Governance systems for skilled health worker migration, their public value and competing priorities: an interpretive scoping review

Figures & data

Table 1. Distribution of content areas from the primary studies included in the review

Area of inquiry based on the framework	Category	Sub-categories	Number of articles (%)
Public Value proposition
	Facilitate SHW mobility between countries	-Part of broad initiatives aimed at securing economic value for both source & destination countries -Addressing SHW unemployment in source countries, and workforce shortages in destination countries. -Maintaining health services near shared national borders. -Comparability of competences, and integration of health systems.	34 (53.9%)
	Achieve health workforce sustainability	-Track workforce needs and migration flows. -Health workforce development, and their distribution -Coordinate labour market activities	14 (22.2%)
	Build capacity for SHW migration governance	-Monitoring of migration flows and their impact -Identification & dissemination of best practices -Mechanisms for monitoring implementation	9 (14.3%)
Competing Public Values
	Patient safety in destination countries	-Concerns about quality of SHWs attracted, and its impact on patient safety	10 (15.9%)
	SHW shortages in destination countries	-Addressing SHW shortages in destination countries, less concern on impact in source countries	15 (23.8%)
Handling Competing Public Values
	Equality and equity	-Mitigating negative effects of migration -Health workforce development	43 (68.3%) 15 (23.8%)
	Protecting a country’s autonomy	-State parties exercise regulatory discretion to protect their county’s public health interests.	34 (54.0%)
	A focus on cooperation	-Seeking to forge solidarity between state parties	18 (28.6%)
	Delegating authority to a regional governance system	-A regional council is recognised as the unbiased arbiter on competing interests between state parties	3 (4.8%)
Enabling/Constraining factors
	Authorising environment	Alignment of interests/prevailing social pressure Funds Data Technical resources	4 (6.3%) 15 (23.8%) 12 (19.0%) 3 (4.8%)
	Capacity to harness available resources	Implementation mechanisms Monitoring ability	19 (30.2%) 4 (6.3%)

*SHW – Skilled Health Workers

Figure 1. Summary of search, selection and inclusion process.

Figure 2. List of countries reflected in the reviews.

Figure 3. Public values and competing public values in SHW migration governance.

Figure 4. Handling competing public values in the global governance of SHW migration.

Figures 5. Enablers and constraints in creating public value and handling competing public values in the global governance of SHW migration.

Table

Migration
1. brain drain.mp. or migration.sh. or emigration.sh. or immigration.sh
Health professionals
2. (skilled and (health* or medical) and (profession* or personnel or staff or worker* or manpower or workforce)).mp.
3. nurse*.mp.
4. physician*.mp.
5. doctor*.mp.
6. dentist*.mp.
7. (midwife* or midwiv*).mp.
8. pharmacist.mp.
9. 2 or 3 or 4 or 5 or 6 or 7 or 8
Governance
10. (governance or government).sh.
11. administration.sh.
12. decision making.sh.
14. regulation.sh. or regulation*.mp.
15. (health policy or regional policy).sh. or policy.mp. or policies.mp. or policy.sh. or government policy.sh. or policy respons*.mp. or intervention*.mp. or agreements.mp. or regulation.mp.
16. planning.mp. or planning.sh. or work planning.sh.
17. 10 or 11 or 12 or 13 or 14 or 15 or 16
Health professionals AND Migration AND Governance
18. 1 and 9 and 17

Table

Migration
S1 ‘brain drain’“
S2 migration
S3 (MH ‘Emigration and Immigration/LJ/EI’)
S4 S1 or S2 or S3
Health professionals
S5 health professional
S6 health personnel
S7 health staff
S8 health worker
S9 health manpower
S10 “health workforce “
S11 nurse
S12 doctor
S13 physician
S14 pharmacist
S15 dentist
S16 S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15
Governance
S17 (MH ‘State Government’) OR (MH ‘Government’) OR ‘governance’
S18 administration
S19 ‘decision making’
S20 (MH ‘Professional Regulation’) OR (MH ‘Rules and Regulations’) OR (MH ‘Government Regulations’) OR ‘regulation’
S21 (MH ‘Public Policy’) OR (MH ‘Policy Making’) OR (MH ‘Health Policy’) OR ‘policy’
S22 ‘intervention’
S23 (MH ‘International Business’) OR (MH ‘Negotiation’) OR ‘agreements’
S24 (MH ‘Strategic Planning’) OR ‘planning’
S25 S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S22 OR S23 OR S24
Health professionals AND Migration AND Governance
S30 S4 AND S16 AND S25

Table

			Content areas (Bullet point (•) indicates a content area identified in each article)
First Author (Year of Publication)	Study design /article type	Level of governance	PVP	AE	OC	CPV^¥	HaCPV^¥
Abuagla, A. (2016)(1)	Case study	Bilateral International	*	*	*	*
Arnold, P.C. (2011)(2)	Essay	Bilateral	*		*	*
Balasubramanian, M. (2016)(3)	Qualitative study	Bilateral Regional International	*	*	*
Balasubramanian, M. (2011)(4)	Qualitative study	International
Bidwell, P. (2014)(5)	Qualitative Content Analysis	Bilateral	*		*
Brush, B.L. (2008)(6)	Integrative Literature Review	Bilateral International	*	*
Brush, B.L. (2010)(7)	Historical analysis	Bilateral	*			*
Buchan, J. (2010)(8)	Analytical Review	International			*	*
Buchan, J. (2011)(9)	Editorial	International	*		*	*
Buchan, J. (2003)(10)	Report	Regional, International	*	*
Cheng, M.H. (2009)(11)	Report	Bilateral International	*			*
Connell, J. (2011)(12)	Analytical Review	Bilateral Regional International	*	*	*	*	*
Cowan, D. (2006)(13)	Editorial	Regional	*	*	*
Dhillon, I.S. (2010)(14)	Book	Bilateral Regional International	*	*	*	*
Ennis, C.A. (2018)(15)	Transnational Analysis	Bilateral Regional, International	*	*		*
European Observatory on HealthSystems and Policies (2014)(16)	Book	Bilateral Regional International	*	*	*
Gerlinger, T. (2007)(17)	Analytical Review	Regional	*	*	*	*	*
Hawthorne, L. (2015)(18)	Project report	Bilateral Regional International	*	*	*	*
Jourdain, A. (2017)(19)	Review	Regional International	*				*
Kalipeni, E. (2012)(20)	Analytical Review	Bilateral
Kanchanachitra, C. (2011)(21)	Review	Bilateral Regional International	*	*	*		*
Kingma, M. (2001)(22)	Commentary	Bilateral Regional International	*	*		*
Kingma, M. (2006)(23)	Meeting Presentation	Bilateral Regional International	*		*	*
Kupfer, L. (2004)(24)	Program report	Bilateral Regional International	*	*		*
Lewis, P. (2011)(25)	Case Study	Bilateral Regional International	*	*
Ling, K. (2014)(26)	Commentary	Bilateral Regional	*	*			*
Lofters, A.K. (2012)(27)	Commentary	Bilateral Regional International	*	*	*
Makulec, A (2014)(28)	Working Paper Series	Bilateral International	*	*	*
Manning, C. (2007)(29)	Case study	Regional International	*
Morgan, W.J. (2005)(30)	Case Study	International	*		*	*
Nullis-Kapp, C. (2005)(31)	WHO News Bulletin	Bilateral International	*
Ognyanova, D. (2012)(32)	Mixed-Methods Qualitative Study	Bilateral Regional International	*		*	*	*
Pagett, C. (2007) (33)	Review	Bilateral Regional International	*	*	*	*
Pastor‐Bravo, M. (2019)(34)	Case Study	Bilateral	*			*	*
Plotnikova, E.V. (2012)(35)	Document analysis & Qualitative Interviews	Bilateral Regional, International	*	*	*	*	*
Plotnikova, E.V. (2012)(36)	Qualitative Content Analysis	Bilateral Regional, International	*	*		*	*
Reardon, C. (2014)(37)	Qualitative study	Bilateral International	*
Salmon, M.E. (2007)(38)	Program Report	Bilateral Regional	*	*
Simoens, S. (2005)(39)	Working Paper	Bilateral Regional International	*
Siyam, A (2013)(40)	Progress report	Bilateral Regional International	*	*	*		*
Squires, A. (2011)(41)	Qualitative study	Regional	*	*
Stilwell, B. (2004)(42)	Commentary	Bilateral Regional International	*			*
Tangcharoensathien, V. (2015)(43)	Commentary	Bilateral Regional International	*	*
Tangcharoensathien, V. (2017)(44)	Qualitative Policy analysis	Bilateral International	*		*
Tankwanchi, A.B.S (2014)(45)	Correspondence	International	*
Te, V. (2018)(46)	Scoping Review	Regional International	*	*	*	*
Tsujita, Y. (2017)(47)	Research Report	Bilateral Regional	*			*	*
Villegas, B.M (1993)(48)	Narrative Review	Regional	*			*
Walton-Roberts, M.J. (2020)(49)	Book Chapter	Bilateral, International	*
Wangchuk, K. (2015)(50)	Brief Communication	Bilateral Regional	*
Willetts, A. (2004)(51)	Review	International	*	*		*
World Health Organization, Regional Office for The Western Pacific (2003)(52)	Meeting Report	Bilateral Regional, International	*		*		*
WHO (2003)(53)	Report	International	*				*
World Health Organization (2006)(54)	Report	Bilateral Regional International	*			*
World Health Organization Regional Committee for Africa. (2009)(55)	Technical Report	International	*	*	*	*	*
World Health Organization Regional Office for South-East Asia. (2009)(56)	Technical Paper	International Bilateral	*	*		*	*
World Health Organization Regional Office for the Western Pacific. (2003)(57)	Meeting Report	Bilateral Regional, International	*		*
World Health Organization Regional Office for the Western Pacific (2013)(58)	Analytical Review	Regional, International	*		*
Yagi, N. (2014)(59)	Policy Analysis	Bilateral Regional International	*	*	*	*
Yeates, N (2013)(60)	International Policy Report	Bilateral Regional International	*	*	*	*
Yeates, N. (2018)(61)	Analytical Review	Bilateral Regional International	*		*	*	*
Yeates, N. (2019)(62)	Research Monograph	Bilateral Regional International	*	*	*	*	*
Young, R. (2013)(63)	Evaluation Study (Mixed Methods)	Bilateral International	*	*	*	*

Key: PVP – public value proposition, AE – authorising environment, OPC – operational capacity, CPV – competing public values, HaCPV – handling of competing public values. ^{¥ -} Articles mentioned at least one CPV or an approach for HaCPV

Table

Item and its interpretation	Code
1. Level of migration governance:
• Bilateral agreements/initiatives: If the governance decisions (for skilled health migration) and/or their implementation was between two countries only.	Bil.Agree/Init
• Regional agreements/initiatives: If the governance decisions (for skilled health migration) and/or their implementation was within a region (i.e. between countries that have shared characteristics e.g. Africa, Europe, Asia, Europe, North America etc)	Reg.Agree/Init
• International agreements/initiatives: If the governance decisions (for skilled health migration) and/or their implementation was between three or more countries that do not necessarily share the same characteristics (e.g. between countries in Africa, and those in Europe)	Int.Agree/Init
2. What was the public value proposition offered by agreement/governance initiative? Look for the main vision or desired outcome of the agreement. Also look for the mission (i.e. steps taken to achieve the overall vision), strategic goals that were stated for each skilled health workforce migration policy or initiative	Main.Aim
3. Were there competing public values (i.e. competing aims between participating countries)? If yes, please code them. 4. Examples of public values are as follows: economic values – speaks to economic gains for the country/organization and the citizens, social and cultural value – speaks to social capital/cohesion, what binds people together, breeds trust and commitment to one another, political value – what increases democratic dialogues and public participation, ecological value – what preserves the environment, reduces waste and ensures sustainable development, social value – from the perspective of citizens as they use public health services. Protecting citizen’s/migrant rights is another public value.	Economic values: Pub.Val_Econ Social & cultural value:Pub.Val_Soc.Cult Political value:Pub.Val_Pol Ecological value:Pub.Val_Ecol Social value:Pub.Val_Soc Protecting citizen’s/migrant rights: Pub.Val_Rights
5. How were these competing public values handled? Codes for this section include: • Cooperation (Solidarity)- look for evidence on whether participating countries/organizations tried to forge a shared sense of identity, partnership and collective action towards a common interest. • Autonomy – look for evidence of competition between countries for scarce skilled health workers, where singular national/organizational interests was the focus instead of the collective, whether there was so much focus on self-determination or sovereignty of participating countries/organizations. • Equality and equity – look for evidence for the utilization of standards for guiding decision making, including ethical standards, codes of conduct, consultation between participating countries to ensure transparency and accountability. 6. Authority – look for evidence for the presence of an arrangement for enforcing regulatory mechanisms; their reliability and efficiency.	Solidarity: Comp.Pub.Val_Sol Autonomy:Comp.Pub.Val_Aut Equality and Equity:Comp.Pub.Val_EE Authority:Comp.Pub.Val_Auth
7. Enabling and Constraining Factors? Look for information on what enabled or constrained the attainment of the public value propositions and the ability to address competing priorities.	Ena/Cons
8. Provide information on what changed concerning health professional migration between participating countries. What changed concerning the migration of health professionals between these countries?	Chang.Mig

Table

SECTION	ITEM	PRISMA-ScR CHECKLIST ITEM	REPORTED ON PAGE #
TITLE
Title	1	Identify the report as a scoping review.	1
ABSTRACT
Structured summary	2	Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.	2
INTRODUCTION
Rationale	3	Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.	4
Objectives	4	Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g. population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.	5
METHODS
Protocol and registration	5	Indicate whether a review protocol exists; state if and where it can be accessed (e.g. a Web address); and if available, provide registration information, including the registration number.	5
Eligibility criteria	6	Specify characteristics of the sources of evidence used as eligibility criteria (e.g. years considered, language, and publication status), and provide a rationale.	6
Information sources*	7	Describe all information sources in the search (e.g. databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.	7
Search	8	Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.	Appendix 1
Selection of sources of evidence†	9	State the process for selecting sources of evidence (i.e. screening and eligibility) included in the scoping review.	7
Data charting process‡	10	Describe the methods of charting data from the included sources of evidence (e.g. calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.	8
Data items	11	List and define all variables for which data were sought and any assumptions and simplifications made.	8
Critical appraisal of individual sources of evidence§	12	If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).	N/A
Synthesis of results	13	Describe the methods of handling and summarizing the data that were charted.	8
RESULTS
Selection of sources of evidence	14	Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.	Figure 1
Characteristics of sources of evidence	15	For each source of evidence, present characteristics for which data were charted and provide the citations.	Appendix 2
Critical appraisal within sources of evidence	16	If done, present data on critical appraisal of included sources of evidence (see item 12).	N/A
Results of individual sources of evidence	17	For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.	Appendix 2
Synthesis of results	18	Summarize and/or present the charting results as they relate to the review questions and objectives.	Table 1, Figures 3–5
DISCUSSION
Summary of evidence	19	Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.	17
Limitations	20	Discuss the limitations of the scoping review process.	21
Conclusions	21	Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.	21
FUNDING
Funding	22	Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.	23

JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

* Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites.

† A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g. quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote).

‡ The frameworks by Arksey and O’Malley (6) and Levac and colleagues (7) and the JBI guidance (4, 5) refer to the process of data extraction in a scoping review as data charting.

§ The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of ‘risk of bias’ (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g. quantitative and/or qualitative research, expert opinion, and policy document).

From: Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D PRISMA Extension for Scoping Reviews (PRISMAScR): Checklist and Explanation. Ann Intern Med. 2018;169:467–473. doi: 10.7326/M18-0850.