Journal of Aging & Social Policy

ISSN: 0895-9420 (Print) 1545-0821 (Online) Journal homepage: https://www.tandfonline.com/loi/wasp20

Migrant Care Workers or Migrants Working

in Long-Term Care? A Review of Australian
Experience

Anna L. Howe PhD

To cite this article: Anna L. Howe PhD (2009) Migrant Care Workers or Migrants Working in Long-
Term Care? A Review of Australian Experience, Journal of Aging & Social Policy, 21:4, 374-392,
DOI: 10.1080/08959420903167140

To link to this article: https://doi.org/10.1080/08959420903167140

Published online: 30 Sep 2009.

Submit your article to this journal

Article views: 1253

View related articles

Citing articles: 5 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=wasp20
Journal of Aging & Social Policy, 21:374–392, 2009
Copyright © Taylor & Francis Group, LLC
ISSN: 0895-9420 print/1545-0821 online
DOI: 10.1080/08959420903167140

Migrant Care Workers or Migrants Working

1545-0821
0895-9420
WASP
Journal of Aging & Social Policy,
Policy Vol. 21, No. 4, August 2009: pp. 0–0

in Long-Term Care? A Review of Australian

Experience

ANNA L. HOWE, PhD

Migrant
A. L. Howe
Care Workers

Consultant Gerontologist, Melbourne, Australia

Discussion of the role of migrant care workers in long-term care

(LTC) that has gained increasing attention in the United States
and other developed countries in recent years is of particular rele-
vance to Australia, where 24% of the total population is overseas-
born, two-thirds of them coming from countries where English is
not the primary language. Issues of interest arise regarding meeting
LTC workforce demands in general and responding to the particu-
lar cultural and linguistic needs of postwar immigrants who are
now reaching old age in increasing numbers. This review begins
with an account of the overseas-born components of the aged care
workforce and then examines this representation with reference to
the four factors identified as shaping international flows of care
workers in the comparative study carried out for the AARP Public
Policy Institute in 2005: migration policies, LTC financing
arrangements, worker recruitment and training, and credential-
ing. The ways in which these factors play out in Australia mean
that while overseas-born workers are overrepresented in the LTC
workforce, migrant care workers are not identifiable as a margin-
alized group experiencing disadvantage in employment conditions,
nor do they offer a solution to workforce shortages. The Australian
experience is different from those of other countries in many
respects, but it does show that the experience of migrant care work-
ers is not unique to LTC and points to the need to extend the search
for solutions to workforce shortages and improving conditions of
all care workers well beyond LTC systems to wider policy settings.

Received March 26, 2009; revised June 10, 2009; accepted June 26, 2009.
Address correspondence to Anna Howe, PhD, 2/25 Wills Street, Balwyn, VIC, Australia 3103.
E-mail: anna.howe@bigpond.com

374
 Migrant Care Workers 375

KEYWORDS Australia, immigration, long-term care, overseas

workers, workforce

INTRODUCTION

The role of migrant care workers in long-term care (LTC) has emerged as a
topic of increasing discussion in the United States and elsewhere since
Stone and Wiener (2001) raised the question about the extent to which
immigration might offer a pool of workers that could assist in meeting
future workforce demands. The scope of the debate has extended to critical
analysis of the interaction of globalization, population aging, and women’s
migration and has canvassed the positive and negative effects on migrant
care workers and other LTC workers in countries of origin and destination
and for recipients of formal care from migrant workers and informal care of
older family members left behind (Browne & Braun, 2008).
These issues are of particular relevance to Australia where, at the 2006
census, 24% of the total population was born overseas, some two-thirds of
them in countries where English is not the primary language. Early postwar
immigration boosted Australia’s baby boom, which occurred later and lasted
longer than in the United States, and aging of these enlarged cohorts is
projected to bring an increase of 133% in the population aged 65 and older
from 2006 to 2036, when 24% of the population will be in this age group
compared to 14% currently. More significantly for the future of LTC, an
increase of 230% is projected for those aged 85 and older among whom the
need for care is highest, and the aging of postwar migrants adds an extra
dimension of diversity to the future of LTC in Australia.
A number of recent Australian reports have flagged workforce demands
associated with these demographic trends as challenges facing the LTC sector.
In the Review of Pricing Arrangements in Residential Aged Care, Hogan
(2004) identified shortages of nurses as a critical issue, and prompted in part
by this review, the Australian federal government worked with the sector
through 2004/2005 to develop a National Aged Care Workforce Strategy
(Australian Government Department of Health and Ageing, 2005). Workforce
shortages were also raised in an account of trends in aged care compiled by the
Productivity Commission (2008), which links the aged care workforce to an
earlier examination of the wider health workforce (Productivity Commission,
2005). Aged and Community Services Australia (ACSA), the industry body rep-
resenting the not-for-profit sector, has provided a further forum for discussion,
focusing on the nursing workforce but also canvassing wider issues, including
prospects of overseas recruitment (ACSA, 2007, 2008). However, none of these
reports has examined the current role of migrant workers in LTC or the extent
to which immigration might assist in meeting future workforce demands.
376 A. L. Howe

This review aims to address this gap in research in Australia. It builds

on the account of migrant care workers in the LTC workforce in the United
States compiled for the AARP Public Policy Institute by Redfoot and Hauser
(2005). The AARP study included comparative snapshots of Japan, the
Scandinavian countries, the United Kingdom, Italy, and Austria and identi-
fied four sets of factors that shaped participation of migrant care workers in
LTC: migration policies, LTC financing arrangements, worker recruitment and
training, and credentialing. These factors provide a framework for reviewing
the Australian experience and highlighting similarities and differences with
other countries’ experiences that might inform future LTC workforce policies.
Although the term aged care is more commonly used in Australia than
LTC (since LTC also includes disability care), LTC is used synonymously
with aged care in this paper. Residential aged care covers high care pro-
vided in nursing homes and low care provided in homes akin to assisted
living facilities in which personal care and social care are provided, but not
24-hour skilled nursing services. The Home and Community Care (HACC)
Program, the mainstay of community care, provides a wide range of services,
including nursing and some allied health care, as well as personal care,
home help, day care, and other social care. Other community care programs
that deliver packages of care services are based on case management
approaches and are usually delivered by agencies that also deliver residen-
tial care and/or HACC services.

PROFILE OF OVERSEAS-BORN WORKERS

Identifying Overseas-Born Workers
The National Aged Care Workforce Strategy recognized that the lack of
information on the current workforce was a major limitation in formulating
actions to address shortages and skills deficits and therefore recommended
that an extensive survey be carried out. The National Institute of Labour
Studies (NILS) was commissioned to carry out this work, and its report
provides the first comprehensive account of the Australian LTC workforce
(Martin & King, 2008). This study, referred to here as NILS 2008, involved a
census of all providers receiving public funding to provide residential care
and/or community care for the aged and a random sample of workers at
each service outlet. The methodology of NILS 2008 built on a 2003 survey of
the residential care workforce conducted by NILS (Richardson & Martin, 2004),
and it provides a reliable account of the LTC workforce as a whole and of
the residential and community care segments. Public funding of aged care
in Australia is extensive and covers providers in the for-profit, not-for-profit,
and public sectors, and apart from care provided by family caregivers,
services operating outside the funded care system are largely limited to
domestic help and so employ few direct care workers.
 Migrant Care Workers 377

NILS 2008 covered two of the three levels of skills in the LTC workforce
identified in the AARP study, namely nurses and other skilled workers, and
lower skill aides and direct care workers who make up the major part of the
LTC workforce. The third group of unskilled domestic service workers was
not included in NILS 2008. Residential care accounted for 63% of the Austra-
lian LTC workforce of approximately 125,000 full-time equivalent workers,
and personal care workers (PCs) made up 64% of this segment. Community
care workers (CCWs) accounted for 82% of the community care workforce;
the higher proportion of lower-skill workers is because community care work
includes some domestic tasks done by non–care workers in residential care.
Overseas-born workers were identified in NILS 2008 on the basis of
country of birth and whether workers spoke a language other than English
and, if so, whether they used this language in their work. No data were
collected on year of arrival in Australia or where qualifications were
obtained. Since more than 90% of the LTC workforce is female, NILS 2008
included comparisons of the LTC workforce with the total Australian female
workforce. The total LTC workforce was also compared to new hires,
defined as those taking up their current, but not necessarily their first, LTC
job in the last 12 months; new hires accounted for 24% of the LTC work-
force, with little difference between residential and community care or
nurses compared to PCs and CCWs.

Birthplace of Aged Care Workers

A number of differences between the birthplace distribution of the LTC work-
force and the total Australian female workforce are evident in Table 1. Com-
pared to approximately 20% of the total female workforce, a higher proportion
of the LTC workforce was born overseas, ranging from just over 25% of the
community care workforce to about one-third of the residential care workforce
and recent hires in both LTC segments. As the proportion of the total female
workforce and the LTC workforce born in English-speaking countries is similar
at about 12%, it is workers born in non–English-speaking countries who
account for the higher proportion of overseas workers in the LTC workforce.
There is considerable diversity in the representation of workers born in
various non–English-speaking countries or groups of countries. Those born
in Asian countries are the largest group, and they are particularly overrepre-
sented in residential care compared to community care and the total female
workforce. Flows of migrants from these countries to Australia have varied
in volume and timing: a steady flow of migrants from Vietnam has contin-
ued since the peak in the late 1970s, more migrants coming from Hong
Kong and China have arrived since the mid 1990s, and the smaller flow
from the Philippines has been steady for decades.
In contrast, workers born in Italy, Greece, Germany, and the Netherlands
are overrepresented in community care compared to both the residential
378 A. L. Howe

TABLE 1 Country of Birth of Aged Care Workers, Australia, 2007

Community Residential
Workforce(a) care Care
Australian
Recent Recent female
Country of birth Total hires Total hires workforce(a)

Australia 73.3 69.0 67.5 66.4 79.8

All overseas countries 26.7 31.0 32.5 33.6 20.2
English-speaking countries 11.9 12.6 12.7 11.5 11.4
United Kingdom, Ireland, South Africa 8.5 9.2 9.2 7.6 8.3
New Zealand 3.4 3.4 3.5 3.9 3.1
Non–English-speaking countries 14.9 18.1 19.9 22.2 8.8
China, Vietnam, Philippines 2.3 2.8 5.2 5.2 3.4
Italy, Greece, Germany, Netherlands 3.1 3.2 1.9 1.3 1.9
India 0.4 0.5 1.3 1.8 1.4
Poland 1.1 0.8 0.3 0.7 1.2
Fiji 0.3 0.7 1.6 0.9 0.9
Other 7.7 10.1 9.6 12.3 0.0
Total(b) 100.0 100.0 100.0 100.0 100.0

Note. Source: Table compiled from data reported in Martin & King, 2008.
(a)
Data for the Australian workforce cited in the NILS study taken from Australian Bureau of Statistics
Labour Force Australia, Catalogue No. 6291.0.55.001 ST LM6, October 2007. The countries included in
the “other” category reported separately for the NILS survey data are included in the ABS categories as
follows: Countries in Sub-Saharan Africa are included with United Kingdom, Ireland, and South Africa;
Special Administrative Regions and Taiwan Province are excluded from China, Vietnam, Philippines;
Countries in the remainder of Southern and Eastern Europe are included with Italy, Greece, Germany,
Netherlands; Countries in the remainder of Oceania and Antarctica are included with Fiji.
(b)
Figures may not add to 100% due to rounding.

care and total female workforces. Since there has been only limited migra-
tion to Australia from these countries since the early 1970s, these workers
are identified as mostly long-standing migrants, many of who migrated as
children. Poland, Fiji, and India each account for small shares of the LTC
workforces and approximate their shares in the total workforce; these
diverse migration flows have varied from time to time.
“Other” countries account for approximately 10% of the LTC workforce
overall, with the proportion being lower in community care and higher in
residential care and among new hires compared to the total workforce in
each segment. The way in which NILS 2008 defined this group of “other”
countries meant that none accounted for as many workers as the countries
that are specifically identified in Table 1; hence, this diverse group is made
up of small numbers coming from many different countries over many years
rather than substantial or more recent flows from any one or two countries.

Bilingual Workers
Three sets of data on bilingual workers from NILS 2008 are detailed in Table 2.
First, around 25% of the LTC workforce overall spoke a second language
 Migrant Care Workers 379

TABLE 2 Employment of Bilingual Workers in Aged Care Services

Indicator of employment of bilingual workers Residential care Community care

Staff speaking a language other than English 27.7 22.2

Nurses 24.9 11.1
PCs and CCWs 29.4 23.9
Bilingual staff using second language in job 49.1 67.1
Nurses 52.3 83.1
PCs and CCWs 46.7 65.6
Services by share of staff who are bilingual 33.0 49.0
Less than 1/3 42.0 16.0
More than 1/3 25.0 35.0
Note. Source: Compiled from data reported in Martin & King, 2008.

as well as English, higher than the proportion born overseas in non–

English-speaking countries. This difference can be attributed to Australian-
born children of migrant parents who have retained their familial languages.
Second, the proportion of bilingual workers was higher in the residential
care workforce than in community care, but there was little difference
between PCs and nurses in residential care. Bilingual CCWs were more
likely than PCs to use their second language in their jobs, and while a much
smaller proportion of nurses in community care were bilingual, they were
very likely to use their language skills.
Third, bilingual workers were unevenly spread across services. Overall,
residential care services were more likely to employ bilingual staff, but com-
munity care services were more likely to have more than one-third of their
staff bilingual. At the same time, the finding that one-third of residential care
homes and half of all community care services employ no bilingual workers
indicates that these workers do not routinely constitute the base of PCs and
CCWs across the LTC sector.
These NILS 2008 findings are consistent with a study of languages spoken
by workers in the community services sector carried out for the Australian
Council of Social Services (Meagher & Healy, 2005). Analyses of 2001 and
1996 census data found that workers who spoke a language other than
English were marginally underrepresented in caring occupations in the
community services sector as a whole and overrepresented only in nursing
homes. Fully 96% of all bilingual care workers were proficient in English,
and variations in the representation of different language groups accorded
closely with the associated birthplaces reported in NILS 2008.

Migrant Care Workers or Migrants Working in LTC?

The profile of overseas-born workers drawn from NILS 2008 shows a more
significant contribution to the LTC workforce than to the Australian female
workforce as a whole and that there are a number of differences between
380 A. L. Howe

the birthplace composition of the total female workforce and the LTC work-
force, between the community and residential care segments of the LTC
workforce, and between the total segments and newly hired workers. While
those born in non–English-speaking countries are especially overrepre-
sented, their countries of birth indicate that these workers are drawn from
diverse flows of migrants who have come to Australia from different countries
at different times. There is not a clearly identifiable, recent flow of migrant
care workers from particular countries. The reasons for these patterns of
representation of migrants in the LTC workforce can be found in Australia’s
migration policies and factors shaping employment in aged care services.

MIGRATION POLICIES
Changing Migration Flows
Australia’s large and diverse migrant population is the product of sustained
migration over the postwar years, and past emphasis on family settlers means
that many of those now in the workforce came to Australia as children and
have since grown and been educated in Australia. Making up some 15% of
the workforce, migrants born in non–English-speaking countries are more
common in Australia than in the United States and European countries.
Redfoot and Hauser (2005) report that 12.3% of the U.S. population is overseas-
born, including those from Canada and other English-speaking countries.
Excepting the special case of Luxembourg, Austria leads the European Union
countries, with 12.5% born in other countries.
Migration to Australia occurs through a clearly structured and well-
controlled program that involves streams of family, skilled and humanitarian
migration, independent and sponsored migration, and entry on permanent
and temporary visas. Data published by the Department of Immigration and
Citizenship (2008) and the Australian Bureau of Statistics (2007) show that
the number of permanent settlers arriving annually increased by 70% from
1996 to 2006, and of the 205,940 migrants entering Australia on permanent
visas in 2007/2008, the Skills Stream accounted for 52%, and 25% were in
the Family Stream, a reversal of the balance of a decade earlier. While there
have also been shifts in countries of origin, the United Kingdom and Ireland
still make up the largest single source in these two streams.
The Family Stream enables migration of close relatives, many of them
dependents, to join family members who have previously migrated to
Australia; the skill levels of family migrants of workforce age range from little
formal education to professional qualifications. Of those entering through the
Skills Stream, about half are primary applicants and the others are dependents
with generally commensurate skills. Both groups of dependents are able to
work, and they enter the workforce across a range of skills rather than being
unduly channeled into low-skill jobs in the services sector, including LTC.
 Migrant Care Workers 381

The Humanitarian Program has remained relatively constant with an

intake of approximately 15,000 refugees per year over the decade to 2007/
2008. While countries of origin of those entering through this program
change in line with international events, refugees are characterized by a wide
range of skill levels.
Finally, approximately 25,000 New Zealanders come annually under
reciprocal arrangements that allow unrestricted entry, and migration between
Australia and New Zealand includes a substantial number of health profes-
sionals (Zurn & Dumont, 2008). Initial migration to New Zealand then to
Australia also provides a means of entry for individuals born in Fiji and
other Pacific Islands.

Factors Limiting Entry of Low-Skill Care Workers

Three features of Australia’s migration program limit entry of low-skill workers,
including low-skill care workers. First, permanent and temporary migration of
skilled workers is based on a Skilled Occupations List for each visa cate-
gory, and applicants are rated on an associated points system that takes
account of English language proficiency, age, work experience, and other
factors. The Skill Stream does not provide an avenue for either temporary or
permanent entry for low-skill care workers simply because care work,
whether with children, people with disabilities, or older people, is not listed
on any of the Skilled Occupations Lists.
Second, skilled migration in recent years has been targeted to work-
force shortages arising in the strong labor market associated with the
economic boom that Australia experienced through the late 1990s to 2008.
In particular, Temporary Business Visas (457 visas) have been used to fast-
track entry of skilled workers sponsored by employers or recruited by
labor hire companies under Labor Agreements that address particular
workforce shortages. Further, those who come on temporary visas are not
necessarily short-term residents. The boundary between temporary and
permanent residence is permeable because onshore migration enables
many who enter on temporary visas to become permanent residents. Those
entering Australia on temporary student visas, for example, can apply for
onshore migration once they have obtained Australian qualifications. Tem-
porary migrants to Australia are thus not low-skill migrant care workers of
the kind covered in the AARP report.
Migration of nurses recruited from overseas is a case in point. Regis-
tered nurses are now the largest single professional group entering Australia
on 457 visas, with numbers increasing steadily from fewer than 100 a month
in January 2007 to more than 250 a month a year later. However, ACSA
(2008) reports that only a small number of overseas nurses have been
recruited by LTC providers. This outcome contrasts with the United States,
where sustained growth of overseas-born nurses over the decade from 1990
382 A. L. Howe

to 2000 has been much more pronounced in LTC settings than in hospitals
(Redfoot & Hauser, 2008).
Third, Australia is conspicuous among OECD countries in not having a
“guest worker” component in its migration program, which continues to focus
on permanent settlers. Nor is there significant illegal migration; obvious geo-
graphic factors make it difficult to enter Australia other than through an
airport or port, and few enter without a visa and related documentation. The
same geographic factors also limit the kind of frequent, short-term movement
of workers that occurs between Western and Eastern European countries.

LONG-TERM CARE FINANCING ARRANGEMENTS

Cash Payments for Care
The AARP study found that employment of migrant care workers in Austria
was associated with payment of cash benefits that make up a substantial
part of Austria’s LTC system. Significant components of cash benefits in the
LTC systems in Germany, the Netherlands, and Italy have also been linked
to employment of migrant workers, notably from the Eastern European
countries that joined the European Union in 2001. While Israel’s LTC insur-
ance scheme does not pay cash benefits, Iecovich (2007) reports that the
large influx of migrants from the former Soviet Union as well as workers
from the Philippines and China has resulted in foreign workers accounting for
20% of the home care workforce and almost all live-in home care workers.
The Australian government provides two cash benefits as part of its
LTC system, but neither is paid in lieu of services. The Carer Payment is
paid as income support to family members who have had to leave the
workforce because of caregiving responsibilities and, hence, is not effec-
tively available to pay others; it is paid at the same rate as other income
support benefits (A$2250 per month) and is means-tested. The Carer Allow-
ance is paid to family caregivers to assist with extra costs associated with
caregiving. Take-up of the Carer Allowance is high amongst eligible caregivers,
and aggregate expenditure on the Carer Allowance amounts to almost as
much as is spent on the HACC Program. There are no restrictions on how
the Carer Allowance can be spent, but the amount (A$200 per month) is too
small to purchase anything more than a few hours of care if it is used to pay
a worker. Where this does occur, it appears to be by way of “topping up”
hours of service provided by an agency and purchased from the agency
rather than hiring private workers.

The Unregulated Sector

No data are available on employment of domestic workers in private house-
holds, but several factors suggest that this type of employment is limited in
 Migrant Care Workers 383

Australia. Not only is there no historic tradition of domestic service but con-
temporary social mores mean that Australians are generally disinclined to be
either employed as or to employ domestic workers. Employee preferences
are for work in the regulated workforce with standard pay and conditions,
and where higher income families do employ domestic workers, it is largely
for cleaning and related chores and less often for child care or elder care
and rarely on a live-in basis. While some domestic workers are no doubt
employed privately and paid cash-in-hand, increasing legal responsibilities
imposed on those employing domestic workers, such as insurance against
work-related accidents and compulsory pension contributions, have driven
the growth of franchised operations in recent years.
The main limiting factor is that the great majority of frail elders who
need care could not afford to employ care workers privately since they rely
on the Age Pension for their incomes. The need for private employment of
workers is minimized by reasonable access to services provided through the
HACC Program, for which most clients pay only nominal fees. The HACC
Program target population is defined as those needing supervision or assis-
tance in activities of daily living, and it has been estimated that two out of
three in this target population access formal services (Howe, 2008). Although
the level of support received by clients varies widely, coverage is more gen-
erous than in many other countries, and it commonly complements family
care rather than being restricted to those who have no informal caregivers.
Levels of unmet need are conversely low, with fewer than 10% of those in
the target population reporting a need for more formal assistance with self-
care, health care, or meal preparation (AIHW, 2007).
The demand for HACC services in turn translates into jobs in the formal
sector, and as already noted, there is little employment of direct care workers
outside this sector. Further, although the LTC workforce is not highly union-
ized, oversight of employment practices in all services by union officials
ensures that regulated wages and conditions are met.

Meeting Special Needs of Culturally Diverse Clients

Those from culturally and linguistically diverse backgrounds are recognized
as a special needs group in planning and resource allocation in all aged
care programs in Australia, and the quality assurance systems for residential
and community care call for specific attention to be given to responding to
these needs. The acronym CALD, which stands for culturally and linguisti-
cally diverse, is now part of the lexicon of aged care in Australia.
The scale of need for workers with cultural and language skills is indicated
variously by the proportion of the older population born in non–English-
speaking countries, some 21%, and the proportion who are not proficient in
English, a much lower 5% (Howe, 2006). Similarly, while 16% of the permanent
residents of aged care homes were born in non–English-speaking countries,
384 A. L. Howe

only some 7% reported a language other than English as their preferred

language (AIHW, 2008). The scale of future need is indicated by the 139%
increase projected for the population aged 65 and older born in non–
English-speaking countries from 1996 to 2026 and an even greater increase
of 321% in the 80 years and older group (Gibson, Braun, Benham, & Mason,
2001).
The most common response to these needs is for providers to employ
workers with the same backgrounds as their clients, and bilingual workers
are regarded as a positive resource and one that will be increasingly needed
in future. Table 2 shows that substantial proportions of services employ
bilingual workers and that a high proportion of these workers use their
second language in their job, especially in community care. These outcomes
are the result of federal funding of ethno-specific residential care homes and
ethno-specific services through the HACC Program, including a large number
of day centers for many different CALD groups.
Notwithstanding the number and variety of ethno-specific services, the
majority of CALD clients receive services from generic providers, so demand
for bilingual workers is widespread. By way of example, there are no ethni-
cally based home health care agencies in Melbourne. Instead, the Royal
District Nursing Service (RDNS) covers the whole metropolitan area, and
migrants from 147 countries who speak 105 languages make up one-third of
RDNS clients; 11% of the 1,432 RDNS staff members are bilingual, speaking
49 languages other than English among them (RDNS, 2008).
Matching clients and staff of the same background is a complex task
because CALD communities vary in their geographic distribution, migrants
have settled overwhelmingly in capital cities, and there are wide variations
among local areas within metropolitan areas (Howe, 2006). The extent to
which services are able to match workers and clients is evident in two studies
that identified bilingual workers (rather than birthplace).
In Victoria, Local Government Councils are the main providers of
home care and personal care services (other than nursing) through the
HACC Program. An audit of bilingual workers employed in council HACC
services found that 25% of the workforce in the 29 metropolitan councils
spoke a language other than English and that there was a close match
between the languages spoken by these bilingual workers and the older
population in each municipality (Municipal Association of Victoria, 2006).
A second study of the match between the cultural and linguistic back-
ground of staff and residents in aged care homes in the Southern Metropolitan
Region of Melbourne reported similar findings: 86% of homes had at least
one resident who spoke a language other than English, and 56% had staff
who spoke to residents in their own languages (Runci, O’Connor, &
Redman, 2005). These matches come about largely because the LTC work-
force is recruited locally and so reflects the ethnic composition of the local
population.
 Migrant Care Workers 385

WORKER RECRUITMENT
Shortages
The LTC sector has had to compete in a very tight labor market over the
decade to mid-2008 and found it particularly difficult to compete with the
acute care sector, in which nurses’ salaries are higher. NILS 2008 reports that
LTC providers, particularly those in rural and remote regions, experienced
considerable problems in filling vacancies for nurses but had less difficulty
in recruiting PCs and CCWs. While 30% of residential care homes had
vacancies, two-thirds of the most recent vacancies were filled within 2 weeks.
Vacancy levels in community care were lower: fewer than 8% of outlets had
vacancies for nursing or allied health staff, and while 25% had vacancies for
CCWs, half of the most recent vacancies were filled within 2 weeks.
Vacancies and time taken to fill them were seen as more reliable indi-
cators of the state of the labor market than turnover, which involves consid-
erable churning in the sector. Turnover of 25% was reported in NILS 2008 to
be only marginally higher than in the female workforce overall and indicates a
relatively stable workforce compared to turnover estimates of 45% and more
in the LTC workforce in the United States (Stone & Wiener, 2001). NILS
2008 also reported that shortages were moderated by the high proportions
of workers who wanted to work more hours—28% of the residential care
workforce and fully 40% of the community care workforce. Short hours of
work were a factor limiting workers’ incomes as well as pay rates, and total pay
stood out as the only area of marked dissatisfaction. Overall satisfaction among
LTC workers was comparable to that of the female workforce as a whole and
was higher among CCWs and lowest among nurses in residential care.

Trends in New Hires

Comparison of NILS 2008 and the NILS 2003 surveys shows that the propor-
tion of overseas-born workers in the residential care workforce and in new
hires increased over the 5 years.
The overall balance of groups from different countries changed little
between the two surveys as workers from the main English-speaking coun-
tries also increased. Other shifts between birthplace groups, notably
increases in workers born in Asian countries, parallel recent shifts in migra-
tion flows.
While workers born in Pacific Island countries increased fastest, they
still accounted for very small numbers. The small flow of workers from Fiji
fluctuates, driven by social and economic instability, but even over the
longer term, the health care workforce of Fiji and other Pacific Islands is too
small to provide a large flow of nurses or other less-skilled care workers. In
contrast, India has the capacity to generate a sustained flow of workers:
increasing representation of LTC workers (mostly women) born in India is
386 A. L. Howe

likely to be a by-product of the increased migration of skilled workers

(mostly men) from India to Australia over the last decade.
Contrary to the expectation that newly arrived migrants might take jobs
in LTC as a pathway into the wider workforce, NILS 2008 found that only
11% of PCs and 7% of CCWs had no previous paid employment before they
took their first LTC jobs.

Recruitment from Developing Countries

ACSA’s account of the experience of a small number of its members with
recruiting nurses from Asian and African countries states that it was usually
done “out of desperation” when protracted efforts to recruit in Australia had
failed repeatedly. Case studies show that recruitment of overseas nurses
from outside the United Kingdom and New Zealand was focused on
English-speaking recruits from South Africa, Zimbabwe, and the Philippines.
Activity was on a very small scale, with numbers recruited to work in LTC in
the twos and threes, rather than tens, and certainly not hundreds, and
recruitment agencies were used as often as providers themselves attempting
to recruit (ACSA, 2008; Curtis, 2007). ACSA also identified a number of
barriers and disadvantages for workers as well as providers that indicate
that recruitment from developing countries is not likely to become a ready
source of LTC workers.

TRAINING AND CREDENTIALING

Recognition of Overseas Qualifications
By definition, all registered and enrolled nurses and allied health workers
have post–high school qualifications, and overseas-trained workers in these
fields must have their qualifications formally recognized in line with guide-
lines set by the National Office for Overseas Skills Recognition (Department
of Education, Employment, and Workplace Relations, 2008). Although formal
qualifications are not required to work as a PC or CCW, high proportions of
these workers obtain relevant qualifications through the Technical and
Further Education (TAFE) system. NILS 2008 found that the majority of PCs
and CCWs had relevant TAFE certificate–level qualifications and that only
24% had no post–high school qualification. Many providers promote take-
up of these courses because the quality assurance systems covering residen-
tial and community care require providers to employ a workforce that is
appropriately trained and has the skills to deliver the types of care that
clients need.
There is little evidence to suggest that overseas-trained workers are work-
ing at levels below their qualifications. Further analysis of data on occupations
of residential care workers by birthplace from the 2003 NILS survey showed
 Migrant Care Workers 387

only minor differences between the balance of nurses and PCs among those
born in Australia, in English-speaking countries, and in non–English-speaking
countries (Fine & Mitchell, 2007), but two particular findings warrant note.
First, the proportion of nurses compared to PCs was higher among workers
born in India, Sri Lanka, China, and Southeast Asian countries than among
Australian-born workers, suggesting that the increase in workers from these
countries and their conspicuous representation in residential care in NILS
2008 reflect sustained migration of skilled workers. Second, while only 4%
of the total workforce was employed as “diversional” therapists who deliv-
ered activity programs, the proportions were markedly higher among all
European-born workers, suggesting that some whose nursing or other qual-
ifications were not recognized are employed in these positions because
their language skills and cultural backgrounds are relevant to clients from
the same backgrounds.
NILS 2008 reports a decline since 2003 (from close to 17% to just over
10%) in the proportion of PCs with nursing qualifications and who appear
to be overqualified for their jobs. While this decline was attributed to the
tightening of the labor market over the period that saw workers move to
other jobs, it may also be due, in part, to overseas-trained nurses (whose
qualifications were not recognized) completing training to gain registration
and taking up nursing positions in LTC or other fields.

Training-Related Recruitment Opportunities

While the extent to which providers are turning to recent migrants to recruit
workers appears marginal and incidental rather than large-scale, two oppor-
tunities for recruitment of workers who may be attracted to features of
employment in LTC, including training opportunities, warrant note.
First, the conditions attached to international student visas limit employ-
ment to 20 hours a week, a limitation that suits LTC providers seeking work-
ers prepared to work short and flexible hours. International students of
nursing and other health sciences have a relevant knowledge base and skills
as well as competency in English and are thus not very different from their
local counterparts. Local experience also assists international students
applying for onshore migration should they want to become permanent
Australian residents when they complete their training. Combined with sus-
tained numbers of student nurses from Asian countries, onshore migration
of this kind is likely to have contributed to the increase of almost 20% in the
share of residential care workers born in Asian countries between NILS 2003
and 2008.
Second, over the last decade and currently, labor market programs
have provided a number of initiatives for new and existing workers to
obtain and upgrade vocational qualifications to address workforce shortages,
including shortages in LTC (Department of Education, Employment, and
388 A. L. Howe

Workplace Relations, 2008). TAFE places for PCs and CCWs have expanded
steadily, while bridging courses have enabled overseas nurses to qualify to
work in LTC but not in acute care; other schemes have involved 1 year of
supervised work to obtain full registered nurse registration, and this year is
often spent in LTC. These training initiatives have enhanced the skills of
local and overseas-born workers alike.

CONCLUSIONS

The main conclusion drawn from this review of Australia’s experience with
overseas-born workers in LTC is that the kinds of low-skill migrant care
workers who account for a substantial but marginalized component of the
LTC workforce in other developed countries are not a readily identifiable
element of the LTC workforce in Australia. Rather, while overseas-born
workers, and especially those born in non–English-speaking countries, are
overrepresented in the LTC workforce compared to the total Australian
female workforce, they are mostly long-standing migrants who have grown
up and been educated in Australia, with smaller groups of more recently
arrived migrants who have come from many different countries. There is no
one country or group of countries that generates a major flow of LTC work-
ers parallel to the flow from the Philippines to the United States.
This review has shown that migrant workers in the LTC workforce have
been drawn from across the large migrant population that has built up in
Australia over many years, including from secondary flows associated with
migration of family members and skilled workers. International students are
a further source of LTC workers, and many will become permanent resi-
dents who will join the skilled workforce as their careers advance, but LTC
is not a common pathway to employment for recently arrived refugees.
This broad conclusion is supported by a range of findings that shows
that the forces shaping the representation of overseas-born workers in other
countries play out differently in Australia. Two main factors associated with
the presence of low-skill migrant care workers in other countries are absent
in Australia. First, skills-based immigration policies largely preclude the
entry of low-skill care workers; with no inflow of migrant care workers as
such, the LTC workforce has to be drawn from the local population that
includes a large number of long-standing migrants and a smaller number of
more recent migrants. Even though migration of nurses has grown in
conjunction with the increase in employer-based sponsorship of migrants
entering Australia on temporary visas, LTC providers have not engaged in
recruitment of overseas nurses to any degree. The level of illegal migration
to Australia is also insignificant and so is not a source of LTC workers.
Second, cash benefits that have fostered employment of migrant care work-
ers in some OECD countries are not part of the Australian LTC system, and
 Migrant Care Workers 389

there is very little employment of care workers outside the formally regu-
lated aged care system.
Against these limiting factors, several other factors have promoted the
employment of long-standing migrants in the LTC workforce. Principal
among these has been recognition of the special needs of the diverse
groups that make up Australia’s older population now and increasingly in
the future, and funding of services to respond to these needs has led to the
recruitment of bilingual workers by both ethno-specific and generic providers
who serve diverse populations. Training and credentialing of LTC workers
is a second force driving convergence of different groups in the workforce.
Further, the expansion of training places, in an effort to meet LTC work-
force demands, has drawn in Australian-born workers and long-standing
migrants alongside more recent arrivals.
These conclusions are consistent with an OECD study of workforce
integration of migrants in Australia (Liebig, 2007). Positive outcomes by way
of high rates of employment at appropriate skills levels were attributed to a
mix of pre-arrival factors, principally the selection of migrants, and post-
arrival settlement supports, notably access to English language lessons.
Looking at broader indicators of integration, Liebig found little evidence of
discrimination in hiring and noted that access to citizenship is easy and
encouraged. Initial disadvantages had largely disappeared within 2 years,
and outcomes for the second generation were especially favorable compared
to other OECD countries. The position of migrants working in LTC is not
very different from that of migrants in the wider Australian workforce, and
in turn, not very different from their Australian-born counterparts.
The parameters of Australia’s migration program and its aged care
programs mean that many features of the experience of migrants working in
LTC are different from those reported in other countries. When this experi-
ence is set in the context of migrants in the wider Australian workforce, the
lesson that emerges, by exception, is that the phenomenon of low-skill
migrant workers must be seen as the product of social and economic policies
rather than being unique to LTC. To the extent that the experiences of
migrant and other care workers has much in common with workers in other
low-skill and low-paid service sectors, the search for solutions to workforce
shortages and improving conditions of work in LTC has to extend well
beyond LTC systems.
Migrant care workers are neither a marginalized group in the Australian
LTC workforce nor a solution to workforce shortages. Just 2 years ago,
ACSA proposed lobbying the federal government on a number of measures
to facilitate overseas recruitment of LTC workers, including relaxation of
skills requirements to facilitate entry of personal care workers. But ACSA
stressed that overseas workers should not be seen as a long-term solution to
workforce dilemmas and that priority attention must be given to attracting
more local workers into the sector.
390 A. L. Howe

Dramatic changes in Australia’s economic conditions with the onset of

the global financial crisis since mid-2008 have seen a rapid easing in the
labor market. One response was the announcement in early 2009 of reduc-
tions in immigration levels below the record levels of recent years. There
will be few exits from Australia since the majority of migrants are already
permanent residents, and onshore immigration will enable many temporary
visa holders to become permanent residents. However, the impact of the
global economic downturn is likely to be especially harsh on migrant care
workers in other countries, and many may find that, in line with the title of
the AARP report, they shall travel on once more.

REFERENCES

Aged and Community Services Australia (ACSA). (2007). Working together: Aged
and community care workforce background paper. Melbourne: ACSA.
Retrieved September 2, 2009 from http://www.agedcare.org/POLICIES-&-
POSITION/Position-and-Discussion-papers/Overseas-Workers-for-the-Aged-
Core-Sector.pdf
Aged and Community Services Australia (ACSA). (2008). Overseas workers for the
aged care sector: Scoping paper. Melbourne: ACSA. Retrieved September 2,
2009 from http://www.agedcare.org./POLICIES-&-POSITION/Position-and
Discussion-papers/Overseas-Workers-for-the-Aged-Care-Sector.pdf
Australian Bureau of Statistics. (2007). Australian social trends, 2007: Migration:
Permanent additions to Australia’s population. ABS Catalogue no. 4102.0.
Retrieved October 10, 2007, from http:/www.abs.gov.au/AUSSTATS
Australian Government Department of Health and Ageing. (2005). National aged
care workforce strategy. Canberra: Department of Health and Ageing. Retrieved
September 2, 2009 from www.health.gov.au/internet/main/publishing.nsf/
Content/ageing-wf-nacws.htm
Australian Institute of Health and Welfare (AIHW). (2007). Australia’s welfare 2007.
AIHW cat. no. AUS 93. Canberra: AIHW.
Australian Institute of Health and Welfare (AIHW). (2008). Residential aged care in
Australia 2006-07: A statistical overview. AIHW cat. no. AGE 56. Canberra: AIHW.
Browne, C. V., & Braun, K. L. (2008). Globalization, women’s migration, and the
long-term-care workforce. The Gerontologist, 48(1), 16–24.
Curtis, K. (2007). Passport careers: Global RN recruitment in the spotlight. National
Healthcare Journal, September–October, 28–30.
Department of Education, Employment, and Workplace Relations. (2008). The
National Office for Overseas Skills Recognition is part of Education Australia
International. Retrieved September 2, 2009 from www.aei.gov.au (employ-
ment initiatives related to the aged care workforce are detailed on
www.deewr.gov.au).
Department of Immigration and Citizenship. (2008). Immigration update 2007–08.
Canberra: DIAC. Retrieved September 2, 2009 from www.immi.gov.au/media/
publications/statistics/immigration-update/update-june08.pdf
 Migrant Care Workers 391

Fine, M., & Mitchell, A. (2007). Immigration and the aged care workforce in Australia:
Meeting the deficit. Australasian Journal on Ageing, 26(4), 157–61. (Note: The
authors have advised of a correction to Table 3 in this paper: 52.5% of the
Australian-born workforce were personal care attendants and of those born in
Asian countries (Vietnam, etc.), 39.3% were registered nurse Division 1, 10%
registered nurse Division 2, 44.8% personal care attendants, 2.5% diversional
therapists, 1% physio and speech therapists, and 2.5% other.)
Gibson, D., Braun, P., Benham, C., & Mason, F. (2001). Projections of older migrants:
People from culturally and linguistically diverse backgrounds, 1996–2036,
Australia. AIHW Cat. No. AGE 18. Canberra: Australian Institute of Health and
Welfare.
Hogan, W. (2004). Review of pricing arrangements in residential aged care
(pp. 219–233). Canberra: Department of Health and Ageing.
Howe, A. L. (2006). Cultural diversity, ageing and HACC: Trends in Victoria in the
next 15 years. Melbourne: Victorian Department of Human Services.
Howe, A. L. (2008). Is bigger better when it comes to defining target populations
for aged care programs? Australasian Journal on Ageing, 27(1), 14–19.
Iecovich, E. (2007). Client satisfaction with live-in and live-out home care workers
in Israel. Journal of Aging and Social Policy, 19(4), 105–122.
Martin, B., & King, D. (2008). Who cares for older Australians? A picture of the resi-
dential and community-based care workforce, 2007. Adelaide, Australia:
National Institute of Labour Studies, Flinders University. Retrieved September 2,
2009 from http://nils.flinders.edu.au/publications
Meagher, G., & Healy, K. (2005). Who cares: Volume 1: A profile of care workers in
Australia’s community services industries. Sydney: Australian Council of Social
Services Paper 140.
Municipal Association of Victoria. (2006). MAV HACC workforce bilingual audit.
Melbourne: Municipal Association of Victoria. Retrieved September 2, 2009
from http://mav.asn.au
Liebig, T. (2007). The labour market integration of immigrants in Australia.
OECD Social, Employment, and Migration Working Papers. No. 49. Paris:
OECD.
Productivity Commission. (2005). Australia’s health workforce. Productivity Com-
mission Research Paper. Canberra: Productivity Commission. Retrieved
September 2, 2009 from www.pc.gov.au/publications
Productivity Commission. (2008). Trends in aged care services: Some implications.
Commission Research Paper. Canberra: Productivity Commission. Retrieved
September 2, 2009 from www.pc.gov.au/publications
Redfoot, D. L., & Hauser, A. N. (2005). “We shall travel on”: Quality of care, eco-
nomic development and the international migration of long-term care workers.
Washington, DC: American Association of Retired Persons Public Policy Insti-
tute Report # 2005-14.
Redfoot, D. L., & Hauser, A. N. (2008). The international migration of nurses in
long-term care. Journal of Aging and Social Policy, 20(2), 259–275.
Richardson, S., & Martin, B. (2004). The care of older Australians: A picture of the
residential aged care workforce. Adelaide, Australia: National Institute of
Labour Studies, Flinders University.
392 A. L. Howe

Royal District Nursing Service (RDNS). (2008). Celebrating diversity: Annual report
2008. Melbourne: RDNS. Figures on clients from annual report, figures on staff
provided by RDNS.
Runci, S., O’Connor, D., & Redman, J. (2005). Language needs and service provision for
older persons from culturally and linguistically diverse backgrounds in south-east
Melbourne residential care facilities. Australasian Journal on Ageing, 24, 157–162.
Stone, R. I., & Wiener, J. M. (2001). Who will care for us: Addressing the long-term
care workforce crisis. Washington, DC: The Urban Institute and the American
Association of Homes and Services for the Ageing.
Zurn, P., & Dumont, J-C. (2008). Health workforce and international migration:
Can New Zealand compete? OECD Health Working Papers. No 33. Paris: OECD