Reviewing the Code: Two insights and a concern

Imagine a few hot days in June in a closed and stuffy meeting room in Geneva. This was the scene for the first public hearing of the Expert Advisory Group tasked to review the WHO Code of Practice on International Recruitment of Health Personnel (hereafter: the Code) that I attended. Not an ideal setting, you would think, right? But thanks to the participants, who remained cool-headed, committed and consistent in their drive to improve the Code as an instrument to strengthen the global health workforce, it turned out to be a truly inspiring and important meeting.

Nine years after the Code’s adoption, this public hearing kickstarted the second review of its relevance and effectiveness. It brought together different stakeholders, including from the World Health Organization (WHO), International Organization for Migration (IOM), civil society, academia, unions, professional associations, and migrant health workers representatives. They touched on different topics such as the historical perspective of the Code, its implementation status and how it relates to current trends such as the 18 million shortfall of health workers and the increasing number of bilateral agreements on health worker mobility between states.

The main aim of the presentations and discussions was to inform the Expert Advisory Group in order to enable them to conduct a thorough and well-based assessment of the relevance and effectiveness of the Code. Their report is due by the end of 2019, in time for submission to the World Health Assembly in 2020.

Misconception

“Our work [on the Code] needs to be better understood. The name of the game is: how to manage mobility so that it doesn’t harm the low resource settings.”

As a relative newcomer in the health workforce policy field, it was a truly informative meeting, with extremely knowledgeable and experienced ‘old hands’, as well as a number of ‘new arrivals’, only recently engaged with the Code. After having digested all information shared in the two-day meeting, two insights and one concern stuck with me.

First of all, the name of the Code is misleading. Most people I talk to about the Code refer to it as the ‘Code of practice on ethical recruitment’, and many seem to think the Code is about stopping international migration of health workers. This is a misconception. To quote the text, it “honors the right for any individual, including health personnel, to leave any country and to migrate to any other country that wishes to admit and employ them”. 

The Code is definitely very outspoken on unethical recruitment practices that violate the rights of health workers or where health workers are ‘poached’ from countries with critical shortages. But this is by no means its only focus. An essential element in the Code is the responsibility of all “Member States to strive to meet their health personnel requirements with their own human resources for health”. In other words: to educate, train, and deploy health personnel in the quality and quantity that corresponds with the country’s population’s health needs. Failing to do so creates shortages and understaffed health services, and this means that people’s right to health cannot be fulfilled. 

“We can look at health care as a market, but it’s a market that fails terribly. That market failure should keep us awake at night.” 

At the same time, the ever-changing demand and supply of health workers in different parts of the world and over time creates a waterbed-like global movement of health workers which naturally results in a bigger flow towards countries and settings where working conditions are better, to the detriment of countries and facilities where these are poorer. But again, halting health workers’ mobility as such is by no means the aim of the exercise. What the Code promotes are investments, in decent jobs, with safe working conditions, adequate supervision and continuous professional development, because this helps in retaining health workers. 

Solution-oriented

There are many reasons to be critical or get frustrated about the neglect of (investments in) decent health worker jobs in many contexts. However, the Code’s text does not carry this judgment and instead focuses on solutions. Irrespective of the underlying causes of health worker shortages, the Code explicitly aims to “facilitate and promote international discussion and advance cooperation between Member States in order to strengthen health systems worldwide”. It doesn’t waste energy on blaming anybody, but instead looks for ways to solve a globalized health workforce crisis.

Secondly: the Code is really a quality piece of work. While preparing my own presentation[1], I read the text once more, and couldn’t help but admire how its wording must have been weighed, rephrased and fine-tuned, in order to do justice to the complexity of health worker mobility and the interests of source countries, destination countries, and the individual migrant health worker. 

Everybody’s concern…..

Still, alongside the delicate wording, the Code is strong in its language on the right to health for all, on the right to migrate of the individual migrant and on the shared international responsibilities for a strong global health workforce. And these responsibilities do not only apply to Member States’ governments; the Code also “speaks directly to non-state actors, including health workers, recruiters, employers, health-professional organizations [….], whether public or private, governmental or non-governmental”.


So the Code is a unique instrument because it is the product of inclusive consultation with active involvement from a wide range of stakeholders every step of the way. This is rare in non-binding international agreements. Its monitoring and review processes are similarly inclusive, inviting the aforementioned organizations and individuals to present evidence and participate in deliberations. 

And this is exactly where my concern lies: in spite of all the opportunities for engagement, the level of engagement with the Code’s implementation remains very low. Even though 80 (out of 194) Member States have submitted reports for the third round of reporting on the Code’s implementation, with a number of them reporting for the first time, many Member States are still not reporting or have stopped reporting. And although the number of independent stakeholders reporting on the Code’s implementation has risen from 1 to 14 between 2015 and 2019, this can hardly be considered a triumph in absolute terms. 

“The number of independent stakeholder reports is abysmal. How can we ensure more involvement?”

The result is insufficient data and evidence to properly assess the Code’s effectiveness and relevance. This makes it increasingly difficult to review the Code in order to adjust it to be more relevant to the world today. This, in turn, renders it increasingly less interesting to engage with, leading to a vicious cycle.

…and everybody’s business, too!

This begs the question of who is responsible for increasing the awareness about and engagement with the Code. Member States, as signatories to the Code, bear the brunt of this responsibility. But as civil society, the Health Workers for All Coalition and its individual members have an important role to play as well. I’m very much hoping that we can engage with our respective governments on the principles of the Code, including, but certainly not limited to, ethical recruitment practices. And that the Coalition can then engage at global level in processes that aim to improve the Code’s relevance and effectiveness. Let’s stay in close contact with each other on how we can fulfil our important watchdog function.


[1]I was invited to give a presentation on the 14 Independent Stakeholder Reports on the implementation of the Code, submitted to WHO Secretariat in 2018, and meant to inform the EAG’s work.

First public hearing of the Expert Advisory Group to review the WHO Global Code of Practice on International Recruitment of Health Personnel on June 18th, 2019

The WHO Code of Practice on the International Recruitment of Health Personnel aims to establish and promote voluntary principles and practices for the ethical international recruitment of health personnel and to facilitate the strengthening of health systems. It was designed by Member States to serve as a continuous and dynamic framework for globaldialogue and cooperation. It was adopted in 2010 (resolution WHA63/16). Since 2010, three reporting rounds of its implementation have taken place, and one review (2015). The second review is taking place now, in 2019, by an Expert Advisory Group consisting of twelve WHO Member States and will result in a document to be submitted to the World Health Assembly in 2020.