Medical Migration

Navigating Medical Licensing for International Graduates in Aotearoa New Zealand: PhD Research Overview

Johanna Thomas-Maude

Research Context

My PhD research has explored the complex journey of international medical graduates (IMGs) in Aotearoa New Zealand as they navigate the medical licensing process.  More than 40% of New Zealand’s medical doctors were trained overseas, yet pathways to professional registration differ significantly depending on where the doctor received their qualifications.  While long-term specialist registration generally occurs on a case-by-case basis, general registration is usually available to doctors who completed their primary qualifications, or have worked for a minimum time period, in 24 high-income countries (such as the U.K., Australia, or the U.S.A.) known as Comparable Health Systems (CHS).  For IMGs trained in these countries, the registration process is often relatively straightforward.  

However, IMGs who did not train or work in CHS countries face more obstacles, including the costly and time-consuming New Zealand Registration Examination (NZREX).  IMGs on the NZREX pathway are also required to complete two years of supervised work in local hospitals.  However, first year positions, known as Postgraduate Year One (PGY1), are limited and prioritised for New Zealand medical graduates (NZMGs).  As a result, a bottleneck has delayed or prevented many of these IMGs, typically originating from lower- and middle-income countries, from finding PGY1 employment.  While a pathway to registration may exist for NZREX doctors on paper, this pathway is, as one research participant described, “broken” – it is unpredictable and often unattainable in practice.  This PhD research has addressed a knowledge gap by exploring the relationship between IMG experiences, professional outcomes, and their designated pathway to registration. 

Research Design

This research employed an exploratory sequential mixed methods design, consisting of three phases:

  1. Interviews: Semi-structured interviews with 24 IMGs were conducted to understand firsthand experiences and challenges in navigating the registration process.  In addition, 9 local experts were consulted to seek further contextualisation and clarification on the policy landscape that shape IMG experiences.
  2. Online Questionnaire: Themes from the first phase of interviews informed the development of an online questionnaire.  This was completed by 80 IMGs and provided broader insights into their experiences and outcomes, with a particular focus on their licensing pathways.
  3. Document Analysis: 370 historical policies, grey literature, and media reports were analysed to contextualise and compare contemporary experiences with historical practices.

Theoretical Framework

This study applied a capabilities approach to mobility justice, which focuses on the real freedoms and opportunities available to IMGs, and seeks to understand the impact of these “broken pathways” on both doctors and the broader healthcare system in Aotearoa New Zealand. 

  • Mobility Justice: This concept addresses fairness and equality in how people and/or things move within and across borders.  In this context, the approach helps to make sense of how, for example, IMGs from wealthier countries tend to face fewer barriers compared to their counterparts from lower- and middle-income nations.  This imbalance reflects broader global inequalities that favour certain countries while disadvantaging others. 
  • Capabilities Approach: This approach, pioneered by Amartya Sen and Martha Nussbaum, examines what people are truly able to do and be.  It goes beyond formal rights and opportunities to assess whether people have the real freedom to pursue the lives they value.  In the context of IMGs in Aotearoa New Zealand, the capabilities approach is useful in conceptualising the ways in which the medical registration process facilitates opportunities and/or hinders doctors from reaching their full potential.

By integrating these frameworks, this research has explored how the medical registration process in Aotearoa New Zealand produces uneven mobilities and capabilities, leading to injustices.  While pathways to registration exist, they are often “broken” or unpredictable, with many doctors unable to secure the necessary steps to practise medicine.

Research Findings

Overall, the research found that IMGs experience differential processes and outcomes when seeking to practise medicine in Aotearoa New Zealand, depending on their training and work experience, and their designated medical licensing pathway. 

Professional Mobilities and Capabilities

The research explored how IMGs’ professional mobilities and capabilities are shaped by the recognition (or lack thereof) of their qualifications and experience.  A key finding is the uneven translation of IMGs’ professional capabilities into recognised skills within the Aotearoa New Zealand healthcare system.  While not without their own challenges, doctors from CHS countries generally faced fewer barriers than those on the NZREX pathway.  This disparity leads to “brain waste”, where skilled professionals are underutilised or unable to practise medicine due to structural bottlenecks.

The research also highlights how the cost of exams, delays in the registration process, and the impact of COVID-19 further exacerbated inequalities, disproportionately affecting IMGs from lower- and middle-income countries.  The registration process can take years for some IMGs, especially those on the NZREX pathway.  During this time, many doctors are unable to practise medicine, leading to financial strain and personal hardship.  Some IMGs may find themselves taking up jobs unrelated to their medical qualifications simply to make ends meet, while they wait for their registration to be processed.

In addition, preparation for the NZREX exam can be a source of significant stress due to challenges accessing training materials, with no guarantee of success on the first attempt.  Several research participants felt that the best preparation for the NZREX exam was to take it and accept an unsuccessful outcome – they felt there were insufficient resources available to help them prepare for this exam in any other way. 

Identity, (Mis)recognition, and Culture

The research also considered the interpersonal and cultural dimensions of the IMG experience, exploring how personal characteristics such as gender, ethnicity, and nationality influence IMGs’ interactions with medical registration and working in the health system.  (Mis)recognition was a key theme here; IMGs from lower- and middle-income countries reported how they often faced implicit biases, with their professional identities frequently questioned or undervalued compared to their Comparable Health System counterparts.

In addition, the research raised questions around the role of gender in shaping IMGs’ experiences.  Female IMGs often encountered additional challenges, such as balancing family responsibilities and professional demands, which may delay their career progression.  A majority of research participants who had not yet achieved registration as doctors in Aotearoa New Zealand identified as females on the NZREX pathway – many of whom accompanied a spouse who obtained a skilled migrant visa to work in another profession in Aotearoa New Zealand, and were unprepared for the obstacles they would face when striving to convert their medical degrees in their new country.  However, gendered dynamics were seen not only for doctors required to take the NZREX exam, but also those on the Comparable Health System pathway – the recent clinical work experience requirements for this pathway, for example, may inadvertently restrict the ability of some IMGs with young families where a doctor has taken parental leave, or worked for reduced hours, on more than one occasion in the past four years. 

Furthermore, issues of cultural safety were discussed frequently, with some IMGs describing experiences where they felt culturally unsafe in their work environments.  Despite the existing emphasis on culturally safe practices for patients – which is crucial for equitable healthcare services – there is currently little attention in the policy landscape on how IMGs and other health practitioners may encounter and overcome potential biases and discrimination in the workplace.

Transparency, Support Networks, and Workarounds

Many IMGs also struggled with a sense of confusion about the system and a lack of institutional support.  Research participants described how they often struggled to navigate a non-transparent medical licensing system, where the criteria for recognition, progression, and employment are unclear.  Some participants turned to informal support networks to bridge gaps in the system.  Peers and informal mentors were seen to play a critical role in helping IMGs navigate the complex requirements of the registration process, particularly on the NZREX pathway.  These networks often provided emotional support as well as practical advice, serving as a lifeline for IMGs who felt isolated within the system. 

However, there was also a sense of illegitimacy surrounding these networks, particularly in relation to the NZREX exam.  Participants felt conflicted between wishing to access and share the necessary preparation materials with their peers, while expressing concerns about violating Medical Council of New Zealand (MCNZ) policies around discussing the content of the NZREX beyond the exam setting.

Additionally, some IMGs looked for other options to work towards their professional goals, such as seeking alternative roles in healthcare or engaging in advocacy.  However, the fear of potential repercussions prevents many IMGs from publicly challenging the status quo, creating a tension between the desire for reform and the risks associated with speaking out.

Reflection of Global Inequalities

The experiences of IMGs in Aotearoa New Zealand reflect broader global inequalities in the medical profession.  Training in high-income countries is often assumed to be superior in some ways, resulting in a tendency for training in lower- and middle-income countries to be viewed with greater suspicion or scepticism.  Ensuring equity in the registration process is a matter of professional and social justice – and for ensuring IMGs are able to be assessed based on their skills and competencies, rather than the development indicators of the country in which they trained. 

Furthermore, the unequal experiences of IMGs on different licensing pathways are related to policies originating from the late 19th and early 20th centuries, when Aotearoa New Zealand was still under imperial rule as a British colony.  The medical registration system in Aotearoa New Zealand has undergone numerous policy changes over the years, yet many of the challenges faced by IMGs today resemble those from over a century ago.  For example, while policy in 1905 prioritised overseas doctors with training considered “equal in status”, nowadays training or experience must be considered “comparable” – little has changed in terms of the language used to describe doctors from different backgrounds, and current pathways continue to favour doctors who are more likely to be of European and/or North American backgrounds.

The cyclical nature of policy reforms further contributes to the challenges faced by IMGs.  This research found that these policies not only reflect historical inequalities but actively reproduce them, maintaining a system that continues to disadvantage certain groups of doctors.  This (post)colonial cycle needs to be examined, evaluated, and reformed, to pave the way for more equitable medical regulation in Aotearoa New Zealand.

Recommendations for Change

Addressing the issues identified in this research is vital for several reasons.  Medical licensing challenges for IMGs contribute to “brain waste”, whereby some IMGs already residing in Aotearoa New Zealand were unable to work as doctors, even during the global COVID-19 pandemic.  Like many countries, Aotearoa New Zealand faces ongoing shortages in its healthcare workforce, particularly in rural and other underserved areas.  IMGs make up a significant portion of the medical workforce in Aotearoa New Zealand, and streamlining their registration process could thus help address workforce shortages and improve healthcare delivery in these regions.  Current challenges with medical registration for qualified individuals who have met the required standards present a disadvantage not only to these IMGs and their families, but also the under-resourced medical workforce and, consequently, the broader population of Aotearoa New Zealand in need of healthcare.

IMGs and local experts who participated in this research called for more equitable, inclusive, transparent, and supportive processes in medical licensing.  These included:

  • Reform the NZREX Pathway: The NZREX pathway should be re-evaluated to ensure that it provides clear, transparent, and equitable opportunities for all IMGs.  The emphasis was on increasing the availability of PGY1 positions. 
  • Increase Transparency: This includes providing clearer licensing guidelines, reducing ambiguity in decision-making, and ensuring that all IMGs have access to the same information.
  • Recognise a Greater Range of Clinical Experience: IMGs bring a wealth of diverse experiences to Aotearoa New Zealand’s healthcare system.  Many on the NZREX pathway have worked in resource-limited settings, often providing care in challenging environments.  These experiences can be invaluable in enhancing the cultural safety and diversity of the medical workforce, ultimately leading to better patient care and outcomes.
  • Support for IMGs: More comprehensive support structures should be established, including formal mentorship programmes, peer support networks, and professional development opportunities.
  • Cultural Safety Training: Both IMGs and their colleagues would benefit from more extensive training in cultural safety, ensuring that all healthcare professionals can work together effectively in a diverse and inclusive environment, for both patients and the healthcare workforce.

Conclusion

This research provides a comprehensive analysis of the experiences and barriers faced by international medical graduates, particularly those from low- and middle-income countries, in becoming registered to practise medicine in Aotearoa New Zealand.  By applying the capabilities approach to mobility justice, the study also highlights the global inequalities embedded in the medical licensing process and compiles participant recommendations for creating a more just and equitable system.  By better recognising the value and expertise of doctors from all parts of the world, Aotearoa New Zealand could build a more diverse and effective healthcare workforce.

Additional Information

For further information, a more detailed working paper is available that summarises some of the key findings from this research:

  • Thomas-Maude, J. (2024). Understanding the registration experiences of overseas-trained medical doctors in Aotearoa New Zealand: A snapshot. IDS Working Paper Series. Institute of Development Studies, Massey University. http://hdl.handle.net/10179/70259

Other publications associated with this research include:

Further publications are also planned.

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Published by Johanna Thomas-Maude

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