# Changes in Physician Emigration and Density After the 2010 WHO Global Code of Practice

## TL;DR

A 2010 WHO policy reduced physician emigration from shortage countries by nearly 30%, but did not improve their physician density.

## Contribution

First empirical evaluation of the WHO Code's impact on physician migration and density over 21 years.

## Key findings

- Physician emigration from shortage countries dropped by nearly 30% after the WHO Code.
- Physician density in shortage countries declined slightly compared to nonshortage countries.
- The WHO Code reduced outflow but did not increase domestic physician supply.

## Abstract

Was the 2010 World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel (WHO Code) associated with changes in physician migration and physician density in shortage countries?

In this difference-in-differences analysis of 56 WHO-designated shortage countries (135 888 physicians) and 116 nonshortage countries (516 030 physicians), the WHO Code was associated with a reduction in annual physician emigration by nearly 30% during the first 5 years. However, physician density in shortage countries declined relative to nonshortage countries during the study period.

Although the WHO Code was associated with reductions in physician outflow from shortage countries, broader investments are needed to strengthen physician supply and health systems in those countries.

Physician emigration from low- and middle-income countries to high-income countries is a major driver of inequitable distribution of health care and health outcomes across the world. World Health Organization (WHO) signatory countries unanimously signed the voluntary Global Code of Practice on the International Recruitment of Health Personnel (WHO Code) in 2010. The goal was to reduce health care workforce emigration by discouraging active recruitment of physicians from WHO-designated shortage countries and by promoting investment in the physician workforce in those countries. This study adds to the literature by providing evidence about whether the goal has been achieved 10 years after worldwide implementation of the WHO Code.

To evaluate whether the WHO Code was associated with changes in physician emigration and physician density in WHO-designated shortage countries after 2010.

A difference-in-differences design was used to examine trends in physician supply before and after 2010. The data (from 2000 through 2021) were collected by the Organization for Economic Co-operation and Development (OECD) and were used to examine physician outflow from 56 WHO-designated shortage countries vs 116 nonshortage countries. The data analysis took place October 2024 to September 2025.

Worldwide adoption of the 2010 WHO Code.

The primary outcome was annual physician migration to OECD countries and the secondary outcome was physician density by country and year (per 1000 population using World Bank data) in the origin countries.

A total of 135 888 physicians emigrated from WHO-designated shortage countries during 2000 to 2021 and 516 030 physicians emigrated from nonshortage countries. Compared with nonshortage countries, there was a decrease in physician outflow by 47.03 physicians (95% CI, −92.29 to −1.76 physicians) per country per year after 2010 in WHO-designated shortage countries and the WHO Code was associated with a reduction of nearly 30% in the average annual outflow of physicians from these countries. However, there was a slight decrease in physician density in the WHO-designated shortage countries after 2010 (−0.22 [95% CI, −0.33 to −0.11] physicians per 1000 population) compared with the nonshortage countries.

This study found that voluntary implementation of the WHO Code was associated with lower physician outflow from WHO-designated shortage countries without improvement in physician density in those countries.

This difference-in-differences study evaluates whether the 2010 World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel was associated with changes in physician emigration and physician density in WHO-designated shortage countries compared with nonshortage countries.