Health Inclusion

By José Ramón Fernández-Peña, Associate Professor, Department of Health Education, San Francisco State University

José Ramón Fernández-Peña
Associate Professor, Department of Health Education, San Francisco State University

Immigrants in the United States often face difficulties gaining comparable employment held in their home countries. Despite substantial experience in their field, advanced degrees and credentialing, and a need for a diverse health field in the United States, many barriers keep educated immigrants under and unemployed. The Welcome Back Initiative (WBI) was established in San Francisco, CA to help address these difficulties. Since its inception in 2001, the Welcome Back Initiative’s model of service has been adopted in 11 centers across 9 states in the United States.

Following with its mission statement to “Build a bridge between the need for more culturally and linguistically diverse health professionals and the untapped resource of immigrants trained in a field of health in another country who are now living in the US”, the WBI aims to assist immigrants re-enter comparable positions held in their country of origin. This is accomplished through educational case managers providing participants with assistance in re-licensing, career options, knowledge of the U.S. health sector and necessary educational resources and support.

To address the growing diversity in culture and linguistics in the United States, the WBI aims to improve the diversity of the health work force to match the cultural and linguistic needs of an increasingly diverse U.S. population. To date, WBI centers has served over 15,000 participants from 167 different countries. The WBI has helped thousands of health professionals re-enter the health workforce. On average, participants in increasing their annual income by 255% from initial contact to the completion of their goals.

In Germany, Hannover’s Ethno-Medizinisches Zentrum has developed the award-winning MiMi programme that recruits, trains and supports individuals from within immigrant communities to become cultural mediators who can help navigate new and different ways of dealing with traditions of health and illness and the body. The goal of the program is to make the German health system more accessible to immigrants, increase their health literacy while simultaneously empowering immigrant communities by prompting their direct participation in the process.

In the UK, organizations like Maslaha are promoting health to Muslim communities with culturally sensitive resources and tools –and achieving health outcomes that have captured the attention of national health authorities.

What works 

There are commonalities among programs that have successfully integrated immigrants into the health field. For example, Volunteering for Health, Heart and Work at the Elizabeth Knox Home and Hospital in Auckland, NZ gives immigrants the opportunity to volunteer in residential health for seniors and persons with disabilities. The program helps volunteers practice in their field of choice, helping them gain experience while improving their English and interview skills for gainful employment.

At Toronto’s St Michael’s Hospital, Career Bridge, is a structured internship program that allows hospitals to assess skilled immigrants for permanent jobs.  In Portugal, the classic case study is that of the Professional Integration of Immigrant Doctors programme(PIID) which helps internationally trained doctors (and nurses) navigate licensure processes while providing structured social support tailored to their needs. Why? To put their professional skills and cultural competencies to work for better services and health outcomes in the increasingly diverse population.  This program saw much success, with over 90% of doctors in the pilot program began a career in medicine in Portugal. Like the WBI, these programs include elements of language skills, cross cultural communication, and literacy in the health field. All three programs build on the potential of their participants and focus on providing them with specific supports that will help match their skills and training to healthcare sector needs.

Health inclusion requires a wide lens

The best healthcare is preventative, and uses a “whole-of-community” approach. In Toronto, that includes hearing and vision clinics at school that ensure immigrant children in families not yet fluent in the official language don’t get overlooked and left behind academically, as well as programmes that mediate culturally sensitive topics like sexual health.  In Auckland, parents and students use a Walking Schoolbus to promote health and safety and foster a community of good neighbours.  Access to sport and recreation, parks and green space are also important components of healthy living.

What doesn’t work

While a growing number of programs are helping integrate immigrant professionals into the health workforce, many barriers remain.  Limited funding is available for the costly licensure and re-training programs that specifically serve this population. Private funds are usually time-limited and public funds tend to have un-realistic goals given the complexity of the re-licensure processes and the myriad variables at play.  Without dedicated  staff and support, these programs end up being dismantled or integrated into other departments resulting in fragmented services and worse outcomes.

Cost of Exclusion

The under and unemployment of highly skilled immigrants is detrimental to the countries in which they reside. In the United States, a recent study conducted by the Migration Policy Institute finds that underemployment of immigrant college graduates results in tens of billions of dollars in forgone earnings and taxes annually, which in turn affects the economy at every level by lowering productivity and consumer demand. MPI estimates this is costing an average of 39.4 billion dollars per year in forgone wages and 10.2 billion dollars in forgone taxes.

Minority populations are severely underrepresented in the health field. In the United States, there are four times as many Hispanics in the general population than there are represented in the health field. According to the Sullivan Commission report, health professions have not kept pace with the diversity of societies. This contributes to more health disparities faced by minorities. For example, minorities are more likely to adhere to treatment when practitioners are of the same ethnicity. Another challenge in the U.S. is the shortage of health providers in lower-income and rural areas. Immigrant health professionals are more willing than their U.S.-trained counterparts to work in these underserved areas, yet they are not being utilized.

Underemployment also results in a lack of civic integration. Immigrants employed in the field in which they were educated are more likely to contribute to their families and their communities.

Immigrants also face many exclusionary, protectionist policies in certain countries. These ill –guided policies make it almost impossible to enter the workforce. While it is imperative to ensure that health professionals are well prepared to do their job, some of these policies seem to be more concerned with protecting the professional associations’ financial interest than the public’s safety.

In sum, to successfully incorporate immigrant health professionals into their new countries, policies are needed to support health professionals in the recognition of their licenses from other countries. For example, the Bologna Process was created to insure a standard of higher education in 48 different European nations making degrees more compatible. It aims to create greater mobility and employability among college-trained workers. The Professionals Access to Healthcare (PATH) Act is a proposed bill in the United States that would ease the transition for internationally trained professionals to work in healthcare under the Health Equity and Accountability Act.


The Author

José Ramón Fernández-Peña, MD, MPA – is an Associate Professor and the Associate Chair of the Department of Health Education at San Francisco State University where his works focuses on health workforce diversity and cross cultural communication in health. He is the founder and director of the Welcome Back Initiative (WBI), a program to assist immigrant health professionals already living in the U.S. through the necessary steps to enter the U.S. health workforce. The WBI currently includes centers in California, Massachusetts, Rhode Island, Washington, Maryland, New York, Colorado, Pennsylvania, and Maryland. In 2010, the program was recognized by the Maytree Foundation as one of the world’s 15 most successful programs for immigrant integration. In 2011, it received the E Pluribus Unum prize from the Migration Policy Institute. The program has served more than 15,000 people from 170 countries and has assisted thousands in joining the US health workforce.
He received the “Champion of Health Professions Diversity” award from The California Wellness Foundation in 2011. Also, in 2011, he was recognized by the White House as a “Champion of Change” for his work on immigrant integration. In 2012, he received the Henry J Montes President’s Award from the American Public Health Association (APHA) Latino Caucus for his work with the Latino community.



In sum, to successfully incorporate immigrant health professionals into their new countries, several factors have been shown to assist in the process:

  • Individualized guidance and support that includes a full exploration of the challenges and opportunities for licensure is essential.
  • Contextualized language acquisition programs are a critical service needed for success.
  • Building a sense of community promotes positive outcomes for immigrants, therefore, efforts to expand social and professional networks among health professionals will help contribute to a better transition.


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