The impact of international health worker migration and recruitment on health systems in source countries: Stakeholder perspectives from Colombia, Indonesia, and Jordan.

INTRODUCTION: To address domestic shortages, high-income countries are increasingly recruiting health workers from low- and middle-income countries. This practice is much debated. Proponents underline benefits of return migration and remittances. Critics point in particular to the risk of brain drain. Empirical evidence supporting either position is yet rare. This study contributes to filling this gap in knowledge by reporting high-level stakeholders' perspectives on health system impacts of international migration in general, and active recruitment of health workers in specific, in Colombia, Indonesia, and Jordan. METHOD: We used a multiple case study methodology, based on qualitative methods integrated with information available in the published literature. RESULTS: All respondents decried a lack of robust and detailed data as a serious challenge in ascertaining their perspectives on impacts of health worker migration. Stakeholders described current emigration levels as not substantially aggravating existing health workforce availability challenges. This is due to the fact that all three countries are faced with health worker unemployment grounded in unwillingness to work in rural areas and/or overproduction of certain cadres. Respondents, however, pleaded against targeting very experienced and specialised individuals. While observing little harm of health worker migration at present, stakeholders also noted few benefits such as brain gain, describing how various barriers to skill enhancement, return, and reintegration into the health system hamper in practice what may be possible in theory. CONCLUSION: Improved availability of data on health worker migration, including their potential return and reintegration into their country of origin's health system, is urgently necessary to understand and continuously monitor costs and benefits in dynamic national and international health labour markets. Our results imply that potential benefits of migration do not come into being automatically, but need in-country supportive policy and programming, such as favourable reintegration policies or programs targeting engagement of the diaspora.

How can community participation strengthen a health insurance system? The case of health insurer's user associations in Colombia.

BACKGROUND: Colombia's universal health coverage programme has enrolled 98% of the population, thereby improving financial protection and health outcomes. The right to participate in the organisation of healthcare is enshrined in the 1991 Colombian Constitution. One participatory mechanism is the legal and regulatory provision that citizens can form user associations. This study examines the functionality of health insurance user associations and their influence on citizen empowerment and health insurance responsiveness. METHODS: The mixed methods study includes document review (n=72), a survey of beneficiaries (n=1311), a survey of user associations members (n=27), as well as interviews (n=19), focus group discussions (n=6) and stakeholder consultations (n=6) with user association members, government officials, and representatives from insurers, the pharmaceutical industry, and patient associations. Analysis used a content-process-context framework to understand how user associations are designed to work according to policy content, how they actually work in terms of coverage, public awareness, membership, and effectiveness, and contextual influences. FINDINGS: Colombia's user associations have a mandate to represent citizens' interests, enable participation in insurer decision-making, 'defend users' and oversee quality services. Insurers are mandated to ensure their enrollees create user associations, but are not required to provide resources to support their work. Thus, we found that user associations had been formed throughout the country, but the public was widely unaware of their existence. Many associations were weak, passive or entirely inactive. Limited market competition and toothless policies about user associations made insurers indifferent to community involvement. CONCLUSION: Currently, the initiative suffers from low awareness and low participation levels that can hardly lead to empowered enrollees and more responsive health insurance programmes. Yet, most stakeholders value the space to participate and still see potential in the initiative. This warrants a range of policy recommendations to strengthen user associations and truly enable them to effect change.