Addressing the pull

2.11.3.1 Codes of practice

When examining which pull factors to focus on, it is important to weed out those which are not feasible; for example, we cannot decrease salaries in destination countries just to discourage migration from countries like Malawi. Pull factors most commonly targeted link to enabling and grab factors such as active recruitment. After receiving complaints from South Africa and the Caribbean, the UK NHS took steps to

discourage active recruitment from a number of prescribed countries through the development of a code of practice (Pagett and Padarath 2007). The code was revised in 2001, and a more exhaustive list of countries banned from active recruitment was developed. It was revised for a third time in 2004 to include agency-recruited, temporary and locum healthcare organisations.

However, the code has drawn a number of criticisms, which relate mainly to the lack of a formal mechanism to ensure compliance, as it is not legally binding (Padarath et al 2003). A number of loopholes exist, so that many health workers are able to join the

NHS through the ‘back-door’ (through private care homes or agencies) (Kline 2003). Research has shown that the private health sector continues to recruit nurses from the banned list (Windisch et al 2009). Ultimately, although the code denounces active recruitment, it does not prevent migration as the NHS maintains that "international recruitment is a sound and legitimate contribution to the development of the health care workforce" (DoH 2004:7). Similar criticisms have also been made of other codes of practice. A review by EQUINET (the Regional Network on Equity in Health in Southern Africa) concluded that codes have in general been ineffective in stemming migration, as often the framework for their implementation is weak (Pagett and Padarath 2007). Despite their shortcomings, codes form an important part of the global effort to highlight unethical recruitment practices and mitigate the negative impacts of nurse migration. A number of national and international codes of practice have been developed in recent years and are summarised in Table 2.11.

Table 2.11 Codes of practice

Code of Practice

Date Purpose Status

NHS Code of Practice for International Recruitment of Healthcare Professionals 2001, revised December 2004

Applicable to the UK to guide the international recruitment of health workers (HWs)

Process is voluntary and private

organisations only have to sign up to its principles, although the NHS has a mandate to deal only with recruitment agencies that comply with code Melbourne Manifesto: A Code of Practice for International Recruitment of Healthcare professionals

May 2002 To promote the best possible standards of health care around the world; encourage rational workforce planning by all countries; discourage activities which could harm any country’s health care system It comprises of a list of recommendations Commonwealth Code of Practice for the International Recruitment of Health Workers Adopted May 2003

To provide governments with framework for international recruitment. The code discourages the targeted recruitment of HWs from countries experiencing shortages and aims to protect internationally recruited HWs and ensure that they are treated fairly in terms of pay and professional

development

Not a legal document, it is hoped that governments will subscribe to it

Voluntary Code of International Conduct for the Recruitment of Foreign- Educated Nurses to the United States

May 2008 Includes a minimum set of standards for a number of laws including the equal pay act and medical leave act. Makes recommendations for best practices for the ethical treatment of IRNs

The code is not law in the US and subscription is voluntary WHO Global Code of Practice for Health Worker Migration Adopted at the 63rd World Health Assembly (WHA) in May 2010

The code aims to establish and promote voluntary principles and practices for the ethical international recruitment of health personnel

Subscription is voluntary

Sources: Commonwealth Secretariat (2003), DoH (2004), Pagett and Padarath (2007), Alinsao et al (2008), Health Worker Migration Global Policy Advisory Council (2009), The Melbourne Manifesto (2002), World Health Assembly (2010)

Bilateral and multilateral agreements have also been developed to foster ethical recruitment, promote technical exchange between countries, and encourage circular and temporary migration whereby emigrating health professionals can return to their home countries to teach (Health Worker Migration Global Policy Advisory Council 2009). Important agreements include the multi-lateral agreement on Trade and

Services (GATS Modes 1-4 health services) of the World Trade Organisation, and the memorandum of understanding between South Africa and the UK (2003) (Pagett and Padarath 2007). In 2009, Malawi and South Africa signed a bilateral agreement to promote cooperation in the field of public health, including the technical and

professional training of health workers through exchange programmes (MoH Malawi 2009).

The development of these codes and agreements testifies to the considerable interest in health worker migration (Martineau et al 2004), and has led to a number of regional and global responses to migration and health worker shortages in general. These include the establishment of the Global Health Workforce Alliance (GHWA) in 2006 to identify and implement solutions to the health workforce crisis. The GHWA

acknowledges that migration of health workers is a reality, but calls for appropriate mechanisms to shape the market in favour of retention (WHO 2008). The 2008 GHWA meeting led to the Kampala declaration, a framework for coordinating, expanding and supporting health workforces over the next decade (Koch 2009). The G8 (a group of eight high-income countries, including the UK) has also supported this declaration (G8 2008).

When discussing codes of practice it is important to consider the debate on the rights of migrants and rights to health. According to the Universal Declaration of Human Rights, article 13, the freedom to migrate is a fundamental human right (UN 2010), suggesting that it is inappropriate to prevent nurses migrating from Malawi. Many observers, including the ICN (2002), have highlighted the need for balancing a migrant’s human rights and concern for the health of the source country’s population. In reality, it is difficult to achieve this balance, and this is becoming a greater

challenge in light of widening health worker density disparities (Health Worker Migration Global Policy Advisory Council 2009). To protect the rights of health workers, debates have focused on ethical recruitment policies. The International Council of Nurses (ICN) issued a statement calling on governments and employers to adopt principles on ethical recruitment (ICN, 2002). There have also been repeated calls to ensure that the social and economic costs and benefits of migration are

equitably distributed between source and destination countries (Pagett and Padarath 2007). Despite these debates, some observers argue that no effective policy has yet been developed to solve the global shortage of health workers or diminish their maldistribution (Van Rijckevorsel 2005). The Health Worker Migration Global Policy Advisory Council (2009) has argued that in order for policy solutions to be effective there is a need for increased dialogue and coordination between nations. The Council maintains that there is still a need to recognise the consequences of an over-reliance on internationally trained health workers from source nations with their own HRH crises (Health Worker Migration Global Policy Advisory Council 2009).

2.11.3.2 General destination country solutions

The recognition of an over-reliance on internationally trained health workers is especially applicable to the UK. Eastwood et al 2005 have commented that the UK needs to urgently review why, in contrast to many European countries it continues to rely on low-income countries for health workers. The authors propose a number of solutions for destination countries, including an increase in domestic training and encouraging health worker return. One way to support source countries is for the destination country to provide compensation such as a tax paid per health worker recruited (WHO 2004a, Mwapasa 2005). This option was first discussed in the 1970s (Martineau et al 2004), and has been intensely debated since because it is unclear who should pay, how much and to whom, especially if health workers work in different countries during their lifetime. No mechanisms exist currently to provide compensation (Pagett and Paradath 2007), and observers have suggested that compensatory payments are unlikely to be successful, especially as many high-income countries lack the political will to make a formal commitment (Nullis-Kapp 2005 cited in Pagett and Paradath 2007, Eastwood et al 2005).