Restrictions on health worker migration proving problematic

Everybody's working on it, but it's a complex problem and much more needs to be done.

That's the answer you'll get from pretty much anyone you speak to in the international health care community about the issue of health care worker migration from poorer nations to the developed world.

Unquestionably, it is an enormous problem. The World Health Organization (WHO) estimates that the global need for more health care workers currently stands around 4.3 million. Of the 57 countries with critical shortages in health care workers, 36 are in sub-Saharan Africa where diseases like HIV/AIDS, tuberculosis and malaria require an urgent injection of skilled human capital.

And in the face of that need, out-migration from those countries with critical shortages has greatly increased since the 1980s. Many are going to the developed world. On average, 18% of physicians and 11% of nurses now practising in the member-countries of the Organisation for Economic Co-operation and Development are foreign born.

A recent study indicates the number of foreign trained doctors has essentially tripled in member nations over the past 3 decades (Soc Sci & Med May 2007:64;1876-91). In some European countries, the average annual growth rate of foreign-trained doctors has reached 10%.

And as the populations of developed countries age — doctors and patients alike — the demand for trained health care professionals will only increase.

Many have charged that the outflow from developing nations, de facto, constitutes a subsidy of wealthier nations. The International Organization for Migration has estimated that developing nations shell out US$500 million per year to train health workers who leave to work in North America, Asia or Europe.

It was this sort of daunting information that led the World Health Assembly to launch the Health Worker Migration Policy Initiative in 2004.

The initiative, co-chaired by the United Nations High Commissioner for Human Rights Mary Robinson and Global Health Workforce Alliance Executive Director Dr. Francis Omaswa, was tasked with providing recommendations to WHO member states aimed at helping to develop a “global Code of Practice for health worker migration that clarifies the responsibilities of both ‚source' and ‚destination' countries for managing health workforce and migration policies.”

Their work follows the lead of several individual countries that have drafted recruitment and migration management guidelines of their own, like the one that exists between the United Kingdom and South Africa, as well as the Commonwealth Secretariat's Code of Practice for the International Recruitment of Health Workers, which Canada supports.

Their work is also being watched carefully by the European Union, which is drafting its own code of conduct.

But while codes of practice are instrumental in focusing attention on the ethical and labour issues involved in health worker migration, they are not legally binding in any way.

“It's not a treaty. It's not a legally binding document,” says the Commonwealth Secretariat's Peggy Vidot. “The countries come together and adopt these documents by consensus. … This means that federal governments agree not to recruit … but private agencies are not in active government.” They are therefore not bound to follow the rules.

Vidot says it's a complex issue that will need multifaceted solutions and require a range of actions from the local to the global level to develop a framework in which migration can take place.

One reported result of existing codes is a domino effect. According to a report written for the Migration Policy Institute, the United Kingdom has replaced many of its health professionals who have migrated to North America with German health care workers. Germany, in turn, is bringing in a growing number of physicians from the Czech Republic. The Czechs are coping by recruiting from Slovakia. And so on and so on.

And if the much larger economic issues of “source” or “push” countries are not addressed at the same time as the codes are established, the codes will have very limited impact.

The simple fact is, the ability to migrate to a country that provides a better standard of living, access to a safe workplace and better opportunities for continued training are human rights that cannot be restricted. You can't tell a doctor in an impoverished and war-torn country such as Rwanda that he can't relocate to a safer, more prosperous country. You can't force someone to stay and attempt to work in a place that is lacking even minimum provisions for them to do their job.

“If you tell them they can only hand out band-aids and aspirin, no one will stay,” says Dr. Otmar Kloiber, secretary general of the World Medical Association. “People should have the privilege to migrate. For medical workers it's important to have exchanges in order to learn and to work. You can't put someone on a dead end road and ask them to build a health care system.”

Kloiber says decades ago the German government restricted recruitment to training-only, requiring students to then return to their homelands. “But there are problems with this because then students complain that they can't find a job at home.”

He says there's no ideal model yet and that policy has to be redeveloped to include personal safety, decent working conditions, livable wages and access to training — basically, a massive overhaul that would shift developing countries' economies from agriculturally based to service based and strengthen their entire health care systems.

“And this is not something that we can do alone,” says Kloiber. “They have to help themselves as well. … We can try and steer the obligations of the [aid] recipient countries to provide better health care for their people but without their participation, nothing will change.”

Kloiber says there must be serious investment in health care and the International Monetary Fund and the World Bank must understand their place in providing aid and direction as well. “If you look at the richness of countries, this should not be insurmountable. Some places are spending a hell of a lot of money on weapons. Perhaps they need to focus on the well-being and survival of their people instead of new wars with their neighbours.”

The Health Worker Migration Policy Initiative is set to present a framework and recommendations for the Global Code of Conduct to the World Health Assembly in May 2008. That will follow presentations at the Global Forum on Human Resources for Health in Kampala, Uganda and at a high-level WHO-Organisation for Economic Co-operation and Development meeting dedicated specifically to health workforce migration in Geneva, Switzerland. A Global Forum on International Migration and Development is also being held in the Philippines in October 2008.

Given the philosophic complexities and the number of countries involved, as well as the raft of international stakeholders and organizations, including the International Labour Organization, the World Health Assembly will do well to have the code of conduct in place by 2009. — Christina Lopes, Paris, France

Figure. Restricting migration of health care workers from the developing to the industrialized world is perceived by many human rights experts as a violation of an individual's right to migrate to a nation that provides a higher standard of living and a safer environment for them and their families. Image by: Photos.com