Margaret Walton-Roberts

While the international mobility of nurses and other health professionals has long been a feature of national health systems, the dynamism of this mobility has intensified alongside globalization.  We need to understand the global migration of health professionals as a form of capital circulation across public-private systems shaped by an increasingly globally orientated corporatized health sector. Gendered analysis of nurse migration has also been encouraged by using intersectional analysis, understanding how race, class, gender, ethnicity, and nationality interact with labour market segmentation, as well as Global Care Chain (GCC) approaches, that reveal how the international division of reproductive labour depends on the extraction of care labour from feminized and racialized women in low-income nations by higher income nations (Parreñas, 2000). Other frameworks that bridge economic, labour and development geography, and incorporate multiple scales and sources of agency in commercial networks includes the concepts of global value chains (GVCs) and global production networks (GPNs) (Coe et al 2004). GPNs and GVCs are particularly relevant to this case since migrant health workers are incorporated into an evolving geographically extended labour process activated through numerous migration pathways. Yet despite the potential of combining the gendered analysis of GCC with GPNs, the disconnect between these concepts is evident.  This is unfortunate, since expanding GPN analysis through a gendered lens such as GCC encourages deeper analysis of the role of  the state, skills, and sex (gender and the household).

The state

The state remains an important actor in production systems, through industrial policy and regulatory governance. Horner (2016) argues that the role of non-firm actors in production networks, including the state and public-private actors, has been further advanced using the GPN approach. Based on the emerging literature that does engage the state in GPNs, Horner suggests a typology of mechanisms of state influence in GPNs using the notions of facilitator, regulator, producer, and buyer. States can act to support or engage in these roles through policy decisions, but can also under regulate, or de-regulate sectors, such as in labour rights (Yeung 1998).

Skills

The development of GVCs and GPNs has allowed for more knowledge diffusion throughout supplier networks, but this also requires skills upgrading as states and firms attempt to derive more from higher value processes and activities. To assess the interactional effect between the state and firms the context must be understood in relation to local and national systems of training and the position of the state in the international division of labour. Value chain research explores outsourcing and externalization of functions across various firm boundaries, this has an impact on employment organization and conditions.  The reorganization of employment and labour processes that occurs within the GVC /GPN organizational forms must also be assessed from the perspective of major labour market divisions, including that of gender. 

Sex (gender) and the household

Wilma Dunaway (2014) has highlighted how early global systems thinking in commodity chains identified gender and the household as an essential element of the surplus value process embedded in global production. Despite the feminization of global labour in manufacturing and service work, the de-gendering of work on global production has been evident, with the absence of an assessment of the household scale in value chains especially evident (Yeates, 2004). Dunaway reminds us that scholars of value chains must understand biological reproduction in the household, the presence or absence of social protection during economic crisis, and the social reproduction of worker households and communities. Dunaway advocates that scholars of value chains overcome productivist and masculinist bias against the effective analysis of how productive and reproductive spheres overlap and intersect revealing how every economic system reflects the gendered patriarchal norms of its society, institutions, and social geography. The gender implications of health worker migration are particularly significant, since female migrants are overrepresented in health and personal care sectors of the global economy, which are often undervalued in terms of income security and status. While the specific policy context of migrant nurse integration into different national labour markets varies, there is a structural trajectory of convergence of such workers being incorporated into national health systems facing restructured or diminished state spending (Williams 2012).

Conclusion

Feminist inspired research on services in the care economy (child, dependent and elder care, health and personal services), has been developed through an extensive literature on the global care chain, but this approach has not been incorporated into broader literature on value chains and production networks. The corporatization, commoditization and privatization of health and personal care services mean they are an increasingly central feature of the productive economy. Health care is a leading sector for global growth, where total spending overall is growing faster than GDP, the time is ripe for our analysis of this sector to integrate global care chain with value chain or global productive network approaches.