Supporting the WHO Code of Practice on International ......... Stakeholder mapping and ... (stock)...

© WHO all rights reserved

This draft protocol is intended to support data collation and analysis in the context of a specific project. A further versio n

incorporating lessons learned from its use will be developed and formally published in future. 1

“Brain drain to brain gain” project:

Supporting the WHO Code of Practice on International Recruitment of Health Personnel, for Better Management of

Health Worker Migration

Protocol for first phase project data collection

March 2015

(European Commission: Thematic Programme of cooperation with third countries in the

areas of Migration and Asylum)




Table of Contents

1.Introduction ..................................................................................................................... 3

2.Project context................................................................................................................. 4

2.1 The WHO Code and designated “national authority” reporting ................................... 4

2.2 Project context: Stocks and Flows (Entry, Exist, Exit) ................................................ 5

2.3 Project context: Health workforce registry and minimum data set ............................... 7

3. The Project ..................................................................................................................... 8

3.1 Objective and results ................................................................................................. 8

3.2 Project coverage........................................................................................................ 9

4. The Protocol ..................................................................................................................10

4.1 Introduction .............................................................................................................10

4.2 Protocol Stage 1: Stakeholder mapping and engagement ...........................................13

4.3 Protocol Stage 2: Data acquisition............................................................................15

4.4 Protocol Stage 3: Data verification and analysis ........................................................18

4.4.1 Surgical workforce: Data verification and analysis ..............................................19

4.5 Protocol Stage 4: Data gap identification..................................................................20

4.6 Protocol Stage 5: MDS data source identification .....................................................21

4.7 Protocol Stage 6: Initial country reports ....................................................................22

Annex 1. Protocol Tool......................................................................................................27

A six stage process.........................................................................................................27

Box 1: Protocol stages and indicative timeline ............................................................27

Stage 1: Stakeholder mapping and engagement ..............................................................28

Template A: Record of Stakeholder engagement and data identification.......................28

Stage 2: Data acquisition ...............................................................................................29

Template B: Current record of relevant data sources and data providers identified ........29

Stage 3: Data verification and analysis............................................................................30

Template Ci: Viable data sources to monitor entry, exist and exit of migrant health

workers......................................................................................................................30

Template Cii: Viable data sources to monitor entry, exist and exit of migrant health

workers working in surgical care: use a separate template for each profession, cadre ....31

Stage 4: Data gap identification ......................................................................................31

Stage 5: MDS data source identification .........................................................................32

Template D: MDS and workforce registry- Core data items and current availability .....32

Stage 6: Initial country reports ........................................................................................33

Template E: Data, Information, and Analysis hierarchy for country reports ..................34

Annex 2: Detailed description of data sources.....................................................................36




1.Introduction

This protocol has been developed to facilitate the first phase of the EC funded “Brain drain

to brain gain” project. This project has been developed by WHO/GHWA to support the full

implementation of the WHO Code of Practice on International Recruitment of Health

Personnel, with the overall aim to achieve better understanding and management of health

worker migration.

The purpose of this project is to generate momentum and accelerate progress in Code

implementation, and to support the work undertaken by WHO on producing guidelines for

minimum data sets and reporting requirements for Code implementation. It has been

recognised that a lack of accurate, reliable, standardized, and timely data of health workers at

national and sub-national levels hamper wider efforts at managing inward and outward

migration flows of health workers. Currently, health workforce information based on

minimum data set standards is mostly absent in low- and middle-income countries, and a

lack of standards-based electronic or web-enabled health workforce registries compounds the

problem, leading to lack of real-time documentation of workforce profile and mobility. These

limitations constrain effective and timely reporting on the WHO Code.

The overall project is therefore focused on improving data, analysis and on supporting

implementation of the Code. The primary coverage of the project is on 3 priority source

countries (Uganda, Nigeria and India), 1 destination country (Ireland) and a country that is

both a source and destination for migratory flows of health workers (South Africa).

The purpose of this protocol is to ensure a consistent methodology is applied during the first

phase of the project, in each of the five countries, in terms of data gathering approaches and

initial analysis. It has been developed after a desk review of project documents and relevant

literature, a project inception meeting (17-18 December, 2014), and engagement with

implementation partners and the EC delegation to ensure the optimum approach to research

and evidence generation is identified and implemented.

There are two linked elements to the protocol. This document is the user guide. It sets out the

project context and rationale, and gives guidelines on the approach to be followed by each

country project team in the first phase of the project, as they develop stakeholder

engagement, identify, acquire and assess data, and analyse and report initial findings. The

second element of the protocol is the protocol tool, which collates the various templates




described within the user guide, to provide a standard structure for reporting on information

and data acquisition. Annex 1 of this user guide provides this tool, comprised of all the

necessary templates.

2.Project context

2.1 The WHO Code and designated “national authority” reporting

The WHO Global Code of Practice on the International Recruitment of Health Personnel was

adopted by the 63rd World Health Assembly on 21 May 2010

(http://www.who.int/hrh/migration/code/practice/en/index.html)

The main purposes of the WHO Code are to:

Establish and promote voluntary principles for the ethical international recruitment of

health personnel, taking into account the rights, obligations and expectations of source

countries, destination countries and migrant health personnel.

Serve as a reference for Member states in establishing or improving the legal and

institutional framework required for the international recruitment of health personnel.

Provide guidance that may be used where appropriate in the formulation and

implementation of bilateral agreements and other international legal instruments.

Facilitate and promote international discussion and advance cooperation on matters

relating to the ethical international recruitment of health personnel as part of

strengthening health systems, with a particular focus on the situation of developing

countries.

The WHO Code gives a central role to the member states and to other stakeholders

(recruiters, employers, professional organizations, NGOs, etc.) for its implementation (for

more details, see Article 8 “Implementation of the Code”). In particular, member states are

encouraged to publicize and implement the Code in collaboration with all stakeholders, to

incorporate the Code into applicable laws and policies, and to consult with all stakeholders in

the decision-making process and involve them in other activities related to the international

recruitment of health personnel.

Member states are required to periodically report measures taken, results achieved,

difficulties encountered, and lessons learnt in implementation of the Code, as well as

http://www.who.int/hrh/migration/code/practice/en/index.html




information and data related to monitoring the international migration of health workers. The

first report of the member states to the WHO Secretariat was made in 2012. The distribution

of the next national reporting instrument is scheduled for 01 March 2015

http://www.who.int/hrh/migration/code/code_nri/en/ In order to take the lead on systematic

reporting, member states are required to designate a “national authority” who is responsible

for the exchange of information regarding health personnel migration and implementation of

the Code, and is contact point for information flow between member state and WHO

Secretariat, framed by the national reporting instrument.

2.2 Project context: Stocks and Flows (Entry, Exist, Exit) The issue of effective tracking of migration flows has been given an added impetus by the

WHO Code requirements. As noted earlier, this project stems from a recognition that there is

often incomplete data on, and monitoring of, health workforce migration. It is evident that

there is an urgent need to improve monitoring in many countries, but it is also critical that any

such efforts are related to overall improvement of data for planning and policy making, not

just to look at migration in isolation from other labour market dynamics.

There are two main ways of examining and monitoring health worker migration – by looking

at workforce “stocks” and “flows”. The protocol provides a template approach to identify

which data sets are available to assist in tracking stocks and flows.

The “stock” of migrant health workers in a country is measured by assessing the numerical

size and composition of the migrant health workforce (age, gender, occupation etc). The size

(stock) of this migrant workforce relative to the total size of the workforce in the health sector

in a destination country is an indicator of the level reliance of that country on in-migration as

a source of supply. A high proportion of immigrant health workers suggests that a destination

country is far from being “self-sufficient” in health workforce terms.

Comparing the size of the stock of out-migrated health workers who have moved from the

source country to destination countries, with the size of the health workforce remaining in the

source country (what the OECD have termed the “expatriation rate” ) also gives a measure of

just how significant has been outflow over the years. Measures of stock therefore enable

estimates to be made of the relative size (and perhaps composition) of the remaining

workforce, or departed workforce.

http://www.who.int/hrh/migration/code/code_nri/en/




The main limitation of assessment of stock is that it does not enable a real sense of the

dynamics of migration to be assessed. It does not indicate if the health workers left the source

country last week, or last year, or twenty years ago. To fill this gap, “flow” data is required to

enable the dynamic nature of migration to be captured in data sets. This requires some

mechanism to assess trends in the numbers leaving (or entering) the country in a systematic

and regular manner.

Year-on-year measures of outflow of health workers can give policy makers in the country a

clearer picture of the extent to which this outflow is growing or reducing. Comparison of the

size of the annual outflow with the size of stock in the source country gives a measure of how

significant is the outflow. Monitoring of outflow can also help identify the main destination

countries, which can enable policy makers to identify which countries they should engage in

policy dialogue over the matter of migration of health workers.

To capture the different elements of workforce flow, WHO/GHWA have identified the four

major health workforce functional categories as part of the life‐cycle of health workforce:

Pre‐Entry, Entry, Exist, and Exit, which are shown in Figure 1.

Figure 1. Context of health workforce registry: person‐centric information system

Source: WHO, 2015, MDS. Adapted from WHO, World Health Report, 2006.

The Pre‐Entry category involves workforce planning and alignment with service needs and

funding.

In the Entry category, new workers entering the health care labour market from training are

monitored. This comprises part of inflow, which can also include workers re-entering the




labour market after career break, and workers entering the labour market from international

sources and as temporary or permanent migrants.

In the Exist Process (the stock) employed licensed health professionals and other health

workers serving in public or private health facilities are listed. Managing workforce demands

various information‐intensive functions such as payroll, in‐service training, performance

based finance, re-licensure, and other functions.

During the Exit (or outflow) process, health professionals exit the employment processes, to

retirement, to other sectors and other countries.

The key to improving the monitoring of stocks and flows, or entry/exist/exit is to understand

that this is a dynamic process which will change over time, as different flows change in

magnitude in response to policy and labour market changes. This protocol therefore is

designed to ensure the identification and use of available data sets which can enable

monitoring of trends both of stocks and flows.

2.3 Project context: Health workforce registry and minimum data set

One key element of the overall “Brain Drain to Brain Drain” project is to contribute to the

full development and implementation of a standard HRH Minimum Data Set (MDS). WHO is

developing a MDS for use in developing a national health workforce registry (WHO 2015,

Minimum Data Set for Health Workforce Registry, forthcoming).

An electronic health workforce registry can be developed to become the single and

authoritative source of health workforce information at national level. A single authoritative

national source is essential for strengthening national health systems at all levels. Accurate

and timely health workforce data is crucial for HRH planning, national referral, training,

reducing or eliminating misinformation and duplicate health workers, improving regulation

of practice and track appropriate licenses of health professionals. The registry can also ensure

quality control, provide easy access of information on production, distribution and utilization

of health personnel, and budgeting, research development and advocacy.

The project partners in each of the five countries will advocate with professional councils to

reflect the Minimum Data Set for Health Workforce Registry as the basis for capturing health

workforce data relevant to the project, and to augment the current implementation efforts of




standards-based electronic health workforce registry to capture relevant workforce data at

entry and exit.

The workforce registry concept advocated for by GHWA/ WHO provides a tool for health

workforce planners and decision makers intended for developing an electronic system or

modify an existing health information system to count and document all health workers

within national and subnational context. The MDS linked to the registry can be used for by

ministries of health to support the development of standardized health workforce information

system. The MDS allows standardization of data values within existing electronic human

resources for health (HRH) information systems. Fig xx below shows the MDS components.

Fig 2: Proposed data elements in the GHWA/ WHO Minimum Data Set (MDS)

Source: WHO Minimum Data Set for Health Workforce Registry (draft, 2014)

This protocol therefore provides a template to assess the current extent to which the country

under examination can provide the data items for the MDS listed in t Figure 2, so that current

status and future progress in MDS development and registry implementation can be assessed.

3. The Project

3.1 Objective and results

The overall objective of the “Brain Drain to Brain Gain” project is: Improving the

management of migration flows from sub-Saharan Africa and Asian countries towards

Europe with a special regard on the management of labour migration of health

personnel.




The expected results are:

Evidence generated on inward and outward migration flows on surgical care,

general medical practice and midwifery workforce in the involved countries.

Policy and decision makers are sensitized and consulted about best practices in

tackling health workers migration challenges and relevance/ effectiveness of

WHO Code.

Stakeholders at global level are empowered in their knowledge and capacity to

lead and facilitate Code implementation.

The five countries involved within the Action will be able to demonstrate an improved

understanding of the evidence base required to take concrete steps to address the issue of

health worker migration and will be better equipped to report on implementation of the Code

for the next reporting cycles.

3.2 Project coverage

The project is intended to be a catalyst to enable broad based engagement with stakeholders

within each of the five countries. These stakeholders will be organisations and entities with a

legitimate role, or potential role, in the monitoring, regulating, and managing of health

worker in- migration and/or out-migration, and those with a broader policy responsibility or

interest in health worker flows and labour market consequences. Amongst others, it is

anticipated that the project at country level will address the target groups set out in Table 1

below:

Table 1 Target groups for consideration for stakeholder engagement

national authorities charged with reporting on the Code,

professional councils,

national data managers in ministries of health, ,

various line ministries in the countries involved - including health, education, finance,

Ministries dealing with immigration

regulatory bodies,

professional associations,

training institutes,

student bodies,




international recruitment agencies,

labour unions representing health workers,

diaspora groups including associations representing foreign health professionals,

senior managers and boards of hospitals and/or health districts,

civil society,

private sector organizations.

4. The Protocol

4.1 Introduction

This protocol has been developed to support the first phase of the overall project, which is :

The collation of data, analysis and synthesis of evidence on migration of selected cadres

(surgical workforce in year 1; general practitioners in year 2; midwifery cadres in year

3) in selected countries (Nigeria, Uganda, India, Ireland, South Africa).

The protocol is designed to be applied at national level (or, in the case of India and Nigeria, at

state level), and to be used by the lead project partner (research team) responsible for each

country (India, Ireland, Nigeria, Uganda, South Africa) to guide their work, and to ensure that

there is scope for common reporting and assessment across the countries.

The protocol is set out in six stages, and makes use of five different data gathering/ recording

templates at different stages (Templates A, B, C/Ci, D, and E). The stages, templates and

timings are summarised in Box 1.

Box 1: Protocol stages and indicative timeline

Stage of protocol Indicative

timing*

1. Stakeholder mapping and engagement [Template A] February 2015

onwards

2. Data gathering [Template B] February 2015-

April 2015

3. Data verification and analysis [Templates Ci and Cii] March-June

2015

(report on

surgical

workforce , May)

4. Data gap identification March- June

2015




5. MDS data source identification [Template D] To be agreed in

each country

based on local

context

6. Initial country case study reports [Template E] July/ August

2015 *To be adapted based as needed based on actual timeframe of contractual process

Each of the six stages is described in more detail below. Whilst these are set out sequentially,

there will be some need for the project partner to track back to previous stages to verify and

check on data, analysis and assumptions being made at each stage. There will also be a need

to undertake follow up action on stakeholder engagement, data identification, verification and

analysis. This will not be a “one off” exercise to be completed by April/ May 2015 but a

process of improvement and refinement across the three year period of the project. The

research protocol itself will remain a living document, to be adapted and improved as guided

by the experience gathered in the implementation of the project activities. The protocol

templates are also provided as a stand-alone tool in Annex 1.

To ensure that migration data and broader HRH data are aligned, the “national authority”

identified for WHO Code reporting purposes should be centrally involved from project

inception at country level, and be fully involved in, and informed about, the project

objectives, methods, data requirements and outputs. WHO will confirm the name and contact

details of the designated national authority.

Due to high variance in completeness and availability of data across the five countries, it is

envisaged that at project inception the evidence base, and data sources, will vary considerably

by country. The aim of using a common protocol is to ensure that these data identification

and analysis activities are documented and conform to a standard approach. And that

variations do not detract from achieving an overall analysis that enables comparison between

the countries, and allows current status of data, and progress in data analysis to be tracked.

It is also anticipated that the degree of data variance should become less pronounced across

the lifetime of the project, as common protocols are more fully developed and as engagement

within countries leads to an iterative process of more standardised reporting and greater

compliance with core MDS requirements.




The overall focus of the activities underpinned by the protocol will be for the lead project

partner in each country to engage with stakeholders to document and explore the current

status on data availability related to health workforce migration. The activity will entail

exploring the current evidence base on health workforce migration data, identifying key

sources of data and critical data gaps. There will be a specific focus on assessing if relevant

surgical workforce, general medical practice workforce and maternal health workforce are

captured at entry and exit in a continuous manner. The scope for using the WHO MDS will

be assessed, and this will be complemented through a qualitative analysis on the policy

context.

To achieve stakeholder support and participation in the first phase of the project and to

achieve the longer term objectives of the project, it is likely that each project partner

responsible for a country will establish a national working committee or implementation

taskforce, which will represent a broad range of necessary expertise and relevant

stakeholders. Achieving this early “buy-in” of stakeholders will help to involve and commit

all interested parties for the duration of the project. Possible stakeholders may include

representatives from the list in Table 1 above. It may also be necessary to establish a separate

technical sub- committee which has responsibility for detailed aspects of HRH data review

and development.

In the first year of the project, there is a specific requirement to report on data availability to

analyse the mobility patterns of the surgical workforce. This is in the context of WHA

resolution on “Strengthening emergency and essential surgical care and anaesthesia as a

component of universal health coverage”, which requires member states to “ expand efforts to

close gaps, in both infrastructure and human resources for essential and emergency surgical

care. Improving workforce distribution, with special attention being given to rural areas,

should be a priority………..”( http://apps.who.int/gb/ebwha/pdf_files/EB136/B136_27-

en.pdf ). In parallel to the WHA resolution, the report of the Lancet Commission on Surgery

will be published in May 2015. This will inform international discourse in 2015 that this

project will immediately benefit from.

The focus on the surgical workforce will include specialists, surgeons and anaesthesiologists

as well as other as any general practitioners, nurses, clinical medical officers, non-physician

clinicians and other professionals who have received specific training in surgical care. The

project partners will define, as part of the initial scoping and adaptation of the research

http://apps.who.int/gb/ebwha/pdf_files/EB136/B136_27-en.pdf

http://apps.who.int/gb/ebwha/pdf_files/EB136/B136_27-en.pdf




protocol to the national context, which other cadres and titles, if any, may need to be

considered in each country.

4.2 Protocol Stage 1: Stakeholder mapping and engagement

In each country an initial mapping of ongoing stakeholder involvement in data management

and in efforts and mechanisms at tracking and managing health workforce availability,

distribution and migratory flows will be undertaken. This will include contact with the

national authority, and also will enable the identification of key stakeholders to engage in the

project activities, and specifically, to sources of HRH data-sets relevant to stocks and flows

monitoring. These will include national professional councils and the designated national

authorities for reporting on the WHO Code, as well as other relevant entities and

organisations, including, but not limited, to those listed in Table 1 above.

As previously noted, it is likely that each project lead will establish a working committee or

implementation taskforce, which will represent a broad range of necessary expertise and

relevant stakeholders drawn from the list in Table 1 above; and it may also be necessary to

establish a separate technical sub- committee which has responsibility for detailed aspects of

HRH data review and development.

The initial contact with stakeholders will serve three purposes - firstly to make them aware of

the project and its linkages to broader based issues related to the WHO Code and the

development of the MDS; secondly to generate interest in being engaged in the project and

build momentum in support of its activities, including advocacy and policy dialogue

opportunities; and thirdly to make an initial assessment of their possession of any data-sets

that may provide material for analysis of migration of health workers, assist in monitoring

for Code purposes, and for development of the MDS.

In order to standardise and systematise the stakeholder mapping approach, each country

project team should use Template A below to focus their efforts on engagement and to

capture and report an initial summary of the results of early engagement.




Template A: Record of Stakeholder engagement and data identification

Stakeholder Level of engagement/ data availability [tick one]

Engaged/

data

available

Responded/

no data

Contacted

/no

response

Not

contacted

N/

A

1. Designated national authority

2. professional councils,

3. national data

managers in ministries of health,

4. national authorities charged with reporting on the

Code,

5. various line ministries

- including health, education, finance, Ministries dealing with immigration

6. regulatory bodies,

7. professional associations,

8. training institutes,

9. student bodies,

10. international recruitment agencies,

11. labour unions representing health

workers,

12. diaspora groups

including associations representing foreign health professionals,

13. senior managers and boards of public/

private hospitals and/or health districts,

14. civil society,

15. private sector health organizations.

16. Recruitment agencies

17. Other




Where relevant data and data sets are identified, any issues identified in relation to data

protection, or other reason for lack of access should also be recorded.

4.3 Protocol Stage 2: Data acquisition

The second stage is for the project team to acquire the data sets from stakeholders identified

in the initial mapping. At this early stage the aim should be to identify all significant sources

of data on health worker migration in the country in order to identify which, if any may be of

greatest utility, and which can actually be obtained in a timely manner. In essence the

objective is to assess two aspects of data set availability- that the data is obtainable, and that

the content will enable project analytical objectives be achieved. The former will include

identification of issues about data protection, sourcing and data run capacity in stakeholder

organisations.

As noted earlier, when the HRH MDS was being discussed, there are often a range of

potential sources of data which can enable policy makers to improve monitoring of migration,

from different government departments and agencies, and from professional associations,

regulatory bodies and education institutes. The aim is to engage with the national authority

and with all other stakeholders that may have a relevant contribution to make, and who may

possess relevant health workforce migration data.

Main data sources that should be considered when building up a picture of the available data

sets and their potential monitoring capacity are listed in Table 1 below. The utility, strengths

and limitations of these different data types is discussed in more detail in Annex 2.




Table 2: Data sources for monitoring migration of health workers

Main data source Can be used for: Report on likely strengths/ limitations

Professional registers

Stock and/ or flow measure, depending on

type of registration process

ENTRY/EXIST/EXIT

Number on the register,

by country of nationality or country of training.

Entries to the register; applications from registrants to be

registered in another country

Likely to be relevant only for professional occupations. Can be used to assess inflow our outflow (“verifications”

“certificates of good standing”) but shows intent to leave the country not the actual move. May be delays between approval and actually moving. Moves may be related to short term/ temporary education rather than employment. Can be

used to assess stock of migrant workers if this data is recorded but only useful if the register is live and periodically updated.

Not all countries have mandatory registration; some registers are not well maintained or are “live”; some countries that do have effective registration have a devolved system with multiple jurisdictions

Professional licensure/ examination data

Flow measure ENTRY/EXIT

Annual number of applicants/ successful

candidates sitting entry exam/ license exam

Likely to be relevant only for professional occupations.

Can give two measures- overall applications, and successful applications, by source country. Will only show applications and successes- does not necessarily mean the applicant will

actually move if successful. May be delays between success and actually moving.

Migration visas Flow measure ENTRY/EXIT

No. of new visas issued to applicants from specific countries

Can give an indication of trend in inflow, by source country. Visa data is sometimes collated at occupation level. Can help

differentiate between migration for work and migration for education. Visa requirements, types and designations vary country by country, so not easy to have cross country comparison

Work permits Stock/ Flow measure ENTRY/EXIST/EXIT

No. of new permits issued to applicants from specific countries

Can give an indication of trend in inflow, by source country and by occupation. Will not easily “capture” migration where there is job change- e.g. a nurse moving and working as a care assistant

Population censuses Stock measure/ EXIST

Numbers/ nationalities

recorded in population

Can give detailed information on demographic profile, country of birth etc. May have some limited information on occupation Censuses tend to be infrequent.




census

Administrative / population registers

Stock/ flow measures ENTRY/EXIST/EXIT (depending on type of measure).

Numbers of nationals registered/ new registered nationals

Can give recent picture of stock of migrants, but may not record occupation or employment status. Often general measures rather than occupation specific Often incomplete due to non compliance, so can underestimate

Employer surveys/ censuses

Stock measure/ EXIST

Number of employees from other countries/ other nationalities

Can give data on composition of the workforce, and number/ profile of foreign nationals by source country. This data not

always collected by employers. May not be available in countries with many employers

Labour force surveys

Stock measure/ EXIST

Survey of employment

Labour force surveys focus on workforce and may be more frequent than population censuses but likely to be sample survey based, and may not focus on nationality/ country of training

Recruitment agency databases

Stock and or flow measures

Recruitment agencies will have records on how many workers they have facilitated in moving internationally

The identified sources of migration data which are identified should be summarised in

Template B below. This will enable a record to be kept of the pattern of data availability and

potential provision, by different stakeholders. Where data is available, it should be noted if

this will allow monitoring of ENTRY, and/ or EXIST, and / or EXIT. The template should

be updated as more sources are identified to ensure a current record is available.

Template B: Current record of relevant data sources and data providers identified

Data source Data available that

has potential for

health worker

migration tracking?

(Yes/ No/ Don’t know)

If yes, is

data for:

ENTRY/

EXIST/

EXIT?

Key stakeholder

source(s).(List

contact details)





Entry

Exist

Exit

2. Professional registers etc

3. Professional licensure/ examination data

4. Migration visas

5. Work permits

6. Population censuses

7. Administrative / population registers

8. Employer surveys/ censuses

9. Labour force surveys

10. Recruitment agency data bases

11. Other

4.4 Protocol Stage 3: Data verification and analysis

The third stage is for an audit to be undertaken of the data sets that have been acquired, to

assess their validity, accuracy, completeness and timeliness for the purposes of the project.

This should be undertaken by a project group which includes, at minimum, a representative

of the designated national authority, and where appropriate, technical representatives from

the main stakeholders who have been identified as potential data suppliers in stage 2. One

aspect of this work will be to make an assessment of the capacity of the HRH information

system or systems ( should these exist), in terms of timeliness of the system; validity of the

information contained within the system; consistency across information sources; level of

disaggregation of the information within the system.




Where similar data-sets are available from different sources, or where different data sets exist

that can serve the same monitoring purpose, the group should collate the information and

make decisions on which are the data sources of greatest utility for the project purposes - to

asses migration flows, enable reporting for the WHO Code, and as a source of MDS data.

Template Ci below sets out a matrix to enable the project group to assess and record which

data sources can provide viable data that will enable aspects of “entry”, “exist” and ”exit” of

migrant health workers to be monitored, and related analysis of trends to be undertaken

subsequently.

Template Ci: Viable data sources to monitor entry, exist and exit of migrant health

workers

ENTRY EXIST EXIT

1. Register

2. Licensure/

exam

3. Census

4. Employer

census/surveys

5. Labour Force

Survey

6. Migration

permits/visa

7. Work permits

8. Recruitment

agency

databases

9. Other

4.4.1 Surgical workforce: Data verification and analysis

In the first year of the project there is a specific requirement to provide a more in depth

assessment of the migration flows of health workers in surgical care (this will be followed in

years 2 and 3 by a focus on general practitioners and on midwifery cadres). The ‘surgical

workforce’ is a description most often used to describe specialists, surgeons and




anaesthesiologists. However, it is recognised that different occupations and professions may

provide surgical care in different countries.

Each project team will have to give specific attention to identifying which occupations are

relevant as working within surgical care within the country. Relevance will take account of

which cadres are engaged in the provision of the recommended interventions included in the

WHO Programme for Emergency and Essential Surgical Care (EESC).

http://www.who.int/surgery/en/ , Once the cadres are known, the project team will then

identify which aspects of “entry”, “exist” and ”exit” of migrant health workers working in

surgical care can be identified. This should be recorded separately in Template Cii below,

with a separate template being used for each identified profession, cadre.

Template Cii: Viable data sources to monitor entry, exist and exit of migrant health

workers working in surgical care: use a separate template for each profession, cadre

ENTRY EXIST EXIT

1. Register

2. Licensure/

exam

3. Census

4. Employer census/surveys

5. Labour Force Survey

6. Migration permits/visa

7. Work permits

8. Recruitment agency databases

9. Other

4.5 Protocol Stage 4: Data gap identification

The group will then be in a position to identify any gaps between what data is required, and

what data is available, for monitoring of migrant health worker flows through assessment of

“entry, exist and exit”, and is required to support to development of the MDS. The main




issue is to determine if any of these HRH data gaps are critical to preventing the attainment

of project objectives.

Any empty columns in Template Ci will point to a basic gap in data; and if there are few

cells in any column this may point to inadequacies. If gaps are identified and agreed to be

critical, decisions will have to be made about how to fill them- e.g. working with appropriate

stakeholders to develop relevant data sets, and perhaps as a short term measure by

undertaking primary research and/or using best judgment to make assessments or estimates.

Ideally the approach should be to provide a solution that leads to the gaps being filled on a

systematic basis in the longer term, not a “one-off” supplementary exercise.

4.6 Protocol Stage 5: MDS data source identification

One key element of the project is to contribute to the understanding of the scope and potential

for full development of a GHWA/ MDS HRH Minimum Data Set (MDS). While the roll-out

of minimum data sets and health workforce registries is a broader activity of WHO (beyond

the specific scope of this project), the project will contribute to it by advocating the same

conceptual model and sequential approach which entails the following steps:

a. Engage stakeholders from the beginning

b. Address policy and governance mechanism

c. Establish a list of authorized health workforce data submitting entities

d. Assure financing of full implementation

e. Agree on a common place to locate the registry

f. Provide training for essential staff

g. Methodically enter primary data to electronic health workforce registry

As a starting point in contributing to MDS development, the project team in each country

should complete template D, below, which lists the WHO MDS items required for the “core”

workforce registry. They should indicate which data items are available, and also which

source or sources can provide the data item. Where there are multiple sources, the team

should report these, and indicate how data items are recorded by different sources. The team

should also make preliminary assessment of the scope to develop a single registry, and




identify which stakeholder (s) appear to have the potential to be most effective in the role of

registry “owners”.

Template D: MDS and workforce registry- Core data items and current availability

Data item available?

yes/ no/ don’t know

Data source (s)

(list contact details)

1. ID

2. Name

3. Birth

4. Citizen/ country

5. Address

6. Contact details

7. License

8. Employments status

9. Employment address

10. (Data submission institution)

4.7 Protocol Stage 6: Initial country reports

For each country, it is planned that three case studies will be developed with the involvement

of national researchers through the life-span of the project (one per year). The aim will be to

explore migration issues from both a quantitative perspective, and a qualitative one to assist

in the interpretation of the institutional context, governance environment, and policy options

to improve management of health workforce migration in the country.

One key aspect to be covered in these reports will be to build on and beyond the reporting of

data and data sets, to provide an accurate narrative of the policy and labour market context

for health worker migration in the country. This could include analysing and interpreting

trends in flows, identifying key migration connections (e.g. significant destination countries)

and examining the impact of any policy instruments in place that are intended to “manage”

migration flows (e.g. bilateral agreements) or improve retention of health workers to reduce




outflow. In addition, as noted earlier, there will be a need to place HRH migration trends and

policy issues in the broader HRH and labour market context.

Whilst one focus of the project is to contribute to developing the scope for a MDS, it is

recognised that no single source of data, or MDS, can capture all the dynamics and different

types of international migration of health workers, trends in mobility, reasons for mobility,

and policy responses.

Any country that is trying to monitor effectively the levels of health worker migration, to

inform policy or to provide monitoring data to WHO, will have to collate and analyse data

and information from more than one source, to provide a complete and accurate picture of

changing trends and dynamics.

Template E below provides a matrix to act as an aide- memoire in structuring the initial

country reports, and gives examples of four types/ levels of information and analysis that

may be feasible at country level:

1) Minimum data — the basic information about stock and flow (entry, exist, exit) of the

health workforce. This is the basic database, can enable data reporting on flows for

the WHO code, and can be used for a MDS.

2) Additional data — other data items and information on the location and profile of the

workforce derived from organisational data and workforce plans, which, whilst not

being essential, may also be available or could be collected as supplementary and

relevant information. The balance between minimum data and additional data will

vary from country to country, depending on current availability, and on resources and

need.

3) Qualitative information on motivation, career plans etc — the motivations and

experiences and career tracks and plans of individual health workers is an important

component in developing an understanding of current and likely future patterns of

mobility. This information could be obtained from any recent research, staff surveys,

staff audits that have been conducted in the country.

4) Policy analysis- This should include: 1) an introductory background that sets the stage

for the other sections; and 2) an analytical/ policy recommendations section that

summarizes both the quantitative/ qualitative and contextual information and uses it

for the formulation of context-specific practical recommendations.




Much of the data items listed are at the level of the individual worker or institution;

part of the process of analysis should be to aim at developing a national picture.

Template E: Data, Information, and Analysis hierarchy for country reports

“Minimum” data

Additional data

Qualitative information

HRH Policy Context

Flows

ENTRY/

EXIT

Numbers

leaving/entering (by destination/source country)

Numbers leaving/ entering (by occupation)

Gender

Race/ethnicity

Age profile

e.g.Work/sector

location of leavers/ joiners

Years of service/qualifications of leavers/ joiners

e.g.Reasons for

leaving / entering

Nature of leaving/ entering- e.g. planned

temporary/ planned permanent

Review policy

reports, agreements, documents, laws on HRH planning/

strategy and HRH migration.

e.g.Is there an overall HRH or health workforce strategy at

national level? Who “owns” it? Is it functioning effectively?

How are stakeholders

engaged in HRH strategy development?

What are the objectives of planning, and

what is the HRH planning capacity?

What policy instruments are in use to assist in “managing” HRH

migration? How effective are they?

Stock

EXIST

Total number in workforce

Numbers working

in each occupation

Gender

Race/ethnicity

Age profile

Geographical distribution

Numbers by main

type of work location

Length of stay

Career plans

(Stay, return, move on?)

Previous career history (Other countries?)

Cultural adaptation issues

(ethical/effective recruitment?)

Job satisfaction




Methods could include adopting a labour market approach to categorize information on

underlying factors of observed migratory flows; or conducting a policy tracing analysis to

identify the relevant contextual and institutional information on health workforce

development efforts, and formulating country-specific recommendations on how to tackle

health workforce imbalances and problems related to over-reliance on foreign-trained health

personnel or unplanned out-migration. It is recognised that the approach in each country will

be different, based on varying resources and data sources. Where sources of research and

analysis are identified, these should be referenced, and if possible, attached as source

material.

At minimum, the fourth section, on policy analysis, should present clear findings on the

current extent and effect of policies intended to manage, direct or respond to HRH migration,

and specific recommendations on how new relevant policies could be shaped and

implemented. The Table 2 below provides examples of various policy instruments and

responses that should be considered, with reporting of which are in use in the country, and

which have been evaluated.

Table 3: Examples of policy challenge and policy responses

Level Characteristics/ examples

Organisational

‘Twinning’ Hospital in ‘source’ and ‘destination’ country develops links based on staff

exchange, staff support and flow of resources to source country.

Staff exchange Planned temporary move of staff to another organization, based on career

and personal development opportunities/ organizational development.

Educational support Educators and/or education resources and/or funding in temporary move

from ‘destination’ to ‘source’ countries.

National

Government to

government bilateral

agreement

‘Destination’ country develops agreement with ‘source’ country to

underwrite costs of training additional staff and/ or recruiting staff for a

fixed period, linked to training and development prior to staff returning to

source country, or to recruit ‘surplus’ staff in source country.

Ethical recruitment

code

‘Destination’ country introduces a code that places restrictions on

international recruitment, in terms of numbers recruited, countries that can

be targeted etc.




‘Compensation’ Destination country ‘pays’ compensation, in cash of in form of other

resources, e.g. educational investment.

‘Managed migration’ Country (or region) with outflow of staff initiates a programme to stem

unplanned out-migration, by e.g. attempting to reduce ‘push’ factors, and/

or e.g. by supporting interventions that encourage planned migration (e.g.

bilateral agreements).

‘Train for export’ Can be a subset of ‘managed migration’; government or private sector

makes explicit decision to develop training infrastructure to train health

professionals for export market- for training fees and/ or to generate

remittances.

International

International ethical

code

Ethical code with regional or global coverage- e.g. Commonwealth Code,

2003; WHO Code, 2010.

Mutual recognition

agreement (MRA)

Multi-national regulatory agreement for “free” mobility of designated types

of health professionals

Source: adapted from Buchan and Perfilieva




Annex 1. Protocol Tool

A six stage process The protocol is set out in six stages, and makes use of five different data gathering/ recording

templates (A, B, C/Ci, D, and E). (Box 1).

Box 1: Protocol stages and indicative timeline

Stage of protocol Indicative

timing*

7. Stakeholder mapping and engagement [Template A] February 2015

onwards

8. Data gathering [Template B] February 2015-

April 2015

9. Data verification and analysis [Templates Ci and Cii] March-June

2015

(report on

surgical

workforce , May)

10. Data gap identification March- June

2015

11. MDS data source identification [Template D] To be agreed in

each country

based on local

context

12. Initial country case study reports [Template E] July/ August

2015

The templates required to complete each stage of the process are set out below. Each of the

six stages is described in more detail below. Whilst these are set out sequentially, there will

be some need for the project partner to track back to previous stages to verify and check on

data, analysis and assumptions being made at each stage. There will also be a need to

undertake a follow up action on data identification, verification and analysis. This will not be

a “one off” exercise to be completed by April/ May 2015 but a process of improvement and

refinement across the three year period of the project.




Stage 1: Stakeholder mapping and engagement

Identify and map stakeholder engagement in HRH migration, and their potential as sources of

relevant data sets. Use Template A to direct mapping and record results (and refer to Table 1,

p15).

Template A: Record of Stakeholder engagement and data identification

Stakeholder Level of engagement/ data availability [tick one]

Engaged/

data

available

Responded/

no data

Contacted

/no

response

Not

contacted

N/

A


2. professional councils,

3. national data managers in ministries of health,

4. national authorities charged with reporting on the

Code,

5. various line ministries - including health, education, finance, Ministries dealing

with immigration

6. regulatory bodies,

7. professional associations,

8. training institutes,

9. student bodies,

10. international recruitment agencies,

11. labour unions representing health

workers,

12. diaspora groups including associations representing foreign health professionals,

13. senior managers and boards of public/

private hospitals and/or health districts,




14. civil society,

15. private sector health organizations.

16. Recruitment agencies

17. Other

Stage 2: Data acquisition The identified sources of migration data which are identified should be summarised in

Template B below. This will enable a record to be kept of the pattern of data availability and

potential provision, by different stakeholders. Where data is available, it should be noted if

this will allow monitoring of ENTRY, and/ or EXIST, and / or EXIT. The template should

be updated as more sources are identified to ensure a current record is available.

Template B: Current record of relevant data sources and data providers identified

Data source Data available that has

potential for health worker

migration tracking? (Yes/ No/ Don’t know)

If yes, is data for:

ENTRY?

EXIST?

EXIT?

Key stakeholder

source(s).(List

contact details)

Designated national authority

Professional registers

Professional

licensure/ examination data

Migration visas

Work permits

Population censuses

Administrative / population registers

Employer surveys/ censuses




Labour force surveys

Other

Stage 3: Data verification and analysis

Audit the data sets that have been acquired, to assess their validity, accuracy, completeness

and timeliness for the purposes of the project. Use Template Ci to summarise relevant data

availability to track entry, exist and exit.

Template Ci: Viable data sources to monitor entry, exist and exit of migrant

health workers

ENTRY EXIST EXIT

1. Register

2. Licensure/

exam

3. Census

4. Employer

census/surveys

5. Labour Force

Survey

6. Migration

permits/visa

7. Work permits

8. Recruitment

agency

databases

9. Other

In the first year of the project there is a specific requirement to provide a more in depth

assessment of the migration flows of health workers in surgical care. It is recognised that

different occupations and professions may provide surgical care in different countries. The




focus on the surgical workforce will include specialists, surgeons and anaesthesiologists as

well as other as any general practitioners, nurses, clinical medical officers and other

professionals show have received specific training in surgical care.

Each project team will have to give specific attention to identifying which occupations are

relevant within the country, and then identify which aspects of “entry”, “exist” and ”exit” of

migrant health workers working in surgical care can be identified. This should be recorded

separately in Template Cii below:

Template Cii: Viable data sources to monitor entry, exist and exit of migrant

health workers working in surgical care: use a separate template for each

profession, cadre

ENTRY EXIST EXIT

1. Register

2. Licensure/ exam

3. Census

4. Employer census/surveys

5. Labour Force Survey

6. Migration permits/visa

7. Work permits

8. Recruitment

agency databases

9. Other

Stage 4: Data gap identification Any critical gaps should be identified, between what data is required, and what data is

available, for monitoring of migrant health worker flows by “entry, exist and exit”, and what

is required to support to development of the MDS. The point is to determine if any of these

HRH data gaps are critical to preventing the attainment of project objectives.

Any empty columns in Template Ci above will point to a basic gap in data; and if there are

few cells in any column this may point to inadequacies. If gaps are identified and agreed to




be critical, decisions will have to be made about how to fill them- e.g. working with

appropriate stakeholders to develop relevant data sets, and perhaps as a short term measure

by undertaking primary research and/or using best judgement to make assessments or

estimates. Ideally the approach should be to provide a solution that leads to the gaps being

filled on a systematic basis in the longer term, not a “one-off” supplementary exercise.

Stage 5: MDS data source identification One key element of the project is to contribute to the understanding of the scope and potential

for full development of a GHWA/ MDS HRH Minimum Data Set (MDS). While the roll-out

of minimum data sets and health workforce registries is a broader activity of WHO (beyond

the specific scope of this project), the project will contribute to it.

As a starting point in contributing to MDS development, the project team in each country

should complete template D, which lists the WHO MDS items required for the “core”

workforce registry. They should indicate which data items are available, and also which

source or sources can provide the data item. Where there are multiple sources, the team

should report these, and indicate how data items are recorded by different sources. The team

should also make preliminary assessment of the scope to develop a single registry, and

identify which stakeholder (s) appear to have the potential to be most effective in the role of

registry “owners”.

Template D: MDS and workforce registry- Core data items and current availability

Data item available?

yes/ no/ don’t know

Data source (s)

(list contact details)

1. ID

2. Name

3. Birth

4. Citizen/ country

5. Address

6. Contact details

7. License

8. Employments status




9. Employment address

10. (Data submission institution)

Stage 6: Initial country reports For each country, two case studies will be developed with the involvement of national

researchers. One key aspect to be covered in the country reports is to build on and beyond the

reporting of data and data sets, to provide an accurate narrative of the policy and labour

market context for health worker migration in the country.

Template E below provides a matrix to use in structuring the initial country reports, and

gives examples of the four types/ levels of information and analysis that may be feasible at

country level:

1) Minimum data — the basic information about stock and flow (entry, exist, exit) of the

health workforce. This is the basic database, can enable data reporting on flows for

the WHO code, and can be used for a MDS.

2) Additional data — other data items and information on the location and profile of the

workforce derived from organisational data and workforce plans, which, whilst not

being essential, may also be available or could be collected as supplementary and

relevant information. The balance between minimum data and additional data will

vary from country to country, depending on current availability, and on resources and

need.

3) Qualitative information on motivation, career plans etc — the motivations and

experiences and career tracks and plans of individual health workers is an important

component in developing an understanding of current and likely future patterns of

mobility. This information could be obtained from any recent research, staff surveys,

staff audits that have been conducted in the country.

4) Policy analysis- This should include: 1) an introductory background that sets the stage

for the other sections; and 2) an analytical/ policy recommendations section that

summarizes both the quantitative/ qualitative and contextual information and uses it

for the formulation of context-specific practical recommendations.

Much of the data items listed are at the level of the individual worker or institution;

part of the process of analysis should be to aim at developing a national picture.




Template E: Data, Information, and Analysis hierarchy for country reports

“Minimum” data

Additional data

Qualitative information

HRH Policy Context

Flows

ENTRY/

EXIT

Numbers leaving/entering (by destination/source country)

Numbers leaving/

entering (by occupation)

Gender

Race/ethnicity

Age profile

e.g.Work/sector location of leavers/ joiners

Years of service/qualifications of leavers/ joiners

e.g.Reasons for leaving / entering

Nature of leaving/ entering- e.g.

planned temporary/ planned permanent

Review policy reports, agreements, documents, laws

on HRH planning/ strategy and HRH migration.

e.g.Is there an overall HRH or health workforce

strategy at national level? Who “owns” it? Is it functioning effectively?

How are

stakeholders engaged in HRH strategy development?

What are the objectives of

planning, and what is the HRH planning capacity?

What policy instruments are in use to assist in

“managing” HRH migration? How effective are they?

Stock

EXIST

Total number in workforce

Numbers working

in each occupation

Gender

Race/ethnicity

Age profile

Geographical distribution

Numbers by main

type of work location

Length of stay

Career plans

(Stay, return, move on?)

Previous career history (Other countries?)

Cultural adaptation issues

(ethical/effective recruitment?)

Job satisfaction

Methods could include adopting a labour market approach to categorize information on

underlying factors of observed migratory flows; or conducting a policy tracing analysis to

identify the relevant contextual and institutional information on health workforce

development efforts, and formulating country-specific recommendations on how to tackle




health workforce imbalances and problems related to over-reliance on foreign-trained health

personnel or unplanned out-migration. It is recognised that the approach in each country will

be different, based on varying resources and data sources. Where sources of research and

analysis are identified, these should be referenced, and if possible, attached as source

material.

At minimum, the fourth section, on policy analysis, should present clear findings on the

current extent and effect of policies intended to manage, direct or respond to HRH migration,

and specific recommendations on how new relevant policies could be shaped and

implemented.




Annex 2: Detailed description of data sources Professional registers/ Examination or licensure data

If the country maintains a professional register which is relatively accurate and up to date,

and records applicants from other countries/ other nationalities, this data may provide a

source of stock data and inflow data. In addition, where registered health professionals must

apply to the registration body if they wish to be registered to practice in another country, this

can be another measure of outflow (often called a “certificate of good standing” or

“verification”). However some registers are out of date or incomplete, and being registered

does not necessarily mean that the individual is practising, or even in the country.

Furthermore, new registrants from other countries may be entering for education rather than

employment purposes.

Some countries provide licensing or registration data at two levels- the total number of

applicants, and the number who are successful. This double measure gives a broad indicator

of overall interest in moving to the country, plus a more specific measure of the number who

actually were able to enter.

Population censuses/labour force surveys/ employer surveys or censuses

Census data can provide detailed information on the migrant profile, such as demographics

and socioeconomic characteristics but censuses provide a “stock” measure – they are not

useful in determining flows. Population censuses tend to be carried out infrequently, and that

failure to use standardized classifications of occupations (such as the International Labour

Organization's ISCO-88 or the equivalent) at the appropriate level does not allow researchers

to distinguish health workers from other professional workers. A recent report by OECD uses

census data to map out the migratory flows of health professionals (Dumont and Zum 2007).

Labour force surveys are another potential source of “stock” data (see Gupta et al, 2003).

They are usually based on sample surveys, and often include questions about nationality and

place of birth, and thus allow for assessment of the stock of migrants in a country. However

the size of the sample may limit their potential in assessing the stock of specific health

occupations. . A similar source of stock information may be employer surveys or censuses, if

data on nationality or country of training is held.

Administrative registers (population registers, foreign registers, etc.)




Some countries have population registers which can provide data on all migrant flows

(inflows and outflows of both national and foreigners, however defined). Stilwell et al, 2003,

note that the identification of migrants is subject to the rules concerning inscription in or de-

registration from the registers, and that non-compliance with these rules might lead to

underestimation of the true extent of migration. They suggest that registers of individuals

leaving the country is likely to be lower than for incoming migrants, since individuals leaving

the country are often reluctant to register their departure.

Migration visas

Many countries require immigrants to have a visa. Often a range of different types of visa is

available, depending on the status of the immigrant and the nature of their visit (e.g.

temporary/ fixed term/ open ended; employed/ for educational purposes/ tourist). Visa data

can provide relevant data about specific occupations of migrants, and may assist in

differentiating those who have migrated for educational purposes from those who are

working in the health sector.

Work permits

Another potential source is work permits. In addition to visas to enter a country, some

countries also require immigrant workers to have a work permit enabling them to work in

specified employment, often for a defined period of time and/or with a specified employer.

This data can provide useful information on inflow of workers in particular categories and

occupations, and trends can be assessed over time where the data is collated systematically

and consistently.

Coverage of work permit type data varies from one country. However, many health workers

from developing countries work outside the health system when they move to a destination

country. Examples include a doctor driving a taxi, or a nurse working as a cleaner. Work

permit data in the destination country will not capture this dynamic, and as such may lead to

an underestimation of migration flows of health workers.

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