____________________________________________ High-Level Preparatory (HLP) Meeting for the Regional Committee WHO/SEARO, New Delhi, 29 June – 2 July 2009 Agenda item 2.1 SEA/HLP-Meet/2.1 8 June 2009 CODE OF PRACTICE FOR THE INTERNATIONAL RECRUITMENT OF HEALTH PERSONNEL The impact of international migration of health workers on health systems of especially source countries has been debated extensively in recent years. In order to provide a global response, the 2004 World Health Assembly adopted resolution WHA57.19, which requested the Director-General of WHO to develop a code of practice for the international recruitment of health personnel, in consultation with Member States and with all relevant partners. Through a comprehensive consultative process involving multistakeholders, an outline of the code of practice was developed during the first half of 2008. The text was built on existing regional and bilateral agreements, Memoranda of Understanding, national and regional codes of practice, as well as on discussions from the virtual Global Dialogue on Migration, and the First Global Forum on Human Resources for Health. The report of the Secretariat containing the draft resolution and the code of practice was presented to the 124th Executive Board in January 2009 for its deliberations. While expressing appreciation to the Secretariat for the work done so far, Member States expressed the view that more consultations at country and regional levels were needed on the draft code. On the recommendation of the Executive Board, the Director-General, WHO has requested that this item be placed in the formal agenda of the Sixty-second session of the Regional Committee for South-East Asia, planned to be held from 7-10 September 2009 in Kathmandu, Nepal. This technical paper describes the background, the process of development of the code of practice, the key elements, and the probable questions the Member States may wish to examine before expressing the collective view of the SEA Region to the Committee. The attached working paper is submitted to the High-Level Preparatory (HLP) Meeting for its review and recommendations. These recommendations will be submitted to the Sixty-second Session of the Regional Committee for its consideration.
SEA/HLP-Meet/2.1 Introduction 1. The debate on international migration of health workers and its impact on health systems has got pronounced in recent years. As a consequence of the globalization of health and health services, every country has shown its interest in the long-term objective of improving its health systems to respond to the rapidly-changing health landscapes. The negative impact of international migration of health workers and of international recruitment on primary health care, which is a global public health priority, too has been acknowledged. 1 2. At various international forums, concern has long been expressed regarding the need for effective cooperation to address the impact of health worker migration on health systems. The numbers of migrating health workers have increased significantly in recent decades, with patterns of migration becoming more complicated and involving more countries. While migration of health personnel can bring mutual benefits to both source and destination countries, migration from countries especially those that are experiencing a health workforce crisis, particularly the 57 countries identified in the 2006 World Health Report, 2 (six countries from the SEA Region) would breakdown the already weakened health systems, and seriously impede the achieving of health-related Millennium Development Goals (MDGs). 3. In order to provide a global response, the World Health Assembly, in 2004, adopted resolution WHA57.19 3 , which requested the Director-General to “develop a code of practice on the international recruitment of health personnel, in consultation with Member States and all relevant partners”. 4. The Secretariat developed a comprehensive programme on the issue of health worker migration, in particular on the development of a WHO code of practice on the international recruitment of health personnel. 4 To support WHO in developing a code of practice, a multi- stakeholder process, the Health Worker Migration Policy Initiative, was established. This initiative comprises: (i) a Migration Policy Advisory Council, led by the Global Health Workforce Alliance, and a nongovernmental organization, Realizing Rights: the Ethical Global Initiative, and (ii) a WHO-led Technical Working Group. 5. At its 122nd session in January 2008, the Executive Board recommended that consultations with Member States on developing a code of practice should begin in early 2008 and that a draft code should be submitted to it at its 124 th session in January 2009 and then, should the Executive Board so decide, to the Sixty-second World Health Assembly in May 2009. 5 6. Following consideration of the development of the proposed code at several global forums, including the First Global Forum on Human Resources for Health, held in Kampala, Uganda in March 2008, and the G8 Summit, held in Toyako, Japan in July 2008, the Secretariat prepared the first draft of the WHO code of practice in August 2008. That text built upon existing national and regional codes of practice on health worker recruitment, global agreements and declarations, as well as the collaborative work of the Health Worker Migration Policy Initiative. SEA/HLP-Meet/2.1 Page 2 7. On 1 September 2008, the Secretariat launched a global, web-based, five-week public hearing on the first draft of the WHO code of practice. 6 In addition, in September and October 2008, informal discussions on health worker migration and on development of a WHO code of practice took place at the respective sessions of the WHO regional committees of the European Region, the South-East Asia Region and the Western Pacific Region. The Secretariat revised the text and prepared the draft code of practice in light of comments received during the hearings. 8. The report of the Secretariat report containing the draft resolution, and the draft code of practice were presented to the 124th Executive Board session in January 2009 for its deliberations. 7 While expressing their appreciation to the Secretariat for the work done in preparing the ‘draft code of practice’, Member States agreed that more consultations at both country and regional levels with effective participation of Member States was essential before finalizing and adopting the code. Features of the WHO code of practice 9. While there is a wide variety of instruments to facilitate international cooperation, including binding instruments, such as treaties, and voluntary non-binding instruments, such as resolutions, declarations and codes of practice, the choice to use a non-binding code of practice to address concerns about the international recruitment of health personnel reflects the will of WHO Member States, as expressed in resolution WHA57.19. This resolution makes it clear that the WHO code, like most intergovernmental codes, such as the Commonwealth Code of Practice for the International Recruitment of Health Personnel, should be designed as a non-binding instrument. 10. Such non-binding approaches to international cooperation are becoming increasingly important and are commonly being used in a variety of areas of international concern, ranging from the environment to arms control to global fisheries issues. A code of practice once formally adopted by the World Health Assembly would be the expression of the will of the international community across the widest possible global health forum. The process of negotiating a code of practice would initiate a dialogue among and within WHO Member States and other actors that may expand awareness and national and multilateral action on this critical global health concern. In addition, it is expected that the WHO code of practice would encourage countries to enter into further bilateral or multilateral agreements to formalize their commitments to mutually-agreeable policies and practices on health worker migration. 11. Over the past decade or so, a number of codes of practice and similar instruments have been developed by many organizations to address concerns arising from migration of health personnel. However, a formally adopted WHO code of practice would be the first international instrument on health worker recruitment developed with a worldwide scope, and applicable to both source and destination countries. The WHO code of practice 12. The Code of Practice for the International Recruitment of Health Personnel consists of eleven articles that describe its (i) objectives; (ii) nature and scope; (iii) guiding principles; (iv) recruitment practices and treatment of health personnel; (v) mutuality of benefits; (vi) national health workforce SEA/HLP-Meet/2.1 Page 3 sustainability; (vii) data gathering and research; (viii) information exchange; (ix) implementation of the code; (x) monitoring and institutional arrangements; and (xi) partnerships, technical collaboration and financial support. The draft code of practice is given in annexed to this working paper. 13. International health workforce migration is a complex and multidimensional global health challenge. The following subsections describe some of the key issues that Member States may wish to consider when elaborating the text of a WHO code of practice, including those upon which there may be divergence among Member States. Objective(s) and guiding principles 14. An important area requiring consensus by Member States is the determination of what objective(s) and guiding principles should steer the development and use of the code of practice. Certain key issues on the introductory provisions of the code of practice, including the objective(s) and guiding principles have emerged during consultations. With respect to the objective(s), a question has arisen as to whether the WHO code of practice should focus on establishing voluntary principles, standards and practices of international recruitment or whether the scope of this instrument should be broadened to address the impact of health worker migration on health systems. 15. During consultations, issues have also arisen with respect to the elaboration of guiding principles and how such principles should be operationalized in subsequent sections. Balancing the individual rights of health worker to leave any country, including their own with the enjoyment of the highest attainable standard of health for the population in both source and destination countries have emerged as one of the fundamental issues. While health workers have the human right to migrate to countries that wish to admit and employ them, and destination countries can appropriately strengthen their health systems by employing foreign health workers, the devastating impact on large- scale migration of health workforce on health systems of source countries needs consideration. Similarly, there is a divergence among Member States on how to balance the interests of source and destination countries in the guiding principles and on how these principles should be reflected in the rest of the WHO code of practice text. 16. The process of determining the code’s objective(s) and guiding principles can help to build consensus among Member States on the code of practice. States may not agree on single, specific solution to any one problem, but may be able to agree upon a common goal based on the general principles that should guide their efforts in achieving the said goal. The discussion leads to the question, “What objective(s) and guiding principles should guide the development and implementation of the WHO code of practice”? International recruitment practices 17. A key issue that has emerged in discussions with respect to the elaboration of the code of practice is how such an instrument should promote the equality of rights and opportunities for internationally-recruited health workers. The rights of migrant workers are generally recognized in the corpus of international human rights law. All persons, regardless of their nationality, race, legal or other status, are entitled to fundamental human rights, including migrant workers. There have been reports from some countries that international health workers have been exploited, and are being misled about their career prospects, pay levels and employment conditions. SEA/HLP-Meet/2.1 Page 4 18. The principles of transparency and fairness are considered key in the recruitment process of migrant health workers. There is a divergence among some Member States on whether and how such broad principles should be incorporated into a code of practice. While some suggest that a code of practice should include specific provisions encouraging states to regulate and monitor recruiters and employers, some are of the view that a code of practice should include a specific provision calling upon Member States to ensure that services performed in connection with international recruitment should be performed free of charge to health workers. Member States also hold widely different views on whether recruitment from states experiencing critical workforce shortages should be limited. 19. The debate about the code of practice leads to a few questions that need to be answered carefully. Should it include specific recommendations on regulating or/and monitoring activities of recruitment agencies and employers of internationally-recruited health personnel? Should it spell out the standards needed to encourage equality of treatment between national and migrant health workers? Should the code of practice include a provision recommending that Member States limit international recruitment in countries with critical health workforce shortages? Should it include a provision encouraging Member States to ensure that services performed in connection with the international recruitment or placement of health personnel are rendered free of charge to such health personnel? Mutuality of benefits 20. An important question that has emerged in consultations on the code of practice is in what ways can the instrument reflect and encourage an appropriate balance between the interests of source and destination countries? Within this context there is an increasing recognition that a coherent policy approach is required that aligns both international health worker recruitment and aid development policies. In particular, there is a substantial concern that aid projects related to health systems could be undermined by certain international recruitment practices. The process of consultation on the code of practice has highlighted some important areas of continuing debate and divergence among Member States on issues relating to mutuality of benefits and how these issues should be reflected in the final text of the instrument. 21. Agreements between source and destination countries/institutions: One area of divergence among states is whether the code of practice should promote bilateral agreements between source and destination countries and, if so, what should be the content of such agreements. Different types of policy interventions can be addressed in such bilateral agreements, such as strengthening domestic training/education capacity in source countries; improving quality of education; providing technical assistance; better matching of education/training with local population health needs; facilitating educational and staff exchanges between countries through institutional 'twinning', and harnessing professional experience of health worker diasporas in recipient countries to encourage return and 'circular' migration. 22. Compensation and/or international cooperation: Some Member States have proposed that some type of compensation and/or international cooperation should be recommended to source countries in respect of the code of practice. Some suggest that an approach to compensation should be a component of the final text of the code of practice, as lower-income countries, in particular those identified by WHO as being in crisis 8 , are indirectly subsidizing health education systems in higher-income destination states. Others oppose such a compensation approach as unworkable. SEA/HLP-Meet/2.1 Page 5 With respect to international cooperation, some countries highlight that the code of practice should emphasize international technical and/or financial assistance as all countries have an interest in strengthening health systems in all states. 23. The critical questions that remain to be answered are should a code of practice promote the formulation and implementation of bilateral and multilateral agreements based upon the principle of mutuality of benefits? Should it include a provision recommending that destination states provide source states with financial compensation? If so, what types of technical and/or financial cooperation should be encouraged? National health workforce sustainability 24. Whether or not the code of practice should include provision(s) promoting national health workforce sustainability is central to discussions. The concept focuses on strengthening national health workforce education. More broadly, achieving self-sufficiency or sustainability in the health workforce is about effective retention and deployment of available workers. 25. Most countries, either developing or developed, also suffer from unequal distribution of the health workforce, in particular between urban and rural/remote areas. Currently, in many higher- income countries, migrant health workers play a key role in servicing rural and remote territories, and staffing unpopular disciplines and shifts. Meeting the need for health-care workers in “difficult-to-fill” positions or underserved areas is challenging, and yet essential for achieving well-functioning health systems. 26. Similarly, in source countries, implementing policies aimed at improving retention and distribution is essential to maximize the effects of policies aimed at migration “pull” factors, such as strengthening professional development and improving working conditions. It should be noted that WHO has launched a programme to increase access to health-care providers in rural and remote areas through improved retention. 9 27. Two critical questions that arise in regard to national health workforce sustainability are: Should the concept of national health workforce sustainability be included in the code of practice? And if so, how could this broad concept of sustainability be defined and operationalized into specific recommendations in the code? Data gathering, research and information exchange 28. Good information systems and effective mechanisms for exchange of information are key tools in monitoring the situation and collecting evidence for development of appropriate policies. In the field of health worker migration, improvement in data gathering and research efforts is necessary for a number of critical reasons. Most significantly, the current evidence-base on health worker migration trends and patterns is weak and fragmented. The formulation of effective policies addressing the drivers, trends and impacts of health worker migration needs to be grounded in a sound evidence base. The challenges involved in data collection and analysis are compounded by the lack of consistency in definition of relevant data items among countries. Consensus needs to be reached on common definitions and approaches to data gathering. SEA/HLP-Meet/2.1 Page 6 29. Ideally, international migration of health personnel should be monitored by gathering evidence on the annual number of health workers moving from one country to another. At present, however, many countries do not have accurate, complete and timely data on the numbers of nationals working abroad or leaving the country. The objective should be to strengthen information systems to enable policy-makers to assess or plan for current and future health workforce needs, including the tracking of migration. However, it should not be the intention to establish parallel or duplicate information systems, with one system dedicated only to generating data on migration. 30. While the importance of a sound evidence-base for the formulation of appropriate polices is widely recognized, there is as yet no consensus among states on the type and scope of data gathering on health workforce migration, the type of information exchange, and the mechanisms to allow such exchanges that could be recommended in the code of practice. Should the code of practice include a recommendation encouraging countries to collect data on health worker migration and its impact on health systems? If so, what type of data should be collected? Should a tool be developed to encourage harmonization and comparability of data collected? What information should the code of practice recommend that Member States exchange? These are some of the vital questions that need to be answered with a more broad consensus. Implementation mechanisms: reporting and monitoring 31. National reporting is generally viewed as a central mechanism for ensuring implementation of an international instrument’s provisions and is common in international practice. Many international instruments generally call upon states to submit reports or transmit information at periodic intervals on measures taken, difficulties encountered and headway made in implementing an instrument. In contemporary international practice, mechanisms for monitoring and implementation are common in both binding and non-binding instruments. 32. National reporting encourages Member States to undertake a more comprehensive and a systematic review of their existing policies. This may encourage various government agencies and others to coordinate their actions within a country. Reporting can also serve an educational function, allowing states to benefit from the experience of others. In terms of implementation, reporting promotes transparency. Reporting also makes it possible to judge the effectiveness of a code of practice and assess the need for further action. 33. Some Member States have suggested that developing a system for the monitoring of the implementation of the WHO code of practice is of the highest importance and is essential if the code is to become a meaningful component of policy responses to the issue of health worker international recruitment. Some other states have suggested that an implementation mechanism is not appropriate for a voluntary code of practice. The important questions in this regard are: Should there be a provision for international monitoring and review of the implementation of the code of practice? What information on implementation should be compiled and included in state reports? What other provisions can be included in the WHO code to encourage compliance by both state and non-state actors? SEA/HLP-Meet/2.1 Page 7 Need for further consultations 34. It should be stressed that this document is not intended to provide a comprehensive analysis of all of the possible elements of the WHO’s code of practice on the International Recruitment of Health Personnel. Rather, the issues highlighted in this document are those that need to be carefully evaluated by each Member State of the SEA Region as it consists of both source and destination countries. 35. The short-term and long-term impacts of the proposed code of practice on individual Member States of the SEA Region, as well as the Region as a whole, need to be carefully identified. While it is proposed that the subject be further discussed at the Sixty-second session of the Regional Committee, there is a need to place the topic under careful scrutiny of relevant stakeholders in each country before arriving at the regional perception on the proposed code. SEA/HLP-Meet/2.1 Page 8 References 1. World Health Organization. The world health report 2008. Primary Health Care Now more than ever: Geneva, 2006 2. World Health Organization. The world health report 2006: Working together for Health. Geneva, 2006. 3. http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R19-en.pdf 4. EB 124/13. http://www.who.int/gb/ebwha/pdf_files/EB124/B124_13-en.pdf 5. EB122/16 Rev.1 http://www.who.int/gb/ebwha/pdf_files/EB122/B122_16Rev1-en.pdf 6. EB124/Info.Doc/2. A summary of the public hearing 7. EB124/13 http://www.who.int/gb/ebwha/pdf_files/EB124/B124_13-en.pdf 8. http://www.who.int/whr/2006/en/index.html 9. http://www.who.int/hrh/migration/en/ SEA/HLP-Meet/2.1 Page 9 Annex Draft WHO Code of Practice on the International Recruitment of Health Personnel Article 1 – Objectives The objectives of this code are: (a) to establish and promote voluntary principles, standards and practices for the international recruitment of health personnel; (b) to serve as an instrument of reference for Member States in establishing or to improving the legal and institutional framework required for the international recruitment of health personnel and in formulating and implementing appropriate measures; (c) to provide guidance that may be used where appropriate in the formulation and implementation of bilateral agreements and other international legal instruments, both binding and voluntary; (d) to facilitate and promote international discussion and advance cooperation on matters related to the international recruitment of health personnel, with a particular focus on the situation of Member States facing a critical health personnel shortage. Article 2 – Nature and scope 2.1 The code is voluntary. Member States and other stakeholders are strongly encouraged to comply with the code. 2.2 The code is global in scope and is directed toward Member States and Associate Members of WHO, health personnel, recruiters, employers, health-professional organizations, relevant sub regional, regional and global organizations, whether governmental or nongovernmental, and all persons concerned with the international recruitment of health personnel. 2.3 The code applies to all health personnel, including all people engaged in actions in the public and private sectors whose primary intent is to enhance health, and covers those working on a temporary, locum or permanent basis. 2.4 The code provides principles applicable to the international recruitment of health personnel in a manner that promotes an equitable balance of interests among health personnel, source countries and destination countries. SEA/HLP-Meet/2.1 Page 10 Article 3 – Guiding principles 3.1 Addressing present and expected shortages in the health workforce is crucial to protecting global health. International recruitment can make a legitimate contribution to the development and strengthening of a national health workforce. However, the setting of voluntary international standards and the coordination of national policies on international health personnel recruitment are desirable in order to maximize the benefits to, and mitigate the potential negative effects on, health systems, particularly in those countries facing a critical shortage of health personnel, and to safeguard the rights of health personnel. 3.2 All Member States have the sovereign right to strengthen their health systems in order to progressively achieve full realization of the right of everyone to the enjoyment of the highest attainable standard of health. Member States should take the code into account when developing their national health policies and cooperate with each other, as appropriate. 3.3 Nothing in this code should be interpreted as impinging on the rights of health personnel to migrate to countries that wish to admit and employ them. 3.4 International recruitment of health personnel should be conducted in accordance with the principles of transparency, fairness and mutuality of benefits. 3.5 Member States, in conformity with national legislation and applicable international legal instruments to which they are a party, should promote and respect fair labour practices for all health personnel. In all terms of employment and conditions of work, migrant health personnel should enjoy the same legal rights and responsibilities as the domestically trained health workforce, without discrimination. 3.6 Member States should strive to create a self-sufficient health workforce and work towards establishing effective health workforce planning that will reduce their need to recruit migrant health personnel. Policies and measures to strengthen the health workforce should be appropriate for the specific conditions of each country and should be integrated into national development programmes. 3.7 The specific needs and special circumstances of countries, especially those developing countries and countries with economies in transition that are particularly vulnerable to health workforce shortages and/or have limited capacity to implement the recommendations of this code, should be considered. 3.8 Effective gathering of national and international data, research, and sharing of information on the international recruitment of health personnel are essential to achieve the objectives of this code. 3.9 All aspects of the employment and treatment of migrant health personnel should be without distinction of any kind, such as, race, colour, gender, religion, national or social origin, birth or other status. 3.10 Member States, health personnel, recruiters, employers, health-professional organizations, relevant subregional, regional and international organizations, whether governmental or nongovernmental, and all persons concerned with the international recruitment of health personnel should collaborate in the fulfilment and implementation of the objectives contained in this code for the benefit of present and future generations in all countries. SEA/HLP-Meet/2.1 Page 11 Article 4 – Recruitment practices and treatment of health personnel 4.1 Member States and other stakeholders should recognize that ethical international recruitment practices provide health personnel with the opportunity to assess the benefits and risks associated with employment positions and to make timely and informed decisions. In accordance with the principle of fairness, ethical recruitment practices should also promote equality of treatment of migrant health personnel with the domestically-trained health workforce and ensure that migrant health personnel are not subjected to improper or fraudulent conduct. 4.2 Member States should ensure that, subject to national laws and relevant international legal instruments to which they are a party, migrant health personnel enjoy the same legal rights and responsibilities as the domestically-trained health workforce in all terms of employment and conditions of work. 4.3 Member States should, to the extent possible, ensure that recruiters and employers provide migrant health personnel with relevant and accurate information about any health personnel position that they are offered. 4.4 Member States should, to the extent possible, ensure that recruiters and employers observe fair and just contractual practices in the employment of migrant health personnel. 4.5 Migrant health personnel should enjoy opportunities for employment commensurate with their level of education, experience and competence on the basis of equality of treatment with the domestically-trained health workforce. 4.6 Migrant health personnel should be hired, promoted and remunerated on the basis of objective criteria such as levels of qualification, years of experience and degrees of professional responsibility on the basis of equality of treatment with the domestically-trained health workforce. 4.7 Measures should be taken to ensure that migrant health personnel enjoy opportunities and incentives to improve their professional education, qualifications and status on the basis of equality of treatment with the domestically-trained health workforce. 4.8 Member States should, to the extent possible, regulate and monitor recruiters and employers to ensure that the services performed in connection with the recruitment and placement of migrant health personnel are rendered free of charge to health personnel. 4.9 All migrant health personnel should be offered appropriate induction and orientation programmes that enable them to operate safely and effectively within the health system of the destination country. Article 5 – Mutuality of benefits 5.1 In accordance with the principle of mutuality of benefits, both source and destination countries should derive benefits from international recruitment of health personnel. 5.2 Member States are urged to enter into bilateral and multilateral arrangements that comply with this code to promote international cooperation and coordination on migrant health personnel recruitment processes. Such arrangements should maximize the benefits and mitigate the SEA/HLP-Meet/2.1 Page 12 potential negative impact of international recruitment of health personnel through the adoption of appropriate measures. Such measures may include the provision of targeted technical and developmental assistance, support for health personnel retention, support for training in source countries that is appropriate for the disease profile of such countries, twinning of health facilities, support for capacity building in the development of appropriate regulatory frameworks, access to specialized training, technology and skills transfer, and the support of return migration, whether temporary or permanent. 5.3 Member States should recognize the value both to their health systems and to health personnel themselves of professional exchanges between countries and of opportunities to work and train abroad. Member States in both source and destination countries should encourage and support health personnel to utilize work experience gained abroad for the benefit of their home country. Article 6 – National health workforce sustainability 6.1 As the health workforce is central to sustainable health systems, Member States should take effective measures to educate, retain and sustain a health workforce that is appropriate for the specific conditions of each country, including areas of greatest need, and is built upon an evidence-based health workforce plan. 6.2 Member States should recognize that improving the social and economic status of health personnel, their living and working conditions, their opportunities for employment and their career prospects is an important means of overcoming existing shortages and improving retention of a skilled health workforce. Member States should adopt a multisectoral approach to addressing these issues in national development programmes. Article 7 – Data gathering and research 7.1 Member States should recognize that the formulation of effective policies on the health workforce requires a sound evidence base. 7.2 Member States should establish or strengthen, as appropriate, programmes for national data- gathering on health personnel migration and its impact on health systems. Member States should collect and analyse data that are required to support effective health workforce human resource policies and planning. 7.3 Member States should establish or strengthen, as appropriate, national research programmes in the field of health personnel migration and coordinate such research programmes through partnerships at regional and international levels. To this end, Member States should ensure that appropriate research is conducted on all aspects of international recruitment of health personnel. 7.4 Member States should ensure that comparable data are generated, collected and reported pursuant to paragraphs 7.2 and 7.3 above for ongoing monitoring, analysis and policy formulation. To this end, the Secretariat should develop appropriate guidelines to support implementation of this Article. SEA/HLP-Meet/2.1 Page 13 Article 8 – Information exchange 8.1 Member States should, as appropriate and subject to national law, promote the establishment or strengthening of information exchange on international health personnel migration and health systems, nationally and internationally, through national institutions, academic and research institutions, health professional organizations, and subregional, regional and international organizations, whether governmental or nongovernmental. 8.2 In order to promote and facilitate the exchange of information that is relevant to this code, each Member State should: (a) progressively establish and maintain an updated database of laws and regulations related to health personnel recruitment and migration and, as appropriate, information about their implementation; (b) progressively establish and maintain updated data from national data gathering programmes in accordance with Article 7.2; and (c) provide data collected pursuant to paragraphs (a) and (b) above to the WHO Secretariat on a biennial basis. 8.3 For purposes of international communication, each Member State should designate a national authority responsible for the exchange of information regarding health personnel migration and the code. The designated national authority should be authorized to communicate directly or, as provided by national law or regulation, with designated national authorities of other Member States and with the WHO Secretariat and other regional and international organizations concerned, and to submit reports and other information to the WHO Secretariat pursuant to paragraph 8.2(c) above and Article 10.1. 8.4 A register of designated national authorities pursuant to paragraph 8.3 above shall be established, maintained and published by WHO. Article 9 – Implementation of the code 9.1 The code should be published and implemented by Member States in collaboration with health personnel, recruiters, employers, health professional organizations, subregional, regional, and international organizations, whether governmental or nongovernmental, and other interested stakeholders. 9.2 Member States should establish and maintain an effective legal and administrative framework at the local and national level, as appropriate, to give effect to the code. 9.3 Member States should ensure that representatives of health-professional organizations, recruiters, employers, nongovernmental organizations and other stakeholders are consulted in decision-making processes and involved in other activities related to the international recruitment of health personnel. 9.4 All stakeholders should understand their shared responsibilities to work individually and collectively to ensure that the objectives of this code are achieved. All stakeholders should observe this code, irrespective of the capacity of others to observe the code. Recruiters and employers should cooperate fully in the observance of the code and promote the principles expressed by the code, irrespective of a Member State’s ability to implement the code. SEA/HLP-Meet/2.1 Page 14 9.5 Member States should, to the extent possible, maintain a record, updated at regular intervals, of all recruiters authorized by competent authorities to operate within their jurisdiction. 9.6 Member States should, to the extent possible, monitor and regulate public and private recruiters and employers to promote adherence with this code. Article 10 – Monitoring and institutional arrangements 10.1 Member States should periodically report, as appropriate, to the WHO Secretariat on measures taken, results achieved and difficulties encountered in implementing this code. The initial report should be made within two years after the adoption of this code by the Health Assembly and the periodicity of reporting thereafter should be decided by the Health Assembly. The purpose of the monitoring process is to identify challenges and successes in implementing the code and to assist countries in building capacity to implement the code. 10.2 The Director-General shall keep under review the implementation of this code, on the basis of periodic reports received from designated national authorities, pursuant to Article 8.3, and other competent sources and report periodically to the Health Assembly [at a frequency to be decided by that body] on the effectiveness of the code in achieving its stated objectives and suggestions for its improvement. 10.3 WHO shall: (a) coordinate the information exchange system and the network of designated national authorities specified in Article 8; (b) develop guidelines and make recommendations on practices and procedures and such joint programmes and measures as specified by the code or as may be required to make the code effective; and (c) maintain liaison with the United Nations, the International Labour Organization, the International Organization for Migration, and other competent regional and international organizations as well as concerned nongovernmental organizations to support implementation of the code. 10.4 Nongovernmental organizations and other interested stakeholders are invited to report their observations on activities related to the implementation of the code to the WHO Secretariat. 10.5 The Health Assembly should periodically review the relevance and effectiveness of the code. Article 11 – Partnerships, technical collaboration and financial support 11.1 Member States and other stakeholders should collaborate directly or through competent international bodies to strengthen their capacity to implement the objectives of the code, taking into account the needs of developing countries and countries with economies in transition. 11.2 International donor agencies and financial institutions should increase their technical and financial support to assist the implementation of this code and support health system strengthening in developing countries and countries with economies in transition that are experiencing health workforce shortages and/or have limited capacity to implement the objectives of this code.