The Impossible Dream? Codes of Practice and the International Migration of Skilled Health Workers

Volume 3, Issue 3 • 2011 • Article 3

The Impossible Dream? Codes of Practice and theInternational Migration of Skilled Health Workers

John Connell, University of SydneyJames Buchan, Queen Margaret University, Edinburgh

Connell, John and Buchan, James (2011) "The Impossible Dream? Codes of Practice and theInternational Migration of Skilled Health Workers," World Medical & Health Policy: Vol. 3: Iss. 3,Article 3.Available at: http://www.psocommons.org/wmhp/vol3/iss3/art3DOI: 10.2202/1948-4682.1175

©2011 Policy Studies Organization

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The Impossible Dream? Codes of Practice andthe International Migration of Skilled Health

Workers

John Connell, University of SydneyJames Buchan, Queen Margaret University, Edinburgh

Abstract

The international migration of skilled health workers has increased significantly from the1990s. Many source countries have expressed concern over losses of health workers, resultingin regional Codes of Practice and bilateral Memoranda of Understanding being established since1999 to achieve more effective, equitable and ethical international migration. The finalisation ofa Global Code in 2010 drew attention to continued migration concerns. Codes have three keyobjectives – protecting rights of migrant workers, adequate workplace support for migrant workersand ensuring that migration flows do not disrupt health services in source countries. There is noagreed definition of ethical international recruitment, and no consensus on the significance andlocation of harmful recruitment practices. Most codes have covered relatively few regions andexhibit a high degree of generality. Several source countries encourage rather than discouragemigration. Migration is a right and occurs in contexts that do not necessarily involve health issues.There are no incentives for recipient countries and agencies to be involved in ethical internationalrecruitment. All codes are voluntary which has restricted their impact. Substantial migration andrecruitment have occurred outside their scope, and codes have diverted skilled health workersbeyond regulation. The private sector is effectively excluded from codes. Bilateral agreements andmemoranda have a greater chance of success, enabling managed migration and return migration, butare more geographically limiting. The most effective constraints to the unregulated flow of skilledhealth workers are the production of adequate numbers in present recipient countries and provisionof improved employment conditions in source countries.

KEYWORDS: migration, health workers, codes of practice, policy

Author Notes: Conflict of interest: None declared. Corresponding author: John Connell, Professor,The University of Sydney, Australia Email: [email protected]

Introduction

…‘developing a policy response on ethical recruitment is extraordinarily

complex…there is no obvious solution or quick fix’ (McIntosh,

Torgerson, and Klassen 2007, 22)

Human resources are central to healthcare systems, and especially essential for the

delivery of services to patients. In the past decade substantial international

migration of health workers has contributed to an ongoing healthcare crisis in

several regions, which is particularly acute in Sub-Saharan Africa. The shortage

of health workers is, however, a global phenomenon, with the World Health

Organization (WHO) estimating a global shortfall of as many as 4.2 million

workers in 57 countries, mainly small island states or those in Sub-Saharan Africa

(WHO 2006). Concern about the likelihood of accelerated recruitment by

relatively developed countries, where populations are aging, expectations of

healthcare are increasing, and local recruitment of health workers (especially

nurses) has often been poor and attrition considerable, has intensified the crisis in

relatively poor countries. This has raised complex ethical, financial, and health

questions, which have also emphasized the more complex and nuanced context of

the “brain drain” that has parallels in policy debates when the concept was first

introduced for health workers in the 1960s (Connell 2010). Rights to health thus

involve not simply nation states’ obligations, but also obligations in countries

recruiting health workers, hence requiring considerations of transnational social

justice.

Policies have been formulated at various times to counterbalance and

compensate for the outward flow of skilled health workers. These have ranged

from compensation payments, encouraging the return (permanently or

temporarily) of overseas migrants, the stimulation of remittance flows, twinning

of institutions in developed and developing countries, and, most recently, the

development of ethical codes of practice for recruitment (Lowell and Findlay

2002; Connell et al. 2007). Most policies have been of limited value, took little

note of specific occupations and the particularities of individual countries, were

hard to implement, or received little support. With growing awareness of these

limitations, rising numbers of migrants, and adverse effects of health worker

migration on source countries, demands for ethical international recruitment (EIR)

policies increased. After 1997, when Nelson Mandela criticized the UK for

recruiting nurses from South Africa, the first code on health worker recruitment

emerged in the National Health Service (NHS) in England. From 1999 onwards

several countries and regions developed Codes of Practice and Memoranda of

Understanding designed to move towards EIR. Concerns expressed at the 57th

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Connell and Buchan: International Migration of Skilled Health Workers

Published by De Gruyter, 2011

World Health Assembly in 2004 further emphasized the need for more effective

regulations to mitigate the adverse effects of the migration, while the Global

Health Workforce Alliance (GHWA), formed in 2006, has stressed the need for a

global code. This paper provides an initial evaluation of the impact of existing

codes and Memoranda of Understanding (MOUs). It follows on from and takes up

some of the themes of more speculative studies undertaken as codes were being

formulated (Morgan, Sives, and Appleton 2005; Wiskow 2005; Martineau and

Willetts 2006), but is constrained by a weak data base (e.g., Buchan et al. 2009).

Codes and MOUs on the international recruitment and migration of health

workers are quite recent and developed by a few mainly OECD countries. The

first Code was developed for NHS England, building on the initial policy

statement of 1999 (2001, revised 2004), and later the first multi-country Code was

adopted: the Commonwealth Code of Practice (2003). Subsequent Codes were

introduced in NHS Scotland (2006), and the Pacific Code of Practice (2007).

Finally, after much deliberation, a Global Code was agreed at the World Health

Assembly in 2010. The formulation of codes was largely evolutionary, with later

codes building on their predecessors.

MOUs differ from Codes in the sense that they are bilateral and thus more

specific. They include those between the Philippines and the UK (2002), Spain

and the UK (2001), South Africa and the UK (2002), and the Netherlands and

Poland (2003). These are examined here, and reference is made to other MOUs in

terms of their overall impact. More recent examples of bilateral MOUs include

those adopted between Kenya and Namibia, and Kenya and Lesotho, on the

recruitment of nurses.

Constraints to Codes

It is often stated that mobility with regard to internal migration is a basic human

right, often enshrined in national constitutions, and thus should not be

constrained. An open international market is said to offer efficiency and economic

gains, particularly where skills are scarce. Remittances from migrants, including

professionals, benefit those at home and professionals return to the home country

with additional skills acquired in the destinations. However, while there are gains

in economic efficiency at an aggregate level, those gains are localized in receiving

countries. Skill deficits occur in source countries, remittances may not reimburse

training costs (and support the private rather than the public sector), and return

migration is limited and not necessarily of the most useful workers (Connell

2010). Consequently, as the evidence of costs to national health, economic, and

social systems has mounted, there has been greater interest in developing policies

and mechanisms to diminish and mitigate the negative impacts of migration.

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World Medical & Health Policy, Vol. 3 [2011], Iss. 3, Art. 3

http://www.psocommons.org/wmhp/vol3/iss3/art3DOI: 10.2202/1948-4682.1175

However not all so-called “source” countries have sought to prevent

migration, and some like India, Cuba, Egypt, China, and the Philippines

purposefully export skilled health workers. In several countries, such as the

Philippines, tensions exist between government departments, where migration is

perceived as a valuable economic policy but an inappropriate health policy

(Watkins 2004; Lorenzo et al. 2007). In many more countries migration may be

perceived as a right, and attempts to intervene in that process are deemed

unethical. Nonetheless there is still concern over what may be excessive

migration. A consistent challenge has therefore been to find an appropriate

balance between the sustainability of health services in source regions and rights

to freedom of movement. The context for developing codes and MOUs lies in the

ongoing migration of health workers, especially from relatively poor to relatively

rich countries, as well as concern over the implications of this migration for the

effectiveness of healthcare delivery in the source countries. Concerns also exist

over what amounts to the costs of training health workers for migration, and also

for the well-being and utility of those who migrate. Although the development of

codes was initially directed to preventing adverse effects of migration on health

systems in sending countries and protecting the rights of workers, in practice the

destination codes especially (e.g., NHS England and Scotland) primarily

concerned the rights and activities of migrant workers.

Evaluating the impact of the migration of skilled health workers in their

source countries is difficult. Exactly what constitutes a shortage of workers is

immeasurable, relative, and varies over time and space (see, e.g., Zurn et al. 2004)

as do concepts of workforce self-sufficiency and sustainability (e.g., Buchan,

Naccarella, and Brooks 2011). Expectations change, and disadvantages are

compounded by fluctuations in healthcare needs, such as the rise and fall of

HIV/AIDS in Sub-Saharan Africa and elsewhere (WHO 2006; Garrett 2007).

Even in regions widely recognized as experiencing skilled health worker

shortages, such as Sub-Saharan Africa, there are countries and regions with

significant numbers of unemployed health workers (see, e.g., Hamilton and Yau

2004). National financial constraints have precluded effective human resource

planning, and it is not unreasonable that skilled but unemployed workers should

move elsewhere.

Migrants make decisions as part of extended families. Migration is not

necessarily, or even primarily, about relationships between two different health

systems. Several countries that are sources of skilled health workers have a long

independent tradition of migration, usually following post-colonial routes

(Connell 2009). Skilled health workers have been migrating for decades (see, e.g.,

Mejia, Pizurski, and Royston 1979). Moreover with the lone but partial exception

of teachers, no codes regulate other kinds of professional migration. Hence skilled

health workers constitute a special and virtually unique category (Morgan, Sives,

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and Appleton 2005). Many countries, most unions and professional associations

representing health workers, and the skilled workers themselves broadly support

the rights of individuals to migrate. There are therefore multiple stakeholders.

Establishing comprehensive agreements at a national (let alone regional or global)

scale is a massive task, and monitoring such agreements is demanding, potentially

expensive, and requires new bureaucratic procedures that may be unfamiliar to

Ministries/Departments of Health, and so places new impositions on public

agencies. The challenges to the formulation and implementation of codes have

therefore been considerable.

The Establishment of Codes

Codes and MOUs have been formulated by various entities, usually government

agencies, or regional bodies (such as the Commonwealth Secretariat and the

Pacific Forum). The content of codes is variable, in the approaches that have been

taken, the terminology used, the workers, sectors, and region(s) covered, and the

expectations embedded in them. They are primarily directed at health sector

employers (usually national governments), but also unions/professional

associations, recruitment agencies, and individual workers. Each of these

stakeholders has different interests. Even contacting all such diverse groups is a

formidable task. Most codes are brief—no more that a dozen pages—which tends

to emphasize generalities.

The earliest regional code was the Commonwealth Code of Practice

(2003), which was developed from earlier international instruments such as

International Labour Organisation (ILO) conventions on the rights of workers

(Wiskow 2005), while the British codes were developed independently.

Subsequent codes, like the Pacific Code, have been largely based on the

Commonwealth Code, as was intended. The Global Code similarly developed

from these regional predecessors. Not all countries (including Canada, the UK,

and the United States) were signatories to ILO Conventions, such as the 1977

Nursing Personnel Convention (Bach 2007), that in many ways were partial

prototypes for the codes.

The various codes have three key objectives: (i) protecting individual

health workers from unscrupulous recruiters and employers, (ii) ensuring that

individuals are properly prepared for and supported for the job (which may mean

effective supervision at work, adequate conditions, and new training), and (iii)

ensuring that flows of migrant health workers do not unduly disrupt the health

services of source countries (which may have implications for compensation and

non-recruitment). Within these basic and broad objectives, which constitute a

mutuality of benefits, are generalities about more efficient health workforce

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planning, informed decision making, meeting best possible healthcare standards,

etc. The “second generation” of codes (Scotland and the Pacific) was more subtle

and more oriented towards the needs of sending countries.

Memoranda of Understanding (MOUs) are much more specific in

referring, usually, to particular groups and numbers of workers and particular time

periods. Most were developed in response to particular circumstances. Thus the

2003 MOU between the Philippines and the UK responded to concerns in the

Philippines over the treatment of Filipino nurses in English nursing homes. It was

also intended to enable Filipino nurses to have opportunities to enhance their

skills and experience and be involved in best practice while in the UK.

Until the global code was established, all codes were limited in

geographical coverage. Some significant countries and regions were hitherto

largely beyond their general scope. Engaging with major recipient countries

outside the Commonwealth, such as Ireland, the United States, and the Gulf

states, “proved more challenging than making progress within the Commonwealth

family” (Commonwealth Secretariat 2007, 3). There has been a continuum from

those countries apparently reluctant to endorse international recruitment to those

actively promoting it; hence quite different policies and practices exist in the

United States and the UK. Similar differences in attitude had been apparent for

the Commonwealth Code. There are further parallels with the reluctance of some

developed countries to subscribe to global targets and policies that mitigate the

consequences of global warming, where local costs are thought to be significant.

The key themes in the national and regional Codes relate to the protection

of migrant workers and supporting their effectiveness in the work environment.

The Codes have centered on the first two objectives, and thus are significant

within recipient countries. The relatively recent NHS Scotland Code has seven

guidelines, six of which concern the rights of migrant workers and of the recipient

healthcare system. Just one code focused on the supply side: “developing

countries should not be targeted for recruitment unless there is an explicit

government-to-government agreement with the UK to support recruitment

activities.” The NHS Scotland Code did not extend on this provision other than to

state that “Individual healthcare professionals from developing countries who

volunteer themselves by individual personal application should be considered for

employment.” Without reservations, this denied what had gone before concerning

the rights and needs of developing countries, and emphasizes the conflict between

individual rights and national needs. By contrast, the more recent Pacific Code

emphasizes the rights of sending countries, the need for reciprocity, and some

form of compensation.

The third theme, the need to protect source countries from overly

aggressive international recruitment of health workers to the extent that there are

definite reductions in the efficiency of their healthcare systems, was much less

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evident. The rights of migrant health professionals had more significance than the

rights to health of populations in source countries (Plotnikova 2011). This issue,

one rationale for the establishment of codes, and especially the Global Code (see

below), is the most difficult to implement, monitor, and assess. While the first two

aims are not easy to implement (for example in terms of cultural and language

issues), they raise fewer issues than the third. Uncertainties concern defining what

is equitable, how any reduced effectiveness of source country healthcare systems

might be measured, and what constitutes “aggressive” recruiting, in comparison

with unsolicited individual choice. (“Active” recruitment may be distinguished

from “passive” recruitment when an employer takes the lead in encouraging a

migratory move that might not otherwise have existed, but that need not

necessarily be “aggressive.”) Practices deemed “unfair” or unethical might

include bringing health workers to meet destination communities, sending out

emails, setting up booths at job fairs in developing countries, and advertising in

professional journals of developing countries (but advertising vacancies in rich

world professional journals has the same effect, since the journals are readily

available) (McIntosh, Torgerson, and Klassen 2007, 12–13, 20–21). The Internet

has reduced the significance of in-country recruiting. Given these uncertainties,

defining and reaching a consensus on what is equitable, and appropriate, in a

cross-cultural context has been challenging; hence codes exhibit a high level of

generality over what should happen.

Where codes, such as the 2003 Commonwealth Code, were more specific,

in having introduced a clause on compensation, developed countries, like Canada

(McIntosh, Torgerson, and Klassen 2007), have refused to endorse fully the Code.

The more precise Codes become, the greater likelihood of their not having the

expected number of signatories.

The Implementation of Codes

Codes are voluntary, framed around the notion of “guiding principles,” giving

them some political weight as “soft law” or moral injunction, but they are not

binding legal documents. Thus the 2004 NHS England Code, that had been

revised from its predecessor to include recruitment agencies and private sector

providers contracted to the NHS, stated “All employers are strongly commended

to adhere to this Code” (Department of Health 2004, 4) and the NHS is

“commended only to use recruitment agencies that comply with the Code”

(Department of Health 2004, 4, 5). Such guidelines are voluntary, focus only on

“active” recruitment, and are limited to NHS-funded employers and organizations

providing NHS-funded care. Verbal warnings have been given to UK recruitment

agencies that breached the code and the most extreme punishment was the

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banning of 11 recruiters (DFID 2007), while the NHS in Scotland sought to take

action against one NHS Board that had planned to enter into a contractual

agreement with a consortium of South African radiologists. Otherwise there is no

evidence of punitive actions beyond moral pressures, and no incentives for

countries and agencies to be part of EIR processes. Support for codes has been

rhetorical rather than real. No country has yet developed a mechanism that

effectively monitors compliance, even within recipient countries. In Canada it has

been argued that exercising legal compliance is neither necessary nor practical

given the legislative changes that would be required (McIntosh, Torgerson, and

Klassen 2007). As long as codes are voluntary, they are unlikely to achieve key

goals.

Monitoring of “flows” of health workers has several limitations if used as

a test of the effectiveness of a code. First, where there are codes, not all migrant

health workers are covered. Many health workers migrate as individuals (and

sometimes not as health workers) beyond the “control,” regulation, or knowledge

of Ministries of Health in recipient and source countries. For example, almost

6,000 Filipino nurses were reported registered in the UK in 2002–2003, but only

186 were reported to have been recruited via bilateral agreements (Buchan and

Seccombe 2005, 25). Thus in the country where there has been the greatest

attempt to implement codes, more than half of migrant nurses arrived by other

means, effectively finding their own way into the system. Secondly, even where

there is data suggesting a change in flow, it is not possible to attribute this only to

the impact of a code; other factors such as changes in demand in the destination

country may reduce inflow, as happened in the NHS in the UK after 2005 (see

Buchan et al. 2009). Thirdly, codes do not cover all employers in the health

system: the primary focus has been on government and the public sector. The

private sector has usually not been fully covered by codes. For example, the NHS

England Code does not cover private sector employers (unless they are involved

in providing services to the NHS) and does not prevent health professionals taking

the initiative to apply for employment in the UK, or going to the UK for training

purposes, and staying on. Through such loopholes the private sector has

effectively become a “staging post” (Kingma 2006, 128) for “backdoor

recruitment” into the public sector (Buchan, Jobanputra, and Gough 2004;

Eastwood et al. 2005) for workers who had already independently moved or been

recruited into the private sector in the UK. By then their country of origin had

become irrelevant, because they would be classified as having been recruited from

within the UK.

Just as some hospitals, recruiters, and nursing homes operated outside

codes, some workers migrated beyond them. In some Pacific states, notably

Tonga and Samoa, the migration of skilled workers was largely independent of

recruitment as migrants went to such countries as New Zealand to join kin and

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only subsequently sought employment (Connell 2009; Connell and Kerse 2009).

A substantial amount of migration occurred outside the formal guidelines of

codes—usually deliberately so—which subverted both their effectiveness,

especially for source countries, and their moral authority.

Between 2001 and 2006 in the UK, there was little sign of any marked

trends in the registration of doctors or nurses from listed countries, compared with

list-exempt countries. Moreover, for the two listed countries of Ghana and Kenya,

although active recruitment from the UK was perceived to have declined

significantly, it was not clear that the Code had influenced this, or that the decline

in recruitment was the outcome of other factors, notably improved pay and

conditions in both countries which had paralleled reduced employment

opportunities in Britain (Buchan et al. 2009). None of many diverse respondents

in Ghana believed that the Code had had a significant impact on recruiting but in

Kenya there was some indication that unscrupulous recruiting had declined,

though in both countries there had been no attempts to monitor recruitment

activity (Buchan et al. 2009). In both countries there was little knowledge of the

Code, as “dissemination of the contents of the Code to relevant parties within the

case study countries had apparently been largely absent” (Buchan et al. 2009, 8).

Similarly in the Pacific, at least in two of the principal island states, the Code was

poorly publicized and few senior health officials were even aware of its existence

(Connell and Kerse 2009) emphasizing basic issues of management. The Codes

were complex documents that imposed on restricted managerial abilities, had

limited bearing on the immediate problems that Ministries of Health dealt with,

and introduced another bureaucratic task, where monitoring would be extremely

difficult.

The Source Countries

Only the Pacific Code makes any provision for measuring the impact of migration

from developing countries. The most detailed codes are partial in their coverage

of issues, especially the principal one—the negative effect in sending countries—

that had stimulated initial consideration of Codes, and which eventually produced

the Global Code. The revised (2004) NHS England Code mentions only the

problem of “active recruitment” and makes no mention of monitoring any impacts

of migration. The NHS did not then have the necessary data to monitor its own

active recruitment of international nurses (Buchan and Seccombe 2005). Even the

Commonwealth Code simply argued that recruiters “should not seek to recruit

health care workers who have an outstanding obligation to their home country.” It

did however introduce the notion of compensation and reparation where

destination governments obtain “advantages” by recruitment (a situation that is

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universal). Both the Commonwealth and Pacific Codes noted that in many

countries that have funded training costs, workers are expected and bonded to

work for their home countries for a reasonable set period and should not be

recruited. This appears to be the definition of those with “outstanding

obligations.” Neither code referred to those with particular skills who have

completed the bonding period.

Recognition that recruiting skilled health workers from some countries

was unethical led to drawing up a list of such offending countries. The English

Department of Health, guided by the Department for International Development

(DFID), did not initially identify which countries it considered to be

“developing,” but subsequently listed over 150 countries (Buchan and Seccombe

2005). Monitoring whether countries should be, and stay, on such a list could be

complex and demanding, as workforces and health needs change. Countries may

have an “excess” of nurses but a “deficit” of doctors, and there is no consensus on

the impact, significance, and locations of harmful recruitment practices.

Moreover, the task of management of codes has primarily occurred within the

recipient countries, which may not necessarily be firmly committed to their

implementation, and are poorly placed to evaluate the impact in source countries,

and have little incentive to do so.

While the Commonwealth Code viewed the issue of compensation for

migratory workers as optional, the Pacific Code stated that governments

recruiting from Pacific countries “should in some way compensate source

countries” for example through building capacity in local training institutions or

providing re-insertion training. Norway sought to fund the training of all workers

who worked within the country’s borders. African countries meeting in 2006 and

2007 similarly moved towards this practice. In February 2006 the East Central

and Southern African Health Community sought to “adopt a common position on

compensation for health workers recruited by developed countries” and in April

in the following year the African Union Conference of Ministers of Health were

“insisting on agreements that take into account the investment made by African

countries as well as the right and freedom of individuals” (M. Awases, personal

communication 2007). African countries never introduced a regional code and

this objective was eventually subsumed in the Global Code.

The available evidence suggests that codes have had variable and usually

limited effect on the migration of skilled health workers, and in some cases may

have diverted flows (for example from the Caribbean to the United States instead

of the UK) rather than reducing them. Even monitoring advertising practices has

proven challenging. Over the five-year period 2000–2004, there were over 2,500

recruitment advertisements in the South African Medical Journal alone (most

from the UK, Canada, and Australasia). Some of those countries seeking recruits

included countries on the UK Department of Health list (Rogerson and Crush

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2008). However, the most aggressive forms of recruiting have diminished so that

UK employers no longer enter overseas workplaces and directly distribute

information (DFID 2007). Canada, for example, does not regard itself as being

engaged in active recruiting, but ongoing advertising in South African journals

and promotion of migration by private recruiters blurs the distinction between

active and passive recruitment (Labonté, Packer, and Klassen 2006). A soft sell,

in the age of web pages and Internet connections, may be equally effective.

Where packages of changes, such as superior wages and better access to training

and technology, have been implemented, as in Kenya and Ghana, this has proved

a more effective deterrent to migration than the formulation of codes (Buchan et

al. 2009). In both countries reduced emigration of skilled health workers was

locally perceived to be one outcome of a greater difficulty in obtaining visas, and

more limited employment opportunities in the UK, suggesting that regulation of

migration might better be undertaken at national borders rather than through

health ministries. The limited diffusion of Codes in many places suggests at least

a degree of scepticism over their efficacy, in contexts where migration (and

attrition) are not and cannot be routinely recorded.

The Global Code

The culmination of the development of Codes was the endorsement in 2010 by

the World Health Assembly of the WHO Global Code of Practice, following a

process of six years of discussion, refinement, and redrafting. The Global Code

had similarities with the Commonwealth Code in both its focus and content, and

in its coverage of many countries with different health systems, labour market

conditions, and regulatory environments. Its two core themes were that states

should seek to achieve a balance between the rights, obligations, and expectations

of source countries and migrant health workers, and that international health

worker migration should have an overall positive impact on the health system of

developing economies, economies in transition, and small island states. The Code

recommended that “active recruitment … from developing countries facing

critical shortages of health workers” be ended unless bilateral or multilateral

agreements existed, since workers had an “outstanding legal responsibility” to

their own countries, and that states should aim “to create a sustainable health

workforce … to reduce their need to recruit migrant health personnel.” Developed

countries were also encouraged to provide technical and financial assistance to

developing countries, “to the extent possible,” and facilitate return (circular)

migration. The Code recommended that each country should set up “a national

authority responsible for the exchange of information regarding health personnel

migration and the implementation of the Code” (WHO 2010a).

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The Global Code also sought to emphasize the primary needs of the

source countries, and thus was rather more like the Pacific Code than any of its

other predecessors in emphasizing the rights of sending countries, the need for

reciprocity and for some form of compensation (though the word was never used).

It highlighted the 57 countries addressed in the 2006 World Health Report (WHO

2010b), and argued that migration from those countries was further weakening

already fragile health systems and was a “serious impediment” to meeting the

Millennium Development Goals. Although it was again a voluntary code, it

covers employers and recruitment agencies, and set 2102 as the first timeline for

member states to report on the implementation of the Code. To achieve a global

consensus, some compromises were made in the final content of the Code. The

issue of “compensation”, more evident in drafts, was replaced in the final version

by a broader reference to “mutuality.” The possibility of financial compensation

to source countries for losses of workers has long proved impossible to

implement, because of rejection of the specificity of health worker migration, the

impossibility of estimating costs, movement of workers between the private and

public sectors, uncertainty over the duration of employment and the migration of

individual health workers between several countries, as well as the natural

reluctance of most destination countries to “pick up the tab” for the training of

health workers from other countries. The notion that recruiting countries should

provide some financial and technical support for countries that they recruit from is

not new, but carries extra weight through being incorporated in a WHO code

(Buchan 2010). That a comprehensive, binding, and global code of practice for

the migration of skilled health workers has been achieved is testimony to the

remarkable industry of WHO and the goodwill of many recipient countries, but

implementation and monitoring will both be massive tasks.

Memoranda of Understanding

The Global Code highlights the use of bilateral agreements and MOUs in

supporting more “ethical” recruitment. As noted earlier, bilateral agreements and

MOUs (such as the 2001 agreement between Spain and the UK) are tailored to the

particular conditions of healthcare systems and workers in both source and

recipient countries, sometimes specifying numbers and time periods and

indicating that at the end of the time period return migration should occur. This

offers potential for the much sought after “win-win” situation of managed

migration where migrant workers acquire new skills, experience, and capital, and

return to poorer countries and households that can benefit from this.

The 2003 MOU between South Africa and the UK, which focused on

sharing expertise and time-limited placements, resulted in all the South African

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nurses who had worked in the UK returning at the end of the two-year period. The

ability to achieve ubiquitous return migration was invaluable since in most

circumstances, without regulation, a significant proportion of health workers do

not return, and where they do they fail to take up positions in the health service,

so emphasizing the “myth of return” (Kingma 2006; Brown 1997; Connell 2010).

The MOU also resulted in joint research, the development of South Africa’s

capacity to deal with particular disease outbreaks and emergencies, and various

twinning arrangements to share skills and expertise (Chetty and Maslin 2006).

Not all bilateral MOUs have been so successful. After the two-year 2002

bilateral agreement between the Netherlands and Poland (against the background

of significant demand in the Netherlands and substantial unemployment of nurses

in Poland), most Polish nurses stayed in the Netherlands. Although this is a

specific case of more general trends for initially temporary migration to extend

into permanency, even with restrictive clauses, it was a practical response to a

lack of jobs in Poland (and to the lack of intra-EU migration regulations) and thus

satisfied conditions in both sending and receiving countries, alongside the

interests of the nurses. MOUs and other bilateral agreements are likely to be more

effective than more wide-ranging Codes by having a specificity, in being tailored

to the particular conditions of healthcare systems and workers in both source and

recipient countries, and having a finite duration.

DFID (2007) has urged support for workers seeking to return and for

those countries seeking to monitor and evaluate the flow of health workers. Such

issues might best be addressed via support for training regimes within developing

countries, as is stressed in Caribbean concepts of “managed migration” (Salmon

et al. 2007), and the Global Code’s concern with mutuality, and emphasized in

MOUs. Capacity building is a potentially effective restitutive mechanism (most

obviously in source countries), unless purely directed at training health workers

for export. MOUs have opened up possibilities for other forms of bilateral

relationship, but particularly the temporary movement of health professionals

from developing countries. In 2005 the Department of Health in Gauteng province

(South Africa) developed a strategy that enabled nurses to have a two-year period

of work overseas and return to a secure post with no loss of benefits. Such

strategies, like more formal MOUs, offer possibilities for nurses to acquire

incomes overseas, return with new skills and experience, and not suffer the

disadvantages (such as return to the lowest status in the system) that return

migrants have suffered in some other contexts (thus effectively discouraging

return). Small-scale bilateral schemes and MOUs have proved to be more

effective than more wide-ranging codes in meeting particular vacancies and

enabling return. Such “managed migration” framed around temporary movements

enhances skills, generates incomes (and remittances), and does not deplete

workforces over the long term.

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Conclusion: The Ever Unfinished Story

Detailed information on the impact of Codes and MOUs is scarce, since much

migration is unrecorded (and is extremely difficult to record) and codes have been

minimally monitored, while labour markets vary between countries and regions,

and across time, for many reasons. Variations in the form and context of

migration, and inevitable lack of precision about impacts, weaken any consensus

on regulation and require considerable flexibility over time and place. In some

countries and regions the notion of any regulation of “free” migration has little

support, especially in a context of neoliberal globalization, where deregulation of

healthcare has reduced the policy capacity of states (London and Schneider 2011).

The range of stakeholders has made it difficult to produce and generate support

for Codes that potentially cut across the public and private sector, and involve

several operational government sectors (including health, education, labour,

immigration, and international development). Until such major recipient countries

as the United States and some Gulf states, and organizations within those

countries (especially the private sector), are actively involved in EIR, progress in

the implementation of a code will be limited. Achieving endorsement of a Global

Code in this context has been a substantial triumph, but implementation and

monitoring will be more crucial.

International mobility is just one of many flows of health workers. Many

others move within countries, from rural to urban areas, from the public to the

private sector, and from the health sector to other sectors. A focus only on

international migration deals with just one symptom, and not the root causes, of

skill shortages: limited funding, low pay, restricted career opportunities,

inadequate facilities, poor management, and economic and political instability.

Shortages of health workers must be addressed through more effective and wide-

ranging workforce policy and planning, supported by adequate resources and

consistent political commitment.

The first two generations of codes provided guidelines for the recruitment,

conditions, and supervision of migrant workers, but had no impact on protecting

the health systems of source countries. Codes mainly concern circumstances in

recipient countries, despite the needs of several source countries being critical and

of primary concern, hence the need for a Global Code. Widespread consensus that

unregulated migration of skilled health workers is problematic is basic to

success.The willingness of some states to encourage, or even train, health workers

for migration suggests that a “surplus” of unemployed or underemployed health

workers is more widely available. Migration is increasingly embedded in

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household, national, and international political economies, and global interests

vary.

The most important constraint to the unregulated flow of health workers

from developing countries remains the production of national workforce needs

within recipient countries, and the provision of more adequate conditions for

skilled workers in source countries, so that demand is reduced and return

migration is a more attractive proposition. There is little prospect of this

happening in most recipient countries in the near future, even in countries where

some will to do so exists (e.g., Buchan, Naccarela, and Brooks 2011). In source

countries the tasks of implementing a now familiar litany of proposals ranging

from superior wages, transparent promotion structures, better access to training

and equipment, etc. (e.g., Connell et al. 2007; Dovlo 2007; Connell 2010) has

similarly proved difficult to put in place when health budgets are limited. Greater

attention to the long-term issues of planning, production, and retention in both

sending and recipient countries, rather than a short-term focus on recruitment,

would reduce the need for one element of the Code.

Codes do not cover effectively some individual migrants, who move

without being recruited, secure in the knowledge that their skills will gain them

jobs overseas, nor those who are educated and trained overseas. In several Pacific

island states, this “dual culture of migration” (Connell 2009) is the major

contributor to the loss of skilled health workers rather than recruitment. Codes

cannot cover all facets of migration. The Global Code has both drawn attention to

the weaknesses of national and regional codes and reasserted the severity of issues

in many source countries. Ultimately the success of any code depends on

compliance by and support from the state (as the institutional base of training),

employers (including the private sector), and recruiting agencies.

Certain general guiding principles are crucial and have been clearly

identified: global social justice, the right to health, personal autonomy,

transparency and accountability, fairness, mutuality of benefits and reciprocity

between countries, provider competency, equitable workplace practices, and

workplace and cultural integration (McIntosh, Torgerson, and Klassen 2007; de

Mesquita and Gordon 2005; Plotnikova 2011). Codes have moved beyond moral

principles to emphasize more practical and reciprocal objectives. Exactly how

effective monitoring might be accomplished and by whom is yet to be clarified in

contexts where all forms of management pose problems, and not all countries are

enthusiastic or fully informed signatories.

Codes are blunt instruments for restructuring the international migration

of health workers; hence the early codes converged to become more like MOUs.

The Global Code offers important overriding principles, guidelines, and

generalizations; regional codes develop particular important themes and MOUs

are even more specific. All countries are different; generalizations covering more

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than 150 countries are of limited value, but may provide a frame within which

specific bilateral or multilateral agreements are likely to be most effective. Codes

have emphasized critical concerns and the key principles of EIR through which

human resource policies might be given stronger moral foundation, alongside

MOUs that can develop effective managed migration schemes, within a

hierarchical ethical framework. Implementing such a framework however remains

a critical challenge. Codes are essentially soft law, symbolic rather than practical.

References

Bach, S. 2007. “Going Global? The Regulation of Nurse Migration in the UK.”

British Journal of Industrial Relations 45: 383-403.

Brown, D. 1997. “Workforce Losses and Return Migration to the Caribbean. A

Case Study of Jamaican Nurses.” In Caribbean Circuits. New Directions

in the Study of Caribbean Migration, ed. P. Pessar, New York: Center for

Migration Studies, 197-223.

Buchan, J. 2010. “Challenges for WHO Code on International Recruitment.”

British Medical Journal 340 (29 March) 1486.

Buchan J, and Seccombe, I. 2005. Past Trends Future Imperfect? A Review of

the UK Nursing Labour Market in 2004/5. London: Royal College of

Nursing.Buchan, J., R. Jobanputra, and P. Gough. 2004. London Calling?

The International Recruitment of Health Workers to the Capital. London:

King’s Fund.

Buchan, J., B. McPake, K. Mensah, and G. Rae. 2009. “Does a Code Make a

Difference—Assessing the English Code of Practice on International

recruitment.” Human Resources for Health 7 (33): 1-8.

Buchan, J., L. Naccarella, and P. Brooks. 2011. “Is Health Workforce

Sustainability in Australia and New Zealand a Realistic Policy Goal?”

Australian Health Review 35: 152-155.

Chetty, K., and A. Maslin. 2006. “A Memorandum of Understanding Between the

Governments of South Africa and the United Kingdom and Northern

Ireland on the Reciprocal Educational Exchange of Healthcare Concepts

and Personnel.” Commonwealth Secretariat, mimeo.

Commonwealth Secretariat. 2007. “Comparison of the Commonwealth Code with

the March 2007 Pacific Code.” mimeo, London.

Connell, J. 2009. The Global Health Care Chain. From the Pacific to the World.

New York and London: Routledge.

Connell, J. 2010. Migration and the Globalisation of Health Care. Edward Elgar

Cheltenham.

15



Connell, J. and L. Kerse. 2009. “The Pacific Code of Practice for Recruitment of

Health Workers. An Analysis for Tonga and Samoa.” unpublished report

to WHO, Suva.

Connell, J., P. Zurn, B. Stilwell, M. Awases, and J.-M. Braichet. 2007. “Sub-

Saharan Africa: Beyond the Health Worker Migration Crisis.” Social

Science and Medicine 64: 1876-1891.

Department of Health. 2004. Code of Practice for the International Recruitment

of Healthcare Professionals. London: Department of Health.

Department for International Development (DFID). 2007. “Evaluating the UK’s

Code of Practice on International Recruitment of Health Workers.”

mimeo, London.

Dovlo, D. 2007. “Migration of Nurses from Sub-Saharan Africa: A Review of

Issues and Challenges.” Health Services Review 42: 1373-1388.

de Mesquita, J. and M. Gordon. 2005. The International Migration of Health

Workers: Human Rights Analysis. London: Medact.

Eastwood, J., R. Conroy, S. Naicker, P. West, R. Tutt, and J. Plange-Rhule. 2005.

“Loss of Health Professionals from Sub-Saharan Africa: The Pivotal Role

of the UK.” The Lancet 365: 1893-1900.

Garrett, L. 2007. “The Challenge of Global Health.” Foreign Affairs 86 (1): 14-

38.

Hamilton, K., and J. Yau. 2004. The Global Tug-of-War for Health Care

Workers. Washington: Migration Policy Institute.

Kingma, M. 2006. Nurses on the Move. Migration and the Global Health Care

Economy. Ithaca: Cornell University Press.

Labonté, R., C. Packer, and N. Klassen. 2006. “Managing Health Professional

Migration from Sub-Saharan Africa to Canada: Stakeholder Inquiry into

Policy Options.” Human Resources for Health 4 (22): 1-15.

London, L., and Schneider, H. 2011. “Globalisation and Health Inequalities: Can

a Human Rights Paradigm Create space for Civil Society action?” Social

Science and Medicine 73. doi:10.1016/j.socscimed.2011.03.022

Lorenzo, F., J. Galvez-Tan, K. Icamina, and L. Javier. 2007. “Nurse Migration

from a Source Country Perspective: Philippine Country Case Study.”

Health Services Research 42: 1406-1418.

Lowell, L., and A. Findlay. 2002. Migration of Highly Skilled Persons from

Developing Countries: Impact and Policy Response, Geneva: ILO

International Migration Papers No. 44.

McIntosh, T., R. Torgerson, and N. Klassen. 2007. “The Ethical Recruitment of

Internationally Educated Health Professionals: Lessons from Abroad and

Options for Canada.” CPRN Research Report H/11, Ottawa.

16



Martineau, T., and A. Willetts. 2006. “The Health Workforce: Managing the

Crisis Ethical International Recruitment of Health Professionals: Will

Codes of Practice Protect Developing Country Health Systems?” Health

Policy 75: 358-367.

Mejia, A., H. Pizurski, and E. Royston. 1979. Physician and Nurse Migration:

Analysis and Policy Implications. Geneva: WHO.

Morgan, W., A. Sives, and A. Appleton. 2005. “Managing the International

Recruitment of Health Workers and Teachers: Do the Commonwealth

Agreements Provide an Answer?” The Round Table 94: 225-238.

Plotnikova, E. 2011. “Cross-Border Mobility of Health Professionals: Contesting

Patients’ Right to Health.” Social Science and Medicine 73.

doi:10.1016/j.socscimed.2011.02.012

Rogerson, C., and J. Crush. 2008. “The Recruiting of South African Health Care

Professionals.” In The International Migration of Health Workers, ed. J.

Connell. New York and London: Routledge, 199-224.

Salmon, M., J. Yan, H. Hewitt, and V. Guisinger. 2007. “Managed Migration:

The Caribbean Approach to Addressing Nursing Services Capacity.”

Health Services Research 42: 1354-1372.

Watkins, S. 2004. “Migration of Health Care Professionals: Practical and Ethical

Considerations.” Clinical Medicine 5: 240-243.

Wiskow, C. 2005. “Management of International Health Worker Migration:

Instruments on Ethical Recruitment and Other Policy Options.”

unpublished mimeo, Geneva.

WHO. 2006. Working Together for Health. Geneva: WHO.

WHO. 2010a. The WHO Global Code of Practice on the International

Recruitment of Health Personnel. Geneva: WHO.

WHO. 2010b. User’s Guide to the WHO Global Code of Practice on the

International Recruitment of Health Personnel. Geneva: WHO.

Zurn, P., M. Dal Poz, B. Stilwell, and O. Adams. 2004. “Imbalances in the Health

Workforce.” Human Resources for Health 2 (13): 1-12.

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The Impossible Dream? Codes of Practice and the International Migration of Skilled Health Workers

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