Ethical recruitment and migration of health workers

Professor Ruairí Brugha

Irish Forum for Global Health Symposium on the Health Workforce

School of Nursing, Dublin City University20th October 2011

Abstracts

• Ethical Recruitment of Health Workers: page the Global Code

85• International Nurse Recruitment,

Risk and Recession: The Irish Experience 83• RN4CAST Nurse Forecasting in Europe:

findings relating to nurse migration in Ireland 87• The Migration of Sudanese Doctors to Ireland:

Push and Pull Factors 80• The Doctor Migration Project 81

WHO global code of practice on the International Recruitment of Health Personnel

• A voluntary code adopted by member states (including Ireland) at the World Health Assembly, May 2010.

• Health Worker Global Policy Advisory Council drafted the code over 3 years (8 meetings) chaired by President Mary Robinson

• The code specifies the ‘rights and responsibilities’ of countries (source and destination), employers and health workers

• It commits countries to adhere to principles and practices, e.g. “member states should ...” “...are strongly encouraged to ...” Practice ethical international recruitment of health personnel Develop health workforce and strengthen health systems. Monitor implementation of code and share data

How is Ireland performing? trends in nurses

0

500

1,000

1,500

2,000

2,500

3,000

2000 2001 2002 2003 2004 2005 2006 2007 2008

Chart 2: Nurses Newly Registered with the Irish Nursing Board 2000-2008 (N=27,679)

Ireland EU Non-EU

16,289 nurses newly registered with Irish Nursing Board between 2004 and 2008, 45% from non-EU countries, 12% from other EU countries, 43% were Irish 45% of non-EU nurses from India 45% from Philippines

Ireland ranked 1st for foreign nurses (47%) New Zealand 2nd (23%): OECD 2008

How is Ireland performing? trends in Doctors

Irish Medical Council registrations by country of qualification, categorised as Irish, non-Irish EU and Non-EU for the period 2000-2010

Ireland ranked 2nd for foreign doctors (35%) New Zealand 1st (39%): OECD 2008

Total registrations Irish Medical Council, 2000-2010

Year Irish graduates (n)

IMGs (n) International medical graduates as % of workforce

2000 11,300 1,752 13.4

2005 12,611 4,279 25.3

2010 12,459 6,261 33.4

Countries where doctors qualified

Consequences for sending countries?

• Philippines: managed nurse emigration policychildren trained for emigration (remittances sent by 87%)but loss of nurse trainers and specialists (India also)?

• Cost of training doctorsSudan: 21,000 Drs registered 12,000 (57%) overseas

1,500 graduate annually 800 (53%) emigrate

• Potential benefits?Sudan: main reason for emigrating: training (44% of 120)

career intentions: intend to go home (95%)have same training opportunities as Irish Drs (10%)

• Need for research Career experiences of foreign Drs in Ireland (RCSI-TCD) Effects on sending countries’ health systems (methodological difficulties in

researching the loss of staff)

Responsibilities of all countries

• International recruitment should be done in a way that promotes “sustainability of health systems in developing countries”

• “Member states should take effective measures to educate, retain and sustain (its)health workforce . . . .”

• Ireland failing to retain its domestic and immigrant nurses In 2008, 1,000 Irish and 1885 Indian nurses applied to have their

qualifications verified by overseas registration bodies (up from 335 Indian nurses who sought verifications in 2007 )

In 2007, during the height of the economic boom, 11 of 21 nurses interviewed in-depth planned to leave Ireland. Why? lack of family friendly immigration and work permit policies

• Large annual shortfalls in domestic supply of nurses in Ireland predicted up to 2021

Health workers have rights!• Freedom of health workers to migrate, subject to national laws

(much discussion at the Council, which concluded that it is neither ethical nor feasible to limit migration – but HWs have duties too)

• A right to receive accurate information Specialised nurses – Theatre and CCU – expected that their expertise would be

used in Ireland – not that they would be assigned to Geriatric wards. Recent media reports that foreign doctors were promised higher salaries than

they are receiving in Ireland• “Equality of treatment with the domestically trained health work

force . . . Same legal rights and responsibilities . . . Opportunities and incentives to strengthen their professional qualifications” Access to postgraduate training programmes? Other forms of training?

• Freedom from discrimination 53% of Sudanese doctors reported discrimination by

colleagues 22% bullying reported by immigrant nurses *CHECK*

Monitoring the Code

• 4 of 10 ‘articles’ in the Code cover data and research, information exchange, implementation and monitoring

• Member states to have designated a “national authority for the implementation of the WHO Global Code” by June 30th 2011

• The data on foreign nurses used by the Dept of Health have come from the RCSI nurse migration study (see Humphries et al.)

• Spreadsheet of medical doctor registration data from the Irish Medical Council, 2000-10 has been cleaned and transformed by Pat Dicker, as part of the HRB Foreign Doctors in Ireland study

These will enable Ireland to fulfil its reporting duties and report Level A (core data) to the World Health Assembly, in May 2012

An example of a researcher–policy maker partnership, where the first research output enables the policy maker fulfil its global reporting duty

Cross-Cutting Issues / Questions

• Health workers are expensive to produce and can be considered a highly marketable resource in a globalised world.o It is cheaper for countries to import than to produce doctors + nurses (US)o What does a heavy reliance on recruiting doctors and nurses from

overseas say about a country’s health system?

• Given Ireland’s ‘outlier’ position in respect to recruitment and reliance on foreign health workerso What are Ireland’s responsibilities (if any) to the doctors AND

to the countries from which it recruits?o How can it discharge those duties?

• Retention and Migration – push and pull – are two side of the same coin. What research should we be doing to link the two facets of this phenomenon?