Will the WHO Global Code benefit health workforces?

The following report, ‘The WHO Global Code and Health Professionals’ Mobility: A Lever for Stimulating Better Health Workforce Planning?’, was written by Dr Paul De Raeve, Nina Kirk Olesen and Silvia Gomez from the European Federation of Nurses Associations (EFN), and Sascha Marschang from the European Public Health Alliance (EPHA)…

The WHO Global Code of Practice on the International Recruitment of Health Personnel is a non-binding multilateral framework for rectifying the shortage in the global health workforce and migration of healthcare workers to affluent receiving countries in the European Union and elsewhere. It draws attention to the needed balance between the individual’s right to free movement in a globalised job market where health professionals in some countries and continents are particularly sought after, and the consequences that mobility can have on health systems, including an increase of health inequalities, ‘brain drain’ (De Raeve, 2003, 2004) and sustainability problems. At the same time, the WHO Code underlines the ethical dimension of health workforce planning: its voluntary nature means that its success is fully dependent on implementation efforts made by sending and receiving countries.

The purpose of this article is therefore twofold: it is an appeal from civil society for political decision-makers to implement the Code and explore the mechanisms available to achieve tangible results. It provides an overview of what has been achieved thus far, while critically analysing some of the challenges pertaining to the health workforce. At the same time, the article emphasises the European dimension of the Code given that health systems’ self-sustainability will be compromised if uncontrolled levels of mobility are to continue. In particular, some Central and Eastern European countries struggle to maintain their health workforce, a situation that is creating new health inequalities and workforce imbalances and is potentially threatening public health at large. But not only ‘new’ EU member states risk losing their human capital in the health sector, the IMI data (2011) show that, for instance, Germany has one of the highest export numbers of nurses to neighbouring countries.

The 2010 WHO Global Code of Practice
The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted in May 2010 by the 193 member states of the World Health Assembly (WHA) represents a response to the large-scale migration of skilled health personnel from low-income source countries to middle and high income receiving countries, including the EU member states, where demand for health personnel is insatiable for a number of reasons related to demography (eg an ageing population and concomitant increases in multiple chronic diseases and morbidities), the restructuring of health systems, and, perhaps most importantly, lack of long-term strategies in health workforce planning and policymaking. This has led to a massive ‘brain drain’ of health professionals from developing and transition economies, but also from the post-accession economies of Eastern Europe. The effects have been harsh as certain countries’ health systems are on the verge of collapse, thereby posing a genuine threat to public health. According to the WHO’s World Health Report 2006, 57 countries, the majority in sub-Saharan Africa, were facing a health workforce crisis, with fewer than 23 health workers (doctors, nurses, midwives) available per 10,000 people. This unacceptable status quo was also highlighted by the Global Forum for Human Resources for Health resulting in the Kampala Declaration and Agenda for Global Action (2008), an urgent call to governments and development partners to redress the situation that is threatening the achievement of the health related Millennium Development Goals.

But shortages, geographical misdistribution and inadequate skill mix are not only creating new health inequalities in the poorest countries. The health systems of the new EU member states in Central and Eastern Europe have yet to experience the positive effects of accession, especially since austerity measures were adopted in almost all countries to mitigate the effects of the financial and economic crisis that started in 2008 (EFN, 2011). As a result, thousands of doctors and nurses have migrated to the West, a mobility phenomenon that began in 2004 with the first wave of accession countries and that is repeating following the EU accession of Romania and Bulgaria in 2007. In Bulgaria, around 1,200 nurses leave the country every year – mainly to the UK, Italy, Malta, Canada and the USA – to look for a better salary and career, while in Slovakia there is an increasing number of nurses migrating, in spite of a national shortage of nurses, because of difficulties finding jobs across regions due to low salaries, difficulty finding accommodation, etc (EFN, 2011).

To rectify these alarming imbalances, the WHO Code recognises that ‘an adequate and accessible health workforce is fundamental to an integrated and effective health system and for the provision of health services’ (p. 2). Its signatories, i.e. national Ministers of Health, agreed to stop recruiting health workers from developing countries unless agreements are in place to protect the health workforce, and to provide technical and financial assistance to strengthen these countries’ health systems. In addition, the Code includes four important objectives:

• To establish and promote voluntary principles and practices for the ethical international recruitment of health personnel, taking into account the rights, obligations and expectations of source and destination countries, and migrating health personnel;
• To serve as a reference for (WHO) member states in establishing or improving the legal and institutional framework required for international recruitment of health personnel;
• To provide guidance that may be used where appropriate in the formulation and implementation of bilateral agreements and other international legal instruments; and
• To facilitate and promote international discussion and advance cooperation on matters related to the ethical international recruitment of health personnel as part of strengthening health systems, with a particular focus on the situation of developing countries.

As the italicised parts demonstrate, the added value lies in the Code’s flexibility: as a reference and guidance tool for better international dialogue, improved information exchange and cooperation on health workforce mobility it surpasses its original remit of strengthening the health systems of developing countries, economies in transition and small island states. Rather, it emphasises the urgent need to ‘think global and act local’ in the sense that health sector employment is characterised by strong interlinkages between global and national forces.

For example, some of the gaps created by the intra-European migration of health workers from East to West (and, to a lesser extent, from South to North) are increasingly being filled by qualified workers from neighbouring non-EU countries (eg Russia, the Ukraine, Balkan states, Moldova), as well as from Asia and Africa. At the same time, the poorest and most peripheral regions in Europe struggle to retain qualified health workers and experience marked health inequalities as a direct consequence of mobility. In Lithuania, migration and poor working conditions have led to a severe shortage of nurses, which is increasing the workload of those that remain, who already face very low salaries and a lack of resources as a result of the financial crisis (EFN, 2011). The resulting impact on patient safety and quality of care is one that cannot be ignored for much longer. Although ignored by politicians, policymakers and healthcare managers, mainly focusing on performance measurement and cuts, patient safety and quality of care becomes a time bomb in the years to come if the health sector is not able to invest in human capital that is highly qualified for advanced roles to achieve an appropriate skill mix in the healthcare sector.

In the EU as elsewhere, health system sustainability is a valid concern, especially since working conditions, possibilities for career development and levels of remuneration differ significantly between the 27 member states – eg €250 in Romania and €2,500 net in the Netherlands – meaning that salaries in the West can exceed Eastern European ones by a factor of 10. Therefore, one must be very cautious about viewing the pull factors – automatic recognition, better working conditions, higher wages, employment benefits, job growth, education and training, and improved lifestyle – as the main challenge, while the push factors – low wages, poor resources or technology, lack of employment benefits, poor lifestyle conditions, restricted opportunities for professional development and political instability – are mainly and seriously undermining the quality of care and compromising the sustainability of health systems. Therefore, the educational level of the health professionals is crucial for providing high-quality and coordinated health services to guarantee patient safety, ensuring social cohesion and preventing health threats such as epidemics and outbreaks of communicable diseases that can compromise public health at large.

From a public health and civil society perspective, one country’s sustainability cannot depend entirely on another’s health workforce. Every country’s health workforce better understands the local needs (e.g., social, cultural and political) and has developed competencies through an education and experience totally adapted towards the regional and national situation. Hence, each member state shall invest in their own workforce while enriching the benefits of sustainable mobility of health professionals.

Crucially, the WHO Code’s guiding principles expressly acknowledge the role of governments in taking responsibility for public health:

"Governments have a responsibility for the health of their people, which can be fulfilled only by the provision of adequate health and social measures. Member states should take the Code into account when developing their national health policies and cooperating with each other, as appropriate" (Article 3, p.4).

Hence, it is hoped that the Code will stimulate reinforced activity at European and national levels to revise and improve health workforce planning, education and training, recruitment and retention practices, based on evidence-based policymaking.

Implementation: a challenge and an opportunity
Before exploring in more detail some of the challenges that the WHO Code poses in the European context, it is necessary to take a step back and ask the fundamental question: ‘Who will ensure that the Code is implemented?’

After all, it is one thing to proclaim one’s commitment but quite another to follow through and ensure that both source and destination countries derive benefits from free movement, especially at a time when health systems are suffering financial constraints, shortages, lack of retention of skilled workforce, as well as general demotivation and unattractiveness as a result of the reasons outlined above. Given that the Code is not mandatory, it merely strongly encourages its signatories to incorporate its principles into laws and policies at national and sub-national levels, but other than public ‘naming and shaming’, there are no sanctions for non-adherence. Unfortunately, there is a strong tendency amongst relevant stakeholders to disregard or not follow through with the implementation of codes of conduct if they are merely optional. If the WHO Code is to have an impact on recruitment and retention strategies, it is imperative that its content and desired effects are put in the context of the larger economic crisis, most notably the impact of austerity measures on national healthcare systems.

However, one cannot help but wonder why the Code was not conceived as legally binding instrument. In their article, Taylor & Dhillon (2011) track its development process from the initial negotiation stages to formal adoption. They view the Code as a good example of the evolution of global health diplomacy, arguing that non-binding instruments, while dependent on political commitment, can nonetheless make a key contribution. This is especially the case in the complex field of global health governance where numerous stakeholders pursue contradictory goals difficult to regulate. The authors conclude that:

"The choice of a non-binding instrument to address these challenges may reflect recognition of the political realities and complexities associated with the issue, as well as an understanding of the role of such instruments in shaping state behaviour" (p. 22).

However, they also caution that, while the Code was made possible in a ‘spirit of multilateralism and goodwill’ (ibid), the scarcity of resources available to the WHO Secretariat may prevent its proper implementation if not rigidly monitored. Therefore, at this stage of the economic crisis, it is important to reflect on the question ‘who is doing what?’. The OECD, EUROSTAT, WHO, DG Internal Market, DG Sanco, and also DG Employment, and probably more institutions, all collect data related to mobility and skills. Has the time not come to harmonise all these efforts to strengthen implementation?

Therefore, it is also likely that there will be a difference in perception between governments and civil society regarding implementation efforts. Whatever cooperation will take place between the relevant authorities will not generate harmonised results. Different countries dispose of differing financial resources and human and technical capacities, and political priorities tend to shift. What may be portrayed as a big step undertaken may not satisfy civil society. Hence, it is necessary that civil society, and especially national professional associations and regulators, are actively engaged in the monitoring and identifying what mechanisms to support the future design of the EU workforce for health.

Clearly, the Code cannot provide solutions to redress all the overlapping effects of the health workforce demands and supplies challenges. But nonetheless it is an opportunity that must be seized: as an international reference to be respected and ‘best practice framework’ offering much-needed guidance for developing policy and legislative approaches to strengthen health systems, its value is considerable and its principles – transparency, fairness and promotion of sustainability of health systems – are well worth pursuing. At time of writing, over 69 countries have designated a national authority responsible for the exchange of information on health worker migration and Code implementation, yet implying inaction in many WHO member states and confirming that commitment is in itself a challenge. Yet it is only through sustained and coordinated effort that concrete, tangible results can be derived. Meanwhile, WHO Europe has urged those member states that have not yet identified a national authority responsible for the implementation of the Code to do so, and a concept paper to support the implementation is expected to be published later this year.

Monitoring Code implementation
Unsurprisingly, in its role as instigator and supervisor, the WHO itself is the driving force monitoring that member states are implementing the Code, which it views as a landmark achievement forming part of a larger approach to strengthen health systems as set out in numerous WHO global policy recommendations such as ‘Increasing access to health workers in remote and rural areas through improved retention’, the resolutions on strengthening nursing and midwifery, and actions to improve HR information systems and scale-up education.

Furthermore, a guidance document by the WHO Secretariat (2010) proposes a two-tier implementation strategy to support member states and stakeholders. The strategy includes four activities at the global level (communication and advocacy for the Code, development of institutional mechanisms and guidelines, establishment of partnerships, resource mobilisation) in addition to providing guidance in specific areas at national and regional levels, all linked to objectives, targets and indicators. In addition to the strategy, there is a User’s Guide (2010) that provides the necessary background information and main recommendations on ethical recruitment applying to all stakeholders.

A key element in the WHO’s HR strategy is the three-yearly report of the Director-General to the World Health Assembly, the first of which is to be presented in 2013, which in turn will be partly based on country reports to be submitted by member states to the WHO Secretariat (also every three years) starting in 2012. In 2011, the WHO Secretariat also released draft guidelines on monitoring implementation, including a model self-assessment tool for member states. It is hoped that the regular national updates will enable WHO to examine the global status of health personnel recruitment, to explore time trends and to take concrete action in the field.

Taking a holistic approach, the strategy calls on NGOs and other non-state stakeholders to work with the WHO to achieve ‘meaningful commitment and action’, including the submission of additional monitoring reports to identify the Achilles in the system. In this context, the present article can be viewed as a continuation of the engagement of civil society under the umbrella of the European Public Health Alliance briefing on the Code (2011). It is particularly important for civil society, including the social partners, to keep tabs on their recruitment practices and inform their national government and the WHO of known breaches. All reports will be posted on the WHO website to maintain transparency.

Yet so far, attempts to chart the progress of the Code have been few, a notable exception being the study undertaken by Action for Global Health (2011), which describes the implementation effort in the five biggest EU countries with regard to the global dimension of the health workforce issue. But as one would expect from a snapshot of countries with different post-colonial ties and dissimilar waves of post-war worker migration, no coherent picture emerges and the reliance on foreign health workers differs as widely as do their countries of origin. Overall, the report concludes that:

"On the one hand, EU member states are ostensibly boosting the health workforce in developing countries. On the other hand, they are taking the very same health workforce away. The net result is that the beneficiaries of this manifestation of globalisation are almost exclusively rich nations, with poor countries, and naturally, the poorest of the poor, bearing the cost" (p. 36).

Notwithstanding this sombre assessment, the report also makes a number of valuable recommendations for EU member states on development cooperation policy and domestic health policy. Regarding the latter, it specifically urges EU member states to:

• Develop clear time-bound national action plans with measurable goals and SMART and gender-sensitive indicators guiding the full implementation of the WHO Code;
• Develop coherent, sustainable and gender-sensitive national health workforce policies to enable self-sufficiency and remove the need for international recruitment; this notably includes improvements regarding the education and training, distribution and retention of health workers;
• Institute national health workforce information systems that allow the monitoring of migration trends and evidence-based policy making;
• Act to regulate international recruitment by private agencies, not currently covered by the WHO Code; and
• Maintain levels of investment in the national health systems and adequate salaries for public sector workers, even in the face of budget deficits.

While it does appear at the moment that some effort is being made in Europe to curb international recruitment, this may be related to the ongoing crisis. It does not mean that there is no demand for international health personnel given that in countries like Germany, where the ageing problem is particularly acute, 5,000 vacancies were recorded in 2009 for doctors alone, also because German doctors have themselves migrated in large numbers to access better salaries in Switzerland, the USA and elsewhere (Brill, 2010). The same can be observed for German nurses, with 4,540 having migrated to other countries during 2007-2010, in particular to Denmark, Austria, Luxembourg, the UK and Switzerland (European Commission, 2011). Similar trends have also been observed for doctors and nurses in the UK. In fact, evidence suggests that changes to UK immigration policy have led to reduced numbers of non-EU nurses and healthcare assistants seeking employment in the UK, while an increasing number of UK nurses are leaving to work overseas (EFN, 2011).

According to Taylor et al (2011), the WHO Code is currently being incorporated into national law and practice in a number of countries. In Europe, this includes Norway, which, although not part of the EU, is a popular destination country due to its prosperity, good job prospects and social system. Leading the way for EU member states, Norway has put into place measures to ensure education and training for sustainability and stop recruitment from countries facing critical shortages (Buchan, 2008). Effort has also been undertaken by Norway to encourage multi-stakeholder dialogue to advance Code implementation and monitoring, as well as to raise awareness of the Code’s provisions.

The EU is of course an important partner for implementing the Code, and as a WHO member it is in the EU’s interest to promote and adhere to it. Resulting from the 2010 Council Conclusions, the recent European Commission Staff Working Document on an Action Plan for the EU Health Workforce (2012) summarises the various EU initiatives in the health workforce sector and it makes explicit reference to the WHO Code and ethical recruitment, stating that a number of EU policies in education, development aid and migration will help support its execution. As mentioned above, a Joint Action on Health Workforce Planning and Forecasting (EC/2011/358/06) will begin its work at the end of 2012, creating a partnership between the EU member states and professional organisations. Strategically, it is seen as crucial to supporting evidence-based policy and to tackling the expected future health workforce shortage in Europe by putting into practice a platform for collaboration for member states in order to better prepare the future of the entire European health workforce. This will be supported by a joint EU-OECD study on training capacities and structures. The revision of the Professional Qualifications Directive will also facilitate mobility of health professionals within the Single Market, and thus it is vital that these facilities are not misused for massive recruitment either from EU countries or third countries.

Whether or not these initiatives will bring long-term positive results, the WHO Code appears to have triggered a heightened awareness amongst European decision-makers that more cooperation is needed, including action on the development of common terminologies, joint health workforce planning, the form and content of minimum HRH datasets, sharing and comparability of data sources (national sources as well as statistics collected by, for example, Eurostat, WHO, OECD, professional regulators), mobility trends, etc. While the respective elements are mainly national competences, the architecture of the Code favours a common approach for drawing evidence-based conclusions.

Broader health workforce challenges
What is clear is that common health workforce challenges are experienced in all EU countries, a dilemma that can only be solved by international cooperation between the WHO, the EU and national stakeholders, with European civil society forming a bridge for bringing them together. The looming shortage of highly skilled health professionals – nurses and doctors in particular – who are the cornerstones for the operation of innovative and efficient health systems, and guarantors of universal access to healthcare in Europe, spells a particularly severe problem. Not only is Europe’s population rapidly ageing and, consequently, demand for healthcare services is steadily rising, but Europe’s health workforce is itself becoming very mature, with large cohorts of doctors and nurses in many countries about to retire (European Commission, 2012). This needs to be seen in conjunction with the redundancies in posts as a consequence of budgetary constraints. In other words, the health workforce is ageing, it is going to retirement and the financial situation does not allow filling the arising vacancies with new posts. On the contrary, in 2011 the Irish Government even set a target of 6,000 nurses to take voluntary early retirement without being replaced, which obviously sparked huge concerns about the impact on health services and patient safety (EFN, 2011).
The European Commission thus estimates a potential shortfall of about one million healthcare workers by 2020, to which must be added long-term care and ancillary positions. New healthcare delivery models and skills will also be required to meet the ageing challenge and will need to move towards integrated and community care delivered by a highly motivated and qualified health workforce. At the same time, no coherent – and certainly no harmonised – effort has been made to render the health professions more attractive by matching up training and skills, engaging in long-term planning, drawing ‘new blood’ into the health community and retaining and offering carers opportunities for development to existing staff.

Clearly, health workforce planning is a complex, multifaceted and long-term effort that requires vision and investment in order to get it right. Against this backdrop, migration is only one element of the much broader and global human resources for health (HRH) challenge, which is a direct consequence of incoherent and fragmented planning.

As has been commented by a number of researchers (RN4 Cast, PROMeTHEUS), obtaining accurate, reliable and comparable data is a precondition for effective planning. In our globalised world, migration is a multifaceted phenomenon and it is often hard to track exactly when people are moving, where they are headed, and for what reasons. Regarding health professional mobility, there is a dearth of qualitative studies and although EU-funded research projects exist to close the gap (eg PROMeTHEUS, MohProf), the push and pull factors of health professional mobility are many (Wismar et al, 2011) and include such diverse reasons as low wages, poor resources or technology, political stability and job growth. In this context, the modernisation of the Mutual Recognition of Professional Qualifications could help identify and describe health professionals’ mobility through the now proposed mandatory use of the Internal Market Information System.

In addition, migration patterns are often difficult to predict. For example, the recent migration of Central and Eastern European health professionals to Ireland, the UK, and the Nordic countries must be assessed in connection with the long transition periods imposed by neighbouring countries like Austria and Germany, where it was feared that a big influx could trigger mass unemployment. Although these countries’ job markets were already de facto accessible (eg to the self-employed and certain health professions), the transition period created a psychological deterrent for many would-be migrants. Hence, it is not only collecting data that is important, but also monitoring trends over time, especially since changing patterns can already be observed now that all EU countries have fully opened their job markets to the first wave of accession countries, and some also to Romanian and Bulgarian professionals. Crisis related employment losses in Spain, the UK and Ireland are redirecting flows to other EU countries, while increased return migration is occurring, eg to Poland, where both public and private sector employers have offered financial and other incentives to willing returnees and healthcare salaries have risen significantly since 2007 (Kautsch & Czabanowska, 2011).

The Polish example stresses the importance of making system adjustments to render the health professions more attractive. While not posing a significant threat, the migration of health professionals left a noticeable mark on the Polish health system, and in parts there is an ongoing shortage of medical specialists in particular, also because mobility has been much higher amongst young graduates and the mismatch between demand and supply in the education system (Warsaw University Centre of Migration Research, 2011). Although migration to Poland is still very low, the gaps are increasingly being filled by non-EU health professionals, eg from neighbouring Ukraine and Belarus (ibid). To rectify the problem, the Polish Ministry of Health has embarked on a reform programme, salaries have been increased and employment conditions have been raised. Moreover, unemployment in the big cities is uncharacteristically low as Poland has not been hit as hard by the crisis as other CEE countries. The currency has also gained in comparative value to the euro, making foreign salaries less attractive.

In addition, the government has made an effort to win back young, qualified professionals of the Polish diaspora in the UK and elsewhere. In spite of these improvements, there are also many options for professionals to work in transnational space: as a result of the post-accession exodus: Polish cities are well linked to Western Europe via low-cost airlines, international coach services and trains, allowing uptake of short-term and weekend contracts abroad (Kautsch & Czabanowska, 2011). With Germany’s job market now fully opened and soliciting Polish health professionals (Warsaw University Centre of Migration Research, 2011), it is even possible to commute across the border. However, it is equally true that foreign minimum wages and social benefits can still eclipse a full-time Polish salary in certain positions, which means that health professionals’ long-term return will depend on what is being offered to them at home. Those with migration experience might also be willing to leave again should the crisis begin to hit hard.

In contrast, the case of Romania illustrates that inaction yields unsatisfactory results. Since EU accession in 2007, thousands of doctors and nurses have already left the country to work and fill gaps in the West, and the country has the lowest density of health professionals in Europe (Vlădescu & Olsavsky, 2009). Romanian professionals tend to be well educated and often also have excellent language skills, which makes them attractive targets for international recruitment. The negative effects of out-migration are however alarming: in 2011, the Romanian College of Physicians (CMR) warned that if current migration trends continue – an estimated 2,000 departures were recorded in 2011 alone – the already below average doctor-patient ration will become worrisome. While doctors are migrating mainly to France, Germany and the UK for higher salaries and better career opportunities, nurses are drawn everywhere, including Italy and Spain where a large Romanian community resides.

As other countries’ job markets are gradually opening up, the temptation to pursue other forms of employment may also be high given that even simple jobs abroad can be better remunerated. This is due to the extremely low remuneration, combined with salary cuts of 25% for professionals across the Romanian healthcare sector in face of the financial and economic crisis (EFN, 2012). Yet it is crucial to educate and invest in young health professionals as they are desperately needed in rural and peripheral areas, and to serve disenfranchised groups such as the Roma minority. The Romanian example illustrates that health inequalities are amplified by the lack of a health workforce strategy, and that the WHO Code’s implementation must also take into account intra-European mobility.

Successful recruitment and retention strategies have a direct impact on the quality and performance of health systems, thereby creating more safety for patients and an attractive environment for health workers. They depend on many things, such as setting realistic education and training quotas, adequate salaries, and opportunities for professional and personal growth. One area that will require increased attention is the development of the right skill-mix and competencies. Both need to be updated consistently in line with new professional realities, responsibilities and technological progress. The move towards personalised healthcare, for example, implies a number of important changes in this respect. As the evidence collected by Wismar et al (2011) has shown, migrants leave and return for many different reasons. Lifelong learning and continuous professional development (CPD) are two concepts that also support professional growth over time and hence render working environments more attractive. Retention is particularly important for the future self-sufficiency of health systems that have seen important out-migration over the last years, such as Romania and Bulgaria. Recognising skills and qualifications gained abroad will also be important, especially when it comes to reinserting professionals.

Of particular importance in this context is the importance of needs-driven planning not only by governments and industry but in consultation with health professionals, patients and civil society. What are future health needs and how can they be met in an ethical way?

The danger of not addressing the issue of wider HWF planning in relation with the WHO Code is that health inequalities will only rise and rise. Between and within countries, qualified health professionals will continue to seek better working conditions, better adequacy and resources at workplace and possible higher salaries in European capitals and economically strong secondary cities at the expense of rural and economically deprived areas. As Maier et al. (2011) have noted, the volume of flows is not always the best indicator since the departure of even a few specialists makes a huge difference for healthcare provision in underserved areas. This not only puts individuals at risk but means that certain population groups, such as some Roma communities in Hungary and elsewhere, cannot access adequate healthcare services. As a consequence, source countries may be forced to recruit themselves from non-EU countries such as India, the Philippines, Nigeria or Kenya, where a surplus of health professionals is being trained, and unemployment is high.

Mechanisms for improved health workforce management
An example of planning for a very diverse health workforce is the UK, where the reliance of recruitment of health personnel both from ‘global’ and European sources has been significant: together with Ireland, over the last decade the UK was the only EU country with high or very high reliance on foreign trained doctors and nurses (Maier et al. 2011). The National Health Service (NHS) is one of the biggest employers in the country and, unsurprisingly, it experiences high staff turnover and is in constant need for qualified staff in order to serve a growing and increasingly diverse clientele. Today, the NHS employs significant numbers of health professionals from Commonwealth countries, other source countries in Asia and Africa, old EU member states (eg Spain, Germany, France), as well as Eastern Europe, the numbers of which rose spectacularly following EU accession and the early opening of the British job market. After significant expansion in the 1990s, the UK introduced guidelines on international nursing recruitment in 1999, followed by the subsequent introduction of a national Code of Practice to discourage recruitment from developing countries in 2001 (refined in 2004), and the 2003 Commonwealth Code of Practice (Gross, Jessica et al, 2011).

Yet while the UK is often cited as a model for the integration of health professionals in an open market economy, a number of high-profile cases have underscored that mobility must not occur at the expense of patient safety (Kelly, 2011; Daniel Ubani case). More specifically, they show that clinical expertise alone does not mean that an individual will be able to perform without the necessary support to adapt to a new professional environment and culture. This even prompted the UK General Medical Council (GMC) to rule that basic training courses would be introduced for foreign doctors. There is a need to offer the right support to health professionals to acquire the necessary communication skills when they are employed in other countries. This is currently being addressed within the modernisation process of the Professional Qualifications Directive.

In support of the WHO Code, the UK has concluded a number of bilateral agreements with non-EU countries, mainly those belonging to the Commonwealth. In this way, a major transfer of knowledge and capacities has occurred. Similar schemes are also being operated by the four other countries surveyed in the Action for Global Health (2011) report. Other examples of policy interventions for directing health workforce migration include practices such as twinning, staff exchanges, providing education support, country-specific recruitment codes, and compensation (Buchan, 2008), albeit not all of these produce successful outcomes.

The circular migration model may also be a good mechanism in support of the WHO Code. By engaging in short-term, fixed duration contracts, health professionals can gain new experiences and skills abroad while not entirely withdrawing from the home job market, which means that it will be easier to maintain transnational links and to reintegrate than if a full migration process is undergone. One of the reasons that the UK continues to be a magnet for health professionals is that the British healthcare system offers professional opportunities to their health workforce and is very dynamic, open and flexible: it relies heavily on short-term workers, which allows Eastern Europeans and third country professionals to travel back and forth without having to make a definitive commitment to one country.

The increased use and monitoring of EU Structural and Social Cohesion Funds is another mechanism that can help put the poorer countries’ health systems on a par with those in the West. Structural Funds can be used to strengthen and invest in the health workforce, to foster health accessibility to the population and thus prevent health risks (eg awareness campaigns, transfer of knowledge and technology, skills development), to enhance the sustainability of health systems by facilitating innovative changes and improving the availability of resources (eg technology to improve healthcare delivery including e-health, ICT solutions, developing centres of excellence, etc). One problem that has become particularly obvious in Romania is that the absorption rate of Structural Funds has been worryingly low (Constantin, Goschin and Danciu, 2011). This is due to a number of reasons related to lack of management capacity and additional resources to process them, difficult co-financing requirements, but also owing to corruption (EurActiv, 2011). This highlights the urgent need for a more comprehensive management and monitoring framework for Structural Funds, including expert help from European and international bodies to ensure that these funds can play their part in modernising health systems and improving working conditions for health professionals, which has been observed in Lithuania (Padaiga, Pukas and Starkienè, 2011), Poland, Malta and elsewhere, which in turn will help to implement the WHO Code.

The WHO Code as a lever for better health workforce planning
The above discussion has shown that the WHO Code functions as a global architecture, including ethical norms and legal and institutional arrangements, to guide national action and multilateral cooperation. As Article 5 affirms, ‘all member states should strive to meet their health personnel needs with their own human resources for health, as far as possible’.

Hence, the Code’s key principles focus on developing sustainable health systems, protecting the human rights of migrant health personnel and supporting health systems in low and middle-income countries, in part by providing technical and financial assistance for health professional education and personnel development. Such development is critical to achieving the Code's four objectives. Health personnel development remains chronically underfunded in national budgets and cooperative development efforts.

It is increasingly difficult to view global and intra-European recruitment as two separate modes; not only has professional mobility become more complex and transnational, but less employment from outside of Europe will also elicit increased migration from poorer EU regions to richer ones, thereby deepening health inequalities and menacing universal access to healthcare, which spells a huge problem for public health in Europe.

As Taylor et al (2001) rightly affirm, "the Code’s success will ultimately be judged according to whether it leads to concrete improvements in the lives of the people and communities most affected by the workforce crisis". The real challenge is thus to find a workable balance that can benefit individual migrants as much as home and host countries’ health systems. This is not to say that health professionals should not be allowed to access better opportunities by migrating elsewhere, but that the challenge of investing in high-quality, equitable and sustainable health workforce and health systems must be urgently tackled. Seen in this light, health workforce mobility is a warning that sheds light on health systems’ entrenched difficulties.


¹ For example, Structural Funds were used for bridging courses for Polish Nurses in 2004.


Authors
Sascha Marschang, MA
Policy Coordinator for Health Systems, European Public Health Alliance

Nina Kirk Olesen
Policy Advisor of the European Federation of Nurses Associations

Silvia Gomez, RGN, MSc
Policy Advisor of the European Federation of Nurses Associations

Paul De Raeve, RGN, MSc, MQA, PhD
Secretary General of the European Federation of Nurses Associations


Bibliography
Action for Global Health (2011), Addressing the Global Health Workforce Crisis: Challenges for France, Germany, Italy, Spain and the UK.

Brill Klaus (2010), ‘Ärztemangel – Nur nicht Rumänien!‘, Süddeutsche Zeitung, www.sueddeutsche.de, 18 August 2010.

Buchan James (2008), How can the migration of health service professionals be managed so as to reduce any negative effects on supply? WHO Policy Brief.

Constantin Daniela, Goschin Zizi and Danciu Aniela R (2011), ‘The Romanian Economy from Transition to Crisis. Retrospects and Prospects’. World Journal of Social Sciences, Vol. 1, No. 3, July 2011, pp. 155-171.

Daniel Ubani case – see www.bbc.co.uk/news/uk-england-14296744.

De Raeve Paul (2003), The Nursing Shortage: A European Perspective. Journal of Advanced Nursing.

De Raeve Paul (2004), Nursing and Health Developments in Central and Eastern Europe. Nursing Standard.

De Raeve Paul (2004), The Free Movement of Nurses: A win-win situation if based on ethical recruitment guidelines. EuroHealth.

EurActiv (2011), ‘Warning over Romania’s inability to absorb EU money’. Article available at www.euractiv.com/regional-policy/warning-romanias-inability-absor-news-506535 (accessed on 19 March 2012).

European Commission (2005), The Professional Qualifications Directive includes the principle of automatic recognition for five categories of health professionals, including doctors, nurses, pharmacists and midwives. More information on related policy developments is available on the website of the European Commission’s Directorate-General for the Internal Market and Services:
www.ec.europa.eu/internal_market/qualifications/policy_developments/index_en.htm.

European Commission (2012), Commission Staff Working Document on an Action Plan for the EU Health Workforce, SWD(2012) 93 final, 18th April 2012.

European Commission (2011), Database on Cross Border statistics for Nurses 2007-2010. Data obtained 8th December 2011.

European Commission (2011) Implementing Decision (2011/C/358/06).

European Commission Staff Working Document on an Action Plan for the EU Health Workforce (2012), p. 3.

European Federation of Nurses Associations (2011). ‘Caring in Crisis: The Impact of the Financial Crisis on Nurses and Nursing’.

European Federation of Nurses (2011), ‘Caring in Crisis: The Impact of the Financial Crisis on Nurses and Nursing’.

European Public Health Alliance (2011), ‘EPHA Briefing on the WHO Global Code on International Recruitment of Health Personnel’, www.epha.org/a/4649.

General Medical Council (GMC), see www.guardian.co.uk/society/2011/sep/16/gmc-induction-training-foreign-doctors.

Global Forum for Human Resources for Health resulting in the Kampala Declaration and Agenda for Global Action (2008).

Gross Jessica M et al (2011), ‘The Impact of Out-migration on the Nursing Workforce in Kenya’. Health Services Research, Volume 46, Issue 4, pp. 1300-1318, August 2011.

Kautsch, Marcin and Czabanowska, Katarzyna (2011), ‘When the grass gets greener at home: Poland’s changing incentives for health professional mobility’. In: Wismar, Matthias et al. (eds.), ‘Health Professional Mobility and Health Systems – Evidence from 17 European countries’, pp. 419-448.

Kelly Charles (2011), ‘Foreign Doctor and Romanian Nurse row continues’. Post available at www.immigrationmatters.co.uk/foreign-doctor-and-romanian-nurse-row-continues.html (accessed on 15 April 2012).

Maier Claudia B et al (2011), ‘Cross-country analysis of health professional mobility in Europe: the results’. In: Wismar, Matthias et al. (eds.), ‘Health Professional Mobility and Health Systems – Evidence from 17 European countries’, pp. 23-66.

Padaiga, Žilvinas., Pukas, Martynas and Starkienè, Liudvika(2011), ‘Awareness, planning and retention: Lithuania’s approach to managing health professional mobility’. In: Wismar, Matthias et al. (eds.), ‘Health Professional Mobility and Health Systems – Evidence from 17 European countries’, pp. 395-417.

Taylor Allyn L and Dhillon Ibadat S (2011), ‘The WHO Code of Practice on the International Recruitment of Health Personnel: The Evolution of Global Health Diplomacy’, Global Health Governance, Volume V, No 1 (Fall 2011), www.ghgj.org
Taylor, Allyn L. et al (2011), ‘Stemming the Brain Drain – A WHO Global Code of Practice on International Recruitment of Health Personnel’, New England Journal of Medicine; 365:2348-2351, December 22, 2011, www.nejm.org/doi/full/10.1056/NEJMp1108658#t=article

Vlădescu Cristian and Olsavsky Victor (2009), ‘Migration of Nurses: The Case of Romania’, Management in Health, Vol. 13, No 4.

Warsaw University Centre of Migration Research (2011), ‘National profile of migration of health professionals – Poland’. Available at MohProf project website: www.mohprof.eu/LIVE/DATA/National_profiles/Poland.pdf.

Wismar Matthias et al (eds 2011), ‘Health Professional Mobility and Health Systems – Evidence from 17 European countries’. WHO on behalf of the European Observatory on Health Systems and Policies.

World Health Organization (2006), ‘Working together for health – The World Health Report 2006’ WHO Press, Geneva. Available at www.who.int/whr/2006/whr06_en.pdf.

World Health Organization (2010), WHO Global Code of Practice on the International Recruitment of Health Personnel’, http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R16-en.pdf.

World Health Organization (2010), ‘The WHO Global Code of Practice on the International Recruitment of Health Personnel – Implementation by the Secretariat’.

World Health Organization (2010), ‘User’s Guide on the WHO Global Code of Practice on the International Recruitment of Health Personnel’.

World Health Organization (2011), ‘Draft guidelines on monitoring the implementation of the WHO Global Code’, www.who.int/hrh/migration/draft_guidelines.pdf.