The Code of Practice and its enduring relevance in Europe and Eastern and Southern Africa

The recruitment of health workers from abroad is part of an expansive pattern of skilled workforce migration that has existed since the rapid welfare state expansion of many countries in the 1950s and 1960s. Already in 1972, 6 % of the world’s physicians were located outside their country of origin [1]. The development of the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel (referred to as the ‘Code’ henceforth) was preceded by bilateral codes that aimed at mitigating the migration of health workers to richer countries. For instance, the United Kingdom Department of Health introduced a Code of Practice for international recruitment for National Health Service employers in 2001 [2]. A study that assessed the relevance of this code concluded that it was difficult to evaluate its actual impact due to a limited monitoring capacity, a multiplicity of factors besides active recruitment that influence the mobility of the workforce, and the limited visibility of this code in source countries [3]. Other voluntary codes of practice and similar non-binding instruments have been widely criticized as weak and ineffective in mitigating workforce imbalances related to the migration of health workers [4]. Despite this criticism, in 2004, the World Health Assembly mandated the Director General to develop a non-binding code of practice on the international recruitment of health personnel [5]. Simultaneously, the Joint Learning Initiative on Human Resources for Health and Development called for mobilizing and strengthening human resources for health (HRH) as a key strategy to combat the health crises in the world’s poorest countries and to build sustainable health systems everywhere [6]. In order to cope with the health workforce crisis, the Joint Learning Initiative report proposed that effective country strategies should be reinforced internationally, “Ultimately, the crisis in human resources is a shared problem requiring shared responsibility for cooperative action” [6]. This agenda was enforced with the release of the World Health Report 2006, Working Together for Health [7], and the creation of the Global Health Workforce Alliance (GHWA) in 2006. A decade of action on HRH thus commenced.

In an interconnected world, globalization and scarcity are closely linked. The fiscal realities that frame available public financing for health systems and health workforce salaries are shaped by such issues as untaxed wealth, capital flight, wealth inequalities, etc. This fiscal crisis (including former ‘ceilings’ on expenditure of the health workforce public wage bill, imposed by the International Monetary Fund in a number of African countries until 2007) has contributed to external migration, which, in turn, has caused significant savings in training costs to importing countries [8].

In nine African source countries, the estimated government-subsidized cost of a doctor’s education ranges from US$ 21,000 in Uganda to US$ 58,700 in South Africa. The overall estimated loss of return on investment for all doctors currently working abroad is US$ 2.17 billion, ranging from US$ 2.16 million for Malawi to US$ 1.41 billion for South Africa. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom (US$ 2.7 billion) and the United States (US$ 846 million) [9]. As a counter-argument Clemens reasons that many countries in the African region simply lack the absorption capacity to integrate the workforce either in the public or private sector [10]. Migrated African physicians in the United States and Canada send, on average, more than $ 4,500 per year to their countries of birth; these remittances will be used by private actors within the country and are higher than what leaves the public coffers [10]. However, several countries, especially those from the WHO African Region, when discussing the second draft of the Code during WHO’s Executive Board meeting in January 2009, expressed the view that it needed more ‘teeth’ for enforcement and advised that it should include mechanisms to compensate developing countries for the migration to higher income countries [11]. High-income countries, especially the United States, recommended not to link the provision of development assistance to recruiting practices. During the drafting and consultations on the Code that lasted from 2008 to 2010, the Health Worker Migration Initiative, a partnership of Realizing Rights (the ethical globalization initiative chaired by Mary Robinson), GHWA, and WHO, facilitated the negotiations. This included the commissioning of a paper on potential strengths of non-binding instruments in international legal practice. The Health Worker Migration Initiative, together with Norway and the WHO Regional Office for Europe, also convened an inter-regional dialogue in Madrid in May 2010 to allow participants to get acquainted with the text and discuss content issues. The Code’s non-binding character is considered as an advantage, as it allows flexibility, including with regards to future adaptation. The code sets forth a “deep legal and institutional framework” and may “promote deeper commitments” than legally binding instruments [11]. A week later, the Code was adopted at the sixty-third World Health Assembly, slightly modified though as high-income countries argued that the tone was too prescriptive or mandatory for a non-binding instrument – this modification has perhaps softened the sense of obligations amongst countries to comply with the different articles of the code [11]. The Code focuses on ethical international recruitment and fair treatment of migrant health workers, but also includes statements on self-sustainability in national health workforces, international cooperation, support to developing countries, data gathering, and information exchange. Therefore, it comprehensively lays the ground for engagement on several aspects of the health workforce, especially in developing countries.

WHO recommended that the Code be incorporated into national policies and laws so that it can become legally binding. However, some states suggested that a more formal system for monitoring and implementing the Code was necessary for it to become a meaningful response to global HRH recruitment. The adoption of the Code, unfortunately, marked the end of a few ‘good years for HRH’ in global health policy. The economic crises in the United States and Europe led to a reduction of funds for GHWA and WHO to effectively work on Code implementation and monitoring. Austerity in Europe and the United States put a strain on health systems, including the health workforce [9]. Despite these resource constraints, a small but dedicated group of actors from different organizations and countries have been actively involved in the Code follow-up and implementation in recent years.

The health workforce crisis should not be dealt with within its own thematic ‘silo’ , but should rather be looked at in a systemic way. The global health workforce gap has increased rather than decreased since the release of the World Health Report in 2006. Given current population growth rates in different regions in the world, an ageing workforce, and an epidemiological transition to chronic disease worldwide, there is a desperate need for more skilled health workers. In 2013, approximately 7.2 million more midwives, nurses, and physicians were “missing and thus not in action” – and this shortfall is predicted to rise further to at least 12.9 million in the coming decade [12]. The Ebola outbreak in West Africa in 2014 indicated how vulnerable health systems really are when a skilled workforce with core capacities for epidemic response is missing. The outbreak was yet another wake-up call for the international community and national governments to develop the global health workforce urgently [13].

The period of implementation of the Code in the European region has coincided with the financial and economic crisis. The latter impacts directly on the relationship between investment in health workforce development and health workforce mobility, which is at the heart of the Code: the resulting new intra-European Union (EU) wage imbalances and the persisting shortages of health workers confer to the Code a renewed relevance in the region.

Although countries in Europe have responded to the economic crisis in various ways, most have adopted large-scale cuts and public sector reforms: in the context of the austerity packages implemented in 2009–2011, public spending on health fell in many countries [14]. As health worker costs account for the largest share of spending on health, these costs have been a common target for budget cuts, also in countries where salaries are relatively low [15].¹ Wage imbalances between countries (depending on changes in wages in immigration countries compared to emigration countries) or within countries (if the private and public sector have different rates of pay) are therefore changing considerably and have the potential to increase health workforce mobility in the region and beyond [16]. This new trend comes on top of already existing shortages: in 2012, the European Commission predicted in its Staff Working Document on an Action Plan for the EU Health Workforce, a potential shortfall of around 1 million healthcare workers by 2020, if no further measures were taken to meet existing challenges [17].

The response coming from EU institutions adopts a perspective that stems from considerations on the employment potential of the health sector.² Health care is identified in the Action Plan for the EU Health Workforce as a highly labour-intensive sector [17]. As such, it is given a role in stimulating ‘a job-rich recovery’ from the economic crisis. Along the same lines, mobility of health personnel within the EU is facilitated,³ as the assumption is that the EU Single Market functions as a mechanism to distribute health workers to where they are most needed [18].

Using this frame, public health considerations thus tend to take second place to market development approaches. The evidence shows, however, that the free movement of health workers leads to some seeking better opportunities abroad, creating a conflict in which personal and professional ethics sometimes collide [19] at the expense of an equitable distribution of health workers in the region and beyond. This is not entirely consistent with the principles of the EU’s own Health Strategy and with the Health Programme 2014–2020, which assigns an important role to the reduction of health inequalities in the region.

The Code can be a key tool to solve this incoherence, as it brings back a much needed public health perspective into the debate on the mobility of health workers by looking at the impact, in terms of brain drain, on health systems of origin. While the value of the Code as a policy framework to manage health workforce mobility is formally acknowledged in several EU level policy documents [20], its voluntary nature implies that bold steps are yet to be taken to integrate its principles into the functioning of the Single Market: this can be done through a system of incentives and retention measures in countries of origin, and specifically by orienting EU Cohesion policy – which shapes the programming and deployment of Structural Funds – with a view to increasing support for the equitable internal distribution of a skilled health workforce.

In the above context, non-governmental actors, including health professionals’ organizations, trade unions, non-governmental organisations, and universities, are autonomously taking steps to implement the public health approach to health workforce mobility promoted by the Code. Civil society organisations in eight European countries⁴ have been involved in documenting these efforts as a further indication of the relevance of the Code to actors on the ground. A selection of case studies, looking at both national and local levels, is briefly presented below. The case studies focus on key areas such as ‘mobility, migration, recruitment’ , ‘planning and forecasting’ , ‘rights, working conditions, protection’ , and ‘coherence, collaboration, solidarity’.

As the labour market becomes more globalized, rising demand is driving migration and mobility amongst health personnel.

Planning, forecasting, and providing for domestic health workforces without resorting to international recruitment are key to the development of sustainable health workforces globally and a fundamental step towards reducing brain drain. This also requires reliable data about inflow and outflow of health personnel.

The Code extensively covers the promotion of (and respect for) fair labour practices as well as the provision of equal rights to all health personnel. Several case studies show that there are barriers, but also identify solutions.

Contributions from Europe towards achieving a sustainable health workforce and strengthening health systems worldwide require cooperation amongst several actors and a more common understanding and awareness – from global to local.

These case studies indicate that the public health approach to health workforce mobility promoted by the Code is already translated into practice in many local and national contexts, thanks to the efforts by a variety of non-governmental actors. They are also a confirmation that the multi-stakeholder approach promoted by the Code is key to its successful implementation. These efforts, however, are often fragmented – it is time for a more systemic approach.

As a contribution towards this end, the civil society-led Call to Action: A Health Worker for Everyone, Everywhere [33] was launched in 2014: it is currently gaining support at EU level, with more than 60 institutional endorsements indicating that there is a constituency of actors across Europe demanding Code implementation. The Call provides recommendations to EU institutions and Member States for strong health workforces and sustainable health systems around the world.

A study in the ESA region, with 10 countries in the region represented, found that 3 years after the Code was adopted by the World Health Assembly, the main HRH concerns in the region were considered to be internal migration, maldistribution, and absolute shortages of health professionals, rather than external migration [34]. Regarding the content of the Code, there was a perception among stakeholders that African policy interests in the negotiations on compensation and mutuality of benefits were not adequately covered in the final Code, and there were concerns regarding its voluntary nature. According to the research, Code implementation was lacking in all countries in the region, dissemination of the Code had not materialized in the region, and only one country had a designated authority. Barriers to Code implementation included lack of champions/designated authorities, poor preparedness, weak mobilisation of stakeholders, and low involvement of civil society.

The Code has not realised its potential to galvanise action on HRH in the ESA region, and yet it is one of the regions most affected by the HRH crisis. For instance, the topics of policy focus alluded to in the Code include improving migration monitoring (e.g., through a minimum core data set), managing migration flows (for instance, through bilateral agreements, memoranda of understanding, guidelines), HRH policy and practice (covering areas such as protection of the rights of migrants, promotion of circular migration, incentives for retention, better working conditions), strengthening health systems (through approaches such as health workforce planning, education, retention strategies), and coordination, collaboration, and monitoring progress. Clearly, most of the strategies needed to combat the health workforce challenges in the region can be adequately addressed through implementation of the Code.

It goes without saying that the Code is relevant in driving forward the HRH agenda, and yet there has not been much progress in implementing the Code in the ESA region since it was adopted in 2010; most progress in implementation took place in European/Organisation for Economic Co-operation and Development countries [35]. Challenges cited in the ESA region include lack of country champions, little effort by regional organisations and virtually no activity by civil society organisations (CSOs) in the region, the need to engage multiple stakeholders involved in the decision-making process on health workforce migration and international recruitment, lack of coordinated and comprehensive data on health personnel mobility, weak national capacity to deal with health workforce issues, lack of shared understanding between stakeholders, lack of inter-country cooperation in exchanging data, and lack of proper mechanisms for sharing good practices to better manage health worker mobility [34]. The silent voice of CSOs since the adoption of the Code is noteworthy. Civil society was part and parcel of the negotiations for the Code from the outset, throughout the entire process and up to the last minute when the Code was unanimously adopted at the World Health Assembly. The CSO voice has gone silent in recent years, however, partly because funding for further CSO engagement on the Code has dried up. Without that voice, there is no one to whip countries and governments into action on the Code. A strong finding was that the Code content was not well known in the countries [34]. Strong CSO action would have ensured proper dissemination and local interpretation of the Code.

The Code is relevant and has the potential to spur action on virtually all aspects of the HRH challenges in the developing world. Nevertheless, action has been lacking on both the part of governments and CSOs.