George et al. BMC Health Services Research          (2019) 19:109 
https://doi.org/10.1186/s12913-019-3896-5
RESEARCH ARTICLE Open Access
What is the financial incentive to
immigrate? An analysis of salary disparities
between health workers working in the
Caribbean and popular destination
countries
Gavin George1, Bruce Rhodes2* and Christine Laptiste3
Abstract
Background: The continuous migration of Human Resources for Health (HRH) compromises the quality of health
services in the developing supplying countries. The ability to increase earnings potentially serves as a strong
motivator for HRH to migrate abroad. This study adds to limited available literature on HRH salaries within the
Caribbean region and establishes the wage gap between selected Caribbean and popular destination countries.
Methods: Salaries are reported for registered nurses, medical doctors and specialists. Within these cadres,
experience is incorporated at three different levels. Earnings are compared using purchasing power parity (PPP)
exchange rates allowing for cost of living adjusted salary differentials, awarded to different levels of work
experience for the chosen health cadres in the selected Caribbean countries (Jamaica, Dominica, St Lucia and
Grenada) and the three destination countries (United States, United Kingdom and Canada).
Results: Registered nurses in the destination countries, across all experience levels, have greater spending power
compared to their Caribbean counterparts. Recently qualified registered nurses earn substantially more in the UK
(86.4%), US (214.2%) and Canada (182.5% more). The highest PPP salary ($) gap amongst more experienced nurses
(5-10 years) is found within the US, with a gap of 163.9%. PPP salary gaps amongst medical doctors were pronounced,
with experienced cadres (10–20 years of experience) in the US earning 316.3% more than their Caribbean counterparts,
whilst UK doctors (183.5%) and Canadian doctors (251.3%) also earning significantly more. Large salary differentials
remained for medical specialists and consultants. US specialist salaries were 540.4% higher than their Caribbean based
counterparts, whilst UK and Canadian specialists earned 95.2 and 181.6% more respectively.
Conclusion: The PPP adjusted HRH salaries in the three destination countries are superior to those of comparable HRH
working in the Caribbean countries selected. The extent of the salary gaps vary according to country and the health
cadre under examination, but remain considerable even for newly qualified HRH. The financial incentive to migrate for
HRH trained and working in the Caribbean region remains strong, with governments having to consider earning
potential abroad when formulating policies and strategies aimed at retaining health professionals.
Keywords: Human resources for health (HRH), Salaries, Caribbean, Migration, Purchasing power parity
* Correspondence: Rhodesb@ukzn.ac.za
2School of Accounting, Economics and Finance, University of KwaZulu-Natal,
Durban, South Africa
Full list of author information is available at the end of the article
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
George et al. BMC Health Services Research          (2019) 19:109 Page 2 of 11
Background The failure to adequately retain and replenish HRH,
Developed countries, experiencing an increased demand either through the continued production of trained
for health services and an inadequate supply of Human health personnel, and retention of HRH, will result in
Resources for Health (HRH), have actively recruited the deterioration of the health service. The prevalent
health professionals from some of the world’s poorest poor working conditions may dangerously perpetuate
countries—despite these same countries facing acute the out migration of health professionals, with the
health worker shortages of their own [1]. The Caribbean remaining health professionals motivated to leave the
region is contextualized by high migration rates, hinder- profession or seek opportunities abroad themselves [12].
ing the delivery of adequate health services [2], and Whilst poor working conditions and burnout remain a
threatening the regions ability to meet objectives set in strong motivator for HRH to migrate [7, 13–15], litera-
the Strategy for Universal Access to Health [3, 4]. ture highlights a number of additional factors contribut-
Aggressive recruiting by destination countries coupled ing to migration, including the availability of better
with difficult economic circumstances in source coun- remuneration abroad [16, 17, 18]; accompanied by im-
tries create the ideal circumstances for the outflow of proved standards of living and upward social mobility
labour. For example, the decade of the 1990s and into [19], and better opportunities for professional develop-
the 2000s, a time of economic turbulence for Jamaica, ment [13, 16, 19]. Whilst research suggests that the lure
saw experienced nurses recruited to the United King- of better salaries is the biggest factor contributing to the
dom and the United States [5]. Research suggests that migration of Caribbean HRH [16, 20], little exists on the
over 50,000 nurses have migrated from the Caribbean salary differentials between HRH in the Caribbean in re-
community, whilst 50% of all physicians trained in lation to HRH in the US, UK and Canada. Literature has
Jamaica since 1991 have also migrated [6, 7]. The most gone on to suggest that the real motivator of migration
popular destination countries for Caribbean HRH in- is the actual gap between the potential migrants’ current
clude the predominantly English-speaking United States salary level and the level they could potentially attain
(US), United Kingdom (UK) and Canada, with these abroad, positing that the larger the gap, the greater the
countries suffering their own HRH shortages and relying incentive to migrate [21]. Identifying salary disparities
on foreign trained health professionals to augment their through examining only exchange rates however, limits
health workforce [8]. Whilst the far larger portion of the our understanding of the true financial advantages of
migrants from the Caribbean are unskilled, there re- migration. The cost of living varies across destination
mains inadequate data on migration flows in order to countries thereby requiring an analysis of wages and
determine the true effect an uncontrolled drain of med- their purchasing power in order to fully determine the
ical staff may have on the health profile of local popula- extent of the financial motive to migrate. This study
tions [9]. Literature has, however, pointed to the dual evaluates the strength of foreign salaries by using a PPP
impact of health worker migration, highlighting not only based method to equalise the cost of living between se-
the erosion of critical skills, but also the lost financial in- lected destination and Caribbean countries. The use of
vestment in training and educating HRH [3]. As a result the PPP method has previously been used by Govern-
of the high cost of training health care workers in devel- ments to adjust staff salaries whilst literature has advo-
oping countries, migration has been perceived as a per- cated for the adoption of the PPP method in studies
verse subsidy by the poorer source countries to the involving multi-country comparisons of salaries [22].
richer destination countries [4].
If skilled health personnel continue migrating, health sys- Methods
tems within source countries and the underserved areas in The method for this paper closely follows that of
those countries in particular, are likely to be compromised pre-existing work [23–25] and as such the theory of pur-
[10]. Policies and strategies are therefore required to arrest chasing power parity and their applicability for inter-
the effect of the erosion of HRH to ensure that the domes- national salary comparisons is well documented. In sum,
tic health system is able to function optimally. However, in PPP exchange rates between two national currencies, are
order to adequately develop effective policies which seek to those that equalise the cost of living between those two
address the migration of Caribbean HRH, there has to be countries. This provides a more realistic comparison of
an understanding of the dynamics of health worker em- salaries between countries as a better alternative to using
ployment opportunities, together with the political will to market based spot exchange rates. As such a PPP based
explore strategies aimed at the recruitment and retention of salary comparison is more informative for potential mi-
appropriate human resources within the health care system grating labour.
[11]. This policy alignment is essential in offsetting the im- The IMF calculates its PPP estimates based on the bas-
pact of market dynamics and the resultant mobility of HRH ket of goods selected by the International Comparison’s
from the Caribbean region [11]. Program (ICP) [26]. The World Bank designed a basket
George et al. BMC Health Services Research          (2019) 19:109 Page 3 of 11
of products for household consumption called the “Glo- and corresponding PPP ratios are then applied to these
bal List” and from that the Economic Commission for figures. Tax rates vary across countries but preliminary
Latin America and the Caribbean (ECLAC) generated a post tax comparisons with and without PPP application
“Regional List”, according to the characteristics of the did not change the rankings in the results.
region. This was to ensure ‘representativeness’ and ‘com-
parability’ across participant countries [27]. The latter Caribbean region
criteria can involve some technical trade–offs because Based on data availability, the selected countries in the
not all the same products are available in all countries. Caribbean region for this study included Jamaica,
The task of the ICP is to compare prices; thus requiring Grenada, Dominica and St Lucia. In terms of HRH qual-
goods and services that could be found in all countries, ifications needed to practice as a nurse or doctor and
even if they were not fully representative of the con- the required steps to be promoted to higher salary levels,
sumption in each participant country [27]. Based on this the requirements of both are so similar across the island
criteria, in the case of the Caribbean, the ICP uses 570 nations that a country by country breakdown within this
different goods and services, each having an ICP code region was deemed not useful. Rather a more general
and a product description [27]. Salary estimates for this description of qualifications and experience is sufficient.
paper are from the 2016 or 2017 salary schedules so a For instance, a registered nurse in the Caribbean region
comparison on earnings is made using the 2016 pur- requires a Bachelor’s of Science/Diploma in Nursing
chasing power parity (PPP) exchange rate estimate from from an accredited institution and must be registered
the International Monetary Fund [28]. with the relevant nursing council or medical accredit-
ation body [31–34]. Training entails a three year general
Data nursing program, twelve months of midwifery and one
Salaries are reported in a series of three tables for year on a nursing assistant program [35].
nurses, doctors and specialists, respectively. For the lat- A medical officer (MO) is generally required to have a
ter category it was not possible to distinguish between Bachelor of Medicine and Bachelor of Surgery (MBBS)
different specialisations [29, 30] for the Caribbean coun- or equivalent medical degree recognised by the relevant
tries. For the migrant country comparisons at the spe- medical council as well as at least two years of post-in-
cialist level, an average salary calculated from two of the ternship working in a hospital, preferably including some
more highly paid, common and familiar areas of special- accident and emergency experience [36–39]. Specialists
isation were chosen: anaesthetist and general surgeon. and consultants often require a postgraduate qualifica-
These specialists all have an early career starting point tion in their chosen field of expertise and a practicing
and can generally be considered consultants as the years certificate [40]. This needs to be supported by at least
of experience increase. It was generally found that the two, sometimes five years of work experience in the spe-
salaries of these two specialists were comparable across cialist field as well as five years of experience in a clinical
the selected destination countries. setting or general practice [18, 19].
Each table presents the basic salary in a national cur- Data for St Lucia and Grenada were gathered from
rency unit (NCU), the US dollar equivalent and then the Government publications detailing salaries and increases
PPP adjusted salary in US dollars. Finally, percentage from promotions and career progression [41, 42]. In the
gaps between country PPP salaries, using the selected case of Jamaica, data were retrieved from the Compensa-
Caribbean country figures as a base, is presented as a tion Unit (responsible for public sector job evaluations
comparator because these take account of the cost of and wage policy), operating within the Ministry of
living between interspatial salaries. Finance and Public Service, which publishes HRH salary
The basic salaries that are reported exclude any scales, including details of career progression and subse-
weightings based on location and other allowances or quent salary increases [43]. Data on Dominica HRH sal-
benefits. Some countries have more location based salary aries were considered less reliable, with only ‘estimates’
variation than others. Indeed any lower and upper for the 2016/2017 period found and less clarity on career
bound estimates were reduced to a single point average. progressions resulting in salary increases [43]. Nurses
Whilst it is acknowledged that the ability to earn per- generally start on scale point 19 and move to scale 12
formance benefits will vary across countries and experi- after approximately 5 years [44]. It was not clear if they
ence, these would only accrue to specific individuals remained on this latter scale significantly beyond 5 years
under specific circumstances and were not considered in so the most conservative approach (no movement) was
this study. adopted. A similar situation emerged for medical doc-
The basic, before tax salary is reported below, includ- tors. This is illustrated in the results tables for these two
ing any reported weightings based on location and other HRH categories for Dominica. The final consultant/spe-
allowances or benefits. The dollar market exchange rates cialist category did not require such disaggregation.
George et al. BMC Health Services Research          (2019) 19:109 Page 4 of 11
United Kingdom data. Doctors in the US are required to have a 4-year
The UK data for all the HRH categories was gathered undergraduate degree, 4 years of medical school training,
using NHS sources [41, 42] which have been used in 3–7 years of residency training and must have passed the
previous studies analysing HRH salary data [23, 24]. Medical Licensing Examination (USMLE) [61, 62]. Foreign
Scales were revised in April 2016 under the ‘Agenda for applicants need, inter alia, a license from the state in
Change’ and is based on a points system within different which they intend to work, pass the first two steps of the
bands [41]. In addition, there is also a weighting for USMLE, get into an accredited US or Canadian based
HRH working in London [41]. Early career nurses start residency program then return to pass stage three of the
in band 4, point 15 [45]. Early career, or junior doctors, USMLE, all of which can take several years [63]. This also
are paid both a basic salary and a band supplement, applies to specialists. Anaesthetists and general surgeons
which varies on the hours worked [46]. Foreign trained require graduate training that leads to a medical degree,
nurses, outside of the European Economic Area (EEA), followed by 4 years of residency training, although the
will need to register with the Nursing and Midwifery residency may be longer for surgeons [64, 65].
Council which will then compare their training with that
required by the UK. This is regardless of working within Canada
the public or private healthcare sector, with the registra- Payscale.com was used to determine Canadian HRH sal-
tion process completed following an examination [47]. aries, again due to the large variation across the country
In the UK, a junior doctor requires at least Foundation [66]. In particular, nurses operating in remote areas can
2 as a career starting point [48]. In some countries a potentially command considerably higher salaries, and as
resident medical officer (RMO) is a junior doctor in such a median is reported to remove outlier influence
training, whilst in the UK, the term RMO generally re- on the mean [67]. Historically, Canadian provinces only
fers to a doctor in a private hospital [49]. Foreign trained required a diploma as a minimum entry requirement
doctors outside the EEA will need to register and get a into nursing but since 1998 (for the Atlantic provinces
UK license from the General Medical Council (GMC) re- at least), nurses require a Bachelor’s degree and the sub-
gardless of whether they work in the public or private sequent nursing training can then be completed within 2
health sector. The GMC prescribes its own criteria to de- to 4 years [68]. Potential applicants do not apply to a
termine whether a doctor is fit to practice in the UK [50]. central body but rather to a specific facility/hospital [69].
The National Careers Service database was used to de- Provinces have their own entry and licensing require-
termine salaries for the selected UK based specialists ments with variation found at the city level where, for
[51–53]. Anaesthetists and general surgeons working in example, a nurse applying to a hospital in Quebec must
the NHS generally require a 5-year degree in medicine, a be proficient in both French and English [69].
2-year foundation program of general training, 6–8 years Once prospective doctors working in Canada have
of specialist training and in the case of surgeons, 2 years passed the Medical Council of Canada Evaluating Exami-
of core surgical training and they both receive a similar nations (MCCEE – parts 1 and 2), the Medical Council of
level of pay [52, 53]. Canada awards a qualification known as the Licentiate of
the Medical Council of Canada (LMCC), which allows the
United States graduate to practice medicine in Canada [70]. For special-
Payscale.com, supported by the 2017 Medscape report ists such as anaesthetists and surgeons, in addition to the
on Compensation for Physicians, provided the data for standard medical training, they must pass the Royal Col-
all the HRH categories for the United States and lege of Physicians and Surgeons of Canada (RCPSC) ex-
accounted for the large salary variation across the coun- aminations [71]. Whilst there is considerable regional
try [54–58]. Entry level nurses were found to have the variation, the Canadian Medical Council has set up the
highest variation with a lower and upper bound of National Assessment Collaboration (NAC) creating a
US$41,000 – US$70,000 respectively. New York, California, pan-Canadian model that sets common standards, tools
Boston and Seattle can be 30–50% above national average and materials for Practice-Ready Assessment (PRA) pro-
whereas Indianapolis and St Louis are 8 and 14% below the grams across Canada. These PRA programs are designed
national average [59]. to evaluate international medical graduates and foreign
Generally a registered nurse working in the US requires trained medical practitioners wanting to practice in
an Associate of Science (ASN) in Nursing or a Bachelor of Canada. This is to ensure that all PRA programs operate
Science (BSN) in Nursing and a pass in the National in a consistent and comparable manner across provinces
Council Licensure Examination (NCLEX) [57, 58]. Licens- and territories [72] .
ing and qualification requirements do vary across the A distinction could not be made between private and
country as they do in Canada [60]. Similarly, salaries vary publically employed consultants/specialists and only
across the country with a national average reported in the general averages were obtained. A large proportion of
George et al. BMC Health Services Research          (2019) 19:109 Page 5 of 11
Canadian specialists, depending on the province, are pri- gap of registered nurses with 5–10 years’ experience is
vate practitioners who have their own expenses, reve- not as wide as their entry level colleagues. The highest
nues, assets and overheads [73, 74]. Petch et al., (2012) (and most enticing) PPP gap can be still found in US
found that accounting for overhead charges ‘substan- with a 163.9% increase for nurses with 5–10 years
tially’ affects income estimates. Estimates reveal that of work experience. Canada is the next highest at 140.1%
these can be between 12.5% for emergency medicine to and the UK at 92.1% which still promises a great deal
42.5 for ophthalmology (based in Ontario), varying by more spending power compared with nurses working in
speciality [75]. Whilst we acknowledge this issue, the re- the Caribbean countries. For the most experienced
sults below were not adjusted for any possible overhead nurses, the UK offers the top percentage PPP increase
charges that consultants/specialists may wish to levy on over their Caribbean counterparts at 164.5%. Next highest
their clients. is the US and Canada at 153.6 and 133.8% respectively.
A similar hierarchy and consistency in PPP gaps can be
Results found with regard to medical doctors (Table 2), with US
Tables 1-3 reveal that the different categories of HRH salaries highest across all levels of experience. The salary
operating abroad have greater spending power than their gap between the US is 123.5% over newly or recently
Caribbean counterparts. Newly or recently qualified reg- qualified medical doctors working in the Caribbean.
istered nurses earn significantly more in the UK (86.4%), Canada offers the next highest (88.3%) followed by the UK
US (214.2%) and Canada (182.5%) (Table 1). The salary (41.9%). Medical doctors with 5–10 years’ experience earn
Table 1 Registered nurse salaries of selected countries for three levels of work experience
Jamaica5 Dominica8 St Lucia11 Grenada UK US20 Canada21
0-3 NCU1 1,120,696 27,032 42,06311 27,88814 21,69217 52,252 59,660
yrs
XCD2 23,764 27,032 42,063 27,888 80,043 142,125 122,900
US ($)3 8737 9938 15,464 10,253 26,846 52,252 45,099
PPP ($)4 13,091 14,891 23,171 15,362 30,989 52,252 46,976
% PPP ($) gap over Caribbean average (16,629) 86.4 214.2 182.5
5–10 yrs NCU 1,764,9166 37,451 47,35712 43,88415 30,76418 60,364 69,084
XCD 37,424 37,451 47,357 43,884 113,517 164,190 142,313
US ($) 13,759 13,769 17,411 16,134 38,073 60,364 52,223
PPP ($) 20,615 20,630 26,087 24,174 43,948 60,364 54,397
% PPP ($) gap over Caribbean average (22,877) 92.1 163.9 140.1
10–20 yrs NCU 2,575,0357 37,451 53,02913 50,72416 49,93419 68,393 80,085
XCD 54,602 37,451 53,029 50,724 184,255 186,029 164,975
US ($) 20,074 13,769 19,469 18,649 61,798 68,393 60,539
PPP ($) 30,078 20,630 29,212 27,942 71,334 68,393 63,059
% PPP ($) gap over Caribbean average (26,966) 164.5 153.6 133.8
1salary in own national currency unit
2Author calculations. Eastern Caribbean Dollars (XCD) using average 2016 market rate [85]
3Author calculations. US dollars using average 2016 market rate [85]
4Author calculations. International dollar purchasing power parity (PPP) [86]
5 [43]
6Mid-point of grade 4
7End of grade 6
8 [43] Scale point 19
9,10 Scale point 12
11 [87]. Starting salary on grade 9
12mid-point of grade 10
13 end point of grade 11
14 [88]. Starting on grade G
15point 5 of grade H
16point 5 of grade I
17Corresponds to Band 4, point 15 [41, 45]
18 Band 6 [41, 45]
19Band 7 to 8c [41, 45]. Directors of nursing can earn an additional 50% more [89]
20Variation is large for the US as reported above [59]
21Canadian nurses start at step 1, mid-career (5–10 years is step 3) with some regional variation especially due to remote region allowances [67]
George et al. BMC Health Services Research          (2019) 19:109 Page 6 of 11
Table 2 Medical doctor salaries of selected countries for three levels of work experience
Jamaica5 Dominica8 St Lucia11 Grenada14 UK17 US20 Canada
0-3 yrs NCU1 2,403,8795 51,6068 58,32211 46,956 28,425 63,984 68,46721
XCD2 50,973 51,606 58,322 46,956 104,888 174,036 141,042
US ($)3 18,740 18,973 21,442 17,263 38,562 63,984 51,854
PPP ($)4 28,079 28,428 32,127 25,866 40,607 63,984 53,911
% PPP ($) gap over Caribbean average (28,626) 41.9 123.5 88.3
5–10 yrs NCU 2,793,0796 57,5049 63,61512 61,28415 40,92518 108,387 115,97622
XCD 59,226 57,504 63,615 61,284 151,013 294,813 238,911
US ($) 21,774 21,141 23,388 22,531 55,520 108,387 87,835
PPP ($) 32,625 31,677 35,043 33,759 58,464 108,387 91,320
% PPP ($) gap over Caribbean average (33,276) 43.1 235.8 174.4
10–20+ yrs NCU 3,255,3487 57,50410 68,34213 61,28416 70,01819 146,847 157,12922
XCD 69,028 57,504 68,342 61,284 258,366 399,424 323,686
US ($) 25,377 21,141 25,126 22,531 94,987 146,847 119,002
PPP ($) 38,025 31,677 37,647 33,757 100,026 146,847 123,724
% PPP ($) gap over Caribbean average (35,276) 183.5 316.3 251.3
1salary in own national currency unit
2Author calculations. Eastern Caribbean Dollars using average 2016 market rate [85]
3Author calculations. US dollars using average 2016 market rate [85]
4Author calculations. International dollar purchasing power parity (PPP) [86]
5 [43] Medical Officer level 2 (MO2)
6 MO3
7 MO4
8,9,10 [44] No available data on salary progression
11 [87]. Grade 13
12 step 3 or 4 of grade 14
13 end point of grade 15
14 [88]. Grade J at entry level
15grade J after 10 years
16grade J after 20 years or more
17 Foundation yr. 1 and 2 respectively. In the UK a medical officer is generally classed as a junior doctor. [90]
18 Doctors continue to work and move onto a specialty [90]
19Additions to basic salaries can be substantial through clinical excellence awards [42]
20 [54]
21The Canadian doctor starter salary is based upon 1–4 years of experience [91]
22Additional years of experience could not be clearly identified so the same increases for the US were used as a reasonable proxy [54] but it is acknowledged that
some regional variation would apply to Canada [92]
43.1% more in the UK, with the US revealing the highest Discussion
income disparity at 235.8% more than their Caribbean This study evaluated HRH salaries of selected health
counterparts. Canadian doctors earn 174.4% more than cadres across selected Caribbean countries and com-
doctors in the Caribbean with similar experience. Medical pared them with the salaries on offer in three popular
doctors with the highest level of experience can potentially destination countries. Analyses of salaries using the PPP
realize the highest PPP adjusted increases. Compared to method affirms the theory that salaries in destination
their Caribbean counterparts, US doctors earn 316.3%, countries are superior and would potentially act as a
Canadian doctors 251.3% and UK doctors 183.5% more ‘pull’ factor for Caribbean based HRH [76]. HRH across
than the PPP adjusted Caribbean salaries at this level. the health cadres in the US, UK and Canada enjoy con-
Salaries of consultants and specialists of selected coun- siderably greater spending power than their HRH coun-
tries from entry level up to 20 years of experience are terparts in the Caribbean, with the extent of the PPP
shown in Table 3. For the specialist/consultant category adjusted salary gap varying between different destination
the salary trends continue. The US continues to offer countries and across HRH cadres. Whilst it is acknowl-
the highest salaries at some 540.4% more than their edged that these HRH salaries are broad estimates based
Caribbean based counterparts. Canada is next highest at on average salaries across three health cadres and are
181.6%, with the UK a more ‘modest’ offering of 95.2% subject to considerable variation, nonetheless the results
more than the specialists counterparts working in the are indicative and remain useful for comparative
Caribbean countries. purposes.
George et al. BMC Health Services Research          (2019) 19:109 Page 7 of 11
Table 3 Consultant/Specialist salaries of selected countries
Consultant/ Specialist Jamaica5 Dominica6 St Lucia7 Grenada8 UK9 US10 Canada11
Entry level to 20 yrs experience NCU1 4,597,824 66,810 74,817 63,420 57,783 270,734 199,627
XCD2 101,946 66,810 74,871 63,420 213,219 736,398 411,232
US ($)3 37,480 24,563 27,506 23,316 78,389 270,734 151,188
PPP ($)4 56,158 36,803 41,214 34,936 82,547 270,734 119,046
% PPP ($) gap over Caribbean average (42,278) 95.2 540.4 181.6
1salary in own national currency unit
2Author calculations. Eastern Caribbean Dollars using average 2016 to date market rate [85]
3Author calculations. US dollars using average 2016 to date market rate [85]
4Author calculations. International dollar (purchasing power parity, PPP) [86]
5 [43] MO6 with no promotion to MO7 after 20 yrs.
6 [44] No available data on salary progression
7 [87] Grade 17 with no promotion to 20 yrs. experience
8 [88] Grade k at entry level to 20 yrs. experience
9 [52] [53]
10 [55] [56] [93]
11 [94, 95]
The findings of this research provide the first estimates include the UK-South Africa Memorandum of Under-
of actual salary differentials between selected Caribbean standing (MOU) and the Pacific Code and the Caribbean
HRH and their counterparts in the US, UK and Canada. Community (CARICOM) agreement. However, a World
Previous research has noted that salary gaps exist be- Bank report on nurse labour markets in the Caribbean
tween source and destination countries [16, 20] without community noted that bilateral initiatives between source
providing actual figures. More recent literature has af- and destination countries have, to date, had limited impact
firmed the notion of out-migrating workers earning due to the different interests and agencies involved [57].
more than their peers who remained in the home coun- Despite the potential limitations of these arrangements,
try, whilst also enjoying better working and living condi- receiving countries and sending countries need to con-
tions [77]. In fact, this same study suggested that highly sider a development policy that places greater emphasis
qualified health personnel from abroad, including med- on temporary movement, incentives to return home and
ical doctors and specialists, could in fact enjoy a small on resolving the institutional failures that are resulting in
wage premium over their indigenous colleagues [77]. health professionals leaving the Caribbean in pursuit of
It is however understood that the decision to migrate is better economic opportunities [13]. Literature emphasises
not solely based upon salary differentials, however large. that whatever policy is introduced, it should be buttressed
We know that a number of factors drive migration whilst by accurate migration data that can be used for appropri-
there remain other considerations as well, including the ate decision-making. Murphy et al. (2016) bemoan the fact
challenge of finding work in another country [20]. All des- that the minimal formal tracking of health worker migra-
tination countries will require formal proof of qualifications tion from Jamaica specifically, results in the scientific ana-
and may require some prescreening in the form of exami- lysis of its consequences of migration difficult [11]. This
nations and testimonies. This process can be prohibitively conclusion can comfortably be applied to other countries
costly in terms of time and out-of-pocket expenses. in the Caribbean region.
The World Bank has advocated for a number of national
Policy recommendations for the Caribbean policies and strategies that seek to limit the consequences
Thomas-Hope (2002) has warned to refrain from attempt- of out migration, including: increasing completion rates of
ing to ‘manage’ migration by limiting peoples’ ability to medical students; increasing nurse training capacity; mobil-
move [7], especially in the Caribbean, where there remains izing inactive HRH; and improving the allocation and effi-
a positive association with outward movement and free- ciency of existing operational HRH. Of concern, the report
dom and opportunity. The WHO Code of Practice on the identified that only 55% of medical students completed
International Recruitment of Health Personnel sets out their studies within the Caribbean region, rendering the
ethical principles applicable to the international recruit- number of drop outs a tremendous loss of potential HRH.
ment of health personnel in a manner that strengthens What is more, existing infrastructure constraints for nurse
the health systems of developing countries, and mentions training can be reduced if additional finances and more
small island states specifically [78]. Adherence to this clinical opportunities are provided [46].
Code, together with bilateral agreements, could potentially Literature has suggested that source countries revisit
ensure the controlled and responsible migration of skills their wage and incentive structure in light of international
between countries. Examples of bilateral agreements disparities [79]. Whilst this study provides valuable salary
George et al. BMC Health Services Research          (2019) 19:109 Page 8 of 11
data which could be used to benchmark HRH salaries, exchange. However, it is recognized that the method it-
policies on working conditions, wage rates and incentives self is limited in that the basket of goods and services
have had limited effect due to global uneven development, used to estimate the PPP is unlikely to be fully represen-
problems of national economic development or intensified tative. This has been acknowledged by the ICP and best
recruitment – with even the rare integrated policies prov- estimates are always provided [27]. The consequences of
ing largely ineffectual [80]. inaccuracy would be to change the PPP ratio but this is
The results of this study should be interpreted against not expected to result in vast differences and the results
its limitations. This study did not review private health would not change significantly.
sector salaries which are potentially higher. It was felt
that the more useful comparison should be made be- Conclusion
tween the public health sectors in the selected countries, This study contributes to a greater understanding of the
especially Canada where HRH requirements vary across extent of the salary disparity between the Caribbean and
provinces and private specialists may incur significant popular destination countries across HRH cadres. The
overhead costs [74]. It should be acknowledged that the financial incentive for Caribbean HRH to seek work
private health sector in the Caribbean is playing a sig- abroad remains strong when considering differences in
nificant role in growing the medical tourism industry the cost of living, even for HRH with little career experi-
within the island states and is thought to be playing a ence. Governments therefore have to consider the earn-
positive role in retaining domestically trained HRH and ing potential abroad when formulating policies and
even attracting health personnel from abroad due to the strategies aimed at retaining health professionals.
improved salaries on offer [81]. Of course the private
sector may also provide an additional employment Abbreviations
choice for domestic HRH thereby further compromising ASN: Associate of Science; BSN: Bachelor of Science (Nursing);
the ability of the public health care system to recruit and CARICOM: Caribbean Community; CMA: Canadian Medical Association;CSME: Caribbean Single Market and Economy; HRH: Human Resources for
retain health personnel. Comparing private and public Health; LMCC: Licentiate of the Medical Council of Canada; LMIC: Lower
sector based remuneration would be a worthy consider- Middle Income Countries; MBBS: Bachelor of Medicine and Bachelor of
ation for future research. Furthermore, this study did Surgery; MCCEE: Medical Council of Canada Evaluating Examinations;MOU: Memorandum of Understanding; NCLEX: National Council Licensure
not factor in the demand and new technologies affecting Examination; NCU: National Currency Unit; NHS: National Health Service;
the HRH cadres analyzed in this study, and recognizes PPP: Purchasing Power Parity; RCPSC: Royal College of Physicians and
that the ability of Caribbean trained HRH to find com- Surgeons of Canada; RMO: Resident Medical Officer; SGU: St. George’sUniversity; TAMCC: T.A. Marryshow Community College; USLME: United
parable employment abroad will depend on these fac- States Medical Licensing Examination; XCD: Eastern Caribbean Dollar
tors. It is recognized that domestically trained medical
students are often drawn into specific specialties due to Acknowledgments
salary and workload benefits, which in the US has in- None.
cluded radiology, ophthalmology, anesthesiology and
Funding
dermatology (ROAD) [82], resulting in fewer available Not applicable. No funding was required for this study.
vacancies for foreign trained specialists to fill. In
addition, employment prospects are affected by techno- Availability of data and materials
logical advances, with the increased use of artificial All data generated or analysed during this study are included in this
published article.
intelligence impacting both the demand and salary of ra-
diologists in the US for example [83]. Authors contributions
Lastly, selecting countries which have considerable GG conceptualized the study, wrote the abstract, interpreted the results and
spatial variation of wages within a particular profession contributed to writing the literature review, discussion and policy
recommendations sections of the manuscript. BR wrote the methods
will always introduce some unreliability into the data. section, conducted all the numerical calculations regarding the purchasing
Accurately determining levels of experience and the con- power ratio – exchange rate comparisons detailed in Tables 1 to 3 and
sequence for wage increases can only be made on a gen- contributed to the interpretation of the results. BR also compiled the
references. CL sourced all the Caribbean data and provided the necessary
eral basis and individual cases, in different countries, and essential background to HRH in the region. As such she wrote large
may depart considerably from general expectations due parts of both the literature review, discussion and policy recommendations
to other factors that affect their earning potential. All of sections of the manuscript. The paper was an entirely collective effort. All the
authors read and approved successive drafts as each of the individual
those effects cannot be captured here. The strength of contributions built the manuscript. Furthermore, each author was tasked
this study is that wage comparisons were made using with addressing the comments from the reviewers which again were
PPP ratios provided by the IMF which were calculated approved by all the authors before the manuscript was resubmitted.
from data provided by the ICP [84]. Accounting for dif-
Ethics approval and consent to participate
ferences in the cost of living provides a more insightful No ethics approval was required for this study and is therefore not
investigation compared to just using market rates of applicable.
George et al. BMC Health Services Research          (2019) 19:109 Page 9 of 11
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