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International recruitment of health personnel: a WHO code of practice

Jean-Marc Braichet, Coordinator

Health Workforce Migration and Retention Team

Department of Human Resources for Health

World Health Organization, Geneva

World Health Editors NetworkMaking Global Health News

Geneva 17-18-May 2009

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International and internal migration: complementary but different responses required

Responses to international migration of HRH

- bilateral agreements (e.g. South Africa - UK; Philippines - Japan, etc.)

- regional codes (e.g. Pacific code)

- draft global code of practice on the international recruitment of health personnel

Responses to internal migration:

- national measures

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WHO is developing to major and complementary projects

Developing a draft global code on the international

recruitment of health personnel

Implementing a programme which aims to improve the

retention of health workers in rural and remote areas

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Main objectives of a WHO code of practice

To establish and promote voluntary principles.

To serve as an instrument of reference.

To provide guidance.

To facilitate and promote international discussion and advance cooperation.

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Process to develop a WHO code of practice on the international recruitment of health personnel 1/2

Jan08 Mar08 April08 May08 June08 July08 August08 Sept08 Oct08

Draft Code

EB Migration Progress Report

Kampala Forum

Draft Outline for a Code

Tallinn EuroMinisterial

Manila Forum

PAC – TWG meeting

Launch of GlobalDialogue on Migration

G8 Summit Public Hearings

Drafting of the Code

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Process to develop a WHO code of practice on the international recruitment of health personnel 2/2

Jan09 May09 June09 July09 August09 Sept-October 09 January10 March10 May10

Draft Code

WHO RCs

Progress Report for EBDraft ResolutionDraft Code

Draft Code for the WHA?

Progress Report for EB

------------ Consultations ----------

Background Paper

Technical Briefing WHA09

Global consultation?

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A WHO program on increasing access to health workers in remote & rural areas through improved retention

For at least three main reasons:

1. needs clearly identified

2. calls for action

3. renewal of PHC

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1- Need has been clearly identified in all countries

Inequitable distribution of health workers

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A programme built on three strategic pillars

1- Building the evidence base on effective retention strategies

– literature reviews, expert consultations, synthesis of the evidence, identification of knowledge gaps and commissioning research

2- Supporting countries to evaluate and adapt retention strategies

– work with interested countries to evaluate past and on-going strategies and to develop and implement country-specific plans

3- Developing and disseminating global recommendations on increasing access to health workers in remote and rural areas through improved retention

– a time-bound participatory process involving all relevant stakeholders following the steps set out by the WHO Guidelines Review Committee

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An ongoing calendar

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Thank you for your attention !

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Definitions

No consensus on a definition for “rural areas” - usually defined as “non-urban”

Each country has its own definition based on:– the settlement profile:

• population density • availability of economic structures

– the accessibility from an urban area: • distance in kilometres or hours drive.

Remote/underserved = areas where relatively poorer populations reside:• remote rural areas; • small or remote islands; urban slum areas; areas that are in conflict or post-conflict; refugee camps; areas inhabited by

minority or indigenous groups*

* Not specifically included in the current literature review

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A complex issueno ‘single bullet’ type of answer

Ministry of Health

Ministry of Finance

Ministry of Labour

Ministry of Public

Administration

Health workers

Populations/Communities

Civil Service Commission

Ministry of Transport

Professional Associations

Ministry of Higher

Education

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Categories of interventionsCategory of intervention Examples

A. Education and regulatory interventions

Targeted admission of students from rural background

Recruitment from and training in rural areas

Changes / improvements in medical curricula

Early and increased exposure to rural practice during undergraduate studies

Educational outreach programmes

Community involvement in selection of students

Compulsory service requirements (bonding schemes)

Conditional licensing (license to practice in exchange of location in rural areas)

Loan repayment schemes (paid studies in exchange of services in rural areas for 4-6 years)

Producing different types of health workers (mid-level cadres substitution task shifting)

Recognize overseas qualifications

B. Monetary compensation (direct and indirect financial incentives)

Higher salaries for rural practice

Rural allowances, including installation kit

Pay for performance

Alter the remuneration methods (fee for service, capitation etc)

Loans (housing, vehicle)

Grants for family education

Other non-wage benefits

C. Management, environment and social support

General improvement in rural infrastructure (roads, phones, water supplies, radio communication)

Improving working and living conditions, ensure adequate supplies of technologies and drugs

Supportive supervision

Support for continuous professional development, career paths

Special awards, civic movement, and social recognition

Flexible new contract opportunities for part-time work

Reduce the feeling of isolation (professional networks, telemedicine, distance learning)

Increase chances for recruitment to civil service

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How can we measure “success”?

Disparities in the rural/urban ratio of health workers to population density

Percentage of health workers to choose to work in rural areas as a consequence of an intervention

Vacancy rates

Duration in post

Service utilization rates (before and after)

Patient satisfaction surveys

Health workers satisfaction surveys

Health outcomes (confounding factors!)

GP density per1,000 pop

1.54 - 1.67

1.84 and more

1.43 - 1.54

Less than 1.43

1.67-1.84

GP density per1,000 pop

1.54 - 1.67

1.84 and more

1.43 - 1.54

Less than 1.43

GP density per1,000 pop

1.54 - 1.67

1.84 and more

1.43 - 1.54

Less than 1.43

GP density per1,000 pop

1.54 - 1.67

1.84 and more

1.43 - 1.54

Less than 1.43

1.67-1.84

GP density per 1000 pop

France: General Practitioner density

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Guiding principles of a WHO code of practice 1/2

The code is voluntary.

The individual right "to leave any country, including [one's]

own".

Right of everyone to the enjoyment of the highest attainable standard of health.

International recruitment can make a legitimate contribution to the development and strengthening of a national health workforce.

The development of voluntary international standards and the coordination of national policies on international health worker recruitment.

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Guiding principles of a WHO code of practice 2/2

International recruitment of health personnel should be

conducted in accordance with the principles of transparency,

fairness and mutuality of benefits.

The specific needs and special circumstances of countries

should be considered.

Effective national and international data gathering, research

and information sharing are essential.