Empirical impact evaluation of the WHO Global Code of Practice on the International Recruitment of Health Personnel in Australia, Canada, UK and USA.
ABSTRACT: The active recruitment of health workers from developing countries to developed countries has become a major threat to global health. In an effort to manage this migration, the 63rd World Health Assembly adopted the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel in May 2010. While the Code has been lauded as the first globally-applicable regulatory framework for health worker recruitment, its impact has yet to be evaluated. We offer the first empirical evaluation of the Code's impact on national and sub-national actors in Australia, Canada, United Kingdom and United States of America, which are the English-speaking developed countries with the greatest number of migrant health workers.42 key informants from across government, civil society and private sectors were surveyed to measure their awareness of the Code, knowledge of specific changes resulting from it, overall opinion on the effectiveness of non-binding codes, and suggestions to improve this Code's implementation.60% of respondents believed their colleagues were not aware of the Code, and 93% reported that no specific changes had been observed in their work as a result of the Code. 86% reported that the Code has not had any meaningful impact on policies, practices or regulations in their countries.This suggests a gap between awareness of the Code among stakeholders at global forums and the awareness and behaviour of national and sub-national actors. Advocacy and technical guidance for implementing the Code are needed to improve its impact on national decision-makers.
Project description:WHO Member States adopted the Global Code of Practice on the International Recruitment of Health Personnel 10 years ago. This study assesses adherence with the Code's principles and its continuing relevance in the WHO Europe region with regards to international recruitment of health workers. Data from the joint OECD/EUROSTAT/WHO-Europe questionnaire from 2010 to 2018 are analyzed to determine trends in intra- and inter-regional mobility of foreign-trained doctors and nurses working in case study destination countries in Europe. In 2018, foreign-trained doctors and nurses comprised over a quarter of the physician workforce and 5% of the nursing workforce in five of eight and four of five case study countries, respectively. Since 2010, the proportion of foreign-trained nurses and doctors has risen faster than domestically trained professionals, with increased mobility driven by rising East-West and South-North intra-European migration, especially within the European Union. The number of nurses trained in developing countries but practising in case study countries declined by 26%. Although the number of doctors increased by 27%, this was driven by arrivals from countries experiencing conflict and volatility, suggesting countries generally are increasingly adhering to the Code's principles on ethical recruitment. To support ethical recruitment practices and sustainable workforce development in the region, data collection and monitoring on health worker mobility should be improved.
Project description:The International Code of Marketing of Breast-milk Substitutes (the Code) adopted by the World Health Assembly (WHA) in 1981 and regularly updated through subsequent WHA resolutions, represents the international policy framework for protecting breastfeeding against inappropriate marketing practices. By March 2016, at least 135 countries had some measures covering provisions of the Code in their legislation. The translation of the International Code into national measures was investigated in the context of the advocacy efforts undertaken by the Alive & Thrive (A&T) initiative with UNICEF and partners. A real-time evaluation was carried out over 22 months in seven Southeast Asian countries (Cambodia, Indonesia, Lao People's Democratic Republic [Lao PDR], Myanmar, Thailand, Vietnam, and Timor-Leste) and two African countries (Burkina Faso and Ethiopia). Drivers of policy change and progress were examined. Two theory-based approaches were used: developmental evaluation and contribution analysis. Data collection methods included participant observation, key informant meetings, in-depth interviews, reflective practice, and desk review. Overall, countries made significant progress in translating the International Code into national measures and in moving forward throughout the policy cycle. The main driver of policy change was the creation of a strategic group, which engaged key relevant actors and supported the government in the performance of 15 critical tasks, which the analysis reveals is a second driver. Those critical tasks are described in this paper and could help public health advocates to anticipate the stages and challenges of policy change and develop more effective strategies to translate the Code into their legal framework.
Project description:BACKGROUND:Although human resources for health (HRH) represent a critical element for health systems, many countries still face acute HRH challenges. These challenges are compounded in conflict-affected settings where health needs are exacerbated and the health workforce is often decimated. A body of research has explored the issues of recruitment of health workers, but the literature is still scarce, in particular with reference to conflict-affected states. This study adds to that literature by exploring, from a central-level perspective, how the HRH recruitment policies changed in Timor-Leste (1999-2018), the drivers of change and their contribution to rebuilding an appropriate health workforce after conflict. METHODS:This research adopts a retrospective, qualitative case study design based on 76 documents and 20 key informant interviews, covering a period of almost 20 years. Policy analysis, with elements of political economy analysis was conducted to explore the influence of actors and structural elements. RESULTS:Our findings describe the main phases of HRH policy-making during the post-conflict period and explore how the main drivers of this trajectory shaped policy-making processes and outcomes. While initially the influence of international actors was prominent, the number and relevance of national actors, and resulting influence, later increased as aid dependency diminished. However, this created a fragmented institutional landscape with diverging agendas and lack of inter-sectoral coordination, to the detriment of the long-term strategic development of the health workforce and the health sector. CONCLUSIONS:The study provides critical insights to improve understanding of HRH policy development and effective practices in a post-conflict setting but also looking at the longer term evolution. An issue that emerges across the HRH policy-making phases is the difficulty of reconciling the technocratic with the social, cultural and political concerns. Additionally, while this study illuminates processes and dynamics at central level, further research is needed from the decentralised perspective on aspects, such as deployment, motivation and career paths, which are under-regulated at central level.
Project description:The Dutch Public Health Status and Forecasts report (PHSF Report) integrates research data and identifies future trends affecting public health in the Netherlands. To investigate how PHSF contributions to health policy can be enhanced, we analysed the development process whereby the PHSF Report for 2010 was produced (PHSF-2010).To collect data, a case study approach was used along the lines of Contribution Mapping including analysis of documents from the PHSF-2010 process and interviews with actors involved. All interviews were recorded and transcribed ad verbatim and coded using an inductive code list.The PHSF-2010 process included activities aimed at alignment between researchers and policy-makers, such as informal meetings. However, we identified three issues that are easily overlooked in knowledge development, but provide suggestions for enhancing contributions: awareness of divergent; continuously changing actor scenarios; vertical alignment within organizations involved and careful timing of draft products to create early adopters.To enhance the contributions made by an established public health report, such as the PHSF Report, it is insufficient to raise the awareness of potential users. The knowledge product must be geared to policy-makers' needs and must be introduced into the scenarios of actors who may be less familiar. The demand for knowledge product adaptations has to be considered. This requires continuous alignment efforts in all directions: horizontal and vertical, external and internal. The findings of this study may be useful to researchers who aim to enhance the contributions of their knowledge products to health policy.
Project description:BACKGROUND: Economically developed countries have recruited large numbers of overseas health workers to fill domestic shortages. Recognition of the negative impact this can have on health care in developing countries led the United Kingdom Department of Health to issue a Code of Practice for National Health Service (NHS) employers in 1999 providing ethical guidance on international recruitment. Case reports suggest this guidance had limited influence in the context of other NHS policy priorities. METHODS: The temporal association between trends in new professional registrations from doctors qualifying overseas and relevant United Kingdom government policy is reported. Government policy documents were identified by a literature review; further information was obtained, when appropriate, through requests made under the Freedom of Information Act. Data on new professional registration of doctors were obtained from the General Medical Council (GMC). RESULTS: New United Kingdom professional registrations by doctors trained in Africa and south Asia more than doubled from 3105 in 2001 to 7343 in 2003, as NHS Trusts sought to achieve recruitment targets specified in the 2000 NHS Plan; this occurred despite ethical guidance to avoid active recruitment of doctors from resource-poor countries. Registration of such doctors declined subsequently, but in response to other government policy initiatives. A fall in registration of South African-trained doctors from 3206 in 2003 to 4 in 2004 followed a Memorandum of Understanding with South Africa signed in 2003. Registrations from India and Pakistan fell from a peak of 4626 in 2004 to 1169 in 2007 following changes in United Kingdom immigration law in 2005 and 2006. Since 2007, registration of new doctors trained outside the European Economic Area has remained relatively stable, but in 2010 the United Kingdom still registered 722 new doctors trained in Africa and 1207 trained in India and Pakistan. CONCLUSIONS: Ethical guidance was ineffective in preventing mass registration by doctors trained in resource-poor countries between 2001 and 2004 because of competing NHS policy priorities. Changes in United Kingdom immigration laws and bilateral agreements have subsequently reduced new registrations, but about 4000 new doctors a year continue to register who trained in Africa, Asia and less economically developed European countries.
Project description:Approaches that root national climate strategies in local actions will be essential for all countries as they develop new nationally determined contributions under the Paris Agreement. The potential impact of climate action from non-national actors in delivering higher global ambition is significant. Sub-national action in the United States provides a test for how such actions can accelerate emissions reductions. We aggregated U.S. state, city, and business commitments within an integrated assessment model to assess how a national climate strategy can be built upon non-state actions. We find that existing commitments alone could reduce emissions 25% below 2005 levels by 2030, and that enhancing actions by these actors could reduce emissions up to 37%. We show how these actions can provide a stepped-up basis for additional federal action to reduce emissions by 49%-consistent with 1.5?°C. Our analysis demonstrates sub-national actions can lead to substantial reductions and support increased national action.
Project description:BACKGROUND:Enhancing primary health care (PHC) is considered a policy priority for health systems strengthening due to PHC's ability to provide accessible and continuous care and manage multimorbidity. Research in PHC often focuses on the effects of specific interventions (e.g. physicians' contracts) in health care outcomes. This informs narrowly designed policies that disregard the interactions between the health functions (e.g. financing and regulation) and actors involved (i.e. public, professional, private), and their impact in care delivery and outcomes. The purpose of this study is to analyse the interactions between PHC functions and their impact in PHC delivery, particularly in providers' behaviour and practice organisation. METHODS:Following a systems thinking approach with data obtained through a three-round European Delphi process, we developed a framework that captures (1) the interactions between PHC functions by analysing correlations between PHC characteristics of participating countries, (2) how actors involved shaped these interactions by identifying the actor and level of devolution (or fragmentation) in the analysis, and (3) their potential effect on care delivery by exploring panellists' opinions. RESULTS:A total of 59 panellists from 24 countries participated in the first round and 76% of the initial panellists (22 countries) completed the last round. Findings show correlations between governance, financing and regulation based on their degree of decentralisation. This is supported by panellists, who agreed that the actors involved in health system governance determine the type of PHC financing (e.g. ownership or payment mechanisms) and regulation (e.g. competences or gatekeeping), and this may impact care delivery and outcomes. Governance in our framework is an overarching function whose impact in PHC delivery is mediated through the degree of decentralisation (both delegation and devolution) of PHC financing and regulation. CONCLUSIONS:The application of this approach in policy implementation assessment intends to uncover limitations due to poor accountability and commitment to shared objectives. Its application in the design of health strategies helps foresee (and prevent) undesired or unexpected effects of narrow interventions. This approach will assist in the development of the realistic and long-term policies required for health systems strengthening.
Project description:BACKGROUND:Despite its well-known benefits, breastfeeding practices remain suboptimal worldwide, including in Southeast Asia. Many countries in the region have thus enacted policies, such as maternity protection and the World Health Assembly International Code of Marketing of Breast-milk Substitutes (the Code), that protect, promote, and support breastfeeding. Yet the impact of such national legislation on breastfeeding practices is not well understood. OBJECTIVE:This study aims to review the content, implementation, and potential impact of policies relating to maternity protection and the Code in Myanmar, the Philippines, Thailand, and Vietnam. METHODS:This mixed methods study includes a desk review, trend and secondary data analyses, and quantitative and qualitative data collection. Desk reviews will examine and compare the contents, implementation strategies, coverage, monitoring, and enforcement of national policies focusing on maternity protection and the Code in each country with global standards. Trend and secondary data analyses will examine the potential impact of these policies on relevant variables such as breast milk substitute (BMS) sales and women's workforce participation. Quantitative data collection and analysis will be conducted to examine relevant stakeholders' and beneficiaries' perceptions about these policies. In each country, we will conduct up to 24 in-depth interviews (IDI) with stakeholders at national and provincial levels and 12 employers or 12 health workers. Per country, we will survey approximately 930 women who are pregnant or have a child aged 0-11 months, of whom approximately 36 will be invited for an IDI; 12 partners of the interviewed mothers or fathers of children from 0-11 months will also be interviewed. RESULTS:This study, funded in June 2018, was approved by the Institutional Review Boards of the relevant organizations (FHI 360: April 16, 2019 and May 18, 2020; and Hanoi University of Public Health: December 6, 2019). The dates of data collection are as follows: Vietnam: November and December 2019, May and June 2020; the Philippines: projected August 2020; Myanmar and Thailand: pending based on permissions and funding. Results are expected to be published in January 2021. As of July 2020, we had enrolled 1150 participants. We will present a comparison of key contents of the policies across countries and against international standards and recommendations and a comparison of implementation strategies, coverage, monitoring, and enforcement across countries. We will also present findings from secondary data and trend data analyses to propose the potential impact of a new or amended policy. For the surveys with women, we will present associations between exposure to maternity protection or BMS promotion on infant and young child feeding practices and their determinants. Findings from IDIs will highlight relevant stakeholders' and beneficiaries' perceptions. CONCLUSIONS:This study will increase the understanding of the effectiveness of policy interventions to improve breastfeeding, which will be used to advocate for stronger policy adoption and enforcement in study countries and beyond. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/21286.
Project description:BACKGROUND:In successfully negotiating the Framework Convention on Tobacco Control (FCTC), the World Health Organization (WHO) has led a significant innovation in global health governance, helping to transform international tobacco control. This article provides the first comprehensive review of the diverse campaign initiated by transnational tobacco corporations (TTCs) to try to undermine the proposed convention. METHODS AND FINDINGS:The article is primarily based on an analysis of internal tobacco industry documents made public through litigation, triangulated with data from official documentation relating to the FCTC process and websites of relevant organisations. It is also informed by a comprehensive review of previous studies concerning tobacco industry efforts to influence the FCTC. The findings demonstrate that the industry's strategic response to the proposed WHO convention was two-fold. First, arguments and frames were developed to challenge the FCTC, including: claiming there would be damaging economic consequences; depicting tobacco control as an agenda promoted by high-income countries; alleging the treaty conflicted with trade agreements, "good governance," and national sovereignty; questioning WHO's mandate; claiming the FCTC would set a precedent for issues beyond tobacco; and presenting corporate social responsibility (CSR) as an alternative. Second, multiple tactics were employed to promote and increase the impact of these arguments, including: directly targeting FCTC delegations and relevant political actors, enlisting diverse allies (e.g., mass media outlets and scientists), and using stakeholder consultation to delay decisions and secure industry participation. CONCLUSIONS:TTCs' efforts to undermine the FCTC were comprehensive, demonstrating the global application of tactics that TTCs have previously been found to have employed nationally and further included arguments against the FCTC as a key initiative in global health governance. Awareness of these strategies can help guard against industry efforts to disrupt the implementation of the FCTC and support the development of future, comparable initiatives in global health.
Project description:BACKGROUND:Accountability for ensuring sexual and reproductive health and rights is increasingly receiving global attention. Less attention has been paid to accountability mechanisms for sexual and reproductive health and rights at national and sub-national level, the focus of this systematic review. METHODS:We searched for peer-reviewed literature using accountability, sexual and reproductive health, human rights and accountability instrument search terms across three electronic databases, covering public health, social sciences and legal studies. The search yielded 1906 articles, 40 of which met the inclusion and exclusion criteria (articles on low and middle-income countries in English, Spanish, French and Portuguese published from 1994 and October 2016) defined by a peer reviewed protocol. RESULTS:Studies were analyzed thematically and through frequencies where appropriate. They were drawn from 41 low- and middle-income countries, with just over half of the publications from the public health literature, 13 from legal studies and the remaining six from social science literature. Accountability was discussed in five health areas: maternal, neonatal and child health services, HIV services, gender-based violence, lesbian/gay/bisexual/transgender access and access to reproductive health care in general. We identified three main groupings of accountability strategies: performance, social and legal accountability. CONCLUSION:The review identified an increasing trend in the publication of accountability initiatives in Sexual and Reproductive Health and Rights (SRHR). The review points towards a complex 'accountability ecosystem' with multiple actors with a range of roles, responsibilities and interactions across levels from the transnational to the local. These accountability strategies are not mutually exclusive, but they do change the terms of engagement between the actors involved. The publications provide little insight on the connections between these accountability strategies and on the contextual conditions for the successful implementation of the accountability interventions. Obtaining a more nuanced understanding of various underpinnings of a successful approach to accountability at national and sub national levels is essential.