The primary dilemma facing any proposal for regulation is how to balance the rights and the needs of the main actors involved - healthcare professionals, developed countries and developing countries.
Most observers of globalisation agree that freedom of movement to improve one's professional and personal circumstances is a basic human right. Denial of this right by source countries is not a tenable strategy for dealing with the problem of migration. However, unfair terms of trade and the legacy of colonialism have created market conditions in which a wholesale reliance on free markets will devastate healthcare provision in developing countries.
The types of policies that can best improve outcomes for sending countries should focus on meeting domestic needs and addressing the "push" factors that motivate healthcare workers to emigrate. There is an urgent need for countries to examine medical education curricula to ensure that training programmes focus on domestic, rather than foreign, healthcare problems
Source countries could also intervene in the healthcare labour market by raising the cost of recruiting RNs or MDs from a developing country, in the form of a tax or a tariff on such transactions, to recover some of the training costs
Another strategy that some developing countries have actually initiated involves "bonding" graduates of healthcare training programmes. Bonding requires graduates of nurse and physician training programmes to work in the country that funded the training for a period of time, in partial payment for their publicly-funded education. However, implementing and enforcing these types of provisions have proved difficult
In the absence of established and effective policies, and in the face of a growing consensus that the current patterns of globalisation affecting healthcare workers do not serve the interests of developing countries, some observes have called for developing countries to disengage from the current system. As a case in point, Physicians for Human Rights (PHR) has recommended that African countries resist the efforts to liberalise trade in health services advocated by the World Trade Organization
Policies that can be implemented by receiving countries to solve their problems and to generate more equitable outcomes for all parties should focus primarily on reducing the strength of "pull" factors that artificially increase migration. Some countries have already taken voluntary steps of this kind
Another approach to regulating the migration of healthcare professionals is the signing of inter-country agreements that place limits on the number of professionals who can be recruited, thus minimizing the damage to the sending country's health system. In 2000, the UK signed such an agreement with Spain to engage in "the systematic and structured recruitment" of Spanish nurses for the NHS
In 2003, the NHS and the South African government reached agreement on an exchange programme entitling healthcare professionals of both countries to work in the other country for up to six months. Although the programme will probably bring more South African RNs and MDs to the UK than the reverse, the migration will be for a fixed period of time
Perhaps the most ambitious attempt to address the problems caused by the recruitment of healthcare professionals is the 2003 Commonwealth Code of Practice for International Recruitment of Health Workers. The code establishes an ethical framework to discourage the recruitment of such workers from countries experiencing shortages, and safeguards the rights of healthcare employees who choose to migrate
However, the most direct way of reducing the power of pull factors in developed countries is for those nations to address the reasons underlying the shortages of healthcare professionals they encounter more aggressively. Ultimately, recruiting RNs and MDs from abroad is a stopgap strategy. These countries need to take steps to train and retain the personnel they need from among their own populations. Falling medical school enrolments are a major factor contributing to the shortage of physicians in the US, and a second contributing factor is soaring malpractice insurance rates.
The various policy initiatives discussed here constitute useful first steps toward addressing the problems associated with the increased migration of healthcare workers induced by the global crisis in national healthcare systems.
However, a long-term solution will require more active involvement from another group of actors – international and regional organizations such as the WHO, the ILO and PHR. These organizations have played an important role in examining and documenting the seriousness of migration and have also developed guidelines and codes of conduct that encourage the parties involved in migration to engage in responsible and ethical practices