of physicians reflect market failure? An examination of the New Zealand experience, 1981–87. Environment and Planning A 25(6): 827–846.

18.

Barnett

Kearns

(1998) Declining professional dominance? Trends in the proletarianisation of primary care in New Zealand. Social Science & Medicine 46(2): 193–207.

19.

Barrientos

(2001) Gender, flexibility and global value chains. IDS Bulletin 32(3): 83–93.

20.

Bartels

Naslund

(2013) The underside of the silver tsunami: Older adults and mental health care. New England Journal of Medicine 368(6): 493–496.

21.

Batnitzky

McDowell

(2011) Migration, nursing, institutional discrimination and emotional/affective labour: Ethnicity and labour stratification in the UK National Health Service. Social and Cultural Geography 12: 181–202.

22.

Bell

MacDougall

(2013) Adapting online learning for Canada’s Northern public health workforce. International Journal of Circumpolar Health 72. Available at: https://dx-doi-org.web.bisu.edu.cn/10.3402/ijch.v72i0.21345 (accessed 26 January 2014).

23.

Bochaton

(2014) Cross-border mobility and social networks: Laotians seeking medical treatment along the Thai border. Social Science and Medicine 124: 364–373.

24.

Bondi

(2004) ‘A double-edged sword’? The professionalisation of counselling in the United Kingdom. Health & Place 10: 319–328.

25.

Bondi

Burman

(2001)Women and mental health: A feminist review. Feminist Review 68(1): 6–33.

26.

Bornat

Raghuram

Henry

(2011) Geriatric medicine and the management of transitions into old age: The hospital bed as a site of spatial practice. Area 43: 430–437.

27.

Bourke

Taylor

Humpheys

Wakerman

(2013) ‘Rural health is subjective, everyone sees it differently’: Understandings of rural health among Australian stakeholders, Health & Place 24: 65–72.

28.

Boyer

Reimer

Irvine

(2013) The nursery workspace, emotional labour and contested understandings of commoditised childcare in the contemporary UK. Social and Cultural Geography 14: 517–540.

29.

Bradley

Kamwendo

Masanja

de Pinho

Waxman

Boostrom

McAuliffe

(2013) District health managers’ perceptions of supervision in Malawi and Tanzania. Human Resources for Health 2013: 11–43.

30.

Breivik

(2012) Health migration from Norway to Spain – ambiguous belongings. Ethnic and Racial Studies 35: 1634–1653.

31.

Brown

(1995) Ironies of distance: An ongoing critique of the geographies of AIDS. Environment and Planning D 13: 159–183.

32.

Brown

Craddock

Ingram

(2012) Critical interventions in global health: Governmentality, risk, and assemblage. Annals of the Association of American Geographers 102: 1182–1189.

33.

Brown

Moon

(2012) Geography and global health. Geographical Journal 178: 13–17.

34.

Brugha

Kadzandira

Simbaya

Dicker

Mwapasa

Walsh

(2010) Health workforce responses to global health initiatives funding. Human Resources for Health 8(1): 8–19.

35.

Brush

Vasupuram

(2006) Nurses, nannies and caring work: importation, visibility and marketability. Nursing Inquiry 13(3): 181–185.

36.

Bunton

Petersen

(eds) (2002) Foucault, Health and Medicine. London: Routledge.

37.

Buse

Walt

(2000) Global public-private partnerships: Part I – a new development in health? Bulletin of the World Health Organization 78(4): 549–561.

38.

Buykx

Humphreys

Wakerman

Pashen

(2010) Systematic review of effective retention incentives for health workers in rural and remote areas: Towards evidence-based policy. Australian Journal of Rural Health 18(3): 102–109.

39.

Byrne

Morgan

(2011) How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance. International Journal of Gynecology and Obstetrics 115(2): 127–134.

40.

Carrel

Emch

(2013) Genetics: A new landscape for medical geography. Annals of the Association of American Geographers 103(6): 1452–1467.

41.

Chen

Evans

Anand

Boufford

Brown

Chowdhury

Cueto

Dare

Dussault

Elzinga

Fee

Habte

Hanvoravongchai

Jacobs

Kurowski

Michael

Pablos-Mendez

Sewankambo

Solimano

Stilwell

de Waal

Wibulpolprasert

(2004) Human resources for health: Overcoming the crisis. The Lancet 364(9449): 1984–1990.

42.

Chikanda

Dodson

(2013) Bandaid transnationalism: Remittance practices of emigrant Zimbabwean medical doctors. Migration and Development 2: 57–73.

43.

Chomitz

Setiadi

Azwar

(1998) What Do Doctors Want? Developing Strategies for Doctors to Serve in Indonesia’s Rural and Remote Areas. Washington, DC: World Bank Working Paper No. 1888.

44.

Choy

(2003) Empire of Care: Nursing and Migration in Filipino American History. Durham: Duke University Press.

45.

Coe

(2013) Geographies of production III: Making space for labour. Progress in Human Geography 37(2): 271–284.

46.

Coe

Hess

(2013) Global production networks, labour and development. Geoforum 44: 4–9.

47.

Coe

Dicken

Hess

(2008) Global production networks: Realizing the potential. Journal of Economic Geography 8(3): 271–295.

48.

Collinson

Adazu

White

Findley

(2009) The Dynamics of Migration, Health and Livelihoods. Farnham: Ashgate.

49.

Colls

Evans

(2014) Making space for fat bodies? A critical account of ‘the obesogenic environment’. Progress in Human Geography 38(6): 733–753.

50.

Connell

(2009) The Global Health Care Chain: From the Pacific to the World. London: Routledge.

51.

Connell

(2010) Migration and the Globalisation of Health Care: The Health Worker Exodus. Cheltenham: Edward Elgar.

52.

Connell

(2011a) A new inequality? Privatisation, urban bias, migration and medical tourism. Asia Pacific Viewpoint 52: 260–271.

53.

Connell

(2011b) Medical Tourism. Wallingford: CABI.

54.

Connell

(2013) Contemporary medical tourism: Conceptualisation, culture and commodification. Tourism Management 34(1): 1–13.

55.

Connell

(2014) The two cultures of health worker migration: A Pacific perspective. Social Science and Medicine 116: 73–81.

56.

Connell

Buchan

(2011) The impossible dream? Codes of practice and the international migration of skilled health workers. World Medical and Health Policy 3(3): 1–17.

57.

Connell

Negin

(2012) The malaise of modernity: Urbanization, mobility and HIV in the Pacific. Pacific Studies 35(3): 369–397.

58.

Connell

Stilwell

(2006) Merchants of medical care: Recruiting agencies in the global health care chain. In: Kuptsch

(ed.) Merchants of Labour. Geneva: ILO, 239–253.

59.

Cresswell

(2006) On the Move: Mobility in the Modern Western World. New York: Routledge.

60.

Crone

(2008) Flat medicine? Exploring trends in the globalization of health care. Academic Medicine 83(2): 117–121.

61.

Crooks

Andrews

(eds) (2009) Primary Health Care: People, Practice, Place. Farnham: Ashgate.

62.

Crooks

Turner

Snyder

Johnston

Kingsbury

(2011) Promoting medical tourism to India: Messages, images, and the marketing of international patient travel. Social Science and Medicine 72: 726–732.

63.

Crush

Pendleton

(2011) Brain flight: The exodus of health professionals from South Africa. International Journal of Migration, Health and Social Care 6(3): 3–18.

64.

Cuban

(2010) ‘It is hard to stay in England’: Itineraries, routes, and dead ends: an (im)mobility study of nurses who became carers. Compare: A Journal of Comparative and International Education 40(2): 185–198.

65.

Cummins

Curtis

Diez-Roux

Macintyre

(2007) Understanding and representing ‘place’ in health research. Social Science & Medicine 65(9): 1825–1838.

66.

Curtis

(2004) Health and Inequality: Geographical Perspectives. London: SAGE.

67.

Curtis

Riva

(2010a) Health geographies I: Complexity theory and human health. Progress in Human Geography 34(2): 215–223.

68.

Curtis

Riva

(2010b) Health geographies I: Complexity and health care systems and policy. Progress in Human Geography 34(4): 513–520.

69.

Davidson

Henderson

(2010) ‘Travel in parallel with us for a while’: Sensory geographies of autism. Canadian Geographer 54: 462–475.

70.

Davies

(2006). Patterning the geographies of organ transplantation: Corporeality, generosity and justice. Transactions of the Institute of British Geographers 31(3): 257–271.

71.

Davies

Day

Williamson

(2004) The geography of health knowledge/s. Health & Place 10(4): 293–297.

72.

Day

Alfonso

Chen

Guo

Lee

(2013) Overweight, obesity, and inactivity and urban design in rapidly growing Chinese cities. Health & Place 21: 29–38.

73.

Delamater

(2013) Spatial accessibility in suboptimally configured health care systems: A modified two-step floating catchment area (M2SFCA) metric. Health & Place 24: 30–43.

74.

DeLyser

Shaw

(2013) For menopause geographies. Area 45: 504–506.

75.

Durey

(2005) Settling in: Overseas trained GPs and their spouses in rural Western Australia. Rural Sociology 15: 38–54.

76.

Dyck

(2005) Feminist geography, the ‘everyday’, and local–global relations: Hidden spaces of place-making. Canadian Geographer 49(3): 233–243.

77.

Dyck

Dossa

(2007) Place, health and home: Gender and migration in the constitution of healthy space. Health & Place 13: 691–701.

78.

Dyer

McDowell

Batnitzky

(2008) Emotional labour/body work: The caring labours of migrants in the UK’s National Health Service. Geoforum 39: 2030–2038.

79.

Engels

Connell

(1983) Indian doctors in Australia: Costs and benefits of the brain drain. Australian Geographer 15(5): 308–318.

80.

England

(2014) Nurses across borders: Global migration of registered nurses to the US. Gender, Place and Culture. DOI: 10.1080/0966369X.2013.832658.

81.

England

Dyck

(2012) Migrant workers in home care: Routes, responsibilities and respect. Annals of the Association of American Geographers 102: 1076–1083.

82.

England

Eakin

Gastaldo

McKeever

(2007). Neoliberalizing home care: Managed competition and restructuring home care in Ontario. In: England

Ward

(eds) Neoliberalization: States, Networks, Peoples. Malden: Blackwell, 169–194

83.

England

Henry

(2013) Care work, migration and citizenship: International nurses in the UK. Social & Cultural Geography 14(5): 558–574.

84.

Evans

(2006) ‘Gluttony or sloth’: Critical geographies of bodies and morality in (anti)obesity policy. Area 38: 259–267.

85.

Farndale

Scullion

Sparrow

(2010) The role of the corporate HR function in global talent management. Journal of World Business 45(2): 161–168.

86.

Feng

Boyle

(2014) Do long journeys to work have adverse effects on mental health? Environment and Behavior 46(5): 609–625.

87.

Fish

(2008) Navigating queer street: Researching the intersections of lesbian, gay, bisexual and trans (LGBT) identities in health research. Sociological Research Online 13(1). DOI: 10.5153/sro.1652.

88.

Foley

Babou

(2011) Diaspora, faith, and science: Building a Mouride hospital in Senegal. African Affairs 110(438): 75–95.

89.

Foucault

Burchell

Gordon

Miller

(eds) (1991) The Foucault Effect: Studies in Governmentality. Chicago: University of Chicago Press.

90.

Fuller

Troyo

Alimi

Beier

(2014) Participatory risk mapping of malaria vector exposure in northern South America using environmental and population data. Applied Geography 48: 1–7.

91.

Gabriel

(2013) NAFTA, skilled migration, and continental nursing markets. Population, Space and Place 19: 389–403.

92.

Garrett

(2007) The challenge of global health. Foreign Affairs 86(1):14–38.

93.

Gatrell

(2011) Mobilities and Health. Farnham: Ashgate.

94.

Gatrell

Elliott

(2011) Geographies of Health. Oxford: Blackwell.

95.

Gatrell

(2013) Therapeutic mobilities: Walking and ‘steps’ to wellbeing and health. Health & Place 22: 98–106.

96.

Gesler

(1992) The Cultural Geography of Health Care. Pittsburgh: University of Pittsburgh Press.

97.

Gesler

Kearns

(2002) Culture/Place/Health. London: Routledge.

98.

Giesbrecht

Crooks

Williams

(2010) Scale as an explanatory concept: Evaluating Canada’s compassionate care benefit. Area 42: 457–467.

99.

Gish

(1971) Doctor Migration and World Health. London: Bell.

100.

Gish

Godfrey

(1979) A reappraisal of the ‘brain drain’ with special reference to the medical profession. Social Science and Medicine 13C: 1–11.

101.

Glinos

Baeten

(2014) Dream vs. reality: Seven case-studies on the desirability and feasibility of cross-border hospital collaboration in Europe. Social Science and Medicine 117: 18–24.

102.

Good

Hunter

Katz

(1979) The interface of dual systems of health care in the developing world. Social Science & Medicine 13D(3): 141–154.

103.

Grant

(2006) From the Transvaal to the prairies: The migration of South African physicians to Canada. Journal of Ethnic and Migration Studies 32: 681–695.

104.

Halford

(2003) Gender and organisational restructuring in the National Health Service: Performance, identity and politics. Antipode 35(2): 286–308.

105.

Hall

(2000) ‘Blood, brain and bones’: Taking the body seriously in the geography of health and impairment. Area 32(1): 21–29.

106.

Hamnett

Connell

(1981) Diagnosis and cure: The resort to traditional and modern medical practitioners in the North Solomons. Social Science and Medicine 15B(4): 489–498.

107.

Hampshire

Owusu

(2013) Grandfathers, Google and dreams: Medical pluralism, globalization and new healing encounters in Ghana. Medical Anthropology 32: 247–265.

108.

Hardill

Spradbery

Arnold-Boakes

Marrugat

(2005) Severe health and social care issues among British migrants who retire to Spain. Ageing and Society 25: 769–83.

109.

Hart

(1971) The inverse care law. The Lancet 297: 405–412.

110.

Hinchliffe

Allen

Lavau

Bingham

Carter

(2012) Biosecurity and the typologies of infected life: From border lines to borderlands, Transactions of the Institute of British Geographers 38(4): 531–543.

111.

Hossler

(2013) The privatization of the Milwaukee Clinical Campus: A case (study) for geographic approaches to medical services. Geoforum 49: 81–90.

112.

Huang

Yeoh

Toyota

(2012) Caring for the elderly: The embodied labour of migrant care workers in Singapore. Global Networks 12: 195–215.

113.

Hugo

(2005) Population movement in Indonesia: Implications for the potential spread of HIV/AIDS. In: Jatrana

Toyota

Yeoh

(eds) Migration and Health in Asia. London: Routledge, 17–40.

114.

Hunter

(1966) River blindness in Nangodi, Northern Ghana: A hypothesis of cyclical advance and retreat. Geographical Review 56: 398–416.

115.

Ingram

(2013) Viral geopolitics: Biosecurity and global health governance. In: Dobson

Barker

Taylor

(eds) Biosecurity: The Socio-Politics of Invasive Species and Infectious Diseases. Abingdon: Routledge, 137–150.

116.

Jackson

Neely

(2014) Triangulating health: Toward a practice of a political ecology of health. Progress in Human Geography 39(1): 47–64.

117.

Jayne

Valentine

Holloway

(2008) Geographies of alcohol, drinking and drunkenness: A review of progress. Progress in Human Geography 32(2): 247–263.

118.

Johnson

Noyes

Haines

Thomas

Stockport

Ribas

Harris

(2013) Learning from a Brazilian community health worker model in North Wales. Globalization and Health 9(25). Available at: http://www.globalizationandhealth.com/content/9/1/25 (accessed 26 January 2015).

119.

Jonson

Giertz

(2013) Migrant care workers in Swedish elderly and disability care: Are they disadvantaged? Journal of Ethnic and Migration Studies 39: 809–825.

120.

Joseph

Phillips

(1984) Accessibility and Utilization: Geographical Perspectives on Health Care Delivery. New York: Harper and Row.

121.

Kalipeni

Semu

Mbilizi

(2012) The brain drain of health care professionals from sub-Saharan Africa: A geographic perspective. Progress in Development Studies 12: 153–171.

122.

Kane

(2010) Charity and self-help: Migrants’ social networks and health care in the homeland. Anthropology Today 26: 8–12

123.

Kearns

(1993) Place and health: Towards a reformed medical geography. The Professional Geographer 45: 139–147.

124.

Kearns

(1995) Medical geography: Making space for difference. Progress in Human Geography 19(2): 251–259.

125.

Kearns

Moon

(2002) From medical to health geography: Novelty, place and theory after a decade of change. Progress in Human Geography 26(5): 605–625.

126.

Kearns

Gesler

(eds) (1998) Putting Health into Place: Landscape, Identity, and Well-being. Ithaca: Syracuse University Press.

127.

Kim

Farmer

Porter

(2013) Redefining global health-care delivery. The Lancet 382(9897): 1060–1069.

128.

King

(2012) ‘We pray at the church in the day and visit the Sangomas at night’: Health discourses and traditional medicine in rural South Africa. Annals of the Association of American Geographers 102: 1173–1181.

129.

King

(1967) Medical Care in Developing Countries. Nairobi: Oxford University Press.

130.

Kofman

Raghuram

(2006) Gender and global labour migrations: Incorporating skilled workers. Antipode 38(2): 282–303.

131.

Kolstad

(2013) How does additional education affect willingness to work in rural remote areas in low-income contexts? An application on health workers in Tanzania. Journal of Development Studies 49(2): 301–314.

132.

Kruk

Prescott

de Pinho

Galea

(2009) Are doctors and nurses associated with coverage of essential health services in developing countries? A cross-sectional study. Human Resources for Health 7(27): 1–9.

133.

Kuhn

(2005) A longitudinal analysis of health and mortality in a migrant-sending region of Bangladesh. In: Jatrana

Toyota

Yeoh

(eds) Migration and Health in Asia. London: Routledge, 177–208.

134.

Kwan

(2012) Geographies of health. Annals of the Association of American Geographers 102: 891–892.

135.

Kyriakides

Virdee

(2003) Migrant labour, racism and the British National Health Service. Ethnicity & Health 8(4): 283–305.

136.

Learmonth

(1988) Disease Ecology. Oxford: Blackwell

137.

Learmonth

Curtis

(2013) Place shaping to create health and wellbeing using health impact assessment: Health geography applied to develop evidence-based practice. Health & Place 24: 20–22.

138.

Leeuw

Maurice

Holyk

Greenwood

Adam

(2012) With reserves: Colonial geographies and First Nations health. Annals of the Association of American Geographers 102(5): 904–911.

139.

Legg

(2013) Planning social hygiene: From contamination to contagion in interwar India. In: Peckham

Pomfret

(eds) Imperial Contagions: Medicine, Hygiene, and Cultures of Planning in Asia. Hong Kong: Hong Kong University Press, 105–122.

140.

Léonard

Stordeu

Roberfroid

(2009) Association between physician density and health care consumption: A systematic review of the evidence. Health Policy 91: 121–134.

141.

Levitt

Rajaram

(2013) Moving toward reform? Mobility, health, and development in the context of neoliberalism. Migration Studies 1(3): 338–362.

142.

Lewis

(2009) Mental health in sexual minorities: Recent indicators, trends, and their relationships to place in North America and Europe. Health & Place 15(4): 1029–1045.

143.

Talaei-Khoei

Seale

Ray

MacIntyre

(2013) Health care provider adoption of eHealth: Systematic literature review. Interactive Journal of Medical Research 2(1). DOI: http://www.i-jmr.org/2013/1/e7/.

144.

Lovell

Kearns

Prince

(2014) Neoliberalism and the contract state: Exploring innovation and resistance among New Zealand health promoters. Critical Public Health 24(3): 308–320.

145.

Maantay

Becker

(2012) The health impacts of global climate change: A geographic perspective. Applied Geography 33: 1–3.

146.

MacDonnell

Andrews

(2006) Placing sexuality in health policies: Feminist geographies and public health nursing. GeoJournal 65(4): 349–364.

147.

McGregor

(2007) Joining the BBC (British Bottom Cleaners): Zimbabwean migrants and the UK care industry. Journal of Ethnic and Migration Studies 33(5): 801–824.

148.

Mackintosh

Raghuram

Henry

(2006) A perverse subsidy: African trained nurses and doctors in the NHS. Soundings 34: 103–13.

149.

McNeil

Mitchell

Parker

(2013) Interprofessional practice and professional identity threat. Health Sociology Review 22(3): 291–307.

150.

Mansfield

(2012) Environmental health as biosecurity: ‘Seafood choices’, risk, and the pregnant woman as threshold. Annals of the Association of American Geographers 102: 969–976.

151.

May

(1959) The Ecology of Human Disease. New York: MD Publications.

152.

Mayer

(1996) The political ecology of disease as one new focus for medical geography. Progress in Human Geography 20: 441–456.

153.

Meade

Florin

Gesler

(1988) Medical Geography. New York: Guilford Press.

154.

Meurk

Broom

Adams

Sibbritt

(2013) Rurality, mobility, identity: Women’s use of complementary and alternative medicine in rural Australia. Health & Place 21: 75–80.

155.

Miller

Laugesen

Lee

Mick

(1998) Emigration of New Zealand and Australian physicians to the United States and the international flow of medical personnel. Health Policy 43: 253–270.

156.

Milligan

(2000) ‘Bearing the burden’: Towards a restructured geography of caring. Area 32: 49–58.

157.

Milligan

Atkinson

Skinner

Wiles

(2007) Geographies of care: A commentary, New Zealand Geographer 63: 135–140.

158.

Milligan

Conradson

(eds) (2006) Landscapes of Voluntarism: New Spaces of Health, Welfare and Governance. Bristol: Policy Press.

159.

Milligan

Wiles

(2010) Landscapes of care. Progress in Human Geography 34(6): 736–754.

160.

Milligan

Kearns

Kyle

(2011) Unpacking stored and storied knowledge: Elicited biographies of activism in mental health. Health & Place 17: 7–16.

161.

Mohan

(1988). Restructuring, privatization and the geography of health care provision in England, 1983–1987. Transactions of the Institute of British Geographers 13: 449–465.

162.

Nair

(2012) Moving with the Times: Gender, Status and Migration of Nurses in India. New Delhi: Routledge.

163.

Nichter

(1996) The primary health care center as a social system: Primary health care, social status, and the issue of team-work in South Asia. In: Nichter

Nichter

(eds) Anthropology and International Health. Amsterdam: Gordon and Breach, 367–391.

164.

Nordfeldt

Roalkvam

(2010) Choosing vaccination: Negotiating child protection and good citizenship in modern India. Forum for Development Studies 37(3): 327–347.

165.

Ormond

(2013) Neoliberal Governance and International Medical Travel in Malaysia. Abingdon: Routledge.

166.

Ormond

Sulianti

(2014) More than medical tourism: Lessons from Indonesia and Malaysia on South–South intra-regional medical travel. Current Issues in Tourism. DOI: 10.1080/13683500.2014.937324.

167.

Pallikadavath

Singh

Ogollah

Dean

(2013) Human resource inequalities at the base of India’s public health care system. Health & Place 23: 26–32.

168.

Parreñas

(2001) Servants of Globalization: Women, Migration, and Domestic Work. Stanford: Stanford University Press.

169.

Pearce

Barnett

Moon

(2012) Sociospatial inequalities in health-related behaviours: Pathways linking place and smoking. Progress in Human Geography 36(1): 3–24.

170.

Philo

(1987) ‘Fit localities for an asylum’: The historical geography of the nineteenth-century ‘mad-business’ in England as viewed through the pages of the Asylum Journal. Journal of Historical Geography 13(4): 398–415.

171.

Portes

Fernandez-Kelly

Light

(2012) Life on the edge: Immigrants confront the American health system. Ethnic and Racial Studies 35: 3–22.

172.

Prasad

(2012) Imaginative geography, neoliberal globalization, and colonial distinctions: Docile and dangerous bodies in medical transcription ‘outsourcing’. Cultural Geographies 19: 349–364.

173.

Pratt

(1999) From registered nurse to registered nanny: Discursive geographies of Filipina domestic workers in Vancouver, B.C. Economic Geography 75(3): 215–236.

174.

Procter

Clarke

Ransley

Cade

(2008) Micro-level analysis of childhood obesity, diet, physical activity, residential socioeconomic and social capital variables: Where are the obesogenic environments in Leeds? Area 40: 323–340.

175.

Prothero

(1965) Migrants and Malaria. London: Longmans.

176.

Qian

(2013) Smoking spaces as enabling spaces of wellbeing. Health and Space 24: 173–182.

177.

Raghuram

(2006) Gendering medical migration: Asian women doctors in the UK. In: Agrawal

(ed.) Migrant Women and Work. New Delhi: SAGE, 73–94.

178.

Raghuram

(2009) Caring about ‘brain drain’ migration in a postcolonial world. Geoforum 40(1): 25–33.

179.

Raghuram

Bornat

Henry

(2011) The co-marking of aged bodies and migrant bodies: Migrant workers’ contribution to geriatric medicine in the UK. Sociology of Health & Illness 33(2): 321–335.

180.

Rainham

McDowell

Krewski

Sawada

(2010) Conceptualizing the healthscape: Contributions of time geography, location technologies and spatial ecology to place and health research. Social Science & Medicine 70: 668–676.

181.

Rogerson

Crush

(2008) The recruiting of South African health care professionals. In: Connell

(ed.) The International Migration of Health Workers. New York: Routledge, 199–224.

182.

Rosenberg

(2014) Health geography I: Social justice, idealist theory, health and health care. Progress in Human Geography 38(3): 466–475.

183.

Ruckert

Labonté

(2014) Public–private partnerships (ppps) in global health: The good, the bad and the ugly. Third World Quarterly 35(9): 1598–1614.

184.

Rutherford

(2013) The confusions and exuberances of biopolitics. Geography Compass 7(6): 412–422.

185.

Sanders

Aguilar

Bacon

(2013) A spatial analysis of the geographic distribution of musculoskeletal and general practice healthcare clinics in Auckland, New Zealand. Applied Geography 44: 69–78.

186.

Scott

Shanker

(2010) Tying their hands? Institutional obstacles to the success of the ASHA community health worker programme in rural north India. AIDS Care 22(S2): 1606–1612.

187.

Shannon

Willoughby

(2004) Severe acute respiratory syndrome (SARS) in Asia: A medical geographic perspective. Eurasian Geography and Economics 45: 359–381.

188.

Sharma

Ladd

Unnikrishnan

(2013) Healthcare inequity and physician scarcity: Empowering non-physician healthcare. Economic and Political Weekly 48(13): 112–117.

189.

Skeldon

(2009) Of skilled migration, brain drains and policy responses. International Migration 47(4): 3–29.

190.

Smallman-Raynor

Cliff

Haggett

(1992) London International Atlas of AIDS. Oxford: Blackwell.

191.

Smith

Chanda

Tangcharoensathien

(2009) Trade in health-related services. The Lancet 373(9663): 593–601.

192.

Sparke

(2009) Unpacking economism and remapping the terrain of global health. In: Kay

Williams

(eds) Global Health Governance: Crisis, Institutions and Political Economy. Basingstoke: Palgrave Macmillan, 131–159.

193.

Sparke

Anguelov

(2012) H1N1, globalization and the epidemiology of inequality, Health & Place 18: 726–736.

194.

Stevenson

(1987) Inequalities in the distribution of health care facilities in Sierra Leone. In: Akhtar

(ed.) Health and Disease in Tropical Africa. Chur: Harwood, 403–414.

195.

Stilwell

Diallo

Zurn

Dal Poz

Adams

Buchan

(2003) Developing evidence-based ethical policies on the migration of health workers. Human Resources for Health 1(1): 8. Available at: http://www.human-resources-health.com/content/1/1/8 (accessed 26 January 2015).

196.

Tyner

(2013) Population geography I: Surplus populations. Progress in Human Geography 37(6): 701–711.

197.

Valentine

(2003) Geography and ethics: In pursuit of social justice ethics and emotions in geographies of health and disability research. Progress in Human Geography 27(3): 375–380.

198.

Walton-Roberts

(2009) Diasporan philanthropy in Punjab’s health sector: A transnational perspective. In: Dusenbury

Tatla

(eds) Sikh Diaspora Philanthropy: Global Giving for Local Good. Delhi: Oxford University Press, 184–204.

199.

Walton-Roberts

(2012) Contextualising the global nursing care chain: International migration and the status of nursing in Kerala, India. Global Networks 12: 175–194.

200.

Walton-Roberts

(2014) European education regionalization and its impact on the global migration of nurses. In: Walton-Roberts

Hennebry

(eds) Territoriality and Migration Management in the E.U. Neighbourhood. Dordrecht: Springer, 49–64.

201.

Walton-Roberts

(2015) International migration of health professionals and the marketization and privatization of health education in India. Social Science and Medicine 124: 374–382.

202.

Walton-Roberts

Rajan

(2013) Nurse emigration from Kerala: ‘Brain circulation’ or ‘trap’? In: Rajan

(ed.) India Migration Report 2013. New Delhi: Routledge, 206–223.

203.

Wan

Zhan

Zou

Wilson

(2013) Spatial access to health care services and disparities in colorectal cancer stage at diagnosis in Texas. Professional Geographer 65: 527– 541.

204.

Wang

(2007) Immigration, ethnicity, and accessibility to culturally diverse family physicians. Health & Place 13: 656–671.

205.

Wang

Luo

(2005) Assessing spatial and nonspatial factors for healthcare access: Towards an integrated approach to defining health professional shortage areas. Health & Place 11(2): 131–146.

206.

Ward

(2004) Going global? Internationalization and diversification in the temporary staffing industry. Journal of Economic Geography 4(3): 251–273.

207.

Williams

Baláž

(2008) International return mobility, learning and knowledge transfer: A case study of Slovak doctors. Social Science & Medicine 67(11): 1924–1933.

208.

Williamson

(2004) Conceptualising geographies of health knowledge: The emergence of new education spaces for public health. Health & Place 10(4): 299–310.

209.

World Health Organization (WHO) (2006) Working Together for Health. Geneva: WHO.

210.

Wrede

Nare

(2013) Glocalising care in the Nordic countries. Nordic Journal of Migration Research 3: 57–62.

211.

Yeates

(2009) Globalising Care Economies and Migrant Workers: Explorations in Global Care Chains. Basingstoke: Palgrave.

212.

Young

(2013) How effective is an ethical international recruitment policy? Reflections on a decade of experience in England. Health Policy 111: 184–192.