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Challenges in the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel: unequal power relations in global health

Challenges in the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel: unequal power relations in global health

By Lila Sax dos Santos Gomes
on October 13, 2023

The WHO Code of Practice on the International Recruitment of Health Personnel aims to promote ethical norms and principles to guide the international recruitment of health workers. In this blog I explore why the implementation and regulation of the WHO Code of Practice has been ineffective so far.

In 2010, the WHO introduced a set of ethical norms and principles for the ethical recruitment of international health personnel. This was adopted by the World Health Assembly (WHA) under the title WHO Global Code of Practice on the International Recruitment of Health Personnel (“the Code”).  The voluntary Code of Practice aims at addressing the challenges of international mobility of health workers, especially towards achieving a balance between the needs of source and destination countries.

The Code of Practice has two main recommendations. It encourages members states to train and retain its domestic health personnel they need in a national context, to reduce demand for international migration. It also urges bilateral support to strengthen health systems, with a particular focus on the situation in developing countries. This includes attaining to ethical standards in the recruitment of health professionals and not recruiting from countries whose health systems have pressing UHC-related health workforce needs. In addition, the Code suggests that “developed countries should, to the extent possible, provide technical and financial assistance to developing countries and countries with economies in transition aimed at strengthening health systems, including health personnel development” (Code Guiding Principle 3.3). The Code is voluntary, with a reporting system.  Since implementation, there have been four rounds of reporting. The current report in 2022 indicates that approximately 15% of health and care workers globally are working outside their country of birth or first professional qualification.

The Code has not been really effective, despite being relevant.  Why is that so?

The effectiveness of the Code was already called into question in the years after its publication. While the intent to create monitoring and reporting mechanisms was explicitly formulated in the Code, the actual implementation of these measures lagged in the following years. This was in part due to insufficient interest in monitoring of internationally trained health workers by destination countries, but also constrained by challenges of reporting and information systems in LMIC source countries, as this case study from India shows. By 2019, seventy-seven countries submitted a national report. This represented 55% of the world’s population and included most of the countries at the forefront of international health worker recruitment.  However data, especially, from the 47 Safeguard countries on the so-called “red list” was missing, painting an unclear picture of the impact of international recruitment of health workers on their health systems including, for example, the loss of return on government subsidized education for health personal, especially doctors. A case study from Sudan in 2015 pointed to the lack of weak data systems in some countries and “scarcity, inaccuracy and fragmentation” of information as an area in which the reporting mechanisms needed to improve. 

While much of the recent focus on the international recruitment of health personnel has been on ethical cross-border recruiting practices such as Germany’s sustainable recruitment of nurses (Triple Win) program, the Code calls on the states primarily for a sustainable national health personnel policy with the aim of reducing the dependence on foreign-trained professionals. Only secondarily does the Code demand standards for controlled cross-border recruitment and advises against recruiting from countries with severe shortages of health professionals. Critical voices point to an increasing focus on the recruitment of international Health Workers without significant attention to or investments in national health systems, for example The German Platform for global health formulates the situation as follows:

“Sustainable structural solutions to the health system crisis are needed in Germany. Instead, the current focus is on private and state poaching of health professionals from poorer countries, thus (increasing) unequal distribution worldwide of health professionals. With the poaching of health workers, Germany benefits from poor working conditions and the underfunding of health systems in other countries and evades the responsibility to effectively improve working conditions in their own country.”

Among other things this would mean effectively tackling continuing discrimination of foreign trained professionals in the German health system, as well as addressing national inequities and poorly designed health workforce strategies that result in foreign-trained doctors only being recruited to work among disadvantaged populations and in primary care settings, allowing domestically trained doctors work in more attractive hospital settings. In addition, eliminating the exorbitant difference in salary and qualification profile between German nurses and foreign trained professionals should be looked at from an equity point of view.

Retribution and reparation in light of ongoing inequality

At a minimum, we must compensate source countries for the ongoing recruitment of their staff.  Especially in light of Article 5 (Health workforce development and health systems sustainability) and Article 10 (Partnerships, technical collaboration and financial support) of the Code the main focus needs to be shifted to direct and adequate compensation payments as part of international recruiting practices and an effort to create fiscal autonomy for the countries of origin. Real compensation, however, would mean also shifting away from a colonial, exploitative “growth” model in global health and towards a model that sees health and wellbeing as basic human rights that contribute to healthier societies and planetary health. More specifically, this would mean promoting primary health care services, health promotion and sustainable food systems, disease prevention and rehabilitation programs as well as a decommodification and decolonialization of global health. In light of the historical harm inflicted by centuries of colonization and slave trade, and added pressures through climate change, Global North countries must challenge concepts that continue to be based on further resource extraction, including “Human Resources”. A growing number of scholars has called to “decolonize global health” and address power asymmetries in global health. In addition, the impact of the climate crisis – caused to a great extent by Global North countries – will have a grave impact not only on the economies and livelihoods of the Global South, but also on their health systems. If we do not reconsider the way in which unequal power relations impact migration, we will remain in an unending loop of exploitation and harm.

An ongoing effort to collaborate with health labour unions, health professionals and social and climate justice movements is a key element in improving health worker policy efforts. This must go hand in hand with participation possibilities, especially for nurses, for example through establishing chambers of nursing in all European member states. In the coming EU presidency the challenges facing the health workforce will be one of the main priorities of the Belgian presidency. Perhaps this is the beginning of the change we need.

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