WHO health workforce support and safeguards list

The optimal health workforce density depends on the national and local context, including the burden of disease, demographics, skill mix of health workers, division of labour and distribution of health services.

Countries included in the WHO health workforce support and safeguards list 2023 have a health workforce (medical doctors, nursing personnel and midwifery personnel) density less than the median of 49 per 10 000 population, and a universal health coverage (UHC) service coverage index less than 55. The application of these figures to the Support and safeguards list calculation does not imply that it is the health worker density recommended by WHO; rather, this is the threshold used to identify relative shortage of national stock of health workers when compared globally.

WHO also recognizes that health workers other than medical doctors and nursing and midwifery personnel make substantial contributions to health outcomes. However, they have not been included in the analysis for Support and safeguards list because of limitations on data availability to allow for global comparison.

No, the Support and safeguards list does not entail the option to opt-in or opt-out. The WHO Secretariat publishes the Support and safeguards list based on objective criteria that are determined by a Member State-led Expert Advisory Group. Once the criteria, thresholds and policy recommendations for the Support and safeguards list have been agreed upon and finalized, WHO publishes the list of countries and shares them with the Expert Advisory Group, Member States and the public.

The Support and safeguards list is scheduled to be updated every three years or earlier if necessary, following the criteria recommended by the Expert Advisory Group.

The WHO Global Code of Practice on the International Recruitment of Health Personnel and the associated recommendations of the Expert Advisory Group and the Support and safeguards list are not legally binding. However, their provisions can become legally binding when countries adopt the Code and the Support and safeguards list (either elements of it or entirely) in their national policies.

For example, countries could have policies to avoid active recruitment of health workers from countries with the highest health worker shortages but accept direct applications from individual health workers to vacancies in their countries. More information on specific countries’ adoption of the Code principles in national policies is available in the National Reporting Instruments database.

WHO recommends refraining from active recruitment of health workers from countries in the Support and safeguards list. This means avoiding targeted approaches by employers or recruiting agencies to recruit large numbers of health workers from countries with workforce vulnerabilities. As essential safeguards, recruitment could take place through government-to-government agreements after consulting with ministries of health of source countries to ensure enough domestic supply of health workers and providing support to the source countries in priority areas identified by ministries of health. WHO also recommends destination countries, development partners, donors and national and international organizations prioritize support for health workforce development and health system strengthening in countries in the Support and safeguards list. These safeguards can be extended to other low- and middle-income countries.

The Code recommends supporting countries to strengthen health systems and health workforce. The needs of each country are unique and as such the ministries of health are best placed to decide on the priority areas that require support. Health system needs assessment, including health labour market analysis, can help inform and identify priority areas and the type of support required.

Health workers are not commodities that can be bought. They are individuals who make their own decisions on where to work, as allowed by country laws. The health workforce also is a fundamental building block of health system. Therefore, countries need to formulate appropriate policies and to make strategic investments in health worker production, employment and retention to be self-sufficient on the health workforce. Destination countries could support the source countries in these endeavours as required and requested.

The UHC service coverage index (UHC SCI) is a measurement of the Sustainable Development Goal indicator 3.8.1 (coverage of essential health services). It is based on a set of 14 sub-indicators organized by four broad categories: reproductive, maternal, newborn and child health; infectious diseases; non-communicable diseases; and service capacity and access. These sub-indicators are meant to be indicative of service coverage and should not be interpreted as a complete or exhaustive list of the health services or interventions that are required to achieve universal health coverage. The UHC SCI is measured as an index, reported on a unitless scale of 0 to 100 and computed as a geometric mean. More information on the UHC SCI is available in the publication Tracking universal health coverage: 2023 global monitoring report.

WHO does not comment on decisions of individual countries but shares available data and evidence reported by countries on the health workforce. The WHO Global Code of Practice on the International Recruitment of Health Personnel is a voluntary instrument but reporting on its implementation is mandatory.

The WHO Health workforce support and safeguards list is the list of countries that face the most pressing health workforce challenges in the progress towards universal health coverage. WHO discourages active recruitment of health workers from these countries from both public and private sector employers or recruiters, to prevent exacerbation of workforce shortages. However, passive recruitment (where individual health workers respond to vacancies) and recruitment under the terms of bilateral agreements can take place; these practices may include an involvement of the private sector.

The WHO global code of practice on the international recruitment of health personnel and the WHO health workforce support and safeguards list have no provisions limiting the individual pursuit of employment opportunities in other countries. Rather, they aim to discourage systematic and proactive approaches by employers or recruiting agencies to recruit large numbers of health workers from countries of origin with workforce vulnerabilities. In fact, the Code recommends fair and just recruitment and contractual practices for migrant health workers and promotes equal rights to education and career opportunities for people who migrate and domestic health workers.

Migration is a long standing and ongoing phenomenon. Minimizing the negative consequences of international health worker migration requires addressing the health labour market failures as well as collaboration of source and destination countries. The WHO global code of practice on the international recruitment of health personnel is widely recognized as the overarching international framework that links the ethical international recruitment of health workers and the strengthening of health systems. Through the periodic reporting on the implementation of the Code, WHO highlights the trends, key issues and challenges related to international health worker mobility and policy advice to address it, including through publication of the WHO health workforce support and safeguards list, which identifies countries facing the most pressing health workforce challenges. The WHO guidance on bilateral agreements for health worker mobility and migration supports Member States to develop agreements related to health worker mobility and migration in a way that advances health system strengthening of participating countries and welfare of health workers.

Each country will have to assess its situation to develop and implement health workforce strategies that are suited to its context. Health workforce planning requires understanding of the labour market dynamics in each country and using the findings to inform investments in education, employment, and decent working conditions and design appropriate strategies and regulatory interventions. Management, support and retention of available health workforce to cater to population needs while ensuring their security is equally important.

Destination countries should increase production of health workers to meet domestic needs. Source countries should invest through domestic financing and development assistance in health workforce education and retention. All countries should adopt workforce policies to absorb the health workers in their health systems and improve working conditions, including fair remuneration, to enhance retention. Health workforce planning and education policies will have to consider population health needs and likely workforce attrition due to international migration and other issues like retirement and departure from service. Development partners and international organizations should prioritize technical and financial support to countries in the WHO health workforce support and safeguards list and other low- and middle-income countries to strengthen health workforce and health systems.

The WHO health workforce support and safeguards list is based on health workforce and service coverage data available with WHO, and there is wide variation in the availability and quality of data across countries. Countries that are not in the Support and safeguards list have substantial difference in income levels, burden of disease, health systems and health workforce capacity. Therefore, as good practice, WHO recommends that policy recommendations for countries in the Support and safeguards list be extended to other low- and middle-income countries as necessary.