WHO Global Code Of Practice Research Articles

Trends in foreign-educated nurse mobility beyond the COVID-19 pandemic

While the COVID-19 pandemic initially halted the mobility of health professionals, global migration has since returned to pre-pandemic levels and will likely explode in the years beyond the pandemic. Simultaneously, the situation surrounding global health workforce staffing and sustainability is dire; the current global shortage of nurses is estimated at seven million, while the WHO calls for 13 million new nurses by 2030. In response, countries, particularly in high-income regions, seek to fill workforce vacancies with foreign-educated health workers. To both meet the demands of high-income countries’ strained health systems and to ensure ethical and sustainable recruitment practices for equally strained low- to middle-income regions, governments, health systems, and other stakeholders should strive for workforce sustainability via effective and coordinated policy responses, both at the national and international level. If correctly endorsed and implemented, the WHO Global Code of Practice on the International Recruitment of Health Personnel can be an effective tool in helping “destination” countries and regions meet the needs of their strained health workforces while also ensuring sustainability and ethical recruitment from “source” regions that are equally at risk.

Health professional mobility in the WHO European Region and the WHO Global Code of Practice: data from the joint OECD/EUROSTAT/WHO-Europe questionnaire.

WHO Member States adopted the Global Code of Practice on the International Recruitment of Health Personnel 10 years ago. This study assesses adherence with the Code’s principles and its continuing relevance in the WHO Europe region with regards to international recruitment of health workers. Data from the joint OECD/EUROSTAT/WHO-Europe questionnaire from 2010 to 2018 are analyzed to determine trends in intra- and inter-regional mobility of foreign-trained doctors and nurses working in case study destination countries in Europe. In 2018, foreign-trained doctors and nurses comprised over a quarter of the physician workforce and 5% of the nursing workforce in five of eight and four of five case study countries, respectively. Since 2010, the proportion of foreign-trained nurses and doctors has risen faster than domestically trained professionals, with increased mobility driven by rising East-West and South-North intra-European migration, especially within the European Union. The number of nurses trained in developing countries but practising in case study countries declined by 26%. Although the number of doctors increased by 27%, this was driven by arrivals from countries experiencing conflict and volatility, suggesting countries generally are increasingly adhering to the Code’s principles on ethical recruitment. To support ethical recruitment practices and sustainable workforce development in the region, data collection and monitoring on health worker mobility should be improved.

Panel: Care4Care: what is it about the migrant care workforce and how to improve inclusion?

Abstract A round table comprising three panelists will discuss the topic from different perspectives. Gabrielle Jacob, WHO: The WHO Global Code of Practice on the International Recruitment of Health Personnel. How far have we come, where are we now and what’s next?Natasha Azzopardi-Muscat, EUPHA President: The role of public health in raising awareness on the contribution of migrant workers to health systemsScott L Greer, European Observatory on Health Systems and Policies: Governance4Care of the migrant care workforce: what matters?

International migration of health labour: monitoring the two-way flow of physicians in South Africa

IntroductionAlthough health labour migration is a global phenomenon, studies have neglected the flow of health workers into low-income and middle-income countries (LMICs). In compliance with the data-monitoring recommendation of the...

Rosalinda Dimapilis-Baldoz: balancing domestic and international needs for health workers.

Rosalinda Dimapilis-Baldoz talks to Fiona Fleck about the health worker migration policy of the Philippines and discusses the challenges faced by the WHO Global code of practice on the international recruitment of health personnel.

Managing intra-EU mobility\u2014do WHO principles of ethical recruitment have relevance?

BackgroundThe WHO Global Code of Practice on the International Recruitment of Health Personnel provides for guidance in health workforce management and cooperation in the international context. This article aims to examine whether the principles of the voluntary WHO Global Code of Practice can be applied to trigger health policy decisions within the EU zone of free movement of persons.MethodsIn the framework of the Joint Action on European Health Workforce Planning and Forecasting project (Grant Agreement: JA EUHWF 20122201 (see healthworkforce.eu)), focus group discussions were organised with over 30 experts representing ministries, universities and professional and international organisations. Ideas were collected about the applicability of the principles and with the aim to find EU law compatible, relevant solutions using a qualitative approach based on a standardised, semi-structured interview guide and pre-defined statements.ResultsBased on implementation practices summarised, focus group experts concluded that positive effects of adhering to the Code can be identified and useful ideas—compatible with EU law—exist to manage intra-EU mobility. The most relevant areas for intervention include bilateral cooperations, better use of EU financial resources, improved retention and integration policies and better data flow and monitoring.Improving retention is of key importance; however, ethical considerations should also apply within the EU. Compensation of source countries can be a solution to further elaborate on when developing EU financial mechanisms. Intra-EU circular mobility might be feasible and made more transparent if directed by tailor-made, institutional-level bilateral cooperations adjusted to different groups and profiles of health professionals. Integration policies should be improved as discrimination still exists when offering jobs despite the legal environment facilitating the recognition of professional qualifications. A system of feedback on registration/licencing data should be promoted providing for more evidence on intra-EU mobility and support its management.ConclusionsWorkforce planning in EU Member States can be supported, and more equitable distribution of the workforce can be provided by building policy decisions on the principles of the WHO Code. Political commitment has to be strengthened in EU countries to adopt implementation solutions for intra-EU problems. Long-term benefits of respecting global principles of the Code should be better demonstrated in order to incentivise all parties to follow such long-term objectives.

Managing In- and Out-Migration of Health Workforce in Selected Countries in South East Asia Region.

Background: There is an increasing trend of international migration of health professionals from low- and middle- income countries to high-income countries as well as across middle-income countries. The WHO Global Code of Practice on the International Recruitment of Health Personnel was created to better address health workforce development and the ethical conduct of international recruitment. This study assessed policies and practices in 4 countries in South East Asia on managing the in- and out-migration of doctors and nurses to see whether the management has been in line with the WHO Global Code and has fostered health workforce development in the region; and draws lessons from these countries. Methods: Following the second round of monitoring of the Global Code of Practice, a common protocol was developed for an in-depth analysis of (a) destination country policy instruments to ensure expatriate and local professional quality through licensing and equal practice, (b) source country collaboration to ensure the out-migrating professionals are equally treated by destination country systems. Documents on employment practice for local and expatriate health professionals were also reviewed and synthesized by the country authors, followed by a cross-country thematic analysis. Results: Bhutan and the Maldives have limited local health workforce production capacities, while Indonesia and Thailand have sufficient capacities but are at risk of increased out-migration of nurses. All countries have mandatory licensing for local and foreign trained professionals. Legislation and employment rules and procedures are equally applied to domestic and expatriate professionals in all countries. Some countries apply mandatory renewal of professional licenses for local professionals that require continued professional development. Local language proficiency required by destination countries is the main barrier to foreign professionals gaining a license. The size of outmigration is unknown by these 4 countries, except in Indonesia where some formal agreements exist with other governments or private recruiters for which the size of outflows through these mechanisms can be captured. Conclusion: Mandatory professional licensing, employment regulations and procedures are equally applied to domestic and foreign trained professionals, though local language requirements can be a barrier in gaining license. Source country policy to protect their out-migrating professionals by ensuring equal conditions of practice by destination countries is hampered by the fact that most out-migrating professionals leave voluntarily and are outside government to government agreements. This requires more international solidarity and collaboration between source and destination countries, for which the WHO Global Code is an essential and useful platform.

Difficulties experienced by migrant physicians working in German hospitals: a qualitative interview study

BackgroundWith Germany facing a shortage of doctors, hospitals have been increasingly recruiting physicians from abroad. Studies in other countries have shown that migrant physicians experience various difficulties in their work, which might impact the quality of patient care, physician job satisfaction, and, accordingly, retention. The experiences of migrant doctors in Germany have not been systematically studied so far and will likely differ from experiences migrant physicians make in other contexts. A thorough understanding of challenges faced by this group, however, is needed to develop adequate support structures—as required by the WHO Global Code of Practice on the International Recruitment of Health Personnel.MethodsA qualitative study was conducted to give an overview of the multifaceted difficulties migrant physicians might face in German hospitals. Twenty semi-structured interviews with foreign-born and foreign-trained physicians were conducted in German. Participants were recruited via the State Chambers of Physicians and snowballing based on a maximum variation sampling strategy varying purposefully by source country and medical specialty. The interviews were recorded, transcribed verbatim, and analysed using qualitative content analysis.ResultsParticipants described difficulties relating to healthcare institutions, own competencies, and interpersonal interactions. Participants experienced certain legal norms, the regulation of licensure and application for work, and the organization of the hospital environment as inadequate. Most struggled with their lack of setting-specific (language, cultural, clinical, and system) knowledge. Furthermore, behaviour of patients and co-workers was perceived as discriminating or inadequate for other reasons.ConclusionsThis is the first study to describe the broad range of issues migrant physicians experience in Germany. Based on this information, institutional actors should devise support structures to ensure quality of care, physician wellbeing, and retention. For example, training opportunities should be offered where needed to support acquisition of setting-specific knowledge. Discrimination experienced by participants calls for better diversity management as a leadership task in healthcare institutions. Misinformation practices in recruitment could be managed by a voluntary code of ethical conduct. Further research is necessary to identify strategies that adequately address diverging normative positions between migrant health personnel and their patients and colleagues.

Knowledge and potential impact of the WHO Global code of practice on the international recruitment of health personnel: Does it matter for source and destination country stakeholders?

The WHO Global Code of Practice on the International Recruitment of Health Personnel was implemented in May 2010. The present commentary offers some insights into what is known about the Code five years on, as well as its potential impact, drawing from interviews with health care and policy stakeholders from a number of ‘source’ and ‘destination’ countries.

Challenges to implementation of the WHO Global Code of Practice on International Recruitment of Health Personnel: the case of Sudan.

BackgroundThe WHO Global Code of Practice on the International Recruitment of Health Personnel (hereafter the WHO Code) was adopted by the World Health Assembly in 2010 as a voluntary instrument to address challenges of health worker migration worldwide. To ascertain its relevance and effectiveness, the implementation of the WHO Code needs to be assessed based on country experience; hence, this case study on Sudan.MethodsThis qualitative study depended mainly on documentary sources in addition to key informant interviews. Experiences of the authors has informed the analysis.ResultsMigration of Sudanese health workers represents a major health system challenge. Over half of Sudanese physicians practice abroad and new trends are showing involvement of other professions and increased feminization. Traditional destinations include Gulf States, especially Saudi Arabia and Libya, as well as the United Kingdom and the Republic of Ireland. Low salaries, poor work environment, and a lack of adequate professional development are the leading push factors. Massive emigration of skilled health workers has jeopardized coverage and quality of healthcare and health professional education. Poor evidence, lack of a national policy, and active recruitment in addition to labour market problems were barriers for effective migration management in Sudan. Response of destination countries in relation to cooperative arrangements with Sudan as a source country has always been suboptimal, demonstrating less attention to solidarity and ethical dimensions.The WHO Code boosted Sudan’s efforts to address health worker migration and health workforce development in general. Improving migration evidence, fostering a national dialogue, and promoting bilateral agreements in addition to catalysing health worker retention strategies are some of the benefits accrued. There are, however, limitations in publicity of the WHO Code and its incorporation into national laws and regulatory frameworks for ethical recruitment. The outlook is bleak for Sudan unless the country designs and implements a robust national policy for migration management and unless prospects for source–destination country collaboration improve within a more sound version of the WHO Code.ConclusionsThe WHO Code catalysed some vital steps in managing migration and strengthening the national health workforce in Sudan. Nevertheless, the country has not utilized the full potential of this instrument. Revisions of the WHO Code would benefit much from lessons of its application in the context of developing countries such as Sudan.

Implementing the Code of Practice on International Recruitment in Romania - exploring the current state of implementation and what Romania is doing to retain its domestic health workforce.

BackgroundThe Romanian health system is struggling to retain its health workers, who are currently facing strong incentives for migration to Western European health systems. Retention issues, coupled with high levels of migration, complicate Romania’s efforts in providing basic health services for rural, underserved, and marginalized populations, as well as in achieving equitable health access for all. The WHO Global Code of Practice on International Recruitment of Health Personnel (the Code) aims to promote ethical international recruitment and health systems strengthening. We explore Romania’s implementation of the Code’s principles and recommendations.MethodsWe analysed peer-reviewed and grey literature, in English and Romanian, and sought secondary data from the websites of Romania’s largest medical universities. The analysis was guided by the following themes and recommendations in the Code: health personnel development and health systems sustainability, international cooperation, data gathering, information exchange, and implementation and monitoring of the Code.ResultsRomania’s implementation of the Code was observed to be limited. Gaps were identified with regards to several aspects of the Romanian health system, including the lack of support to health personnel training, recruitment, and retention in order to increase the appeal for health providers to practice in Romania and in underserved areas. In terms of international cooperation, the Code recommends various policy instruments to guide recruitment, including bilateral agreements. However, we could not determine which of these instruments were used as a result of the Code and whether or not they were effective. We identified little evidence of initiatives for health workers’ professional and personal support. Insufficient data and few information exchange platforms exist on health workforce issues, hindering active sharing of data on migration with European Union and WHO audiences. We could not identify any evidence of monitoring of the Code’s implementation to date.ConclusionsIn the absence of major system reforms, health workers will continue to migrate to urban areas and abroad. Romanian policymakers should address more of the Code’s recommendations by developing a national policy for human resources for health, a central database to aid health workforce planning and management, stronger platforms for information exchange and civil society engagement, and updated and transparent bilateral agreements.

The surgical workforce shortage and successes in retaining surgical trainees in Ethiopia: a professional survey.

BackgroundMedical workforce shortages represent a major challenge in low- and middle-income countries, including those in Africa. Despite this, there is a dearth of information regarding the location and practice of African surgeons following completion of their training. In response to the call by the WHO Global Code of Practice on the International Recruitment of Health Personnel for a sound evidence base regarding patterns of practice and migration of the health workforce, this study describes the current place of residence, practice and setting of Ethiopian surgical residency graduates since commencement of their surgical training in Ethiopia or in Cuba.MethodsThis study presents data from a survey of all Ethiopian surgical residency training graduates since the programme’s inception in 1985.ResultsA total of 348 Ethiopians had undergone surgical training in Ethiopia or Cuba since 1985; data for 327 (94.0 %) of these surgeons were collected and included in the study. The findings indicated that 75.8 % of graduates continued to practice in Ethiopia, with 80.9 % of these practicing in the public sector. Additionally, recent graduates were more likely to remain in Ethiopia and work within the public sector. The average total number of surgeons per million inhabitants in Ethiopia was approximately three and 48.0 % of Ethiopian surgeons practiced in Addis Ababa.ConclusionsEthiopian surgeons are increasingly likely to remain in Ethiopia and to practice in the public sector. Nevertheless, Ethiopia continues to suffer from a drastic surgical workforce shortage that must be addressed through increased training capacity and strategies to combat emigration and attrition.

Code for ethical international recruitment practices: the CGFNS alliance case study.

Projections indicate a global workforce shortage of approximately 4.3 million across the health professions. The need to ensure an adequate supply of health workers worldwide has created a context for the increased global migration of these professionals. The global trend in the migration of health professionals has given rise to the international recruitment industry to facilitate the passage of health workers from source to destination countries. This is particularly the case in the United States, where the majority of immigrant health professionals have come by way of the recruiting industry. This industry is largely unregulated in the United States as well as in many other countries, for which voluntary codes have been used as a means to increase transparency of the recruitment process, shape professional conduct, and mitigate harm to foreign-educated health workers. The CGFNS Alliance case study presented herein describes a multi-stakeholder effort in the United States to promote ethical recruitment practices. Such codes not only complement the WHO Global Code of Practice but are necessary to maximize the impact of these global standards on local settings. This case study offers both a historical perspective and a conceptual framework for examining the multiplicity of factors affecting the migration of human resources for health. The lessons learned provide critical insights into the factors pertaining to the relevancy and effectiveness of the WHO Code from the perspectives of both source and destination countries. This study provides a conceptual model for examining the usefulness of the WHO Code as well as how best to ensure its viability, sustainability, relevancy, and effectiveness in the global environment. This case study concludes with recommendations for evolving business models that need to be in place to strengthen the effectiveness of the WHO Code in the marketplace and to ensure its impact on the international recruitment industry in advancing ethical practices. These recommendations include using effective screening mechanisms to determine health professionals’ readiness for migration as well as implementing certification processes to raise the practice standards for those directly involved in recruiting skilled workers and managing the migration flow.

The Code of Practice and its enduring relevance in Europe and Eastern and Southern Africa.

BackgroundThe relevance and effectiveness of the WHO Global Code of Practice on the International Recruitment of Personnel will be reviewed by the World Health Assembly in 2015. The origins of the Code of Practice and the global health diplomacy process before and after its adoption are analyzed herein.Methods and ResultsCase studies from the European and eastern and southern African regions describe in detail successes and failures of the policy implementation of the Code. In Europe, the Code is effective and even more relevant than before, but might require some tweaking. In Eastern and Southern Africa, the code is relevant but far from efficient in mitigating the negative effects of health workforce migration.ConclusionsSolutions to strengthen the Code include clarification of some of its definitions and articles, inclusion of a governance structure and asustainable and binding financing system to reimburse countries for health workforce losses due to migration, and featuring of health worker migration on global policy agendas across a range of institutional policy domains.

Diaspora engagement of African migrant health workers – examples from five destination countries

BackgroundMigrant health workers fill care gaps in their destination countries, but they also actively engage in improving living conditions for people of their countries of origin through expatriate professional networks. This paper aims to explore the professional links that migrant health workers from sub-Saharan African countries living in five African and European destinations (Botswana, South Africa, Belgium, Austria, and the United Kingdom) have to their countries of origin.DesignQualitative interviews were conducted with migrant doctors, nurses, and midwives from sub-Saharan Africa (N=66). A qualitative content analysis of the material was performed using the software ATLAS.ti.ResultsAlmost all migrant health workers have professional ties with their countries of origin supporting health, education, and social structures. They work with non-governmental organizations, universities, or hospitals and travel back and forth between their destination country and country of origin. For a few respondents, professional engagement or even maintaining private contacts in their country of origin is difficult due to the political situation at home.ConclusionsThe results show that African migrant health workers are actively engaged in improving living conditions not only for their family members but also for the population in general in their countries of origin. Our respondents are mediators and active networkers in a globalized and transnationally connected world. The research suggests that the governments of these countries of origin could strategically use their migrant health workforce for improving education and population health in sub-Saharan Africa. Destination countries should be reminded of their need to comply with the WHO Global Code of Practice for the international recruitment of health professionals.

Health professional mobility in the European Union: Exploring the equity and efficiency of free movement

The WHO Global Code of Practice on the International Recruitment of Health Personnel is a landmark in the health workforce migration debate. Yet its principles apply only partly within the European Union (EU) where freedom of movement prevails. The purpose of this article is to explore whether free mobility of health professionals contributes to “equitably strengthen health systems” in the EU. The article proposes an analytical tool (matrix), which looks at the effects of health professional mobility in terms of efficiency and equity implications at three levels: for the EU, for destination countries and for source countries. The findings show that destinations as well as sources experience positive and negative effects, and that the effects of mobility are complex because they change, overlap and are hard to pin down. The analysis suggests that there is a risk that free health workforce mobility disproportionally benefits wealthier Member States at the expense of less advantaged EU Member States, and that mobility may feed disparities as flows redistribute resources from poorer to wealthier EU countries. The article argues that the principles put forward by the WHO Code appear to be as relevant within the EU as they are globally.

Monitoring Sub-Saharan African physician migration and recruitment post-adoption of the WHO code of practice: temporal and geographic patterns in the United States.

Data monitoring is a key recommendation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, a global framework adopted in May 2010 to address health workforce retention in resource-limited countries and the ethics of international migration. Using data on African-born and African-educated physicians in the 2013 American Medical Association Physician Masterfile (AMA Masterfile), we monitored Sub-Saharan African (SSA) physician recruitment into the physician workforce of the United States (US) post-adoption of the WHO Code of Practice. From the observed data, we projected to 2015 with linear regression, and we mapped migrant physicians’ locations using GPS Visualizer and ArcGIS. The 2013 AMA Masterfile identified 11,787 active SSA-origin physicians, representing barely 1.3% (11,787/940,456) of the 2013 US physician workforce, but exceeding the total number of physicians reported by WHO in 34 SSA countries (N = 11,519). We estimated that 15.7% (1,849/11,787) entered the US physician workforce after the Code of Practice was adopted. Compared to pre-Code estimates from 2002 (N = 7,830) and 2010 (N = 9,938), the annual admission rate of SSA émigrés into the US physician workforce is increasing. This increase is due in large part to the growing number of SSA-born physicians attending medical schools outside SSA, representing a trend towards younger migrants. Projection estimates suggest that there will be 12,846 SSA migrant physicians in the US physician workforce in 2015, and over 2,900 of them will be post-Code recruits. Most SSA migrant physicians are locating to large urban US areas where physician densities are already the highest. The Code of Practice has not slowed the SSA-to-US physician migration. To stem the physician “brain drain”, it is essential to incentivize professional practice in SSA and diminish the appeal of US migration with bolder interventions targeting primarily early-career (age ≤ 35) SSA physicians.

Monitoring the implementation of the WHO Global Code of Practice on the international recruitment of health personnel: the case of Indonesia

Background Indonesia has become one of the international nurse migration players that has supported the Code that was endorsed by the World Health Assembly, year 2010. In reference to the Code, the Minister of Health (MoH) as designated by the national authority, issued the regulation on the management of Indonesian nurses’ migration. This study aimed to monitor the implementation of the Code on state policy changing in facilitating nurse migration. Go to: Materials and methods Qualitative and quantitative data were collected in order to understand the impact of the Code on Indonesian nurse migration. A triangulation approach was achieved through semi-structured interviews with key stakeholders, and records review of nurses’ migration in the last two years. Go to: Results The Global Code of Practice contributed to shape the migration policy at the national level. This regulation provided a shift change of migration policy, which can be conducted by a country that had an agreement with Indonesia or a country that had a law on migrant protection. Acknowledging the importance of the Code, the MoH translated the Code into Indonesian, and disseminated the material to multiple stakeholders. By the spirit of this Code, Indonesia received financial and technical cooperation and agreement with Japan on the improvement of nursing capacity. The challenge faced by the MoH was a need for strong regulation which could accommodate the relevant players to coordinate on the national level, notably for the MoH, National Board for The Placement and Protection of Indonesia Manpower, Ministry of Foreign Affairs and private recruiters. Quantitative data showed that there was a significant flow of nurse migration, especially on nurses’ movement before and after the code was adopted. Nurse migration was increased four-fold between 2010 (567 nurses) to 2012 (2512 nurses) compared to three years before the Code was adopted. Indonesia’s government should carefully assess the flow of migration as the country has suffered a shortage of nurses. Lack of HRH information system and no integrated national HRH observatory hinder the policy maker to promote a strategic approach in nurse migration. Go to: Conclusions The Code has been utilized by the Ministry of Health to manage migration. This guideline at the least provides direction that may be used where appropriate in the formulation and implementation of nurse migration. A stronger regulation which not only ties the MoH, but also other stakeholders in health migrant placement needs to be established. Further, strengthening HRH information system and research on the impact of migration on Indonesia’s health system must be conducted soon.

The Third Global Forum: framing the health workforce agenda for universal health coverage.

The 2006 World Health Report recognised that adequate human resources for health are needed to accelerate progress and sustain achievements in the context of the MDGs, and called for a decade of action on human resources for health: the launch of the Global Health Workforce Alliance (GHWA), the convening of two global forums on human resources for health (in 2008 and 2011), and the introduction in 2010 by the World Health Assembly of the WHO Global Code of Practice on International Recruitment of Health Personnel are among the key milestones of this period, having bolstered political attention to human resources for health. As leaders worldwide embrace the broader aspiration of universal health coverage “based on an adequate, skilled, well-trained and motivated workforce”, a forward-looking human resources for health agenda to which countries and other stakeholders can commit and that is tailored to achieving this objective needs to be outlined. Universal health coverage, a key component of the post-2015 development agenda,15 needs comprehensive health services that are responsive to people’s needs to address the full range of promotion, prevention, treatment, rehabilitation, and palliation services. Given the centrality of the health workforce in this agenda, human resources for health commitments announced at the Forum will also serve as foundations for future collaboration and mutual accountability to accelerate progress towards the attainment, and sustainability ofuniversal health coverage.

Stemming the Brain Drain — A WHO Global Code of Practice on International Recruitment of Health Personnel

The world faces a shortage of about 4.3 million health professionals required for delivering essential services. The WHO Global Code of Practice on the International Recruitment of Health Personnel addresses the migration of health workers from lower-income countries.