The WHO Code and the reporting requirements that it encompasses is but one tool in the protection of the rights of migrating health and care workers as well as health and care systems and by extension the rights of non-migrating health and care workers. Indeed, there are several international agreements, codes and conventions that impact the different types of migration pathways of health and care workers across different country contexts, some of which are listed in chronological order of development in Fig. 2. Each of these agreements, codes and conventions are historically situated reflecting the complexity of health and care worker migration of the era when they were developed. The impact of these different agreements, codes and conventions is dependent on countries’ commitments to them, existence of local policies and programmes developed in concordance, and the completeness of the cyclical reporting on these activities.

Fig. 2

Selection of relevant international agreements on health and care worker migration, 1970–2020

For discussion, we have included examples below (in alphabetical order). These are not meant to be an exhaustive list, but make the point of the complexity that emerges when we consider these international instruments in total. We note how for each institution overseeing these agreements, codes, and conventions there are different reporting standards. Moreover, we recognize that political and bureaucratic factors shape the ability and interest of states to report and comply with requirements [13].

International Labour Organization (ILO)

As noted in Fig. 2, there are two ILO Conventions pertaining to the migration of health and care workers including C149 Nursing Personnel Convention, 1977 and C189 Domestic Workers Convention, 2011. As technical conventions, their standards benchmark ‘decent work in all its dimensions and aspects’, including formalization of work and worker protection. Components of these conventions and recommendations acknowledge actual or potential differences in the status and treatment of migrant nurses and migrant domestic workers. They attach legal obligations to ratifying countries and guide and inform policy at different governance levels. Countries are encouraged to incorporate Convention standards in their health policy frameworks and provide policy guidance for international cooperation, such as bilateral agreements that oblige signatories to the actions, principles of cooperation and goals detailed in memoranda of understanding (MOUs) [14].

The reporting requirements for the ILO are reviewed by their Committee of Experts on the Application of Conventions and Recommendations (CEACR), composed of 20 legal scholars from around the world [15]. If a country ratifies a Convention, it is then responsible for reporting on its implementation every three years regarding fundamental and governance agreements. Reporting for all other conventions occurs every six years. Reports are to be shared by governments with worker and employer organizations to enable these stakeholders to provide supplementary comments directly to the ILO regarding implementation.Footnote 1 The CEACR may offer observations about the country’s application of the Convention, which are made public in their annual report, and may make requests for further information. This process facilitates conversation amongst governments, the ILO, civil society, and private actors [15].

United Nations (UN)

As noted in Fig. 2, the International Convention on the Protection of the Rights of All Migrant Workers and Members of their Families (ICRMW) adopted in 1990 and the Global Compact for Safe, Orderly and Regular Migration adopted in 2018 came into effect through a campaign involving numerous UN agencies and the IOM (which became a related organization of the UN in 2016).Footnote 2 First, states ratifying the ICRMW must report on their efforts to give effect to the Convention within 1 year after the Convention comes into force for that country, and thereafter every 5 years.Footnote 3 As of December 2021, the ICRMW has only been ratified by 56 countries, and the majority of these are predominantly migrant sending states.Footnote 4 Second, the Global Compact reporting structure is through an intergovernmental global platform ‘the International Migration Review Forum’, where Member States discuss their progress in implementing the Global Compact. These forums are intended to occur every four years and include all stakeholders. The Global Compact is also explicit about its relationship to goals included in the 2030 Agenda for Sustainable Development.

Complementing these instruments, the UN High-Level Commission on Health Employment and Economic Growth released its report in 2016. It issued a five-year action plan 2016–2021 aimed at expanding a sustainable health workforce that promotes healthy lives, inclusive growth and equity and economic security for all [16]. The SDGs include agreements on the global indicator framework which includes 231 unique indicators. These are to be refined annually, and reviewed by the UN Statistical Commission in 2020 and 2025.Footnote 5 These indicators include the proportion of total government spending on essential services (education, health and social protection) under 1.a 2., and health worker density and distribution under 3 c.1., and 8.8.2 level of national compliance with labour rights (freedom of association and collective bargaining) based on International Labour Organization (ILO) textual sources and national legislation, by sex and migrant status under 8.8.2.Footnote 6

World Health Organization

Finally, the key WHO instrument relevant to the migration of health and care workers is its Global Code of Practice on the International Recruitment of Health Personnel adopted in 2010. Global health diplomacy has been effective in the creation of a series of voluntary codes of conduct to discourage health worker migrant recruitment from countries experiencing crisis level shortfalls in medical staffing. The WHO Code, adopted in May 2010, is considered a landmark agreement that “suggests evolution in the capacity of the WHO Secretariat, Member States, and civil society to engage in global health ‘law-making’” [17]. One of the main motivations for voluntary codes is a desire for transnational social justice, because the ‘brain drain’ of health workers represents an inequitable distribution of training investments made by the sending region. The goal of the WHO code is to reduce the active recruitment of health workers from countries facing critical shortages of health workers, and for high income receiving nations to commit to achieving health worker self-sufficiency. The reality of achieving this, or of even assessing where countries stand in terms of the relative supply of health care workers through domestic training versus immigration, is challenging to assess. Nevertheless, the WHO Code encourages member states to submit reports every three years on measures taken to implement the Code. Reports from all relevant stakeholders on activities related to the implementation of the Code are considered.Footnote 7

Challenges and limitations

There are several inherent challenges across these different agreements, codes, and conventions. They include aspirational and generalized goals, whereas stakeholders (unions, employers, migrants, governments) have very specific needs and interests that may contradict certain aspects of the voluntary codes. They normally only apply to large public institutions or government health sectors, and thus are limited in coverage making them difficult to enforce [18, 19]. Additionally, many of these reporting functions are not fully aligned across different tools to collect data from countries, different levels of tacit and codified knowledge, varied bureaucratic capacity of individual country respondents to complete these reports [13], as well as a lack of transparency in the reporting process. Reporting structures and processes can also fail to capture data reflecting the broader intersectional gendered and racialized political economy of health and care worker migration. As Wickramasekara [20] suggests, there remains a gap between the promise and delivery of such agreements. In the case of health and care worker migration, we argue that the consequences of an uncoordinated approach are specific and material in terms of health and migration systems at the macro-level as well as at the micro-level experiences of individual health and care workers.

Reporting requirements

As noted above, each of these different international agreements have different reporting requirements with different processes, timing, and target information. Indeed, part of the problem is the sheer number of international agreements relevant to the international migration of health and care workers, and how the reporting for each of these might not generate the outcomes desired of any of them. At the global level, these agreements, codes, and conventions are meant to articulate with each other and other policies, but if this is not built into the reporting mechanisms this may be an unrealistic goal. How do these agreements, codes, and conventions work in tandem? When new agreements, codes, and conventions are adopted or ratified, it may not be clear how these articulate/crosswalk with other agreements. Does one feed into the next? Do new targets take over or subsume previous targets? How do these get rolled into the next agreement, code, and convention? But more to the point of this commentary, what is the impact on reporting? When targets change, it can be difficult to fully assess impact.

Data collection tools

Robust reporting processes for desired targets require high-quality data collection methods (i.e., survey instruments) and the right respondents with access to the requisite knowledge. Reporting on international agreements, codes and conventions can suffer from these two limitations.

In terms of content, survey instruments should ensure coverage of key topics. An explicit intersectional lens can be lacking in the collection, reporting and synthesis of the data provided by countries; this can illuminate the heterogeneity of migrant health and care workers, and how their social positioning may be altered through migration and integration processes. Historic and contemporary specificities inform the construction of the labour market in destination and transit countries and the subsequent reception and placement of these gendered and racialized workers. There can be inherent data and evidence limitations within countries in this regard; for example, from where we are writing in Canada there has been little intersectional data available beyond gender as a binary given our lack of race-based data.

In terms of form, survey instruments should limit overlap across questions and verify that each question addresses only one dimension or topic. Technical assistance to ensure the best form of questions to elicit content is a leading practice in the design of survey instruments. There is value in standardized or pre-tested questions with validated measures across reporting surveys where there is overlap in terms of content. There should be clarity on the measures or granularity of data requested—either at a high level or more granular reflecting the interplay between policies and lived experiences of migrating health and care workers. Surveys should also be designed to ensure ease of completion by participants—digitally enabled with some pre-determined drop-down menus or pre-populated from previous responses to ensure greater completeness and linkage longitudinally. Responses can also be more inclusive of all stakeholders (government, employer, labour and migrant worker representatives).

Capacity of country respondents

With the confluence of various agreements, codes and conventions, our quest for more (and better) data may overwhelm the capacity of institutions to provide it; that is, respondent burden is an important issue to recognize especially in cases where bureaucratic capability is limited [13]. It can be difficult to determine which Ministry should be providing country-based responses to reporting surveys (e.g., health or labour or immigration or trade), which level of government in the case of federated systems, which people with the required knowledge within or across Ministries and what capacity each has to respond to the surveys. If more than one department is involved, it is unclear whether respondents are (or should be) in conversation with one another, raising the persistent challenge of the lack of communication and policy action across government departments. The issue of who prepares country reports, their competency and access to knowledge and data can also be a limiting factor. Across reporting periods, it is unclear whether there is institutional memory given the rapid turnover of civil servants within and across reporting departments.

Corresponding mention of relevant agreements between national partners is limited (such as bilateral labour or mutual recognition agreements). It is unclear internationally what processes are in place to link responses between countries, especially those with existing bilateral and multilateral agreements, and what capacity exists or is needed within countries and/or the international organizations who manage the reporting process to assess such linkages to ensure reliability and validity of the survey responses. The ability to crosswalk data between countries would need to be built into the data collection process, creating datasets with greater reliability and higher quality.

Lack of transparency in the reporting process

Finally, there can be a lack of transparency in the reporting process and accountability for the data provided (or not provided). It is not clear whether there is any recourse for countries for not responding to surveys in their entirety, to specific questions, or for confirming relevance, specificity, reliability, and validity of responses. Added to this, there is often a lack of longitudinal linkages between reports across reporting periods. Capacity for these data quality features requires explicit attention.

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