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APHA Endorses the World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel

Policy Date: 11/1/2011
Policy Number: 201117

Related Policies
APHA Policy Statement 2006-16: Ethical Restrictions on International Recruitment of Health Professionals to the United States[1]
APHA Policy Statement 2008-9: Strengthening Health Systems in Developing Countries[2]
APHA Policy Statement 2009-4: Ensuring the Achievement of the Millennium Development Goals: Strengthening US Efforts to Reduce Global Poverty and Promote Public Health[3]
APHA Policy Statement 2005-3: Expenditure Ceilings Imposed on Poor Countries Must Be Lifted to Achieve the Millennium Development Goals[4]

At the World Health Assembly meeting in 2010, international health leaders from 193 countries made history by adopting new guidelines to mitigate the negative effects associated with the health worker “brain drain” from developing countries.[5] All 193 World Health Organization (WHO) member states unanimously (through a consensus process) adopted the voluntary WHO Global Code of Practice on the International Recruitment of Health Personnel, which sets ethical principles for the international recruitment and migration of health workers. It is only the second time in the assembly’s history that nations have agreed to such an instrument.[6,7]
The code is the culmination of a 6-year effort on the part of national governments, international organizations, and global health advocacy groups, including the Health Workforce Advocacy Initiative. The code acknowledges the right of health workers to migrate, as well as the right of all people to the highest attainable standard of health. It recognizes the responsibility of rich nations to meet their own internal demands for health workers without relying on other countries—most often poor nations—that can least afford to lose health workers.[8]
The critical shortage of health workers in developing countries is staggering.[9] The nation’s capital, for instance, enjoys twice as many doctors as the entire country of Ethiopia.[10] Yet Washington, DC has a population of 600|000 compared with Ethiopia’s 80 million people.
Active recruitment from developing countries systematically deprives entire populations of their right to health.[11] Low-income countries invest significant resources to train health workers, relying on tax dollars along with foreign assistance to support medical and nursing schools.[12] The loss of these investments equates to a form of reverse foreign aid that is simply contradictory.[13]

History of the Code
The code has been in development since 2004. The following items describe its development since that time.
• 2004—WHO member states called on WHO’s director general to develop a code to address the negative impact of health worker migration.
• 2008—WHO’s Executive Board requested that a draft of the code be presented at the 2009 board meeting.
• 2009—In January, the first draft of the code was reviewed by the Executive Board; additional consultations and revisions were requested. In February, the Health Worker Migration Initiative Global Policy Advisory Council issued a recommendations report.
• 2010—The Executive Board reviewed and approved latest draft for the 63rd World Health Assembly.
In May, at the World Health Assembly, a drafting committee was formed to negotiate the final language of the Code of Practice.
On May 21, after deliberation, the Code of Practice was submitted and unanimously adopted—only the second time in history.
• 2011—WHO held a Web-based public hearing on draft guidelines for implementing the Code of Practice and called for all member states to identify their designated national authorities for code implementation by the end of June.

Content of the Code
The code calls on WHO’s director general to develop guidelines for a minimum data set each country should report. It further directs the director general to compile information on each country’s relevant laws and regulations at the national and international levels pertaining to health worker migration. In addition, the code asks the director general to develop suggestions for information exchange mechanisms. The director general must report to the 2013 World Health Assembly and make subsequent reports at least every 3 years.
Member states are encouraged to—

1. Establish a national authority on reporting (the WHO will maintain a registry of these national authorities);
2. Establish national workforce migration research programs;
3. Develop frameworks that strengthen health systems by mitigating the negative effects of migration;
4. Ensure that recruiters and employers observe fair and just recruitment and contractual practices in the employment of migrant health personnel, including discouraging active recruitment from developing countries with critical health worker shortages;
5. Recognize the right to the highest standard of health as well as the right to migrate;
6. Promote fair labor standards for migrant health personnel while ensuring recruited health workers meet any binding obligations in their home countries;
7. Develop sustainable ways for all nations to meet workforce needs;
8. Promote circular migration;
9. Develop bilateral agreements between sending and receiving countries. (Note that the group Realizing Rights has prepared sample bilateral agreements.)

United States’ Responsibility in Global Health Worker Migration Trends
Given that 1 in 4 physicians in the United States is trained abroad (64% of these in a lower-income country),[14] and that the proportion of foreign-educated nurses hit a high of 13% of newly licensed nurses in 2007,[15] the United States bears a special responsibility with regard to the recruitment of international health professionals.
Workforce advocacy coalitions have produced 2 related ethical codes regarding health worker issues in low-income countries. Along with the new Code of Practice, these voluntary codes comprise a package of guidelines to ensure ethical global health practices with regard to human resources for health.

• Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the United States. (This code was developed by the Alliance for Ethical International Recruitment Practices,[16] a nonprofit organization working to ensure that recruitment of foreign-educated nurses to the United States is conducted in an ethical, responsible, and transparent way. This group monitors adherence to its code through surveys of migrant nurses. It is currently expanding its code to include other health care professionals.)
• Nongovernment Organization (NGO) Code of Conduct for Health Systems Strengthening.[17,18] (This code was developed at University of Washington’s Health Alliance International, in conjunction with other progressive, international nonprofit health organizations.)

Principals involved with these codes are also involved with the current effort to support the WHO Code of Practice.
Some countries have already moved to curb their active recruitment practices. In 2007, Norway developed a “framework on global solidarity,” pledging to refrain from recruiting health workers from developing countries.[19] In 1999, the United Kingdom made a similar commitment.[20,21] Canada has significantly ramped up training programs to create less demand for foreign-trained health workers.[22]
As an initial step, to comply with the code, countries must track health worker migration at national and global levels. Current US data systems are fragmented and privatized. The only national data source on physicians is proprietary—available for sale to researchers or marketers by the American Medical Association. Nurse licensure data are available only on a state-by-state basis.[23]
It is anticipated 50.7 million uninsured Americans[24] will soon be eligible for care under the Patient Protection and Affordable Care Act (PPACA). This new demand for services will make more evident the problem of uneven distribution of the US health workforce across urban and rural areas. In addition, the primary care workforce is too small. The US Council on Graduate Medical Education has predicted the United States will be short approximately 85|000 physicians by 2020.[25] The implementation of PPACA will increase demand for health workers of all types, highlighting the need to implement and monitor recruitment practices and to develop bilateral agreements with primary source countries. Further, current migration patterns threaten to undermine the nation’s own global health foreign aid and President’s Emergency Plan for AIDS Relief (PEPFAR) investments, because the loss of health professionals from high-poverty countries threatens the success of our initiatives to strengthen health systems.
Calls to increase the sizes of medical school and nursing school classes have gone largely answered; to do so requires costly investment in higher education. We do, however, have programs that could be expanded to address US workforce problems, such as the National Health Service Corps and state loan repayment programs. In addition, federal legislation and programs (such as PEPFAR, and the Centers for Disease Control and Prevention’s Medical Education Partnership Initiative) offer opportunities to address US workforce problems while strengthening medical education in low-income countries.
In 2010, the United States, along with 192 nations, supported WHO’s Global Code of Practice on the International Recruitment of Health Personnel. Now the United States must show strong leadership by acting decisively to effectively implement the Code of Practice.

The Way Forward
Efforts are currently under way by the WHO Health Worker Migration Initiative and other groups to ensure the effective implementation of the Code of Practice by individual member states and nonstate groups. Discussions are currently being held to determine which indicators should be used and what systems will be needed to support various elements of the Code of Practices—in both developed and developing nations. Article 7 (Information Exchange), for instance, calls for data reporting of “laws and regulations related to health personnel recruitment and migrations” to be submitted to WHO every 3 years, with an initial report due 2 years after the code’s adoption.
Several organizations in the United States have written a collaborative letter (dated September 10, 2010) to the US secretary of health and US secretary of state, stating

We the undersigned, wish to applaud the Administration’s support of the World Health Organization’s new Code of Practice on the International Recruitment of Health Personnel, which, after six years of discussions and preliminary drafts, was adopted by the World Health Assembly in Geneva on May 21, 2010. As organizations and individuals with a longstanding interest in this area, we are enthusiastic about supporting the Administration as it considers ways to encourage compliance with the Code. … The undersigned organizations and individuals have a long-standing interest in the ethical implications of the U.S. reliance on foreign educated health professionals. We stand ready to assist the national authority designated by the U.S. government for purposes of implementing the WHO Code of Practice on the International Recruitment of Health Personnel.[26]

Action Steps
The American Public Health Association, in supporting the Code of Practice on the International Recruitment of Health Personnel, urges the US secretary of health and human services and US secretary of state to work together in the following ways:

1. Appoint leadership. Designate key people who will meet to draft a list of eligible “national authority” agencies and work with other stakeholders to sketch out how the lead agency and supporting task force members might be designated and work together.
2. Assemble a task force. Assemble a task force to identify the data required to make good-faith reports to WHO within the next 1 to 2 years. This task force would examine existing data sources to identify, coordinate, open, link, and report information, and identify new data sources.
3. Create a research program. Fund a research program to examine the intersections between domestic and international workforce production, recruitment, deployment, and retention.
4. Set a policy agenda. Invite the national authority task force to recommend modifications to US policy that arise from the WHO Code, such as our heavy reliance on foreign-trained physicians and nurses, the need to expand our own domestic production of health workers, and the need to better distribute the workforce we currently have.

Discussion of Opposing Arguments
There are those who believe the US health system is in need of health workers trained abroad, and that in a world of free trade, under the Universal Declaration of Human Rights, health workers have the right to seek jobs abroad and US private sector health employers are under no obligation to consider the right to health in developing countries.

These arguments have been well rebutted, however. Health professionals from low-income countries with a tertiary education have been prepared for professional service by 15 to 20 years of education. Their emigration takes with them the expensive training afforded them by the institutions and governments of their home countries. Those investments are made, in part, to improve the living conditions of the collective citizenry of the country. Educational investments are afforded by a collective contribution of taxes and donations by all (or many) of a state’s citizens. Public school tuition almost never pays anything approaching the full cost of a public university education in any country.

In the United States, the primary policy vehicle for luring foreign-trained physicians is the Medicare subsidy on residency training positions by establishing substantially more residency positions available than the number of US medical school graduates each year.[27] This arrangement is tolerated by all, including physician guild interests, because it is widely understood that international medical graduates in their residency training years are employed in America’s large urban hospitals, where acute care and long-delayed attention to chronic conditions are meted out to America’s poor and uninsured populations. Indeed, the top states that import African physicians are New York, California, Texas, Maryland, and Illinois—all states with big inner-city hospitals.[14]
The United States could also address the factors of low pay and poor working conditions for doctors and nurses in low-income countries. In part, this could be done by reversing the externally imposed public spending austerity programs of the international monetary institutions that the United States leads or controls. APHA has called for that policy change in policy 2005-3, “Expenditure Ceilings Imposed on Poor Countries Must Be Lifted to Achieve the Millennium Development Goals.”[4] These International Monetary Fund and World Bank policies of market fundamentalism have restricted the amount of public spending allowable in highly indebted poor countries, especially for health care and education, to increase their capacity to repay significant debts.[28] Reversing these policies could free resources to rapidly increase the pay rates of health care providers and improve working conditions.
The United States has long profited from the fruits of the reverse foreign aid by avoiding the cost burden of training its own physicians, or the political burden of better controlling the distribution of those physicians.

Despite Immanuel Kant’s groundbreaking ethical assertion in 1784 that common ownership of the earth entitles world citizens the right to free movement, it would be ideal if the majority of people were content in their own countries so that few would migrate during their high-productivity years.[29] Liberal democratic states that confront big immigration pressures would do best if they adopted policies that addressed the underlying conditions of poverty, unemployment, working conditions, pay structures, natural disasters, disease, war, and repression that create much of the desire for migration. Despite its idealistic ring, if wealthy countries adopted that approach (coupled with a commitment to invest in the medical education of their own citizenry[30]) it might actually be the most efficient and practical policy in the long run.[13]

References
1. American Public Health Association. APHA Policy Statement 2006-16: Ethical Restrictions on International Recruitment of Health Professionals to the United States. 2006. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1340. Accessed November 29, 2011.
2. American Public Health Association. APHA Policy Statement 2008-9: Strengthening Health Systems in Developing Countries. 2008. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1375. Accessed November 29, 2011.
3. American Public Health Association. APHA Policy Statement 2009-4: Ensuring the Achievement of the Millennium Development Goals: Strengthening US Efforts to Reduce Global Poverty and Promote Public Health. 2009. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1388. Accessed November 29, 2011.
4. American Public Health Association. APHA Policy Statement 2005-3: Expenditure Ceilings Imposed on Poor Countries Must Be Lifted to Achieve the Millennium Development Goals. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1308. Accessed November 30, 2011.
5. World Health Organization. WHO Global Code of Practice on the International Recruitment of Health Personnel. World Health Assembly, May 21, 2010. Available at: http://www.who.int/hrh/migration/code/full_text/en/index.html. Accessed November 29, 2011.
6. Global Health Workforce Alliance. Sixty-third World Health Assembly unanimously adopts the WHO global code of practice on the international recruitment of health personnel. Alliance members and partners applaud Member States. May 24, 2010. Available at: http://www.who.int/workforcealliance/media/news/2010/codestatementwha/en/
index.html. Accessed November 29, 2010.
7. Medicus Mundi International Network. Code of Practice on International Recruitment of Health Personnel Adopted by World Health Assembly. Available at: http://www.medicusmundi.org/en/contributions/news/2010/code-of-practice-on-international-recruitment-of-health-personnel-adopted-by-world-health-assembly. Accessed November 29, 2010.
8. Mills EJ, Schabas WA, Volmink J, et al. Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime? Lancet. 2008;371(9613):685–688.
9. World Health Organization. 2006 World Health Report, Working Together for Health. Geneva, Switzerland: World Health Organization; 2006.
10. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005;353:1810–1818.
11. Friedman E. An Action Plan to Prevent Brain Drain: Building Equitable Health Systems in Africa. Cambridge, MA: Physicians for Human Rights; 2004.
12. Hagopian A, Ofosu A, Fatusi A, et al. The flight of physicians from West Africa: views of African physicians and implications for policy. Soc Sci Med. 2005;61(8):1750–1760.
13. Hagopian A. Recruiting primary care physicians from abroad: is poaching from low-income countries morally defensible? Ann Fam Med. 2007;5:483–485.
14. Hagopian A, Thompson MJ, Fordyce M, Johnson KE, Hart LG. The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Hum Resour Health. 2004;2(1):17.
15. Pittman P, Aiken LH, Buchan J. International migration of nurses: introduction. Health Serv Res. 2007;42(3 pt 2):1275–1280.
16. Alliance for Ethical International Recruitment Practices. Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the United States. Available at: http://www.fairinternationalrecruitment.org/images/uploads/THE%20CODE.pdf. Accessed November 29, 2010.
17. NGO Code of Conduct for Health Systems Strengthening Initiative. Non-governmental Organization (NGO) Code of Conduct for Health Systems Strengthening. Available at: http://ngocodeofconduct.org. Accessed November 29, 2010.
18. Pfeiffer J, Johnson W, Fort M. Strengthening health systems in poor countries: a code of conduct for nongovernmental organizations. Am J Public Health. 2008;98(12):2134–2140.
19. World Health Organization. Address by Jens Stoltenberg, Prime Minister of Norway. May 15, 2007. Available at: http://www.who.int/mediacentre/events/2007/wha60/stoltenberg/en/index.html. Accessed November 29, 2010.
20. Batata A. International nurse recruitment and NHS vacancies: a cross-sectional analysis. Global Health. 2005;1:7.
21. Buchan J. International recruitment of nurses: policy and practice in the United Kingdom. Health Serv Res. 2007;42(3 pt 2):1321–1335.
22. Labonté R, Packer C, Klassen N. Managing health professional migration from sub-Saharan Africa to Canada: a stakeholder inquiry into policy options. Hum Resour Health. 2006;4:22.
23. Diallo K. Data on the migration of health-care workers: sources, uses, and challenges. Bull World Health Organ. 2004;82(8):601–607.
24. US Census. Income, poverty and health insurance coverage in the United States: 2009. Report issued September 16, 2010. Available at: http://www.census.gov/newsroom/releases/archives/income_wealth/cb10-144.html. Accessed November 29, 2010.
25. Council on Graduate Medical Education. Physician Workforce Policy Guidelines for the United States, 2000–2020. 16th Report. Washington, DC: US Dept of Health and Human Services; 2005. Available at: http://www.cogme.gov/16.pdf. Accessed November 29, 2010.
26. Community of Interest on the Code of Practice on the International Recruitment of Health Personnel. Letter to the US Secretary of Health and Human Services and US Secretary of State. September 10, 2010. Available at: http://ngocodeofconduct.org/wp-content/uploads/codeofpractice_sign-onletter10sept10.pdf. Accessed January 1, 2011.
27. Brotherton SE, Etzel SI. Graduate medical education, 2005–2006. JAMA. 2006;296(9):1154–1169.
28. Kim JY, Irwin A, Millen JV, Gershman J. Dying for Growth: Global Inequality and the Health of the Poor. Cambridge, MA: Common Courage Press; 2000.
29. Baubock R. Ethical problems of immigration control and citizenship. In: Cohen R, ed. The Cambridge Survey of World Migration. Cambridge, UK: Cambridge University Press; 1995:551–556.
30. Mullan F. Doctors and soccer players—African professionals on the move. N Engl J Med. 2007;356(5):440–443.