WHO report on global health worker mobility

Overview 1 WHO report on global health worker mobility

WHO report on global health worker mobility WHO report on global health worker mobility ISBN 978-92-4-006664-9 (electronic version) ISBN 978-92-4-006665-6 (print version) © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Graphic design and layout: Trans.Lieu Ltd iii Contents Foreword ................................................................................................................................................. iv Acknowledgements ................................................................................................................................. v Abbreviations ...................................................................................................................................... vi Executive summary ................................................................................................................................. vii 1. Overview ................................................................................................................. 1 1.1 Introduction ............................................................................................................................... 1 1.2 International normative instruments and mandates ................................................................ 2 1.3 Operationalizing data reporting and collation ........................................................................... 4 1.4 International health worker mobility: terminologies, definitions and data elements ................... 5 1.4.1 Terminology and definitions ............................................................................................. 5 1.4.2 Indicators and data sources ............................................................................................. 7 1.5 International health worker mobility in the context of global migratory trends .......................... 9 2. Health workforce mobility patterns ........................................................................... 11 2.1 A global view of data availability ............................................................................................... 11 2.2 A global view of key health occupations .................................................................................... 13 2.2.1 Medical doctors (ISCO-08 221) ......................................................................................... 13 2.2.2 Nursing personnel (ISCO-08 2221, ISCO-08 3221) .......................................................... 16 2.2.3 Dentists (ISCO-08 2261) ................................................................................................... 18 2.2.4 Pharmacists (ISCO-08 2262) ............................................................................................ 20 2.2.5 A comparison of foreign-born and foreign-trained medical doctors and nursing personnel in selected countries .................................................................................... 21 2.3 A comparison of regional health worker mobility ....................................................................... 23 2.4 Cross-sectional analysis of selected countries using census data ............................................ 26 2.5 A global perspective of immigration and emigration patterns and countries’ temporal vulnerabilities ............................................................................................. 27 2.6 Global emergencies affecting health worker availability ............................................................ 30 3. Strengthening health worker mobility data generation – challenges and opportunities .. 31 3.1 Data challenges ......................................................................................................................... 31 3.2 Opportunities............................................................................................................................. 32 3.3 Key findings and global messages ............................................................................................ 35 References ................................................................................................................. 37 Annex 1: Countries included in the report, by WHO region ................................................................... 41 Annex 2: Distribution of foreign-trained medical doctors by country of origin/training, selected destination countries ............................................................................................... 43 Annex 3: Distribution of foreign-trained nursing personnel by country of origin/training, selected destination countries ............................................................................................... 46 Annex 4: Selected country profiles ....................................................................................................... 48 WHO report on global health worker mobility iv Foreword Health worker migration and mobility are natural aspects of the population health and development dynamic occurring in all countries and economies as a means of addressing skills imbalances and responding to labour market demands. This report inaugurates the presentation of health worker mobility data from three global mechanisms of data collection: the National Health Workforce Accounts (NHWA) annual reporting by country focal points; the National Reporting Instrument (NRI) assessing the implementation of the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel (the “Code”); and the data mining activities conducted by the WHO Secretariat using population census and institutional data (such as from professional bodies and associations). In 2010, WHO‘s leading governing body, the World Health Assembly, adopted the Code as a groundbreaking framework which pivoted attention on the concerns and consequences of health worker migration and mobility, and promoted core principles and policy options to mitigate the impacts on health systems. In 2016, the adoption of the Global Strategy on Human Resources for Health: Health Workforce 2030 (GSHRH), invigorated the resolve of countries to improve the collection, analysis and use of health worker data by implementation of the NHWA. In the latest 5-year periodic review of the Code’s relevance and effectiveness (2020), a globally representative Expert Advisory Group (EAG) emphasized the importance of strengthening international health worker mobility (IHWM) data and statistics in support of monitoring implementation of the Code, and outlined a priority action to develop a global data report on IHWM. The report presents two key indicators of estimating health worker mobility as reported by destination countries – the share of the foreign-trained and/or foreign-born health workers. The results presented in this report formulate new thinking around the interlinkages of monitoring Sustainable Development Goal (SDG) Indicator 3.c.1 on health worker density and distribution and health worker mobility and migration. This report provides the most comprehensive compendium of data on health workforce migration ever published, with data from 134 countries, territories, and areas, covering all six WHO regions. This report emphasizes the importance of accurately measuring and monitoring health worker mobility – as a lever of influence – in designing, implementing and assessing remedial policies aimed at addressing skills imbalances and future health systems performance development. Jim Campbell Director Health Workforce Department World Health Organization WHO report on global health worker mobility v Acknowledgements The WHO report on global health worker mobility was produced by the WHO Health Workforce Department. It was coordinated and developed by Teena Kunjumen, Amani Siyam and Khassoum Diallo, with technical inputs from Miranda Bain, Mathieu Boniol, James Campbell, Giorgio Cometto, Ibadat Singh Dhillon, Agya Mahat, Maria Sarah Nabaggala and Tapas Sadasivan Nair. We wish to acknowledge WHO Member States’ designated national authorities (DNA) and focal points for the NRI and the NHWA, for their continued engagement and dedicated efforts in reporting the data used in this report. In this respect, we strongly recognize the efforts of WHO regional and country human resources for health (HRH) colleagues for their close involvement with the countries and partners and in ensuring the compilation of quality HRH data and statistics that facilitated the analysis and results presented in this report. We also acknowledge the trilateral partnership of the Organisation for Economic Co-operation and Development (OECD), Eurostat and WHO Regional Office for Europe for the effective implementation of the annual Joint Questionnaire (JQ) data collection and open data sharing on foreign-trained medical doctors and nurses, which has tremendously improved data availability. WHO report on global health worker mobility vi Abbreviations CHE current health expenditure DNA designated national authority EAG Expert Advisory Group GSHRH Global Strategy on Human Resources for Health: Workforce 2030 HLM health labour market HRH human resources for health HRHIS human resources for health information system HWSSL Health Workforce Support and Safeguards List IHWM international health worker mobility ILO International Labour Organization IOM International Organization for Migration ISCO International Standard Classification of Occupation JQ OECD/ EUROSTAT/WHO-Europe Joint Questionnaire on non-monetary health care statistics NHWA National Health Workforce Accounts NRI National Reporting Instrument OECD Organisation for Economic Co-operation and Development SDG Sustainable Development Goal UHC universal health coverage UNECE United Nations Economic Commission for Europe WHO World Health Organization WTO World Trade Organization WHO report on global health worker mobility vii Executive summary The WHO report on global health worker mobility represents a momentous effort that is reversing the tide of scarcity of data on health worker migration. The report presents consolidated data on health worker mobility gathered across diverse data sources and geographies, covering 134 countries using three operational mechanisms (NRI periodic reporting, NHWA annual reporting, and data mining from population census and other sources). It is the culmination of concerted efforts involving the three levels of WHO and effective partnerships with OECD and Eurostat, which have been instrumental to the improved data availability, particularly in the period 2011–2021. The report presents comparative results on the dependency of national health systems on foreign workers obtained through the NHWA proposed indicators for estimating the share of foreign-trained and foreign-born health workers in the active total stock of health workers in destination countries and reveals crucial linkages between health worker mobility and SDG Indicator 3.c.1 – health worker density and distribution. In Annex 4, the report provides selective country profile summaries with more detailed information on the related health workforce indicators and other demographic, migration and health goal- level progress indicators. The report illustrates how countries interchange in their status as destination and source countries of health worker mobility and the fundamental influences of language and geographical proximity, and the known and unknown levels of bilateralism and multilateralism operating between countries and regions. Unequivocally, in the last two decades, the cluster of destination countries remained mostly unchanged; key ones being Australia, Canada, France, Qatar, Saudi Arabia, the United Kingdom of Great Britain and Northern Ireland, and the United States of America, to name a few. In contrast, the cluster of source countries expanded to include Egypt, Germany, New Zealand, Romania, Russian Federation and the United Kingdom, compared with earlier evidence, which focused attention on India, Pakistan, the Philippines and South Africa. The report highlights the importance of considering distinct mobility patterns for each of the four key occupations (medical doctors, nursing personnel, dentists and pharmacists) to gain a better understanding of their individual labour market perspectives and prospects. Data from 93 countries indicate that mobile medical doctors are mostly working in six top destination countries (Australia, France, Germany, Saudi Arabia, the United Kingdom and the United States of America) and that seven source countries alone (Egypt, Germany, India, Pakistan, Romania, Russian Federation and the United Kingdom) are the countries of training for more than 30% of them globally. Data from 129 countries show that the largest percentage of mobile nursing personnel primarily migrate to the United Kingdom and United States of America. Data on mobile dentists from 68 countries strongly distinguish the situation of countries where the percentage of foreign-trained dentists lies below 40% as a delineator of where true market demand is the force behind the observed mobility pattern, rather than education and training capacities. By contrast, in countries where the percentage of foreign-born dentists exceeds 80%, there could be a stronger indication of insufficient or absent training capacity. Similarly, data on mobile pharmacists from 70 countries strongly suggest a tiered dependency situation between countries of low (< 20%), moderate (20–50%) and high (> 50%) demand for foreign-trained pharmacists due to differential market demand. Using a regional lens comparison, and notwithstanding intraregional variations, the report illustrates that the WHO Eastern Mediterranean Region holds the highest median percentage of foreign-trained medical doctors WHO report on global health worker mobility viii (> 60%) and foreign-trained nursing personnel (> 30%). In all WHO regions, the presence of foreign-born health workers is much lower than that of foreign- trained health workers, which testifies to the reliance on foreign education rather than health labour market (HLM) factors. The estimated median percentage of foreign- trained medical doctors remains highest (> 30%) in high-income countries. Interestingly, the median percentage of foreign-trained nursing personnel remains comparable among all economies (around 10–16%). However, results vary slightly if the percentage of foreign-born nursing personnel is analysed. In terms of mobility indicators, gleaning the evidence when using the share of foreign-trained versus the share of foreign-born health workers is quite mixed, yet equally informative. For example, in the case of Australia, foreign-born nursing personnel are close to 40% compared with close to 20% being foreign-trained, which implies that a considerable percentage of foreign-born nursing personnel are trained nationally in Australia. In contrast, results for Oman show an identical match between the share of foreign-trained and foreign-born nursing personnel (close to 50%), which would imply a direct pattern of international migration by recruitment. Therefore, one key finding of this report is that measuring health worker mobility requires both metrics to be examined given different dynamics such as the voluntary movement of health workers seeking better career opportunities and the subsequent movement of health workers due to the migration of whole families. The report strongly illustrates the importance of strengthening institutional capacities to identify and collect mobility data. The consistency of annual reporting in the NHWA, the OECD/Eurostat/ WHO-Europe JQ and follow-up with countries provide the impetus; however, more support and investment are needed to build capacities and allocate time and resources for NHWA focal points to collect these data. The report also provides background on the potential data sources necessary, each of which require specific expertise and resources to be established and maintained in a sustainable manner. Lastly, future monitoring will require global partnerships to devote further attention and resources to strengthening the data sources for monitoring health worker mobility as a constituent of monitoring SDG Indicator 3.c.1 on health worker density and distribution. Equally important is the extent to which health worker data are disaggregated by relevant equity dimensions such as age, gender and immigration status (for nationals and immigrants) to gain a more factual understanding of the current and future education requirements and HLM in countries. 11. Overview 1.1 Introduction More people are moving across countries and continents than ever before, driven by various socioeconomic, political and cultural factors – all of which have been influencing the increased levels and the patterns of health worker mobility for the past few decades (1). Reliable and timely data on the mobility of health workers are essential to enable countries to understand, measure, monitor, manage and make policies and plans informed by the impact of their movements on the production and availability of health workers. Data on international mobility topics such as migrant stocks, mobile students, refugees, asylum seekers, human trafficking, remittances and ratification of international conventions are collected regularly (2). However, fewer data are collected on other aspects such as migrant flows, return migration, the impact of migration policies and migrant health. Many of these topics influence international health worker mobility (IHWM), which has proven difficult to measure, due to challenges in adequately defining such mobility as well as in devising a cohesive and global monitoring framework. In recent years, efforts aimed at monitoring health workforce development have been strengthened with the introduction of normative and operational instruments, including mandates to monitor foreign- born and foreign-trained health workers. Adopted in 2010 by the Sixty-third World Health Assembly, the WHO Global Code of Practice on the International Recruitment of Health Personnel (the “Code”) (3), reinforced Member States’ political will and technical considerations regarding the need to better understand and monitor IHWM. In 2016, the GSHRH (4) was adopted by the Sixty-ninth World Health Assembly to ensure the universal accessibility, acceptability, coverage and quality of the health workforce within strengthened health systems (5). The Sixty-ninth World Health Assembly urged all Member States to ensure “the progressive implementation of National Health Workforce Accounts (NHWA), to support national policy and planning and the Global Strategy’s monitoring and accountability framework” (5). The NHWA, the fourth pillar of the GSHRH, provides a vital mechanism by which countries can progressively improve the availability, quality and use of HRH data. Via a set of tracer indicators, NHWA implementation contributes to the monitoring and evaluation of progress made towards universal health coverage (UHC) as well as the health and health-related SDGs. Unequivocal evidence shows that the countries with the highest burden of disease, expressed in disability- adjusted life years, also have the lowest densities of health workforce required to deliver essential health services (6). National health worker densities can also mask the inequity of health worker distribution at the subnational level (7), aggravated by uneven implementation and results of policies aimed at improving retention in rural and hard-to-reach areas (8). The primary goal of this first monitoring report is to present new insights on IHWM as a new determinant of the inequitable distribution of health workers using global data and information reported to WHO as part of monitoring the implementation of the Code and the NHWA. WHO report on global health worker mobility 2 Migration is a fundamental concern of several global instruments and frameworks. SDG Target 3.c emphasizes the need for a sustainable and equitable health workforce, seeking to “increase substantially health financing and the recruitment, development and training and retention of the health workforce in developing countries,” especially in least developed countries and small island developing states (9). Conjointly, SDG 10.7 requests countries “to facilitate orderly, safe, and responsible migration and mobility of people, including through implementation of planned and well-managed migration policies” (9). Using survey data from 111 countries, the 2020 SDG report revealed that 54% of countries have a comprehensive set of policy measures to facilitate the best practices stated by SDG 10.7 (10). The first objective of the Global Compact for Safe, Orderly and Regular Migration, “to collect and utilize accurate and disaggregated data as a basis for evidence-based policies”, was broadly framed to align with SDG 10.7, thus emphasizing the integral role of data in developing cogent policy-making (11). In response to this first objective, the global Migration Data Portal was established to collect and utilize accurate and disaggregated data to contribute to evidenced-based policy-making (12). It includes disaggregated data by gender, youth, displaced status, as well as information on migration data sources, big data, human trafficking, environmental migration and migration and health. Pre-dating these initiatives, the Code, adopted in 2010, promotes voluntary principles and practices for the ethical recruitment of health personnel, and has since been widely recognized as the universal framework linking health worker mobility to health systems strengthening activities (3). In 2020, the Code’s EAG recommended that the UHC service coverage index (the official indicator for SDG 3.8.1) and health workforce density (official indicator for SDG 3.c.1) should be jointly used to identify countries with the most urgent health workforce challenges pertaining to UHC, and, where safeguards around active international recruitment may be warranted (Fig. 1.1) (13). All recommendations of the EAG were adopted by WHO Member States at the Seventy- third World Health Assembly (13). This resulted in the development of the WHO Health Workforce Support and Safeguards List (HWSSL), wherein 47 countries were identified as having the most pressing health workforce challenges. A subsequent update to the list undertaken in 2023 resulted in the list being expanded to 55 countries (14). The EAG suggested that countries identified should be prioritized for intensified health workforce related support and active safeguards pertaining to international recruitment. Qualifying countries should be prioritized for health personnel development, health systems related support, and active recruitment safeguards, as urged by the Code. The EAG also emphasized the importance of strengthening IHWM data and statistics, in support of monitoring implementation of the Code, and outlined a priority action to develop a global data report on IHWM. 1.2 International normative instruments and mandates Overview 3 Fig. 1.1 Countries with low UHC service coverage index (< 55) and low health workforce density (< 49 per 10 000 population) are on the WHO HWSSL (2023) (n=55) A unique mechanism was established to monitor the progress achieved in implementation of the Code and its associated challenges. The NRI (15) was developed by the WHO Secretariat to provide Member States and independent stakeholders with a common 0 10 20 30 40 50 60 70 80 90 100 0 50 100 150 200 250 300 Association between health workforce density and UHC service coverage index (194 countries) Health workforce density per 10 000 population (includes medical doctors, nursing personnel, and midwifery personnel) UH C se rv ic e co ve ra ge in de x ( 0- 10 0) Note: Countries included in the blue rectangle are included in the Support and Safeguard List. They have a health workforce density less than the median of 49/10 000 pop and a UHC service coverage index less than 55 Source: WHO. platform to share comparable data and information regarding the Code’s implementation. Since 2010, four rounds of reporting have taken place using the NRI, in 2012, 2015, 2018 and 2021. WHO report on global health worker mobility 4 Fig. 1.2 WHO Member States with a NHWA focal point (2022) Monitoring the implementation of the Code has demonstrated an overall increased engagement among Member States and stakeholders (Fig. 1.3). 178 (92%) of 194 WHO Member States appointed a designated national authority (DNA) to support the Code’s implementation, while 77 Member Focal point available No focal point Not applicable 0 2000 40001000 km Source: WHO States, reflecting 55% of the world’s population and comprising most of the major destination economies, submitted a national report to the fourth round of reporting on implementation of the Code to the WHO Secretariat by May 2022 (16). 1.3 Operationalizing data reporting and collation For over a decade, WHO has actively engaged at the global, regional and national level with relevant bodies and mechanisms such as JQ to gather data (discussed in Part 2) to monitor health worker mobility. To improve efficiency, WHO streamlined the reporting processes of the GSHRH milestones and the NRI to align with NHWA annual reporting. The establishment of an NHWA data platform was instrumental to the collation of data reported by the two mechanisms and it currently hosts IHWM data from 134 countries, territories and areas, covering all six WHO regions. The strength of the NHWA reporting mechanism is well demonstrated by the increasing number of countries engaged via their NHWA focal points (Fig. 1.2). Overview 5 Fig. 1.3 Member States with a designated national authority (DNA) on the Code and national reports submitted to the fourth round of reporting (NRI 2021–2022) 1.4 International health worker mobility: terminologies, definitions and data elements 1.4.1 Terminology and definitions SDG Target 3.c is monitored via Indicator 3.c.1, health worker density and distribution, currently disaggregated by sex and selected health occupations (9) WHO defines health workers as “all people engaged in actions whose primary intent is to enhance health” (17) and the global reporting and monitoring of their size and composition is facilitated via the mapping of countries’ national occupations to the International Labour Organization (ILO) International Standard Classification of Occupation (ISCO) 2008 (18). Currently, monitoring SDG Indicator 3.c.1 is operationalized as measuring the density and sex distribution for medical doctors, nursing and midwifery personnel, dentists and pharmacists. Although no explicit mention has been made of monitoring their mobility, each health occupation exhibits different mobility patterns, which influence their equitable distribution globally. Hence, it is extremely important to integrate the metrics and knowledge of health worker mobility in monitoring Indicator 3.c.1 and in the dialogue around health worker distribution. However, there are various approaches to defining health worker mobility, that will be discussed subsequently, and there is no single metric that stakeholders have reached agreement on. The terms “migration” and “mobility” create further complexity in such discussions. Migration has often been utilized in the context of labour market forces and relating to the movement of people across borders on a permanent or semi-permanent basis (19). In some policy arenas, mobility can refer to semi-permanent Source: WHO WHO report on global health worker mobility 6 or internal movement of people, whereas in others it pertains to the broader, permanent movement of individuals. Mobility has also been described as the subject that migration studies seek to understand (20). In some contexts, mobility and migration are not delineated and even used interchangeably (21). In contrast, other scholars note a dichotomy between intranational and international migration, while mobility encompasses a broader measure of movement, including, for example, the scale and differentials of immigrants’ emigration when compared with nationals (22). The International Organization for Migration (IOM) defines migration as “the movement of persons away from their place of usual residence, either across an international border or within a State”, while labour migration is “the movement of persons from one State to another, or within their own country of residence, for the purpose of employment” (23). Health professional mobility has more specifically been defined as “any movement across a border by a health professional after graduation with the intention to work, that is, deliver health-related services in the destination country, including during training periods” (24). A salient aspect of this phenomenon even more difficult to measure is that of medical and health sciences students who intentionally seek health and medical educational attainment with the aim of subsequently finding employment in their country of training. This report uses the broad term of mobility to encompass the complex experiences of health professionals’ movement and follows the definition of the United Nations Economic Commission for Europe (UNECE), as the most comprehensive and relevant for its scope. UNECE defines international labour mobility as all movement of natural persons from one economy to another for the purpose of employment or supply of services (Fig. 1.4) (25). The World Trade Organization (WTO) notes that “international health worker mobility, including professional registration and employment or supply of services in multiple jurisdictions, is also becoming increasingly common” (26). The WHO World report on the health of refugees and migrants (27) emphasized the need to consider three additional key aspects when measuring health worker mobility: • the impact of displacement on the health workforce; • the need for mechanisms to incorporate refugee and migrant health professionals; and • the case of countries where large parts of the health workforce are migrants. Fig. 1.4 Relationship between usually resident population, international migration, labour force and labour mobility in an economy Resident population International migrants International labour mobility Potential labour force Labour force (a) International migrant workers resident in the country (b) Non-resident foreign workers Source: Measuring international labour mobility (UNECE, 2018). Overview 7 1.4.2 Indicators and data sources As noted, it is challenging to measure health worker mobility through a single metric. The framework below (Fig. 1.5) helps to explain health worker mobility using two dimensions, place of training and place of birth, via four categories. The first category describes nationally trained national health workers who are born and trained in the same country. At first glance, albeit beyond the scope of this report, it may seem that these health workers do not fit the concerns of health worker mobility and its effects. However, a closer look at countries with a federal system of government and service delivery reveals that while these health workers may not necessarily move between international borders, they move intranationally between their place of birth and their place of training or even to another subnational or federated unit. This poses a considerable challenge to the attainment of a national equitable distribution of health workers. For example, health worker shortages are more than twice as high in rural areas compared to urban areas, and retention is often considered an even greater issue than distribution (28). Fig. 1.5 Framework for understanding health worker mobility Place of training Place of birth Nationals Foreign-born Nationally trained Nationals who are nationally trained Foreign-born who are nationally trained Foreign-trained Natives who are foreign-trained Foreign-born who are foreign-trained The second category of health workers are those who are foreign-born and nationally trained. Here, foreign- born indicates the health worker’s place of birth was outside the country of interest, but not necessarily that their nationality is foreign (29).1 1 Note that two thirds of international migrants are migrant workers; the majority of the remaining third are children migrating with parents, or spouses, or older adults. The third category are those who are foreign- trained nationals. This evidences an international health student mobility trend whereby nationals of a particular country seek health education and training abroad, possibly due to limited education and training capacity in their home country, and then return home to participate in the labour force. The fourth category of health workers are those born and trained in a foreign country outside the country of interest. The country of birth and country of training may be the same or different. Data to measure and distinguish the four categories accurately rarely exist, which limits the focus of this report to examining data availability on health workers who are foreign-trained (with no distinction between nationals and foreign-born) and foreign-born (with no distinction between those nationally and foreign- trained). Since 2017, data availability has been largely facilitated by the global implementation of the NHWA which is shaped by the HLM framework (30) (Fig. 1.6). The NHWA handbook presents indicators related to HLM stock and flows. Indicators measure entries to and exits from the HLM and include data elements that distinguish between national and foreign health workers, as well as monitoring both voluntary and involuntary exits from the labour market (31). The NHWA handbook provides three indicators to measure and monitor health worker mobility: · Indicator 1 – 07: The share of foreign-born health workers: defined as the percentage of active foreign-born health workers (calculated by dividing the number of active foreign-born health workers by the total number of active health workers [stock]) and collected in disaggregation by occupation. · Indicator 1 – 08: The share of foreign-trained health workers: defined as the percentage of active foreign-trained health workers (calculated by dividing the number of active foreign-trained WHO report on global health worker mobility 8 health workers by the total number of active health workers [stock]) and collected in disaggregation by occupation, and by occupation and country of training. · Indicator 5 – 03: Entry rate of foreign health workers: defined as the percentage of newly active foreign-trained health workers to the total stock of active health workers (calculated by dividing the number of newly active foreign-trained health workers in any given year by the total number of active health workers [stock]) and collected in disaggregation by occupation. These indicators provide comparable statistics across countries that can be monitored over time, and, when juxtaposed with additional data on place of birth and/ or training data, illustrate a clearer pattern between blocks of destination and source countries. In general, countries are both destination and source countries; however, from a measurement perspective, health worker mobility (as defined by the two indicators 1 – 07 and 1 – 08) is pivoted on the data availability and reporting by destination countries. Fig. 1.6 The health labour market framework The NRI has been primarily used by countries as a self-assessment tool to monitor implementation of the Code. In 3-year cycles (from 2012), countries were able to provide numbers of foreign-born and foreign-trained health workers by country of origin. At the country level, the NHWA focal point and DNA (responsible for the NRI reporting) work together to collect reliable IHWM data for each round of reporting on the Code implementation and regular annual NHWA reporting. The NHWA and NRI data collection mechanisms are well-aligned and synchronized with the JQ established by OECD, Eurostat and the WHO Regional Office for Europe. The JQ collects non-monetary health data on an annual basis, part of which is the stock of foreign-trained medical doctors and nurses, including those who are country nationals (32, 33). The main data sources of the JQ IHWM data are professional registries managed either by professional organizations or government agencies. Hi gh s ch oo l Education in health Pool of qualified health workers Health care sector Other sectors Health workforce equipped to deliver quality health service Employed Unemployed Out of labour force Education in other fields Abroad Un iv er sa l h ea lth c ov er ag e wi th sa fe , e ffe ct iv e, pe rs on -c en tre d he al th se rv ic es Policies on production • on infrastructure and material • on enrolment • on selecting students • on teaching staff Policies to address inflows and outflows • to address migration and emigration • to attract unemployed health workers • to bring health workers back into the health care sector Policies to address maldistribution and inefficiencies • to improve productivity and performance • to improve skill mix composition • to retain health workers in underserved areas Policies to regulate the private sector • to manage dual practice • to improve quality of training • to enhance service delivery Economy, population and broader societal drivers Education sector Labour market dynamics Migration Source: WHO. Overview 9 Strong collaborative efforts support all mechanisms in the collection of quality-driven data and facilitate the establishment of a global picture of IHWM. To date, all the data collected through the NRI and JQ are integrated into the NHWA data platform and now accessible through the NHWA portal for 134 countries, territories and areas for several occupations (34). Section 2 of this report provides selective analytics facilitated by NHWA data availability and elaborates some trends analysis for selected countries as well as a cross-sectional analysis using population-based census data. 1.5 International health worker mobility in the context of global migratory trends The global community has long debated the best way to monitor health worker mobility. This partly stemmed from the notion of “brain drain”, where highly skilled workers born and or trained in poorer countries move to a richer country therefore decreasing the high cost of training in the “receiving” country. However, the concept of brain drain does not stand true for all mobility scenarios. As illustrated in Fig. 1.5, not all foreign-trained doctors are foreigners, as they may be citizens of the country in which they are working but simply have trained in a foreign country, and thus this would not be relevant in discussions regarding brain drain (24). Over the past three to four decades, different patterns of migration have emerged. Step-wise migration features the mobility strategy to transit to an intermediate country and eventually to a destination country. Typically, in step-wise migration, a foreign- born and foreign-trained health worker practises their profession in one or multiple countries for several years and then moves to another foreign country, which is often their destination country. Serial migration, on the other hand is where a person migrates to several countries over a period of time, but without the intentionality observed in step-wise migration (35, 36). Regardless of which migration pattern exists in one setting or another, it is bound to affect all health systems alike. Health systems continue to face various challenges in achieving and sustaining an equitable distribution of health workers at the subnational level and service delivery models. The results to follow in Section 2 offer groundbreaking evidence of the recent trends of IHWM and emphasize the unbalancing impact these have on health systems. With a continuing acceleration of IHWM, there is more potential to exacerbate the imbalance and mismatch between the supply of and economic demand for health workers the world over (37).

11 2. Health workforce mobility patterns The improving availability of health workforce data through the NHWA continues to provide increasing insight into the significance of IHWM. While there has been a notable number of studies and reports scrutinizing health workforce mobility patterns (24, 38), this report is the first of its kind on a global scale. Featuring data from 134 countries, territories and areas, it showcases patterns of health worker mobility across different health occupations. The findings of this first report are focused on the health workforce mobility of medical doctors, nursing personnel, dentists and pharmacists. The report includes data points from 93 countries for medical doctors, 129 countries for nurses, 68 countries for dentists and 70 countries for pharmacists. More data points exist on nurses than other occupations as a primary benefit of the purposive multi-partnered data collection that culminated into the State of the world’s nursing 2020 report (39). Although the NHWA database presents IHWM data from 2000 to 2021, the reference period of the analysis presented in this report is 2011–2021, (except in the case of three countries, for which data from between 2006 and 2009 was considered),2 covering countries, territories and areas across all six WHO regions. 2 Belarus, Egypt, Mali. Data extracted from the global NHWA database are data integrated from the NHWA annual reporting, four rounds of NRI reporting (taking place every 3 years) and complementary data mining (using national population census data). Regular NHWA reporting follows the guiding principles of data collation and triangulation from multiple data sources such as ministry of health, professional registries, human resources for health information systems (HRHIS), payroll data to name a few. The NHWA database is subject to annual data validation and quality checks carried out by the WHO Secretariat. In the case of a missing national value but non-missing foreign and total stock values, the former was estimated using the total stock value reported minus the foreign value, and vice versa. Fig. 2.1 provides a snapshot of health worker mobility data availability in the NHWA data platform for SDG Indicator 3.c.1 by number of occupations. Fig. 2.2 provides a different snapshot of the countries with data availability on place of birth, place of training, or both. 2.1 A global view of data availability 12 WHO report on global health worker mobility Fig. 2.1 Country health worker mobility data availability (measured as either share of foreign-born or share of foreign-trained health workers) by number of occupations Fig. 2.2 Country health worker mobility data availability for the two indicators (place of birth and place of training) Number of occupations Data on > 10 occupations Data on 6-10 occupations Data on 1-5 occupations No data reported Not applicable 0 2000 40001000 km HW migration data on Place of birth only Place of training only Place of training and place of birth No data reported Not applicable 0 2000 40001000 km Source: NHWA (2022). Source: NHWA (2022). 13 Health workforce mobility patterns Fig. 2.3 Share of foreign-trained doctors in selected countries (where percentages > 10%) (2011–2021) 2.2 A global view of key health occupations % foreign-trained medical doctors Distribution of 68 countries (3-way split) 0 20 40 60 80 100 Brunei Darussalam Qatar Palau Saint Lucia Bhutan Oman Jordan Cameroon Gabon Chad Saudi Arabia Israel Kuwait Trinidad and Tobago Seychelles Guyana New Zealand Singapore Kiribati Ireland Malaysia Switzerland Australia United Kingdom Sweden Canada United States of America Zimbabwe Chile Malta Greece Nigeria Slovenia South Africa Paraguay Germany Belgium France Lao People's Democratic Republic El Salvador > 37.4% foreign-trained 7.5% - 37.4% foreign-trained < 7.5% foreign-trained Bhutan, Brunei Darussalam, Monaco and Palau are trained in a foreign country, which could indicate limited availability of medical schools in these countries. In contrast, in several countries, such as Austria, Brazil, Cyprus, Hungary, Indonesia, Netherlands (Kingdom of the), Pakistan, Panama, Thailand, Türkiye and Uganda, foreign-trained medical doctors constitute less than 10% of the total active stock. Fig. 2.3 also depicts a three-way split of countries where one third have a low proportion of foreign-trained medical doctors (< 7.5%), one third a moderate to high proportion (7.5–37.4%), and one third with very high proportion (> 37.4%). The following graphics display discernible trends by health occupation as well as a variety of mobility patterns in countries and regions. 2.2.1 Medical doctors (ISCO-08 221) Figs 2.3 and 2.4 feature the share of foreign-trained and foreign-born doctors, respectively, for selected countries. The share of foreign-trained medical doctors in a broad of mix of countries is shown in Fig. 2.3. Almost all medical doctors in countries, such as Source: NHWA (2022). 14 WHO report on global health worker mobility Some countries, such as Oman, Qatar, Saudi Arabia and the Seychelles, have a considerable percentage (> 60%) of foreign-born medical doctors, while in other countries such as Bangladesh, El Salvador, Italy, Mexico, Nigeria and Sri Lanka, the percentage of foreign-born doctors is extremely low (< 5%). Fig. 2.4 Fig. 2.4 Share of foreign-born doctors in selected countries (where percentages > 10%) (2011–2021) % foreign-born medical doctors Distribution of 61 countries (3-way split) 0 20 40 60 80 100 Qatar Oman Seychelles Saudi Arabia Maldives Namibia Brunei Darussalam Botswana Australia Saint Lucia Democratic People's Republic of Korea United States of America Sweden Norway Belgium South Africa Trinidad and Tobago Palau Malta Gabon France Uganda Pakistan Mozambique Paraguay Chad Czechia Jordan Slovenia Bahrain Iceland Hungary Greece Benin > 20.6% foreign-born 5.2% - 20.6% foreign-born < 5.2% foreign-born also shows a three-way split of countries, where one third have a low proportion of foreign-born medical doctors (< 5.2%), one third a moderate proportion (5.2– 20.6%), and the remaining third have a high proportion (> 20.6%). Source: NHWA (2022). 15 Health workforce mobility patterns Fig. 2.5 Top destination countries for medical doctors by select countries of training/birth (2011–2021) Fig. 2.5 shows top destination countries for medical doctors (by country of training/birth) among the reported mobile doctor populations. The largest percentage of mobile doctors from India (64%) and China (75%) are working in the United States of America. The top destination countries for most of these mobile doctors include Australia, France, Germany, Saudi Arabia, the United Kingdom and the United States of America. Overall, medical doctors trained in just seven countries (Egypt, Germany, India, Pakistan, Romania, Russian Federation and the United Kingdom) constitute more than 30% of the mobile doctors globally. Language and geographical proximity are two influential factors in determining migratory patterns. Close to 50% of the mobile medical doctors trained in Colombia are in Chile, Ecuador and Mexico, where Spanish is the common language. Similarly, close to 50% of the mobile medical doctors trained in Germany are in Switzerland and Austria, where German is spoken. Over 45% and 72% of the mobile doctors trained in Egypt and Sudan, respectively, are in Saudi Arabia, where Arabic is the common language. Destination countries also display an interesting mix of patterns. Taking the largest destination country, more than 50% of the foreign-trained doctors in the United States of America were originally trained in Canada, Dominica, Grenada, India, Pakistan, Mexico and the Philippines; while 78% of the foreign-trained doctors in Chile were originally trained in three neighbouring countries (Colombia, Ecuador and Venezuela). These results and others are shown in Annex 2. Close to 60% of the foreign-trained medical doctors in the United Kingdom were trained in a geographically mixed set of countries (Egypt, Greece, India, Ireland, Nigeria and Pakistan). About 35% of the foreign- trained doctors in Germany were originally trained in Austria, Greece, Poland, Romania, Russian Federation and the Syrian Arab Republic, of which the Syrian and Romanian trained doctors constitute 17%. Over 74% of the foreign-trained medical doctors in Switzerland were originally trained in four neighbouring countries (Austria, France, Germany and Italy). Similarly, 50% of the foreign-trained doctors in Australia were originally trained in India, New Zealand, South Africa and the United Kingdom. Conversely, taking New Zealand Co un tr ie s of t ra in in g/ bi rt h Top three destination countries for medical doctors personnel by select countries of origin 0 10 20 30 40 50 60 70 80 90 100 India Pakistan Egypt Romania Russian Federation Germany United Kingdom Sudan Nigeria China Slovakia Algeria Serbia Germany France Czechia Germany Norway USA USA Saudi Arabia OthersUK UK Ireland OthersSaudi Arabia USA New Zealand OthersAustralia USA Austria OthersSwitzerland Israel Germany OthersUSA Germany USA OthersFrance USA UK OthersSaudi Arabia UK Ireland OthersUSA UK Austria OthersUSA Australia Canada Others Others Switzerland Germany USA Slovenia Others Others Source: NHWA (2022). 16 WHO report on global health worker mobility as a destination country, over 76% of its foreign- trained doctors were originally trained in Australia, India, Ireland, South Africa, the United Kingdom and the United States of America. In Saudi Arabia, a key destination country of the Gulf States, over 80% of the foreign-trained doctors were originally trained in Egypt, Pakistan and Sudan. These results and others are shown in Annex 2. 2.2.2 Nursing personnel (ISCO-08 2221, ISCO-08 3221) Figs 2.6 and 2.7 feature the share of foreign-trained and foreign-born nurses, respectively, for a selected number of countries. Almost all of nursing personnel in the British Virgin Islands, Qatar and Tokelau are foreign-trained. By contrast, in several other countries, such as Afghanistan, Algeria, Bangladesh, Bulgaria, Costa Rica, Côte d’Ivoire, Cuba, El Salvador, Estonia, Ghana, Indonesia, Malaysia, Pakistan, Paraguay, Poland, Senegal, Sri Lanka, Türkiye and Uganda, the percentage of foreign-trained nursing personnel is close to zero or less than 1%. In terms of proportion, Fig. 2.6 provides a three-way split, with a third of countries where the proportion of foreign-trained nursing personnel is very low (< 1.7%), a third where it is moderate (1.7–16.3%), and the remaining third where it is higher (> 16.3%). Figs 2.6 and 2.7 also provide a contrasting picture for some countries. For example, in the case of Australia, foreign-born nursing personnel are close to 40% compared with almost 20% being foreign-trained. This could imply that a considerable percentage of foreign-born nursing personnel are trained nationally in Australia. In contrast, results for Oman show an identical match between the percentage of foreign- trained and foreign-born nursing (close to 50%), which would imply a direct pattern of international migration by recruitment. Remarkably, just as results show that more than 95% of nursing personnel in Kuwait, and Qatar are foreign-born, in contrast, almost all nursing personnel in countries such as Afghanistan, Cuba, Ghana, Indonesia, Thailand, Tonga and Zimbabwe are nationals. A three-way split of foreign-born nursing personnel show a similar pattern as foreign-trained personnel. Fig. 2.6 Share of foreign-trained nursing personnel in selected countries (where percentages > 10%) (2011–2021) % foreign-trained nursing personel Distribution of 93 countries (3-way split) 0 20 40 60 80 100 Tuvalu Niue Honduras Oman Kuwait Zambia Timor-Leste Nauru Maldives Ireland Saint Lucia Saudi Arabia Namibia Marshall Islands Switzerland New Zealand Yemen Democratic Republic of the Congo Belize Cook Islands Bhutan Australia Eswatini India Mexico Vanuatu Papua New Guinea Antigua and Barbuda Jordan United Kingdom Brunei Darussalam Palau Chad Israel < 1.7% foreign-born 1.7% - 16.3% foreign-born > 16.3% foreign-trained Source: NHWA (2022). 17 Health workforce mobility patterns Fig. 2.8 shows top destination countries for nursing personnel (by country of training/birth) among the largest reported mobile nurse populations. The larg- est mobile nursing personnel primarily migrate to the United States of America and the United Kingdom. The Philippines (62%) and the United Kingdom (40%) have the highest percentage of their emigrant nurs- es working in the United States. The United States of America is not only a top destination country for nurs- es, but certain groups of mobile nurses exclusively move there to work, rather than any other country in the world. Examples are nursing personnel emigrat- ing from Canada (94%), Haiti (99%), Jamaica (97%), Mexico (close to 100%) and Nigeria (88%). Language and geographical proximity are strong influential factors in determining migratory patterns among nursing personnel. All mobile nurses trained in the Philippines are in Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America, where English is the common language. Regarding French, 87% of mobile nurses trained in Belgium are in France and 94% of mobile nurses trained in France are in Switzerland. Nurses trained in India and the Philippines constitute 53% of the foreign-trained nurses in the United Kingdom. Nurses trained in Belgium, Morocco and Tunisia constitute 63% of the foreign-trained nurses in France. Nurses trained in Egypt, India, the Philippines and Sudan constitute 94% of foreign-trained nurses in Saudi Arabia. Nurses trained in India, the Philippines and the United Kingdom constitute 80% of foreign- trained nurses in Ireland. These results and others are shown in Annex 3. It worth noting that data on foreign-trained and foreign-born midwifery personnel were also examined (but not presented in this report) and indicated very low mobility rates in comparison with medical doctors and nursing personnel. Most countries report exceptionally sparse numbers (and hence close to zero percentages) of foreign-trained and foreign-born midwives, which could be also attributed to varying education pathways leading to a conceded limitation that countries face in distinguishing between nursing and midwifery personnel. Fig. 2.7 Share of foreign-born nursing personnel in selected countries (where percentages > 10%) (2011–2021) % foreign-born nursing personel Distribution of 80 countries (3-way split) 0 20 40 60 80 100 Qatar Kuwait Malaysia Saudi Arabia Tuvalu Pakistan Oman Bahrain Sierra Leone Israel Niue Maldives Australia Ireland Democratic Republic of the Congo Belize Cook Islands Cameroon Eswatini Papua New Guinea Marshall Islands Germany Antigua and Barbuda Brunei Darussalam Mexico United States of America Belgium Norway Portugal Greece Chad Namibia < 1.8% foreign-born 1.8% - 16.0% foreign-born > 16.0% foreign-trained Source: NHWA (2022). 18 WHO report on global health worker mobility 2.2.3 Dentists (ISCO-08 2261) This report presents for the first time a global view of the share of foreign-trained (Fig. 2.9) and foreign-born (Fig. 2.10) dentists for selected countries. One can speculate that in countries where the percentages of foreign-trained dentists lies below 40% (such as Australia, Austria, New Zealand and Norway) there could be an indication of a labour market demand rather than inadequacies in education and training capacities. By contrast, in countries where percentages of foreign-born dentists (Fig. 2.10) exceed Co un tr ie s of t ra in in g/ bi rt h Top three destination countries for nursing personnel by select countries of origin 0 10 20 30 40 50 60 70 80 90 100 Philippines India United Kingdom Nigeria Mexico Jamaica Germany Haiti Poland Romania China Russian Federation Canada France Belgium Ukraine Spain Portugal Zimbabwe Kazakhstan Egypt Sweden Norway USA Finland Others Saudi Arabia USA Canada Others USA GreeceBelgium USA Autralia OthersUK USA France OthersUK Belgium Israel OthersUSA USA Netherlands OthersFrance USA Belgium OthersSwitzerland Germany Israel OthersUSA Australia Canada OthersUSA UK USA OthersItaly USA UK OthersGermany Switzerland France OthersUSA Australia Ireland OthersUSA Saudi Arabia USA OthersUK CanadaUSA OthersUK UK Canada OthersUSA UKUSA USA USA Canada Australia OthersUSA France USA OthersUK Others Fig. 2.8 Top three destination countries for nursing personnel by select countries of training/birth (2011–2021) 60% (such as in Ireland, Maldives and Qatar), there could be a stronger indication of insufficient or absent training capacities. In a closer look at the proportion of foreign-trained dentists, Fig. 2.9 shows that a third of countries seem to have moderate proportion (< 9.3%), a third have a high proportion (9.3–33.2%), and a very high proportion for the remaining third (> 33.2%). There is a reduced proportion of foreign- born dentists compared with foreign-trained dentists shown in Fig. 2.10. Source: NHWA (2022). 19 Health workforce mobility patterns Fig. 2.10 Share of foreign-born dentists in selected countries (where percentages > 10%) (2011–2021) % foreign-born dentists Distribution of 48 countries (3-way split) 0 20 40 60 80 100 El Salvador Qatar Maldives Oman Ireland Saudi Arabia Australia Palau Gabon Namibia Brunei Darussalam Malta Austria Belgium Norway United States of America Nigeria Sweden Slovenia Hungary Uganda France Germany Czechia Zimbabwe Bahrain Greece > 26.0% foreign-born 4.1% - 26.0% foreign-born < 4.1% foreign-born % foreign-trained dentists Distribution of 47 countries (3-way split) 0 20 40 60 80 100 Tonga Palau Saint Lucia Bhutan Brunei Darussalam Belize Qatar Gabon Jordan Sao Tome and Principe Ireland Oman Namibia Zimbabwe New Zealand Cameroon Malta Malaysia Norway Australia Nigeria Austria Sweden Slovenia Pakistan Maldives Monaco Uganda Belgium Iran, Islamic Republic of 9.3% - 33.2% foreign-trained < 9.3% foreign-trained > 33.2% foreign-trained Fig. 2.9 Share of foreign-trained dentists in selected countries (where percentages > 10%) (2011–2021) Source: NHWA (2022). Source: NHWA (2022). 20 WHO report on global health worker mobility 2.2.4 Pharmacists (ISCO-08 2262) Figs 2.11 and 2.12 provide a novel view of the percentages of foreign-trained and foreign-born pharmacists for selected countries. What can be noted is that there could be three country groupings – where the percentage of foreign-trained pharmacists lies below 20% (Australia, Jordan, Malaysia, New Zealand and Zimbabwe); ranges between 20–50% (Cameroon, Canada, Ireland, Norway); and above 50% (Gabon, Namibia and Oman), which may indicate a situation of low, to moderate, to high reliance on Fig. 2.11 Share of foreign-trained pharmacists in selected countries (where percentages > 10%) (2011–2021) % foreign-trained pharmacists Distribution of 43 countries (3-way split) 0 20 40 60 80 100 Tonga Timor-Leste Palau Saint Lucia Bhutan Brunei Darussalam Qatar Namibia Monaco Gabon Jamaica Papua New Guinea Oman Ireland Canada Cameroon Norway Singapore Jordan Zimbabwe Maldives Malaysia Australia New Zealand > 46.2% foreign-trained 7.2% - 46.2% foreign-trained < 7.2% foreign-trained foreign-trained pharmacists. As observed for earlier occupations, over 80% of pharmacists in Maldives and Qatar are foreign born. Taking a closer look at the proportion of foreign-trained pharmacists, Fig. 2.11 shows that one third of countries seem to have low proportion (< 7.2%), one third a moderate to high proportion (7.2–46.2%) and the remaining third a very high proportion (> 46.2%). A reduced proportion of foreign-born pharmacists compared with foreign- trained pharmacists is shown in Fig. 2.12. Source: NHWA (2022). 21 Health workforce mobility patterns Country data were also used to compare the percentages of foreign-born and foreign-trained medical doctors (in 87 countries) and nursing personnel (in 114 countries). Some countries show a stark contrast between the percentages of foreign- born and foreign-trained medical doctors (Fig. 2.13). Data from Australia, Seychelles and the United States of America indicate higher percentages of foreign-born than foreign-trained medical doctors, which would imply that individuals immigrate to these countries to train and then remain to work. In other countries such as Niue and Tuvalu, findings show a dominating percentage of foreign-trained rather than foreign-born nurses (Fig. 2.14), which suggests inadequate training capacity in these countries and that national nurses rely on foreign training before returning to their home country to work. It is also worth noting that some countries show a significant reliance on both foreign- born and foreign-trained nurses – these include Ireland, Kuwait, Maldives, Oman, Qatar and Saudi Arabia compared with Antigua and Barbuda, Eswatini, Mexico, and Papua New Guinea, which have lower estimates (< 20%) for both percentages. 2.2.5 A comparison of foreign-born and foreign-trained medical doctors and nursing personnel in selected countries Fig. 2.12 Share of foreign-born pharmacists in selected countries (where percentages > 10%) (2011–2021) % foreign-born pharmacists Distribution of 42 countries (3-way split) 0 20 40 60 80 100 Qatar Maldives Saudi Arabia Papua New Guinea Oman Hungary Namibia Australia Palau Norway Gabon Botswana United States of America Sweden Ireland Zimbabwe Brunei Darussalam Belgium France < 4.6% foreign-born 4.6% - 28.9% foreign-born > 28.9% foreign-born Source: NHWA (2022). 22 WHO report on global health worker mobility Fig. 2.13 Comparing the percentages of foreign-born and foreign-trained medical doctors in selected countries (where percentages of foreign-trained > 10%) (2011–2021) 0 10 20 30 40 50 60 70 80 90 100 Foreign-trained Foreign-born Br un ei D ar us sa la m Qa ta r Pa la u Sa in t L uc ia Bh ut an Jo rd an Ca m er oo n Ga bo n Ch ad Se yc he lle s M al ay sia Sw ed en Zi m ba bw e M al ta Ni ge ria So ut h Af ric a Pa ra gu ay Be lg iu m El S al va do r % o f f or ei gn -b or n an d fo re ig n- tr ai ne d m ed ic al d oc to rs Fig. 2.14 Comparing the percentages of foreign-born and foreign-trained nursing personnel in selected countries (where percentages of foreign-trained > 10%) (2011–2021) 0 10 20 30 40 50 60 70 80 90 100 Foreign-trained Foreign-born Tu va lu Ni ue Om an M al di ve s Ire la nd Sa ud i A ra bi a M ar sh al l Is la nd s De m oc ra tic R ep ub lic of th e C on go Be liz e Co ok Is la nd s Es wa tin i Pa pu a Ne w Gu in ea An tig ua a nd B ar bu da Br un ei Da ru ss al am Pa la u Ch ad % o f f or ei gn -b or n an d fo re ig n- tr ai ne d nu rs in g pe rs on ne l Source: NHWA (2022). Source: NHWA (2022). 23 Health workforce mobility patterns Fig. 2.15 Distribution of foreign-trained medical doctors and nursing personnel by WHO region (2011–2021) African Region Region of the Americas South-East Asia Region European Region Eastern Mediterranean Region Western Pacific Region Di st rib ut io n of th e f or eig n- tra in ed h ea lth p er so nn el (% ) Medical doctors Nursing personnel Note: Horizontal line inside the box and whisker plot indicates the median share of foreign-trained health personnel. 2.3 A comparison of regional health worker mobility WHO Member States are grouped into six geographical regions which vary in population size and number of countries: African Region (n=47), Region of the Americas (n=35), South-East Asia Region (n=11), European Region (n=53), Eastern Mediterranean Region (n=21) and Western Pacific Region (n=27). Analysing regional estimates of foreign-trained and foreign-born health workers can only capture the degree of reliance rather than the more complex and interconnected mobility patterns. The available estimates (shown in Fig. 2.15) on foreign-trained medical doctors and nursing personnel pertain to 108 countries,3 territories and areas across the six WHO regions. Taking the median estimates, the Eastern Mediterranean Region appears to have the highest percentage of foreign- trained medical doctors and nursing personnel, while comparatively speaking, the European Region has the 3 Countries with data on either or both (foreign-trained medical doctors, foreign-trained nursing personnel). lowest percentage for both indicators. Results from all regions indicate a higher median percentage of foreign-trained medical doctors than foreign-trained nursing personnel. Source: NHWA (2022). 24 WHO report on global health worker mobility Fig. 2.16 Distribution of foreign-born medical doctors and nursing personnel by WHO region Di st rib ut io n of th e f or eig n- bo rn h ea lth p er so nn el (% ) African Region Region of the Americas South-East Asia Region European Region Eastern Mediterranean Region Western Pacific Region Medical doctors Nursing personnel Note: Horizontal line inside the box and whisker plot indicates the median share of foreign-born health personnel. The estimates (shown in Fig. 2.16) on foreign-born medical doctors and nursing personnel pertain to 95 countries,4 territories and areas across all six WHO regions. In global terms, taking the median estimates, the Eastern Mediterranean Region appears again as the one with the highest percentage of foreign-born medical doctors and nursing personnel, while the Region of the Americas has the lowest percentages for both indicators. Median percentages of foreign- born medical doctors are slightly higher than those of foreign-born nursing personnel in all regions except the Eastern Mediterranean Region. In all WHO regions, the presence of foreign-born health workers is much lower than that of foreign-trained health workers testifying more toward the reliance on foreign education rather than health labour markets. 4 Countries with data on either or both (foreign-born medical doctors, foreign-born nursing personnel). Figs 2.17 and 2.18 also provide a similar comparison using the World Bank income groups. Expectedly, the estimated median percentage of foreign-trained medical doctors remains highest (> 30%) in high- income countries (Fig. 2.17). By contrast, the estimated median percentage of foreign-born medical doctors is comparable between high- and upper-middle income countries (around 20%) (Fig. 2.18). Interestingly, the median percentage of foreign-trained nursing personnel remains comparable among all economies (< 10%) unlike that for the foreign-born ones (Figs 2.17 and 2.18). Therefore, it is important to note that measuring health worker mobility requires both metrics to be examined given different dynamics such as the voluntary movement of health workers seeking better career opportunities and the subsequent movement of health workers due to migration of entire families. Source: NHWA (2022). 25 Health workforce mobility patterns Di st rib ut io n of th e f or eig n- tra in ed h ea lth p er so nn el (% ) LIC: Low-income countries; LMIC: Lower-middle income countries; UMIC: Upper-middle income countries; HIC: High-income countries. Medical doctors Nursing personnel Note: Horizontal line inside the box and whisker plot indicates the median share of foreign-trained health personnel. Fig. 2.17 Distribution of foreign-trained medical doctors and nursing personnel by World Bank income groups Source: NHWA (2022). Fig. 2.18 Distribution of foreign-born medical doctors and nursing personnel by World Bank income groups Di st rib ut io n of th e f or eig n- bo rn h ea lth p er so nn el (% ) LIC: Low-income countries; LMIC: Lower-middle income countries; UMIC: Upper-middle income countries; HIC: High-income countries. Medical doctors Nursing personnel Note: Horizontal line inside the box and whisker plot indicates the median share of foreign-born health personnel. Source: NHWA (2022) 26 WHO report on global health worker mobility 2.4 Cross-sectional analysis of selected countries using census data Table 2.1 highlights the variability of mobility patterns across countries and regions. The highest percentage of foreign-born health workers are estimated for medical doctors in Brazil (46.7%) and personal care workers engaged in health services in France (43%) and the United States of America (55%). In contrast, the smallest percentages of foreign-born health workers are estimated in the United States of America for pharmaceutical workers (0.4%) and psychologists (1.0%). The proportion of foreign-born medical doctors is consistently higher than foreign-born nursing personnel in all countries except Benin. In almost all countries (except Brazil), personal care workers in health services constitute the highest percentage of foreign-born health workers. Analysing population-based census data of selected countries provides further insight into mobility patterns among a number of health worker occupations. Census data capture health workers’ foreign-born rather than foreign-trained status. Table 2.1 A comparison of the percentages of foreign-born health workers in selected countries using census data (2006–2015) Health occupation Benin Brazil France Greece Mali USA Medical doctors (ISCO 221) 11.6 46.6 14.9 21.6 27.7 15.0 Nursing personnel (ISCO 2221, 3221) 11.6 10.2 13.3 18.9 21.0   Midwifery personnel (ISCO 2222, 3222) 6.1   0.5 1.5 8.4   Dentists (ISCO 2261)   15.5 2.1 5.8   6.0 Pharmacists (ISCO 2262) 5.5 2.3 3.8 4.0 26.0 0.4 Physiotherapy personnel (ISCO 2264, 3255)   4.9 2.7 2.3   3.8 Psychologists (ISCO 2234)     3.7 1.3   1.0 Personal care workers in health services (ISCO 53) 37.2 7.0 42.9 33.7   55.1 Other health workers 28.0 13.4 15.9 10.8 16.8 18.5 Source: NHWA (2022). 27 Health workforce mobility patterns 2.5 A global perspective of immigration and emigration patterns and countries’ temporal vulnerabilities Migration patterns among health workers, by occupation and by region, are clearly wide-ranging. Social, cultural and economic factors, among others, influence mobility patterns. While there is a general trend of mobility of highly skilled health workers, such as doctors and nurses, towards high-income countries, it is not a simple case of South to North migration. The findings of this report provide clear evidence of health worker mobility among high- income countries. For example, a vast majority of Canadian-trained nurses migrate to the United States of America and Australia. Medical doctors trained in Colombia move to Chile and the United States of America in relatively equal proportions. However, these mobility patterns seem to underpin the inequities in health outcomes that can be attributed to the higher health worker densities in high-income countries in comparison with low- and lower-middle income countries and their continuing struggle to train and retain their health workforce (40). Migration patterns among health workers, by occupation and by region, are clearly wide-ranging. A spotlight analysis of health worker mobility data in the NHWA from 16 countries compared the latest available data point closest to 2010 with the latest available data closest to 2021 and reveals that the percentage of foreign-trained medical doctors increased in Australia, Germany, Sweden and Switzerland, attenuated in Brazil, Finland, Israel, New Zealand and South Africa, and remained close to constant in Denmark, Norway and the United Kingdom (Fig. 2.19). Fig. 2.19 A comparison of changes in the percentage of foreign-trained medical doctors between 2000– 2010 and 2011–2021 for selected countries % fo re ig n- tra in ed m ed ica l d oc to rs 28 WHO report on global health worker mobility Fig. 2.20 A comparison of changes in the percentage of foreign-trained nursing personnel between 2000–2010 and 2011–2021 for selected countries In contrast, the percentage of foreign-trained nurses increased in in Australia, Belgium, New Zealand and United Kingdom, attenuated in Denmark, Latvia and Switzerland, and remained close to constant in France, Greece, Israel, Italy and Sweden (Fig. 2.20) An analysis of 64 destination countries which reported data on foreign-trained medical doctors and nurses by country of training revealed that countries on the WHO HWSSL 2023 were among the top list source countries. For example, two HWSSL countries (Nigeria and Pakistan) are among the top 20 source countries for medical doctors; and three HWSSL countries (Ghana, Haiti and Nigeria) are among the top 20 source countries for nursing personnel. In effect, high-income countries are disproportionately benefiting from highly skilled mobile health workers arriving from all countries across the economic spectrum, which undermines and hinders Member States’ efforts and investment toward achieving UHC by 2030. The report’s findings also showed sizeable disparities in the percentage of foreign-born and foreign-trained health workers due to prevailing country policies that target the recruitment of international health workers to mitigate gaps in their health workforce supply. For example, Australia, Canada, most of the Gulf States, Ireland, the United Kingdom and the United States of America engage in active recruitment of foreign-trained health workers. In-depth analysis of individuals’ data is required to understand how many of the foreign-born health workers completed their formal health training in their place (country) of birth, the country in which they currently work, or elsewhere. Such analysis would provide more insight into the distinction between national capacities for medical and health training versus the demand for health workers that exceeds the current supply. Regarding training capacities, Table 2.2 presents a descriptive analysis of correlations between the ratio of graduates to active stock and the percentages of foreign-trained and foreign-born health workers for a limited number of countries where data on graduates % fo re ig n- tra in ed n ur sin g pe rs on ne l 29 Health workforce mobility patterns are available for the same year when the health mobility indicators are calculated. Here, a negative correlation would imply that countries with a low ratio of graduates to total stock ratio (which could indicate low training and production capacity) are more likely to have higher percentage of foreign-trained/ foreign-born health workers. This seems to be the case for foreign-trained medical doctors and nursing personnel, albeit results lack statistical significance (p > 0.05). However, the inference of the correlation is perplexing and goes in the reverse direction in the case of the percentage of foreign-trained dentists and pharmacists. These correlations may become more meaningful if more data were to become available on the number of graduates by occupation in tandem with the improving health worker mobility data. Table 2.2 Correlation between the ratio of graduates to the total active stock with the percentage of foreign-trained or foreign-born health workers by occupation (2011–2021) Medical doctors Nursing personnel Dentists Pharmacists % of foreign-trained Correlation coefficient (r) -0.23 -0.08 0.78 0.63 Bonferroni-adjusted significance level (p value) 0.30 0.60 <0.01 0.03 No. of countries 23 44 17 12 % of foreign-born Correlation coefficient (r) -0.11 0.70 -0.04 -0.11 Bonferroni-adjusted significance level (p value) 0.63 <0.01 0.88 0.75 No. of countries 23 40 18 11 Equally important is the dynamic of oversupply of health workers in a given country, that can lead to individuals completing their formal training with the full intention to be recruited internationally. For example, foreign health workers (originally trained in India, Pakistan and the Philippines, amongst others) recruited in the Gulf States (a transit destination) are not guaranteed permanent residency, resulting in a good proportion of them moving on to countries such as Australia, Canada, Ireland and the United States of America, to gain permanent residency status (as a final destination). A similar pattern is observed among nurses trained in Australia who migrate to Ireland or the United Kingdom to acquire experience and certification in a foreign country to advance their careers. Among the various pathways for international mobility of health workers, the use of bilateral agreements (including regional, bilateral and multilateral agreements) has been on the increase. More than 150 bilateral agreements have been reported to WHO through the fourth round (2021-2022) of the NRI reporting on implementation of the Code. Agreements vary substantially in terms of their objective and content, with foci ranging from addressing workforce shortages and promoting health workers’ rights to education, health cooperation, technical support and trade. Analysis of the text of agreements reveals limited engagement of health ministries in the development of most of them, which could partially explain the absence of commitments in the agreements to strengthen health systems of source countries (24). WHO’s specific advice on the engagement of health ministries during the negotiation of bilateral agreements with countries in the HWSSL could also be extended to other countries as good practice (41). 30 WHO report on global health worker mobility 2.6 Global emergencies affecting health worker availability Health workers have been at the forefront of the COVID-19 crisis and confronted the huge strain the pandemic placed on health services. The COVID-19 pandemic has altered international mobility flows; countries most dependent on international migration may experience slower progression of their overall stock up to 2030 (42). The rising demand for health personnel has prompted contrasting government measures. While some countries have introduced a moratorium on the outward migration of health personnel, a greater number of countries have simplified the process for inward migration and professional licensure to facilitate rapid recruitment of international personnel. The combined impact on the mobility and migration of health workers will have to be monitored in the years to come. The negative health, economic and social impacts of COVID-19, combined with the potential acceleration of international migration, may lead to increasing vulnerabilities within countries already suffering from low health workforce densities (13). 31 3. Strengthening health worker mobility data generation – challenges and opportunities 3.1 Data challenges The findings of this report reassert the progress made in the improved reporting of health worker mobility data, particularly through the multiple rounds of the NRI since 2010 and the annual NHWA reporting mechanism established in 2017. This report features data from 134 countries, territories and areas, and presents an analysis focusing on the latest available data for the period 2011–2021. Data are collated on the NHWA platform from multiple sources of data, including annual reporting by national focal points, national ministries of health, professional associations, the NRI reports, JQ data, population census data and labour force surveys. One challenge lies in how to compare and triangulate data elements between countries when recorded by different sources and sometimes derived from slightly different years. Data sources also vary on whether they report on place of birth or place of training data, or both. A hidden complexity, depending on the data source used, is that health workers can be licensed to practise in several countries and in several subnational areas within a country, and hence there is a risk of being counted more than once in national statistics. Where countries’ data were available for both place of birth and place of training, the two indicators did not necessarily align as they tend to capture different information. In addition, the difference in metadata and different collection methods and data sources indicate just one challenge of monitoring health worker mobility. Another challenge is the lack of consistency in defining, framing and enumerating health worker mobility, be it health workers moving into a country or leaving a country. It is difficult to track health workers moving into a country, but even more difficult to count health workers leaving a country. Although the NHWA data align with the ISCO-08 coding for all occupations, identifying national occupation titles on a country-by- country basis and mapping those to a global dataset is not a straightforward task. More broadly than only for the health workforce, unified standardized measure(s) of mobility are perhaps needed with more consistent reporting globally to monitor IHWM and to accurately evaluate regional patterns of mobility. Understanding health workers’ mobility within a country is also crucial to assess how their geographical distribution and retention can impact 32 WHO report on global health worker mobility subnational areas differently (for example, between rural and remote settings compared with urban and peri-urban regions). Therefore, to adequately capture and explain health worker mobility patterns and trends (nationally and internationally), several dimensions need to be monitored: • health workers moving out of a country; • health workers moving into a country; • activity levels of health workers (practising, professionally active, licensed to practise); • employment status of health workers; • sector of employment of health workers; and • main occupation of the health workers. 3.2 Opportunities Strengthening national HRHIS is a fundamental investment in improving HRH data availability and quality. In tandem, countries’ implementation of NHWA opens up diversification of data sources (national statistics bureau, ministries of foreign affairs, education and labour etc.), which can strengthen data gathering on labour and mobility. In general, mobility data are often collected as stock-based, while flow- based data are also required to gain an adequate understanding of health workforce dynamics (43). Stock-based data for the health workforce monitor the number of workers participating in the HLM at a given time, while flow-based data describe flows within and out of the health workforce. Frequently accessed data sources for health workforce information are national HRHIS, HRH payroll systems and professional associations. However, these sources vary in their content and capability to capture detailed information on place of formal training or place of birth. Other sources that may be utilized to understand health worker mobility are records at immigration offices, where detailed records of health workers migrating for long-term settlement or recruited for short and fixed term are all captured. Professional licensure bodies may be able to count the annual inflow of health workers based on the number of health workers applying for license to practise. Table 3.1 provides an outline of sources for mobility data and some key benefits and limitations of each. 33 Strengthening health worker mobility data generation – challenges and opportunities Table 3.1 Potential sources of health workforce mobility data: a comparative overview Source Key concept Measures of Place of training/ birth Employment status (to distinguish active/ inactive) stocks inflow Foreign- trained Foreign- born Surveys of health personnel In some countries, the health ministry or other bodies regularly conduct (or commission) surveys on health personnel, usually separately by occupation type. These surveys can provide a broad set of data on education, migration and employment, with variable frequency (ranging from annual surveys, to once every 3 to 5 years). Yes Yes Yes Noa Yes Labour force surveys These are implemented globally to collect data on labour market participation, covering all sectors and all occupations in the economy. Yesa Noa Noa Yes Yes International migration household surveys An example of these is the MED-HIMS5 (Household International Migration Surveys in the Mediterranean countries) – a regional programme of coordinated international migration surveys requested by the national statistical offices of most of the countries of the European Neighbourhood Policy – South Region. Yesb Yesb Yesb Yesb Yesb Population censuses Conducted once every 10 years, censuses provide nationally representative information on health workers’ country of birth, nationality/ citizenship, previous place of residence and/or place of residence at a given time in the past (e.g. 5 years) as key information on the migration status among medical, nursing and other health professionals. Yes No Noa Yes Yes Work permit issuing entities including ministry of interior Except within free movement areas, migrants intending to move to another country to work or settle usually need to apply for and be granted a work permit. No Yes No No No Recognition of foreign qualifications Qualification recognition is one of the requirements for health workers to be able to practise. The ministry of health or education, regulatory authority for health practitioners or a commissioned entity6 could be responsible for recognition of qualifications acquired outside of the country. No Yesc Yes Yesc No 5 https://ec.europa.eu/eurostat/web/european-neighbourhood-policy/enp-south/med-hims 6 For example the Commission on Graduates of Foreign Nursing Schools (CGFNS) and Education Commission for Foreign Medical Graduates (ECFMG) are organizations that foreign-trained nurses and doctors with a comprehensive assessment of their academic records use to facilitate admission to academic programmes or entry to practise in the United States of America. 34 WHO report on global health worker mobility Source Key concept Measures of Place of training/ birth Employment status (to distinguish active/ inactive) stocks inflow Foreign- trained Foreign- born Professional registries maintained by regulators Regulators maintain a registry of health workers who have been authorized to enter into practice. The information in the registry varies between countries and regulators. In some countries the registration or licensure of health workers is time-limited and requires periodic renewals while in others it can be valid for life. Yesd Yes Yes Yese No Government registries on HRH and/or information systems (national/ subnational) Information on employed health workers are captured and documented in human resources records and may include “country of birth”, “citizenship at birth”, “country of present citizenship”, “country of residence”, as well as “country of professional training”. HRHIS data are commonly used as a “stock only” source; however, increasingly, more countries are investing in using unique identification numbers for their health workers, which could be an opportunity for the “inflow” aspect to be addressed. Yes Yes Yes Yes Yes Notes: a Limited capacity. b Conducted in source countries with the potential to include HRH data. c Not all those requesting qualification validation may actually move (e.g. some may not meet other requirements, others may change their mind). It is more a measure of intention of inflow than actual inflow. d Depends on how the registry is maintained. Data on stocks could be valid if registries include data on entry and exit. When exit data are not included, the stock data are not accurate since they may include deceased and retired workers and those who have moved to another country or jurisdiction. e May capture nationality insteadof place of birth. Source: Adapted from Strengthening the collection, analysis and use of health workforce data and information: a handbook, Chapter 6 (WHO, 2022). Finally, the importance of multistakeholder engagement at the national level cannot be overstated in harnessing awareness, knowledge and actions on the merits of collecting and sharing health worker mobility data. As articulated in the NHWA implementation guide, this is a vital principle for effective and regular data gathering from multiple sources and entities, using concise metadata and data sharing protocols that can support analysis, interpretation, coverage and data use, whilst improving data quality. At the national level, drawing on the role and expertise of the NHWA technical working group is a key advantage as the group can guide the formation of the data sharing protocols, the definition of the quality assurance criteria, and the harmonization of mobility data from different sources. Their expertise can also support the triangulation of data for the same indicator emanating from different sources (44). With the harmonization and centralization of the health worker mobility data into the NHWA reporting mechanism, quality and sustainability can only grow over time. 35 Strengthening health worker mobility data generation – challenges and opportunities 3.3 Key findings and global messages This global report provides a unique and first presentation of health worker mobility data emanating from 134 countries representing 64% of the world’s population. It provides crucial comparisons using two interdependent statistics: the percentages of foreign- trained and foreign-born health workers measured (by occupation) at national level by using the total stock of active health workers as the denominator, and the numbers of foreign-trained and foreign-born health- workers, as numerator. Key features and selected findings of this report: • This report presents the largest global coverage, to date, of countries’ health worker mobility data from the past two decades: for medical doctors (93 countries), nursing personnel (129 countries), dentists (68 countries) and pharmacists (70 countries). • Source country data have expanded to include Egypt, Germany, New Zealand, Romania, Russian Federation and the United Kingdom compared with previous evidence, which focused attention on India, Pakistan, the Philippines and South Africa. • The strong influence of language and geographical proximity – almost all mobile nursing personnel trained in the Philippines are in Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America, where English is the common language. Where French is the common language, 87% of mobile nursing personnel trained in Belgium are in France; 94% of mobile nurses trained in France are in Switzerland. These patterns may also be a product of bilateral and multilateral agreements between countries and a common system of recognition of qualifications. • Data from 93 countries indicate that mobile medical doctors are mostly working in the top six destination countries (Australia, France, Germany, Saudi Arabia, the United Kingdom and the United States of America) and that seven source countries alone (Egypt, Germany, India, Pakistan, Romania, Russian Federation and the United Kingdom) are the place of training for more than 30% of them globally. • Data from 129 countries indicate that the largest percentage of mobile nursing personnel primarily migrate to the United Kingdom and the United States of America. The United States of America is not only a top destination country, but certain groups of mobile nursing personnel (notably those trained in Canada, Haiti, Jamacia, Mexico and Nigeria) exclusively move there to work, rather than any other country. • Data on mobile dentists from 68 countries clearly highlight the situation of countries where the percentage of foreign-trained dentists lies below 40% – a delineator of where true market demand is the force behind the observed mobility pattern, rather than education and training capacities. By contrast, in countries where the percentage of foreign- born dentists exceeds 80%, there could be a strong indication of insufficient or absent training capacities. • Similarly, data on mobile pharmacists from 70 countries strongly suggest a tiered dependency situation between countries of low (< 20%), moderate (20–50%) and high (> 50%) percentages of foreign-trained pharmacists due to differential market demands. • The report also features the situation of small island developing states (British Virgin Islands, Palau, Niue, Timor-Leste to name a few), that have high proportions of foreign-trained health workers in key health occupations. The situation of these countries illustrates the need for technical cooperation (a core principle of the Code) to support sustainable and effective policies to produce an adequate supply of health workers. • Using a regional lens comparison, and notwithstanding intraregional variations, 36 WHO report on global health worker mobility the report illustrates that the WHO Eastern Mediterranean Region has the highest median percentage of foreign-trained medical doctors (> 60%) and foreign-trained nursing personnel (> 30%). In all WHO regions, the presence of foreign-born health workers is much lower than that of foreign-trained health workers, which testifies to reliance on the international education market rather than the HLM. • Using an economic lens, the estimated median percentage of foreign-trained medical doctors remains highest (> 30%) in high-income countries. Interestingly, the median percentage of foreign-trained nursing personnel remains comparable among all economies (< 10%). However, results slightly vary if the percentage of foreign-born health personnel is used. While this report has depicted the scope of patterns and trends that can be gleaned from the improved availability of health worker data, it has also revealed key challenges and limitations to reflect upon. Firstly, reporting on health worker mobility remains incomplete as almost all the calculus comes from destination countries alone. Most source countries have no reliable way to track the emigration of their skilled health workers. Secondly, collecting data on the total stock of the active workforce by place of training is a significant undertaking for destination countries and requires a dedicated and mandated system of individual-level data to collect this information. Here, consulting professional registries may not be accurate enough as being registered does not necessarily mean being actively employed. Thirdly, the observed patterns of “foreign-trained” health workers offer a limited interpretation of destination country dependencies in the absence of reflective data on the education market (e.g. number of health and medical institutions, number of admissions, number of graduates among others).7 7 Modules 2 and 3 of the NHWA. It is well accepted that both migration and mobility are necessary for addressing skills imbalances and responding to labour market demands (19). Here, the report also provides a strong case to target national, regional and global investments that support and strengthen the generation of health worker mobility data to monitor and better plan for the future HLM demands, by: • Strengthening national capacities in HRH data collection, analysis and use through the progressive implementation of NHWA and engagement with various stakeholders – ministries of health, labour, foreign affairs and education, professional associations amongst others. • Strengthening the alignment and multistakeholder engagement required for an effective implementation of the NHWA and regular monitoring of the Code. • Adhering to EAG recommendations on monitoring the HLM situation of the HWSSL countries on a regular basis, regarding international recruitment, at each time point that the list gets updated. 37 References 1. A dynamic understanding of health worker migration. 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Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/275473, accessed 27 December 2022). 41 An ne x 1: C ou nt rie s in cl ud ed in th e re po rt, b y W HO re gi on A fr ic an R eg io n (n =2 5) Re gi on o f t he A m er ic as (n =2 6) So ut h- Ea st A si a Re gi on (n =1 1) Eu ro pe an R eg io n (n =3 3) Ea st er n M ed ite rr an ea n Re gi on (n =1 4) W es te rn P ac ifi c R eg io n (n =2 1) Al ge ria An tig ua a nd B ar bu da Ba ng la de sh Ar m en ia Af gh an is ta n Au st ra lia Be ni n B el iz e Bh ut an Au st ria Ba hr ai n Br un ei D ar us sa la m Bo ts w an a B ra zi l D em oc ra tic P eo pl e’ s R ep ub lic of K or ea Be la ru s Eg yp t Ca m bo di a Ca bo V er de Ca na da In di a Be lg iu m Ira n (Is la m ic R ep ub lic o f) Ch in a, H on g Ko ng S AR Ca m er oo n Ch ile In do ne si a Bu lg ar ia Jo rd an C oo k Is la nd s Ch ad C ol om bi a M al di ve s C yp ru s Ku w ai t Fi ji C ôt e d’ Iv oi re C os ta R ic a M ya nm ar C ze ch ia Li by a Ki rib at i D em oc ra tic Re pu bl ic o f t he C on go Cu ba N ep al D en m ar k O m an La o P eo pl e’ s D em oc ra tic Re pu bl ic Es w at in i Ec ua do r Sr i L an ka Es to ni a Pa ki st an M al ay si a G ab on El S al va do r Th ai la nd Fi nl an d Q at ar M ar sh al l I sl an ds G ha na G re na da Ti m or -L es te Fr an ce Sa ud i A ra bi a M ic ro ne si a (F ed er at ed S ta te s of ) Ke ny a G uy an a G er m an y Su da n N au ru Le so th o H on du ra s G re ec e Ye m en N ew Z ea la nd M al i Ja m ai ca H un ga ry N iu e M oz am bi qu e M ex ic o Ic el an d Pa la u 42 WHO report on global health worker mobility A fr ic an R eg io n (n =2 5) Re gi on o f t he A m er ic as (n =2 6) So ut h- Ea st A si a Re gi on (n =1 1) Eu ro pe an R eg io n (n =3 3) Ea st er n M ed ite rr an ea n Re gi on (n =1 4) W es te rn P ac ifi c R eg io n (n =2 1) N am ib ia Pa na m a Ire la nd Pa pu a N ew G ui ne a N ig er ia Pa ra gu ay Is ra el Sa m oa S ao T om e an d Pr in ci pe Pe ru Ita ly Si ng ap or e Se ne ga l Pu er to R ic o La tv ia To ng a Se yc he lle s Sa in t L uc ia Li th ua ni a Tu va lu Si er ra L eo ne Sa in t V in ce nt a nd th e G re na di ne s M al ta Va nu at u So ut h Af ric a Su rin am e M on ac o U ga nd a Tr in id ad a nd T ob ag o N et he rla nd s (K in gd om of th e) Za m bi a U ni te d St at es o f A m er ic a N or w ay Zi m ba bw e U ru gu ay Po la nd Ve ne zu el a (B ol iv ar ia n Re pu bl ic o f) Po rt ug al Ro m an ia Sl ov ak ia Sl ov en ia Sw ed en S w itz er la nd Tü rk iy e U ni te d Ki ng do m 43 Annexes An ne x 2: D is tri bu tio n of fo re ig n- tra in ed m ed ic al d oc to rs b y c ou nt ry o f o rig in / tra in in g, s el ec te d de st in at io n co un tri es Mo za m bi qu e M al i C hi le U ni te d St at es o f A m er ic a Jo rd an Sa ud i A ra bi a C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) Cu ba (6 9. 5) C ôt e d’ Iv oi re (2 3. 3) Ve ne zu el a (3 8. 4) In di a (3 5. 1) U kr ai ne (3 7. 2) Eg yp t ( 41 .6 ) D em oc ra tic P eo pl e’ s R ep ub lic of K or ea (2 3. 2) Bu rk in a Fa so (1 6. 7) Ec ua do r ( 20 .4 ) Pa ki st an (1 0. 1) Ch in a (1 7. 5) Su da n (3 9. 1) Ch in a (2 ) G ha na (6 .7 ) C ol om bi a (1 9. 5) G re na da (9 ) Eg yp t ( 13 .9 ) Pa ki st an (8 .2 ) C on go (1 ) Fr an ce (6 .7 ) Cu ba (5 .3 ) D om in ic a (8 .2 ) Ru ss ia n Fe de ra tio n (8 .5 ) N ig er ia (5 .8 ) In di a (0 .8 ) N ig er (6 .7 ) Bo liv ia (P lu rin at io na l S ta te of ) ( 3. 8) Ph ili pp in es (7 .9 ) Ye m en (7 .8 ) In di a (5 .4 ) Ita ly (0 .6 ) U ni te d St at es o f A m er ic a (6 .7 ) Ar ge nt in a (3 .8 ) M ex ic o (7 .9 ) Al ba ni a (6 .5 )   Sa o To m e an d Pr in ci pe (0 .6 ) Ca m er oo n (6 .7 ) U ru gu ay (1 .9 ) Ca na da (7 .5 ) Su da n (4 .4 )   Vi et N am (0 .4 ) Ru ss ia n Fe de ra tio n (3 .3 ) Pe ru (1 .4 ) D om in ic an R ep ub lic (5 .1) Ba hr ai n (1 .5 )   O th er c ou nt rie s (1 .8 ) O th er c ou nt rie s (2 3. 2) O th er c ou nt rie s (4 .8 ) O th er c ou nt rie s (9 .2 ) O th er c ou nt rie s (2 .8 )   44 WHO report on global health worker mobility Fr an ce G er m an y S w itz er la nd U ni te d Ki ng do m C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) Ro m an ia (1 8. 6) Sy ria n Ar ab R ep ub lic (8 .6 ) G er m an y (5 2. 6) In di a (2 9. 5) Al ge ria (1 4. 7) Ro m an ia (8 .4 ) Ita ly (9 .1) Pa ki st an (1 1. 9) Be lg iu m (6 .6 ) G re ec e (5 .4 ) Fr an ce (7 .1) N ig er ia (6 .8 ) Ita ly (6 .3 ) Ru ss ia n Fe de ra tio n (4 .6 ) Au st ria (6 ) Eg yp t ( 6) Sy ria n Ar ab R ep ub lic (3 .9 ) Au st ria (4 .3 ) Ro m an ia (2 .7 ) Ire la nd (3 ) M or oc co (3 .5 ) Po la nd (3 .7 ) G re ec e (1 .8 ) G re ec e (2 .3 ) Tu ni si a (3 .3 ) Bu lg ar ia (3 .3 ) Be lg iu m (1 .5 ) Su da n (2 .3 ) Sp ai n (2 .8 ) U kr ai ne (3 .2 ) H un ga ry (1 .4 ) Ro m an ia (2 .2 ) O th er c ou nt rie s (4 0) Se rb ia (3 .1) Sp ai n (1 .4 ) Ira q (2 .2 )   O th er c ou nt rie s (5 5) O th er c ou nt rie s (1 5. 6) O th er c ou nt rie s (3 3. 6) 45 Annexes M al di ve s Ti m or -L es te A us tr al ia N ew Z ea la nd C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) Au st ria (1 2. 7) Cu ba (9 7.9 ) U ni te d Ki ng do m (1 9. 9) U ni te d Ki ng do m (4 2. 1) Ba ng la de sh (9 .4 ) In do ne si a (1 .3 ) In di a (1 7. 6) So ut h Af ric a (9 .9 ) El S al va do r ( 7. 5) Fi ji (0 .5 ) N ew Z ea la nd (6 .9 ) Au st ra lia (8 .2 ) A ze rb ai ja n (7 .3 ) Pa pu a N ew G ui ne a (0 .2 ) So ut h Af ric a (5 .9 ) In di a (6 .9 ) In di a (6 .7 )   Sr i L an ka (5 .5 ) U ni te d St at es o f A m er ic a (5 .5 ) Eg yp t ( 6)   Pa ki st an (3 .9 ) Ire la nd (4 .4 ) Pa ki st an (5 )   Ire la nd (3 .5 ) G er m an y (2 .5 ) N ep al (4 )   Ba ng la de sh (2 .8 ) N et he rla nd s (K in gd om o f t he ) ( 1. 6) O th er c ou nt rie s (4 1. 3)   O th er c ou nt rie s (3 4) Sr i L an ka (1 .5 )       O th er c ou nt rie s (1 6. 9) WHO report on global health worker mobility 46 An ne x 3: D is tri bu tio n of fo re ig n- tra in ed n ur si ng p er so nn el b y c ou nt ry o f o rig in / tra in in g, s el ec te d de st in at io n co un tri es M al i Be ni n U ni te d St at es o f A m er ic a Ca na da Sa ud i A ra bi a C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ou nt ry o f o rig in /t ra in in g (% ) C ôt e d’ Iv oi re (4 0. 9) To go (4 7.1 ) Ph ili pp in es (1 6) Ph ili pp in es (3 4. 4) In di a (7 9. 2) Bu rk in a Fa so (1 3. 6) N ig er ia (2 3. 5) M ex ic o (5 .9 ) In di a (1 6) Ph ili pp in es (5 .5 ) N ig er (9 .1) C ôt e d’ Iv oi re (2 3. 5) Ja m ai ca (5 .6 ) U ni te d Ki ng do m (6 .6 ) Eg yp t ( 5) Se ne ga l ( 9. 1) N ig er (5 .9 ) N ig er ia (5 .2 ) U ni te d St at es o f A m er ic a (5 .9 ) Su da n (4 .5 ) G ui ne a (4 .5 )   H ai ti (5 .2 ) Fr an ce (4 .2 ) O th er c ou nt rie s (5 .8 ) Fr an ce (4 .5 )   G er m an y (4 ) Ch in a (3 .5 ) C on go (4 .5 )   Ch in a (2 .9 ) Ira n (Is la m ic R ep ub lic o f) (2 .3 )   To go (4 .5 )   Cu ba (2 .6 ) O th er c ou nt rie s (2 6. 9)   O th er c ou nt rie s (9 )   O th er c ou nt rie s (5 2. 3)     47 Annexes Fr an ce Ir el an d U ni te d Ki ng do m M al di ve s Ti m or -L es te Au st ra lia N ew Z ea la nd C ou nt ry o f o rig in / tr ai ni ng (% ) C ou nt ry o f o rig in / tr ai ni ng (% ) C ou nt ry o f o rig in / tr ai ni ng (% ) C ou nt ry o f o rig in / tr ai ni ng (% ) C ou nt ry o f o rig in / tr ai ni ng (% ) C ou nt ry o f o rig in / tr ai ni ng (% ) C ou nt ry o f o rig in / tr ai ni ng (% ) Be lg iu m (4 3. 8) U ni te d Ki ng do m (3 6. 1) Ph ili pp in es (3 0. 9) In di a (9 7. 6) In do ne si a (1 00 ) U ni te d Ki ng do m (2 5. 1) Ph ili pp in es (3 5. 6) M or oc co (1 4. 4) In di a (2 4. 1) In di a (2 2. 9) Sr i L an ka (1 .6 )   In di a (2 0. 9) U ni te d Ki ng do m (2 2) N on -W H O M em be r St at es (1 3. 8) Ph ili pp in es (2 0. 4) Ro m an ia (6 .8 ) Pa ki st an (0 .5 )   Ph ili pp in es (1 6. 8) In di a (2 0. 8) Sp ai n (6 .9 ) U ni te d St at es o f Am er ic a (3 .1) Po rt ug al (4 ) Ph ili pp in es (0 .3 )   N ew Z ea la nd (1 2. 2) Au st ra lia (5 .1) Po rt ug al (5 .2 ) Po la nd (2 .6 ) Sp ai n (3 .5 )     Ire la nd (3 .8 ) So ut h Af ric a (3 .8 ) Tu ni si a (4 .4 ) N ig er ia (2 .2 ) N ig er ia (3 .4 )     So ut h Af ric a (3 ) Fi ji (2 .6 ) G er m an y (2 .4 ) G er m an y (1 .1) Ita ly (3 .2 )     Ch in a (2 .5 ) U ni te d St at es o f Am er ic a (1 .2 ) U ni te d Ki ng do m (2 .2 ) So ut h Af ric a (1 .1) So ut h Af ric a (2 .7 )     O th er c ou nt rie s (1 5. 6) Ch in a (0 .9 ) O th er c ou nt rie s (6 .8 ) O th er c ou nt rie s (9 .9 ) O th er c ou nt rie s (2 2. 1)       O th er c ou nt rie s (7 .4 ) 48 WHO report on global health worker mobility YES Algeria (WHO African Region) Percentage foreign-trained and foreign-born health workers for selected occupations * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 12.0 17.2 Nursing and midwifery personnel per 10 000 population 19.3 15.5 Dentists per 10 000 population 3.1 3.7 Pharmacists per 10 000 population 2.2 4.5 Net* migration rate (per 1000 population) 2000 2010 2021 -0.6 -0.9 -0.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 103.8 27.6 YEARS 0.748 (rank 91 of 189) 100% 0.0 0.2 0.4 0.6 0.8 1.0 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 75 43 090 987 On HWSSL 2023? Has a NHWA focal point? Has a DNA? Has responded to the rounds of the NRI? 2012 2015 2018 2021 Lower middle income country (2021) Annex 4: Selected country profiles NO 49 Annexes Australia (WHO Western Pacific Region) High income country (2021) Has a NHWA focal point? Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 33.4 41.3 Nursing and midwifery personnel per 10 000 population 104.0 131.4 Dentists per 10 000 population 5.2 6.2 Pharmacists per 10 000 population 8.7 9.0 Net* migration rate (per 1000 population) 2000 2010 2021 5.8 7.6 4.6 2012 2015 2018 2021 Yes Yes Yes Population size (2020): Population sex ratio (males per 100 females): Median age: Human Development Index (2019): 98.5 36.7 YEARS 0.944 (rank 7 of 189) 0 20 40 60 80 100 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % YES NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 87 25 544 179 Domestic health expenditure as % of current health expenditure (CHE) (2019): 100% YES Percentage foreign-trained and foreign-born health workers for selected occupations 50 WHO report on global health worker mobility Austria (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 48.0 52.9 Nursing and midwifery personnel per 10 000 population 67.2 105.6 Dentists per 10 000 population 5.6 105.6 Pharmacists per 10 000 population 6.6 5.7 Net* migration rate (per 1000 population) 2000 2010 2021 2.2 2.7 2.3 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 96.9 42.6 YEARS 0.922 (rank 18 of 189) 100% 0 10 20 30 40 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 82 8 901 106 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES YES High income country (2021) * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 51 Annexes Belgium (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 29.1 60.8 Nursing and midwifery personnel per 10 000 population 100.9 200.8 Dentists per 10 000 population 7.0 11.0 Pharmacists per 10 000 population 11.5 19.8 Net* migration rate (per 1000 population) 2000 2010 2021 3.1 5 4.5 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 97.5 40.8 YEARS 0.931 (rank 13 of 189) 100% 0 5 10 15 20 25 30 35 40 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 85 11 541 273 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes Yes YES High income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 52 WHO report on global health worker mobility Bhutan (WHO South-East Asia Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 2.5 5.0 Nursing and midwifery personnel per 10 000 population 10.0 20.8 Dentists per 10 000 population 0.1 1.0 Pharmacists per 10 000 population 0.2 0.7 Net* migration rate (per 1000 population) 2000 2010 2021 10.4 -1.7 0.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 112.8 27.6 YEARS 0.654 (rank 13 of 189) 93% 0 10 20 30 40 50 60 70 80 90 100 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 62 770 004 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Lower middle income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 53 Annexes Brunei Darussalam (WHO Western Pacific Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 14.5 16.1 Nursing and midwifery personnel per 10 000 population 74.8 59.0 Dentists per 10 000 population 2.2 2.5 Pharmacists per 10 000 population 1.1 1.7 Net* migration rate (per 1000 population) 2000 2010 2021 5 1.2 -0.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 107.3 31.3 YEARS 0.838 (rank 47 of 189) 100% 0 10 20 30 40 50 60 70 80 90 100 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 77 439 893 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes YES High income country (2021) NO Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 54 WHO report on global health worker mobility Cameroon (WHO African Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 0.8 1.3 Nursing and midwifery personnel per 10 000 population 5.3 3.6 Dentists per 10 000 population 0.03 0.11 Pharmacists per 10 000 population 0.02 0.01 Net* migration rate (per 1000 population) 2000 2010 2021 -1.4 -0.5 -0.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 99.5 17.4 YEARS 0.563 (rank 153 of 189) 85.8% 0 10 20 30 40 50 60 70 80 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 44 26 137 129 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes YES Lower middle income country (2021) YES YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 55 Annexes Chad (WHO African Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 0.4 0.6 Nursing and midwifery personnel per 10 000 population 1.8 2.0 Dentists per 10 000 population 0.01 <0.01 Pharmacists per 10 000 population 0.03 0.03 Net* migration rate (per 1000 population) 2000 2010 2021 0.5 0.9 0.5 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 100.8 14.9 YEARS 0.398 (rank 187 of 189) 79.6% 0 10 20 30 40 50 60 70 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 28 16 379 185 Has a NHWA focal point? 2012 2015 2018 2021 Yes YES Low income country (2021) YES YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 56 WHO report on global health worker mobility Costa Rica (WHO Region of the Americas) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 23.1 33.0 Nursing and midwifery personnel per 10 000 population 18.6 38.0 Dentists per 10 000 population 3.7 11.5 Pharmacists per 10 000 population 2.9 11.9 Net* migration rate (per 1000 population) 2000 2010 2021 3.4 1 0.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 100.2 32.4 YEARS 0.81 (rank 61 of 189) 100% 0 5 10 15 20 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 78 5 105 359 Has a NHWA focal point? 2012 2015 2018 2021 Yes YES Upper middle income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 57 Annexes El Salvador (WHO Region of the Americas) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 18.8 28.7 Nursing and midwifery personnel per 10 000 population 13.7 18.3 Dentists per 10 000 population 7.6 8.7 Pharmacists per 10 000 population 3.8 6.5 Net* migration rate (per 1000 population) 2000 2010 2021 -16.2 -8.9 -4.3 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 91 25.9 YEARS 0.673 (rank 124 of 189) 99.4% 0 5 10 15 20 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 76 6 280 922 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Lower middle income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 58 WHO report on global health worker mobility Finland (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 32.7 46.4 Nursing and midwifery personnel per 10 000 population 142.6 223.1 Dentists per 10 000 population 7.9 10.8 Pharmacists per 10 000 population 11.1 19.2 Net* migration rate (per 1000 population) 2000 2010 2021 0.5 2.6 2.7 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 97.6 42.2 YEARS 0.938 (rank 11 of 189) 100% 0 1 2 3 4 5 6 7 8 9 10 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 83 5 525 215 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES High income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 59 Annexes YES Gabon (WHO African Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 1.0 6.5 Nursing and midwifery personnel per 10 000 population 50.1 21.1 Dentists per 10 000 population 0.2 0.2 Pharmacists per 10 000 population 0.2 1.1 Net* migration rate (per 1000 population) 2000 2010 2021 2.4 10.1 0.6 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 104 21.6 YEARS 0.703 (rank 119 of 189) 99.4% 0 10 20 30 40 50 60 70 80 90 100 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 49 2 267 995 Has a NHWA focal point? 2012 2015 2018 2021 Upper middle income country (2021) YES NO Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 60 WHO report on global health worker mobility Greece (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 58.8 63.1 Nursing and midwifery personnel per 10 000 population 37.6 37.3 Dentists per 10 000 population 13.5 12.9 Pharmacists per 10 000 population 10.2 10.9 Net* migration rate (per 1000 population) 2000 2010 2021 3.2 -2.3 -1.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 96.1 44.4 YEARS 0.888 (rank 33 of 189) 99.9% 0 5 10 15 20 25 30 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO NO NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 78 10 543 346 Has a NHWA focal point? 2012 2015 2018 2021 High income country (2021) Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 61 Annexes Hungary (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 28.9 60.6 Nursing and midwifery personnel per 10 000 population 64.3 69.2 Dentists per 10 000 population 5.3 7.4 Pharmacists per 10 000 population 5.9 8.4 Net* migration rate (per 1000 population) 2000 2010 2021 1.5 1.1 2 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 92 42.5 YEARS 0.854 (rank 42 of 189) 100% 0 5 10 15 20 25 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 73 9 770 120 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes Yes YES High income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 62 WHO report on global health worker mobility Indonesia (WHO South-East Asia Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 1.4 6.2 Nursing and midwifery personnel per 10 000 population 8.2 39.5 Dentists per 10 000 population 0.4 1.2 Pharmacists per 10 000 population 0.1 0.9 Net* migration rate (per 1000 population) 2000 2010 2021 -0.2 -0.3 -0.1 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 101.5 29.3 YEARS 0.718 (rank 110 of 189) 99.4% 0 10 20 30 40 50 60 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 59 270 825 848 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes Yes YES Lower middle income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 63 Annexes Ireland (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 41.3 34.9 Nursing and midwifery personnel per 10 000 population 134.7 179.8 Dentists per 10 000 population 6.0 6.7 Pharmacists per 10 000 population 10.0 13.7 Net* migration rate (per 1000 population) 2000 2010 2021 8.3 -6 3.1 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 98.2 37.3 YEARS 0.955 (rank 3 of 189) 100% 0 10 20 30 40 50 60 70 80 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 83 4 925 074 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES High income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 64 WHO report on global health worker mobility Iran (Islamic Republic of) (WHO Eastern Mediterranean Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 5.4 15.8 Nursing and midwifery personnel per 10 000 population 16.9 20.8 Dentists per 10 000 population 1.4 4.5 Pharmacists per 10 000 population 1.0 2.9 Net* migration rate (per 1000 population) 2000 2010 2021 6 1.7 0.3 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 102.3 31.4 YEARS 0.783 (rank 70 of 189) 100% 0 5 10 15 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 77 86 990 162 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Lower middle income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 65 Annexes Italy (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 38.2 39.5 Nursing and midwifery personnel per 10 000 population 55.2 62.7 Dentists per 10 000 population 5.7 8.4 Pharmacists per 10 000 population 8.7 12.1 Net* migration rate (per 1000 population) 2000 2010 2021 0.9 4.5 0.5 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 95 46.4 YEARS 0.892 (rank 29 of 189) 100% 0 1 2 3 4 5 6 7 8 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 83 59 639 898 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes Yes YES High income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 66 WHO report on global health worker mobility Jordan (WHO Eastern Mediterranean Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 22.3 26.6 Nursing and midwifery personnel per 10 000 population 35.3 33.5 Dentists per 10 000 population 7.8 7.8 Pharmacists per 10 000 population 12.6 10.4 Net* migration rate (per 1000 population) 2000 2010 2021 -5.1 0.7 1.3 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 107.9 23.1 YEARS 0.729 (rank 103 of 189) 96.9% 0 10 20 30 40 50 60 70 80 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 60 10 817 077 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Upper middle income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 67 Annexes Lao People’s Democratic Republic (WHO Western Pacific Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 2.0 3.5 Nursing and midwifery personnel per 10 000 population 8.6 11.9 Dentists per 10 000 population 0.4 0.8 Pharmacists per 10 000 population 2.3 Net* migration rate (per 1000 population) 2000 2010 2021 -6.2 -4.3 -1.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 101.7 23.5 YEARS 0.613 (rank 137 of 189) 78.8% 0 5 10 15 20 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 50 7 265 653 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Lower middle income country (2021) YES YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 68 WHO report on global health worker mobility Lithuania (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 39.1 50.8 Nursing and midwifery personnel per 10 000 population 75.9 100.8 Dentists per 10 000 population 7.9 14.0 Pharmacists per 10 000 population 9.2 12.7 Net* migration rate (per 1000 population) 2000 2010 2021 -8.6 -9.2 -4.2 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 88.1 43.5 YEARS 0.882 (rank 35 of 189) 99.6% 0.0 0.2 0.4 0.6 0.8 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 70 2 835 900 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes Yes YES High income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 69 Annexes Malaysia (WHO Western Pacific Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 11.7 22.9 Nursing and midwifery personnel per 10 000 population 32.0 34.8 Dentists per 10 000 population 1.4 3.1 Pharmacists per 10 000 population 2.8 3.5 Net* migration rate (per 1000 population) 2000 2010 2021 7.6 4 1.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 104.8 29.5 YEARS 0.81 (rank 63 of 189) 100% 0 10 20 30 40 50 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 76 33 003 638 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Upper middle income country (2021) * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations NO 70 WHO report on global health worker mobility Maldives (WHO South-East Asia Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 14.4 20.5 Nursing and midwifery personnel per 10 000 population 51.1 46.6 Dentists per 10 000 population 0.9 1.0 Pharmacists per 10 000 population 6.8 6.5 Net* migration rate (per 1000 population) 2000 2010 2021 0.5 17.4 2.3 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 136.7 29.9 YEARS 0.74 (rank 98 of 189) 98.4% 0 10 20 30 40 50 60 70 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 69 510 890 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Upper middle income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 71 Annexes Malta (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 21.5 28.6 Nursing and midwifery personnel per 10 000 population 68.5 94.8 Dentists per 10 000 population 4.4 4.8 Pharmacists per 10 000 population 7.3 12.9 Net* migration rate (per 1000 population) 2000 2010 2021 4.5 7.3 20 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 107.4 39 YEARS 0.895 (rank 28 of 189) 100% 0 5 10 15 20 25 30 35 Foreign-trainedForeign-born PharmacistsDentistsMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 81 509 595 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes YES High income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 72 WHO report on global health worker mobility Mozambique (WHO African Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 0.5 0.9 Nursing and midwifery personnel per 10 000 population 4.0 4.8 Dentists per 10 000 population 0.03 0.1 Pharmacists per 10 000 population 0.02 0.1 Net* migration rate (per 1000 population) 2000 2010 2021 -3.3 -1.3 -0.3 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 96.3 16.7 YEARS 0.456 (rank 181 of 189) 37.3% 0 5 10 15 20 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 47 30 720 752 Has a NHWA focal point? 2012 2015 2018 2021 Low income country (2021) YES NO YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 73 Annexes Namibia (WHO African Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 3.9 5.9 Nursing and midwifery personnel per 10 000 population 28.7 19.5 Dentists per 10 000 population 0.5 0.7 Pharmacists per 10 000 population 1.2 2.4 Net* migration rate (per 1000 population) 2000 2010 2021 3.1 -4 -1.7 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 93.3 21.2 YEARS 0.646 (rank 129 of 189) 95.3% 0 10 20 30 40 50 60 70 80 90 100 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 62 2 467 077 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes YES Upper middle income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 74 WHO report on global health worker mobility Nigeria (WHO African Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 3.8 3.8 Nursing and midwifery personnel per 10 000 population 13.6 15.0 Dentists per 10 000 population 0.5 0.2 Pharmacists per 10 000 population 0.7 1.2 Net* migration rate (per 1000 population) 2000 2010 2021 0.3 0.1 -0.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 102.1 16.9 YEARS 0.539 (rank 161 of 189) 87.3% 0 5 10 15 20 25 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 44 205 780 595 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Lower middle income country (2021) YES YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 75 Annexes Norway (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 41.2 50.5 Nursing and midwifery personnel per 10 000 population 166.7 184.2 Dentists per 10 000 population 8.8 9.0 Pharmacists per 10 000 population 6.4 8.8 Net* migration rate (per 1000 population) 2000 2010 2021 2.2 8.8 2 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 101.7 39 YEARS 0.957 (rank 1 of 189) 100% 0 10 20 30 40 50 Foreign-trainedForeign-born PharmacistsDentistsNursing personnel % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 86 5 367 955 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes Yes YES High income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 76 WHO report on global health worker mobility Oman (WHO Eastern Mediterranean Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 19.3 17.7 Nursing and midwifery personnel per 10 000 population 42.3 39.4 Dentists per 10 000 population 2.2 3.0 Pharmacists per 10 000 population 4.1 5.7 Net* migration rate (per 1000 population) 2000 2010 2021 -8.4 96 -4.6 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 163.8 28.8 YEARS 0.813 (rank 56 of 189) 100% 0 10 20 30 40 50 60 70 80 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 69 4 589 136 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes YES High income country (2021) NO * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 77 Annexes Pakistan (WHO Eastern Mediterranean Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 8.1 11.2 Nursing and midwifery personnel per 10 000 population 5.6 4.8 Dentists per 10 000 population 0.6 1.2 Pharmacists per 10 000 population 0.5 1.5 Net* migration rate (per 1000 population) 2000 2010 2021 6.1 -2.2 -2 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 102.2 20 YEARS 0.557 (rank 154 of 189) 92.9% 0 5 10 15 20 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 45 225 112 860 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Lower middle income country (2021) YES YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations YES 78 WHO report on global health worker mobility Palau (WHO Western Pacific Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 16.1 17.7 Nursing and midwifery personnel per 10 000 population 66.1 64.6 Dentists per 10 000 population 2.6 3.3 Pharmacists per 10 000 population 1.1 2.8 Net* migration rate (per 1000 population) 2000 2010 2021 4 -19 0.2 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 109.1 35.6 YEARS 0.826 (rank 52 of 189) 73.6% 0 10 20 30 40 50 60 70 80 90 100 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 59 17 947 Has a NHWA focal point? 2012 2015 2018 2021 Yes YES Upper middle income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 79 Annexes Paraguay (WHO Region of the Americas) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 11.5 10.5 Nursing and midwifery personnel per 10 000 population 18.5 16.6 Dentists per 10 000 population 4.4 1.6 Pharmacists per 10 000 population 1.5 0.3 Net* migration rate (per 1000 population) 2000 2010 2021 -3.1 -4.5 -1.2 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 100.9 25.3 YEARS 0.728 (rank 104 of 189) 100% 0 5 10 15 20 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 61 6 573 039 Has a NHWA focal point? 2012 2015 2018 2021 Yes YES Upper middle income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 80 WHO report on global health worker mobility Qatar (WHO Eastern Mediterranean Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 37.3 24.9 Nursing and midwifery personnel per 10 000 population 57.2 72.0 Dentists per 10 000 population 4.8 6.1 Pharmacists per 10 000 population 10.3 8.9 Net* migration rate (per 1000 population) 2000 2010 2021 34.7 38.4 -11.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 265.6 32 YEARS 0.848 (rank 45 of 189) 100% 0 10 20 30 40 50 60 70 80 90 100 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 74 2 828 630 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES High income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 81 Annexes Saint Lucia (WHO Region of the Americas) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 16.5 6.4 Nursing and midwifery personnel per 10 000 population 20.0 31.5 Dentists per 10 000 population 1.6 1.7 Pharmacists per 10 000 population 1.5 4.4 Net* migration rate (per 1000 population) 2000 2010 2021 -4.8 2.6 0 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 98.2 32.7 YEARS 0.759 (rank 86 of 189) 99% 0 10 20 30 40 50 60 70 80 90 100 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 72 178 922 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes YES Upper middle income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 82 WHO report on global health worker mobility Saudi Arabia (WHO Eastern Mediterranean Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 24.1 27.4 Nursing and midwifery personnel per 10 000 population 47.3 58.2 Dentists per 10 000 population 3.3 5.6 Pharmacists per 10 000 population 5.4 8.6 Net* migration rate (per 1000 population) 2000 2010 2021 0.8 8.1 -4.3 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 138.2 29.2 YEARS 0.854 (rank 40 of 189) 100% 0 10 20 30 40 50 60 70 80 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 73 36 229 972 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes YES High income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 83 Annexes Senegal (WHO African Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 0.6 0.9 Nursing and midwifery personnel per 10 000 population 4.4 5.4 Dentists per 10 000 population 0.1 0.1 Pharmacists per 10 000 population 0.1 0.1 Net* migration rate (per 1000 population) 2000 2010 2021 -4.4 -3.5 -0.6 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 96.6 17.6 YEARS 0.512 (rank 167 of 189) 82.1% 0 10 20 30 40 50 60 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 49 16 215 467 Has a NHWA focal point? 2012 2015 2018 2021 Lower middle income country (2021) YES YES NO Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 84 WHO report on global health worker mobility Seychelles (WHO African Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 11.0 22.5 Nursing and midwifery personnel per 10 000 population 45.1 229.5 Dentists per 10 000 population 2.1 4.3 Pharmacists per 10 000 population 0.4 12.8 Net* migration rate (per 1000 population) 2000 2010 2021 4.7 4.1 1.4 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 111.3 32.2 YEARS 0.796 (rank 69 of 189) 100% 0 10 20 30 40 50 60 70 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 70 105 006 Has a NHWA focal point? 2012 2015 2018 2021 YES High income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 85 Annexes Sri Lanka (WHO South-East Asia Region) Doctors per 10 000 population 2000–2010 2011–2021 Doctors per 10 000 population 7.2 12.3 Nursing and midwifery personnel per 10 000 population 17.5 25.0 Dentists per 10 000 population 0.5 1.1 Pharmacists per 10 000 population 0.4 1.0 Net* migration rate (per 1000 population) 2000 2010 2021 -4.9 -1.3 -4.2 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 93 32.2 YEARS 0.782 (rank 73 of 189) 98.6% 0 5 10 15 20 25 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 67 21 683 162 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes YES Lower middle income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 86 WHO report on global health worker mobility Slovenia (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 24.4 32.8 Nursing and midwifery personnel per 10 000 population 82.6 104.6 Dentists per 10 000 population 6.2 7.3 Pharmacists per 10 000 population 5.4 7.3 Net* migration rate (per 1000 population) 2000 2010 2021 -0.8 3.7 2.2 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 100.8 42.9 YEARS 0.917 (rank 24 of 189) 100% 0 5 10 15 20 25 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 80 2 116 252 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes YES High income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 87 Annexes Sweden (WHO European Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 38.0 70.9 Nursing and midwifery personnel per 10 000 population 115.9 118.5 Dentists per 10 000 population 8.1 8.2 Pharmacists per 10 000 population 7.6 16.2 Net* migration rate (per 1000 population) 2000 2010 2021 3.1 6.5 7.7 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 101.3 39.5 YEARS 0.945 (rank 7 of 189) 100% 0 5 10 15 20 25 30 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 87 10 321 414 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES High income country (2021) YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 88 WHO report on global health worker mobility Thailand (WHO South-East Asia Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 3.9 9.5 Nursing and midwifery personnel per 10 000 population 20.6 31.5 Dentists per 10 000 population 1.8 2.7 Pharmacists per 10 000 population 1.3 6.3 Net* migration rate (per 1000 population) 2000 2010 2021 1.9 0.8 0 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 94.7 38.8 YEARS 0.777 (rank 80 of 189) 99.9% 0.0 0.5 1.0 1.5 2.0 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 83 71 389 374 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Upper middle income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 89 Annexes Timor-Leste (WHO South-East Asia Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 7.6 Nursing and midwifery personnel per 10 000 population 11.5 17.5 Dentists per 10 000 population 0.1 0.02 Pharmacists per 10 000 population 0.1 2.1 Net* migration rate (per 1000 population) 2000 2010 2021 -14.3 -1.5 -1.5 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 104.1 20 YEARS 0.606 (rank 141 of 189) 69% 0 10 20 30 40 50 60 70 80 90 100 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 53 1 289 754 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes YES Lower middle income country (2021) YES YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 90 WHO report on global health worker mobility Tonga (WHO Western Pacific Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 5.6 9.5 Nursing and midwifery personnel per 10 000 population 38.5 45.4 Dentists per 10 000 population 1.0 1.4 Pharmacists per 10 000 population 0.4 0.8 Net* migration rate (per 1000 population) 2000 2010 2021 -15.6 -18 -8.9 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 98 21.4 YEARS 0.725 (rank 105 of 189) 71.7% 0 10 20 30 40 50 60 70 80 90 100 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 56 104 873 Has a NHWA focal point? 2012 2015 2018 2021 Yes YES Upper middle income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. Percentage foreign-trained and foreign-born health workers for selected occupations 91 Annexes Uganda (WHO African Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 1.2 1.5 Nursing and midwifery personnel per 10 000 population 13.6 16.4 Dentists per 10 000 population 0.04 0.1 Pharmacists per 10 000 population 0.1 0.4 Net* migration rate (per 1000 population) 2000 2010 2021 -2.2 -5.2 0.9 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 98 15.7 YEARS 0.544 (rank 160 of 189) 58% 0 5 10 15 20 25 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 50 43 685 863 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Low income country (2021) YES YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations 92 WHO report on global health worker mobility United States of America (WHO Region of the Americas) Percentage foreign-trained and foreign-born health workers for selected occupations Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 27.1 26.1 Nursing and midwifery personnel per 10 000 population 125.9 156.9 Dentists per 10 000 population 5.8 6.1 Pharmacists per 10 000 population 9.2 Net* migration rate (per 1000 population) 2000 2010 2021 5.3 3.3 1.7 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 98.3 37.5 YEARS 0.926 (rank 17 of 189) 100% 0 5 10 15 20 25 30 35 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % NO Demographic and socioeconomic indicators: UHC service coverage index (2019): 83 335 388 238 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes Yes YES High income country (2021) YES Has a DNA? On HWSSL 2023? Has responded to the rounds of the NRI? * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. 93 Annexes Zimbabwe (WHO African Region) Latest available data 2000–2010 2011–2021 Doctors per 10 000 population 1.3 2.0 Nursing and midwifery personnel per 10 000 population 8.3 21.4 Dentists per 10 000 population 0.1 0.2 Pharmacists per 10 000 population 0.04 1.1 Net* migration rate (per 1000 population) 2000 2010 2021 -11.5 -10.3 -1.6 Population size (2020): Population sex ratio (males per 100 females): Median age: Domestic health expenditure as % of current health expenditure (CHE) (2019): Human Development Index (2019): 89.1 17.9 YEARS 0.571 (rank 150 of 189) 70.4% 0 5 10 15 20 25 30 35 40 Foreign-trainedForeign-born PharmacistsDentistsNursing personnelMedical doctors % Demographic and socioeconomic indicators: UHC service coverage index (2019): 55 15 505 226 Has a NHWA focal point? 2012 2015 2018 2021 Yes Yes Yes YES Lower middle country (2021) YES YES * The ratio of net migration during the year to the average population in that year. The value is expressed per 1000 inhabitants. On HWSSL 2023? Has a DNA? Has responded to the rounds of the NRI? Percentage foreign-trained and foreign-born health workers for selected occupations Health Workforce Department World Health Organization 20 Avenue Appia CH 1211 Geneva 27 Switzerland https://www.who.int/teams/health-workforce