Building Capacities: Policy, Advocacy: Emily DeRiel


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Curbing the Demand for Foreign Health Workers: Policies and proposals in
industrialized countries aimed at reducing “brain drain” from developing countries

Emily DeRiel, Health Alliance International

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Building Capacities: Policy, Advocacy: Emily DeRiel

  1. 1. Curbing the demand for foreign workers: A review of policies aimed at reducing the depletion of health workers from developing countries Emily deRiel, MPH [email_address] WRIHC • April 4, 2009
  2. 2. Outline <ul><li>Background on health worker shortage and migration </li></ul><ul><li>Responses from industrialized countries </li></ul><ul><ul><li>Resolutions and codes </li></ul></ul><ul><ul><li>UK example </li></ul></ul><ul><li>Thoughts on U.S. response </li></ul>
  3. 3. Health worker shortage disproportionately affects Africa <ul><li>Africa: 24% of global disease burden, 3% of health workers </li></ul><ul><li>4.3m health workers needed (2.4m MDs/RNs/midwives) </li></ul><ul><ul><li>Goal: 2.5 per 1000 pop. </li></ul></ul><ul><ul><li>2008: 1.3 in Africa (4.1 global average) </li></ul></ul>WHO Global Health Report, 2006
  4. 4. Migration adds to shortage crisis Labonté et al, 2006 Joint Learning Initiative report, 2004 Buchan et al, 2003 (Int’l Nurse Mobility) WHO: “On average one in 4 doctors and one nurse in 20 trained in Africa is working in OECD countries.” – Migration of Health Workers Fact Sheet (#301, 2006)
  5. 5. Migration impetus is push-pull <ul><li>Push factors </li></ul><ul><ul><li>Low pay </li></ul></ul><ul><ul><li>Poor work environment </li></ul></ul><ul><ul><li>Lack of opportunity for training </li></ul></ul><ul><ul><li>Political/economic upheaval </li></ul></ul><ul><ul><li>Lack of security </li></ul></ul><ul><ul><li>HIV/AIDS </li></ul></ul><ul><ul><li>Feeling undervalued </li></ul></ul><ul><ul><li>Culture of leaving </li></ul></ul><ul><li>Pull factors </li></ul><ul><ul><li>Good pay </li></ul></ul><ul><ul><li>Good working conditions </li></ul></ul><ul><ul><li>Job security </li></ul></ul><ul><ul><li>More opportunity for training and advancement </li></ul></ul><ul><ul><li>Safety </li></ul></ul>From Nguyen et al (2008), Labonte, Packer et al (2007), Hagopian et al (2005)
  6. 6. Response requires consideration of rights, ethics, economics, politics <ul><li>Right to migrate / right to health </li></ul><ul><li>Investment in training health workers / remittances from workers abroad </li></ul><ul><li>Active recruitment by industrialized countries / social justice </li></ul>
  7. 7. Growing concern translates to… <ul><li>Resolutions </li></ul><ul><ul><li>World Health Assembly (2004) </li></ul></ul><ul><ul><li>World Federation of Public Health Associations (2005) </li></ul></ul><ul><ul><li>American Public Health Association (2006) </li></ul></ul><ul><li>Codes of practice/conduct </li></ul><ul><ul><li>WONCA’s “Melbourne Manifesto” (2002) </li></ul></ul><ul><ul><li>Commonwealth Code of Practice (2003) </li></ul></ul><ul><ul><li>Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the U.S. (2008) </li></ul></ul><ul><ul><li>WHO Code of Practice on the international recruitment of health personnel (draft 2008) </li></ul></ul>
  8. 8. Responses share some common elements <ul><li>Acknowledge right to migrate </li></ul><ul><li>Worker protections </li></ul><ul><li>Bilateral agreements to prohibit active recruitment </li></ul><ul><li>Compensation/reciprocity </li></ul><ul><li>Help improve working conditions in source countries </li></ul><ul><li>Develop sufficient workforce in destination countries </li></ul><ul><li>Monitor movement of workers across borders </li></ul>
  9. 9. UK Response: Code, Agreements <ul><li>2001 code, updated 2004 </li></ul><ul><ul><li>Bilateral agreement required for recruitment from proscribed countries </li></ul></ul><ul><ul><li>Applies to recruiters and temporary employees </li></ul></ul><ul><li>MOU with South Africa (Oct ’03) </li></ul><ul><ul><li>Sharing expertise and info </li></ul></ul><ul><ul><li>Time-limited exchanges </li></ul></ul><ul><ul><li>Monitored throughout the year </li></ul></ul><ul><li>MOUs with Philippines, India; Agreements with China, Spain </li></ul>
  10. 10. Do we know what works? <ul><li>How should we define success? </li></ul><ul><ul><li>“ Are we finding ways to help lower-income countries strengthen and increase their health workforce, and are we finding ways to guide higher-income countries to recruit ethically and take responsibility to increase their own health worker training and placement?” </li></ul></ul><ul><ul><ul><ul><li>Robinson and Clark (Lancet, 2008) </li></ul></ul></ul></ul>
  11. 11. UK nurse/midwife registry: top 12 source countries show declines Nursing and Midwifery Council, Philippines S. A. agreement Oct 2003 India Overseas (non-EU) new registrants: 4,830 (total new registrants: 27,704)
  12. 12. But migration from developing countries has continued (Non-EU)
  13. 13. Several other countries are exploring different responses <ul><li>Canada </li></ul><ul><ul><li>Proposes policy statement or code developed at provincial level </li></ul></ul><ul><ul><li>Focus on planning for domestic self-sufficiency </li></ul></ul><ul><li>Norway </li></ul><ul><ul><li>Bilateral agreements to limit foreign nurse recruitment </li></ul></ul><ul><ul><li>Policy coherence across health, labor, education, development, foreign policy </li></ul></ul>From Robinson and Clark (Lancet, 2008)
  14. 14. A U.S. country-level response would be a step forward <ul><li>Address domestic undersupply and maldistribution </li></ul><ul><li>Improve data and tracking </li></ul><ul><li>End aggressive recruitment </li></ul><ul><li>Support adequate health worker education at home and abroad </li></ul><ul><li>Support diaspora return / time-limited exchanges </li></ul><ul><li>Strengthen public health systems in low resource countries </li></ul>
  15. 15. An NGO Code of Conduct addresses health system strengthening <ul><li>Developed by: </li></ul><ul><ul><li>Health Alliance International, Partners in Health, Action Aid International USA, Physicians for Human Rights, Health GAP Coalition, Oxfam UK </li></ul></ul><ul><li>Internal brain drain issues, also relevant to migration </li></ul><ul><ul><li>Art. 1: Hiring practices in country </li></ul></ul><ul><ul><li>Art. 3: Invest in training </li></ul></ul><ul><ul><li>Art. 6: Advocate for health systems strengthening </li></ul></ul>
  16. 16. Health migration requires local and global response <ul><li>Advocacy opportunities </li></ul><ul><ul><li>Removal of macroecon constraints </li></ul></ul><ul><ul><li>Debt cancellation </li></ul></ul><ul><ul><li>Funding of health systems </li></ul></ul><ul><ul><li>Support for U.S. resolution </li></ul></ul><ul><li>Combination of policies are needed at many levels to reduce “push” factors, eliminate the “pull” and ensure ethical recruitment </li></ul>