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Does a voluntary code of conduct promote ethical recruitment of international doctors?

A recently published Canadian study has gained significant press coverage for its eye-catching headline “Doctor brain-drain costs Africa $2 billion”.

At the heart of the matter is an accusation that rich countries such as the USA, Canada and Australia are poaching doctors from poor and vulnerable nations (especially in sub-Saharan Africa) who can ill afford to lose them.

It is undeniable that there is a stark inequity between nations with regards to the number of doctors per population and it is no surprise that the World Health Organization uses this statistic as one of its key health indicators*.

Such macro level statistics dispassionately represent countless stories of individuals who fail to receive adequate healthcare for want of a doctor to treat them.

So what are those of us that recruit doctors supposed to do with this information? Healthcare is a sector that tends to attract altruistic types so one would expect there to be some consideration for the best interests of humanity, rather than the narrow interests of self or organization.

However, by way of example, it is not so easy for an Australian health employer with a critical role to fill, or a Canadian recruiter with clients to service to immediately connect their day to day activities with negative consequences for sick patients in Darfur.

One predominant strategy currently implemented is the internationally agreed code of conduct. For example, the WHO Global Code of Practice in International Recruitment of Health Personnel 2010 lays out some context and guidelines as to how stakeholders should behave.

Despite reading it a few times I struggle to come away with a clear sense of how these should be applied to the medical workforce sector. For those who don’t want to read it here is my (subjective) interpretation of the key points:

  • Don’t break any laws and comply with all regulatory requirements
  • Conduct a fair and open recruitment process
  • Give migrant doctors equal pay and conditions
  • Don't actively approach doctors in developing countries but feel free to take them if they come to you
  • Encourage circular migration (i.e. by all means take some doctors but give them back in a better state than you found them)
  • Build a good health system so people will want to work in it
  • Develop good workforce management policy and practice
  • Only use recruitment agencies that observe the code

Much of the above seems to be generic best recruitment and management practice. Not much in the way of clear directives for the reader to take away and implement.

The earlier Commonwealth Code of Conduct from 2003 showed that implementation can be subject to interpretation. In this case it was sporadic, selective and largely self-serving.

For example, the United Kingdom’s NHS allows hospitals to hire directly from developing nations but not through agencies, even when the mode of initial contact is identical. At least the NHS implemented something, though it does not extend to private sector employers in the UK, i.e. it is organization but not country specific.

Australia is a signatory to the agreement but you would be hard pressed to find an Australian health employer who is aware of the code, let alone abiding by it. Some Canadian provinces have stringent rules around adherence to the code - others don't.

It seems that further thought needs to go into the WHO Code of Conduct or any guidelines that succeed it. Here are a few suggestions:

  • The Code is voluntary which immediately robs it of authority - signatory countries should be held more accountable for their promises to uphold the Code.
  • The WHO needs to do more to promote the Code. It seems to be poorly publicized with its intended target audience.
  • The Code needs tighter definitions around directives and objectives. Over 14 pages it struggles to make its purpose clear and is often self-contradictory.
  • Perhaps the WHO could issue Code of Conduct Certification in the same way that Fair Trade Certification has revolutionized retail and catering. I believe health employers and agencies would fall over themselves to be able to publicly display their ‘ethical' credentials on their website.

In fairness to the WHO, at least they have done something. Their Code of Conduct is only one year old and in its first draft, so it will undoubtedly evolve and improve over time. Governments, health employers and the medical recruitment industry can contribute much to the discussion. Whilst imperfect the WHO Code of Conduct certainly forms an initial framework around which we can all rally.

A final thought. The idea that rich health systems actively and deliberately poach from developing nations would seem laughable to many of the doctors who have been allegedly lured away. If anything it is these doctors themselves that resort to extreme measures to leave their countries of origin, endure hardships and indignities to gain registration and employment, and yet often end up driving taxis in their new host country rather than returning home to look after their fellow countrymen. Perhaps the question one should ask is - why are they so keen to leave home in the first place?

* Note – The WHO Global Health Statistics report 2010 has misrepresented Australia as having a 1:1000 doctor to population ratio. The WHO 2011 statistics appear to have corrected this with a figure of 3:1000

Dr John Bethell

Director Wavelength International

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