European Health Management AssociationEuropean Health Management Association Transitional Countries Network launch

Mobility of health workforce:The challenges for Europe

Albena Arnaudova, Dr Galina PerfilievaBudapest, Hungary, 19 May 2009

Mobility of health workforce:The challenges for Europe

Albena Arnaudova, Dr Galina PerfilievaBudapest, 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:

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 ProfileHealth Workforce - Global Profile

Increased demand for health professionals at all 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 challengesDriving 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:

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

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 workforce crisis at global level, 2006

First Global Forum on HRH, Kampala, Uganda, March 2008

– The Kampala declaration and Agenda for Global Action

Call from G8 Summit, Toyako, July 2008

The response of WHOThe response of WHO

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 May08 June08 July08 August08 Sept08 Oct08 January09

Draft Code

EB122 Migration Progress Report

Kampala Forum

Draft Outline for a Code

Tallinn EuroMinisterial

Draft revised

PAC – TWG meeting

Launch of GlobalDialogue on Migration

G8 Summit Public Hearings

Drafting of the Code

Progress Report for EB124, incl.Draft ResolutionDraft Code

First Global Forum on Human Resources for Health, Kampala, Uganda, March 2008)

Global Forum adopted the Global Forum adopted the Kampala Declaration and Kampala Declaration and Agenda for Action Agenda for Action

The Kampala Declaration The Kampala Declaration called on WHO to accelerate called on WHO to accelerate negotiations for a global code negotiations for a global code of practice of practice

WHO/Europe - commitment WHO/Europe - commitment to managing migration and to managing migration and collaboration with all relevant collaboration with all relevant partners partners

WHO Regional Office for Europe initiates policy dialogue between “source” and “destination”

countries, EURO roundtable, Kampala.

Draft code was outlined by the WHO Secretariat

The Kampala Declaration called to accelerate negotiations for a Code

Fundamental and interconnected strategies1. Building coherent national and global leadership for health

workforce solutions

2. Ensuring capacity for an informed response based on evidence and joint learning

3. Scaling up health worker education and training

4. Retaining an effective, responsive and equitably distributed health workforce

5. Managing the pressures of the international health workforce market and its impact on migration

6. Securing additional and more productive investment in the health workforce

Web-based public hearings: September 2008

Classification of Comments (n=96)

Others (CGFNS, HWMPI, NAM, PHRHA,

Equinet, GWHA)6%

Academic Institutions6%

NGOs16%

WHO11%

International Organizations

3%

Countries20%

Professional Associations

23%

Individuals15%

Conclusions of the EB 124 and key issues on the draft code, Geneva, January 2009

Member States welcomed and supported the draft, but agreed 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

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

Draft Code

Global Consultation?

WHO RCs

Draft Code for the WHA?

Issue Paper

Progress Report for EB

Technical Briefing during WHA09

National Consultations

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 flowsIn 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

P

Distribution of physicians in the European RegionDistribution of physicians in the European Region

Source: WHO HFA database, 2008

<= 700

<= 580

<= 460

<= 340

<= 220

No data

Min = 100

Physicians per 100000

Lastavailable

European Region338.43

Diversity in the European regionDiversity in the European regionHealth 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

Contribution of the foreign-trained doctors to the net increase in the number of practicing doctors in selected OECD countries, percentage 1970-2005

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.

Growing reliance on foreign trained doctors

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

Number % Number % Number % Number %

Austria 461 1.8 964 3.3 Denmark 4 618 6.0 5 109 6.2

Denmark 1 695 7.7 2 769 11.0 Finland 122 0.2 274 0.3

England 25 360 27.3 38 727 32.7 New Zealand (1) 6 317 19.3 9 334 24.3

Finland 687 3.6 1 816 7.2 Sweden (1) 2 517 2.5 2 878 2.7

France (1) 7 644 3.9 12 124 5.8 Canada 14 910 6.4 19 230 7.6

Ireland 1 198 10.3 3 990 27.2 New Zealand (1) 6 317 19.3 9 334 24.3

Sweden (1) 3 633 4.3 5 061 4.9

Switzerland 2 982 11.8 5 302 18.8 Belgium 1 009 0.7 1 448 1.0

Canada 13 342 23.1 13 715 22.3 Germany 27 427 4.2 25 462 3.8

New Zealand 2 970 34.5 3 203 35.6 Turkey 25 - 45 -

Japan 95 - 146 -

United States (1) 207 678 25.5 208 733 25.0

Belgium 1 341 3.1 1 633 3.4

Germany 14 603 4.0 18 582 4.6

Norway 2 327 15.1 2 833 31.5

Slovak Rep. (1) 130 0.7 139 0.8

(1) 2004 instead of 2005.

Source: International Migration Outlook (OECD) 2007

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This decade has seen a growing reliance on foreign trained health professionals, in Europe and elsewhere

Other key challenges in HRH in Europe

MaldistributionSkill imbalancesLow productivity

Low salariesPoor work environmentsWeak knowledge base

Labour flexibilityLack of social protectionUncontrolled migration

Growing shortagesIncreasing role of private

sector

Unfinished agenda

New challenges

57th session of the WHO Regional Committee for

EuropeBelgrade, Serbia

17-20 September 2007

Health workforce policies in the WHO European Region: Resolution EUR/RC57/R1 Health workforce policies in the WHO European Region: Resolution EUR/RC57/R1

Member States are urged:

to improve and expand the information andknowledge base on the health workforce, encourage research and build capacities to develop, embed and mainstream policies onhealth 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

Health workforce policies in the WHO European Region: Resolution EUR/RC57/R1

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 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 self-management;

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 tothe future challenges is a priority

Demographic and epidemiological change

Technological and organizational change

Political and economic change

Health workforce: from issues to policy questionsHealth workforce: from issues to policy questions

Issue: Imbalances in the health workforcePolicy question:

“What is the most efficient mix of skills to achieve the desired coverage of health interventions in a country?”

Issue: Skills shortagesPolicy 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 mobilityPolicy question:

“How can mobility be managed and regulated?”

Health workforce: from issues to policy questionsHealth 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 questionEvidence required to answer policy question

Policy briefs

(some) Strategies

1. Building realistic strategies

2. Strengthening strategic intelligence (information and evidence)

3. Building institutional capacity

4. Improving education for better performance

5. Planning for the future

6. Regulating HRH framework

7. 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 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. 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.

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 2009How 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 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,

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

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 long-

needed health reforms Role of professional associations The EU cooperation – a huge potential The south-east European Health Network of WHO