Ethical Planning

Significant numbers of African-trained health workers migrate every year to developed countries including Canada. They leave severely crippled health systems in a region where life expectancy is only 50 years of age, 16 per cent of children die before their fifth birthday and the HIV/AIDS crisis continues to burgeon. The population of Sub-Saharan Africa totals over 660 million, with a ratio of fewer than 13 physicians per 100,000. [from introduction]

This document highlights the potential advantages and perils of career moves and migration for nurses, describes some of the main nurse migration trends and establishes a list of critical questions as an ethical framework for nurse recruitment. [adapted from author]

The aim of the Code of Practice is to promote high standards of practice in the international recruitment and employment of healthcare professionals. This is underpinned by the principle that any international recruitment of healthcare professionals should not prejudice the healthcare systems of developing countries. Therefore a key component of the Code of Practice is to preclude the active recruitment of healthcare professionals from developing countries, unless there exists a government-to-government agreement to support recruitment activities. The Code of Practice also acknowledges the reality that the international movement of healthcare professionals is a long established practice that will continue.

The Code develops a consensus approach to dealing with the problem of international recruitment of health workers, while remaining sensitive to the needs of recipient countries and the migratory rights of individual health professionals. The Code covers issues of transparency, fairness, mutuality of benefits, compensation/reparation/restitution, selection procedures, and registration. [Description from author]

As part of the East, Central and Southern African College of Nursing’s 7th Scientific Conference, this presentation describes the ethical considerations for health professionals in terms of conflict of interest. The author describes how this conflict can compromise effective health service delivery, defines some potential sources, gives information on available guiding global instruments, and makes recommendations for governments and health professionals on how to alleviate this problem. [adapted from author]

Past attempts to estimate the cost of migration were limited to education costs only and did not include the lost returns from investment. The objectives of this study were: (i) to estimate the financial cost of emigration of Kenyan doctors to the United Kingdom (UK) and the United States of America (USA); (ii) to estimate the financial cost of emigration of nurses to seven OECD countries (Canada, Denmark, Finland, Ireland, Portugal, UK, USA); and (iii) to describe other losses from brain drain. [author’s description]

The aim of this paper is to examine some key issues related to the international migration of health workers in order to better understand its impact and to find entry points to developing policy options with which migration can be managed. [from abstract]

The study was conducted with the aim of generating evidence needed to enhance the Ministry of Health and Social Services’ (MoHSS) endeavours to redressing inequities in resource allocation in Namibia. It specifically purports to develop a needs-based allocation formula that will assist the MoHSS to shift its resource allocation mechanism away from the historical incrementalist type. [from executive summary]

Many countries are using the strategy of international recruitment to make up for shortages of health professionals. This is often to the detriment of health systems in the poorest parts of the world. Codes of practice on ethical international recruitment or similar instruments are beginning to be introduced at both national and international levels to protect the health systems of vulnerable countries. This study was designed to review the potential impact of existing instruments. [from executive summary]

Increasing the numbers of health workers and improving their skills requires that countries confront a number of ethical dilemmas. The ethical considerations in answering five important questions on enabling health workers to deal appropriately with the circumstances in which they must work are described.

This presentation was part of the “Call to Action: Ensuring Global Human Resources for Health” conference. It defines ethical recruitment and outlines the 2003 Commonwealth Code of Practice for International Recruitment of Health Workers including the underlying principles and complementary policy measures.

This report calls for provincial governments to take a closer look at the way they hire doctors, nurses and other health professionals from developing countries. Canada has always relied on newcomers to help deal with shortages in this field, but increasingly these professionals are coming from developing countries, especially from Africa and Asia, which have staffing shortages and critical health problems of their own. The report, The Ethical Recruitment of Internationally Educated Health Professionals: Lessons from Abroad and Options for Canada, looks at how other countries are handling the issue, examines the views of key players and outlines some first steps for Canada’s provinces to begin the process of developing a code of practice or series of guidelines. [publisher’s description]

The Royal College of Nursing commissioned this report into the employment policy and practice implications of the rapid growth in the number of internationally recruited nurses working in the UK. [from summary]

This paper discusses the implications for health personnel of the HIV epidemic, and health sector responses to it, in southern Africa, using Malawi as a case study. Published and grey literature has been consulted to assess the situation and its implications for equity. [author’s description]

This study estimates the personnel cost implications of implementing the newly proposed Integrated Management of Childhood Illness (IMCI) algorithm in the first level health care facilities in rural Bangladesh. Policy makers need to know the additional resource requirements for IMCI before its actual implementation so that appropriate levels and combinations of personnel and drugs can be allocated. [abstract]

A human rights framework provides a formal and explicit way to examine the different social, political and economic problems that both give rise to, and result from, international migration, in particular inequality. It also allows clear and explicit articulation of where the obligation to do something about these human rights impacts lies under international human rights law, together with migration of health workers; and ensures that any improvements in the right to health are achieved without any express limitation of any other rights, including freedom of movement and rights in work. The most appropriate response to the problem of health worker migration is likely to be an integrated one: a combination of preventative and mitigating responses that address the human rights causes and consequences of the migration of health workers; and ensures that any improvements in the right to health are achieved without any express limitation of any other rights, including freedom of movement and rights in work.

This publication provides an overview of some of the key challenges for policy-makers in addressing the linkages between migration, health and human rights.The first section explains why we are addressing the issue of migration and health and what is meant by doing this through a human rights framework. It then explores some of the terminology used. The second section links the reasons why people migrate with the health and human rights implications of moving on the populations left behind. The third section considers the health implications for those on the move both in the context of public health as well as in relation to the health of the individual.

Whilst the issue of international migration of health workers is sometimes presented as a one-way linear ‘brain drain,’ the dynamics of international mobility, migration and recruitment of health workers are complex. Against this complex backdrop, the main objectives of this paper, drawing from the terms of reference, are: to examine trends in the inflow of health workers to the UK; to examine the methods used in the international recruitment of health workers to the UK; to report on the Department of Health Code of Practice; to provide case studies in the impact of outflow of health workers from developed countries (Ghana and Barbados); and to discuss the international policy context of health workers recruitment and migration and identify current knowledge gaps for future research.

This paper assesses the reasons for recent growth in recruitment of registered nurses from other countries to the United Kingdom (UK). It aims to examine trends in inward recruitment of nurses to the UK, assess the impact of free mobility of registered nurses in the European Union from a UK perspective, examine the impact of the introduction of ethical guidelines on international recruitment of nurses to the UK, and explore the reasons why registered nurses are internationally mobile. [from introduction]

This guidance sets out the key considerations and principles for ensuring both ethical recruitment and employment of internationally recruited nurses. [from author’s description]

London is more reliant than other parts of England on the international recruitment of health professionals. This raises several questions. How can employers support and develop such a diverse workforce? How can they retain hard-won international health care staff in the face of increasing international competition? And is it ethical to recruit workers from developing countries experiencing their own shortages? This research summary profiles the capital’s international health care workforce for the first time, with case studies detailing the experiences of three London NHS trusts. It is the first publication of a wider programme of work on the international recruitment of health workers to the capital. [publisher’s description]

Canada is a major recipient of foreign-trained health professionals, notably physicians from South Africa and other sub-Saharan African countries. Nurse migration from these countries, while comparatively small, is rising. African countries, meanwhile, have a critical shortage of professionals and a disproportionate burden of disease. What policy options could Canada pursue that balanced the right to health of Africans losing their health workers with the right of these workers to seek migration to countries such as Canada? [author’s description]

Shortages of skilled health workers occur in most countries in the world, and most significantly in countries where education levels are relatively high. Migration has tended to be at some cost to relatively poor countries where the costs of production are considerable and losses are not compensated. The costs of global mobility are thus unevenly borne by the poorer source countries and the benefits are concentrated in the recipient countries. Since migration cannot be ended, and source countries have only limited scope for substantial policy change that will improve the number and status of health workers in the home countries, the onus has increasingly shifted towards the role of recipient countries in ensuring that, if migration is to continue, then it be more equitable and that there be adequate compensation for losses incurred in source countries.

One major challenge for all countries is to establish workforce planning mechanisms that effectively meet the demands for health care and provide workforce stability. However, few nations have developed strategic plans for meeting nursing resource requirements that effectively address supply and demand. Instead, many developed countries choose to implement short term policy levers such as increased reliance on immigration, sometimes to the detriment of developing countries. This has prompted calls for developed countries to employ a model of so-called self sufficiency in addressing nursing and other health human resource shortages.

An honest and critical examination of the role of Health Care Professionals (HCPs) during communicable disease outbreaks is needed in order to provide guidelines regarding professional rights and responsibilities, as well as ethical duties and obligations. With this paper, we hope to open the social dialogue and advance the public debate on this increasingly urgent issue. [summary]

This paper focuses on nurses who have migrated and are registered/licensed/authorized to practice, post-adaptation/orientation, and are working as a nurse in a given country. The term international nurse is used for nurses who have been educated abroad and have either been recruited or have chosen to migrate. This paper aims to provide an overview of the influences of international policies and agreements, the social and personal benefits and costs of migration for international nurses based on their experiences, and to outline a possible framework to develop positive practice environments to support long-term integration and the retention of this valuable resource.

The purpose of this guide is to explain why it is necessary to ground health workforce planning in human rights, and how to develop a plan that does just that. [from summary]

This editorial describes the widespread recruitment of health workers from sub-Saharan Africa to developed nations by recruiting agencies. The authors describe international efforts to criminalize this practice and express concern at the continued practice of recruitment.

This report summarizes the results of the first year of the two-year project entitled International Recruitment of Nurses to the United States: Toward a Consensus on Ethical Standards of Practice. It examines the structure and basic practices of the U.S. based international nurse recruitment industry. The purpose of the project is to facilitate consensus among stakeholders on how to reduce the harm and increase the benefits of international nurse recruitment for source countries and for migrant nurses themselves. [from author]

The Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the United States reflects the mutual recognition of stakeholder interests relevant to the recruitment of foreign educated nurses. It is based on an acknowledgement of the rights of individuals to migrate, as well as an understanding that the legitimate interests and responsibilities of nurses, source countries, and employers in the destination country may conflict. It affirms that a careful balancing of those individual and collective interests offers the best course for maximizing the benefits and reducing the potential harm to all parties.