1. Ethical recruitment and migration of health workers Professor Ruairí Brugha Irish Forum for Global Health Symposium on the Health Workforce School of Nursing, Dublin City University 20 th October 2011

2. Abstracts Ethical Recruitment of Health Workers: page the Global Code85 International Nurse Recruitment, Risk and Recession: The Irish Experience83 RN4CAST Nurse Forecasting in Europe: findings relating to nurse migration in Ireland87 The Migration of Sudanese Doctors to Ireland: Push and Pull Factors80 The Doctor Migration Project81

3. WHO global code of practice on the International Recruitment of Health Personnel A voluntary code adopted by member states (including Ireland) at the World Health Assembly, May 2010. Health Worker Global Policy Advisory Council drafted the code over 3 years (8 meetings) chaired by President Mary Robinson The code specifies the ‘rights and responsibilities’ of countries (source and destination), employers and health workers It commits countries to adhere to principles and practices, e.g. “member states should...” “...are strongly encouraged to...”  Practice ethical international recruitment of health personnel  Develop health workforce and strengthen health systems.  Monitor implementation of code and share data

4. How is Ireland performing?trends in nurses 16,289 nurses newly registered with Irish Nursing Board between 2004 and 2008, 45% from non-EU countries, 12% from other EU countries, 43% were Irish 45% of non-EU nurses from India45% from Philippines Ireland ranked 1 st for foreign nurses (47%) New Zealand 2 nd (23%): OECD 2008

5. How is Ireland performing?trends in Doctors Irish Medical Council registrations by country of qualification, categorised as Irish, non-Irish EU and Non-EU for the period 2000-2010 Ireland ranked 2 nd for foreign doctors (35%) New Zealand 1 st (39%): OECD 2008

6. Total registrations Irish Medical Council, 2000-2010 Year Irish graduates (n) IMGs (n) International medical graduates as % of workforce 200011,3001,75213.4 200512,6114,27925.3 201012,4596,26133.4

7. Countries where doctors qualified

8. Consequences for sending countries? Philippines: managed nurse emigration policy children trained for emigration (remittances sent by 87%) but loss of nurse trainers and specialists (India also)? Cost of training doctors Sudan: 21,000 Drs registered 12,000 (57%) overseas 1,500 graduate annually 800 (53%) emigrate Potential benefits? Sudan:main reason for emigrating: training (44% of 120) career intentions: intend to go home (95%) have same training opportunities as Irish Drs (10%) Need for research  Career experiences of foreign Drs in Ireland (RCSI-TCD)  Effects on sending countries’ health systems (methodological difficulties in researching the loss of staff)

9. Responsibilities of all countries International recruitment should be done in a way that promotes “sustainability of health systems in developing countries” “Member states should take effective measures to educate, retain and sustain (its)health workforce....” Ireland failing to retain its domestic and immigrant nurses  In 2008, 1,000 Irish and 1885 Indian nurses applied to have their qualifications verified by overseas registration bodies (up from 335 Indian nurses who sought verifications in 2007 )  In 2007, during the height of the economic boom, 11 of 21 nurses interviewed in-depth planned to leave Ireland. Why? lack of family friendly immigration and work permit policies Large annual shortfalls in domestic supply of nurses in Ireland predicted up to 2021

10. Health workers have rights! Freedom of health workers to migrate, subject to national laws (much discussion at the Council, which concluded that it is neither ethical nor feasible to limit migration – but HWs have duties too) A right to receive accurate information  Specialised nurses – Theatre and CCU – expected that their expertise would be used in Ireland – not that they would be assigned to Geriatric wards.  Recent media reports that foreign doctors were promised higher salaries than they are receiving in Ireland “Equality of treatment with the domestically trained health work force... Same legal rights and responsibilities... Opportunities and incentives to strengthen their professional qualifications”  Access to postgraduate training programmes? Other forms of training? Freedom from discrimination  53% of Sudanese doctors reported discrimination by colleagues  22% bullying reported by immigrant nurses *CHECK*

11. Monitoring the Code 4 of 10 ‘articles’ in the Code cover data and research, information exchange, implementation and monitoring Member states to have designated a “national authority for the implementation of the WHO Global Code” by June 30 th 2011 The data on foreign nurses used by the Dept of Health have come from the RCSI nurse migration study (see Humphries et al.) Spreadsheet of medical doctor registration data from the Irish Medical Council, 2000-10 has been cleaned and transformed by Pat Dicker, as part of the HRB Foreign Doctors in Ireland study  These will enable Ireland to fulfil its reporting duties and report Level A (core data) to the World Health Assembly, in May 2012  An example of a researcher–policy maker partnership, where the first research output enables the policy maker fulfil its global reporting duty

12. Cross-Cutting Issues / Questions Health workers are expensive to produce and can be considered a highly marketable resource in a globalised world. o It is cheaper for countries to import than to produce doctors + nurses (US) o What does a heavy reliance on recruiting doctors and nurses from overseas say about a country’s health system? Given Ireland’s ‘outlier’ position in respect to recruitment and reliance on foreign health workers o What are Ireland’s responsibilities (if any) to the doctors AND to the countries from which it recruits? o How can it discharge those duties? Retention and Migration – push and pull – are two side of the same coin. What research should we be doing to link the two facets of this phenomenon?