EXECUTIVE BOARD 122nd Session Provisional agenda item 4.13
EB122/16 Rev.1 16 January 2008
International migration of health personnel: a challenge for health systems in developing countries Report by the Secretariat
1. This report summarizes the work undertaken since 2004 to implement resolutions WHA57.19 and WHA58.17, both entitled “International migration of health personnel: a challenge for health systems in developing countries”. It also outlines the work that will be continued into the biennium 2008–2009. 2. The numbers of migrating health workers have significantly increased in the past few decades, and patterns of migration have become more complicated and have involved more countries. Health worker migration from those countries which are already experiencing a crisis in their health workforce, particularly in sub-Saharan Africa, is further weakening already fragile health systems, and represents a serious impediment to achieving the health-related Millennium Development Goals. 3. Resolution WHA57.19 urged Member States, among other things, to develop strategies to mitigate the adverse effects of migration of health personnel, to frame and implement policies and strategies that could enhance effective retention of health personnel, and requested the DirectorGeneral to develop a code of practice on the international recruitment of health personnel. In response, the Secretariat designed a comprehensive, four-pillar approach: improvement of data on health worker migration, development of innovative policy responses, evaluation of the effectiveness of international interventions, and international advocacy for workforce issues. International collaboration plays a key role in implementing this approach, and therefore close partnerships at both technical and political levels have been established with ILO, International Organization for Migration, other bodies in the United Nations system, OECD, the WHO-administered Global Health Workforce Alliance, and the nongovernmental organization Realizing Rights.
IMPROVED INFORMATION ON HEALTH WORKER MIGRATION 4. Quantitative and qualitative data on migratory flows of health workers, though far from complete, have improved considerably in recent years, as illustrated by The world health report 2006.1 However, gaps in reporting migration among WHO regions remain, in particular that from the African Region.
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The world health report 2006: Working together for health. Geneva, World Health Organization, 2006.
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5. Immigration into OECD member countries is significantly higher from some regions than others, especially sub-Saharan Africa and the Caribbean. In this regard, the Secretariat has supported research on health worker migration from sub-Saharan Africa, in collaboration with the WHO Regional Office for Africa. Results show that patterns of such migration have changed and that volumes have increased substantially over the past 30 years. Whereas three decades ago, health worker migrants originated from relatively few African countries and most went to a few industrialized countries outside Africa, migration has since become much more complicated, involving almost all sub-Saharan countries at the same time as revealing heavy migration trends among developing countries within Africa. 6. The Africa Health Workforce Observatory, created in collaboration with the WHO Regional Office for Africa in 2007, is a mechanism to promote evidence-based policy options for health workforce development. The Observatory will help to strengthen the collection of data on health worker migration within and from the African region and, in particular, will develop guidelines for monitoring and evaluating health workforce policies at national and subnational levels. It will also contribute to both institutional and individual capacity building of the health workforce. 7. Overall, OECD countries are a main destination for migrant health workers: OECD figures indicate that 11% of all nurses and 18% of all doctors employed in OECD countries are foreign born.1 These aggregate figures mask, though, important variations across countries, which in turn stem from national differences in health workforce characteristics and in the general patterns of migration, notably for highly skilled workers. 8. Over the past 25 years, the number and share of foreign-trained doctors has increased significantly in most OECD countries, and particularly so in Europe: the recent average annual growth rate in the number of foreign-trained doctors is close to 10% in some European countries. In addition, new migratory patterns are emerging at regional level, such as within the European Union or southern Africa. 9. Improving the monitoring of migration of health workers is an integral part of efforts to improve information on human resources for health. WHO, with other international organizations including ILO and the International Organization for Migration, is compiling a minimum data set on migration.
DEVELOPING EFFECTIVE POLICY RESPONSES TO MIGRATION OF HEALTH WORKERS 10. Migration is provoked by a combination of “push” and “pull” factors. Whereas low pay, poor working conditions, slim promotion possibilities, inadequate management support, heavy workloads, and limited access to good technology and medicines are all push factors encouraging health workers to leave their country, pull factors, such as higher remuneration, better working conditions, and brighter prospects for professional development in recipient countries also play an important role in a worker’s decision to emigrate.
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OECD (2007) International Migration Outlook, Paris.
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11. The Secretariat is working with Member States to frame evidence-based policies and strategies to improve retention and deployment of health workers. Efforts have focused on improving health workforce planning and management strategies. 12. In close collaboration with ILO and the International Organization for Migration, WHO is engaged in facilitating policy dialogue within and among countries to improve the management of migration of health workers at country level, which will contribute to better identification and understanding of regional migration. Programmes are being carried out in five countries, namely Costa Rica, Kenya, Romania, Senegal, and Trinidad and Tobago. 13. WHO is also working with a range of other partners to support the strengthening of health systems, in particular human resources development. It has helped to establish the Scaling up Education and Training Task Force (of the Global Health Workforce Alliance), which is urging significantly increased investment in the education and training of health workers in developing countries. The Organization is also building international commitment for practical solutions in managing migration.
DEVELOPING A GLOBAL CODE OF PRACTICE 14. Various codes of practice for the international recruitment of health workers offer some guidelines on the recruitment, supervision and support of migrant workers, and on encouraging more effective collaboration among countries in managing migration. Most codes have been developed only recently, and information about their effects is still patchy. 15. Even though assessing the impact of codes on health systems in developing countries is complicated, there is interest in a global code for managing health worker migration. 16. A code of practice, though not legally binding, exerts some ethical or moral influence and may be considered a “soft law”. It can provide a benchmark by which international behaviour can be monitored, especially as many countries are likely to adhere to its principles. The recent Pacific Code of Practice for Recruitment of Health Workers in the Pacific region is a positive example, and offers potential options for other regions. However, the scope of unregulated migration of health workers may also raise questions about the overall effectiveness of an international code of practice. 17. Under the aegis of the Global Health Workforce Alliance, the Health Worker Migration Policy Initiative was launched in May 2007. Compositionally, the Initiative is a two-tiered group, with a high-level policy council and a technical working group. One of its priorities is to support WHO in developing a global code of practice for the recruitment of health personnel. The Initiative’s early efforts have focused on the following: reviewing existing memoranda of understanding (such as the two between the United Kingdom of Great Britain and Northern Ireland and, respectively, the Philippines and South Africa); appraising codes of practice; and developing guiding principles for a global code. A framework of these principles will be drafted in early 2008 as a basis for WHO regional and country consultations. 18. In collaboration with Johns Hopkins University, Baltimore, Maryland, United States of America and other partners, WHO has developed an electronic “community of practice” that will enable countries to exchange experiences on migration when they implement the global code of practice.
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INTERNATIONAL ADVOCACY FOR WORKFORCE ISSUES 19. The world health report 2006 and World Health Day 2006 focused on the theme of the health workforce. The former provided a unique forum of advocacy for health workforce issues. 20. The importance of the health workforce, to the functioning of health systems and to achieving the Millennium Development Goals, is widely recognized. Yet identifying and implementing effective policies for the health workforce requires both improved communication between the many actors involved in order to coordinate development assistance better, and an expansion of the knowledge base through more evaluative, action-oriented research. 21. In this regard, the Global Health Workforce Alliance will convene a Global Forum on Human Resources for Health in March 2008 in Kampala. The Forum will allow solutions to be shared and explored, and will favour consensus and capacity building in response to the health workforce crisis, including migration of health workers. Furthermore, a joint WHO-OECD conference is planned for the second half of 2008. The conference will provide a platform for both health policy makers and senior officers from higher- and lower-income countries to discuss the role of health workforce policies – in particular those relating to migration – in addressing the health professions’ current and future needs. 22. WHO is also supporting United Nations initiatives in the field of migration. The Secretariat took part in the General Assembly High-Level Dialogue on Migration and Development (New York, 14–15 September 2006) and in the first meeting of the Global Forum on Migration and Development (Brussels, 9–11 July 2007). Recommendations of the Global Forum included support for work on the global code of practice by WHO and the Global Health Workforce Alliance. 23. A health workforce retention and migration team, established at WHO headquarters in 2007, is working towards the development, implementation and evaluation of policies and technical frameworks, in order to manage migration of health workers effectively and to help retain more health workers in their home countries. 24. More such policy initiatives at global level are needed. It is therefore important to continue to address migration issues at technical and political levels, and to bring together lower- and higherincome countries in the pursuit of strong collaborative efforts.
ACTION BY THE EXECUTIVE BOARD 25. The Board is invited to note the report.
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