1 |1 | 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 Network Making Global Health News Geneva May 2009

2 |2 | 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

3 |3 | 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

4 |4 | 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.

5 |5 | 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 Euro Ministerial Manila Forum PAC – TWG meeting Launch of Global Dialogue on Migration G8 Summit Public Hearings Drafting of the Code

6 |6 | 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 EB Draft Resolution Draft Code Draft Code for the WHA? Progress Report for EB Consultations Background Paper Technical Briefing WHA09 Global consultation?

7 |7 | 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

8 |8 | 1- Need has been clearly identified in all countries Inequitable distribution of health workers

9 |9 | 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

10 | An ongoing calendar

11 | Thank you for your attention !

12 | 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

13 | A complex issue no ‘single bullet’ type of answer Management, environment and social support Direct and indirect financial incentives Education and regulatory interventions 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

14 | Categories of interventions Category of interventionExamples 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

15 | 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 per 1000 pop France: General Practitioner density

16 | 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.

17 | 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.