Managing In- and Out-Migration of Health Workforce in Selected Countries in South East Asia Region

Background: There is an increasing trend of international migration of health professionals from low- and middle- income countries to high-income countries as well as across middle-income countries. The WHO Global Code of Practice on the International Recruitment of Health Personnel was created to better address health workforce development and the ethical conduct of international recruitment. This study assessed policies and practices in 4 countries in South East Asia on managing the in- and out-migration of doctors and nurses to see whether the management has been in line with the WHO Global Code and has fostered health workforce development in the region; and draws lessons from these countries. Methods: Following the second round of monitoring of the Global Code of Practice, a common protocol was developed for an in-depth analysis of (a) destination country policy instruments to ensure expatriate and local professional quality through licensing and equal practice, (b) source country collaboration to ensure the out-migrating professionals are equally treated by destination country systems. Documents on employment practice for local and expatriate health professionals were also reviewed and synthesized by the country authors, followed by a cross-country thematic analysis. Results: Bhutan and the Maldives have limited local health workforce production capacities, while Indonesia and Thailand have sufficient capacities but are at risk of increased out-migration of nurses. All countries have mandatory licensing for local and foreign trained professionals. Legislation and employment rules and procedures are equally applied to domestic and expatriate professionals in all countries. Some countries apply mandatory renewal of professional licenses for local professionals that require continued professional development. Local language proficiency required by destination countries is the main barrier to foreign professionals gaining a license. The size of outmigration is unknown by these 4 countries, except in Indonesia where some formal agreements exist with other governments or private recruiters for which the size of outflows through these mechanisms can be captured. Conclusion: Mandatory professional licensing, employment regulations and procedures are equally applied to domestic and foreign trained professionals, though local language requirements can be a barrier in gaining license. Source country policy to protect their out-migrating professionals by ensuring equal conditions of practice by destination countries is hampered by the fact that most out-migrating professionals leave voluntarily and are outside government to government agreements. This requires more international solidarity and collaboration between source and destination countries, for which the WHO Global Code is an essential and useful platform.


Background
There is an increasing trend of international migration of health professionals from low-and middle-income countries to high-income countries. 1 Health personnel outflow from countries in South East Asia (SEA) to countries in Economic Co-operation and Development (OECD) is significant. 1 Indian born doctors rank top in terms of numbers of foreign health workers in OECD countries. Sri Lanka has the highest expatriate rate: one-third of the total doctors trained in Sri Lanka are practicing in the OECD. 2 Even Timor Leste, which has very few doctors, is contributing to the health workforce in OECD countries: 35 Timor Leste doctors were reported to be practicing in OECD countries, equivalent to 30.7% of the total stock working in Timor, a significant loss. 2 There is also international migration of health workers to countries in the Gulf Cooperation Council (GCC) but the picture is different, as source countries include both developed and developing nations. 5 The motivation for health professionals from developing countries to move to developed ('destination') countries is mainly their need for higher salaries, better work conditions and career advancement. At the same time, push factors in their home (or 'source') countries are often not adequately addressed. The unintended consequence is unmet health needs -especially among the poor and rural populations -in source countries. 3 A number of studies have examined health worker migration since the 2006 World Health Report Working Together for Health. [4][5][6] Kingma provided a comprehensive picture of the complexity of international migration of nursing personnel Implications for policy makers • A mandatory license to practice issued by the national professional councils should be maintained to ensure quality of service, patient safety, and personnel safety for both domestic and in-migrating professionals. • Policies requiring government sponsored medical students trained overseas to return home are needed. This could be done through more effective enforcement of the training contract, together with sanctions if it is broken. • More systematic out-migration management of health professionals, through government to government agreements, could create a win-win situation as well as provide greater benefits and opportunities for health workers. • To effectively capture the number and profile of outflow health professionals, there is a need for improving health workforce data capture and better sharing of migration information between source and destination countries. • The World Health Organization (WHO) Global Code is relevant and useful for addressing health workforce development. All countries should support its implementation as well as regularly reporting on progress.
Implications for the public All 4 countries (Bhutan, Indonesia, Maldives, and Thailand) have committed to progressing towards universal health coverage (UHC). A sufficient, well-performing health workforce is essential for the achievement of UHC. Several policy instruments are being used, in line with recommendations of the World Health Organization (WHO) Global Code: policies by destination countries to ensure expatriate professional quality through licensing and equal practice, and source and destination country collaborative actions to ensure the out-migrating professionals are equally treated by destination country systems. A common problem is that source countries cannot capture the number and profile of out-migrating professionals, except through Government to Government arrangements as in Indonesia. This reiterates the importance of global solidarity especially on the need for destination countries to share health worker migration information with source countries, as mandated by the Code. This study reinforced that the Code is still relevant and is an essential platform for effective collaboration between destination and source countries to strengthen health workforce development. , was created to better address health workforce development and the ethical conduct of international recruitment. It is a global framework for international cooperation and was adopted in May 2010. 8 The Code was developed because the problems of and solutions to international health workforce migration are inter-connected and require collective action across source and destination countries. The Code aims to ensure that migrant health workers are treated fairly, and to ensure that source countries with health workforce shortages are not further depleted by the growing needs of rich countries. Since 2010 there have been 2 rounds of monitoring of progress on its implementation. The number of countries that participated in the first progress report in 2013 was disappointing: only 56 out of 194 WHO Member States (29%) reported. 9 Most of these were destination countries, with 71% being from the WHO European region.
A key finding was that migrant health professionals in most countries had the same legal rights and employment conditions as domestically trained health workers. The main reason for low reporting was lack of awareness of the Code by WHO Member States. Only 3 out of 11 countries from WHO South-East Asia Region (Indonesia, Maldives and Thailand) reported. The reviews of literature pose several policy questions. There is little in-depth analysis of how countries in the SEA Region are addressing international health worker out-migration, especially when they already face health worker shortages. Current policy questions include how are countries with different levels of health workforce density managing to fulfill their national health workforce needs -is it through producing more health workers, or encouraging in-migration and ensuring the professional standards of expatriate workers? Or both? How do source countries ensure their out-migrating professionals are equally treated in destination countries? This paper reviews how policies in 4 countries in SEA are being applied in order to ensure; consistent professional standards and equal practice opportunities for expatriate professionals, their out-migrating professionals are equally treated in destination countries, and continued professional education and relicensing for domestic and expatriate professionals is provided.

Methods
The second progress report on implementing the Code was carried out in 2015. This time, 6 countries from WHO's SEA Region reported: Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, and Thailand. WHO convened a meeting of the 6 countries to discuss progress and challenges with implementing the Code. A common protocol to do a more in-depth analysis of the policy instruments being used was developed and agreed to by the 6 countries. The protocol covered national health workforce context; policies and regulations concerning the rights, terms of employment, recruitment practices and conditions of work for domestically and foreign trained health workers working in-country; licensing and relicensing practices to ensure quality; and policies in place to protect out-migrating professionals, to ensure they are treated the same as domestically trained health workers in destination countries. Four country reports prepared using this protocol provided sufficient information for a qualitative cross-country analysis of policy and practice: Bhutan, Maldives; Indonesia, and Thailand. For the 4 countries, their policies and practices as both a source and a destination country for health professionals are considered.

Health Workforce Context in the 4 Countries
Bhutan and the Maldives both have populations of under 1 million. 10 Neither country can provide domestic training for their doctors, but both have in-country training of nurses and midwives. Both Governments recruit secondary school students to study medicine, fully financed by the government, in other countries in the Region -on the condition that they return to serve in the country's health service once they graduate. All Bhutanese medical graduates from schools outside the country currently return to serve the government health service. However, some Maldivian medical graduates do not return home, despite the existence of contracts with government.
Bhutan faces a critical shortage of health workers. Together, the ratio of doctors, nurses and midwives is 1.24 per 1000 population, 11 below the global threshold of 2.28 per 1000 population. 12   approved by the Council. Similar to physicians, temporary licenses not requiring license examination are also issued by Thailand's Midwifery council for nurses in humanitarian work.
In practice, work permits for professional practice, and employment visas are granted after the medical or nursing council approval in each country once candidates fulfill the required license examination.

Policies in Destination Countries on Equal Employment for Expatriate Professionals
In Bhutan, foreign health workers are usually recruited for a period of 2-3 years, under service conditions as specified by the 2012 Bhutan Civil Service Regulation, which ensures they enjoy the same rights and benefits as domestic professionals. However, the contractual conditions in the Civil Service Regulation do not allow in-or post-service training for foreign professionals.
In the Maldives, there is equal treatment between domestic and foreign trained doctors and nurses. Incoming health personnel are hired, promoted and remunerated based on objective criteria such as qualification, years of experience, and scope of professional responsibility on the same basis as the domestically trained workers. However, high turnover results in the lack of continued professional development.
There are a limited number of international professionals in Indonesia, and they are employed with similar employment conditions to the national professionals. Once professional licenses have been obtained, the Thai labour law provides equal employment conditions between expatriate and domestic professionals.
Actions by Source Countries to Protect their Out-Migrating Professionals Informal observation suggests very few Bhutanese health professionals leave to work abroad. There is no effective mechanism to trace those that do, and no obligation for them to report where they work once they are outside the Royal Civil Service. An unknown number of health professionals leave the Maldives to practice elsewhere. Its small pool of health workers does not attract recruitment through either Government to Government (G to G) agreements or private recruiter arrangements.
In Indonesia, a surplus of training places and limited public sector positions for nurses and midwives triggered the Indonesian government to find employment for them abroad. This is conducted through systematic G to G and private to private (P to P) mechanisms. Under bilateral memorandum of understandings (MOUs) in the G to G agreements, the destination country specifies detailed requirements for numbers and skills, employment terms and conditions. However in practice numbers are determined mostly by an individual's ability to obtain a license to practice in the destination countries.
In the Indonesia-Japan collaboration, rigorous requirements have been agreed between the 2 countries. Minimum qualifications for nurses are either 3-year diploma nurses with 2 years' experience, or 4-year bachelor nurses with 1-year experience. In Indonesia, applicants have to pass a written test, psycho-and aptitude tests, video interview and a Japanese quiz. Nurses who qualify then need medical checkups, 6-month Japanese language training and pre-departure orientation. In Japan, these Indonesia nurses take a 6-month advanced Japanese language course while temporarily working as a nurse assistant. Passing the Japanese national Kangoshi examination is required to become a registered nurse; failure to pass results in returning home. Indonesian registered nurses in Japan have similar pay and benefits as Japanese registered nurses. The number of Indonesian nurses recruited via this mechanism increased from 166 in 2010 to 187 in 2014, fulfilling 50% of the Japanese demand for Indonesian nurses as negotiated between the 2 governments. Between 2008 and 2011, nearly 800 Indonesian nurses and care workers have entered Japan this way. However, difficulties in mastering Japanese results in a low success rate in the Kangoshi examination for registered nurses. By 2011, only 17 Indonesian nurses had passed it. 15,16 Parallel to G to G, several private recruiters in Indonesia are actively recruiting nurses to work in around 45 countries.
Applicants meeting requirements will be registered at the Ministry of Manpower to obtain an Identity Number for Indonesian workers and sign a placement agreement. In the destination country, they need to pass the local professional council's license examination for professional practice. Thailand does not have surplus of domestic health workers, and so has not developed policy and systematic management of out-migration. However, observations show an increasing trend of out-migration of young nurses who are English proficient, mostly through electronic recruitment by destination country employers or recruiters. There are no specific mechanisms to support 'circular' migration: physician or nurse returnees, provided their professional licenses are valid, can work -but this is often in the private sector due to limited public sector vacancies and lower remuneration. A common issue arising from this analysis is that source countries are unable to capture the number and profile of departing health professionals, except under the Indonesian G to G arrangements. This reiterates the importance of global solidarity especially on sharing migration information by destination countries with source countries as mandated by the Code. Table 3 summarizes key findings on managing in-and outmigration of health professionals in these 4 countries.

Discussion
Investment in the health workforce is critical to improve access to health services and achieve UHC. 17 Within the Sustainable Development Goal for health, UHC underpins achievement of other targets such as improved child and maternal mortality and universal access to sexual and reproductive health services. Having sufficient numbers of skilled and motivated health workers requires significant investment in two inter-related areas: health professional education reform, to ensure the workforce is 'fit for purpose' 18 and in actions that retain health workers in places where they are needed most 19 -both in-country, and within the country in rural hard to reach areas. Addressing push factors and having effective implementation of the Code will support retention in country.
We find that 4 countries with different health workforce profiles and needs are responding differently in the ways they manage in-and out-migration, but certain regulatory practices are common to all. For in-migration, a license to practice issued by the national professional council is mandatory, and the profiles of incoming professionals are well captured by these councils. Licenses are more commonly temporary rather than permanent. Language proficiency, commonly required by destination countries, is the major barrier for foreign trained health professionals in passing license examinations. The review also notes that in cases where governments publicly subsidize medical students to be trained overseas, policies to compel the return of medical graduates are needed. For example, in the Maldives a more effective enforcement of the training contract, together with sanctions if it is broken, would be useful. Some good practices are noted. All countries apply equal legal and employment practices between expatriate and domestically trained professionals. Indonesia has the most systematic out-migration management of nurses -through G to G agreements, regulated private to private mechanisms, and pre-departure orientation. This study provides new understanding of the situation in countries in SEA, it indicates that systematic arrangements between source and destination country governments is useful in moderating migration and protecting the outmigrating professionals.
A few policy implications for other countries emerge. In countries with limited local training capacities, governments need to ensure that publicly subsidized medical students trained abroad return home to serve in their country health systems. This can be achieved through positive incentives and also legal sanctions for non-adherence. This will gradually reduce the reliance on the use of foreign professionals. Formal agreements between source and destination governments (the G to G agreements) are a good practice which can have several benefits. They can help to ensure that out-migrating professionals have similar employment rights and benefits to domestically trained professionals. G to G agreements can also moderate the number and qualifications of out-migrating professionals, and help reduce the negative consequences on source country health systems. Private recruiters should be registered, aware of the Code and prevented from using unethical recruitment practices.

Conclusion
This study does not provide particularly different findings from earlier studies on managing health worker migration, but it does expand the body of knowledge on what is happening in countries in Asia by analyzing current policy and practice in 4 countries that have been relatively under examined in this context. It also reaffirms the critical importance of the Global Code of Practice. The main policy instruments being used to ethically manage in-migration are mandatory initial professional licensing and equal employment procedures, and these are found in all 4 countries. Re-licensing requirements are less common. The size of out-migration is unknown, except in Indonesia, where there is some information through Government to Government agreements. Destination countries need to share information on health worker migration source countries, as mandated by the Code. Source country policies to protect their out-migrating professionals are also hampered by the fact that most out-migrating professionals are outside government to government agreements. The analysis reaffirms that systematic arrangements between source and destination country governments are useful in protecting health system integrity, moderating migration, and protecting out-migrating professionals. The Global Code of Practice provides a valuable framework to promote this, and remains an essential platform for more effective collaboration between source and destination countries.

Ethical issues
No ethical approval was required as this manuscript employed secondary data for the analysis.