of the Committee of Ministers to member states
on trans-border mobility of health professionals and its implications for the functioning of health care systems
(Adopted by the Committee of Ministers on 13 September 2006
at the 973rd meeting of the Ministers' Deputies)
The Committee of Ministers, under the terms of Article 15.b of the Statute of the Council of Europe,
Considering that the aim of the Council of Europe is to achieve greater unity between its members and that this aim may be pursued in particular by the adoption of common rules in the health field;
Recalling Article 11 of the European Social Charter (ETS No. 163) on the right to protection of health, and recalling Article 3 of the Council of Europe’s Convention on Human Rights and Biomedicine (ETS No.164) on equitable access to health care of appropriate quality, and its Article 4 on interventions in the health field, including research, which must be carried out in accordance with relevant professional obligations and standards;
Considering that health professionals are key actors in the provision of health care, irrespective of the health care system;
Recognising that actual clinical practice carried out by skilled health care professionals can be homogeneous, despite the variety of health care systems in place in different countries;
Taking into account that circumstances vary from country to country which may lead health professionals to seek mobility with the ensuing positive and negative effects for both home and host countries;
Considering that the mobility of health professionals is an opportunity for member states to ensure that their health care systems mutually benefit from shared knowledge and skills;
Recognising that it is the shared responsibility of governments and other relevant stakeholders to ensure quality of care and patient safety;
Convinced that promotion of social cohesion and social rights includes the right to work, to professional training, fair pay and working conditions, union membership, social and medical assistance and social security;
Recalling in this context the Convention on the Recognition of Qualifications concerning Higher Education in the European Region (ETS No. 165) (Lisbon Convention), which aims to facilitate not only access to higher education but also to the labour market, based on transparent and reliable procedures, without discrimination;
Recalling further that the Lisbon Convention calls for the setting-up of national information centres where proper information can be obtained on the recognition and assessment of qualifications and on the relevant national laws and regulations;
Recognising the commitment of some governments to an ethical approach to recruiting health care professionals and to the development of a code of good practice for the international recruitment of health care professionals;
Aware that some member states have introduced measures for the recognition of professional qualifications based on bilateral agreements;
Concerned in this context about the variety of approaches and legislative frameworks governing these bilateral agreements;
Recalling in this respect its Recommendation No. R (93) 3 on health manpower planning which stipulates that “health manpower planning is an essential element for achieving a proper balance between supply and demand”, and in which it “recommends the governments of member states to undertake health manpower planning, adapted to their needs with a view to enabling each state to meet demand for health care services on its territory and to balance health care manpower supply and demand”;
Considering that the differences in the availability and quality of health professionals throughout Europe need to be addressed through increased co-operation between countries;
Conscious that when drafting long-term strategies, member states shall take into account the requirements for working time of health care professionals in line with International Labour Organization (ILO) regulations;
Taking into account the obligations stipulated by the relevant international legal instruments: Convention on Human Rights and Biomedicine, European Social Charter (ETS No. 163), European Code of Social Security (ETS No. 48), European Convention on Social Security (ETS No. 78), which aim at granting a settled migrant worker equivalent rights as the citizens of the country of residence;
Recommends that the governments of member states that choose to be involved in managed mobility:
i. adopt policies, legislative and other measures necessary for a coherent and comprehensive policy framework that manages mobility of health professionals, in order to safeguard patients, quality of health care and the rights of qualified health professionals;
ii. to this end, whenever feasible, bearing in mind the respective national circumstances, carry out the measures presented in Appendix I to this recommendation;
iii. consider entering into voluntary agreements, following a model framework for managing mobility, as presented in Appendix II to this recommendation;
iv. promote international networking between organisations, research institutions and other parties that are involved in the mobility of health professionals;
v. support dissemination of this recommendation and its explanatory memorandum, where appropriate accompanied by a translation.
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Appendix 1 to Recommendation Rec(2006)11
of the Committee of Ministers to member states on
the transborder mobility of health professionals and its implications for the functioning of health care systems
A. General considerations
1. The international mobility of health professionals can have both winning and losing stakeholders – both in host and home countries. The main objective of managing the mobility of health professionals is to create mutually beneficial, win-win situations for all parties involved, including governments, employers and employees in home and host countries.
2. Taking into account the threat of "brain drain" from countries with less developed health care services, planned recruitment should be encouraged, within the framework of bilateral agreements.
3. Member states, competent authorities, unions and professional bodies should be guided on a voluntary basis by practical instruments. These templates for bilateral agreements are essential for the implementation phase and exchange of best practice.
4. Policies dealing with mobility of health professionals should be based on the values of the Council of Europe: human rights and patients' rights, human dignity, social cohesion, non-discrimination, democracy, equity, solidarity, equal opportunities for men and women, participation and freedom of choice.
5. A fair balance should be sought between sustainability of health services and the fundamental right to move.
B. International issues
1. The following activities should be considered by member states:
i. signing memoranda of understanding or letters of intention between countries and other stakeholders on managed mobility (the organised exchange of health professionals) and/or the integration of health professionals in the framework of bilateral agreements in the field of employment;
ii. promoting bilateral/multilateral agreements between the relevant stakeholders on the managed mobility of health care professionals;
iii. encouraging cross-border collaboration between health care establishments located near the borders;
iv. agreeing on a system of exchanging information on the good reputation of health professionals who intend to migrate;
v. preferring a proactive approach for the exchange of information between host countries, home countries and migrant health professionals, in order to establish a standardised minimal set of data;
vi. giving due consideration to the feasibility of creating a model European code of rules to be followed on international recruitment;
vii. establishing national information centres as part of an international network for the exchange of information on health professionals.
C. Workforce planning for health professionals
1. Each country should carry out workforce planning for health professionals, taking into account where appropriate Recommendation No. R (93) 3 on health manpower planning.
2. The extent of mobility should be routinely recorded and analysed, to enable effective workforce planning for health professionals.
D. Home-country issues
1. Larger scale mobility may need a framework of recruitment process. Individual mobility of health professionals is often based on own initiatives being taken and frequently happens outside an active recruitment process.
2. Establishing a general framework for bilateral or multilateral agreements on managing health professionals’ mobility can lead to better harmonisation of approaches and requirements (See Appendix 2: “A model framework for managing mobility”).
3. National authorities should establish criteria for recognition of the continued education of health professionals working abroad and provide appropriate accreditation and licensing upon the health professionals’ return to the home country.
4. Measures to promote the recruitment and retention of health care professionals should be taken.
E. Host-country issues
1. Workforce planning can be an appropriate means to identify needs and initiate appropriate recruitment and retention strategies at both national and international levels.
a. At national level:
i. the number of students should be increased in order to keep a balance between the needs of health professionals and the capacities of vocational training;
ii. staff who have emigrated should be encouraged to return to work in their home country;
iii. staff retention should be improved;
iv. new career patterns for intermediate professions such as physician assistants, nurse practitioners and dental nurses, should be developed;
v. organisation of health services should be more efficient, and health professionals already working should be used more flexibly and efficiently.
b. At international level:
i. active, managed recruitment by governments, stakeholders and private agencies should be carried out;
ii. collaboration between stakeholders in the home country and host country should be improved in order to offer good opportunities for development of skills; the return of health professionals to the home country should be effectively prepared so that their acquired skills and knowledge is put to the best use.
2. Guest health professionals should have equal access to appropriate training opportunities in the host country.
3. There is a need for co-ordination between relevant stakeholders in the host country to ensure that policy concerning training places, recruitment, employment benefits and immigration are complementary rather than conflicting.
4. Employers should be encouraged to provide induction and integration courses to ensure that guest health professionals have sufficient knowledge to adapt to, and understand, their new working environment.
5. No form of discrimination may be tolerated. Migrant health professionals should be welcomed and their different cultural background should be seen as a benefit to the host country.
6. Relevant stakeholders which actively recruit health professionals from abroad should abide by a code of good practice for international recruitment, based on sound ethical principles.
7. Codes of good practice should cover not just public-sector provision of health services but also the private sector, including recruitment agencies in terms of targeted recruitment.
8. Applicants should be encouraged to spend a specific period in the host country.
F. Information and administrative issues
1. National competent authorities should be encouraged to participate in a European network of information exchange. Its role would be to facilitate mobility, increase public confidence in migrant health professionals, reduce the burden on migrants and speed up processes of recognition and thereby employment.
They can exchange information on:
– health professionals on their registers;
– regulations concerning assessments and registrations;
– training standards;
– the good reputation of, or disciplinary actions taken against, individual professionals;
– the recruitment process.
2. The network may facilitate establishing direct contacts between competent authorities in the host and home countries.
3. National authorities should create focal points for all information on job opportunities available and the requirements of particular countries to practise as a health professional.
4. It should be possible to assess “on-line” the health professionals` equivalence of credentials.
5. All the regulatory organisations and professional bodies should offer the necessary information to its members on the code of conduct and ethical principles prevailing in the given country.
6 All appointed health professionals should be able to demonstrate a level of language proficiency consistent with safe and skilled communication with patients, clients, carers and colleagues.
7. Information/advice centres may be established to provide information to health professionals, wherever possible through the Internet.
8. Many posts are advertised on the World Wide Web, so employers, educational establishments and agencies should make an effort to ensure that their vacancies are posted on the Internet and are easily accessible for health care professionals.
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Appendix 2 to Recommendation Rec(2006)11
of the Committee of Ministers to member states on
the transborder mobility of health professionals and its implications for the functioning of health care systems
Model framework for managing the mobility
This model framework, intended as a voluntary tool for governments to use in managing the planned recruitment of health professionals, consists of a series of items (or checklist) for the attention of:
– home countries, enabling them to follow guidelines in managing the emigration of health professionals;
– host countries, enabling them to follow guidelines in managing the mobility of health professionals, both in the public and private sectors.
This is particularly useful in cases where the larger-scale international mobility of health professionals may have a significant impact on health systems (managed mobility).
Depending on the specific situation of the countries involved (home or host country, surplus or lack of health professionals, scale of mobility), various points of interest should be considered in order to find a proper balance.
The model framework underlines the potential benefits of bilateral agreements between relevant stakeholders to manage the mutual exchange of health professionals; these can include:
– recognition of professional qualifications (specialisation) and possibility of postgraduate education without the need to repeat training;
– recognition of all professional experience, acquired in both the home and host country;
– access to a regulated profession if the health care professional is fully qualified;
– an agreement between national authorities with competence for authorising the right to practice;
– an ethical code of good practice.
This agreement should contain all relevant details of recruitment, employment and incentives for return of the migrants. A clear description of the responsibilities of the various stakeholders is indispensable.
In general, it is up to each member state involved in mobility to decide how such mobility is organised, preferably in connection with a code of good practice relating to recruitment.
In order to ensure the implementation of bilateral agreements, their application can be monitored by an independent body (e.g. a bilateral monitoring committee), established by the contracting parties. Findings should be reported to the responsible stakeholders.
Differences exist between countries regarding the available workforce in relation to the demand in health care services. Consequently, different “push” and “pull” factors arise, which may incite a health professional to move to another country. The resulting mobility of health professionals therefore has positive and negative effects for the home country and the host country. In order to enhance the positive effects and reduce the negative effects, a model framework has been developed to assist the planning of migration flows between countries. The aim of such a framework is to safeguard the rights of migrating qualified professionals, the safety of patients and the quality of health care systems in the home and host countries, taking into account the national migration policies of the host and home countries.
The overall approach follows the four principles developed by the European Committee on Migration of the Council of Europe: order, protection, integration and co-operation.
The goal is twofold:
– to adequately prepare health professionals from home countries to be employed within a host-country health care system at the appropriate level of competence;
– to facilitate the re-entry into the home country health care system after a period of employment abroad.
Several objectives have been identified:
1. to serve the interests of the health care systems of both the home country and the host country;
2. to improve the execution of formal procedures for the employment of migrants in the health care system and health care institutions in the host country;
3. to ensure proper education and guidance of the migrants during the term of employment;
4. to effectively and efficiently bridge the existing gaps in the level of competence regarding the language and the professional practice of the host country;
5. to consider incentives for return;
6. to promote ethical methods of recruitment.
The framework deals with the following aspects:
a. Health professionals
To migrate to another country health professionals will need to meet statutory requirements in relation to their:
– level of qualifications/diplomas;
– professional experience;
– proven clean professional track record as regards any misconduct/malpractice and/or criminal activities/convictions.
In addition, the migrating health professional should meet requirements in relation to the:
– ability to communicate effectively in the language of the host country (a working knowledge);
– personal profile, including motivation and good reputation;
– state of health.
In order to assist the transition of the health professional to the host country, appropriate induction programmes should be provided by the relevant stakeholders. In addition to relevant medical education/training, these could include aspects of differences concerning language and culture, health care systems, legal systems, and needs and expectations the person must face in the host country.
Employment and “on the job” training in the host country
During the period of employment, extended education opportunities may be provided by a relevant stakeholder, as appropriate.
Assessment and registration
Formal professional registration should take place when the guest health professional meets all the requirements.
Return to the home country
Whenever feasible, relevant stakeholders in the home country should make efforts to ensure that the health professionals find equivalent employment in the health care sector on their return.
b. Non-governmental recruitment agencies
All stakeholders, including recruitment agencies, should comply with a code of good practice, and with
this model framework, when dealing with transborder mobility of health professionals.
A system of voluntary or compulsory accreditation of recruitment agencies may be considered.
c. Responsibilities of various stakeholders
A bilateral agreement can be concluded by the following parties:
– the governments or the regional and local authorities of the host country and home country;
– employers in the home country and host country, e.g. health care institutions (hospitals or nursing homes);
– recruitment agencies;
– teaching institutions.
Bilateral and multilateral agreements should promote partnership and co-operation between the host and home countries, encouraging training and assistance programmes in support of health care development in the home countries.
Member states should take responsibility for facilitating the process of exchanging professionals, especially with regard to the criteria for recognition of diplomas, residence permits and work permits.
d. Monitoring of migration flows
Each member state involved in transborder mobility decides how this mobility shall be organised, on the basis of recruitment regulations and practices. The implementation of a bilateral agreement may be monitored and evaluated by an independent body. One of its tasks may also include identifying examples of good practice. This body should work under the supervision of a bilateral steering committee consisting of representatives of the stakeholders who are appointed by the relevant ministries or the competent authorities in the home and host country.