Cehan Si Manea 2012 [618173]

100 Romanian Journal of Bioethics, Vol. 10, No. 1, Janu ary – March 2012
INTERNATIONAL CODES OF MEDICAL
RECRUITMENT: EVOLUTION AND
EFFICIENCY
Irina Cehan*, Teodora Manea**
Abstract
The phenomenon of international migration of health care professionals has increased in the last
decade, emphasizing the issue of medical staff cris is in some countries. In this context,
international recruitment of healthcare professiona ls has turned into a usual practice for many
states, as a solution to cover their lack of medica l staff, causing at the same time a real problem
to developing countries. Thus, after adopting regio nal codes and interstate memoranda, the
World Health Organisation adopted in 2010 The Globa l Code of Practice on the International
Recruitment of Health Personnel to use it as a land mark for establishing and improving the
necessary legal framework of medical staff internat ional recruitment. Our research aims to
highlight the ethical and praxeological codes regar ding the medical staff recruitment and to
analyse the effectiveness of those codes, as well a s the consequences that might result from
disobeying them.

Keywords: international migration, healthcare professionals, ethical international recruitment,
code, memoranda of understanding.

* Postdoctoral researcher, Center of Ethics and Heal th Policies, „Gr.T.Popa” University of Medicine and
Pharmacy, Ia úi, Romania, email: [anonimizat]
** Postdoctoral researcher, Center of Ethics and Heal th Policies, „Gr.T.Popa” University of Medicine and
Pharmacy, Ia úi, Romania, email: [anonimizat] 1. Context: ethical issues
arising from the recruitment
of medical personnel
Human resource is essential for the
healthcare system in any country. The
phenomenon of international migration
of healthcare professionals has increased in the last decade and, although itself it is
not a reason for the world crisis of labour
in the healthcare field, it underlines this
issue at the level of some countries [1].
In 2006 the World Health Organisation
estimated a shortage of 4.2 million
professionals [2]. In this context, the

101 international recruitment of healthcare
professionals became a usual practice in
many countries, as a solution to cover
their lack of staff, but, at the same time, it
became a problem for the developing
countries. The acceleration of the
recruitment from those countries
unbalances their health care systems,
already in danger due to financial
difficulties. Thus, the practice of
recruiting from less developed countries
has a double negative effect. First of all,
the promised wages in the rich countries
encourage doctors to leave. Secondly, the
shortage generated by losing specialists
amplifies the inefficiency of the existing
healthcare systems. A third aspect could
be added to the first two, which refer to
complex topics such as responsibility and
social justice. The poor countries are
constrained by the International
Monetary Fund and the World Bank to
financial sacrifices in the public sector,
and those financial sacrifices hit again
the healthcare system and the
disadvantaged social classes. By
contextualisation of the problem of
medical staff migration from this
perspective, the ethical issue of
responsibility moves from an individual
level (in our case, the doctor who decides
to emigrate) to the level of the rich
countries that become morally
accountable for the problems of social
justice that may come up in the poor
countries, such as impairment of the
fundamental rights of individual to
protect his health. The right to health is
one of the fundamental human rights,
recognised by national and international
legislation. However, it not only involves
a country’s obligations towards its own
citizens, but also the obligations of the
recruiting states, claiming considerations
of transnational justice [3].
Another aspect pertaining to the
social justice is what may briefly be called: the use of resources . Doctors are a
social resource in their country of origin
which invested money, time, and
intelligence to educate them [4]. Is it
right that other states – especially the rich
countries with financial possibilities and
excellent educational means to train their
own doctors – should access and make
use of that resource? The conflict
between the individual right to emigrate
and the social responsibility of the
physicians seems to be a serious dilemma
for the common morality [5]. We will not
try to solve this dilemma here, but we
will project this problem in a specific
context, focusing on the analysis of one
fundamental regulatory instrument for
the medical migration: the recruitments
codes. The protests of some voices
affected by this phenomenon and the
increased attention given to the ethical
aspects involved in the international
recruitment of medical staff have
encouraged certain policies to
compensate the migration flow of
healthcare professionals, which aimed to
financially compensate the poor
countries, to encourage the doctors to
return (permanently or temporarily), to
remit incentives, and the cooperation
between educational and research
institutions from developed countries and
those from developing ones [6].

2. The Origin and Evolution
of International Recruitment Codes
Starting with 1999, simultaneously
with the increase in the international
migration of healthcare professionals and
the consequences resulting from it, many
countries have shown their concern about
the shortage of staff, and the demand for
policies on ethical international
recruitment increased too [7].
Unfortunately, so far there is no known
and agreed definition of the notion of
ethical international recruitment , or

102 consensus about the significance and
location of harmful recruitment practices
[3]. This is hard to accomplish given the
complexity of the ethical, legal,
economic and social aspects associated
with the migration and the different
views, motives and interests of the
stakeholders. A solution to minimise the
negative effects caused by the medical
staff migration was found through the
design and adoption of certain practice
codes and memoranda of understanding
which establish the terms of an ethical
and equitable international migration.
The necessity to remedy the world
crisis of healthcare professionals was
pointed out during the G8 summits in
Tokyo (Japan, 2008) and Aquila (Italy,
2009), and the World Health
Organisation decided to develop a
practice code of international recruitment
which, in 2010, became The WHO
Global Code of Practice on the
International Recruitment of Health
Personnel . This code is not something a
completely new, although its significance
is granted by the worldwide dimension it
wishes to assume and define. The year
1997 was important for the development
of regional codes of practice. At that time
Nelson Mandela criticised Great Britain
for recruiting nurses from South Africa.
In response, in 2001 The National Health
Service (NHS) in Great Britain
developed the first code regarding the
recruitment of healthcare professionals,
based on the 1999’s initial policy.
Beginning with that year several
countries have adopted the Great
Britain’s model and developed codes of
practice and memoranda of
understanding meant to lead towards an
ethical international recruitment.
These regional efforts, together with a
clearer awareness that the ethical issues
related to recruitment can be sorted out
by elaborating suitable policies and tools, made the 2004 World Health Assembly
to underline the need for effective
regulations aimed to reduce the side
effects of the migration. The Global
Health work Alliance (GHWA),
established in 2006, asserted once again
the necessity of a worldwide code for
international recruitment.
Another important aspect about the
origin of the codes deals with their
source . The regional codes of practice
were adopted before the release of the
global code written by various entities,
usually governmental agencies or
regional structures, such as the
Commonwealth Secretariat and The
Pacific Forum. The heterogeneity of the
sources could be seen in the
heterogeneity of the language and the
content. The contents of the codes and
memoranda of understanding were
different in approach, terminology,
topics, sectors and areas covered, as well
as in the implied expectations. Of course,
this was determined by a desire for a
short structuring of the ethical
recruitment principles and for a more
encompassing perspective, which might
ensure an instrumental character to the
codes and their efficiency.
I. National codes adopted:
NHS Code of Practice (2001), UK:
(the first national code) [8]
Code of Practice for International
Recruitment of Healthcare Professionals
in Scotland (2006) [9]
II. Regional codes:
Commonwealth Code of Practice
(2003): (the first regional code) [10]
Pacific Code of Practice (2007)
III. Global codes:
WHO Global Code of Practice on the
International Recruitment of Health
Personnel (2010): (the first global
code) [11]
The first code adopted by Britain’s
NHS and built on the 1999’s initial

103 policy was released in 2001 and reviewed
in 2004. Later on, the first adopted
regional code was the Commonwealth
Code of Practice (2003) and
subsequently a national code was
introduced in Scotland in 2006, and the
Pacific Code of Practice, published in
2007 had regional applications.
The earliest regional code, The
Commonwealth Code of Practice (2003),
was built on prior international
instruments, such as conventions of
International Labour Organisation (ILO)
on the workers’ rights [12]. However, not
all the countries signed those
conventions, such as the 1997 Nursing
Personnel Convention [13], which
partially represented the prototypes for
the codes. That regional code provided
an important stipulation, namely, that
recruiters might not recruit foreign-
trained health professionals because the
latter had a special obligation to their
country of origin, which invested in the
training resources. For the first time, that
code introduced the notions of
compensation and repair in the cases
when the destination countries gained
advantages by foreign recruitment.
Nevertheless, the stipulation was
optional, unlike in the Pacific Code
where it became compulsory. The Pacific
Code , based on the Commonwealth
Code , was one of the most important
regional codes and the only one to
stipulate the necessity for an impact
measurement in the developing countries.
While estimating the possible side effects
of migration, these countries can come
up with policies that might balance the
healthcare labour. We must say that the
first code on recruitment (NHS 2001)
mentioned only the question of active
recruitment, leaving an extremely
important aspect uncovered: monitoring
the impact of the healthcare personnel.
NHS didn’t have the information necessary for monitoring its own
recruitment of nurses [14].
All the subsequent codes relied and
built on the provisions of the prior codes,
up to the 2010 WHO Global Code of
Practice . Until the release of the global
code, all the codes had been limited to a
geographical area and had a high degree
of generalisation, excluding the
application of the provisions to the
private healthcare sector. The last point
was one of the weaknesses of the
regional codes, since the healthcare
system should be seen from a global
perspective, including the private sector,
which also provides medical services
necessary for the population. Even if we
can argue that the private sector may
have its own rules, depending on its
management and economic interests,
some authors [15] believe that the private
sector has become a back door , which
doctors can use to enter the state system.
The high degree of generalisation of the
respective codes didn’t cover situations
specific to certain countries, because they
couldn’t regulate on a large scale, all the
aspects involved in different healthcare
systems, with particular needs.

3. The Objectives of
Regional Codes
The international codes for healthcare
workers released before 2010 focused on
three main objectives:
a) To protect the rights of emigrating
healthcare professionals;
b) To ensure the emigrants’ training
and support for their workplace (aiming
even at actual supervision at work,
proper work conditions, training
sessions);
c) To ensure that the migratory flows
did not affect the provision of healthcare
services in the countries of origin (with
implications of compensation and non-
recruitment from these countries).

104 In fact, these codes focused on the
first two objectives, so they were more
significant in the beneficiary countries.
The third objective was given less
practical importance, the rights of the
emigrating personnel in the destination
country having more significance [16]
than the right to health of the persons in
the countries of origin. For example, the
code of practice in Scotland (2006)
stipulates seven directions, out of which
six concern the rights of the emigrating
workers and of the healthcare system in
the destination country. The third
principle of this code states that the
developing countries won’t be the target
of recruitment unless there are explicit
agreements with Great Britain to support
the recruitment activities. In contrast with
the Pacific Code , which underlines the
rights of the source countries, the
necessity of mutuality and a certain type
of compensation, the code adopted in
Scotland does not mention these aspects,
ignoring the national needs of the
countries of origin and emphasising the
individual rights and privileges even
more.

4. Memoranda of Understanding
To support the ethical recruitment,
along with the regional codes, states have
signed a series of memoranda of
understanding, as the one between
Philippines and Great Britain (2002),
Spain and Great Britain (2001), South
Africa and Great Britain (2002),
Netherlands and Poland (2003) and
recently between Kenya and Namibia,
Kenya and Lesotho concerning the
recruitment of nurses. Memoranda of
understanding (MOUs) were different
from codes in the sense that were
bilateral and had more specific
provisions, focused on particular groups,
to a certain number of citizens and
specific periods of time. Some of them appeared as a result of the concerns of
Philippine state about the treatment of
Philippine’s nurses in Britain’s care
homes [3].
Some MOUs had benefits for the
countries of origin, as the one between
South Africa and Great Britain, when
nurses returned home after two years of
experience with new skills, helping to
improve the provision of medical
services in their country. The small scale
bilateral agreements and MOUs have
favoured the return of emigrants to their
native country, because such temporary
migration has led to achieving
competences and has generated revenue
and remittance solutions. The fact that
recruitment of medical personnel from
source country did not drain the entire
workforce was essential for the
sustainability of that medical system.
MOUs and bilateral agreements were
more effective than codes, being more
specific to a certain extent, and adjusted
to particular conditions of healthcare
systems in both source and destination
countries. At the same time they opened
up new ways for other bilateral
cooperation.

5. WHO Global Code
of Practice on
the International Recruitment
of Health Personnel
The Global Code of Practice on the
International Recruitment of Health
Personnel [11] highlights the practice of
bilateral agreements and memoranda of
understanding for supporting ethical
recruitment, this being the culmination of
the code’s development. This code aims
to establish a series of voluntary
principles and practices for ethical
international recruitment of healthcare
professionals, taking into account the
rights, obligations, expectations of the
source and destination countries, as well

105 as the interests of the migrant healthcare
personnel. The code is supposed to serve
as a reference point for the member
states when they establish and improve
the legal framework regarding the
international recruitment and also to act
as guidelines for the implementation of
international treaties and other legal
instruments. The WHO Code is similar to
the Commonwealth Code as concerns the
objective, the content, the coverage in
many countries with different healthcare
systems, and the conditions on the labour
market; however, it is closer to the
Pacific Code in that it emphasises the
primary needs of the source countries,
the need for mutuality and a certain type
of compensation.
The ethical principles are set out by
the WHO Code differently, so as to
strengthen the healthcare system in the
developing countries, or in those with an
economy in transition, ensuring the
application of the third objective
(protecting the health services in the
countries of origin), which heretofore
was not ensured by the regional codes.
Out of the stipulated principles we
notice:
a) The emphasis on the public health
as a fundamental right based on the
cooperation of each individual and states.
The governments are mentioned to have
a great responsibility in the health care
field, a responsibility that can be met by
adequate regulations and suitable social
measures (WHO Code, 3.1).
b) The solution to the current and
future shortage of health personnel is
important for protecting global health.
Here, we must point out a certain error of
classification: although the shortage of
health personnel is clearly dealt with
from the perspective of the rich countries
on recruitment, it is integrated in forms
as a part of “global health”. Thus, it
becomes a universal ethical imperative for everyone, and, consequently, for poor
countries too. The international migration
of health personnel is said to bring an
essential contribution to the health care
system if the recruitment is carried out in
a proper way (WHO Code, 3.2).
Basically this statement seems to be
pretty ethical, but it concerns the
morality of a way and not the fact itself.
Maybe the problem could be
reformulated this way: Is the idea of
recruitment in itself acceptable from the
ethical point of view? Is it ethic to use a
resource created for another society? The
ethical dilemma can be sharpened more if
it is mentioned that these states do not
have financial problems that could
prevent the investment of funds in
training a sufficient quantity of
healthcare personnel.
c) The developed countries should
technically and financially support the
developing countries as much as possible
and should aim at strengthening the
healthcare systems of those countries and
the development of the health personnel
(WHO Code, 3.3). The Code here
presents another ambiguity: it is not clear
if that refers to the human resources
development, in the sense of contribution
to the specialisation, hence the
qualitative development, of the doctors in
those countries, by training, instruction
sessions, etc. In this respect, the
development objective can theoretically
be attained. However, if we take into
consideration the quantitative dimension
of the development-for example, the idea
that a state should move from 1.9%
doctors per one thousand inhabitants to
3.3%. Then the state clearly needs more
doctors, which absolutely contraries to
the idea of recruitment.
d) The legal provisions of the Code
do not forbid or confine the freedom of
the health personnel, and their emigration
to other countries for employment

106 reasons. Although the point of
“individual freedom” seems to be ticked
off to ensure the ethical dimension of the
document, the freedom is mentioned in
the directory principle 3.4 in a utilitarian
context: the entire cocktail of health
standards for the population in the source
countries, individual rights, existing
legislation must be analysed “to mitigate
the negative effects and maximize the
positive effects of migration on health
systems of the source countries.” (WHO
Code, 3.4). From the philosophical point
of view, it is difficult to put the freedom
and utility at the same level. In the
context of migration, these concepts
rather lie in a disjunction hard to
reconcile: the individual has the right to
freedom , as a fundamental right, and the
society has to minimize its losses and
maximize its profit to ensure the
wellbeing of its own citizens.
e) The international recruitment
should take place in accordance with the
principle of transparency , correctness
and sustainability of the health systems
in the developing countries (WHO Code,
3.5).
f) The member states, as much as
possible, have to create workforce in the
healthcare field, education and training,
and adopt retention strategies that may
reduce the need for recruiting migrant
health personnel (WHO Code, 3.6). This
is a very important principle, which
might deserve a top position.
g) The seventh principle concerns
with the necessity of gathering
information on health personnel
recruitment, which should be made
known to all member states, and with the
dissemination of the information on the
health personnel recruitment.
h) The member states should
facilitate the circular migration of
healthcare professionals, so that both the
source and the destination countries should benefit from the acquired skills
(WHO Code, 3.8).
Besides these principles, the Code
stipulates a series of responsibilities ,
rights and recruitment practices to assist
an ethical recruitment, drawing attention
to some extremely important aspects.
One of these refers to the recruiter’s
understanding of the social responsibility
of the healthcare personnel towards the
source country, as an equitable contract
of services and, consequently,
recruitment is best to be avoided. For the
first time, this Global Code recommends
that active recruitment from the
developing countries, which have an
acute shortage of personnel, should stop,
except the cases where states have
bilateral and multilateral agreements
between governments. In this way the
states have a reciprocity position and the
recruitment process will take place as it
was established, a practical control of the
phenomenon being also possible.
Another aspect refers to the fact that
member states should ensure that ethical
practices of international recruitment will
allow the healthcare personnel to
properly asses the risks and benefits
directly associated with their own
contractual position and therefore take
the best decision accordingly. At the
same time, the medical staff should
comply with their contract obligations.
The Code promotes also the application
of the principle of equal chances and
non-discrimination and therefore the
employment of medical personnel is
recommended to be done on equal basis,
as well as for the local labour, by
granting the same responsibilities and
rights, equal treatment and continuous
professional education. All the
responsibilities, rights and practices
involved in international recruitment of
healthcare personnel, which recall some
stakeholders like: local authorities,

107 recruitment agencies, professional
organizations, medical staff, should have
as central pillar the interest of the patient ,
no matter if we speak about the source
country or the destination one. By
protecting the rights of doctors and the
interests of source countries, the right to
health of patients in source country and
the destination one will also be protected.

6. The effectiveness of the codes
The codes of good practice for the
international recruitment of healthcare
personnel and MOUs as voluntary
instruments for the recruitment
framework do not provide specific
sanctions depending on the seriousness
of encroachments brought to the parties’
agreement. For the non-compliance with
their provisions only few verbal warnings
were recorded towards recruitment
agencies in Great Britain, but the most
severe sanction was the prohibition of
eleven recruitment companies on the
labour market [3].
There is no proof of punitive actions
besides some moral pressures towards
some countries in order to participate to
an ethical international process of
recruitment. Thus, the support for these
codes was more symbolic than real, and
no country developed a mechanism for
monitoring the compliance with code’s
principles. The lack of codes’
effectiveness also results from the fact
that not all the emigrants in the health
system are covered by their provisions.
Many of them emigrate individually and
sometimes not as healthcare worker, and
that’s very difficult to monitor. For
example 6000 nurses from Philippine
state were reported as recorded between
2002 and 2003, but only 186 have been
declared as being recruited on a bilateral
agreement basis [14].
The regional codes do not cover all
the employers in the health system: the first attention was on the public sector
and the private one was left uncovered.
In this way, the private sector became a
niche for backdoor recruitment in public
sector [14] for those who moved
independently or have been recruited in
the private sector in Great Britain. We
can not assign a change of migration
flow only to the impact of codes of
practice to appreciate their effectiveness,
because the migration phenomenon is
influenced by a wide range of factors (for
example, the change of request in the
destination country can reduce the
migration flow).
Until the Global Code, the lack of
regional codes from many places
suggested at least a degree of scepticism
about their effectiveness, which did not
determined states to assume such
commitments. As long as codes will
remain voluntary , it is unlikely to attain
their objectives. Even at the level of
recommendation, they still represent an
important tool to influence the
recruitment’s behaviours [17]. Bilateral
agreements and memoranda of
understanding have a greater chance of
success, being more particular, helping to
the management of migration and to
returning migration, although they are
geographically limited.
A particularly important aspect in
recognizing and applying a code, and
therefore with an impact in his
effectiveness, is its visibility to the agents
involved in healthcare recruitment.
Without knowledge of code’s provisions
actions to an ethical recruitment can not
be deployed. The Global Code
encourages mutual information of states
in the international dialogue, on matters
related to medical personnel and their
own health system, as well as on concrete
measures for implementing the Code
(articles 7.2 and 9.1 from Code). The
WHO Secretariat has developed a series

108 of useful “ Guidelines ” for monitoring the
implementation of Code. They are just
recommendations for the member states
in terms of information and materials
contained in the periodic national
reporting, which will be required starting
with 2012.
The process of reporting is an integral
component of effective implementation
of the Code. In time, the implementation
of these guidelines will provide a
permanent source of information
necessary for the progress evaluation in
compliance with the global practice code
[11]. The facilitation of WHO reporting
of national situations related to the
recruitment of medical staff through
these guidelines represent a support to
the states and a determination at the same
time to applying the provisions of the
Code. Monitoring the implementation of
the Code in the member states will give a
measure of its effectiveness in supporting
the process of ethical international
recruitment. But without a clear
connection between explicit objectives of
the Code and the relevant monitoring
capacity it is not possible to determine
the impact of the current state of a
code[18].
Some member states have suggested
that the development of a monitoring
system for the implementation of the
Global Code is very important in case the
Code becomes a significant component
of political responses on the question of
international medical recruitment, while
other states have supported the idea that
the implementation of a mechanism is
not suitable for a voluntary code of
practice [19].

Conclusions
The existence of practical codes on
ethical international recruitment, and
particularly of the Global Code is a testimony of the need for such
regulations to maintain a global balance
of the healthcare workforce, in
accordance with each country’s needs, to
ensure mutual benefits and to establish
principles of ethical recruitment. The
Global Code will show maximum
efficiency when the member states will
be able to embed the objectives and the
principles of the code in national policies
and legal instruments that can be applied,
and when there will also be effective
mechanisms for their monitoring.
The adoption of the Global Code of
practice still represents a historical step
in the recognition of the mutual
responsibilities of both destination and
source countries in ensuring the citizens’
right to health. But the biggest challenge
that the Code will face will be the
dilemma: individual rights versus states’
rights , that will impact both the
individual in terms of personal choice (to
emigrate or not, to exercise the
profession in a particular country) and
the representative organizations of states,
which are called to guarantee the
fulfilment of the right to health and to
maintain their own health care system.

Note
This paper is supported by European
Social Fund through Sectorial
Operational Programme Human
Resources Development 2007-2013
(SOP HRD), under the project
“Postdoctoral Studies in the Field of
Health Policy Ethics”, implemented by
“Gr. T. Popa” University of Medicine
and Pharmacy Iasi, Romania, contract
number POSDRU/89/1.5/S/61879.
This paper doesn’t obligatory
represent the official opinion of
European Union or Romanian
Government.

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