This article is a synopsis of a longer document put together jointly by EPHA and the European Federation of Nurses Associations (EFN). As a continuation of the advocacy effort that began in 2011 with the EPHA Briefing on the WHO Code, it represents a call to all relevant actors to step up their implementation efforts.


The WHO Global Code of Practice on the International Recruitment of Health Personnel is a response to the large-scale migration of skilled health personnel from low income source countries to middle and high income receiving countries, including the European Union (EU). In the EU as elsewhere, demand for health workers is rising due to the effects of demographic change, the restructuring of health systems, and lack of strategies in health workforce planning and policy-making. This has led to a massive ‘brain drain’ from developing and transition economies driven by complex ’pull’ (e.g., higher wages, opportunities for career development and training) and ’push’ factors (e.g., inadequate resources, poor lifestyle conditions, political instability). The effects have been harsh since a number of countries’ health systems, especially in sub-Saharan Africa, are on the verge of collapse.

But shortages, geographical maldistribution and inadequate skill mix are not only posing a threat to public health and creating new health inequalities in the poorest countries. Since the adoption of austerity measures to mitigate the ongoing economic crisis, thousands of doctors and nurses have migrated from Eastern to Western Europe. This is compromising the (self-)sustainability of health systems all over Europe, with severe service provision gaps experienced in rural and economically deprived areas on the one hand, and dependency on qualified migrant professionals in the rich countries on the other.

The WHO Global Code of Practice

To rectify these imbalances, the WHO Code includes four important objectives in support of the health workforce:
- 1) To establish and promote voluntary principles and practices for ethical international recruitment, taking into account the rights, obligations and expectations of source and destination countries, and migrating health personnel;
- 2) To serve as a reference for Member States in establishing/improving the legal and institutional framework for international recruitment;
- 3) To provide guidance that may be used where appropriate in the formulation and implementation of bilateral agreements and other international legal instruments; and
- 4) To facilitate and promote international discussion and advance cooperation on matters related to ethical recruitment as part of strengthening health systems.

As a flexible reference and guidance tool for international dialogue, information exchange and cooperation on health workforce mobility, the WHO Code surpasses its remit of strengthening the health systems of developing countries, economies in transition and small island states. Moreover, its guiding principles expressly acknowledge the role of governments in taking responsibility for public health.

At a time when health systems are suffering under acute financial constraints, shortages, lack of retention, and professional unattractiveness, the Code becomes also a tool to address the wider health workforce challenges, and it is hoped that it can play a key role in revising and improving health workforce strategies. These are badly needed to improve planning, data collection and analysis regarding mobility, as well as in developing attractive recruitment and retention policies. Moreover, the correct use and management of EU Structural and Social Cohesion Funds can bring the new Member States (e.g., Romania and Bulgaria, where the effects of out-migration have left a noticeable mark on the health system) on a par.

Time to Act Now

While this sounds encouraging, there is one major problem: given that the Code is not legally binding, who will encourage and monitor its full and proper implementation? After all, there is way too much at stake to accept its failure. While the recent European Commission Action Plan for the EU Health Workforce is a step in the right direction that makes explicit reference to the Code, and facilities such as the future Joint Action on Health Workforce Planning and Forecasting are crucial for determining workable long-term solutions, there is a distinct need for civil society to keep a close eye on what is happening in the Member States, both at national and at regional level.

Only by identifying loopholes and reporting breaches will there be enough ’’ethical pressure’’ for the EU’s Member States to do their best to meet the Code’s provisions. Civil society stakeholders therefore play a crucial partner role in ensuring that health systems can really be strengthened, and that source and destination countries are able to reap the benefits of sustainable health professional mobility as envisaged by the WHO Global Code of Practice.

For further information:

- WHO - health workforce
- European Federation of Nurses Associations (EFN)

EPHA related articles:

- The role of Health Workforce in tackling health inequalities - EPHA position
- The Impact of the crisis on nurses and nursing: new evidence from EFN
- Single Market Forum: Joint Statement by EPHA, EPF, EWL and BEUC on maintaining minimum education standards for health professionals
- article 4604
- Council Conclusions on investing in Europe’s health workforce of tomorrow: Scope for innovation and collaboration

Last modified on September 29 2012.