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UN code to halt indiscriminate drain of health workers

 InDepth News 26 July 2019

The World Health Organization (WHO) has developed a 'global code of practice' to stem the 'brain drain' of health-care workers from developing to high-income countries, which weakens health systems in the countries they quit. (1167 Words) - By Richard Johnson


The World Health Organization (WHO) has developed a 'global code of practice' to stem the 'brain drain' of health-care workers from developing to high-income countries, which weakens health systems in the countries they quit. (1167 words, English)

Richard Johnson

Worldwide, there are around 60 million health workers. About two-thirds provide health services; the other one-third is management and support workers. Without them, prevention and treatment of disease and advances in health care cannot reach those in need.

Against this backdrop, WHO -- a directing and coordinating health authority of the United Nations system -- has drafted a Global Code of Practice on the International Recruitment of Health Personnel, which is intended to achieve "an equitable balance of the interests of health workers, source countries and destination countries".

According to WHO, health-care workers, like workers in other sectors of the economy, tend to go where the working conditions are best. "Income is an important motivation for migration, but not the only one. Other reasons include: greater job satisfaction; career opportunities; the quality of management and governance; moving away from political instability, war, and the threat of violence in the workplace."

Migration is often stepwise. People tend to move from the poorest regions to richer cities within a country, and then to high-income countries. In most countries, there is also movement from the public to the private sector, particularly if there are considerable differences in income levels, states a WHO factsheet.

WHO points out that globalization has helped to trigger international migration. At the same time, demand for health workers has increased in high-income countries where not enough required personnel is being trained locally and where the existing workforce is ageing. Demand for health services is also increasing because of ageing populations and the rise of chronic illnesses like diabetes and heart disease, especially in rural areas.

In a number of middle-income countries with good health education systems -- such as Fiji, Jamaica, Mauritius and the Philippines -- a significant proportion of students, especially in nursing schools, begin their education with the intention of migrating, usually in search of a better income. Some countries, notably the Philippines, are seeking to capitalize on the demand for imported health workers by deliberately training graduates for international careers.


The movement of health workers abroad, states WHO, has both negative and positive consequences.

When significant numbers of doctors and nurses leave, the countries that financed their education lose the return on their investment.

Financial loss is not the most damaging outcome, however. When a country has a fragile health system, the loss of its health workforce can bring the whole system close to a collapse, with the consequences measured in lives lost.

"On the positive side, each year, migration generates billions of dollars in remittances (the money sent back to home countries by migrants) to low-income countries and has been associated with a decline in poverty. Health workers also may return and bring significant skills and expertise back to their home countries," WHO points out.


Exploring the scope of migration, WHO says that health systems in a number of high-income countries depend heavily on doctors and nurses who have been trained abroad, in the developing world. Over the last 30 years, the number of migrant health workers increased by more than 5 percent per year in many European countries.

In countries of the Organisation for Economic Co-operation and Development (OECD), around 20 percent of doctors come from abroad. In some Gulf States, such as Kuwait or the United Arab Emirates, more than 50 percent of the health workforce is migrants.

Nurses from the Philippines (110,000) and doctors from India (56,000) account for the largest share of migrant health workforce in OECD countries. "However, countries with smaller populations than India and the Philippines may suffer from a larger impact in terms of expatriation rates," notes the WHO.

Over 50 percent of highly-trained health workers leave for greener pastures abroad in some low-income countries.


Because the number of highly trained and skilled health-care workers wanting to emigrate from developing to high-income countries is increasing, thereby weakening health systems in the countries of origin, WHO proposes following actions to address the negative effects of migration in source countries:

- Better health workforce retention, especially in rural and remote areas;

- Stronger protection and fairer treatment of health workers, who may face difficult and often dangerous working conditions and poor pay; and

- Improved domestic training of health workers and development of policies that facilitate the return of migrants.

On the other hand, WHO proposes for the countries of destination:

- Reduced dependency on migrant health workers notably through educating and training of more health workers domestically and by making better use of the existing health workforce; and

- Responsible recruitment policies by destination/receiving countries and fair treatment of migrant health workers.

As part of an attempt to cope with the situation, the World Health Assembly requested WHO in 2004 to develop a code of practice on the international recruitment of health personnel. In response, WHO initiated a global consultation process. The Code was adopted by the World Health Assembly in May 2010.

The Code of Practice as adopted is voluntary, global in scope and applies to all health workers and stakeholders. It sets out principles and encourages the setting of voluntary standards. The equitable balance of the interests of health workers, source countries and destination countries is promoted, with a particular emphasis on redressing the negative effects of health worker migration on countries experiencing a health workforce crisis.

Key components of the Code include:

- Greater commitment to assist countries facing critical health worker shortages with their efforts to improve and support their health workforce;

- Joint investment in research and information systems to monitor the international migration of health workers in order to develop evidence-based policies;

- Member states should meet their health personnel needs with their own human resources as far as possible and thus take measures to educate, retain and sustain their health workforce; and

- Migrant workers' rights are enshrined and equal to domestically-trained health workers.

Rhee Hetanang, Counsellor at the Permanent mission of Botswana based in Geneva, who was involved in negotiating a global code, says that the Southern African country supports introduction of the new code. In a podcast web posted by WHO, Hetanang said negotiations for the WHO code of practice are a major milestone for landlocked Botswana "because we believe it is a delicate balance following negotiations that were tough".

Supporting the global code, Bjorn Inge Larssen, Norway's chief medical officer points out: "Norway is one of those countries where we over the next 10 to 20 years will need a lot more health resources because the population is ageing and this code clearly states that countries need to plan for their own needs of health personnel. The education of health personnel will probably now be more important when we are working with other countries to improving their systems."


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Originally published by InDepth News. ©

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