A total of forty-four responses were received with all four countries and three sectors represented, yielding an approximate response rate of 11 %. Civil society respondents were from academic institutions, think-tanks, research centres, and workforce planning organizations. Government respondents were from workforce regulation agencies and ministries of health. Private sector respondents were from health worker recruitment and training agencies. Respondent job titles included Associate Deputy Minister, Deputy Director, Senior Team Leader, and Senior Health Economist, among others.
Awareness of the Code
Eighteen respondents (41 %) indicated that they were largely unaware of the Code and its impact despite working in organizations for the licensure of international medical graduates (n = 2), health workforce modeling (n = 4), health workforce planning and research (n = 8), health policy and workforce development (n = 3), and international workforce equity (n = 1).
Ten respondents indicated that their colleagues lacked an awareness of the Code (23 %). One private sector respondent from Canada stated, “Neither the existence of such a global Code, nor the WHO role is known within our health services network” (CAN.PS.1). A civil society respondent from the USA emphasized, “[My colleagues] are unaware of the problem and any possible solutions” (US.CS.1). The two respondents reporting some level of awareness suggested that the Code was likely more familiar to colleagues in developing countries. One respondent mentioned, “My impression is that my Canadian colleagues have minimal awareness of the Code…while colleagues in developing countries where we work, such as Jamaica and Zambia, are much more aware of it” (CAN.CS.2).
Ten respondents reported that their colleagues were likely to be familiar with the Code (23 %). Of these, colleagues who were researchers and senior academics were reported as likely knowledgeable about the instrument (n = 5). However, colleagues whose work directly impacted health workforce planning, such as those working in health authorities and the health policy community were reported to be generally unaware of the Code (n = 4).
Among the three individuals reporting that their colleagues were “very aware” of the Code (7 %), two individuals were from Australia, while one Canadian respondent referred to the Code in conjunction with the Melbourne Manifesto, which, they surmised, collectively provided a basis for discussing issues affecting health worker migration. One of the Australian respondents stated, “I believe all senior academics would be aware of the WHO Code, including its global purpose” (AU.G.1).
Changes resulting from the Code
Of the four individuals reporting anticipated policy or regulatory changes as a result of the Code, a Canadian government respondent declared, “…we are consistently working with colleagues to ensure that our policies follow the Code – I would say that this would be true of all jurisdictions in Canada” (CAN.G.1). However, the vast majority of respondents indicated that they were not aware of any anticipated changes resulting from the Code (n = 21; 48 %). One UK respondent suggested that, as the UK Code of Practice on International Recruitment preceded the WHO Code, it was difficult to determine any specific impacts of the latter. Alternatively, a number of respondents attributed poor implementation to the primacy of domestic health workforce needs and competing priorities. One Canadian civil society respondent claimed, “…I expect there to be a greater emphasis on international recruitment of health workers to Canada as both the general population and key health cadres such as nurses continue to age” (CAN.CS.2). The prioritization of national deficits was echoed by American and Australian respondents, one of whom suggested, “My personal commitment is to produce a workforce in and for the regions in which I work. However, I’m heartened that this social justice issue is on the national and international agenda” (AUS.CS.3). A civil society respondent from the USA corroborated, saying “there is very little incentive for healthcare providers to adhere to the Code – there is actually more domestic incentive to not adhere to the Code, for example through increased funding for ‘diversity’ hires” (US.CS.5).
Key informants suggested that strong personal incentives for health workers to leave their countries of origin explained the lack of change the Code had hoped to achieve. These “pull” factors included the right of individuals to migrate for improved political and socioeconomic stability, as well as to achieve a higher standard of living (n = 3). One Canadian civil society respondent stated, “The real incentive to keep people in their country of origin is addressing the social inequalities in these countries and providing supportive environments…for them to build meaningful lives in safe conditions. People don’t leave unless they really have to” (CAN.CS.3).
Existing national or bilateral agreements were also seen as preeminent to the Code, with respondents referencing tangible regulatory changes following the implementation of the Melbourne Manifesto and the UK Code of Practice, among other international codes (n = 4). The Code was often seen as complementary to these existing agreements, or providing further leverage for their support, albeit largely incapable of inciting change directly. As one civil society respondent from the UK mentioned, “…the UK already had a Code of Practice, [but] the WHO Code has proved useful in terms of encouraging cross departmental work in monitoring the UK Code” (UK.CS.1). One American civil society respondent also pointed out the “synergistic” impact of the WHO Code in legitimizing the work of NGOs in trying to reduce unethical international health worker recruitment (US.CS.8).
Suggestions to improve the Code’s impact
When asked whether the Code had a meaningful impact on health worker recruitment, fifteen respondents disagreed (34 %), with six and eight individuals indicating strong and moderate disagreement, respectively. However, thirteen respondents suggested that no specific amendments to the Code would improve its effectiveness in terms of producing change in health worker recruitment policy or regulation. In explanation, two respondents suggested that the Code’s “principles were good” (CAN.CS.1) and that it was “fairly comprehensive” (US.CS.5), while others cited current domestic changes to reduce health worker recruitment that were independent of efforts to implement the Code (n = 2). One American civil society respondent explained, “[The USA government has] strengthened their investments in health professional education domestically. This was not a result of the WHO Code but it has helped alleviate the problem” (US.CS.8).
Of the eleven respondents suggesting possible changes to the Code to strengthen its impact, four suggested the principles of the Code be more widely disseminated, while nine promoted the idea of international public reporting of individual nations’ adherence. As one Canadian civil society respondent pointed out, “I believe the Code itself is a fully developed tool, but regular international public reporting on developed countries with high levels of their health workforce educated in the second or third worlds would track the relevance or effectiveness of the Code” (CAN.CS.6). Five respondents urged clearer requirements for accountability and consequences for non-adherence, with one American civil society respondent favoring a tax for destination countries and corresponding financial compensation for source countries. However, despite supporting improved accountability mechanisms, one Canadian civil society respondent noted a possible barrier to doing so, citing “…those who are reporting are not those recruiting so there is a mismatch between activity and accountability” (CAN.CS.8). Two civil society respondents suggested promoting action on the social determinants of health to improve living conditions, while a UK government respondent urged, “the [Code] needs to be turned into a monitoring board based on indicators…intentions are nice but numbers are more tangible” (UK.G.1).
Effectiveness of non-binding Codes
Few respondents were of the opinion that voluntary, non-binding codes such as the WHO Code were effective instruments through which to influence national policy (n = 3). The majority of respondents indicated that the Code was only “somewhat” effective, with proponents offering the rationale that the Code raised the international profile of the issue (n = 4) and was an effective tool to support advocacy efforts or to justify implementation of existing bilateral agreements (n = 5). One respondent suggested a particular utility of the Code in enabling the “naming and shaming” of non-adherent countries, claiming, “wealthy countries such as Australia have ‘pride’ and would not wish to be exposed as an exploiter and so have made serious endeavors to adhere to the guidelines” (AUS.CS.3).
Participants reaffirmed that the Code was useful in principle, but that its utility was undermined by national health systems that involved multiple levels of leadership. As stated by one American civil society respondent, “They can be [useful], if they are created with the active participation of the leaders in the field. At least in the USA, that leadership is widely distributed, fluid, and definitely not of a single mind” (US.CS.4). These sentiments were echoed by another American respondent, who argued, “Given that the USA does not have a national health system, disseminating this information and getting multiple different systems and entities to follow this, I feel, will be virtually impossible” (US.CS.3).
Ten participants asserted that voluntary, non-binding Codes were not effective. Respondents cited a lack of necessary accountability mechanisms (n = 5), in addition to prevailing health inequities that remain the primary incentive to migrate (n = 3). Internal pressures to fill under-resourced health sectors, and a sense that the Code was more highly esteemed by developing countries were also listed as reasons for its ineffectiveness. One Canadian participant explained, “In developed countries, there is little sense that these types of WHO edicts apply to them, whereas in low-income countries, the WHO carries a lot of weight. In this case, the voluntary, non-binding nature of the Code makes it a low priority for all” (CAN.CS.5).