Intended for healthcare professionals


Challenges for WHO code on international recruitment

BMJ 2010; 340 doi: (Published 29 March 2010) Cite this as: BMJ 2010;340:c1486
  1. James Buchan, professor
  1. 1Queen Margaret University, Edinburgh
  1. jbuchan{at}

    A global code on international recruitment will have sustained impact only if its signatories support monitoring and also tackle the related issues of workforce planning and retention, says James Buchan

    Earlier this year the executive board of the World Health Organization decided that a draft global code on international recruitment of health workers1 will be on the agenda of the World Health Assembly in May 2010. The code will have implications for any country that recruits doctors and other health workers from abroad. It followed a resolution at the World Health Assembly in 2004 (WHA 57.19) that highlighted concerns about the negative effects of out-migration on the health systems of some developing countries. This article examines how the code has been developed and assesses some of the difficulties of implementation.

    Why have a code?

    In 2006 WHO estimated that there was a shortage of almost 4.3 million doctors, midwives, nurses, and health support workers worldwide.2 The availability of health professionals varies widely, with developing countries in Africa and Asia having low ratios of staff to population (fig 1). Migration of health professionals from developing to developed countries has exacerbated this disparity.


    Fig 1 No of doctors/1000 population in selected countries, 2007 (or most recent year)3

    The debate about the effect of health worker migration on the health systems of developing countries has moved on from an oversimplistic “brain drain” argument, to a recognition of a more nuanced and complex picture.4 5 6 7 However, the argument that we need a more ethical approach to international recruitment that can mitigate any negative effects continues to resonate and has been a driving force in the development of the draft code. Media reports, articles, and online chat rooms continue to spotlight examples of “unethical” recruitment practice.8 9

    Recognition has also been growing that other factors must be considered when assessing the effect of health worker migration. These include the rights of individuals to move, the possibility of international mobility providing work for unemployed professionals or career development, and the possible financial benefit to source countries of remittances sent home by migrant health professionals. Some governments, such as India and the Philippines, support high levels of outflow of health workers because of the income that then accrues back to the country. Although details on the amounts received are sketchy, one survey of Filipino nurses in London reported that three quarters of them were regularly sending money to the Philippines, in most cases amounting to 25% or more of gross income.10 The United Nations Development Programme recently highlighted the positive effects of migration: “Human mobility can be hugely effective in raising a person’s income, health, and education prospects. But its value is more than that: being able to decide where to live is a key element of human freedom.”11

    In developing the code, WHO has had to try to balance these differing and sometimes competing perspectives. Moreover, not all developed countries are equally active in international recruitment or equally dependent on international health workers (fig 2). Some recruit from other developed countries, while others have targeted the developing world. And their level of active recruitment can change quickly. The UK, for example, has switched rapidly from being a high profile international recruiter of nurses to a probable net “loser” of nurses in recent years (fig 3).


    Fig 2 Percentage of foreign trained doctors working in selected OECD countries, 2007 (or latest year)12


    Fig 3 Admissions to the UK nursing register from EU and non-EU countries, 1993-4 to 2007-813

    Developing the code

    The drafting of the code was led by the WHO secretariat, and its primary target audience is member states, but its 11 articles also cover employers, professional organisations, recruitment agencies, and health workers. The draft code is a voluntary instrument, although member states and other stakeholders are being “strongly encouraged” to comply with it (box).

    Draft WHO code1

    The code has four stated objectives:

    • To “establish and promote voluntary principles, standards and practices for the ethical international recruitment of health personnel”

    • To serve as an “instrument of reference” for member states

    • To provide guidance on “bilateral agreements and other international legal instruments,” and

    • To facilitate international discussion on matters related to ethical international recruitment “as part of strengthening health systems, particularly in developing countries.”

    The methods for achieving these objectives are set out in further articles that cover:

    • Guiding principles

    • Mutuality of benefits

    • Rights, responsibilities, and recruitment of migrant workers

    • Sustainability of national health workforce

    • Data gathering

    • Research and information exchange

    • Implementation mechanisms.

    The draft code builds on voluntary codes that are already in use.14 15 16 17 However, the WHO code is much more ambitious in its coverage. The English and Scottish codes focus on one national health system and government, and the Pacific and Commonwealth codes cover clearly defined countries. The WHO code aims for global coverage, which means WHO must secure agreement from governments with a much broader range of health systems and political interests, including federated and decentralised countries and ones in which most health care is delivered by the private sector.

    Two aspects of the code are likely to cause further debate at the assembly and will be difficult to resolve, partly because they have large resource implications. The first relates to mutuality of benefits and the second to monitoring of health worker mobility.

    Mutuality of benefits

    The phrase “mutuality of benefits” covers various initiatives to mitigate the negative effects of outflow of skilled staff, encourage migrants to return, and to achieve “a net positive impact on the health systems of developing countries and countries with economies in transition.”1 Much of the emphasis is on bilateral agreements between governments to manage the process of international recruitment or mitigate its impact.

    Mitigation has caused much controversy, with some commentators advocating that source countries should be compensated for loss of health workers. The two points that cover mitigation in the draft code contain bracketed wording, reflecting the difficulty of resolving an issue that has large resource implications for recruiting countries. Paragraph 3.3 states: “Destination countries should, to the extent possible, provide technical and financial assistance to developing countries and countries with economies in transition aimed at strengthening health systems including health personnel development [to offset the loss of health workers]”. And paragraph 11.3 says: “Member states recruiting health personnel from developing countries or countries in transition [should]/[may wish to] provide technical assistance to the latter, aiming at strengthening health systems capacity including health systems development in these countries.”

    These tentative and optional wordings are likely to be a major focus of debate at the assembly. The suggestion that recruiting countries enter into agreements to provide support for health systems in the countries they recruit from is not new, but would carry greater weight if enshrined in a WHO code.

    Some countries are already taking such steps. One large scale initiative is that by the UK Department for International Development and other donors to supplement the pay of health workers in Malawi and improve staff retention.18 Others have been small scale and often time limited, such as the bilateral link between South Africa and the UK on staff exchange and twinning of institutions.19 These have all been one-off initiatives in response to specific local issues or led by personal contact. The draft code sets out an approach to make mutuality of benefits part of the broader process of international recruitment, rather than an afterthought or an aside.

    Monitoring and compliance

    If the global code is approved in May, major effort will be required to develop effective monitoring of international recruitment activity and movement of health workers. Data on health workforce profile and “flow” are currently limited, incomplete, and often out of date. Many countries have limited capacity to monitor and plan their health workforce. The WHO draft sets out a cycle of monitoring reports from a designated “national authority,” building on national data gathering programmes. It also argues for donor support to assist in implementation. Without external support and resources, some of the most vulnerable source countries will not be able to track the loss of their skilled staff.

    There has been virtually no systematic monitoring or evaluation of the effect of current codes.20 Since the WHO code aspires to global coverage, monitoring will be both challenging and costly. Effective implementation of the code across a diverse and dynamic range of countries, interests, and standpoints will not be about a point in time “signing up” of nation states, it will be about tracking its coverage and impact, and securing the funding to make that possible.

    Local action

    International mobility is just one of several “flows” of health workers. Many others move within countries, from rural to urban areas, from public to private sector, and from the health sector to other sectors. A focus only on international flow would deal with just one symptom, and not the root causes, of skills shortages: limited funding, low pay, limited career opportunities, geographical maldistribution, inadequate infrastructure, and economic and political instability in some countries. The shortages can be addressed only by more effective broad based workforce policy and planning, backed up by necessary resources, to train and retain health workers where they are needed. The WHO draft code argues strongly for more effective workforce planning and retention policies, and WHO is currently sponsoring work on improving health worker retention in rural areas in the developing world.21

    Success of the code will depend on joined up government, and governments. There is little point in a ministry of health or international agency promoting a code to contain international recruitment and focus on self sufficiency if private sector employers are actively recruiting or the ministry of trade is promoting large scale recruitment through trade agreements. The Norwegian government has argued for a broad based national approach, linking national level health workforce planning, home based training, treatment of health professionals, international recruitment of health workers, and donor aid to developing countries.22


    The WHO draft code emphasises the need to look more broadly at issues of effective planning of the health workforce, coordination between countries, and fair treatment of health workers when examining the context and causes of health worker migration. This cannot be achieved in a room in Geneva. If a code is adopted it could become a powerful tool for advocacy and could provide a frame for more detailed cooperation between member states. The danger is that the effort needed to reach agreement on a code is not matched by the energy and resources required to deliver on its objectives. The code can have a sustained impact only if its principles and purpose are widely communicated, if effective monitoring is well supported, and if its signatories also tackle the broader and deeper causes of health worker shortages in the developing world.


    Cite this as: BMJ 2010;340:c1486


    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; externally peer reviewed.


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