Report on the WHO health workforce support and safeguards list

Report on the WHO health workforce support and safeguards list 2023 update Report on the WHO health workforce support and safeguards list, 2023 update ISBN 978-92-4-008401-8 (electronic version) ISBN 978-92-4-008402-5 (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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In no event shall WHO be liable for damages arising from its use. iii Contents Acknowledgments iv Abbreviations and acronyms v Executive summary 1 Introduction 2 Methodology 2 Findings and discussion 3 Policy implications of inclusion of countries in the WHO health workforce support and safeguards list 6 Conclusions and recommendations 7 Annex: Expert Advisory Group terms of reference and composition (2022) 9 iv Acknowledgments This report is part of the World Health Organization (WHO) programme of work on human resources for health. The review of relevance and effectiveness of the WHO Global Code of Practice on the International Recruitment of Health Personnel takes place through a Member States’ led Expert Advisory Group every 5 years. The Expert Advisory Group on the relevance and effectiveness of the Code was reconvened for updating the WHO health workforce support and safeguards list 2020 in response to the added vulnerabilities brought about by the COVID-19 pandemic. The WHO Secretariat coordinated the work of the Expert Advisory Group and analysed data as advised by the Expert Advisory Group. The Secretariat included the following WHO staff members: Agya Mahat, Mathieu Boniol, Giorgio Cometto and Khassoum Diallo under the guidance of Jim Campbell (WHO headquarters). The Expert Advisory Group reviewed the available evidence, the proposed methodology and thresholds to update the WHO health workforce support and safeguards list and the associated recommendations. Its members are listed in the Annex. Independent experts also participated in the discussions of the Expert Advisory Group and are also listed in the Annex. This publication contains the report of the WHO Expert Advisory Group on the Relevance and Effectiveness of the WHO Global Code of Practice on the International Recruitment of Health Personnel and does not necessarily represent the decisions or policies of WHO. v Abbreviations and acronyms HLMA health labour market analysis NHWA National Health Workforce Accounts UHC universal health coverage WHO World Health Organization 1 Executive summary The Expert Advisory Group on the Relevance and Effectiveness of the WHO Global Code of Practice on the International Recruitment of Health Personnel (the “Code”) was re-convened in 2022 to inform decisions on the update of the WHO health workforce support and safeguards list (the “list”) published in 2020. The Expert Advisory Group recognized the additional vulnerabilities in health workforce availability and health service coverage in response to the need to maintain essential health services during the COVID-19 pandemic, while also exploring possible additional criteria to identify countries requiring further support and safeguards. The Expert Advisory Group took note of the limitations in availability of health workforce data for 2021 and 2022 and the lack of correlation between additional parameters and health workforce and service coverage vulnerability. Therefore, its members recommended retaining the density of health workers and the universal health coverage (UHC) service coverage index as the two criteria for the list (consistent with the version published in 2020), with the possibility of revising the thresholds. The Expert Advisory Group recommended that the categorization of countries should be kept simple, retaining the distinction between two groups only (included or not included in the list). Its members advised that the list should also be used to inform policy dialogue at all levels (global and regional) and between countries of origin and destination, as well as advocacy and resource mobilization efforts in support of health workforce education and employment in these countries. Further, the Expert Advisory Group noted the particular relevance of technical tools used by WHO to conduct health labour market analyses (HLMA), which inform national policies on education, deployment and employment, as well as in the development of bilateral agreements on health worker migration. 2 Introduction The Expert Advisory Group tasked with the second review of the relevance and effectiveness of the WHO Global Code of Practice on the International Recruitment of Health Personnel found evidence of both improved Code effectiveness and important gaps in its implementation, particularly in several countries and regions most severely affected by challenges in health service coverage and health workforce shortages. Through decision WHA73(30), the Secretariat was requested to “regularly update the list of countries with critical health workforce shortages” and to “explore analysis that considers the full dynamic of the health labour market in determining health workforce vulnerability”. WHO published the WHO health workforce support and safeguards list, 20201 of countries facing the most pressing health workforce challenges related to UHC, pursuant to the methodology contained in the report of the Expert Advisory Group, prioritizing countries for intensified health workforce related support and safeguards connected with active recruitment, and which scored both a UHC service coverage index of less than 50 (with latest data for the year 2017) and a density of doctors, nurses and midwives of less than the median (with latest data for the year 2018). The fourth progress report on implementation of the Code, contained in document A75/14,2 presented to the Seventy-fifth World Health Assembly, noted that during the COVID-19 pandemic, countries took measures to maintain essential health services, respond to successive waves of infection and operationalize national vaccination programmes; this tested the capacity of health systems and health personnel worldwide. The fact that many countries, primarily high-income countries, once again turned to international recruitment to rapidly increase domestic capacity fuelled an acceleration in the international migration and mobility of health personnel. The negative health, economic and social impact of COVID-19 and the increasing demand for health and care workers in high-income countries led to increasing vulnerabilities within countries already suffering from low health workforce densities. The Secretariat therefore established a process, engaging expertise from Member States, for assessing health workforce implications in this context, and re-convened the Expert Advisory Group to support this process (see the Annex for terms of reference and composition). Methodology In its report to the World Health Assembly (document A73/9), the Expert Advisory Group determined that the UHC service coverage index and health workforce density should be used to identify and target support and safeguards to countries with the most pressing health workforce challenges. The first edition of the WHO health workforce support and safeguards list, published in January 2020, was calculated using two indicators based on national data reported to WHO: the UHC service coverage index in 2017 and health workforce density in 2018. The same criteria were used as a baseline for the initial deliberations of the Expert Advisory Group, drawing on the latest data on the UHC service coverage index up to 2019 and health workforce data up to 2022. 1 WHO health workforce support and safeguards list, 2020. Geneva: World Health Organization; 2020 (https://www.who.int/publications/m/item/health-workforce-support-and-safeguards-list, accessed 5 September 2023). 2 See https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_14-en.pdf (accessed 5 September 2023). 3 The methodological limitations of the UHC service coverage index data up to 2019 were noted, as they hindered assessment of the positive or negative impacts of COVID-19 on the routine delivery of health services. Aware of multiple reports and publications indicating significant disruptions to health services during the pandemic, the Expert Advisory Group therefore requested the Secretariat to explore alternative analytical approaches to measure the impact of COVID-19, reviewing the data availability, feasibility and implications. Four criteria were considered as prerequisites for any candidate parameters that may provide proxies for the UHC service coverage index – candidate parameters should: • be correlated with the UHC service coverage index; • have trend data before and after 2020; • be available for most countries; and • be systematically collected on a regular basis. These criteria resulted in the identification of five candidate parameters: • health indicators, if available, reported by Member States for 2020, 2021 or 2022, and selected from the following sub-indicators of the UHC service coverage index: family planning, antenatal care, DTP3 immunization, care seeking for suspected pneumonia, TB treatment, HIV therapy, insecticide-treated nets, basic water, sanitation and hygiene; • health service disruption (as reported by Member States in the three rounds of the WHO pulse surveys 2020–2021); • socioeconomic vulnerabilities (as reported in the Fragile States Index for 2018–2022);3 • health worker migration (extracted from WHO National Health Workforce Accounts [NHWA]); and • post-COVID-19 economic prospects to 2025 (International Monetary Fund, 2022). For each of these parameters, a two-step approach was adopted. Firstly, testing the correlation with the UHC service coverage index and, secondly, assessing if changes of values in these indicators could be instrumental in the identification of countries at increased risk of a decline in the UHC service coverage index. The findings were used to inform the deliberations of the Expert Advisory Group. Findings and discussion The impact of the COVID-19 pandemic on health systems, health services, health workers and international health worker mobility has been considerable. Published reports and grey literature indicate: • extensive disruptions to the delivery of essential health services, as evidenced by both qualitative pulse surveys conducted by WHO and other quantitative published evidence; • health workforce challenges emerging as the main bottleneck to the delivery of essential COVID-19 tools (supplies, diagnostics, treatment and vaccines); • an emerging growth in health worker migration driven by an expanding demand for health workers in both the public and private sector (in some countries), streamlining of health professional regulation, and terms and conditions of work; 3 Available at: https://fragilestatesindex.org/ (accessed 5 September 2023). 4 • the convergent motivation and monetization of health worker migration by employers (who can fill their vacancies and address service gaps at a lower cost), recruitment agencies (who are paid commission fees) and migrant health workers themselves (who benefit from higher remuneration and better working conditions than in their countries of origin); • an expansion in migration impacting countries of all income classifications, not restricted to those identified in the WHO health workforce support and safeguards list, 2020; and • the impact of migration is not restricted to volume, but also to specialty and subspecialty, where small numbers of migrating specialists and faculty may destabilize health services and health professional education in their countries of origin. The Expert Advisory Group therefore found the review of emerging vulnerabilities was relevant and necessary, also noting that the indicators contributing to the 2020 list do not directly take into account health workforce vulnerabilities arising from the COVID-19 pandemic. Several methodological options were explored for monitoring countries’ vulnerabilities and assessing additional parameters for inclusion on the list. The options presented to revise the list included: • continuing with the status quo using two variables (i.e. health workforce density and UHC service coverage index, with updated data); or • including additional variables which capture the impacts of the pandemic (listed in the methodology section). The quantitative analyses conducted by the Secretariat found that: 1. Maintaining the criteria and thresholds of the 2020 list would lead, on the basis of data available in mid-2022, to a reduction on the list from 47 to 42 countries, mostly on account of slight improvements in the UHC service coverage index in 2019 in some countries; 2. There were concerns about these coverage and health workforce density data, as they still largely depicted the pre-COVID-19 situation and trends; and 3. None of the additional parameters considered were sufficiently correlated to UHC to be used as a proxy for the impact of COVID-19 on UHC, neither did the decline in these parameters show a clear pattern linking them to existing vulnerabilities based on health workforce density and the UHC service coverage index. The best option was therefore considered to be to maintain the methodology and main parameters of the 2020 list, i.e. health workforce density and the UHC service coverage index, but also to explore a revision of the thresholds considered, particularly in light of the uncertainties regarding the reliability of available data to adequately reflect the situation arising from the impacts of the COVID-19 pandemic. An increase in the UHC service coverage index threshold from 50 to 60 – maintaining the same parameter for health workforce density of less than 50 per 10 000 population – would result in the potential inclusion on the list of 19 additional countries, whereas in the case of raising the UHC threshold to 70, but only for countries with a health workforce density of less than 25 per 10 000 population, there would be 14 additional countries on the list (Fig. 1). The countries included in this manner were reviewed and largely matched those known to the Secretariat to be experiencing health system pressures due to out migration. 5 Fig. 1. Additional vulnerabilities using variations in UHC and health workforce density thresholds Source: WHO, based on data available in 2022. It was noted that, owing to data availability, the health workforce density parameter remains based on doctors, nurses and midwives only, whereas in some countries other occupational groups, such as health associate professionals and community health workers, represent a substantial proportion of the health workforce delivering services. Some of the independent experts on the Expert Advisory Group questioned the continuing relevance of the Code provision discouraging active recruitment from countries on the list, arguing that this could infringe the rights of health workers to migrate. Others noted that the right to migrate has to be balanced with the provision “to establish and promote voluntary principles and practices for the ethical international recruitment of health personnel, taking into account the rights, obligations and 0 10 20 30 40 50 60 70 80 90 100 0 50 100 150 200 250 300 UH C se rv ice co ve ra ge in de x ( 0- 10 0) Health workforce density per 10 000 population (includes medical doctors, nursing personnel, and midwifery personnel) Criteria and thresholds from the 2020 Support and Safeguard List (42 countries) Additional countries included with a UHC threshold at 70 and ddensity threshold at 25 per 10,000 (14 additional counties) Additional countries included with a UHC threshold at 60 (19 additional countries) 6 expectations of source countries, destination countries and migrant health personnel”. The Secretariat clarified that: 1. Discouraging active recruitment of health personnel from developing countries facing critical shortages of health workers is an explicit provision of the Code, and, as such, changing it fell outside the mandate of both the Expert Advisory Group and the Secretariat, as only the World Health Assembly could take a decision to drop or reverse a core provision of the Code; 2. The provision refers only to active recruitment, whereas nothing in either the Code or the list discourages or seeks in any way to prevent the independent decision by individual health workers to migrate, which is considered a right under other applicable United Nations policy frameworks. Some Expert Advisory Group members suggested that the inclusion of countries on the list should be validated by the affected countries themselves or take the form of self-selection. The Secretariat noted that this would de facto result in a process of self-nomination by countries to be included or excluded from the list, whereas WHO’s task is to develop, with the Expert Advisory Group, advice and objective criteria, based on evidence and data, in order to identify countries facing health workforce vulnerabilities. Using the same criteria, conversely, allows the list to be comparable and have a common relevance and meaning across the countries included in it. The Expert Advisory Group noted that some issues have evolved considerably and present new complexities compared with 2010, when the Code was adopted, including blurring of the boundaries of what constitutes active recruitment through the use of digital technology; and the challenges of securing firm evidence on the respective proportions of active recruitment versus passive migration, although passive migration likely represents another substantial pathway for international migration. These issues should be considered in the next review of the Code’s relevance and effectiveness in order to identify appropriate solutions and implementation mechanisms. Policy implications of inclusion of countries in the WHO health workforce support and safeguards list The Expert Advisory Group, while primarily focusing on the criteria for updating the list, also considered the policy implications for countries of being included on the list. Expert Advisory Group members considered that, on the one hand, it was necessary to protect and safeguard the health systems of countries already facing pre-existing workforce vulnerabilities, while the governments of countries included on the list strengthened and implemented health workforce policies to increase density and retention. On the other hand, the right of health workers and the opportunities that are opened by international migration needed to be preserved. Different views were expressed on the use of the list, particularly in relation to it serving as the tool for operationalizing the Code provision on discouraging active recruitment from developing countries facing health workforce shortages. The Expert Advisory Group noted that, irrespective of inclusion on the list, there were other pathways for migration and mobility (besides active recruitment and bilateral agreements) which may have possible disadvantages for both health workers and source countries. In this context, observations were made that the list could be used to 7 support formalized migration channels that benefit both source and destination countries, as well as migrant health workers. In addition, countries on the list might benefit from being supported in the development and implementation of their health workforce policies and strategies, as well as migration policy, while taking into account multiple interventions and policy levers, including bilateral agreements. There was broad agreement in the Expert Advisory Group on the importance of linking the list to advocacy and mobilization of additional resources (from both domestic and international sources) for education and health sector jobs in countries affected by health workforce shortages. Conclusions and recommendations The Expert Advisory Group recommended that the update of the list should reflect and be responsive to the additional vulnerabilities that have emerged during the COVID-19 pandemic; but, at the same time, the criteria for updating it should remain stable over time, so as to enable predictability in the process, frequency and transparency of future updates. Expert Advisory Group members took note of the limitations in data availability and the lack of correlation of other criteria explored with health workforce and service coverage vulnerability; they therefore concurred on the need to retain density of health workers and UHC service coverage index as the two criteria for the list. Recognizing the increased level of vulnerability, and the fact that some countries not included in the 2020 list experienced severe migration challenges during 2020–2022, the Expert Advisory Group advised the Secretariat to consider revising the thresholds for health workforce density and/or the UHC service coverage index to identify countries requiring additional support and safeguards. Expert Advisory Group members recommended that the categorization of countries should be kept as simple as possible, retaining the distinction of two groups only (included or not included on the list), rather than introducing a third intermediate category of countries with borderline vulnerability levels. The Expert Advisory Group requested the Secretariat to consider these recommendations as relevant and applicable in the update of the WHO health workforce support and safeguards list. Expert Advisory Group members noted the particular relevance of existing and forthcoming technical tools developed by WHO, such as those to support the conduct of HLMA4 and the development of bilateral agreements on health worker migration (forthcoming). In relation to the latter, and consistent with the 2020 list, some principles and good practices related to bilateral agreements on health worker migration were reiterated, including that they should: • be informed by an HLMA to ensure adequate domestic supply in countries; • explicitly engage health sector stakeholders, including ministries of health, in the dialogue and negotiation of relevant agreements; • be notified to the WHO Secretariat through the respective NHWA and Code reporting processes (the reports would ideally include information on the numbers and occupational groups of health workers recruited, as well as the intended duration of the recruitment); and 4 Health labour market analysis guidebook. Geneva: World Health Organization; 2021 (https://apps.who.int/iris/handle/10665/348069, accessed 5 September 2023). 8 • specify the benefits accruing to the health sector of countries of origin, and such benefits should be commensurate with those of the destination countries. The Expert Advisory Group requested the Secretariat to continue the regular updating of health workforce statistics through the annual NHWA process, noting that longitudinal data would eventually allow estimating trends in health worker migration and changes during the pandemic. 9 Annex: Expert Advisory Group terms of reference and composition (2022) The scope of the Expert Advisory Group’s work, as set out in document A75/14, was to review countries with low health workforce density, including but not limited to those named in the WHO health workforce support and safeguards list, 2020, and consider how disruptions caused by COVID-19, particularly health-related vulnerabilities, might require the revision and extension of safeguards against active international recruitment. The scope of the work required agreement on the methodology, data analysis, discussion on findings, and the preparation of this report to the Director-General, in order to inform and guide decisions on the update of the WHO health workforce support and safeguards list, 2023, to be published ahead of the 152nd session of the Executive Board. The Expert Advisory Group met twice virtually, in June and December 2022, with written exchanges throughout the process. In addition, the Co-Chairs held preparatory and follow-up meetings with the Secretariat to moderate the activities and timing. Its composition included the same Member States and most of the same individuals involved in the Expert Advisory Group during 2019–2020 for the purposes of continuity and consistency. In some cases, Member States nominated a new representative owing to routine turnover. Member States representatives Untung Suseno Sutarjo, Ministry of Health, Indonesia (Co-Chair); Mr Sugiantoi, Ministry of Health, Indonesia (from November 2022) Erlend Aasheim, Norwegian Directorate of Health, Norway; Arne-Petter Sannei, Norwegian Ministry of Health and Care Services, Norway (Co-Chair) (from November 2022) Maureen McCarty, Australian Government Department of Health, Australia (alternate: Jonathan Brayi) Gislain Arnaud Hollo, Ministère de la Santé, Benin Kavita Narayan, Ministry of Health and Family Welfare, India (alternate: Sanjay Royi and Anjula Jaini) Dunstan Bryan, Ministry of Health, Jamaica Joyce T Shatilwea, Ministry of Health & Social Services, Namibia (alternate: Ms Anna Isaacs, Ministry of Health & Social Services, Namibia) Hamed Al-Beloshi, Ministry of Health, Oman Kenneth G Ronquillo, Department of Health, Philippines Zadorożna Małgorzata, Ministry of Health, Poland Ahmed Shadouli, Ministry of Health, Sudan Independent experts (including previous Co-Chair)ii El-Sheikh Badr, Policy Expert, National Qualifications Centre, Abu Dhabi, United Arab Emirates James Buchan, Health Foundation, United Kingdom of Great Britain and Northern Ireland, and University of Technology Sydney, Australia Jean-Christophe Dumont, Organisation for Economic Co-operation and Development Viroj Tangcharoensathien, International Health Policy Program, Thailand (previous Expert Advisory Group Co-Chair) i New member identified by Member State. ii Subset of independent experts in the 2019–2020 Expert Advisory Group with expertise of most direct relevance to the scope of the group’s work in 2022. 10 Declaration of Interests were collected and managed according to WHO policy, and no conflicts of interests were identified that required exclusion or specific measures. 11 World Health Organization 20 Avenue Appia CH 1221 Geneva 27 Switzerland https://www.who.int/teams/health-workforce