Perspective
Global Health
Stemming the Brain Drain — A WHO Global Code of Practice on International Recruitment of Health Personnel
N Engl J Med 2011; 365:2348-2351December 22, 2011
- Article
The World Health Organization (WHO) estimates that the world faces a shortage of 4.3 million health professionals required for delivering essential health care services to populations in need. This shortage constitutes a major barrier to the provision of essential lifesaving health services, such as childhood immunization and the prevention and treatment of HIV–AIDS. International migration and recruitment of health personnel from low- and middle-income countries is an important contributing factor. In Zimbabwe, for example, of 1200 physicians trained between 1990 and 2001, only 360 remained in the country in 2006.
According to the WHO, 57 countries face severe shortages in their health care workforce (see map
Critical Shortages of Health Service Providers (Nurses, Doctors, and Midwives).). Shortfalls are greatest in sub-Saharan Africa, which bears 24% of the world's disease burden but has only 3% of the global health workforce (see graph
Global Distribution of Health Workforce by Level of Expenditure and Disease Burden in Six WHO Regions.). Aging populations and increased specialization of health services are driving up demand for health workers globally, while global underinvestment in the education of health care professionals limits the supply. “Pull factors,” including targeted recruitment efforts by wealthy destination states, combine with “push factors” in source countries, such as low wages, unstable working environments, and weak public health systems, to exacerbate shortages.These shortages, in turn, contribute substantially to the weakness of health systems and obstruct the achievement of public health goals such as reductions in maternal and child mortality; they also hinder implementation of such international legal agreements as the WHO 2005 International Health Regulations, which aim to protect populations from the international spread of disease and to enhance public health security. Strong health systems are essential to improving health outcomes in underserved populations. Without effective health systems employing enough skilled, motivated, well-supported, and adequately supervised health workers, it's unlikely that vaccines and other important medical interventions can improve global health outcomes in any sustainable way.
The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted by the 193 member states of the World Health Assembly (WHA) in May 2010, is a critical multilateral framework for tackling the shortage in the global health workforce and the migration of health care workers from low- and middle-income countries. The crucial challenge now is ensuring that the Code's norms are implemented so that it can contribute to tangible improvements in health systems worldwide.
Strong health systems are strategically important to the global community. They underlie bilateral and multilateral efforts to ensure global health security through preparation for, and early detection of, pandemics and other emergencies; such preparation can protect populations and minimize disruption of global trade and commerce. A 2011 WHA resolution (Resolution 64.6) on strengthening the health workforce highlights the strategic importance of addressing workforce shortages and asserts that because doing so will improve population health, it represents an essential investment in socioeconomic development. The resolution also urges countries to take measures to meet their health workforce needs — for example, to educate, retain, and sustain a health workforce with skills relevant to their population's needs.
The voluntary WHO Global Code of Practice establishes a global architecture, including ethical norms and legal and institutional arrangements, to guide national action and multilateral cooperation. Its key principles focus on developing sustainable health systems, protecting the human rights of migrant health workers, and supporting health systems in low- and middle-income countries, in part by providing technical and financial assistance for personnel development. Such development is critical to achieving the Code's objectives through increased investment in education for health professionals within each country. Despite policy acknowledgment of its importance, health-personnel development remains chronically underfunded in national budgets and cooperative development efforts.1
A number of countries are already working to incorporate the Code into national law and practice. For example, Kenya has entered into bilateral agreements with certain countries (including Namibia, Lesotho, and Rwanda) regarding collaborative health workforce training and promotion of circular migration of health workers (involving the temporary or permanent return to their home countries). In a draft national policy currently awaiting parliamentary approval, Zimbabwe addresses factors contributing to health workforce shortages; supports mechanisms and processes for stakeholder coordination and collaboration; and defines stakeholders' roles and responsibilities in ensuring timely financing, implementation, and monitoring of national human resources for health and in promoting the development and retention of the health workforce. Thailand has organized a national subcommission on the Code's implementation and has created a 3-year plan of action, which includes translating the Code into Thai, convening multistakeholder consultations, and establishing practice guidelines and a registration system for recruiters.
Among high-income countries, Norway has begun implementing the Code by scaling up the education of relevant personnel to ensure sustainability of its own health care system, and it has formally stopped recruiting health personnel from countries facing critical shortages in the health workforce. The Norwegian Directorate of Health is also meeting with stakeholders, including national and municipal employer and labor unions, regional health enterprises, and county administrative offices, to advance Code implementation and reporting, and it has coordinated with the Norwegian Foreign Ministry to promote awareness of the Code. The United States, led by the Office of Global Affairs and the Health Resources and Services Administration, has convened an interagency working group on implementing the Code, which has begun collaborating on the U.S. government response to the Code's reporting provisions and raising awareness of its adoption.
Policy advocacy regarding strengthening human resources for health as part of efforts to achieve the Millennium Development Goals is beginning to translate into allocation of funds from donors toward basic training of a health workforce in some countries.2 For example, the U.S. President's Emergency Plan for AIDS Relief and the National Institutes of Health have joined forces with others in an initiative to transform medical education at selected medical schools in Africa.3 The Medical Education Partnership Initiative (MEPI), along with the U.S. Agency for International Development, the Centers for Disease Control and Prevention, and the Department of Defense, is supporting local health ministries and academic centers in Africa in their efforts to strengthen their countries' health systems; this work includes the provision of technical assistance and guidance on improving the quantity, quality, and retention of health professional graduates. Countries such as South Africa, Malawi, and Nigeria are working with MEPI to transform health workforce education.
The Code's success will ultimately be judged according to whether it leads to concrete improvements in the lives of the people and communities most affected by the workforce crisis. To advance its implementation, the Code institutes a powerful governance framework that includes mechanisms for information sharing, monitoring, and implementation. In November 2011, the WHO secretariat released final guidelines on monitoring implementation, including a model national reporting instrument. In addition, the guidelines attempt to democratize the governance process for global health by incorporating a second reporting instrument enabling all other stakeholders to formally share relevant information. All these reports will be made publicly available through the WHO Web site, so that the Code's effectiveness will be kept under close public scrutiny and continuous review, which will enhance accountability.
Although the Code doesn't provide solutions to all the complex problems of health worker migration, it offers needed guidance on possible policy and legislative approaches. There is growing evidence that its legal framework can work as a platform for cooperation to strengthen health workforce systems. Sixty-nine countries have thus far designated a national authority responsible for the exchange of information on health worker migration and Code implementation. However, greater efforts are needed to ensure effective implementation. It is time for states to muster the political will and resources to act to strengthen health workforce systems everywhere.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From the O'Neill Institute for National and Global Health Law, Georgetown University Law Center (A.L.T.); and the Office of the Secretary, Office of Global Affairs, U.S. Department of Health and Human Services (N.D.) — both in Washington, DC; the African Group of Health Diplomats, World Health Organization, Geneva (L.H.); and the Norwegian Directorate of Health, Oslo (B.-I.L.).
- References
References
1
Frenk J ,Chen L ,Bhutta ZA , et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-1958
CrossRef | Web of Science | Medline2
Medical Education Partnership Initiative (MEPI). Bethesda, MD: Fogarty International Center, National Institutes of Health, June 2010 (http://www.fic.nih.gov/Programs/Pages/medical-education-africa.aspx).
3
HHS partners with PEPFAR to transform African medical education with $130M investment. Bethesda, MD: National Institutes of Health, October 2010 (http://www.fic.nih.gov/Programs/Pages/medical-education-africa.aspx).
- Citing Articles (2)
Citing Articles
1
Timothy Ken Mackey, Bryan Albert Liang. (2012) Rebalancing brain drain: Exploring resource reallocation to address health worker migration and promote global health. Health Policy
CrossRef2
Inbal Fuchs, Alan Jotkowitz. (2012) Reversing the Brain Drain: The Role of Medical Schools. The American Journal of Bioethics 12:5, 42-43
CrossRef
