3.1 MS should account for Code in national policy development and international cooperation. Global nature and challenge of health worker migration. Recognition that action required across sectors, both domestically and internationally. Powerful, well documented, demographic, economic, and epidemiological trends continue to drive HRH shortages and mal distribution; requiring policy action from the sub national to the global level. Trends include population growth; ageing populations in high income states; ageing health workforce; urbanization; increasing privatization of medical and nursing education; liberalization of rules related to skilled migration; and constrained fiscal space, as well as poor working conditions in low/middle income states. The overall magnitude of skilled immigration, particularly HRH, was largely protected from the effects of the financial crisis (Siyam and Roberto Dal Poz i ; Buchan et al ii ). Within the EU, austerity measures have led to new patterns of South North flows in addition to more traditional East West pattern. Moreover, reduction in HRH training budgets linked to austerity measures, as in the UK, speak to potential future needs for intl. recruitment (Buchan et al iii ). ; Policy development in regional fora (e.g. EU, ASEAN, MERCOSUR) deserves special prominence. It is anticipated that the US and the EU will face health personnel shortages of a million each by 2020 (Schultz and Rijks iv ). Recent estimates suggest that by 2025 the US alone will face a shortage of between 46,000 and 91,000 physicians (American Association of Medical Colleges v ). 3.3 Developed countries should provide technical and financial assistance to low/middle income countries aimed at HSS, including HRH development (further elaborated through articles 5.1 and 10.3). In recognition of the extent of reliance in many source countries on foreign trained HRH, alongside the cascade effect of HRH moving from low to high income states. In lieu of discussions around compensation. Policy push towards UHC (e.g. Affordable Care Act in US; SDGs in Low/Middle income) further magnifies continued relevance of the recommendation. Afore mentioned drivers relevant. Reliance on foreign health workers remains strong in OECD countries, growing in many (Dumont vi ). Example, physicians from Sub Saharan Africa working in the US increased by 11% between 2011 and 2013; increase at a faster rate than witnessed previously (Akhenaten et al vii ). Increase in 2 years equivalent to approx. 10% of the entire output of medical graduates in SSA (Mullan et al viii ). Bilateral ODA to least developed countries continues to decline 16% decline in real terms in 2014, despite critical reliance amongst LDCs on such aid (OECD ix ). Aid through General Budget Support/Sector Budget Support, key mechanisms to support recurrent expenditures in low/middle income countries, also declining; with aid becoming increasingly unpredictable. Example GBS/SBS 20% of DFID budget in 2008/09, only 10% in 2012/13 (approx. 40% decline in absolute amounts) (IDC, House of Commons, UK x ). ; need to specify role for developed states in supporting HRH retention in low/middle income (strong relationship to aid modality, dialogue around fiscal space, and budget priority accorded health) 3.5 MS should promote and Evidence of unethical recruitment practices The NRI identified that 91% of respondent countries identified that immigrant health workers enjoyed the same legal rights and responsibilities as domestic staff; with ; Consideration of gender deserves Ibadat Dhillon 1
respect fair labour practices for all health personnel; employment and treatment of migrant health personnel should be without unlawful distinction (further elaborated through articles 4.3 4.6) and treatment of rural immigrant health personnel; wage differentials; and limited opportunities for career progression and skill utilization. immigrant health personnel identified as being compensated and promoted in equality with domestic staff (Siyam et al xi ). It should be noted that there is limited information on the treatment of immigrant health personnel, particularly in new destination countries that are themselves low/middle income. Even in countries with strong labour laws, unfair recruitment practices and unequal conditions in employment continue to persist. As example, a recent study in the US found that 40% of foreign educated nurses reported at least one discriminatory practice with regard to wages, benefit, shifts, or unit of practice. Nurses educated in low income countries and those recruited by staffing agencies were more likely to report inequitable treatment (Pittman et al xii ). special attention given the large share and increasing feminization of the health workforce. Moreover, brain waste remains a significant problem that could continue to increase given the needs of ageing populations. As illustration, 44% of foreign born caregivers in Canada are registered nurses in their countries of origin; 40% of foreign trained health workers in the US are working under their professional attainment (Schulz and Rijks xiii ). 3.6 MS should strive to create a sustainable health workforce; work towards establishing health workforce strategies that will reduce their need to recruit migrant health personnel (further elaborated through articles 5.4, 5.5) To emphasize the need for domestic health policy action (e.g. increasing HRH pipeline, age of retirement, orientation towards prevention and primary care) as necessary to reduce overall reliance on foreign health workers. Growing concern related to anti immigrant sentiments globally. Continued importance of afore mentioned long term demographic, economic and epidemiological trends; with added caution from financial crisis where the implementation of austerity measures has reduced attractiveness of health sector employment in a number of countries (e.g. Italy, with significant decline in registration of foreign health workers) (Siyam A. and Roberto Del Poz xiv ). Evidence of increasing production in some source countries (e.g. US, Australia), but little evidence of declining reliance on foreign health workers (Dumont xv ). Austerity measures in UK, cuts in medical and nurse training, points to potentially greater reliance on immigrant health professionals in the future. 3.7 Effective gathering of national and international data, research and sharing of Article 5.4 goes further to suggest that MS work towards achieving HRH self sufficiency. The lack of robust, comparable, health workforce/ health worker migration While there have been improvements, including efforts towards intra regional collaboration (notably European Commission s 2013 Joint Action Plan for Health Workforce Planning and Forecasting, with special focus on migration and mobility), data gaps and challenges continue to exist, especially so in the case of health worker migration Ibadat Dhillon 2
information on international recruitment of health personnel are needed to achieve the objectives of the Code (further elaborated through articles 6.2 6.4, 7.1, and 7.2) 3.8 MS should facilitate circular migration of health personnel to achieve benefit in both source and destination countries (further elaborated in article 5.3); 8.6 additionally encourages MS to assess the scope and impact of circular migration. 5.1 MS should discourage active recruitment of health personnel from developing countries facing critical shortages of health workers; 8.7 encourages MS to observe and assess active recruitment from countries with critical HRH shortages. 5.2 MS should use the Code as a guide when entering into bilateral, regional, and/or multilateral arrangements, to promote collaboration on international recruitment of related data and information, particularly that from source countries most affected, is a major barrier to appropriate policy action at the national and international level. Mechanisms for information sharing and exchange also found to be lacking. Circular migration was viewed as an important mechanism for the sharing of benefits related to international migration. Shaped by UK experience in limiting NHS recruitment from countries with critical HRH shortages. Mechanism to ensure code principles and recommendations are integrated in such arrangements. related data in countries most affected by out migration. Information on the extent and impact of health worker migration comes predominantly from OECD destination nations; not capturing substantial immigration flows between low/middle income countries. The low response rate to the NRI questionnaire, especially outside the WHO EURO region, points to the continuing challenge in relation to information exchange (Siyam et al xvi ). The low number of countries (11) reporting in the NRI that they have a database of laws/regulations related to international recruitment and migration additionally points to the complexity related to ensuring comprehensive information for policy setting (Siyam et al xvii ). Circular migration remains more relevant to the European model of immigration policy than that of settler nations. While there have been important initiative in recent years (e.g EU/ILO Decent Work Across Border project, MIDA GHANA project, EU Moldova Bilateral Agreement with focus on circular migration), challenges have been identified in relation to labour rights, desirability by workers and employers, and processes related to reintegration of health workers (Yates and Pillinger xviii ) While there have been some policy advancements in this area (e.g. UK; EU Blue Card exception), afore identified global trends and policy drivers continue to make this recommendation important. There is limited information on the magnitude of active international recruitment from countries with critical HRH shortage, especially so from other low/middle income countries. There are also definitional challenges around the use of the term. The NRI reporting system identifies bilateral agreements in place between reporting countries; most occurring prior to Code adoption (Siyam et al xix ). An ILO Decent Work Across Borders review of Bilateral Labour Agreements in the Philippines identified numerous shortcomings in existing instruments, including lack of mechanisms to ensure compliance. (Yates and Pillinger xx ) Perception that regional/multi lateral arrangements becoming of greater importance in Medium; best practice models needed. ; need to clarify whether Code is applicable when broadly engaging in health worker migration related arrangements or Ibadat Dhillon 3
WHO Global COP Recommendations & Policy Drivers health personnel. managing HRH migration than agreements at bilateral level (Yates and Pillinger xxi ). narrowly limited to intl. recruitment coordination. 5.6 MS should adopt a multisectoral approach to addressing these issues [relation to developing a sustainable health workforce] in national health and development policies. 5.7 MS should consider adopting measures to address the geographic maldistribution of health workers and to support their retention in underserved areas. 8.1 MS are encouraged to publicize and implement the Code in collaboration with all stakeholders; 8.3 further encourages MS to consult with all stakeholders in decision making processes. Key challenge to addressing the issue and associated problem is its cross sectoral nature: health, education, labour, migration, justice, finance, foreign affairs; with strong private sector partnership. Recognition that international migration of health workers cannot be separated from efforts focused on retaining health workers in remote areas. Recognition that collaboration amongst public entities, and with private actors, is critical to the meaningful Code implementation; reality that many key stakeholder, especially at national/subnational level, were not present during the Code negotiations. Continued relevance. Evidence of a few countries/regions engaging in such effort (e.g. Philippines, Norway, Ireland, El Salvador, EU Roadmap/ EC Join Action Plan) (Siyam and Roberto Dal Poz xxii ). Urbanization, estimates 5 billion urban population estimated by 2030 (UNFPA) alongside the concentration of wealth, and concentration of political voice is a key driver of geographic maldistribution of health workers in many countries. There is urgent need for a better understanding of impending HRH challenges related to urbanization. Notably, nowhere does the Code explicitly point to international cooperation or support from developed countries with the aim of supporting HRH retention in underserved areas in low/middle income countries (calls for such support for HSS generally and for Health Personnel development specifically). Recent experience suggests that increase in health personnel production does not necessarily equate to sustaining and retaining health personnel in low/middle income countries. 17 countries, through the NRI, reported that they had involved all stakeholders in decision making processes (Siyam et al xxiii ). Philippines provides a good, albeit rare, source country model of advancing this recommendation. Many important stakeholders, remain largely unaware of the Code, especially so in low/middle income countries (Dambisya et al xxiv ). Added weight is provided to the recommendation by the fact that public private partnerships are increasingly becoming important in global health and development assistance. 8.2 MS are encouraged to Essential pathway to Some evidence of such effort, with 15 countries reporting through the NRI that they were ; question whether National Designated Authorities, largely embedded in Ministries of Health/Health institutes, can lead such effort. ; role of international cooperation and support should be more prominent here. Ibadat Dhillon 4
incorporate the Code into applicable laws and policies. 8.5 MS should maintain a record of all recruiters authorized to operate within their jurisdiction; 8.6 MS should encourage good practice by only using those agencies that comply with the guiding principles of the Code. 9.1 MS should report periodically on measures taken, difficulties encountered, and lessons learned. 10.1 MS and stakeholders should collaborate to strengthen Code implementation capacity; 10.3 Intl. donors, financial institutions, others encouraged to assist Code implementation of the Code and HSS support in low/mid income countries ensuring that disease specific funds are used to strengthen health system capacity, including health personnel development; 10.4 MS should be encouraged to strengthen health systems capacity, including HRH development in low/middleincome countries. implementation of the Code recommendations. Sought to advance better MS knowledge of and Code associated supervision over recruiters operating in their domain. Essential for monitoring and information exchange Recognition that resources, technical and financial, are critical both to advance implementation of the Code in income and to health system strengthening/health personnel development in low/middle income countries. in the process of considering changes to laws or policies related to the intl. recruitment of health personnel (Siyam et al xxv ). Afore identified demographic, economic, and epidemiological trends continue to drive public and private recruitment/staffing agencies. Only 10 countries, as reported through the NRI, have a record of all recruiters operating within their jurisdiction (Siyam et al xxvi ). There is continued evidence of unethical behavior by recruitment/staffing agency (Pittman et al xxvii ). 56 countries reported via the NRI, with 37 stating that they had taken steps to comply with the Code (Siyam et al xxviii ). The poor reporting response from low middle incomes speaks in part to limited capacity to implement the Code (including basic dissemination/publication efforts) and the need for technical and financial support. Definitional challenge of Health System Strengthening (Chee xxix ), alongside overall decline in bilateral ODA for LDCs. Narrowing of Global Fund HSS window definition in Round 10 proposals have to establish a clear link to improvements in HIV/AIDS, TB and/or Malaria. Again, lack of clearly articulated support for sustaining and retaining health personnel in countries with critical HRH shortages (bringing in discussions around budgetary priority accorded health and fiscal space). Ibadat Dhillon 5
i Siyam, A. and Roberto Dal Poz (eds), Migration of Health Workers: WHO Code of Practice And The Global Economic Crisis, World Health Organization, 2014. ii Buchan, J. et al (eds), Health Professional Mobility in a Changing Europe: New Dynamics, Mobile Individuals, and Diverse Responses, European Observatory on Health Systems, World Health Organization, 2014. iii Id. iv Schultz, C. and Rijks B., Mobility of Health Professionals to, from and within the European Union, IOM Migration Research Series No. 48, IOM, 2014. v IHS Inc, The Complexities of Physician Supply and Demand, Projections from 2013 2025, Report for the American Association of Medical Colleges, March 2015. vi Dumont J.C., Recent Trends in International Migration of Medical Workers (including data from forthcoming OECD International Migration Outlook 2015), as presented at the 1 st Expert Advisory Group, March 2015. vii Akhenaten, B.S., et al, Has the WHO Global Code of Practice on the International Recruitment of Health Personnel been effective?, Lancet, Vol. 2, No. 7, July 2014. viii Mullan, F. et al, Medical Schools in Sub Saharan Africa, The Lancet, Vol. 377, No. 9771 March 2011 ix Development aid stable in 2014, but flows to poorest countries still falling, Press brief, OECD, April 8, 2015. Available at http://www.oecd.org/dac/stats/development aid stable in 2014 but flows to poorest countries still falling.htm. x Department for International Development s Performance in 2012 2013: the Departmental Annual Report 2012 2013, International Development Committee, House of Commons, United Kingdom, 2014. xi Siyam, A. et al, Monitoring the Implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, WHO Bulletin of the World Health Organization; 2013:91:816 823. xii Pittman, P. et al, Original Research: Perceptions of Employment based Discrimination Among Newly Arrived Foreign Educated Nurses, American Journal of Nursing, Vol. 114, Issue 1, January 2014. xiii Supra note iv. xiv Supra note i. xv Supra note vi. xvi Supra note xi. xvii Id. xviii Yeats, N, and Pillinger J. Human Resources for Health Migration: Global policy responses, initiatives, and emerging issues, The Open University, November 2013. xix Supra note xi. xx Supra note xviii. xxi Id. Ibadat Dhillon 6
xxii Supra note i. xxiii Supra note xi. xxiv Dambisya et al, The engagement of East and Southern African countries on the WHO Code of Practice on the International Recruitment of Health Personnel and its implementation, Regional Network for Equity in Health in East and Southern Africa Discussion Paper No.103, June 2014. xxv Supra note xi. xxvi Id. xxvii Supra note xii. xxviii Supra note xi. xxix Chee, G. et al, Why differentiation between health system support and health system strengthening is needed, International Journal of Health Planning and Management, Vol. 28, 2013. Ibadat Dhillon 7