Country case studies

Civil Society Contribution and advocacy for implementing the WHO Global Code in the European Region

Von Linda Mans, Remco van de Pas and Giulia De Ponte

This article has been submitted to the WHO as a civil society report on the implementation of the Global Code of Practice (CoP) on the international recruitment of health personnel in 9 European countries. The CoP was adopted during the 65th World Health assembly. An overview report of its implementation by member states and other actors (including civil society) will be presented during the 68th World Health Assembly in May 2013.

Uganda (Foto: © Edward Echwalu/IRIN))

Since the beginning of the 21st century, when the Millennium Development Framework had started, several NGOs and academics have pointed to both domestic and international brain drain of the health workforce as a hindrance to reach health development goals in low- and middle income countries (LMIC). They highlighted the effects of loan conditions for macro-economic development by the World Bank and IMF, as well as the WTO’s General Agreement on Trade in Services as “push factors” for people to migrate. Amongst these conditions were fiscal ceilings on public sector spending as well as limited education, training and deployment of health care workers in many LMIC. As a result, many health workers “moved” to the private sector in urban areas or migrated to work in richer countries, including in Europe, where demands for health care had risen due to demographic changes. It was estimated that this incurred a loss of 184.000 US$ per migrating African professional. (Labonte R.) NGOs have called this brain drain a “perverse” subsidy from LMIC to high-income countries and since then have advocated for internationally binding regulations on recruitment, equal access to health care as well as compensation for the incurred losses. (Mensah K et al. 2005)

In the lead up to the eventual CoP, European NGOs have been closely involved at both national and international level to raise the issues of fair recruitment, retention strategies, data sharing, freedom of movement and the right to work, as well as the obligation by states to provide essential health care for all its citizens. This advocacy was done in conjunction with, amongst others, the World Medical Association, The International Council of Nurses and Public Services International.

The organizations called on states to respect and fulfill human rights as part of international agreements on health worker migration. The request for a binding convention has found its way only partly into what has become the WHO Global Code, a voluntary “soft law” tool that is aimed at stimulating action from governments and other parties, but cannot enforce work on sustainable health workforce practices. On the other hand, the Code encourages states to develop national legislation as well as bilateral and multilateral agreements on workforce migration. Civil society actors request these regulatory frameworks to be further developed and have proposed a number of models. (Dhillon et al. 2010) Other human rights conventions such as CEDAW (Convention of the Elimination of Discrimination against Women, more specifically General recommendation No. 26 on women migrant workers. and migration-focused treaty bodies may serve as well as guidelines for further recognition of human rights.

For European CSOs three new challenges have come to the forefront in relation to health workforce mobility. First, their role as advocates has changed to one of cooperation and promotion of the Code at national level at a time that national health systems are under pressure for budget cuts because of economic austerity measures. Secondly, as a result of the treaty of Lisbon that facilitates mobility of employees within the EU as well as more stringent EU migration policies, the attention has now shifted towards internal imbalances within the distribution of health workers in the EU. Besides, migration to the EU predominantly takes place from South-Eastern countries that are part of the WHO–EURO region. This implies that fewer health workers are now migrating to the EU from the so-called 57 crisis countries as defined by the WHO in its World Health Report 2006. Thirdly, the NGOs involved in health workforce migration often have a background in international development cooperation. It is a serious effort to unite organizations, which also work on health system sustainability at national level, like patient federations, labor unions and professional associations. From the government side several ministries should be involved in the matter, e.g. foreign affairs, health, education, labor, and migration. Because of this needed multi-sectoral approach which would move beyond the responsibilities of health ministries it has proven challenging to get the right people involved in national stakeholder processes.

With the existing evidence of workforce mobility within and to Europe (Mobility of Health Professionals 2012 & European Observatory on health systems and policies 2011), and considering that the EU Commission estimates a shortage of one million qualified health professionals by 2020 (European Commission Staff Working Document on an Action Plan for the EU Health Workforce, 2012), civil society actors remain very much involved in mitigating the issue from a moral and rights-based approach that balances individual health worker’s rights with sustainable and equitable strengthening of health systems. The cases below highlight the work of civil society in 9 countries since the CoP was adopted at the 65th World Health Assembly.

The Netherlands

WEMOS, an organization advocating for the right to health and health equity within international policies, has concretely done three things. It has in 2010 initiated the Dutch multi-sectoral HRH alliance that works on sustainable health workforce issues at national and international level. Via media and articles, its work has influenced parliamentarians, health care employees and the MoH to limit the recruitment of foreign health employees and to develop covenants for diversifying and expanding the national workforce. The HRH alliance has produced a policy brief with an actor mapping and recommendations for actions and policy coherence for a sustainable workforce (Wemos and Christel Jansen 2010). Based on this document, the Alliance conducted roundtable discussions with the respective ministries and DNA (Designated National Authority) on code implementation in 2010 and 2011. This has resulted in awareness about the problem, and measures to reduce migration from outside the EU. However, the Dutch government regards the health system as self-regulatory and takes a controlling, rather then a guiding role on its development. Wemos has been a link to European and Global advocacy on the health workforce via its positions within the Medicus Mundi International network and the Global Health Workforce Alliance.


Be-Cause Health, the Belgian platform on international health, has a working group that exchanges good practices and knowledge on HRH as part of development policies. Secondly, it supports the implementation of the Code of Practice at national level. It conducted, a multi-sectoral expert workshop in June 2012 in which a charter on health workforce strengthening was agreed on by all actors (Because health 2012). Belgium will take Code implementation further as member of the WHO - Executive Board since May 2012.


AMREF, an international health development organisation working to produce lasting health change in Africa, has promoted in Italy a campaign called “Personale sanitario per tutti” between March and June 2012: it focused on the shortage of health workers that is estimated to be 35.000 persons per year, on the rights of health workers from Eastern-Europe and non-EU countries and on the impact of their migration on health systems of origin. It worked together with several actors (AMSI, CeSPI, IPASVI, FNOMCeO,OISG, SIMM) to produce a Manifesto (AMREF Italy. Manifesto for Health Workforce strengthening) related to the obligation by the Italian state and health system to implement the Code, which includes 9 recommendations to sign on to. The Manifesto so far has been signed by more then 80 organisations and received ample attention in specialized media. In May 2012 a consultation with relevant ministries, health system authorities, DNA, health professional organizations, NGOs and a WHO representative took place, which elaborated on steps for code implementation in Italy. This institutional dialogue has gained commitment on health workforce strengthening from the ministries involved; at the same time, in a period of severe health budget cuts, it has proved so far difficult to engage regional health authorities who are the real budget holders in a decentralised system like the Italian one, as well as private employers and recruiters. Attention to both issues will be part of the next phase of the campaign.


The Medicus Mundi Switzerland (MMS) network of organizations working on international health and development has a working group focusing on HRH within foreign policies by the Swiss government. The network produced a manifesto in January 2012 on Health workforce migration together with professional associations and labor unions (Manifesto. “Health workforce shortages should not be burdened on the poorest”), the network is part of a international health dialogue group that discusses Swiss global health strategies with the ministries. On the 30th of April 2012 the network had a discussion with the DNA and other departments. The efforts of MMS engaged commitment of Switzerland, where many health workers from neighboring EU countries work, to further implement the Code and to take this also forward in its foreign health policies. It also led the DNA to submit the Code monitoring report to the WHO that includes the position of Swiss Civil Society.


The Organizations Terre des Hommes and OXFAM have been working on health workforce strengthening as part of the Action for Global Health Network (AFGH), a network in 5 European countries that advocates for sustained health investments as part of development cooperation. AFGH produced in 2011 a report on code implementation and health workforce strengthening in those countries. (AFGH. Addressing the global Health workforce crisis) This document describes domestic and development policies on HRH as well as the effect of the workforce shortage in some destination countries. As a follow-up of this report stakeholder dialogues were held at the national level to discuss priorities on code implementation. In March 2012 in a meeting with the DNA and several other actors, it has committed to develop a foreign health policy group that amongst others would work on health workforce strengthening and code monitoring. (AFGH. Teeth for the tiger: Action for Global Health conference 2012) AFGH also runs the campaign

United Kingdom

The UK has a long history of addressing the issue of recruitment of health workers from countries with shortages. The Department of Health developed guidelines on international recruitment in 1999 and introduced a UK Code for the international recruitment of healthcare professionals in 2001 which was strengthened in 2004. This Code covered the National Health Service and some private sector employers. In the development sector, the AFGH Working Group on Human Resources for Health has been closely involved with policymakers since the lead up to the adoption of the Code in 2010. For example, the NGO VSO published a report on “Brain Gain – Making Health Worker Migration work for Rich and Poor Countries” in 2010. As mentioned in the case study on Germany, AFGH produced a study on domestic and development policies addressing the health workforce crisis. The Royal College of Nursing has been monitoring health worker migration and changes in the nursing workforce very closely through annual nursing labour market reviews. The working group also has close relations with the UK All-Party Parliamentary Group (APPG) on Global Health which is chaired by Lord Nigel Crisp. The APPG recently released a report on improved skill–mix within the health workforce as a way to overcome the global health worker crisis. (All Party Parliamentary group on global health 2012) The UK has submitted its report on the implementation of the Code to the WHO mentioning some bilateral cooperation agreements. This bilateral cooperation model might serve as an example for other EU countries.


The Federation of Medicus Mundi Spain (MM-ES) together with the Spanish AFGH network has been monitoring the Spanish efforts on international health development cooperation that includes efforts on health workforce strengthening. This annual report by Medicus Mundi Spain is presented each year in Spanish congress to discuss and shape its policies for foreign health. (MM-ES, Prosalus, MdM) In June 2011 a multi-sector dialogue was organized with the Spanish Ministry of Health regarding the code of practice and how to continue its implementation. (AFGH. “Policy Coherence, sometimes a matter of sharing spaces” 2011) Like Italy, the main budget holders in health and education are the regions, that will have to reduce considerable amount of their public budget over the coming years. MM-ES will monitor its consequences for health workforce development as well as mobility from health workers to, from and within the country.


Humanitarian aid foundation Redemptoris Missio has been working in projects of the Medicus Mundi International network to promote awareness of global health problems. Poland is in the unique situation that many of its health workers migrate abroad while on the other hand it also attracts health workers from neighboring countries to its East. Poland is considered to have good medical educational facilities, that are relative affordable and hence attract medical students from abroad. Professional associations are well organized in Poland. Multi-sectoral discussions with policy makers will be developed over the coming period as Poland is prone to have many push and pull factors for health workers to move (temporarily) abroad, especially when the deficit of health workers within the EU will increase over the coming year.


The Center for Health Policies and Services (CHPS) has analytical and advocacy expertise in health system strengthening within Romania, as part of several EU and international projects on health. Since 1999 it has conducted a number of studies at national level called “Opinion barometers” that includes issues like quality of care, health worker distribution, job satisfaction, professional trainings provided etc. The Reports by CPHS serve a policy guiding for the Ministry of health. Last years Romania had, due to fiscal limitations and EU regulations, to reduce its number of public health workforce. This implies that job opportunities for newly graduated health staff are limited, and hence a push factor to move abroad. In terms of outflows, Romania has one of the highest physician out-migration rates. In 2007, over 9% of all Romanian-trained physicians were practicing in other countries. At that time less than half of those practicing outside of Romania were located in EU countries. This trend is changing. Over 90% of physicians who left Romania in 2007 went to another EU country. At this moment in time there is not yet a DNA for code monitoring, and one observes fragmented responsibilities for data collection and policies development by the health authorities. In the nearby future CHPS will conduct stakeholder dialogues concerning the development of a national HRH strategy, mobility of health workers and how they can be retained for the national health system and remote areas. There are several NGOs with active participation and interests in the development of Romanian health workforce which can be actively involved in the promotion and implementation of the Code.

Steps forward

These 9 country case studies indicate that civil society has taken a considerable role when it comes to the monitoring of health workforce migration. The next steps will consist of a more coordinated action between the countries to exchange data, tools, good practices and understanding: this consolidated work will be taken forward in the next three years by the initiative “Health Workers for all and all for Health Workers”, a partnership bringing together civil society actors from 8 EU countries and supported by a European Commission’s grant. This prospective program will be carried out in close alignment with WHO, and it should then also lead to dialogue and further agreements at the EU level. The CoP is recognized in the EU strategy on its role in Global Health (EU Council conclusions on the EU role in Global Health 2010), as well as the Green paper on European workforce for health. (European Commission. Green Paper on the European workforce for health 2008) Although there is an agreement between social partners on the mobility of health personnel between hospitals in Europe (European federation of public service unions 2008), there should be more regulation to balance the distribution and quality of health workers within the EU, while, at the same time, not depleting human resources in non-EU countries.

The following lessons and recommendations can be taken forward while working on fair and rights-based development of the workforce at national, EU and Global level:

  • Health workforce policies should not be addressed in isolation by the national health department in line with development policies for health, but become part of national global health strategies, drafted by multi-sectoral ministerial groups including eg. migration and economic affairs, and in consultation with NGOs, professional associations etc. This global health strategy should be discussed and approved by Parliament. A part of its focus should be on mobility and its inequities within the Union, and the need for self-sustainability in each of the member states.
  • Development NGOs working on global health workforce issues, should much more liaise with other civil society actors that have a stake in national workforce development; eg labor unions, medical associations, patient and consumer organizations, etc. The manifestos described in the cases above contain concrete entry points for such cooperation.
  • CSO’s can promote and monitor fair, binding, bilateral and multilateral agreements on a balanced health workforce, within the EU as well as with other countries. These should be coherent and / or aligned with other international legal agreements on migration-, labor- and Free Trade that have included protocols on health services and knowledge exchange.
  • CSO’s can promote and become part of national HRH observatories that systematize and monitor data on health workforce developments and mobility. EU member states can learn from the Latin-America region where this has been developed in some countries.
  • CSO’s can look further into mobility of informal and less-formalized health workers like auxiliary nurses or volunteer caregivers within a social or family context. The stress on social protection systems pushes for more care to be conducted in the informal sector. It is in these sectors that there is a growing trend of workforce mobility within and to the EU. Similarly, Europeans that are well off can move to another country where they receive for instance elderly care that is relative cheap but can then put pressure on the local health workforce capacity. In other words, CSOs need further analyse cases of migrant health workers ending up in receiving countries in (a) different sectors (b) the same sectors but lower-qualified jobs or (c) illegal labour arrangements. Taking into account that more women than man work as auxiliary nurses or volunteer caregivers within a social or family context, CSOs will do this from a gender specific point of view.

Two years after adoption of the CoP civil society takes considerably effort in keeping the issue under the attention of policymakers and remain involved at several levels in shaping policies for a stronger, well-balanced, health workforce.

*Linda Mans is Health Advocate at Wemos. As a health scientist her professional focus has been on doing research and providing participatory video workshops within the field of health (care), human rights, gender and diversity - in the Netherlands and internationally. At Wemos Linda will coordinate the EuropeAid funded project 'Health workers for all and all for health workers' in which AMREF Italy is a partner. Contact:

*Remco van de Pas is health advocate at the Wemos foundation. He is a medical doctor specialized in international public health, and worked several years on health systems strenghtening in West-Papua, Indonesia. He has been involved in development and follow-up of the Code of practice on the international recuitment of health personnel. His work focuses on global governance for health and global health diplomacy. Contact:

*Giulia De Ponte is the Advocacy Coordinator at AMREF Italy, with an expertise on health systems strenghtening, access to the right to health in Africa and international cooperation in the health sector. She is presently a member of the Steering Commitee of the Italian Observatory on the fight against AIDS and of the Italian Observatory on Global Health. Contact:



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