Every country’s health system requires an optimal number of doctors, nurses, midwives, technicians, other allied professionals and frontline health workers. Such ‘health workers’ provide a wide range of services in community as well as institutional settings. From birth to death, virtually every individual accesses some of these services.
As the global population grows and extends its life expectancy, there is a growing need for a larger health workforce to meet a wider range of healthcare needs. The World Health Organization estimates a global shortage of 11 million health workers by 2030. The low- and middle-income countries (LMICs) of Africa and Asia will be most affected by the shortages. Among healthcare professionals, nurses will be in greatest shortage.
Globally, this shortage has arisen from underinvestment in health workforce education and professional development. High-income countries (HICs) have, over the past 70 years, resorted to recruitment of trained health workers from LMICs to cover gaps in their health workforce. Higher salaries, better working conditions, skill enhancement, appealing socio-cultural milieu, and educational opportunities for children acted as ‘pull’ factors, while poorly resourced and badly governed health systems as well socio-political instability in some countries acted as ‘push’ factors propelling health worker migration.
To address challenge of growing global inequities in health workforce availability, the WHO framed the Global Code of Practice on the International Recruitment of Health Personnel. This voluntary code, adopted by all WHO members at the 63rd World Health Assembly in 2010, called upon ‘destination countries’—mostly high-income ones—to adopt ethical practices for recruiting health workers from ‘source countries’—mostly LMICs—and protect their rights while ensuring that health systems of the source countries are not drained of the workforce needed to meet their needs.
Despite this, WHO’s database reveals marked inequities in the global distribution of health workforce. According to recent estimates, 23 percent of the world’s doctors, nurses and midwives reside in 10 HICs that comprise 9 percent of the global population. In sharp contrast, only 5 percent of them reside in the 55 countries in the WHO Health Workforce Support and Safeguards List that are home to 21 percent of the world’s population. This inequity is aggravated by continued migration of health workers from LMICs to HICs.
Members of the Organisation of Economic Co-operation and Development and the Gulf Cooperation Council also contribute to health worker migration as premier destination countries. The share of foreign-born doctors in OECD countries rose by 86 percent in the first two decades of the century, while the share of nurses grew nearly two-and-a-half times. While migration of health workers also occurs among HICs, that does not adversely impact their health systems in the manner migration from LMICs to HICs does.
As populations in HICs age and experience falling fertility rates, their ability to draw young people from their own countries into the health workforce is diminished. They increasingly try to recruit qualified persons from LMICs. This is no longer restricted to doctors, nurses or technicians. The need for providing physical and mental support to aged persons has given rise to the ‘care industry’, where assistance is provided to elderly persons and people with physical or mental disabilities for performing activities of daily living. Migration of ‘care workers’ also needs to follow the code set for ‘health workers’.
WHO constituted an international expert committee to advise it on the code revision in 2025. Its report, reviewed through extensive consultations with experts, governments, professional associations and recruiting agencies, was submitted to WHO’s executive board by its director general.
While reiterating the need for better observance of ethical practices in recruitment and protection of migrant workers’ rights, the revision calls for inclusion of ‘care workers’ in the ambit of the code. It calls for ‘co-investment’ by source and ‘destination countries’ to jointly develop health workforce numbers and competencies to meet each other’s needs.
It advocates greater investment in health workforce education by all countries and the need to respond to ongoing demographic, epidemiological and technological transitions while doing so. It urges timely and accurate reporting on in-flows and outflows of health workers by all governments and recruitment agencies.
The expert group also recommended that data on internationalisation of health professional education must be gathered, to track international flows of students and trainees. It emphasises the need for increased research funding on health and care worker migration, to address critical information gaps and enable ethical and efficient management of international flows.
The revised code also draws on the experience of the Covid-19 pandemic to caution that health worker migration should not weaken the capacity of vulnerable countries to effectively respond to public health emergencies. If outmigration continues in large numbers, countries in Africa and Asia will suffer greatly whenever epidemics, natural disasters or other emergencies challenge their health systems.
It is important to ensure that each country’s health workforce is fully functional in a steady state and also has a reserve capacity to create a swift, strong and sustained surge response when a public health emergency arises. Co-investment by all countries can help to ensure that common global threats can be countered competently and confidently during such surges. Prime Minister Narendra Modi, at a recent G20 meeting, proposed the creation of a global emergency medical response force that can rapidly respond to a public health emergency anywhere in the world.
India is increasing investments—both by the government and the private sector—in expanding the health workforce. It also has checks on outmigration, like emigration clearance for nurses and issuance of no-objection certificates for doctors. It aims to use its demographic advantage of a young population by training health workers to meet shortages in the global workforce through the Heal by India programme.
But even as we position ourselves to meet global needs, while planning our health workforce development strategy, we must also correct regional disparities within the country.
K Srinath Reddy | Chancellor of the PHFI University of Public Health Sciences and Chair of the Centre for Universal Health Assurance at the Indian School of Public Policy
(Views are personal)
(ksrinath.reddy@phfi.org)