Personnel—and the blurred boundaries between trade in medical services and migration of health workers

Mode 4: Presence of natural persons. Countries are seeking to attract health workers from abroad to fill domestic shortages. This form of trade is chiefly influenced by regulations concerning entry and presence as well as the qualification and recognition requirements in receiving countries. Although the number of individuals supplying medical services through temporary presence (as defined by GATS) represents a small proportion of health workers crossing borders (the latter generally seeking opportunities for employment or to establish themselves more permanently in a foreign jurisdiction),5 the movement may be driven by pull and push factors that drive labor migration more generally.

Countries may impose limitations on the movement of health workers to other markets out of concern over the loss of human capital. Increasingly, global mobility of health care workers and related trade in medical services is affected by the importing country’s adherence to international governance mechanisms, such as ethical recruitment codes and intergovernmental agreements including the Commonwealth Code of Practice (Commonwealth 2003) and WHO’s Global Code of Practice on the International Recruitment of Health Personnel (WHO 2010), the latter being further discussed in box 1.2. These were established to prevent a brain drain from low- and middle-income countries and ensure adherence to certain principles and norms.

Box 1.2 WHO’s Global Code of Practice on the International Recruitment of Health Personnel—and the blurred boundaries between trade in medical services and migration of health workers

Provision of health services by foreign-born or foreign-trained health workers has been characterized for decades by a recognition of the tension between (a) the right of health workers to pursue professional development opportunities and better working conditions abroad, and (b) the negative consequences that a substantial outflow of health workers from some countries could have on already stretched health systems (WHO 2006).

The long-standing difficulties facing many high-income countries in producing enough health workers to meet domestic needs, the large wage differential across countries of varying socioeconomic development, and the chronic underinvestment by countries at all development levels in education and jobs for the health workforce (WHO 2016) have conspired to determine a substantial level of dependence in many countries (particularly in high-income countries) on foreign-born and foreign-trained health workers (WHO 2020) along with a growing trend in international mobility of health personnel, which had risen by 60 percent in the decade preceding 2016 (Dumont and Lafortune 2017).

To facilitate collaboration and an ethical management of health personnel mobility, the World Health Organization in 2010 adopted a Global Code of Practice on the International Recruitment of Health Personnel (the “WHO Code”), whose provisions encompass (a) upholding the rights of internationally mobile health workers; (b) supporting countries’ efforts to meet health system needs through production and employment of domestically trained health workers; and

(Continued)

Box 1.2 WHO’s Global Code of Practice on the International Recruitment of Health Personnel—and the blurred boundaries between trade in medical services and migration of health workers (Continued)

(c) promoting data sharing and collaboration to ensure that mobility of health personnel translates into benefits for health workers and the health systems of countries involved (WHO 2010).

When countries decide to cover mobility of health personnel as part of trade agreements, sometimes the objectives are broad in scope (with health services being only one of several components and sectors) and limited in time (with provisions for health workers to return to the country of origin after completing their assignments or training periods). However, health workers may often have the opportunity to stay beyond the terms of the agreements, which can enhance concerns about exacerbating health workforce challenges in countries of origin. What may start as a short-term element in a broader trade conversation can, in the specific case of health workers, become part of a longer-term migration trend and no longer fall under trade in services.

In the context of trade relations and agreements between countries, the specific (intended and unintended) consequences on mobility of health personnel should be considered while striving to apply, as relevant, the provisions of the WHO Code. Among others, these provisions include the Ministry of Health’s meaningful participation—together with other relevant authorities (such as trade, labor, and education)—in agreements involving health services, ensuring that benefits also accrue to the health sector and upholding the rights of health workers involved. In this context, services trade agreements and the WHO Code could be mutually reinforcing. For example, the application of health labor market analyses, in both sending and receiving economies, could further clarify the economic or labor market opportunities and further liberalize trade in services by better targeting demonstrated needs (Carzaniga et al. 2019).

The Indonesia-Japan Economic Partnership Agreement is an example of an agreement where the parties negotiated specific commitments and requirements related to temporary migration of Indonesian nurses and caregivers (Efendi et al. 2017). This was achieved through the participation of key Indonesian government institutions under the leadership of the Ministry of Trade, Ministry of Manpower and Transmigration, National Board for the Placement and Protection of Indonesian Overseas Workers, Ministry of Health, Ministry of Foreign Affairs, and Ministry of National Education. The agreement includes a technical assistance program and financial support through a multiyear Japan International Cooperation Agency (JICA) project designed to enhance nursing competency through in-person training.

The different modes of trade in medical services are interlinked and may be used in combination as complements or act as substitutes. These links can enhance medical services trade by facilitating sequential associations and complementing simultaneous ones (Chanda 2006). For example, there may be joint-venture-based foreign direct investment (FDI) in hospitals employing overseas personnel, which in turn helps attract foreign patients for specialized treatments and may result in supporting teleconsultation and telediagnosis services before and after treatment. On the other hand, restrictions on one mode of trade in services may lead to substitution through other modes. Factors such as technology, consumer preferences, the regulatory environment, infrastructure, human resources—all of which drive trade in medical services—also influence the links between modes of trade in health care services.