A perspective from the Global Health Workforce Alliance

Towards the effective implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel

Von Sonali Reddy and Linda Hegarty

The world is currently facing a health workforce crisis. There is a chronic shortage of an estimated 4.2 million health workers. This global shortage of health workers, which is exacerbated by unequal distribution, is a major obstacle in achieving key public health and development priorities. The Global Health Workforce Alliance is addressing the problem with different initiatives.

Aweil, South Sudan (Foto: © Siegfried Modola/IRIN))

According to the World Health Organization (WHO), 57 countries have fewer than three doctors, nurses or midwives for every 1,000 people, many of whom decide to emigrate to countries where they have better opportunities and higher wages. Health worker migration has been identified by the Global Health Workforce Alliance as a fundamental component of the current health workforce crisis.

In March 2008 the Alliance convened the first Global Forum on Human Resources for Health. This first Global Forum recognised the impact of health worker migration and endorsed the Kampala Declaration and Agenda for Global Action, which specified migration and the acceleration of a Code of Practice on the International Recruitment of Health Personnel (the Code) as the main action strategies to address the crisis. In line with this, one of the early activities of the Alliance was to convene and facilitate the Health Worker Migration Initiative, working with the World Health Organization in support of developing a framework for the Code of Practice.

The WHO Code

In a global response to the challenges posed by health personnel migration, member states at the 63rd World Health Assembly, held in May 2010, adopted the WHO Global Code of Practice on the International Recruitment of Health Personnel (the Code). The Code aims to safeguard developing countries’ healthcare systems by setting out guidelines that support international health worker recruitment in an ethical manner. The adoption of the Code brought to fruition the pioneering work seeded by the Alliance with the creation of the Health Worker Migration Initiative.

The Code discourages active recruitment by member states from developing countries who are facing a critical shortage of health staff, and provides a dynamic framework for global dialogue and international cooperation to address the challenges associated with the international migration of health personnel. The code also provides for information exchange on issues related to health personnel and health systems in the context of migration and mechanisms for reporting on the measures taken in implementing the Code. The reporting process is an integral component of the effective implementation of the voluntary principles and practices recommended by the Code. As part of the implementation strategy, member states were also asked to designate a national authority responsible for the exchange of information regarding health personnel migration and the implementation of the Code.

The Code sets out a roadmap for implementation, with countries expected to report back every two years. To monitor the progress made in its implementation and in accordance with the request of the World Health Assembly (Resolution WHA63.16) a national self-assessment tool was created for Member States. Member states were requested to submit their report via this assessment tool by the summer of 2012. The reporting process ended in June 2012, with 45 countries submitting their National Reporting Instruments to the WHO. Through these assessments, the WHO will be able to examine the global status of health personnel recruitment and, where possible, explore time trends. A report will be presented by the WHO Director General to the 2013 World Health Assembly, conjoining the information gathered by the National Reporting Instrument to assess international health workforce migration trends and policies since the pre-recessionary mid-2000s. Member countries are required to submit their next National Reporting Instrument in 2015, and it is expected that considerable progress in the implementation of the Code will have been made by then.

Country Coordination and Facilitation

The Code provides a unique opportunity for source and destination countries to come together around the shared problem of health worker shortages and to find mutually beneficial solutions to this common challenge. The code aims to strengthen capacity and commitment in both source and destination countries in the implementation of measures which will lead to better management of the workforce. Source and destination countries have different roles to play: in the case of source countries, there is the need to understand the conditions which lead health care workers to leave their lives behind in search of better prospects in a foreign country. In the case of destination countries, there is a need to analyse the root causes of the over reliance on health workers who have been trained abroad and find ways to achieve sustainable self-reliance in their health worker needs. Understanding and addressing these underlying issues, and the distinctions between source and destination countries, will result in better implementation of the code.

The Alliance sees the Code is an entry point to addressing the underlying issues which has resulted in millions of people across the globe having inadequate access to health workers. Recognizing that migration is subject to several factors that need to be addressed by a broad HRH policy at country level, the Alliance will continue to strengthen the development of strong national HRH policies, which will identify and influence the determinants of migration. This requires intersectoral work both at the global and national level, where the Alliance will prioritize and support the Country Coordination and Facilitation (CCF; www.who.int/workforcealliance/countries/ccf/ccf/en/index.html ) approach, enabling all HRH stakeholders to undertake Code related functions. The CCF approach supports the necessary governance structures for intersectoral coordination and collaboration to plan, implement and monitor health workforce development and retention at the country level, while working through one national HRH plan .The CCF is currently being implemented in 22 countries worldwide and has had a lot of success in supporting countries tackle their health worker shortages.

“Stand Up for Health Workers”-Initiative

Looking ahead to the effective implementation of the Code, it is vital that countries look beyond their national borders; they must be willing to learn from each other and to share good practices and experiences. With the aim of promoting this kind of sharing and networking, the Alliance has recently launched an initiative called “Stand Up for Health Workers” partnering with colleagues in Geneva-based permanent missions, in order to connect the health attaché community on the issue of health workforce challenges and opportunities. These events have two important functions: first they allow for the channeling of information to relevant policy-makers and second, they create a space where information and countries’ individual experiences in tackling the health workforce challenge can be shared. The first Stand Up was organized in October 2012 with the Permanent Mission of Ireland to the United Nations on the issue of the Code and was attended by 28 country missions.

Another initiative of the Alliance with the aim of facilitating co-operation and information sharing is the creation of an E-platform. The E-platform is an online space which allows Alliance members, partners and other interested parties to come together and share knowledge, expertise and opinions. It offers a space for discussion forums based on members’ information needs and interests.

The Alliance - as one of the main partners in the development of the Code – is committed to the further facilitation of its implementation with multiple partners both at the global and national levels, as mandated by its Governing Board. An example of our collaborative work in the furtherance of the Code is highlighted through the Health Worker Migration Policy Council Innovation Award, with our member the Aspen Institute. This initiative recognized and showcased the achievements of source and destination countries in taking measures to implement the Code. In its inaugural year (2012), Ghana was awarded for its efforts in improving basic health infrastructure, re-engaging returnees, as well as collaborating with stakeholders to encourage the return of health workers and civil societies to increase awareness. As a destination country, Norway was awarded the Innovation Awarded for establishing ethical international recruitment, setting up formal training for unskilled migrant workers and ensuring fair treatment of migrant health personnel.

Along with the work of the Alliance, there are many other organizations making important progress in ensuring better implementation of the code. For example, the Global Forum for Migration and Development (GFMD), who has long recognized the need for a code on ethical recruitment to manage the migration of health workers, has established a Platform for Partnership. The GFMD Platform for Partnerships is another available networking space created by governments to promote the sharing of knowledge, practices and concrete actions on migration and development.

The Alliance will continue to facilitate, directly or with its partners and members, advocacy activities through selected global and regional processes in order to ensure the mainstreaming of HRH policies and interventions in the policy discourse. Part of the advocacy messaging will relate to the adoption and implementation at national and international levels of new benchmarks and targets, emerging evidence and normative guidance on HRH development, including the Code of Practice. There is a lot is being done, but there is still a long way to go to before we achieve our vision that all people everywhere will have access to a skilled, motivated and supported health worker, within a robust health system.

*Sonali Reddy is Communications Officer at the Global Health Workforce Alliance. Contact: reddys@who.int

*Linda Hegarty is Memberships Officer at the Global Health Workforce Alliance. Contact: hegartyl@who.int

http://www.who.int/workforcealliance/en/