review of the relevance and effectiveness of code of practice on … · migration and also (%20) of...

Review of the Relevance and Effectiveness of the Code

Reviewing the Relevance and Effectiveness of the

WHO Global Code of Practice on the International

Recruitment of Health Personnel

Based on the 1st round reporting on the Code implementation – National Reporting Instrument (NRI) and the

semi-final handbook on planning methodologies across EU and the EU report on the applicability of the Code

Expert Committee

Supervisor: Dr. Gholamhossein Salehi Zalani

Mahboubeh Bayat

S. Elmira Mirbahaeddin

Azad Shokri

Samira Alirezaei

Fatemeh Manafi

Najme Bahmanziaei

April 2015


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Introduction

Soon after the first round of an expert advisory group (EAG) meetings in Genève in March 2015

with the aim of reviewing relevance and effectiveness of the Global Code of Practice on the

International Recruitment of Health Personnel (the “Code”), an expert committee was assigned

with the supervision of Dr. Salehi Zalani consisting of seven HRH experts with education

background of Health care planning and health policy studies.

After the first meeting, The EAG was provided with a set of documents including The roughly final

handbook on planning methodologies across EU developed by Joint Action Health Workforce

Planning and Forecasting (JAHWPF) and the data collected through National Reporting

Instrument (NRI) during the 1st round reporting on the Code implementation. The handbook

demonstrated the necessary infrastructures for planning and a collection of seven good practices in

HRH planning methodologies encouraging the member countries by its feasibility to overcoming

planning challenges.

In order to attend to the Code relevance (solutions related to the global challenges of health

personnel and health system strengthening) and effectiveness (influences on action and policies

concerning the health workforce strengthening such as those related to health workforce

implementation systems, planning education and retention strategies at country, regional and

global levels, and also evidences that are changing directives and voluntary instruments and

initiatives of the countries), the first step was developing a better concise understanding of each

article. Therefore, the research group extracted themes of each article by a precise content analysis.

The result was 50 primary themes which were the basis for later studies on both the handbook on

planning methodologies across EU and the 1st round reporting on the Code implementation. Also

the instrument went through the thematic analysis and out of 14 questions 22 themes were

extracted. Thus it primarily showed that there are 28 themes from the Code which is not covered by

the Instrument (See Annex 01).

The research team extracted the themes from the Instrument and located each instrument theme

beneath the most relating article theme which was the basis. Afterwards, country responses were

located under the relating themes in an Excel. The First Part of Synthesis elaborates on the results

and analysis on the relevance and effectiveness of code with regard to the country responses

comparison.

With regard to the five dimensions of HRH planning which is brought by the handbook on

planning methodologies across EU and also the provided applicability report, the measures

implemented by a number of EU countries (seven best practices; Belgium, Denmark, UK, Sweden,

Finland, Spain and the Netherlands and other EU countries; Ireland, Germany and Moldova) have


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been analyzed through their compliance with the extracted themes from 10 articles of the Code in

an Excel file. Further, their specific means of the Code implementation and policies relating to the

code themes were compared. Consequently, it could be realized how each article of the code could

be relevant by the content and report of solutions related to their HRH challenges and the extent of

their effectiveness. The Second Part of Synthesis covers the findings and results of this synthesis.


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First part of Synthesis

Review of the Relevance and Effectiveness of Code with the National Reporting Instrument

(NRI) - The 1st round reporting on the Code implementation

As illustrated in Table 1 the overlap of the themes extracted from the code with the ones addressed

by the Instrument is used to show the parallax and later analyze the responses of contributing

countries against the relevancy (pertinence of the code and the extent to which it informs of

solutions to HRH challenges) and effectiveness of the code articles (the extent to which

implementation of the Code have influenced action and policies concerning the health workforce

strengthening (such as those related to health workforce implementation systems, planning

education and retention strategies) at country, regional and global levels. Also evidences that are

changing directives and policies aimed at strengthening human resources for health in line with

the intentions of the Code and if there is success of a voluntary instrument).

Article 1: Objectives

This article is addressed by Questions 1 and 4. The article themes shows the transparency of rights,

obligations and expectations of stakeholders and is as bilateral agreements and other international

legal Instruments which is introduced as a solution for HRH global.(Qs are defined in Table 1 and

2)

Article 3 – Guiding principles

This article is addressed by Q9 part A and indicates that countries can help effectiveness and

implementation of strengthened health human resources systems and strategically plan for

education and retention of the workforce through sharing information helpful in international

recruitment of the health personnel.

Article 4 – Responsibilities, rights and recruitment practices

This article is covered by questions 1, 2 parts A & B & C and question 3. This article aims at

promoting transparency of rights, obligations and expectations of stakeholders as a solution of

global challenges through legal monitoring mechanisms (to assess the benefits and risks, recruiters

are obligated to individual right of the employees and provision of equal opportunities of promotion

and etc) and also compliance of stakeholders in different professions with the laws as a means of

solution for the ultimate goal of implementing strengthened health human resources systems and

strategic plans for education and retention of the workforce.


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Article 5 – Health workforce development and health systems sustainability

Questions 4 and 5 are in line with this article and articulate that countries provide effective

supports for the retention of HRH in the source countries and their support for return migrations

helped the challenge of HRH shortage, moreover through inhibition of recruiting workforce from

developing countries in shortage of personnel they can reach to a platform for strategic planning

for enhanced education and retention of the workforce.

Article 6 – Data gathering and research

With regard to questions 7 and 13 which associate with this article, it is essential to establish and

promote a comprehensive HRH information system and in order to implement HRH system and

other strategic planning there should be incentives for national, regional and international

researches in relation to the workforce migrations.

Article 7 – Information exchange

Questions 11, 13 and 14 relating to this article show the fact that in order to overcome global

challenges there is a highly essential need for collection and share of the personnel in formation

and recruitment laws of the countries to WHO in a three years period of time and determining a

responsible authority regarding the exchange of migrant personnel. According to question 9 part D

there is an acute need for a database or an information system bearing recruitment laws and

regulation of countries which ultimately assists the implementation of an HRH system and the

strategic plans.

Article 8 – Implementation of the Code

Article 8 is one of the articles in focus of the instrument as it can be seen in questions 8 and 9 all

parts of A, B, C, D, E and concentrates on the effectiveness (strategic plans of education and

retention) through the encouragement of informing of code implementation, involving stakeholder

by consulting in recruitment decisions, provision and update of recruitment records and utilization

of recruitment agencies that comply with the guiding principles of the Code.

Article 9 – Monitoring and institutional arrangements

Question 10 covers this article to some extent and based on the analysis of the research group this

item paves the ground for effectiveness and implementation of the HRH system and the strategic

plans through reporting the measures, results and the solved problems.

Article 10 – Partnerships, technical collaboration and financial support

This article is related to question 12 and relates to technical and financial supports in international

level to reach grounds for achieving effectiveness.


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Results

Annex 01 shows the themes extracted from the code and the instrument. In addition, table 1 shows

the overlap of each code theme with the related instrument theme. According the Frequencies from

the themes analysis in total the instrument covers %39 of the code themes while the most focus is

on article 4 (Responsibilities, rights and recruitment practices) with %71 and article 8

(Implementation of the Code) with %71. However, the least frequencies respectively belong to

article 2 (%0), article 3-Guiding principles (%13) and article 9- Monitoring and institutional

arrangements (%14).

Table 1 Frequencies from the themes analysis

Article code % Frequency

Article 1: Objectives 50

Article 2 – Nature and scope 0

Article 3 – Guiding principles 13

Article 4 – Responsibilities, rights and recruitment practices 71

Article 5 – Health workforce development and health systems sustainability 29

Article 6 – Data gathering and research 50

Article 7 – Information exchange 50

Article 8 – Implementation of the Code 71

Article 9 – Monitoring and institutional arrangements 14

Article 10 – Partnerships, technical collaboration and financial support 67

Total 39

Results according table 2 indicates that among the measures relating to solutions for global

challenges (Relevancy) most participating countries (%91) had equal rights for the migrants in

terms of recruitment and work conditions, on the other hand the least number of participating

countries (%20) had establishment as database of laws and regulations related to recruitment and

migration and also (%20) of all participating countries had technical and/or financial assistance

cooperation agreements or other bilateral/multilateral agreements. On the whole %50 of the

countries had directly addressed and implemented recommended measures of WHO code of

practice.

Table 2 Relevancy frequency of the code analyzed by the Instrument

Questions Frequency Percent

Q1: same legal rights in terms of employment and conditions of work 49 90.74

Q4: entered into bilateral, regional or multilateral agreements 20 37.04

Q6: programs or institutions undertaking research 25 46.30

Q 8: steps to implement the Code 35 64.81

Q11: database of laws and regulations related to recruitment and migration 11 20.37

Q12: technical cooperation agreement - financial assistance 11 20.37

Q13: mechanism or entity to maintain statistical records 33 61.11

Q 14: mechanism or entity to regulate or grant authorization to practice to

recruited 34 62.96

Total 27 50.46


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Since effectiveness is defined in three main categories of one implementation of a health human

resources system and strategic plans such as education and retention of HRH, two the changes that

the code caused actions and policies and three the success of a voluntary instrument in

implementation of code, Table 4 shows that none of the countries measures have been of changes

in actions and policies nor any success of voluntary instrument. Therefore, %100 of these

procedures is included in measures for implementing an HRH system and strategic plans. In the

latter, countries described their actions (i.e. sharing information, involvement of stakeholders and

etc). (%34) countries stated their measures for the implementation of the code, (%26) of them

describes international agreements in recruitment, (%22) provided evidences of legal mechanisms

for having equal right for all personnel and finally (%15) expressed other legal mechanisms for

monitoring. Overall, it unveils that only %20 of the participating countries utilized the code to

reach effectiveness.

Table 3 Effectiveness frequency of the code analyzed by the Instrument

Questions Frequency Percent

Effectiveness-1 100 %

Q2 8 15 Q2-a: using mechanisms to assess the benefits and risk 0 0

Q2-b: promoted and remunerated based on objective criteria 0 0

Q2-c:same opportunities to strengthen their career

progression

0 0

Q2-d: other mechanism 8 15

Q3 12 22 Q3: evidence of the legal mechanisms identified in Q(2) 12 22

Q5 14 26 Q5:describe the bilateral, regional or multilateral

agreements

14 26

Q7 4 7 Q7: details about institutions undertaking research 4 7

Q9 16 34 Q9-a: communicate and share information on recruitment

and migration issues

28 52

Q9-b: involve all stakeholders in any decision-making

processes

18 33

Q9-c: introduce changes to laws or policies on recruitment 19 35

Q9-d: recruiters authorized by competent authorities 12 22

Q9-e: Good practices are encouraged and promoted among

recruitment agencies

12 22

Q9-f: other steps have been taken 8 15

Q10 0 0.00 Q10: main constraints to the implementation 0 0.00

Effectiveness-2 0.00 %

Effectiveness-3 0.00 %

Total 20 %

* Effectiveness (1): a health human resources system and strategic plans such as education and retention of

HRH * Effectiveness (2): the changes that the code caused actions and policies

* Effectiveness (3): the success of a voluntary instrument in implementation of code


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Discussion The present study shows that the current instrument covers the code content only to some extent

(%39); therefore in order to accurately assess the relevancy and effectiveness of the code it is

highly recommended to utilize a more comprehensive instrument. It is noteworthy that article

number 9 (Monitoring and institutional arrangements) is one of the most important items in any

plan and as demonstrated in this study, most countries failed to pay attention to it and may cause

issues for the future plans to be implemented.

In regard to Relevancy, findings of this study indicates that %50 of the countries’ measures has

pertinence t the code contents and perhaps had essential infrastructures for the implementation of

the codes, meanwhile it is inferred that rest of %50 of countries lack the grounds for adopting the

codes. However, there seems to be a non-uniform status among the countries. For instance, %71 of

the participant had laws for equal rights and same working conditions but with respect to the

establishment of information database for laws and regulations and agreements on technical and

financial cooperation (referring to articles 7 and 10 which have substantial role in general

cooperation of countries in international recruitment) almost less than %20 of countries had them

in their considerations which would probably diminish the likelihood to succeed in the achievement

of the code’s goals.

Concerning the effectiveness, countries did not demonstrate any specific measures in change of

actions or policies nor in any success voluntary instrument. Hence countries require extensive

encouragements to legalize the code imperatives through national laws and policies and also

innovative national-specific plans. Moreover findings of majority of the countries show that

especially in monitoring legal mechanisms they are short of effective measures (Article 4).

In sum, despite the shortcomings, this study adopted an innovative approach towards international

views and measures through thematic analysis and later examination of Relevancy and

Effectiveness so that the areas requiring improvement emerge.

The present study had a number of limitations. With regard to the fact that countries responded

some questions in form of Yes or No, thematic analysis of these measures was problematic.

Furthermore, it is not determined if the implemented measures of the participating countries are

initiated after the time when the code was notified or they were already in progress. Therefore, it

cannot imply how much the presented results are due to the notification of the Code to the

countries.


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Second part of Synthesis

Review of the Relevance and Effectiveness of Code in EU countries


Irish Government has proved to be attentive on taking into account the rights, obligations and

expectations of international employees in destination country, especially those from low and

middle income countries like Sudan or Pakistan. In 2008, Ireland was the biggest recruiter of

foreign trained nurses and second biggest for doctors (in % terms) among OECD countries.

Moreover, provision of extra training as career advancement strategies has been helping the new

comers to be better synchronized with the new country rules and routines. On the other hand,

countries like Germany, Finland and Moldova implemented bilateral agreements and other

international legal instruments in order to back their migrant natives in destination countries or

pave the ground for professionals (nurses and physicians) countries like Philippines, Serbia and

Bosnia-Hercegovina to be trained according to the destination requirements. This act is with the

aim of promoting health systems of source countries.

Article 2 – Nature and scope

This article of the code had been relevant to A pilot project in Finland started by the Ministry of

Employment and Economy in 2012 aiming at planning an ethical recruitment model to recruit

nurses and care assistants to Finland from outside of the EU/EEA area by the end of 2014. This

program strengthens the health systems of developing countries, countries with economies in

transition. In addition, countries like Ireland witnessed a great deal of interaction with

stakeholders like backpacker doctors from around the word in 2009 and 2010. This evidence

indicates expansion of ethical recruitment concern that the code has addressed in its scope.

As stated in the code scope, it is a global code involving all stakeholders concerning planning to

educating and implementing HRH policies and it therefore bring responsibilities to governments

and authorities to evolve to the new scope. In the detailed report of the countries there is no direct

mention on code of article as a guide. But the number and structure of workforce was identified in

some countries (UK-. Spain- Belgium) In the UK health system there are a number of

organizations involved in HWF planning and forecasting and a large range of experts and

stakeholders are involved in workforce planning, e.g. Health Education in England has a

headcount of 2666 persons and The Department of Health (excluding agencies) has a headcount of

2208 persons. However, in Spain health system, over the last ten years a few people work on the

HWF planning process but none of them full time .Meanwhile At National Institute for Health and

Welfare AND other organizations, regional councils, primary health care units in hospital districts


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and hospital districts most of the experts involved are not specialized for single professions. In

Belgium, the Unit of Workforce Planning at the Federal Public Service of Health (FPS) provides

administrative and statistical support to the Planning Commission. In Denmark There are 3 people

employed by the Danish Health and Medicines Authority which directly work on the HWF

planning:the head of the division (senior medical doctor ,one dentist ; one special adviser and

Political Science .There’s also one statistician from an external organization. In Norway People

with background in political science and political economy from the Norwegian Directorate of

Health are involved for an amount of two FTE. Also people from other Ministries and the Statistics

Norway (SSB) are involved occasionally. In Spain among 4 people involved in HWF planning at

the Ministry of Health two full-time professionals one technical (part time) in State Register for

Health Professionals.a high technician (part-time) with experience in planning (5 years) supervises

the above; collaborates with experts from the University of Las Palmas in the preparation of reports

and participates in the proposals for making policy decisions. Two experts from University of Las

Palmas have collaborated with the Ministry and the two experts of University of Las Palmas are

university professors of Health Economics. In The Netherlands 7 people and 1 administrative

person who have a background in a healthcare education or healthcare performing function

involved in HWF planning ,also regular pool of experts in the different fields/

professions/specialism and research bureau ’s and other organizations to obtain data that are

necessary to get the job done have cooperation. So as a whole number and profession of the

workforce for health planning were different.

From the above it can be included that one excellent effect of the code had been the embedded

requirement for involving stakeholders of all levels.

Article 3 – Guiding principles

According to the Code, the setting of voluntary international principles and the coordination of

national policies on international health personnel recruitment In Ireland between 2000 and 2008

resulted in dramatic increase of international health professionals. The percentage of registered

foreign trained doctors increased from 12% to 35% and between 2000 and 2006, more than 50% of

all nurses registering in Ireland were non-Irish. It can be inferred that without prepared

infrastructures countries would be hardly able to adopt new forces.

In this part among countries The Netherlands has explanation related to the code. About this part

in the report of The Netherlands there is a clear explanation .so that it have mentioned exactly one

of the restrictions of health workforce and meanwhile proposed the practical suggestion for

education and training .It can be inferred from the report of The Netherlands that In order to

create a sustainable health workforce removing the restrictions is important. Here are several

restrictions. The necessary budget is only one of the restrictions. Removing this restriction is in line


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with appropriate Policies and measures to strengthen the health workforce. For effective education

and training there have to be training institutes that can accommodate the (additional) trainees.

And also there have to be enough trainers. Finally, the medical graduate has to take an interest in

the training program so that this aim became achievable.

Article 4 – Responsibilities, rights and recruitment practices

An innovative initiation like agreements in Moldova is a good example for the cooperation of

regulators, local authorities and other stakeholders for determination of a framework for migrant

professionals. It is reflected in Moldovan guidebook on bilateral agreements to address health

worker migration which is mainly built on concepts in WHO code.

Only in Norway the direct refer has been done on the root of the national planning system

decisions. Full cooperation of Health personnel, health professional organizations, professional

councils and recruiters with regulation which was in this part in the health system of Norway is

based on a Parliamentary decision of 1995.

Article 5 – Health workforce development and health systems sustainability

Countries like Ireland has taken effective measures to educate retain and sustain health workforces

from Pakistan by two years training in surgery, anesthesiology and emergency medicine. There are

also similar discussions with Sudan and plans to extend this cooperation to other low and middle

income countries. There are similar strategies in Germany and Moldova for training the migrants

in such way to have future benefits for their source country

5-5 Member States should undertake Steps to ensure that appropriate training takes place in the

public and private sectors. In this regard in Finland health system guarantee all young people an

opportunity to apply for vocationally/professionally oriented education and training. Meanwhile in

Denmark the Ministry of Higher Education and Science advise the student. In The Netherland the

health system meet both the health care sector and the government’s demand for information in

conjunction with the perceived need and the related capacity for basic medical and dental

education and subsequent specialization. As a whole in The Netherland goals are explicit. They are

translated in specific measurable advices on the range of the yearly intake in any profession that is

concerned. Because these ranges are discussed with the field in advance all training institutes

make action plans for the different scenario’s by using forecasting model. The experts decide which

scenarios are the most likely. This results in a specified range for the needed influx in medical

training for each specialism. As a result in the Netherland scenario writing is implementing and

needed effects in medical training for each specialism.

5-6 In UK health workforce planning system goals are explicit. Some specification of the planning

is as follows: goals are set out the mandate from the Government to Health Education England,


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and both demand and supply of health workforce is considered. It can be inferred that factors

influencing supply and demands will be considered in actions which results in adopting and

implementing effective measures aimed at strengthening health systems and future planning some

demand factors are as following: changing patterns of disease, developments in technology,

introductions of new professional or regulatory standards, financial constraints, new roles

substituting current roles. Factors influencing supply include: current workforce levels, rates of

attrition from training courses, rates of staff turnover, retirement age, inflow and outflow from

other countries and healthcare employers.

In Finland in order to adopt and implement effective measures aimed at strengthening health

systems it can be inferred that promotion of the availability of skilled labor in accordance with

developments in industrial and occupational structures seems necessary. Usually two or three

scenarios are developed to estimate the future workforce demand, a baseline scenario and one or

two alternative scenarios. These alternative scenarios have not considered detailed differences in

the health workforce developments. The main difference is the assumption about the demand for

health care and the corresponding effects on workforce. In Belgium to assure the replacement of

health professionals for the Future this implicit goal influences the planning process .in this

country The mathematical planning model is used to model the current (and future) workforce

situation, but not to model the desired workforce situation and meanwhile forecasting model looks

at both demand and supply of health workforce and estimates trends in the supply of health

workforce, factoring in multiple scenarios regarding various levels of inflows in the workforce .in

this country The planning systems allows to create all the desired scenarios . For each planned

professions, the specific working group decide the number of scenarios to develop. For example:

For physiotherapists, the working group has decided to only develop one baseline scenario. For

nurses three scenarios are developed: a baseline scenario and two alternative scenarios with

different assumptions. The baseline scenario is defined as the most likely scenario of future

development. The alternative scenarios are based on different hypothesis on level of inflow, activity

and demand. Thus, the model provides an upper and a lower limit between which future

developments will take place.

In Norway the mission of the present planning system in the Directorate of Health is to evaluate

the present and future needs of health and social personnel and to follow up on initiatives to

strengthen the capacity and qualification building as needed. The Norwegian health and social

personnel forecast model (HELSEMOD), developed by Statistics Norway, looks at both demand

and supply of health workforce. changes in health service delivery (some reforms are incorporated

in the HELSEMOD 2012 model and in earlier version, for example the Coordination Reform

which presumes that the municipalities will play an increasing part in meeting the growth in

demand for health services; in order to include the reform into the analyses, Statistics Norway has

assumed expansion of home nursing care, general practitioners, physiotherapy and in health


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promoting activities compared to the baseline alternative; another example is a long term national

program to strengthen mental health care resulting in an increased supply of services, reflecting a

former unmet need of mental health care. The model is based on alternative projections based on

different assumptions, and offers different scenarios (i.e. high, medium, low) for the different

approaches. The baseline year for the most recent projections is 2010, and the model projects the

health care personnel needed towards 2035. No specific supply-induced demand is calculated in

spite of a growing health care market introduced by private insurance companies in Norway to

offer additional specialized health care on a personal basis or through the employers (>50000

persons clients exposed to this offer).

As a whole after comparing the health system planning In UK , Finland and Norway which was

specified in the detailed report, it was inferred that in all counties both supply and demand were

used and in all systems different format of scenarios are developed to estimate the future

workforce demand and supply.

5-7 In order to adopt measures to address the geographical misdistribution of health workers and

to support their retention in underserved areas it can be inferred that in the detailed report only in

Finland this subject is considered by the macroeconomic forecasting (VATTAGE model) on

projections of the employment.

Article 6 – Data gathering and research

6-1 Indicating the time period for HRH system implementation can be considered as a useful

decision on formulation of effective policies and plans on the health workforce and having the

sound evidence base .In UK the projections period of the local planning (provider forecast and

LETB aggregate provider forecast) is 5 years (2013 plans foresee up to 2018) The projection

periods in CfWI workforce projects (national planning) vary depending on the characteristics of

the particular workforce and are typically from 15 to 30 years. In the case of medical doctors, for

example, the forecasting model calculates each variable over a 30-year period (currently up to

2040.)in Finland the current projection period regarding demand of new labor is 2008 - 2025. On

the basis of these forecasts the present entrant targets have been adopted for 2011-2016.) The

development plan for education and university research adopted by the Government defines targets

for educational supply within the next five years as entrant targets and output of qualifications for

every field and level of professional and vocational education and training. In Belgium the

projection period is 50 years currently the forecasting model is set from 2004 to 2054. As a result in

Belgium the projection period is the longest which is 50 years.

6-2 based on the content of this part which indicates that countries should encouraged establishing

or strengthening and maintaining, as appropriate, health personnel information system including

health personnel migration, in UK migration inflow and migration outflow are considered in the


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English System Dynamics model. Migration flows concern both the intakes in education system

(students and trainees) and the health workforce. Specific assumptions are set for the different

flows considered. Historical data analysis and estimation based on qualitative methods are used to

populate the model. Also different sources of data are used .The forecasting method used is a

combination of quantitative and qualitative methods (which the last one is used for the demand

model) Parameters that determine potential changes in levels of need and changes in productivity

are applied and these parameters are determined through the Delphi process and are scenario

specific Finnish general economic model does not take into account the migration flows. And

Migration is monitored in general with data from Statistics. The basic structure of the model has

remained stable for a long time. Estimations are based on yearly time series. Every year new actual

data are included in the database of the model once they are published. In Belgium Migration

inflow and migration outflows are quantitative input variables in the Belgian forecasting model for

doctors, dentist, nurse and physiotherapists. Starting from historical data available, the estimation

of the expected future migration levels is based on the observed trends and the insights of the

consulted experts. All data are available annually and are integrated in the individual data base

Data available are aggregated for sex and for age groups but the flow of migration can be divided

by age and sex using a distribution key based on the data in immigration and emigration. However,

regarding migration outflow, no reliable data is currently available; therefore value set to zero in

scenario development.

The projections are segmented by different health sectors. Separate analyses are made between

health care sector and non-health care sector. The collected quantitative data will be analyzed in

combination with qualitative input from the members of the working groups

Article 7 – Information exchange

The challenge of recognized diplomas earned by health professionals led Moldova to convene a

Cross-Sectoral Working Group in July 2013, to cooperate in recommendations for migration.

7-2 According to some parts of this subject it is mentioned that each Member State should establish

and maintain updated data from health personnel information systems. In this regard in UK the

supply models are built using data related to year 2013.and The data are collected from multiple

data sources not having planning as the main purpose. In Finland the model, data and calculations

have been updated continuously every year, although the basic structure of the model has remained

unchanged. Meanwhile the data are used not only for workforce planning purposes. The main

purpose of data collection is to monitor the labor force and personnel but also for general statistical

information of the all Finnish society. It has been used to make projections and calculations both

for specific purposes of the Ministry of Employment and the Economy (medium-term and long-

term growth projections and labor force projections, budgetary planning, employment effect


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estimates, assessing the effects of integration on the labor market) and for other users at the

ministerial and regional. The model data is general GDP calculation data; this is not done only for

planning purposes. In Belgium the current planning project is based on workforce data from 2004

to 2009 for nurses, 2004 to 2010 for physiotherapists, 2004 to 2012 for physicians and dentist and

The main purpose of data collection is different for each data source: the main task of the principal

source of the workforce planning (National Cadaster of Health Professionals) is to support the

planning commission, anyway this data collection also serves to regulate (monitor and control) the

access to the profession; the main purpose of additional data sources from the administration of

the social security and health insurance is not planning-related the which can cause some

incompatibility between the needs of the planning commission and the information content of the

data. In Denmark considering the two main sources of data: the Authorization Register contains

data regarding all health persons with a registration. The register includes historic data on people

who are now dead. The register is updated on a daily basis, The Mobility Register was last updated

with data as of 31st of December 2012. The register contains data regarding the workforce at this

specific date and the year's before. The register is at the moment being updated with data from later

years. According to plan the register from now on is going to be updated once a year. The main

purpose of data collection is different for each data source: the Authorization Register’s main

purpose is to have a database of all persons with authorization to practice for monitoring and

controlling the access to the profession; the Mobility register’s main purpose is to generate data

showing the current and historic number of employed health personnel within professions and

sectors and regions. In Norway the current HELSEMOD projection (2012) is based on data mainly

from 2010. Data on GPs and specialists are updated continuously; in Spain the current planning

project is based on data collected in December 2013 the main data used in the forecasting model

are collected specifically for planning. The complementary data used to reduce the actual lack of

information in the private sector are collected for others main purposes. In The Netherlands

Considering the forecasting exercise made in 2013, the data used on supply side are updated to

January 1st 2013 for the almost all variables considered the data used in the forecasting model are

collected for all kinds of purposes, but never for planning. Data collection for planning purposes is

done only on specific occasion.

Article 8 – Implementation of the Code

In Finland Guidelines of international mediation/public employment services is incorporated in

2011 by the Ministry of Employment and Economy, as in code is mentioned that the relating rules

to ethical recruitment of international workforce should transfer into applicable laws and policies

Article 10 – Partnerships, technical collaboration and financial support


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According to the content of the report, Member States should implement some actions that indicate

the collaboration to strengthen the capacity with other stakeholders or through competent

international bodies to strengthen their capacity to implement the objectives of the Code.

Based on this part, England local and national planning results in the Workforce Plan for England

which sets out the education and training commissions for the 110 workforce roles for which

Health Education England is responsible. The Centre for Workforce Intelligence is commissioned

by DH, HEE and PHE to undertake reviews of specific workforces. The CfWI follows a specific

workflow named Robust Workforce Planning Framework (CfWI, 2014) that is the same for each

workforce role. The DH and HEE set the strategic objectives in the areas of workforce planning.

In Belgium The core of the workflow is in the Planning Commission that is unique for all the

health professions planned. It consists of national representatives of the different health

professions, universities, health insurance companies, different government levels (federal &

regional) and invited experts. The planning commission is assisted by the Unit Workforce Planning

at the Federal Public Service of Health, which provides administrative and statistical support. The

Unit Workforce Planning is as well unique for all the health professions planned. In another word

in the planning commission the core of the workflow of all the health professions are planned.

Furthermore, the planning commission is composed of different working groups, one for each

health profession planned, e.g. nurses, physicians, dentists, physiotherapists. It means that part of

the workflow is differentiating by the specific health profession. Communities (local

administrations) are responsible for managing education and training (examination selections,

numerous clauses policies). Forecasts developed by the Planning Commission on the basis of the

stock and flow model are then used by the Federal Government to regulate the number of

physicians, dentists and physiotherapists that are allowed to practice. Two levels of government are

involved in strategic health workforce planning in Belgium. The Federal Government can regulate

the supply of health workforce by limiting practitioners’ access to practice. The nature of universal

health insurance systems enables government to regulate the supply of some medical and health

professions by restricting their right to reimburse treatment costs. Communities are responsible for

managing the education and training system. Thus, they establish the content of courses and the

standards for selections. They also govern numerous clauses policies.

The stakeholders are officially involved in the Planning Commission in monitoring the workforce

levels and trends of the different health professions using the available statistical information and

detecting bottle-necks. Meanwhile In the Planning Commission there are the following

stakeholders participating: Ministry of Public health; Ministry of social affairs; Flemish

community, French community and German-speaking community; Professional associations

(Physicians needs estimation, validation of reports, providing input for research);Universities with

a full medical curriculum; Universities of Flemish community (University of Antwerp, Ghent

University, Catholic


17 | P a g e

University of Leuven, Free University of Brussels); Universities of French community(University

of Liège, Catholic University of Louvain-La-Neuve, Free University of Brussels) the universities

deliver necessary information which is used in the planning process. They act as stakeholder in the

planning process and participate in the working group meetings; they actively defend their point of

view in the discussions.

As a result in Belgium different groups and stakeholders collaborate with each other in the

planning commission for planning the core of the workflow of all the health professions , it can be

inferred that this actions and cooperation result to strengthening the capacity to implement the

objectives of the Code.

Danish Health and Medicines Authority decide it’s time to update the supply forecast (every2-3

years). The planning and Forecasting Committee is involved in deciding whether the supply model

needs modifications. If modifications are needed a small group with stakeholder representatives

draw up a draft for a new model. The model is presented for The Planning and Forecasting

Committee. Three regional councils for postgraduate education are responsible for announcing

postgraduate training post on the basis of the plan outlined by the Danish Health and Medicines

Authority. The three regions decide how the assigned training posts are to be distributed within the

region. Furthermore they are in charge of composing the postgraduate training posts and their

educational programs. Also the minister for higher education on the basis of advice from the

Danish Health and Medicines Authority decides the student intake for medical doctors, dental,

clinical dental technicians and dental hygienists. The Danish Health and Medicines Authority

decide the yearly number of postgraduate education post for medical and dental specialists. During

preparation of the plan for how many medical specialists and dental specialists are supposed to be

educated on a yearly basis stakeholders are invited to participate in a public hearing process where

they can advise the Danish Health and Medicines Authority as to how many specialists should be

educated. The Danish Health and Medicines Authority with the help of stakeholder representatives

draw up the plan which is presented in the Council for Postgraduate Education. The Danish

Health and Medicines Authority typically follows the council’s recommendations regarding the

plan but is however not obligated to. For both the forecasting of doctors and the dental professions

stakeholders are through the Planning and forecasting committee invited to participate in the

overall designing of the forecasting model. The Danish Health and Medicines Authority has two

planning and forecasting committees. Furthermore the Ministry of Higher Education and Science

is invited to participate in the committee. For the moment they have one active member. Planning

and forecasting committee for dentists, dental hygienists and clinical dental technicians.

The composition of the committee isn’t regulated in the Danish legislation but the Danish Health

and Medicines Authority have decided to invite the following to the committee: The Danish Health

and Medicines Authority (Chairman)Danish Regions (1 member),Ministry of Health and


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Prevention (1 member)Ministry of Higher Education and Science (1member)Association of public

dentists (1member)Danish Dental Association (1member)The Association of dental specialists in

Orthodontics (1 member)The Association of dental specialists in Oral Surgery (1member)Local

Government Denmark (1 member)National association of clinical dental technicians(1member)The

Danish Dental Hygienists Association (1 member)

In Norway, the planning system include 20 groups of health personnel .Plans are conducted on

national, regional (hospitals) and local level (primary health care). In particular the Directorate of

Health manages the National Plan with input from local (municipalities) and regional authorities

(County Governor) and from the four corporations running Norwegian hospitals. Directorate of

Health have the national responsibility: the Health Directorate advises the government department

of health and care which passes the recommendations on to the Ministry of Science in relation to

the annul public budget planning. Stakeholders involved are mainly municipalities, Regional

Health Authorities (RHF),upper secondary school, universities, professional associations.

In Spain, Spanish planning and forecasting is focused on medical doctors (basic education and

specialist training posts). The Council of University Policy, composed by Ministry of Education and

by education officials of autonomous communities, fixes annual offer of University posts. The NHS

Human Resources Commission is mainly responsible for planning the specialists. It is involved in

the planning and design of training programs and human resource modernization of the National

Health System and defines the basic criteria for assessing the competence of healthcare

professionals. It proposes annual vacancies of specialized training. It is composed by health

officials of the autonomous communities (17) and the central administration (Ministry of Health,

Social Services and Equality, Ministry of Education, Culture and Sports , the Ministry of Defense

and the Ministry of Finance and Public Administration). The workflow of the planning process is

the same for all the specializations and it’s focused on the activities of the NHS Human Resources

Commission. National Council of Specialists in Health Sciences must advise the vacancies of

specialized training. The National Council of Specialists in Health Sciences is composed of more

than 500 specialists, representing all specialties.• Health workforce planning takes place at central

level (Ministry of Health Social Services and Equality and Ministry of Education, Culture and

Sport) and local level (Health and Education Departments of Autonomous Communities). Ministry

of Health Social Services and Equality coordinates and approves the number of the specialized

medical training posts. Ministry of Education, Culture and Sport coordinates and approves the

number of enrollments in medical degree courses. Autonomous Communities are involved as

permanent members in the Human Resources Commission (Debarments of Health) and in the

Council of University Policy (Departments of Education). The Human Resources Commission

proposes to the MoH the number of specialized medical training post and the Council of University


19 | P a g e

Policy set the number of admission in the basic education. The final decision on the number of

specialized medical training vacancies is up to the Ministry of Health, Social Services and Equality,

which coordinates the process and approves or modifies the proposal of the Human Resources

Commission of National Health System according to realistic indicators and planning criteria. The

final decision on the number of posts in Faculties of Medicine is up to the Ministry of Education,

Culture and Sport, which also coordinates the process and approves the results of the Council of

University Policy. The Human Resources Commission of the NHS, as part of its mandate from the

Inter-territorial Council of National Health Service (CISNS), has the task of fostering adequate

planning for the needs of the NHS

In The Netherlands The ministry currently has two contracts in place for data collection, analysis

and modeling in order to make recommendations to the health field and back to the ministry on

likely future needs. One contract is related to doctors, mental health professions, dentists and

specialized nurses (and related professions .The other contract is related to nurses, assistant-

nurses, care-takers, social workers and home helpers and is given to a research program.

Experts for each medical specialism are involved to discuss the changes in working processes that

will affect the capacity of the workforce in the future.HWF planning takes place at central level

(Advisory Committee on Medical Manpower Planning - ACMMP, Capaciteitsorgaan) for medical

doctors, dentists, mental health professions and specialized nurses, dental hygienist. The

responsibility for the final decision on the advice is for the members on the board of the ACMMP.

.


Annex 01

Code Articles Code Themes Instrument Themes Overlaps


1-1 transparency of rights, obligations and expectations of stakeholders transparency of rights, obligations and

expectations of stakeholders Q1

1-2 Considering the Code as a legal and institutional reference for

international recruitment of HRH

Creation or improvement of legal frameworks for

the recruitment of international personnel

1-3 Considering the Code as a guide in bilateral and multilateral agreements

and other legal instrument

Considering the Code as a guide in bilateral and

multilateral agreements and other legal instrument Q4

1-4 Facilitate and promote international cooperation with a focus on

strengthening health systems especially low & middle income countries

Article 2 – Nature and

scope

2-1 The Code is Voluntary and using encouraging instruments to apply it

2-2 international cooperation of all involved stakeholders in HRH

international recruitment

All stakeholders should observe the code

2-3 strengthening health systems in developing countries through the

provisions of ethical recruitment principles

Article 3 – Guiding

principles

3-1 critical responsibility of the governments for their nations’ health

3-2 coordination of national policy makings for the management of voluntary

migration of health workforce

3-3 flow of financial and technical aids of developed countries to the low and

middle income countries

3-4 Reducing mal-effects of workforce migration

3-5 discrimination in the employment of international workforce is unlawful

3-6: strengthening the infrastructures for HR planning to decrease need for

migrant workforce

3-7 sharing the information relating to international recruitment of personnel Q- 9a

3-8 observing the principles for the workforce exchange and fair interactions

among countries

Article 4 –

Responsibilities, rights

and recruitment

practices

4-1 observance of all laws and principles by stakeholders of different

professions

Q 3

4-2 there should be transparent mechanisms in legal recruitments


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4-3 observing ethical principles to provide staffs with informed choices

4-4 observing all recruitment and individual rights of the HRH by the

employers

observing all recruitment and individual rights of

the HRH by the employers Q2- b

4-5 creating equal opportunities for international workforce regarding the

recruitment and working conditions

creating equal opportunities for international

workforce regarding the recruitment and working

conditions

Q1

4-6 creating equal opportunities for the international workforce regarding

career promotions and obtaining competencies

creating equal opportunities for the international

workforce regarding career promotions and

obtaining competencies

Q2 - c

4-7 equal Code rights for both temporary and permanent staff

Article 5 – Health

workforce development

and health systems

sustainability

5-1 inhibiting recruitments from developing countries facing workforce

shortage inhibiting recruitments from developing countries

facing workforce shortage Q 5

5-2 providing effective supports for the retention of the workforce in the

source countries and return migration

providing effective supports for the retention of the

workforce in the source countries and return

migration

Q 4

5-3 encouraging the personnel to exchange acquired knowledge from the

destination and the source countries

5-4 education and sustainability of the health workforce according to needs

and conditions of the countries

5-5 making sure of appropriate trainings based on health needs in both public

and private sectors

5-6 adopting a multi-sectorial approach for the development and retention of

health workforce

5-7 adopting retention strategies for the workforce in underserved areas

Article 6 – Data

gathering and research

6-1 encouragement of the countries for evidence based policy making

6-2 creation and strengthening of a comprehensive HRH information

database

creation and strengthening of a comprehensive

HRH information database Q 13

6-3 encouraging national, regional and international researches in migration

of health workforce

encouraging national, regional and international

researches in migration of health workforce Q 6 & Q 7

6-4 production and collection of international data and evidences

Article 7 – Information

exchange

7-1 Information exchange of personnel migration in national and

international levels

7-2-1 existence of a database for recruitment laws and regulations existence of a database for recruitment laws and

regulations Q 9 - d


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7-2-2 collection and sharing personnel information and recruiting laws every

three years with WHO

collection and sharing personnel information and

recruiting laws every three years with WHO Q 11

7-3 determining a responsible authority for the exchange of migrant

personnel information determining a responsible authority Q 13 & Q 14

7-4 sharing the recorded information of the authority for the exchange of

information

Article 8 –

Implementation of the

Code

8-1 encouragement of sharing information and implementing the Code Q 8 & Q 9 - a

8-2 encouraging to adopt the code principles in laws and policies likely to be

implemented

Q 9 - c

8-3 encouraging to consult with all stakeholders in recruitment decisions Q 9 - b

8-4 observing and implementing the Code

8-5 preparation and updating recruitment records and data preparation and updating recruitment records and

data Q 9 - d

8-6 using credible recruitment agencies complying with the code using credible recruitment agencies

Q 9 - e

8-7 assessing the extent of recruitment and the influence of the Code

Article 9 – Monitoring

and institutional

arrangements

9-1 Reporting measures, results and problems faced Reporting measures, results and problems faced

Q 10

9-2 Review and assessment of member countries reports by WHO

9-5 Review of relevance and effectiveness of the Code by WHO

Article 10 –

Partnerships, technical

collaboration and

financial support

10-1 cooperation of the member countries with the competent authorities in order to strengthen their capacities

10-2 , 10-3 Technical and financial supports Technical and financial supports Q12

review of the relevance and effectiveness of code of practice on … · migration and also (%20) of...

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