WORLD HEALTH ORGANIZATION FIFTY-NINTH WORLD HEALTH ASSEMBLY Provisional agenda item 11.12 A59/18 4 May 2006
International migration of health personnel: a challenge for health systems in developing countries Report by the Secretariat
BACKGROUND 1. This report summarizes work undertaken since 2004 to implement the recommendations contained in resolution WHA57.19, and activities that will be continued into this biennium. In response to resolution WHA57.19, the Secretariat has focused on the four main areas described in the following paragraphs. 2. The migration of skilled health workers has in the past decade become more complex, more global and of growing concern to countries that lose much-needed health workers. Some countries suffer disproportionately from the effects of migration. When significant numbers of doctors and nurses emigrate, the countries that financed their education are, usually unwillingly, subsidizing the wealthier countries that receive those health professionals. If a country has a fragile health system, the loss of part of its trained workforce adds further strain. The impact is most severe in rural and underserved areas, from where emigration of health workers is often greatest.
IMPROVED INFORMATION ON HEALTH-WORKER MIGRATION 3. Knowledge about migratory flows of health workers, though far from complete, has improved considerably in the past two years. Major gaps in reporting remain: data are missing for many countries in the Eastern Mediterranean Region that rely heavily on migrant contract health workers; the larger migration within the African Region remains largely undocumented, and trends of immigration over time are not available for a number of recipient countries. In addition, many health workers reportedly migrate but work in other occupations. Nevertheless, available data show the impact of migration of doctors and nurses on some low-income countries, especially in sub-Saharan Africa. For every 100 doctors working in sub-Saharan Africa, 23 African-trained doctors are working in OECD countries. The figure for nurses is lower, but problems in data collection mean that underestimation is likely.1 . Evidence on the extent and impact of migration for other types of health workers is limited.
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The world health report 2006: Working together for health. Geneva, World Health Organization, 2006.
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4. The Regional Office for Africa has carried out substantial research in six African countries to show why workers are migrating, both internally and internationally.1 The most common reason for migration centres around perceptions of low wages and the prospect of improved salaries. Nonfinancial incentives are important motivators for health workers, both to do a good job and to continue working in the public sector. Such incentives include training opportunities, study leave, team work, and support and feedback from supervisors. The provision of adequate housing and transport were found to improve retention of staff in rural areas, as was specifying the amount of time to be spent in the rural area, rather than having an open-ended contract. These findings support previous work and indicate that even simple, relatively low-cost measures can have a positive impact on retention. 5. Creating systems to monitor migratory flows of health workers accurately remains a concern. Efforts are under way to create a human resources observatory in Africa that will collect and share a broad range of information relating to the health workforce, including internal (i.e. within country) and international migration, within the region. 6. The Secretariat has provided support for research better to understand the processes of migration. This has included a case study on India that showed the challenges of exporting large numbers of physicians, and the cultural and social expectations that underlie migration. Conversely, a case study from Israel highlighted the need to make positive, proactive efforts to absorb physician immigrants. Policies were framed that helped successfully to absorb a large number of immigrants. 7. WHO has established a network of partners in order to share information relating to migration of health workers. For example, substantive research has been conducted on women health-worker migrants, that shows how the migration of health workers has an impact on health-service delivery and the conditions of employment in both source and receiving countries.2 8. Although gaps remain in what is known about health-worker migration, the knowledge base has improved considerably during the past two years. Research findings and consolidated knowledge can be found in The world health report 2006.3
DEVELOPING EFFECTIVE POLICY RESPONSES TO MIGRATION OF HEALTH WORKERS 9. Migration of skilled health workers occurs for a variety of reasons. There is, however, a remarkable uniformity in the factors that influence migration, even in quite different regions and contexts. Broadly, they include income, job satisfaction, career opportunity, management and governance, and social and family motivations. 10. In collaboration with Member States the Secretariat has been helping to frame evidence-based policies and strategies to improve retention and deployment of health workers. Efforts have focused on
Awases M et al. Migration of health professionals in six countries: a synthesis report. Brazzaville, WHO Regional Office for Africa 2004. Van Eyck, K ed. Who cares? Women health workers in the global labour market. Ferney-Voltaire, Public Services International, 2005. 3 2
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The world health report 2006.
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improving planning and management strategies, and on exploring options for training mid-level workers who are less likely to migrate and able to meet most primary-care health needs. The aim should be self-sufficiency, i.e. production of adequate numbers of health workers to meet national needs. 11. The impact of ageing populations, innovations in technology and changing consumer demands will most certainly affect the demand for health care and accelerate the movement of health workers. The global shortfall in the health workforce is a result of chronic underinvestment in public health and in health-worker education and training. WHO is working with a range of partners to assess and strengthen educational capacity in Member States. Increasing the production of health workers can mean that benefits deriving from migration could be harnessed without loss of local workforce. Concurrently increasing the capacity of the health system to employ more qualified health workers will also immediately boost the workforce. A tool to assess educational capacity has been developed and tested. Initially focusing on physicians, it has been adapted to assess all health-worker education. 12. Working with partners, the Secretariat is engaging in research, initially in Africa, to determine a package of incentives, pay and non-pay, that will influence recruitment and retention in the health workforce. This work will evolve in the coming year. 13. In close partnership with ILO and IOM, WHO is engaged in facilitating policy dialogue within countries in order to improve the management of migration of health workers at country level. Work has begun with six pilot countries and will be extended during the biennium. Good practices identified through this work will be shared widely.
EVALUATING THE EFFECTIVENESS OF INTERNATIONAL INTERVENTIONS 14. Ethical international recruitment aims to protect both vulnerable-source countries and the rights of individuals. Principles enshrined within existing international recruitment instruments, such as codes of practice, try to balance individual freedom to move with social justice and global equity, aiming for benefits to all countries involved. 15. Most instruments for ethical international recruitment have only recently been developed, and information about their effects is patchy. Best current evidence suggests that their impact may be temporary.1 Nevertheless, a code of practice, though not legally binding, has a political weight and is sometimes considered as “soft law”. A minimum of compliance with such a code is expected, and a code provides a benchmark by which international behaviour can be monitored. 16. The Secretariat has developed a set of principles to guide responsible recruitment, and will be embarking on a series of policy consultations with Member States to seek agreement on the appropriateness and use of these guidelines. 17. Bilateral agreements between countries or institutions promise mutual gain through migration. They are in their infancy, and more information about their longer term effects is needed, though initial effects seem promising. They require broad stakeholder involvement at national level in drawing up the terms of negotiation and reaching agreement. At the same time, they offer a flexible Management of international health worker migration. Instruments on ethical recruitment and other policy options. Document EIP/HRH/PIE/2004/migration. 1
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way for countries to manage exchange of human resources. One such agreement is beginning to show positive effects in terms of managing migration and encouraging return.1 18. WTO’s General Agreement on Trade in Services contains provisions that deal with the movement of natural persons who supply services in the territory of another WTO member (Article I:2). This Agreement may be seen as having the potential to liberalize the temporary movement of people between countries, raising the earnings of skilled people, and enhancing their knowledge and competence.2 In essence, the Agreement is geared to a “brain circulation”, not a “brain drain”, process. To date, there is little evidence on the effect of the Agreement on the movement of health workers. 19. The concept of compensating countries who have lost workers is not new, though it is controversial. During the 1970s there was considerable discussion of the need to, and possibility of, compensating source countries, but no action was taken and the issue faded. The idea of some form of compensation has recently resurfaced after numerous estimates of the financial losses incurred by source countries, recognition that recruitment is accelerating and expression of some interest in establishing ethical recruitment practices. Under consideration is the payment of financial compensation by countries that are receiving, and actively recruiting, foreign health care workers for government health services, in order to compensate for the loss of human capital and of investment in training in source countries. Setting up systems of direct compensation are, however, fraught with challenges. Many health workers do not migrate once, but a number of times, using some countries as a transition to better qualifications that have broader global recognition, raising the question of which country should be providing compensation. 20. Instead of direct compensation linked to health workers, mechanisms have been proposed to increase investment in training by recipient countries. Such an educational initiative could be used to strengthen the quality of educational provision in source countries and increase the production of health professionals. Further work is needed to explore the feasibility of such an initiative and identify methods of managing it.
INTERNATIONAL ADVOCACY FOR WORKFORCE ISSUES 21. The theme of The world health report 2006, and World Health Day (7 April) is the health workforce, offering an opportunity to provide fresh input in strategies to overcome the workforce crisis. Among activities planned for the next 10 years is the definition of mechanisms to strengthen human resources policies, planning and management, from production to performance. 22. The importance of the health workforce to the functioning of health systems is widely recognized, and constraints in the workforce constitute a significant barrier to achieving the Millennium Development Goals and expanding interventions. Although awareness of key issues has been growing, the need remains to coordinate the multiple interested actors, to ensure that development assistance is directed effectively, and to conduct more evaluative, action-oriented
Mafubelu D. Using bilateral arrangements to manage migration of health care professionals: the case of South Africa and the United Kingdom. Paper presented at: IOM/WHO/CDC Seminar on Health and Migration, Geneva, June 2004. World migration 2005. Costs and benefits of international migration. Geneva, International Organization for Migration, 2005. 2
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research in order to broaden knowledge about which policies and strategies are effective in developing the health workforce. 23. A global alliance for the health workforce will be launched in 2006, with the purpose of strengthening advocacy and supporting partnerships at global and country levels for building an effective health workforce during the next decade. Some of the specific targets are that within five years every country, poor or rich, should have a strategic national workforce plan; investment to prepare the workforce through strengthening education and training should be dramatically increased; and local and national innovations should be strengthened through the systematic extension and application of workforce strategies, including better knowledge management. 24. In addition, a programme of collaborative work on migration of health workers has begun between a number of international agencies. A protocol of work, to accompany the existing Memorandum of Understanding, has been drawn up between the International Organization for Migration (IOM) and WHO. ILO is working with both WHO and IOM on migration workforce issues, and the Commonwealth Secretariat will be a partner in the proposed work. Such close collaboration will ensure that there is minimal overlap and the most effective use of joint resources. WHO is now working closely with OECD to harmonize collection of data related to health worker migration, and to improve alignment of policy development initiatives.
ACTION BY THE HEALTH ASSEMBLY 25. The Assembly is invited to note the above report.
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