In a bid to better manage the increasing migration of health workers, in 2010 the World Health Organization (WHO) adopted its Global Code of Practice on the International Recruitment of Health Personnel. The Code has been misinterpreted by many as banning all recruitment from the 57 countries it deemed to have a “critical shortage” of health workers.
But that is neither what the WHO intended, nor what the Code says. Recruitment from these countries was always allowed, even encouraged, as long as it was conducted under a government-to-government agreement. In a new CGD brief, published today, we give the details. Here we summarize that history, welcome the WHO’s recent clarification of what the Code does permit, and explain how well-designed health worker recruitment can implement the Code in any country.
Defining a “critical shortage” of health workers
Concerned that vulnerable countries were losing health workers to migration, the 63rd World Health Assembly adopted the WHO Code. It established voluntary principles and practices to guide the ethical recruitment of health workers and strengthen health systems. Crucially, it recommends that “Member States should discourage active recruitment of health personnel from developing countries facing critical shortages of health workers.”
57 countries fell into this “critical shortage” category, having fewer than 2.28 health workers per thousand population (figure 1). Since the list was calculated in 2006, the world has advanced, improving health outcomes and increasing health worker density. Applying the same calculation to the most recent data would reduce the list to 43 countries, removing countries like India, Malawi, and Morocco.
Figure 1. Countries originally designated by the WHO, in 2006, as having a “critical shortage” of health workers
Note: The full list is available in Table 1. Source: WHO (2006) World Health Report 2006. Geneva: WHO.
What the WHO Code actually says
Many have misinterpreted the WHO Code as recommending an outright ban on any recruitment of health workers from these 57 countries. Many high-income countries have even codified this interpretation; for example, Germany banned all recruitment from these countries in 2013, and the UK banned recruitment from 152 countries.
But bans of this sort do not implement the Code. The guiding principle of the Code is that the migration of health workers can lead to both development and the strengthening of health workers, if recruitment is bilaterally agreed and properly managed. The Code was certainly never meant to bar countries from making agreements that would benefit them.
What the Code discourages is unregulated and unilateral recruitment without an offsetting obligation for the country of destination to provide some form of meaningful development support. Here, the Code mentions things like technical and financial assistance to strengthen health systems and/or improvements in human resource development and training.
The New “Safeguards List”
Early this year, the WHO published a new list. It realized that the “critical shortage” list was no longer fit for purpose, and they wanted to better clarify the positive impacts that health worker migration can bring if properly regulated.
Their new “Safeguards List” uses a new definition, a mixture of health worker density and universal health coverage (UHC) service coverage, to establish a list of 47 countries. Gone are countries like India, Indonesia, Kenya, Zambia, and Zimbabwe. But much of the Pacific has now been added to the list. This new definition is simpler, clearer, and better linked to ongoing policy discussions.
Figure 2. Countries on the new WHO Safeguards List, published in 2021, as having a “critical shortage” of health workers
Note: The full list is available in Table 1. Source: WHO (2021) Health Workforce Support and Safeguards List, 2020, Geneva: WHO.
In this new policy, the WHO explicitly encourages government-to-government agreements with these 47 countries to enable support to health personnel development and health systems strengthening. “Government-to-Government health worker mobility-related agreements,” it says, are “encouraged as good practice.” What was once implicit and thus widely misinterpreted has now been clarified beyond doubt.
This approach has enabled impressive shifts in country of destination policies. For example, the UK’s new Code of practice for the international recruitment of health and social care personnel is enabling the development of government-to-government agreements to promote ethical health worker migration from a range of Code countries.
This is just in time. Both demographic shifts and COVID-19 have exposed the importance of migrant health workers, and such migration is likely to continue. Traditional countries of origin, like the Philippines, are rapidly developing, removing a pipeline of talent which countries of destination had long relied upon. And new countries of origin, such as Ghana, Nigeria, and Sri Lanka are therefore demanding more equitable agreements that channel meaningful assistance towards their health workforce development goals.
What kind of recruitment implements the Code
So what should such a government-to-government agreement include? Crucially, it needs to be done in collaboration with the origin country Ministry of Health and relevant institutions, to prioritize their own health system needs. One way to do this is through a Global Skill Partnership, training health workers within countries of origin and promoting the mobility of some of the trainees.
Crucially, these agreements need to go beyond merely increasing the supply of health workers. Many countries of origin have, paradoxically, both a deficit and a surplus of health workers (in that their public systems cannot afford to pay for more workers). Development support needs to be channeled to improving training infrastructure, strengthening the Ministry of Health, and increasing wages and working conditions to improve the health system overall.
Agreements of this type fulfil the requirements of the WHO Code: They help individual health workers move to countries of destination, they increase the number of skilled workers and improve health systems in countries of origin, and they manage migration in an ethical and sustainable way. They deserve to be piloted, tested, appropriately modified, and scaled.