EU Leadership in Global Health Workforce Recruitment

27 May 2010

The "Global Code of Practice on the International Recruitment of Health Personnel" agreed at the 2010 World Health Assembly is intended to serve as a frame of reference for drawing up bilateral and multilateral legal instruments and institutional measures between countries from which health workers are attracted and those to which they migrate. This accords closely with current EU policy expressed in the "Strategy for Action on the Crisis in Human Resources for Health in Developing Countries", which was reaffirmed in the recent paper on the EU Role in Global Health. In this article we examine the opportunities for the EU to provide leadership in this field by developing a legal basis for health worker migration into and within the EU and mechanisms to support health workforce planning both within EU Member States and partner countries in the developing world.

Health knowledge and skills are vital resources for health systems in both rich and poor countries. As demand for health services and hence health workers increases globally, richer countries have attracted staff from poorer countries leaving many unable to achieve their health-related millennium development goals. Thus, for example, Africa, which is known to bear 24% of the global burden of disease, has only 3% of the world's health workforce. It is estimated that some 30,000 health professionals have migrated away from the continent over the past 25 years. These issues were highlighted in the World Health Report of 2006 - "Working together for Health". The G8 countries at their summit of 2009 encouraged WHO to develop a code of practice for the international recruitment of health personnel. This appeal was reiterated by the ministerial declaration of the 2009 High-Level Segment of the United Nations Economic and Social Council. Since then, WHO has been in a process of developing a global code of practice, which has now finally been adopted by the World Health Assembly of 2010.

The objectives of the code of practice are (1) to establish and promote ethical recruitment of health personnel, balancing the rights of the countries from which migrant health workers originate (source countries), the countries to which health workers migrate (destination countries) and health workers; (2) to serve as an instrument for establishing and improving legal and institutional frameworks for international recruitment of health personnel; (3) to provide guidance for the formulation of bilateral agreements concerning human resources for health; (4) to promote international discussions concerning ethical recruitment of health personnel, with particular focus on the situation in developing countries.

These are undoubtedly important objectives, but the question is whether the current agreement is forceful enough to overcome the obstacles to change in this key requirement to reach the health-related millennium development goals. We must also ask, what steps could the EU take to strengthen and apply the code of practice, as a regional economic and political union of countries which not only attracts many migrant health workers but also experiences internal migration across its national borders.

The code is global in scope and voluntary in nature, establishing ethical principles for the recruitment of health personnel to be applied through bilateral agreements. The rights of individual health workers to migrate are respected by the code of practice, but destination and source countries are asked to address the factors that drive this migration. Destination countries are encouraged to ensure adequate planning of health workforce education and development to meet their own needs and to provide technical and financial assistance to source countries to mitigate the effects of migration of health personnel. This will increase costs and reduce flexibility at a time of financial stress, so it remains to be seen whether destination countries will comply. Source countries will need to establish workforce plans that address working conditions and lack of employment opportunities that push health workers to migrate, but again this may be considered unaffordable so it is also doubtful that they will find it easy to comply.

All WHO member countries are encouraged to improve health workforce planning, including adequate education and in-service training, to achieve a sustainable workforce. However, this does not mean simply projecting the long term need for conventionally trained doctors and nurses. In many resource poor countries it is clear that for the foreseeable future it will simply not be possible to provide primary health care services led by conventionally qualified doctors. In East Africa, for example, current trends in training and retention, suggest that it will be at least 40 years before sufficient qualified doctors could be produced to staff rural health services in this way. A more realistic workforce plan in this region might be based on the existing pattern of nurse led primary care services with medical assistants trained to dispense the available range of basic drugs and perform emergency procedures such as caesarean sections. Further medical knowledge and skills may be available from mobile phone or internet based systems but this is likely to drive a demand for further health workers able to use this technology. Every country will need to plan its pattern of services and the workforce skills it needs to meet its particular needs and capabilities.

Thus workforce planning has to start with a more basic review of each health system and its unique potential and needs. The code recognizes this need and calls for WHO support for national research programmes, information exchange and databases to strengthen the evidence base for policy decisions on human resources for health. However, it is unclear whether the professional competence to pursue the analytical work necessary for these tasks is available in resource poor Ministries of Health. New training programmes may have to be established. Technical and financial assistance from destination countries might be better focussed on supporting partner country capability to plan and develop their workforce in this way rather than simply paying to train further staff for an international market.

It is proposed that conditions for the recruitment of health personnel should be set out in agreements between source and destination countries, establishing the mutual advantages of migration. The sustainability and retention of the health personnel should be reinforced, through improved training, provision of adequate social and economic conditions and evidence-based workforce planning. It is difficult to argue against these statements which are all very reasonable. However, some developing countries will find that the costs of pay and career structures to retain staff are unaffordable, so it is also emphasized that some source countries may need financial assistance from destination countries to address the funding of health services and in the short term the pay and conditions of staff in source countries.

The code suggests that migrant health personnel should be reminded of the responsibilities to their home countries and should also be provided with better information about employment conditions in destination countries. While it is clear that migrating health professionals can be naive in their expectations it is also important to recognise that employment and working conditions for health staff in resource poor countries are major factors driving migration. In many countries staff feel they have to rely on private payments from patients to achieve even a basic standard of living. For nurses and allied health professionals there are often limited opportunity for career progression.

The code also promotes the idea of circular migration, encouraging staff to return to their home country, in the hope that this might lead to mutual benefit for source and destination countries. In practice, however, experience of training schemes and exchanges, in which return is voluntary, suggests that this has not worked well in the past. Even schemes in which return is said to be automatic at the end of training, for example, have proved problematic. A more realistic approach may be to combine a fixed term of migration for health professionals with the creation of training posts in source countries and with conditions of employment sufficient to attract returning staff to pass on the skills they have obtained.

A code of practice for the international recruitment of health personnel is long overdue. Many countries already suffer from a critical shortage of health personnel, often due in part to irresponsible and rash recruitment campaigns from richer countries. The value of health personnel recruited to rich countries calculated from the costs of training are considerable and may be higher than development aid to some of the poor countries. While it is also true that health migrants remit considerable sums to families in source countries this transfers money outside the health sector and thus while their may be some economic benefit to countries as a whole the health sector suffers.

Both donor and destination countries are found in Europe. England, Ireland, Norway and Sweden are among the top destination countries. Romania and Moldavia are major source countries. In addition, some countries are transitional, i.e. they are losing health personnel to richer countries and replacing the loss by recruitment from poorer countries. It may be difficult for such countries to recognize their role in relation to the code of practice. These transitional countries primarily are found among the poorer countries of EU 27. It may be necessary for joint EU action to support these countries, to avoid fruitless discussions about the definition of whether a country is a source or a destination country.

The EU has shared competence for the recognition of health professional qualifications, migration to and within the EU, for supporting global health and aid initiatives and for international agreements in this sphere. It is therefore appropriate for the EU to lead European joint action to address this issue. The EU should seize the opportunity to work with countries such as the Netherlands, the UK, Sweden and others that already operate partnership agreements with resource poor countries in related fields. Building on this experience it is timely to establish a more binding commitment from EU Member States to a common approach to health workforce management and migration.

The EU action programme should address (1) the training and development of health personnel within the EU to meet its own demands, (2) agreement with neighbouring countries on health workforce migration and (3) agreements with other partner countries from which health workers are drawn. While this may seem a simple agenda there are a multitude of research, knowledge sharing, aid and development issues that spring from it. It will also be essential to develop research and educational networks engaging EU countries and partner countries, links with international health professional organisations and relationship with Ministries of Health in partner countries. The agreements and protocols will need to be introduced through sensitive, well informed global health diplomacy.

The code of practice is found at





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