9
10
11
12
13
1
2
3
4
5
6
7
8
14
15
16
17
18
LB1: LATEBREAKER APHA RESOLUTION 2010
Amy Hagopian
University of Washington
4534 11 th Av. NE, Seattle, WA 98105
206-616-4989 hagopian@uw.edu
Submitted on behalf of the INTERNATIONAL HEALTH SECTION
Title: APHA en dorses the World Health Organization’s Global Code Of Practice on the
International Recruitment of Health Personnel
Keywords: Health worker migration, Millennium Development Goals, Right to Health
Summary: APHA should encourage the U.S. to actively implement and comply with the World
Health Assembly’s Global Code of Practice on the International Recruitment of Health
Personnel.
19
20
21
22
At its meeting in 2010, international health leaders from 193 countries met at the 63 rd annual
World Health Assembly to make history by adopting new guidelines to mitigate the negative effects associated with the health worker brain drain from developing countries.
i
23
24
25
26
All 193 WHO Member States unanimously (through a consensus process) adopted the voluntary WHO Global Code of Practice on the International Recruitment of Health Personnel that sets ethical principles on 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.
ii
27
28
29
30
31
32
The Code is the culmination of a six-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 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 them.
iii
LB1-1

1
2
3
The critical shortage of health workers in developing countries is staggering.
iv
Our nation’s capital, for instance, enjoys twice as many doctors as the entire country of Ethiopia.
v Yet,
Washington, D.C. has a population of 600,000 compa red to Ethiopia’s 80 million people.
4
5
6
7
8
Active recruitment from developing countries systematically deprives entire populations of their right to health.
vi Low-income countries invest significant resources to train health workers, relying on tax dollars along with foreign assistance to support medical and nursing schools.
vii
The loss of these investments equates to a form of reverse foreign aid that is simply contradictory.
viii
LB1-2

1 The Code has been in development since 2004:
2 History of the Code
22
23
24
25
26
10
11
12
13
7
8
9
3
4
5
6
14
15
16
17
18
19
20
21

2004
– WHO Member States call on WHO’s Director-General to develop a code to address negative impact of health worker migration.
 2008 – WHO’s Executive Board requests draft of Code be presented at 2009 Board meeting.
 2009
– (January) First draft of Code reviewed by Executive Board; additional consultations and revisions requested.
(February) Health Worker Migration Initiative Global Policy Advisory Council issues recommendations report.
 2010 – Executive Board reviews and approves latest draft for 63 rd WHA.
(May) At WHA, a drafting committee is formed to negotiate final language of the Code of Practice.
(May 21 st ) After deliberation, Code of Practice is submitted and unanimously adopted
– o nly second time in history .
Content of the Code
T he Code calls on the WHO’s Director General (DG) to develop guidelines for a minimum data set each country is asked to report, and further directs the DG 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 DG to develop suggestions for information exchange mechanisms. The DG must report to the 2013 World Health Assembly, and make subsequent reports at least every three years.
27 Member States are encouraged to:
28
29
30
31
32
33
34
35
1. Establish a national authority on reporting (the WHO is to 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 by discouraging active recruitment from developing countries with critical health worker shortages.
LB1-3

4
5
6
7
8
1
2
3
5. Recognize the right to 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: Realizing
Rights has prepared sample bilateral agreements)
9
10
11
12
13
US responsibility in global health worker migration trends
Given that one in four physicians to the U.S. is trained abroad (64 percent of these from a lowerincome country), ix and the proportion of foreign educated nurses hit a high of 13 percent of newly licensed nurses in 2007, x the U.S. bears a special responsibility in regard to the recruitment of international health professionals.
14
15
16
17
Workforce advocacy coalitions have produced two 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.
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the
United States (Developed by the Alliance for Ethical International Recruitment Practices, xi a non-profit working to ensure recruitment of foreign-educated nurses to the United States is conducted in an ethical, responsible, and transparent way.) This group monitors adherence to their code through surveys of migrant nurses. It is currently expanding its Code to include other health care professionals.
 Non-Government Organization (NGO) Code of Conduct for Health Systems
Strengthening xii xiii (Developed at University of Washington’s Health Alliance International, along with like-minded NGOs.) 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.
xiv In 1999, the UK made a similar commitment.
xv
, xvi And Canada has
LB1-4

1
2 significantly ramped up training programs so as to create less demand for foreign trained health workers.
xvii
3
4
5
6
7
As an initial step, to comply with the Code, countries must track health worker migration at national and global levels. Current U.S. 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-bystate basis.
xviii
8
9
10
11
12
13
14
15
16
17
18
It is anticipated 50.7 million uninsured Americans xix 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 U.S. health workforce across urban and rural areas. In addition, the primary care workforce is too small. The U.S. Council on Graduate
Medical Education has predicted the U.S. will be short approximately 85,000 physicians by
2020.
xx The implementation of PPACA will increase demand for health workers of all types, highlighting the need to implement and monitor recruitment practices, and the need to develop bilateral agreements with our primary source countries. Further, current migration patterns threaten to undermine our nation’s own global health foreign aid and PEPFAR investments, as the loss of health professionals from high-poverty countries threatens the success of our initiatives to strengthen health systems.
19
20
21
22
23
24
25
Calls to increase medical school and nursing class sizes have been little answered, as to do so requires costly investment in higher education. We do, however, have programs that could be expanded to address U.S. workforce problems, such as the National Health Service Corps and state loan repayment programs. Additionally, federal legislation and programs (such as the
President’s Emergency Plan for AIDS Relief, or PEPFAR, and the Center for Disease Control’s
Medical Education Partnership Initiative) offer opportunities to address U.S. workforce problems while strengthening medical education in low-income countries.
26
27
28
29
In 2010, the United States, along with 192 nations, supported the World Health Organization’s
Global Code Of Practice on the International Recruitment of Health Personnel.
Now the U.S. must show strong leadership by acting decisively to effectively implement the
Code of Practice.
LB1-5

4
5
6
7
1
2
3
8
9
Way Forward
Efforts are currently underway by the WHO, Health Worker Migration Initiative, and other actors to ensure the effective implementation of the Code of Practice by individual Member States and non-State actors. 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 the WHO every three years with an initial report due two years after the
Code’s adoption.
10
11
12
13
14
15
16
17
18
19
20
A number of organizations in the U.S. have written a letter to the U.S. Secretary of Health and
U.S. Secretary of State (dated September 10, 2010) (reference) , 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 .”
21
22
23
24
Action Steps:
The American Public Health Association urges the U.S. Secretaries of Health and Human
Services and State to work together to:
25
26
27
28
1. APPOINT LEADERSHIP
Designate key individuals 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.
29
30
31
32
2. ASSEMBLE A TASK FORCE
Assemble a task force to identify the data required to make good faith reports to the WHO within the next year or two. This task force would examine existing data sources to identify, coordinate, open, link and report information, as well as to identify new data sources.
LB1-6

1
2
3
3. CREATE A RESEARCH PROGRAM
Fund a research program to examine the intersections between domestic and international workforce production, recruitment, deployment and retention.
4
5
6
7
8
4. SET A POLICY AGENDA
Invite the national authority task force to recommend modifications to U.S. 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.
9
10
15
16
17
18
19
20
21
22
11
12
13
14
Relationship to existing policies:
The proposed policy is consistent with the following APHA policy adoptions:

11/8/2006 Policy Number: 200616 Ethical Restrictions on International Recruitment of
Health Professionals to the United States

Policy Number: 20089 Strengthening Health Systems in Developing Countries

Policy Number: 20094 Ensuring the Achievement of the Millennium Development Goals:
Strengthening US Efforts to Reduce Global Poverty and Promote Public Health
Opposing Arguments: There are those who believe the U.S. health system is in need of health workers trained abroad, and in a world of free trade, under the Universal Declaration of Human
Rights, health workers have the right to seek jobs abroad and U.S. private sector health employers are under no obligation to consider the right to health in developing countries.
i
World Health Assembly, 21 May 2010, http://www.who.int/hrh/migration/code/full_text/en/index.html
ii
See Global Health Workforce Alliance statement (24 May 2010) on migration and the
International Code of Practice on the International Recruitment of Health Workers http://www.who.int/workforcealliance/media/news/2010/codestatementwha/en/index.html also, Medicus Mundi account at http://www.medicusmundi.org/en/contributions/news/2010/code-of-practice-on-internationalrecruitment-of-health-personnel-adopted-by-world-health-assembly iii Mills Edward J, Schabas WA, Volmink J, et al, “Should active recruitment of health workers from subSaharan Africa be viewed as a crime?,” The Lancet, Volume 371, Issue 9613, Pages
685 - 688, 23 February 2008
LB1-7

iv
World Health Organization, 2006 World Health Report, Working Together for Health. Geneva. v Mullan, Fitzhugh. The Metrics of the Physician Brain Drain. N Engl J Med 2005; 353:1810-
1818. October 27, 2005. vi
Friedman, Eric. An Action Plan to Prevent Brain Drain: Building Equitable Health Sytems in
Africa. A White Paper by Physicians for Human Rights. June 2004. vii
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 Oct;61(8):1750-60. viii Hagopian A. Recruiting Primary Care Physicians From Abroad: Is Poaching From Low-
Income Countries Morally Defensible ? Ann Fam Med 2007; 5: 483-485 ix
Hagopian, A., et al., 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): p. 17 . x Pittman, P, L.H. Aiken, and J. Buchan, International migration of nurses: introduction. Health
Serv Res, 2007. 42(3 Pt 2): p. 1275-80. xi
Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the
United States (Developed by the Alliance for Ethical International Recruitment Practices, available at http://www.fairinternationalrecruitment.org/ xii
Non-Government Organization (NGO) Code of Conduct for Health Systems Strengthening, available at http://ngocodeofconduct.org/ xiii Pfeiffer J, Johnson W, Fort M. Strengthening Health Systems in Poor Countries: A Code of
Conduct for Nongovernmental Organizations.
American Journal of Public Health 98:12, 2134-
2140, December 2008. xiv Address by Jens Stoltenberg, Prime Minister of Norway, posted to WHO website, 15 May
2007 http://www.who.int/mediacentre/events/2007/wha60/stoltenberg/en/index.html xv
Batata A. International nurse recruitment and NHS vacancies: a cross-sectional analysis.
Global Health. 2005; 1: 7. xvi
Buchan J. International Recruitment of Nurses: Policy and Practice in the United Kingdom.
Health Services Research 42:3; 1321-1335. June 2007.
xvii Labonte, R, Packer C, Klassen. Managing health professional migration from sub-Saharan
Africa to Canada: a stakeholder inquiry into policy options. Hum Resour Health. 2006; 4: 22.
xviii
Diallo, K. Data on the migration of health-care workers: sources, uses, and challenges.
Bulletin of the World Health Organization. 82:8; 601-607. xix
U.S. Census report issued September 16, 2010. Available at http://www.census.gov/newsroom/releases/archives/income_wealth/cb10-144.html
LB1-8

xx Council on Graduate Medical Education. 16 th Report. 2005, US Department of Health and
Human Services. Physician Workforce Policy Guidelines for the United States, 2000-2020.
LB1-9