First meeting of the Ad hoc Working Group
on Human Resources for Health in Small
Countries in the WHO European Region
First meeting of the Ad hoc Working Group on Human Resources for Health in Small Countries in the WHO European Region
Venice, Italy, 9–10 December 2019
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Document number: WHO/EURO:2020-1295-41045-55723
Contents
Introduction ... 1
Background ...2
Overall purpose ... 2
Expected outcomes ... 3
Participation ... 3
Opening session ...4
Migration and mobility ... 5
Postgraduate training ... 6
An in-depth analysis of postgraduate training in small countries ... 7
Reported examples of national and international collaboration ... 8
What could be done differently? ... 8
Key issues related to postgraduate training ... 9
An in-depth analysis of monitoring and managing health-workforce mobility in small countries ...10
Country feedback on monitoring and managing health-workforce mobility ...11
Implementation of the WHO Code and financial incentives ...12
Cross-country collaboration ...13
Next steps ... 15
References ... 16
Annex 1. Programme ... 17
Annex 2. Participants ... 19
Introduction
Small countries in the WHO European Region face the same full range of challenges related to human resources for health (HRH) as any other Member State in the Region. Their specific and unique characteristics (size, context and dynamics), however, need to be taken into account in developing effective policy responses to HRH challenges and meeting the broader health-policy objectives related to universal health coverage (UHC).
The need to make a detailed assessment of the HRH challenges relevant to, and potential solutions applicable in, small countries provided the impetus for the European Office for Investment for Health and Development and the Division of Health Systems and Public Health to jointly organize a technical meeting (Expert meeting on HRH in small countries in the WHO European Region) in Venice, Italy, on 18–19 December 2018. The aim of this meeting was to enable experts from small countries in the Region to share experiences, discuss enablers and identify ways of resolving sustainable individual and collective solutions to the challenges of HRH. Five priority areas of focus were identified and agreed upon.
Five priority areas of focus were identified and agreed upon:
1. developing the use of the labour market framework in Member States to identify and implement the most effective mix of HRH policies across short-, medium- and long-term priorities;
2. examining and improving how small countries deal with the critical issue of postgraduate training for health professionals;
3. investigating how small countries can best utilize continuous professional development (CPD) and other forms of in-service training to improve and adapt the skills and competences of the current workforce to meet the challenge of changing population health priorities;
4. improving the monitoring and management of workforce mobility (small countries can be particularly vulnerable to even small numerical outflows of migrant health workers and may also be reliant on internationally recruited health workers);
5. enhancing HRH planning and forecasting (planning methods, forecasting ability, data availability and HRH planning capacity); this was recognized as extending beyond technical issues, such as implementing a human-resources information system, to include strategic approaches and the ability to integrate planning into broader HRH strategic development.
In April 2019, the 6th high-level meeting of the small countries endorsed the establishment of the Ad hoc Working Group on HRH with modality options for cross-country collaboration on strengthening HRH. The aim was to foster an exchange of information and ideas, document experiences and map available and relevant policy-support tools. It was agreed that the Ad hoc Working Group on HRH would be established for a 2-year period in the first instance and would focus on the 5 priority areas, reporting regularly at the annual high-level meetings of the small countries.
The Division of Health Systems and Public Health, WHO Regional Office for Europe, and the WHO European Office for Investment for Health and Development provide support to the Ad hoc Working Group on HRH on a collaborative basis.
The first meeting of the Ad hoc Working Group on HRH was held in Venice, Italy, on 9–10 December 2019.
This report reflects the discussions and agreed outcomes of the meeting.
Background
There is growing recognition that, in all countries of the WHO European Region, the main population-health challenges to sustaining UHC and responding to the growing burden of noncommunicable diseases (NCD) require each Member State to develop an effective and adaptive approach to the management of HRH. In May 2016, the Sixty-ninth World Health Assembly unanimously adopted the Global strategy on human resources for health: Workforce 2030 (hereafter “Workforce 2030”) (1), which identifies ways in which Member States can apply an integrated approach to addressing these challenges at the national and international levels.
Health-workforce challenges include: balancing supply and demand; reducing gender inequality and gender imbalances; achieving an appropriate skills mix; addressing geographical misdistribution; dealing with the risks of, or reliance on, health-worker migration; closing gaps in quality; ensuring decent working conditions;
and improving recruitment and retention. In addition, funding constraints can present further complexities for many Member States as they seek to address these challenges. Although Member States in the WHO European Region have made progress in doing so in recent years, much effort is still required to achieve an optimal workforce contribution.
To provide Member States with additional support and ensure sustained regional relevance and country specificity of Workforce 2030 (1), the WHO Regional Office for Europe conducted an extensive consultation process, involving Member States and other stakeholders. This led to the adoption of Towards a sustainable health workforce in the WHO European Region: framework for action (hereafter “European HRH framework”) (2) at the 67th session of the WHO Regional Committee for Europe in 2017.
The European HRH framework (2) is in line with and builds on Workforce 2030 (1). Its overall goal is to accelerate progress towards achieving population-health objectives in the WHO European Region by sustaining a transformed and effective health workforce within strengthened health systems. It sets out key strategic objectives for the Member States, proposes policy options and implementation modalities, and provides guidance to policy-makers, planners, analysts and others with a responsibility for health-workforce issues (1,2).
The European HRH framework (2) enables Member States in the Region to progress towards achieving a sustainable health workforce by implementing the 4 strategic objectives identified in Workforce 2030 (1), which have been adapted to the regional context as follows:
1. to transform education and performance 2. to align planning and investment
3. to build capacity
4. to improve analysis and monitoring.
These 4 strategic objectives framed the work of the first meeting of the Ad hoc Working Group on HRH in small countries.
There is also a need to include consideration of the private sector, which cuts across all the issues being addressed by the Ad hoc Working Group on HRH. Many small-country health systems are hybrids; therefore, in health-workforce planning exercises, the totality of the workforce required – regardless of whether it belongs to the public or private sector – should be taken into consideration.
Overall purpose
In the context of the European HRH framework (2), the meeting offered participants the opportunity to consider and discuss in depth policy questions, challenges and responses in the areas of postgraduate training and monitoring and managing health-workforce mobility. The areas of CPD and HRH planning and forecasting will be explored in depth at the second meeting of the Ad hoc Working Group on HRH, which will take place in December 2020.
Expected outcomes
The meeting aimed at examining critical HRH-related challenges related to 5 priority areas identified at the above-mentioned technical meeting in Venice in December 2018, including examples of promising policy, planning and practice, scope for further knowledge exchange, and priorities for next steps. The last-mentioned included the finalization and dissemination of sets of micro case studies on postgraduate training (9 country responses in total) and monitoring and management of health-workforce mobility (7 country responses in total).
Participation
Experts from Andorra, Cyprus, Estonia, Iceland, Latvia, Luxembourg, Malta, Monaco, Montenegro, Portugal (the Autonomous Province of Madeira), San Marino, Slovenia and Spain (Canary Islands) took part in the meeting, which was jointly supported by staff of the Division of Health Systems and Public Health, WHO Regional Office for Europe, and the WHO European Office for Investment for Health and Development (Annex 2: participants).
Opening session
In welcoming the participants and introducing the theme of the meeting, Francesco Zambon, Coordinator, Investment for Health and Development in Healthy Settings, WHO European Office for Investment for Health and Development, and Gabrielle Jacob, Programme Manager, HRH Programme, WHO Regional Office for Europe, provided an overview of the work carried out so far. This included the development of a programme of work, which is grounded in the Labour Market Framework for Universal Health Coverage (LMF–UHC) and supported by the National Health Workforce Accounts (NHWA) system (3,4), and the decision to split it into 4 strategic objectives, focusing on 2 in 2020 and 2 in 2021 (1). The participants were reminded that LMF–UHC underpins these areas of focus (Fig. 1) (3).
Fig. 1. LMF–UHC areas of focus
Economy, population and broader societal drivers
High school
Education in health
Module 2 Education and training Module 3 Education and training regulation and accreditation Module 4
Education finances
Module 1
Active health-workforce stock Module 5
Health labour-market flows Module 6
Employment characteristics and working conditions Module 7
Health-workforce spending and remuneration
Module 8
Skills-mix composition for models of care
Module 9
Governance and health-workforce policies
Module 10
Health-workforce information systems
Education in other fields
Pool of qualified health workers
Migration
Abroad
Employed
Unemployed
Out of labor force
Health care sector
Other sectors
Health workforce equipped to deliver quality health service
Universal health coverage with safe, effective, person-centred health services Labour market dynamics
Labour force
Education Serving population
health needs Education sector
Source: adapted from Global strategy on human resources for health: Workforce 2030 (1).
Since 2018, the application of LMF–UHC has been further informed. In referring to “…all workers in the health services, public health and in related areas, and workers who provide support to these activities…”, the European HRH Framework might also be applied to other health- and social-care workers, informal carers, support staff, and administrators and managers in areas, such as public health, primary and community care, long-term care, or secondary and tertiary care (2,3).
Due to demographic changes in the European Region, including ageing populations in many countries, social- care services are becoming increasingly important. For this reason, countries need to focus on aligning or integrating health and social care when considering service delivery and the implications of workforce policy.
Another workforce-related challenge is to find ways of attracting enough people to train for work in the health sector. This is due in part to competition between the science, technology, engineering and medicine (STEM) disciplines as career choices for high-school students. In designing undergraduate and postgraduate education studies, countries might consider how best to draw the attention of the young people to the need for the STEM disciplines within the health sector and find ways of attracting them to health-related careers.
In doing so, it should be taken into account that factors motivating new graduates will change in the course of the next 20–30 years and future postgraduate education requirements will need to accommodate this.
Policies and plans relating to the production of the future health workforce must include measures to:
• align education and training with population-health needs
• attract second-level students to third-level programmes
• reduce attrition rates at the undergraduate and postgraduate levels
• attract and recruit clinicians to teaching roles and to retain them in these roles
• manage clinical placements.
In addition, there must be a continuous focus on developing policies to sustain the current health workforce, especially regarding:
• inflows and outflows of health workers to other sectors and other countries (migration and emigration);
• ways of motivating unemployed workers with health-related qualifications and experience to return to the health sector;
• measures to address the unequal geographical distribution of specialists and improve performance and productivity;
• skills-mix composition;
• retention of health workers in underserved areas.
The current situation calls for attention in the following areas: attraction, recruitment and retention of health resources; CPD; working environments; and career pathways.
Using the NHWA system to focus on and improve workforce data would be one way of supporting labour- market analysis and policy determination. Taking a modular approach, this system is aligned with LMF and includes 78 indicators, covering 10 modules aimed at obtaining comprehensive data on all aspects of the health workforce in support of HRH-related policy-making (3,4). The modules focus on education and training, the workforce, and population-health needs. NHWA supports sectoral and intersectoral health-workforce governance and HRH policy-makers, providing guidance on developing appropriate HRH-policy responses to health-workforce challenges, using a progressive implementation approach (4).
NHWA includes indicators of relevance to global, national and regional reporting across the spectrum of health-workforce priorities. Primarily based on a comprehensive health labour-market framework for UHC, they help standardize health-workforce information systems and facilitate interoperability and the tracking of HRH policy performance towards UHC. The first module is relevant to the purposes of the Ad hoc Working Group on HRH since it considers active health-workforce stock. This is done through the collection of data on health-worker density, distributed by age group, sex, facility type, and share of foreign-trained health workers, to name a few (3,4).
To understand a country’s HRH-related policy concerns, it is necessary to have access to data on: (i) the cost of producing a new health workforce; and (ii) the current active health workforce. NHWA helps to
“unpack” details of the health-workforce situation (4). The WHO Regional Office for Europe has developed a policy- focused NHWA resource place, which can be added into.
An evidence review conducted by the Organisation for Economic Co-operation and Development (OECD) found that data collection and dialogue with health-care professionals are the main challenges to health- workforce planning and that, for dialogue to be effective, it is important that it is based on concrete data (5).
Migration and mobility
It is projected in the coming decade that the continuing increase in the international mobility of health workers in OECD countries will persist. International migration is on the rise, the number of migrant physicians and nurses working in OECD countries having increased by 60% over the past 10 years (6). Much of the discourse has been around the movement of health workers from low- to high-income countries. In fact, this movement is also occurring from south to north, south to south and between high-income countries.
The main policy instrument for assisting Member States in developing an effective approach to the international mobility and migration of the health workforce is the WHO Global Code of Practice on the International Recruitment of Health Personnel (hereafter, “the Code”). Adopted by the Sixty-third World Health Assembly in 2010, the Code sets out a range of principles and practical aspects related to managing the migration process rather than to “stopping” people from moving. It views migration in Member States through a health-workforce sustainability lens (7). Small countries are particularly vulnerable to international flows – here, the movement of even a few people can make a difference.
As mentioned above, the Code outlines a range of practical aspects to be considered in connection with the mobility of the health workforce. This includes the requirement that Member States report regularly on their mobility trends and implementation of the Code (7). Every Member State has a designated national authority responsible for reporting. Countries are entering the fourth round of reporting; the report on the third round illustrates how country responses have improved and become more accurate than in previous rounds (8).
The reporting process has confirmed strong recognition of the continued and increasing relevance of the Code (7), though deliberations on its effectiveness were more complex than those on its relevance. WHO is compiling a compendium of examples of bilateral agreements in an effort to show how they can strengthen information and data on implementation of the Code (7). The compendium will also illustrate policy and legislation changes made in the countries towards sustainability of the health workforce. During the First meeting of the WHO Expert Advisory Group on HRH, members of the Group and the WHO Secretariat agreed that the information included in the compendium on (i) health-workforce mobility, (ii) bilateral agreements, and (iii) the lived experiences of migrant health workers should be strengthened.
Regarding the links between service, planning and the development of the joint workforce, joint planning is vital to avoid mismatches between supply and demand, as well as delays in investment due to lack of workforce resources.
Postgraduate training
For health professionals in most small countries, postgraduate training towards specialization will involve a period of external mobility at the end of which they have to decide whether to return home or not. Length of training also needs to be looked at from a cost–effectiveness perspective. In some countries, medical- training modalities remain encased in old models that do not reflect current demographics or career aspirations (for example, low fertility rates, feminization of the medical profession, gaps in the availability of health professionals for family reasons, etc.). For small countries, there is also the challenge of balancing specialization with the provision of generic and comprehensive services. Many of them struggle with gaps in specialist availability, for example in the area of mental health where demand is growing. Small countries can also be more vulnerable to change and are often the first to create policy to deal with it. To do so, they might take innovative steps, for example, in the use of big data.
A number of challenges to postgraduate training were reported during the meeting. Some small countries do not have a medical school and are highly dependent on physicians from other countries. Opportunities to update clinical knowledge, skills sets and competences – criteria often linked to the renewal of licences – can be limited. In some cases, legislation is in place to safeguard these through postgraduate training. Small countries face shortages of specialists, such as pediatricians, anesthesiologists, geriatricians and mental- health professionals. Some of them have experienced that the offer of postgraduate training in conjunction with moving to work in less populated parts of the country boosts mobility among these professionals (7).
Overall, countries expressed the need to strengthen primary health care since it is not feasible that all physicians work as specialists.
Countries need to realize that primary health care needs to be strengthened and that not everyone can work as a specialist.
An in-depth analysis of postgraduate training in small countries
Providing a full range of postgraduate and speciality training presents challenges for small countries that find it necessary to seek collaboration with other (larger) countries to harness the necessary training capacity and input, and clinical experience. Prior to the meeting, the 11 countries represented in the Ad hoc working group on HRH were asked to complete a questionnaire providing information on the postgraduate training situation in their country (delivery; available data and priorities for improving data collection; enablers of and challenges to postgraduate training; cross-country collaboration; and WHO support needed). The questionnaire was completed by 8 of the 11 small countries plus one region. Information gleaned from the results of the questionnaire was synthesized into a set of common themes and key messages (Box 1), which formed the basis of a set of questions that was presented for discussion at the meeting (Box 2). Micro case studies on postgraduate training, based on the result of the questionnaires completed by the 8 countries/
regions, will be made available on the website of the Small Countries Initiative (9).
Box 1. Key messages and highlights deriving from the in-depth analysis of postgraduate training in small countries Key message 1. Postgraduate training in small countries is varied and rich: where one country reports deficits and dependence, others report self-sufficiency and willingness to collaborate.
Country situation
• Some small countries have no medical school or health-sciences faculty and, thus, no possibility of providing postgraduate training, while others have fully-fledged postgraduate-training programmes, for example, for nurses, physicians, dentists and hospital staff.
• Small size is sometimes not conducive to the establishment of postgraduate training programmes.
• Mixed models are used in most small countries (that is, postgraduate training is undertaken partially at home and partially abroad).
• Validation mechanisms exist for specializations abroad.
• Small countries rely on larger or neighbouring countries for postgraduate training.
• There is collaboration between some small and larger European countries, for example, some small countries have links with France, Germany, Italy, Spain and Sweden.
• Many players impact postgraduate training, including ministries of health, education and finance, health professional associations and universities, making for a complex relationship.
• In some countries recent changes have been made in the organization of postgraduate training (such as, splitting functions among ministries, new legislation, etc.).
Key message 2. Some postgraduate training data are available but their collection could be more timely, complete, coordinated, accessible and qualitative.
• Some small countries have no data on the provision of and participation in postgraduate training activities nor on what happens after postgraduate training (entry into working life, departure from the health workforce).
• Other countries reported that data are available, but in various locations.
• Data are available on the entry of trainees into postgraduate training programmes (publicly trained physicians not in private practice) and their progression (through e-portfolio).
• Data priorities reported included: the health professional’s perspective on the quality of postgraduate training;
work location; type of postgraduate training undertaken; number of drop-outs and why; number of job changes (in/
out of health sector), post-resident work.
• Linking of data to facilitate input and access is needed.
Key message 3. Small countries and regions know what works (enablers) and seek guidance and the sharing of experience on addressing challenges that often contribute to reducing the growth and development of postgraduate training.
• Reported enablers: facilitation of postgraduate training for hospital staff; legislation supportive of postgraduate training improvements; political commitment; support of professional unions; subsidized studies; and use of conditional grants and benefits.
• Reported challenges: people-related (relationships); organizational (bureaucracy); need to find ways of operationalizing postgraduate training (for example, mainstreaming innovation, dealing with shortages of staff and expertise).
Box 1. contd
Key message 4. Pockets of innovation relate to a range of postgraduate-training approaches (from digital solutions to supportive policies) but availability currently tends to be project-based or ad hoc.
Examples shared related to:
• obtaining government approval of ways of bringing health professionals (such as nurses) back to the country after working abroad, and of promoting health-related professions;
• setting up a postgraduate training centre for allied health or other health professionals;
• gaining approval of a “policy on health resources to the year 2030”;
• introducing changes in legislation affecting the organization and updating of postgraduate training;
• using big data in strategic planning;
• using digital nomads (highly qualified investigators who live for short periods in a small country or region);
• introducing academic liaison between health professionals and universities;
• implementing shared medical records (including training in how to use them).
Key message 5. Small countries and regions can determine how best to improve postgraduate training (for example, by introducing policy and planning related to speciality training) and identify mechanisms for cross-country collaboration in this area.
• Countries expressed an interest in supporting the establishment of centres of excellence, consortium policies, regular forecasting on HRH, and mechanisms for keeping track of and evaluating available speciality training.
Countries reported on their experiences in cross-country collaboration on postgraduate training (based on a set of key questions related to the results of the questionnaire on postgraduate training (Box 2)).
Box 2. Key questions discussed in relation to postgraduate training
The participants were presented with the following questions after reporting back on the in-depth analysis of postgraduate training in small countries.
• How can cross-country collaboration and WHO best support your country?
• How can the varied and rich postgraduate training available be used to advantage?
• What mechanisms can be put in place to improve postgraduate training data?
• How can the enablers and challenges identified contribute to finding tangible solutions?
• How can innovation in postgraduate training become mainstream?
Reported examples of national and international collaboration
Participants shared their ideas on how national and international collaboration could be further enhanced.
An online workforce market for physicians in small countries would provide them with a forum for expressing their needs and could facilitate the exchange of specialists for short periods of time. In this context, finding a balance between collaboration and competition with neighbouring countries would be key. Since clarity in communicating with patients is critical, some countries considered language requirements important to cross-country exchange while a few felt that for much needed specialists, such as surgeons, anesthesiologists and rare-disease specialists, competency in the local language was not an issue of concern. Some countries felt that, since a whole spectrum of physicians was needed, language requirements could include an element of flexibility. Other challenges to collaboration had to do with the fact that some specializations are not attractive to young physicians for a variety of reasons, including a preference for private practice. The length of study required to obtain a medical degree can also be a barrier and, therefore, some countries were trying to find innovative ways of attracting young people to the health professions. Countries with both private and public sectors are seeing large outflows of physicians and dentists from the public sector to the private sector, which often invests in educating its own staff.
What could be done differently?
Participants were asked what they would change to enhance postgraduate training. Their responses illustrated that if a dual accreditation system were used as an option to assist in addressing shortages (for example, in family medicine, community psychiatry or geriatrics), it would be important to know how best to organize it to avoid lengthening the duration of medical training. Adapting the present roles of health professionals to current health-workforce situations was also considered important. Other possible policies identified by participants included: the need for more specialist training for general practitioners; shorter working hours;
better promotion of health professions; and higher remuneration (for example, corresponding to that of lawyers or people working in business). Agreements with neighbouring countries on the exchange of health professionals would also foster international collaboration.
Key issues related to postgraduate training
Small countries are faced with huge challenges in relation to the availability of training capacity, workforce resources and data.
It is necessary to identify models that allow service and career aspirations to come together. A connection between the labour market and training systems is necessary to ensure a clear pathway to employment after postgraduate training. The main problem for small countries is not the identification of postgraduate-training opportunities, but the retention of health professionals after they graduate abroad. It is important to find a way of motivating them to return to their home countries and work for sustained periods. Another challenge is how to forge and develop careers that allow health professionals to maintain their skills while working in different areas. This does not apply to areas in which there is a shortage of specialists (such as anesthesia, geriatrics and mental health).
The shape of the health workforce should match population needs. It is important to think of training, attracting and retaining personnel in the light of the existing health workforce and the services it needs to deliver to determine where changes in the health workforce might be required.
It is also important to understand how undertaking postgraduate speciality training abroad can contribute to a decision not to return home. This is particularly relevant to forecasting the availability of generalist health professionals and specialists.
It is necessary to reframe to determine whether certain specialist areas (for example, geriatrics, palliative care) will become niches in which few wish to work, or a general part of service provision. There is a need to understand the requirements of the different patient groups (for example, access to a centre of excellence for rare diseases only). Generic postgraduate training, complemented by training in a few niche areas, could be considered as a way of providing knowledge about different specializations. Smaller countries could take the lead on this trajectory with the support of WHO.
In the face of an ageing population, everyone needs to know about geriatrics to some extent; thus, it would be useful to integrate geriatrics into all fields of medicine.
Global and small-country needs. Some challenges related to human resources for health are global and include shortages of skills in anaesthesiology, psychiatry, palliative care, and geriatric care. Those more specific to small countries relate to their size, capacity and/or location.
Legal issues related to cross-country collaboration. The question was raised as to how feasible it would be from a legal perspective to set up an intercountry pool of specialists in rare diseases within European Reference Networks (ERN) (10). The concept of health professionals from one EU country visiting other EU countries is possible and some small countries are working to join ERN (10). The risk of developing a 2-tier system was brought up since, potentially, larger EU countries would find themselves in the inner core and non-EU countries might be left out. In addition, such a system could change the way in which health systems are organized and create disparities between the countries involved in networks such as ERN and those that are not.
In small countries, problems are often magnified, occuring sooner than in large countries. The discussions held during the meeting may well be echoed with respect to large countries in 10–15 years’ time. Clearly, changes in ways of working will be necessary if people are to be attracted to and retained in the health system.
Regarding the private sector, an in-depth understanding of the implications of these changes for health- workforce training is important. It is also important to consider that postgraduate training is only one of the elements that affect the delivery of health services. In addition, an understanding of digital disruption and its effects – both positive and negative – on the health workforce in large countries is necessary.
An in-depth analysis of monitoring and managing health-workforce mobility in small countries
The aim of this session was to gain a better understanding of small-country/regional needs and priorities in relation to monitoring and managing health-workforce mobility. Small countries can be particularly vulnerable to small numerical outflows of migrant health workers, and some may also be reliant on internationally recruited health workers with the risk of their moving on as well. Capacity for monitoring HRH mobility needs to be improved and a better understanding of policy options that could improve its management, such as country-to country bilateral agreements, should be developed. The recently established International Platform on Health Worker Mobility (11) should be investigated and small countries made aware of how they could participate effectively. In addition, efforts to support the implementation of the Code (7) should continue.
Prior to the meeting, the 11 countries/regions represented in the Ad hoc working group on HRH were asked to complete a questionnaire providing information on how monitoring and management of health-workforce mobility was taking place in their countries. They were asked to provide information on: background context;
policies in place for the retention of health professionals; status implementing the Code (7); available data and priorities for improving data collection; initiatives taken; and cross-country collaboration. The questionnaire was completed by 7 of the 11 countries/regions. Information resulting from the completed questionnaires was synthesized into a set of common themes and key messages (Box 3, Table 1) and a set of questions presented for discussion at the meeting (Box 4). Micro case studies on postgraduate training, based on the result of the questionnaires completed by the 7 countries/regions, will be made available on the website of the Small Countries Initiative (9).
Box 3. Key messages deriving from the in-depth analysis of monitoring and managing health-workforce mobility in small countries/regions
Key message 1. Data on the mobility and migration of health professionals in small countries/regions are not available to all practising professionals. Data gaps and systems conducive to producing more timely data are needed (Table 1).
Key message 2. Use of the Code (7) varies among small countries/regions (from a reference source to an implementation guide).
• Some countries are familiar with the Code (7) but do not apply it.
• Some find it useful as a reference in reflecting on national strategy for health personnel.
• Some use it to ensure:
— implementation of effective national action and policies to reduce dependence on the recruitment of international health professionals;
— adherence to the recommendations on international health cooperation with low-income countries (technical and financial assistance);
— ethical recruitment of health workers from source countries.
Key message 3. Small countries/regions use a variety of financial and other incentives to retain health professionals, or encourage them to return to their home countries, such as:
• higher salaries, private-practice opportunities, continued medical education, high-tech equipment; degree recognition;
• facilitation of reintegration into the home country (priority of job applications);
In addition, there are collaborative agreements between hospitals and universities on the retention of health workers.
Key message 4. Data are only one of several elements required for effective HRH planning, such as determining the most effective balance of skill mix.
Gaps were identified regarding:
• skills mix, in connection with which more efficient administration of health workforce on the ground and less bureaucracy are needed;
• planning of labour markets (country-needs assessments, national plans on health workforce, and country specificities regarding health workforce);
• coordination of implementation of and collaboration on national strategies, engaging all health-sector stakeholders and a network of small countries (with the inclusion of some large countries), would be helpful.
Key message 5. Small countries/regions can come together to identify mechanisms for cross-country collaboration in this area
• Interest was expressed in the establishment of centres of excellence, consortium policies, regular forecasting on HRH, and mechanisms for tracking/evaluating speciality training available.
Table 1. Status of availability of data on health-workforce mobility in small countries/regions
Status Data on
Available Health personnel
Health professionals and health-care facilities (registry) Health professionals licensed to practice
Practising health professionals
Contract data of health professionals, including personal characteristics (country of birth, address, nationality, country of diploma, employer data, postgraduate training undertaken, etc.) Personal data of health workers (nationality, age, sex, country of graduation, date of hiring, internal mobility, salary, etc.)
Internal and external mobility of physicians
Could be obtained with additional effort Current and future needs in terms of population health care and the health system (analysis needed)
Current information on health professionals and health-care facilities Working hours of health professionals (in half days) to provide an understanding of availability
Entry/exit of health professionals into/from country
Clinical competences and skills (showing links between human resources and numbers of activities)
Necessary, but not currently available Data on private-sector health-care professionals
Regularly updated data automatically transferred from institutions to national authorities
A unified and complete database on health-workforce mobility at the national level
Improved data collection through use of e-health
Country feedback on monitoring and managing health-workforce mobility
The participants were asked about challenges and approaches related to monitoring and managing health- workforce mobility in their countries, including those related to the retention of health workers.
They were provided with a set of questions based on an analysis of the commonalities resulting from the questionnaire on this issue, which was completed by 7 of the 11 countries. A sense of isolation among health practitioners adds to the complexity of the issue, leading some countries to look at rotation and exchange as ways of managing it (Box 4).
Box 4. Key discussion questions: challenges and approaches to strengthening monitoring and management of health- workforce mobility
The following thought triggers were put to the participants at the beginning of the discussion.
• How could data sharing be encouraged?
• What could be done to produce more timely data?
• What could be done to improve the capacity for monitoring HRH flow at the country level and enhance collaboration?
• What measures could ensure an optimal reporting process in accordance with the Code (7)?
• What might be the best way of sharing experiences on the effectiveness of various types of financial or other incentives (what works best)?
• What else should be in place to ensure effective HRH planning in small countries?
• What is the greatest potential for intercountry collaboration and what steps are needed to this end?
Some small countries are beginning to collect data on health professionals by: profession; place of work after graduation; reason for choice of place of work; places of work 5 and 10 years after graduation; number
sector in providing data for planning and policy purposes, using mechanisms, such as a shared-medical-record system and a central database into which all health professionals (in both the public and private systems) can enter their data. This will help gain valuable information on health-workforce mobility. While collaboration between the public and private sectors takes place in terms of collecting data, it is not always clear from which sectors they emanate.
The geographically hard-to-reach locations of some countries also pose difficulties in attracting health professionals, which results in insufficient human resources to cope with the delivery of health services. Here, the use of technology could provide ways of overcoming isolation, encouraging collaboration and preventing burn out.
Other challenges include: retaining physicians due to the need for a system that safeguards their possibilities of returning to work at home; repurposing ageing workforces; and finding innovative ways of encouraging young people to study medicine. Reducing the duration of study for a medical degree and restructuring the medical curricula in the light of the rapidly evolving technology could help encourage youth to choose medical professions.
Some countries seek to retain physician knowledge and skills by offering retirees the possibility of working in certain settings on a part-time basis. Other countries welcome the integration of health professionals from larger neighbouring countries to counteract shortages in their health workforces. Visiting mobility programmes, sustained through expatriate connections whereby nationals who emigrate can return home 2–3 times a year to provide services, could be an option for helping to retain medical professionals.
In some countries, physicians are leaving the health system in their prime (average age 42) and there is some internal mobility from rural to urban areas and between sectors. Many physicians move from primary health care or emergency care to secondary or tertiary health care. The departure of female physicians for family reasons presents another challenge. Reintegration into the system needs to be facilitated.
Participants were informed that the European Commission has recently published country health profiles for Cyprus, Luxembourg and Malta. These provide a good starting point for bringing about an understanding of the key challenges related to monitoring and managing health-workforce mobility. It is also necessary to consider the epidemiological aspects of the health workforce. Data need to go beyond absolute numbers and be linked to outcomes.
Implementation of the WHO Code and financial incentives
Two specific policy issues related to mobility and migration were discussed: implementation of the WHO Code (7) and financial incentives to retain health personnel.
Implementation of the WHO Code
The focus of the session turned to implementation of the WHO Code (7) and the aspect of data reporting by the designated national authorities. According to the third round of national reporting (8), 31 Member States in the WHO European had reported on implementation of the Code (7). Although the depth of data reporting and information sharing has increased, it has not resulted in the availability of qualitative information. For example, neither the experiences of migrant workers nor the effect of their contributions to the health systems have been captured. This is an information gap. It seems that new efforts are being made to integrate migrant workers into society, create social networks for them, and help them forge connections in their new countries. While these workers can develop professionally, they are otherwise unsupported. In some countries, professional associations are not welcoming of migrant health workers in their health systems.
The responsibilities of destination countries engaged in active recruitment was also brought up with some countries taking these responsibilities more seriously than others. Some countries, such as Germany and Norway, take these responsibilities more seriously than others.
The Code (7) could be a mechanism for bringing different stakeholders together.
Financial incentives
Financial incentives aimed at retaining health workers represent only part of the solution. They also present challenges in terms of health-workforce retention; for example, if a specific group receives a pay rise, this may result in other groups demanding the same. Examples of financial motivation included: incentives for non-resident physicians to provide on-call services; increased remuneration for physicians and nurses who facilitate training programmes; and recognition of work in specific settings, such as emergency care.
The challenge of market segmentation is very real, and it is important to ensure that the demands of the different areas of the labour market can be met cost-effectively.
Experience in the countries indicates that although financial incentives can be effective in the short term, educational and other incentives are more likely to have a longer-term impact. For example, the earlier in their careers that health workers can be motivated to work in much-needed areas (for example, emergency care) and rural districts, the more likely it will be that they will continue to do so.
Cross-country collaboration
The need to plan health systems according to predictable variations in workflow (for example, seasonal changes, such as increased demand in winter) was made clear in this session. In redesigning health services, the aim should be to help workforces perform better. For example, many health workers in emergency services are burnt out after 10 years. This is a service-redesign issue, which must be tackled effectively since it has an impact on retention. A challenge such as this one is more pronounced in smaller countries where options for redesigning services are more limited. At the global level, there are examples illustrating use of the model of onward migration, according to which health workers move on quickly. This model could pose problems for small countries in terms of estimating needs. Therefore, if adopted, close monitoring would be required and legal/regulatory aspects, logistical issues (such as salaries), and the question of how to connect with the local workforce would need to be taken into consideration. Mobility beyond major countries also needs to be made attractive.
Mechanisms for the retention of health workers are context specific: what works in some countries and cultural contexts may not in others. This calls for effective monitoring and management. The education, regulation and employment triangle must be aligned to achieve the right kind of workforce. The extent to which these 3 elements work together varies from country to country so that information from the 3 sources would need to be collated.
Possible areas of collaboration on monitoring and managing health-workforce mobility
The following possible areas of collaboration and coordination among small countries on monitoring and managing health-workforce mobility were identified:
• circular agreements (ways in which WHO could support small countries);
• finding ways of:
- addressing shortages of health professionals;
- engaging the private sector and understanding public–private mixes and their potential role in postgraduate-training and workforce planning, as well as improving access to and the use of private- sector data;
- attracting high-school students to the health area in the light of competitive career environments (for example, STEM, nursing) and changing epidemiology;
- using digital technology effectively and understanding how digital disruption can affect health workforces in small countries, both positively and negatively;
- supporting the engagement of universities, other training institutions and regulatory bodies in small countries;
- improving access to and the use of private-sector data.
Regarding the first point, WHO could investigate the possibility of such collaboration, which is highly dependent on language considerations (ideally level C1 of the Common European Framework of Reference for Languages) and thus may not be equally valuable to all countries. What is important to countries will vary at different points in time. It would also be important to look at existing bilateral, circular and other agreements and at what has been reported on implementation of the Code (7) and consider what other types of agreement may be relevant.
Next steps
It was agreed that attention should be paid to the following issues:
• finding ways of attracting, recruiting and retaining nurses
• finding ways of attracting young people to health-related professions
• the feasibility of circular agreements and the key components to be included
• dual practice and the implications of building sustainable health workforces
• shortages in certain medical specialties (for example, obstetrics/gynaecology, palliative care, geriatrics, surgery, psychiatry and anesthesiology).
Where appropriate, the development of working papers, policy briefs and other related resources should also be considered.
References
11. Global strategy on human resources for health: Workforce 2030. Geneva: WHO; 2016 (https://apps.
who.int/iris/bitstream/handle/10665/250368/9789241511131-eng.pdf?sequence=1).
2. WHO Regional Committee for Europe resolution EUR/RC67/10 on towards a sustainable health workforce in the WHO European Region: framework for action. Copenhagen: WHO Regional Officed for Europe; 2017 (EUR/RC67/10+EUR/RC67/Conf.Doc./5; http://www.euro.who.int/__data/assets/
pdf_file/0011/343946/67wd10e_HRH_Framework_170677.pdf?ua=1).
3. Sousa A, Scheffler RM, Nyonic J, Boermad T. A comprehensive health labour market framework for universal health coverage. Bull World Health Organ 2013;91: 892– 894 (https://www.who.int/docs/
default-source/health-workforce/a-comprehensive-health-labour-market-framework-for-universal- health-coverage.pdf).
4. National Health Workforce Accounts (NHWA). In: Health workforce [website]. Geneva: WHO; 2020 (https://www.who.int/hrh/statistics/nhwa/en/).
5. Ono T, Lafortune G, Schoenstein M. Health workforce planning in OECD countries: a review of 26 projection models from 18 countries. Paris: OECD Publishing; 2013 (OECD Health Working Papers, No. 62; https://doi.org/10.1787/5k44t787zcwb-en).
6. Campbell J. SDG3.c.1. Health worker density and distribution health worker. Labour mobility.
Geneva: WHO; 2018 (https://www.un.org/en/development/desa/population/migration/events/
coordination/16/documents/presentations/5a%20-%20SDG3_WHO.pdf).
7. The Global Code of Practice on the International Recruitment of Health Personnel. Geneva: WHO;
2010 (https://www.who.int/hrh/migration/code/practice/en/).
8. Human resources for health. WHO Global Code of Practice on the International Recruitment of Health Personnel: third round of national reporting. Report by the Director-General. Geneva: WHO, 2019 (https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_23-en.pdf).
9. Small Countries Initiative. In: WHO Regional Office for Europe [website]. Copenhagen: WHO Regional Office for Europe; 2020 (http://www.euro.who.int/en/about-us/networks/small-countries-initiative).
10. European Reference Networks. In: European Commission [website]. Brussels: European Commission;
2020 (https://ec.europa.eu/health/ern_en)
11. International Platform on Health Worker Mobility. In: Health workforce [website]. Geneva: WHO;
2020 (https://www.who.int/hrh/migration/int-platform-hw-mobility/en/).
1 All URLs accessed 8 March 2020.
Annex 1. Programme
Monday, 9 December 2019
Opening session
Welcome and introductions
Francesco Zambon, Coordinator, Small Countries Initiative, WHO European Office for Investment for Health and Development of the WHO Regional Office for Europe
Programme of work and expected outcome of meeting
Gabrielle Jacob, Programme Manager, Human Resources for Health (HRH) Programme, Division of Health Systems and Public Health, WHO Regional Office for Europe
Setting the scene: using the WHO labour market framework and National Health Workforce Accounts (NHWA) to address health-workforce challenges
Introduction of the health labour market framework and NHWA
Jim Buchan, WHO Consultant, WHO European Office for Investment for Health and Development, and Gabrielle Jacob
HRH in small countries: addressing the challenges
Natasha Azzopardi-Muscat, Director, WHO Collaborating Centre on Health Systems and Policies in Small States, University of Malta
Deep dive 1: addressing postgraduate-specialist-training challenges2 Moderators: Natasha Azzopardi-Muscat and Gabrielle Jacob
Summary overview of country questionnaires
Leda Nemer, WHO Consultant, European Office for Investment for Health and Development of the WHO Regional Office for Europe
Roundtable discussion Summary of discussion
Tuesday, 10 December 2019
Introduction to day 2
Deep dive 1: addressing postgraduate-specialist-training challenges2 (contd) Moderators: Natasha Azzopardi-Muscat and Gabrielle Jacob
Roundtable discussion on presentation and country experiences
Deep dive 2: Monitoring and managing health-workforce mobility2 Moderators: James Buchan, Gabrielle Jacob and Natasha Muscat
Summary overview of country questionnaires Leda Nemer
Roundtable discussion on presentation and country experiences Moderators: James Buchan and Gabrielle Jacob
Roundtable discussion
Closing session
Moderators: Francesco Zambon, James Buchan, Gabrielle Jacob Summary and conclusions of the meeting
Next steps
Opportunity for bilateral discussions (voluntary)
Annex 2. Participants
Andorra
Josep Romagosa Massana
Health Systems Information Technician National WHO Counterpart
Health Resources and Medicines Department Ministry of Health
Andorre-la-Vieille AD500
E-mail: josep_romagosa@govern.ad
Canary Islands (Spain) Sara Darias-Curvo Professor
Research Center of Social Inequality and Governance University of La Laguna
San Cristóbal de La Laguna Tenerife
E-mail: sadacur@ull.edu.es
Cyprus
Maria Georgiou Administrative Officer Ministry of Health Nicosia
E-mail: mgeorgiou@moh.gov.cy Angeliki Protopapa
Administrative Officer Ministry of Health Nicosia
E-mail: aprotopapa@moh.gov.cy
Estonia Kersti Esnar
Head of Health Care Resources
Department of Health System Development Ministry of Social Affairs
Tallinn
E-mail: kersti.Esnar@sm.ee
Iceland
Bryndís Þorvaldsdóttir Senior Advisor
Department of Health Services Ministry of Health
Reykjavik
E-mail: bryndis.thorvaldsdottir@hrn.is
Dagmar Huld Matthíasdóttir Special Advisor
Department of Quality and Prevention Ministry of Health
Reykjavik
E-mail: dagmar.matthiasdottir@hrn.is
Latvia Dace Roga Senior Expert
Division of Human Resources Development Ministry of Health
Riga
E-mail: dace.roga@vm.gov.lv
Luxembourg Michèle Wolter
Division of Curative Care, Directorate of Health Ministry of Health
Luxembourg
E-mail: michele.wolter@ms.etat.lu
Madeira, Autonomous Region of (Portugal) Herberto Jesus
Regional Administrator
Regional Institute of Health Administration Funchal
E-mail: Herberto.Jesus@iasaude.madeira.gov.pt
Malta
Maureen Mahoney
Director General (People Management)
Human Resources Department, Ministry of Health Valletta
E-mail: maureen.mahoney@gov.mt Marilisa Darmanin
Human Resources Coordinator Foundation for Medical Services (FMS) Ministry of Health
Valletta
E-mail: marilisa.a.darmanin@gov.mt
Monaco
Alexandre Bordero
Director, Department of Health Affairs Ministry of Health and Social Affairs MC-98000
E-mail: abordero@gouv.mc
Montenegro Natasa Terzic
Director, Center for Health System Development Institute of Public Health
Podgorica
E-mail: natasa.terzic@ijzcg.me Vesna Miranovic
Director, Quality Control and Improvement of Human Resources for Health Ministry of Health
Podgorica
E-mail: vesna.miranovic@mzd.gov.me
San Marino Andrea Gualtieri
Chief, Institute of Social Security Cailungo
E-mail: andrea.gualtieri@iss.sm
Slovenia
Blanka Česnik Wolf Secretary-General Ministry of Health Ljubljana
E-mail: Blanka.Cesnik-Wolf@gov.si
WHO Collaborating Centre Natasha Azzopardi-Muscat
Head, WHO Collaborating Centre on Health Systems and Policies in Small States University of Malta
Msida
E-mail: natasha.muscat@gov.mt
WHO Regional Office for Europe James M. Buchan
Senior WHO Consultant
WHO European Office for Investment for Health and Development E-mail: james_buchan@hotmail.com
Gabrielle Jacob Programme Manager
Human Resources for Health Programme Division of Health Systems and Public Health E-mail: jacobg@who.int
Leda Eugenia Nemer WHO Consultant
WHO European Office for Investment for Health and Development e-mail: nemerl@who.int
Lazar Nikolic Assistant
European Office for Investment for Health and Development WHO Division of Policy and Governance for Health and Well-being E-mail: nikolicl@who.int
Cristina-Maria Popescu Administrative Assistant WHO Country Office, Romania E-mail: cpopescu@who.int Francesca Vezzola
Programme Assistant
Human Resources for Health Programme Division of Health Systems and Public Health E-mail: vezzolaf@who.int
Francesco Zambon
Coordinator, Investment for Health and Development in Healthy Settings WHO European Office for Investment for Health and Development Division of Policy and Goverance for Health and Well-being
E-mail: zambonf@who.int
World Health Organization Regional Office for Europe The WHO Regional Office for Europe
The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves.
Member States Albania
Andorra Armenia Austria Azerbaijan Belarus Belgium
Bosnia and Herzegovina Bulgaria
Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway
Poland Portugal
Republic of Moldova Romania
Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey
WHO/EURO:2020-1295-41045-55723
