European Health Management Association Transitional Countries Network launch

1. European Health Management AssociationTransitional Countries Network launch Mobility of health workforce: The challenges for Europe Albena Arnaudova, Dr Galina Perfilieva Budapest, Hungary, 19 May 2009

2. 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

3. 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.

4. The health workforce crisis • RelativeAs 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

5. Health 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.)

6. Driving forces and challenges

7. 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 newhealth workers are needed in next 6 years for the countries in sub-Saharan Africa to deliver the basic services. More information onhttp://www.globalhealthtrust.org

8. 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

9. The response of WHO AT GLOBAL LEVEL • Joint Learning Initiative (JLI) report, 2004 – need for urgent concerted actionsto 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

10. 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).

11. 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 Tallinn Euro Ministerial EB122 Migration Progress Report Public Hearings PAC – TWG meeting Kampala Forum G8 Summit Drafting of the Code Launch of Global Dialogue on Migration Draft revised Progress Report for EB124, incl. Draft Resolution Draft Code • Draft Code Draft Outline for a Code

12. First Global Forum on Human Resources for Health, Kampala, Uganda, March 2008) Draft code was outlined by the WHO Secretariat • Global Forum adopted the Kampala Declaration and Agenda for Action • The Kampala Declaration called on WHO to accelerate negotiations for a global code of practice • WHO/Europe - commitment to managing migration and collaboration with all relevant partners WHO Regional Office for Europe initiates policy dialogue between “source” and “destination” countries, EURO roundtable, Kampala.

13. The Kampala Declaration called to accelerate negotiations for a Code Fundamental and interconnected strategies • Building coherent national and global leadership for health workforce solutions • Ensuring capacity for an informed response based on evidence and joint learning • Scaling up health worker education and training • Retaining an effective, responsive and equitably distributed health workforce • Managing the pressures of the international health workforce market and its impact on migration • Securing additional and more productive investment in the health workforce

14. Web-based public hearings: September 2008

15. 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

16. 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.

17. 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 maximizethe 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.

18. Next steps in the Process to develop a WHO code • March09 May09 Sept-October 09 January 10 March10 May10 National Consultations WHO RCs Progress Report for EB Technical Briefing during WHA09 Global Consultation? Issue Paper Draft Code for the WHA? • Draft Code

19. The European dimension: migration The WHO European Regionis 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 flows In OECD:11% of employed nurses and 18% of employed doctors are foreign-born; Manyvariations across countries (source, destination and transit countries)

20. 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

21. Distribution of physicians in the European Region P Source: WHO HFA database, 2008

24. Diversity in the European regionHealth professionals / 100.000 population Source: WHO HFA database, January 2009

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

26. 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…

27. Since 2000, reliance on foreign trained professionals has increased in Europe This decade has seen a growing reliance on foreign trained health professionals, in Europe and elsewhere

28. Other key challenges in HRH in Europe Unfinished agenda Maldistribution Skill imbalances Low productivity Low salaries Poor work environments Weak knowledge base Labour flexibility Lack of social protection Uncontrolled migration Growing shortages Increasing role of private sector New challenges

29. Health workforce policies in the WHO European Region:ResolutionEUR/RC57/R1 57th session of the WHO Regional Committee for Europe Belgrade, Serbia 17-20 September 2007

30. Health workforce policies in the WHO European Region: ResolutionEUR/RC57/R1 Member States are urged: • to improve and expand the information and knowledge base on the health workforce, encourage research and build capacities • to develop, embed and mainstream policies on health 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

31. Health workforce policies in the WHO European Region: ResolutionEUR/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

32. 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

33. 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

34. 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).

35. Shaping the European health workforce policies tothe future challenges is a priority Demographic and epidemiological change Technological and organizational change Political and economic change

36. Health workforce: from issues to policy questions • Issue: Imbalances in the health workforce Policy question: “What is the most efficient mix of skills to achieve the desired coverage of health interventions in a country?” • Issue: Skills shortages Policy 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 mobility Policy question: “How can mobility be managed and regulated?”

37. Health 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?”

38. Evidence required to answer policy question Policy briefs

39. (some) Strategies • Building realistic strategies • Strengthening strategic intelligence (information and evidence) • Building institutional capacity • Improving education for better performance • Planning for the future • Regulating HRH framework • Addressing the challenges of health worker migration A health system wide approach

40. The Tallinn Conference and Charter “In a rapidly globalizing world, generation of knowledge, infrastructure, technologies, and aboveall, human resources withthe appropriate skills and competence mix requires long-rangeplanning and investmentto respond to changing health care needs and service delivery models.” The Tallinn Charter, June 2008

41. 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

42. 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.

43. 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

44. 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 2009 How to work with the EC on human resources for health in the accession/potential candidate countries (the acqui communautaire)

45. 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

46. 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

47. 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

48. 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