Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
The relevance and effectiveness of the World Health Organization’s (WHO’s) Global Code of Practice on the International Recruitment of Health Personnel is being reviewed in 2015. The Code, which is a set of ethical norms and principles adopted by the World Health Assembly (WHA) in 2010, urges members states to train and retain the health personnel they need, thereby limiting demand for international migration, especially from the under-staffed health systems in low- and middle-income countries. Most countries failed to submit a first report in 2012 on implementation of the Code, including those source countries whose health systems are most under threat from the recruitment of their doctors and nurses, often to work in 4 major destination countries: the United States, United Kingdom, Canada and Australia. Political commitment by source country Ministers of Health needs to have been achieved at the May 2015 WHA to ensure better reporting by these countries on Code implementation for it to be effective. This paper uses ethics and health systems perspectives to analyse some of the drivers of international recruitment. The balance of competing ethics principles, which are contained in the Code’s articles, reflects a tension that was evident during the drafting of the Code between 2007 and 2010. In 2007-2008, the right of health personnel to migrate was seen as a preeminent principle by US representatives on the Global Council which co-drafted the Code. Consensus on how to balance competing ethical principles – giving due recognition on the one hand to the obligations of health workers to the countries that trained them and the need for distributive justice given the global inequities of health workforce distribution in relation to need, and the right to migrate on the other hand – was only possible after President Obama took office in January 2009. It is in the interests of all countries to implement the Global Code and not just those that are losing their health personnel through international recruitment, given that it calls on all member states “to educate, retain and sustain a health workforce that is appropriate for their (need) …” (Article 5.4), to ensure health systems’ sustainability. However, in some wealthy destination countries, this means tackling national inequities and poorly designed health workforce strategies that result in foreign-trained doctors being recruited to work among disadvantaged populations and in primary care settings, allowing domestically trained doctors work in more attractive hospital settings.
WHO Global Code of Practice on the International Recruitment of Health Personnel. Report of the Expert Advisory Group on the Relevance and Effectiveness of the WHO Global Code of Practice on the International Recruitment of Health Personnel (2010). Geneva: World Health Organization, Sixty-Eighth World Health Assembly: 2015.
Siyam A, Zurn P, Rø OC, et al. Monitoring the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel. Bull World Health Organ. 2013;91:816-823.
Edge JS, Hoffman SJ. Empirical impact evaluation of the WHO global code of practice on the international recruitment of health personnel in Australia, Canada, UK and USA. Global Health. 2013;9:60. doi:10.1186/1744-8603-9-60
Aluttis C, Bishaw T, Frank MW. The workforce for health in a globalized context – global shortages and international migration. Glob Health Action. 2014;7:23611. doi:10.3402/gha.v7.23611
Tankwanchi AB, Ozden Ҫ, Vermund SH. Physician emigration from sub-Saharan Africa to the United States: analysis of the 2011 AMA physician masterfile. PLoS Med. 2013;10(9):e1001513. doi:10.1371/journal.pmed.1001513
Wright D, Flis N, Gupta M. The ‘Brain Drain’ of physicians: historical antecedents to an ethical debate, c. 1960-79. Philos Ethics Humanit Med. 2008;3:24. doi:10.1186/1747-5341-3-24
Zubaran C. Balancing the act: The international migration of medical graduates. Monash Bioeth Rev. 2011; 29(3):05.1-12.
Crisp N, Chen L. Global supply of health professionals. N Engl J Med. 2014;370(10):950-957. doi:10.1056/NEJMra1111610
Tankwanchi AB, Vermund SH, Perkins DD. Monitoring sub-Saharan African physician migration and recruitment post-adoption of the WHO code of practice: temporal and geographic patterns in the United States. PLoS One. 2015;10(4):e0124734. doi:10.1371/journal.pone.0124734
Chen PG, Auerbach DI, Muench U, Curry LA, Bradley EH. Policy Solutions to Address the Foreign-Educated and Foreign-born Health Care Workforce in the United States. Health Affairs. 2013;32:1906-1913.
Mick SS, Worobey JL. The future role of foreign medical graduates in U.S. medical practice: projections into the 1990s. Health Serv Res. 1986;21:85-106.
Bourgeault IL, Neiterman E, LeBrun J, Viers K, Winkup J. Brain Gain, Drain and Waste: The Experiences of Internationally Educated Health Professionals in Canada. CIHR/Health Canada Chair in Health Human Resource Policy; 2010.
Australian Government Department of Health and Ageing. Medical Training Review Panel 11th Report. DoHA; 2008.
Supplement (forthcoming). Reviewing the relevance and effectiveness of the WHO Global Code of Practice on the International Recruitment of Health Personnel. Human Resources for Health; 2015.
Bradby H. International medical migration: A critical conceptual review of the global movements of doctors and nurses.Health (London). 2014;18(6):580-596. doi:10.1177/1363459314524803
Mills EJ, Kanters S, Hagopian A, et al. The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis. BMJ 2011;343:d7031. doi:10.1136/bmj.d7031