A new code of practice on international recruitment should give something valuable back to those countries that export their best doctors, nurses and other health professionals.
After more than a decade of debate, the world’s health ministers approved a new international recruitment code of conduct at their annual meeting in Geneva in May. If effective, it marks a significant step forward towards a solution to the human resource capacity crisis in many poorer countries, particularly in Africa. It also raises the spectre of a planned ‘commoditisation’ of doctors and nurses to feed the North’s health services.
The WHO Global Code of Practice on the International Recruitment of Health Personnel has been long in gestation. It is a voluntary code (anything compulsory would have to be enshrined in an international treaty) but there is enough substance to it to make a difference. Now any country wishing to recruit health professionals will also need to be seen to be supporting the cost of their training in the source countries. The deal should be win-win. The international right of individuals to seek employment in different parts of the world is still safe-guarded, but – if the code works – the process will have become a good deal more equitable.
Will it work? As ever the devil is hidden deep in the detail. There is no better person to ask than Annelies Allain, who spearheaded the code on breast milk substitutes adopted in 1980. She is still working full-time on ensuring adherence to that agreement and as such was a sought-after figure in the side rooms of the Palais de Nations as the World Health Assembly unfolded. “The adoption [of the code] has lifted the ethical recommendations from a bilateral level to the global level,” she said. “Since the code was adopted by consensus, it can now be used as a tool to remind or even shame countries into action. No longer can they pretend that the brain drain is a trend that cannot be reduced or discouraged. But the code by itself will remain a piece of paper unless it is used, and don’t count on the UN to make it come alive, only civil society can keep on reminding governments what is at stake.”
Allain adds that the dilemma of individual rights versus state rights will continue to plague the execution of the code. “This is probably the hardest obstacle to overcome,” she says. “Similarly, the excuse that states cannot interfere in the recruitment by private institutions. In many countries, they can. Private health care facilities need a licence to operate and that licence can limit the number of workers from poor countries. NGOs can highlight the way private bodies go about recruitment; if it is aggressive or deceitful, it must be exposed.”
Without an effective workforce, health systems simply cannot operate. The Global Fund to Fight AIDS, Tuberculosis and Malaria took a while to realise this, but when it found that its initial funding was not having the effect it expected, it adapted and in effect expanded its mandate to include ‘strengthening health systems’, which at its core means having the right numbers of properly trained staff in the right places. Without this, progress is not possible. But it has become increasingly clear that unless there is a global mechanism to manage the process, migration will constantly undermine the best efforts. As Frank Nyonator, a Director of the Ghana Health Service observed: “All too often, just when we get the line management working within a district, a key person leaves and the structure breaks. We call it ‘rupture’.”
As the world’s population ages, the global demand for health professionals – be they nurses, doctors, lab scientists, physiotherapists or other paramedical workers – is expected to grow faster than current training institutions in the developed world can sustain. If the code works, what should begin to happen is that governments start planning ahead and if they think they will need, say, 300 more nurses a year in ten years time, then they will have to enter into negotiations with a potential source country and invest in the training of those (and other) health professionals. This will likely include institution-building costs as well as faculty support. The pay-off for the host country will be that not all of the trainees will want to travel overseas. But for those that do, the cost of the training will have been paid for by the recipient, rather than the host, as is currently the case. It is likely that some governments in the South will position themselves as training bases.
The document presented for adoption this year went through detailed scrutiny at all WHO’s regional committee meetings, at its executive board and at a stakeholders meeting in Madrid shortly before the Assembly and, as the USA (the world’s largest destination country) was backing it, it was expected to be adopted with minimal fuss. Yet it almost fell when, discussing the code’s core task of providing guidelines for ethical recruitment, the Canadian government launched a spirited campaign to have the word ‘ethical’ deleted. After all-night sittings, the document was brought back on the Assembly’s final day for adoption in what one commentator described as “still the ethical version”.
Key points from the code include: international recruitment of health personnel should be conducted in accordance with the principles of transparency, fairness and the promotion of the sustainability of health systems in developing countries; countries should strive to create a sustainable health workforce and work towards establishing effective planning, education and training, and retention strategies that will reduce their need to recruit migrant health personnel; there must be an effective gathering of national and international data and research and the sharing of information; migration
should not be a one-way process – there should be circular migration of health personnel, so that skills and knowledge can be shared to the benefit of both source and destination countries; planning will be crucial; and destination countries are encouraged to collaborate with source countries to equitably achieve mutual training needs.
How important an agreement is it? Mary Robinson, former President of Ireland, member of The Elders and campaigner for social equity has hailed the decision. “Approval of the Code of Practice is an historic step forward in recognising shared responsibilities for realising the right to health,” she said. “The Code affirms that the rights of health professionals, including their right to seek work in other countries, must be protected while addressing the catastrophic shortage of trained health professionals in the developing world. I am pleased that governments came together to create an ethical global framework – one which provides clear guidance for governments and the private sector alike as they recruit health workers, recognising that the benefits of migration must flow to sending as well as receiving nations.”
Francis Omaswa, executive director of the Global Health Workforce Alliance and co-chair of the Health Worker Migration Global Policy Advisory Council agrees: “The Code represents a significant international commitment to addressing the impacts of health workforce shortages on health systems in developing countries.”
