European Health Management Association
Transitional Countries Network launch
Mobility of health workforce:
The challenges for Europe
Albena Arnaudova, Dr Galina Perfilieva
Budapest, Hungary, 19 May 2009
Outline
 Health Workforce Global Profile
 Increase in mobility/migration of health
professionals
 The European perspective
 The EU perspective
 The Response of WHO to HRH Crisis
 Process to develop a WHO code of practice;
guiding principles of the draft WHO code
The health workforce crisis
Which exactly crisis? They all around:
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Flu A(H1N1) – Europe is not spared
Financial / economic – Europe is in recession
Demographic – Europe is aging
EU’s institutional deadlock and the EU
Enlargement – Europe has changed but does
change yet
Health workforce relates to them all.
The health workforce crisis
 Relative As compared to
the 57 countries with critical shortages
the other crises Europe has to deal with
 Uneven Across the WHO European Region,
between countries and groups of countries
 Universal No European country is spared
 Difficult to deal with The urgency - not so
visible, the solutions - long-term, the need to
act and invest - immediate
Health Workforce - Global Profile
 Increased demand for health professionals at all
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levels across the world → competition for health
personnel: migration of health professionals is an
inevitable characteristic of globalisation
Globalisation of labour markets, removing barriers
for labour flows
Global shortage: 4,3 million health workers are
needed to achieve the health related MDGs
Maldistribution: Health worker density: Africa with
2.3 health worker per 1,000 population, Europe
18.9; and Americas 24.8 per 1,000 population
Imbalances within countries (rural areas vs. cities,
composition of the health workforce, etc.)
Driving forces and challenges
The Global shortfall: 4.3 million health workers
 A serious impediment to
achieving the health-related
MDGs.
 13 African nations have
fewer than 5 physicians per
100,000 people.
More than 1 million new
health workers are needed in
next 6 years for the countries
in sub-Saharan Africa to
deliver the basic services.
More information on http://www.globalhealthtrust.org
Health workers move (brain drain) towards:
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higher (absolute & relative) pay
better working conditions
better resourced health systems
improved career opportunities
increased opportunities for education
safety and stability
The ethical questions: rights and needs of health
personnel, of source and destination countries
The response of WHO
AT GLOBAL LEVEL
 Joint Learning Initiative (JLI) report, 2004 – need for
urgent concerted actions to address the HRH crisis
 WHA57.19, WHA58.17 – alarming issues of HRH Migration
 World Health Day and World Health Report 2006
 Launch of Global Health Workforce Alliance (GHWA),
partnership to identify coherent solutions to the health
crisis at global level, 2006
workforce
 First Global Forum on HRH, Kampala, Uganda, March 2008
– The Kampala declaration and Agenda for Global Action
 Call from G8 Summit, Toyako, July 2008
Resolution WHA57.19:
 World Health Assembly Resolution 2004 “International

migration of health personnel: a challenge for health
systems in developing countries”
193 WHO Member States requested the Director General
"to develop, in consultation with Member States and all
relevant partners, a code of practice on the
international recruitment of health personnel…. ".
 Main orientations:
- conduct research (international migration of health personnel)
- explore measures (to assist in fair practices of international
recruitment of health personnel)
- support countries’ efforts (facilitate dialogue and raising
awareness at the highest national and international levels).
Process to develop a WHO code of practice on
the international recruitment of health personnel
Jan08
Mar08
April08
EB122 Migration
Progress Report
Kampala Forum
May08
PAC – TWG
meeting
Launch of Global
Dialogue on Migration
June08
July08
August08
Sept08
Oct08
January09
Tallinn Euro
Ministerial
Public
Hearings
G8 Summit
Drafting of
the Code
Draft revised
Progress Report for
EB124, incl.
Draft Resolution
Draft Code
Draft Outline for a Code
Draft Code
First Global Forum on Human Resources for
Health, Kampala, Uganda, March 2008)
Draft code was outlined by the WHO Secretariat
 Global Forum adopted the
Kampala Declaration and
Agenda for Action
The Kampala Declaration
called on WHO to accelerate
negotiations for a global code
of practice
WHO/Europe - commitment
to managing migration and
collaboration with all relevant
partners
WHO Regional Office for Europe initiates policy
dialogue between “source” and “destination”
countries, EURO roundtable, Kampala.
The Kampala Declaration called to accelerate
negotiations for a Code
Fundamental and interconnected strategies
1. Building coherent national and global leadership for health
workforce solutions
2. Ensuring capacity for an informed response based on evidence
3.
4.
5.
6.
and joint learning
Scaling up health worker education and training
Retaining an effective, responsive and equitably distributed
health workforce
Managing the pressures of the international health workforce
market and its impact on migration
Securing additional and more productive investment in the health
workforce
Web-based public hearings: September 2008
Classification of Comments (n=96)
Academic Institutions
6%
Others (CGFNS,
HWMPI, NAM, PHRHA,
Equinet, GWHA)
6%
Individuals
15%
NGOs
16%
Professional
Associations
23%
WHO
11%
International
Organizations
3%
Countries
20%
Conclusions of the EB 124 and key issues on the
draft code, Geneva, January 2009
 Member States welcomed and supported the draft, but agreed

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
that more consultations and effective participation by Member
States was essential to finalize and adopt the code
Issues raised:
Mutuality of benefits (art.5): should be precise and strengthen
for the profit of developing countries
Debate on "voluntary status"
Debate on inclusion of "Compensation mechanisms"
Retention mechanisms
Self sufficiency - health workforce sustainability
Needs to generate more evidence and data on migration
Financial issues to implement the code
Global Code of Practice on the International
Recruitment of Health Personnel
Objectives:
 To establish and promote voluntary principles, standards and



practices for international recruitment
To serve as an instrument of reference for Member States in
establishing or to improving the legal and institutional
framework and in formulating and implementing measures
To provide guidance that may be used where appropriate in
the formulation and implementation of bilateral agreements
and other international legal instruments, both binding and
voluntary;
To facilitate and promote international discussion and
advance cooperation on matters related to the international
recruitment of health personnel.
Guiding principles of the draft WHO code (1/2)
 The code is voluntary
 Health workers have the right to migrate
 Right of everyone to the enjoyment of the highest attainable

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
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
standard of health – the source countries perspective
International recruitment may contribute to the development and
strengthening of a national health workforce
Voluntary international standards and coordination of national
policies maximize the benefits and mitigate the negative impacts.
Transparency, fairness and mutuality of benefits
Developing and transition countries: particularly vulnerable to
health workforce shortages and/or with limited capacity to
implement the code
Effective national and international data gathering, research and
information sharing are essential.
Next steps in the Process to develop a WHO code
March09
May09
Sept-October 09
January 10
March10
May10
National Consultations
WHO RCs
Progress Report for EB
Technical Briefing
during WHA09
Global Consultation?
Issue Paper
Draft Code for the WHA?
Draft Code
The European dimension: migration
The WHO European Region is an important destination
- EU: 39 mln registered migrants 8% of the total population
- number of irregular migrants - difficult to estimate
Skilled health professionals represent an increasingly
large component of migration flows
In OECD: 11% of employed nurses
and 18% of employed doctors are
foreign-born;
Many variations across countries
(source, destination and transit
countries)
Challenges in assessment HRH stocks and flows
In Europe we observe:
 Limitations and gaps in data,
 Lack of international recording system
 Lack of a single or complete data source
 Different sources give different information - e.g :

“foreign born” OR “foreign trained” OR “foreign
registered”
Main sources include: census, registration data,
migration/work permit data
Distribution of physicians in the European Region
Physicians per 100000
P
<= 700
<= 580
<= 460
<= 340
Last
available
European Region
338.43
<= 220
No data
Min = 100
Source: WHO HFA database, 2008
Diversity in the European region
Health professionals / 100.000 population
Physicians
General
practitioners
Nurses
Pharmacists
European
Region
339.71
68.05
727.45
52.28
EU
322.38
96.71
745.64
71.43
CIS
376.78
28.78
794.73
20.55
Lowest
115.02
(Albania)
17.56
(Azerbaijan)
310.8
(Turkey)
3.35
(Uzbekistan)
Highest
534.59
(Greece)
177.3
(Belgium)
1549.78
(Ireland)
154.0
(Finland)
Source: WHO HFA database, January 2009
Growing reliance on foreign trained doctors
Contribution of the foreign-trained doctors to the net increase in the number of
practicing doctors in selected OECD countries, percentage 1970-2005
90
80
70
1970-2005
60
1995-2000
2000-2005
50
40
30
20
10
0
POL
CAN
BEL
NOR
AUT
DNK
DEU
SWE
NZL
FRA
USA
Source : OECD Health Data 2007 and OECD International Migration Outlook 2007
Note: data for Germany, Belgium and Norway refer to foreign doctors instead of foreign-trained doctors.
GBR
CHE
IRL
 Over the last decade and in response to domestic supply

shortages, developed (EU – OECD) countries have
come to rely on foreign trained doctors
For OECD European countries, less than one third
of foreign born doctors come from other OECD
countries.
The ethical questions: take from the poor
neighbours to take care of the rich
us…
Since 2000, reliance on foreign trained
professionals has increased in Europe
Doctors
2000
Number
%
Number
461
1 695
25 360
687
7 644
1 198
3 633
2 982
13 342
2 970
95
207 678
1.8
7.7
27.3
3.6
3.9
10.3
4.3
11.8
23.1
34.5
25.5
964
2 769
38 727
1 816
12 124
3 990
5 061
5 302
13 715
3 203
146
208 733
%
3.3
11.0
32.7
7.2
5.8
27.2
4.9
18.8
22.3
35.6
25.0
1 341
14 603
2 327
130
3.1
4.0
15.1
0.7
1 633
18 582
2 833
139
3.4
4.6
31.5
0.8
Foreign-Trained
Belgium
Germany
Norway
Slovak Rep. (1)
2005
Foreign
ers
Foreign-trained
Austria
Denmark
England
Finland
France (1)
Ireland
Sweden (1)
Switzerland
Canada
New Zealand
Japan
United States (1)
Foreigners
2000
Nurses
2005
Number
%
Number
Denmark
Finland
New Zealand (1)
Sweden (1)
Canada
New Zealand (1)
4 618
122
6 317
2 517
14 910
6 317
6.0
0.2
19.3
2.5
6.4
19.3
5 109
274
9 334
2 878
19 230
9 334
%
6.2
0.3
24.3
2.7
7.6
24.3
Belgium
Germany
Turkey
1 009
27 427
25
0.7
4.2
-
1 448
25 462
45
1.0
3.8
-
(1) 2004 instead of 2005.
Source: International Migration Outlook (OECD) 2007
This decade has seen a growing reliance on foreign trained health professionals, in Europe and elsewhere
Other key challenges in HRH in Europe
Unfinished agenda
Maldistribution
Skill imbalances
Low productivity
Low salaries
Poor work environments
Weak knowledge base
Labour flexibility
Lack of social protection
Uncontrolled migration
Growing shortages
Increasing role of private
sector
New challenges
Health workforce policies in the WHO European
Region: Resolution EUR/RC57/R1
57th session of the WHO
Regional Committee for
Europe
Belgrade, Serbia
17-20 September 2007
Health workforce policies in the WHO European Region:
Resolution EUR/RC57/R1
Member States are urged:
 to improve and expand the information and
knowledge base on the health workforce, encourage
research and build capacities
 to develop, embed and mainstream policies on
health workforce as a part of health system development
 to assess the trends in and impact of health
worker migration in order to identify and act on
effective migration-related policy options
Health workforce policies in the WHO
European Region: Resolution EUR/RC57/R1
WHO/Europe is urged:
 to give high priority to monitoring health worker
migration and policy interventions at national and
international level
 to facilitate the development of an ethical
guide/framework for international recruitment of
health workers
 to continue building and strengthening networks and
partnerships, to advocate for more effective
investment in health workforce development
Existing Codes of Practice in Europe
• "UK" Department of Health Code of Practice for International
•
•
Recruitment of Health Care Professionals, 2001/2004
Commonwealth Code of Practice for the International Recruitment of
Health Workers, 2003
NHS Scotland Code of Practice, 2006
Common features: they provide guidelines for an ethical
approach to the international recruitment of health workers
• Share three broad objectives:
 Ensuring that flows of migrant health workers do not
unduly disrupt the health services of source countries
Protecting individual migrant workers from unscrupulous
recruiters and employers;
Ensuring that individuals are properly prepared for and
supported for the job
Why are health workers so important?
 Health workers are central to managing and
delivering health services in all countries
 Health system performance depends on the
availability, efforts and skills of the workforce
 The health workforce comprises around 8% of
the total workforce in the European Region,
and absorbs around two thirds of the total
health spending
Why do we need to reform health workforce
policies?
 Rising demand for health services - health
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professionals at all levels;
Evidence of shortages and imbalances in distribution
of health workers;
Globalization of labour markets, removing barriers for
labour flows; increased proportion of health
professionals in migration flows;
The need to shift the focus of health service delivery
towards prevention, early interventions and selfmanagement;
Workforce diversity, serious disparity in the
characteristics of health professions (numbers, job
descriptions, roles and responsibilities, training
paths, regulatory structures).
Shaping the European health workforce policies to
the future challenges is a priority
Demographic and
epidemiological change
Technological and
organizational change
Political and
economic change
Health workforce: from issues to policy questions
 Issue: Imbalances in the health workforce
Policy question:
“What is the most efficient mix of skills to achieve the
desired coverage of health interventions in a country?”
 Issue: Skills shortages
Policy question:
“Should governments invest more in training and building
capacity to ensure and maintain skills?”
“What are the cost–effective strategies for scaling up HRH?”
 Issue: Health worker migration and mobility
Policy question:
“How can mobility be managed and regulated?”
Health workforce: from issues to policy questions
 Issue: Working conditions and health workers
Policy question:
“How can incentives be linked to produce better health services and
better health outcomes?”
Issue: Education and training
Policy question:
“How can professional qualifications be standardized throughout
Europe? What are the policy implications of Bologna process?”
 Issue: External support to HRH development
Policy question:
“How can external support facilitate the HRH development in
compliance with the region?”
Evidence required to answer policy question
Policy briefs
(some) Strategies
1. Building realistic strategies
2. Strengthening strategic intelligence (information and
3.
4.
5.
6.
7.
evidence)
Building institutional capacity
Improving education for better performance
Planning for the future
Regulating HRH framework
Addressing the challenges of health worker migration
The Tallinn Conference and Charter
“In a rapidly globalizing world, generation of
knowledge, infrastructure, technologies, and above
all, human resources with the appropriate skills and
competence mix requires long-range planning and
investment to respond to changing health care needs
and service delivery models.”
The Tallinn Charter, June 2008
Some WHO work in south-east Europe
 National policy dialogues on human resources for
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health - Albania, June 2008; Serbia, April 2009
Joint EC/WHO workshop on human resources for EU
candidate/accession countries - July 2008, Brussels
Annual Conference of European Medical
Associations, March 2009 – workshop
Scaling up international partnerships – Russian
federation-Finland, March 2009
Negotiating with Member States the 2010-2011
framework bilateral agreements
South-eastern Europe Health Network: the
health workforce
SEE and the EU – how they compare
 Commonalities
- Free mobility is a basic human right, as are health and
health care.
- The need for a strong health workforce is a key issue across
the WHO European Region.
 All countries need to develop workforce policies, and
improve information infrastructure and management
mechanisms.
 Many countries have undergone a transition process,
making thorough reforms at great speed.
 Certain differences should not be neglected, however.
South-eastern Europe Health Network: the
health workforce
SEE and the EU – how they compare
Differences
 The relevance of health professionals’ mobility varies
between large and small countries, with a proven impact on
quality, as some countries are hardly, while others – heavily
affected.
 The challenges in ensuring proper and strategic workforce
planning vary across the Region.
 The political context still varies dramatically and the
influence of economic development is not uniform.
 Involvement of non-health sectors – still a concern
The European Union context
 70% of EU’s health care budgets – for staff and
employment related expenses
 The cross-border care saga
 DG SANCO – taking the lead
 The Bologna process
 Green Paper of the European Commission – Dec09
 Czech Presidency of the Council of the EU – statement at
the WHO EB, January 2009
How to work with the EC on human resources for health
in the accession/potential candidate countries (the
acqui communautaire)
The financial and economic crisis
 Undoubtedly impact on the health sector and on the health
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workforce in particular
We do not know yet – demand will raise because supply
shortages and inability of people to pay
Impact on countries with already fragile health systems
Mixed picture – in Western Europe, employment is raising, the
health sector is among the few that continue recruiting
In the long run, the trend will reverse – cost containment
pressure
New mobility patterns are expected – to countries less impacted
by the crisis, leaving those with deteriorated job markets
The financial and economic crisis
Different measures are being taken with regard to health
workers’ levels of pay
 Bulgaria and Hungary have frozen salary levels in
state-owned hospitals.
 Hungary eliminated payment of a 13th month of salary
per year.
 Ireland and Lithuania are also considering pay
reductions.
 Finland and Greece have increased pay levels,
Romania is considering a raise of 7%
 Germany: since November 2008, 33.000 new
employees, rise in recruitment
The financial and economic crisis
 Fewer health workers are retiring early
 Older nurses delay retirement and part-time nursing is rising,
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with more nurses and doctors taking more shifts
Hospitals renovations, expansions and procurement ar ebeing
delayed
More patients are postponing elective surgery or that for which
they have to contribute our of pocket
New graduates – fewer entry level jobs, as health facilities scale
down hiring of new staff
No incentives to hire less experienced health personnel, as
health administrations are required to scrutinize costs
Conclusions
 International migration is an important factor
 Continuous growth in the demand for health professionals in
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
higher income countries
Impact on countries with already fragile health systems
Global approaches to address migration concerns, including
monitoring and research
Global Code of Practice on the International Recruitment of
Health Personnel
No European country is spared
The economic crisis provides opportunities as well – for longneeded health reforms
Role of professional associations
The EU cooperation – a huge potential
The south-east European Health Network of WHO