In Marrakesh, during one of the side-events organized by Public Services International (PSI), European Public Service Union (EPSU), WHO, the Friedrich Ebert Stiftung and the governments of Germany and the Philippines, we presented a discussion paper: Global Skills Partnerships & Health Workforce Mobility: Pursuing a race to the bottom? As many of you may know, Michael Clemens, from the Centre for Global Development, has been the driving force behind this Global Skills Partnerships (GSP) concept . By now, the concept has become part of the Compact under objective 18. GSP have the aim to “Invest in skills development and facilitate mutual recognition of skills, qualifications and competence.” PSI commissioned research to us as to critically assess the skills partnership concept, its drivers and discourses, as GSP might have an impact on health equity and health systems development in both source and destination countries.

Unlike the treatment the average migrant gets at European borders nowadays, the world of ‘migration and development’ welcomed us at this UN Global Compact conference. Perhaps we were biased, but other pre-sessions seemed to indicate a big contribution (and interest) of the private sector in the economic potential of migration contributing to development. In line with mainstream economic thinking, migration was largely framed as a potential economic enabler, facilitating ‘win- win’ solutions. GSP clearly fits in this frame. By using a critical discourse lens it is evident that foremost an economic development approach and indirectly a trade and health objective are pursued through these public-private skills development partnerships facilitating health workforce mobility. The GSP seems to be a short-term cost-effective solution to address deficits in health care systems by sourcing skills transnationally. The investment case and economic benefits are projected to be sustainable and inclusive but both the literature review and interviews that we conducted failed to provide evidence of this. The GSP concept as it currently stands doesn’t adopt a human rights-based approach to health systems development nor does it give much attention to health care services as a global public good.

So, our stance versus GSP is somewhere stuck between a rock and a hard place, currently. The (GSP) picture could of course be improved, in the short-term, by assuring that trade unions and governments are strongly involved when pursuing bilateral labour agreements that include new skills partnerships; and in the longer-term by pursuing regional, and perhaps global governance and public finance model(s) to mitigate the benefits and externalities of health personnel migration.

This requires, however, in our opinion, strong public, multilateral engagement and shouldn’t be left to the market, philanthropy and the private sector. If government and trade union aren’t at the table to protect and promote the public interest, the other parties have ample space to jump in, with other interests. The risk for exactly that to happen is rather high, unfortunately, in the current international environment.

This is the political economy irony and dichotomy (of the rock and the hard place) of global labour migration and skills partnerships. They are being promoted as an efficient solution in places where care demands and financial gains are high. If there is no direct benefit [in the receiving countries] of different types of labour migration, things are, however, instantly framed as a ‘crisis’ that needs to be contained, surveilled and securitized. A more nuanced and fairer political narrative on labour migration in the health care sector (and other sectors) needs to be pursued.  And of course, in an ideal world, decent public investment in health care staff would just make GSP redundant. But we don’t live in an ideal world.

As an end-of-year thought, let us share a quote displayed in bright neon letters at the Irish emigration museum in Dublin: “We All Come From Somewhere”!   

Since investing in health and the health workforce is the talk of the day in the global health community, and the need to restructure the global economic order for health equity reasons follows suit (well, at least in the eyes of many, though perhaps not the ones with most power in the global health architecture), it was with this lens that I read Paul Mason’s book ‘PostCapitalism: a Guide to Our Future’. Mason loves the Wikipedia project; I’d like to refer you to one of its pages for a nice summary of the book and encourage you to read the whole book to know why Mason loves Wiki and how he views this late stage of capitalism.

The second semester of 2018 will feature some interesting conferences for the global health community. One of them is the Global Conference on Primary Health Care in Astana, Kazakhstan. In the run-up to that conference, the Geneva Global Health Hub (G2H2) organised a civil society workshop earlier this year. ‘Health is not only a matter of human rights, but also of justice. Governments who are not making provision for decent health care are denying justice to their people. The Alma Ata declaration recognised the need to restructure the global economic order to address inequalities and enable countries to generate resources for decent health care and tackle the root causes of poor health’, is an excerpt of that workshop’s consultation statement.

Why is restructuring the global economic order necessary to achieve decent health care for all, including a proper health workforce? With his book, Mason shares his study on capitalism as a whole system – social, economic, demographic, cultural, ideological – and what is needed to make a developed society function through markets and private ownership. I was particularly interested in Mason’s description of the state’s (key) role in neoliberalism: ‘The neoliberal system cannot exist without constant, active intervention by the state to promote marketization, privatization and the interests of finance. It typically deregulates finance, forces government to outsource services and allows public healthcare, education and transport to become shoddy, driving people to privatise services.’

How does this system work and who has a say in it, I was pondering? Is ‘governance for health being held captive by private foundations and corporations’? How does it affect governments’ intentions to invest in health? And which actors within governments make certain decisions that either improve health for all or make public healthcare ‘shoddy’? At the big conferences we usually meet ministers or deputy ministers of health, or people that work at the ministry of health, most often accompanied by people working at the ministries of foreign affairs. But if it is, rather, about ‘the interests of finance’, as Mason indicates, are they then the right target group of our advocacy?

Via Twitter I met Ilias Alami, Lecturer in International Politics at the University of Manchester. He recently published the paper ‘On the terrorism of money and national policy-making in emerging capitalist economies’. The title tickled my curiosity and in my view implied that ‘money’ influences national decision-making – including health policies (no, this is not new). I dived into the paper as I more and more think that ‘Health for All’ cannot do without (at least, some) ‘Economic Literacy for All’. What is this money, and can it be invested for the better?

Alami combines the Marxian critique of political economy with crucial insights from radical economic geography and Post-Keynesian/Minskian economics. Alami claims ( if I paraphrase George Orwell’s notorious quote in Animal Farm) that ‘all currencies are equal, but some are more equal than others’. Currencies that are less equal have remained at the bottom of this (financial/capitalist) hierarchy. This, according to Alami, makes the management of monetary and financial affairs particularly difficult in these countries, leading to severe constraints on national policymaking. That perspective provides insights into why ‘state authorities implemented violent bouts of austerity, in desperate attempts to restore international investor confidence, often dramatically worsening domestic socio-political crises’. Others, including Stuckler and Basu, have shown how economic forces translated into austerity and did great harm to people’s health and well-being.

Alami found that some countries, which he calls ‘emerging capitalist economies’ (ECEs) (IMF includes over the period 2005–2014: China, Brazil, Mexico, Turkey, India, South Africa, Indonesia, Malaysia, Poland, Indonesia, Thailand, and Russia), are much more ‘disciplined’ than advanced capitalist countries by the global flows of money and the limits set by the global monetary and financial system. This is what Thomas Friedman, some years ago already, defined as ‘countries putting on a golden straightjacket’.  Friedman considers “The Golden Straitjacket” as the defining political-economic garment of this globalization era, highly influencing – or rather constraining – the capacity for states to set their own national policies. Ultimately, this also impacts people’s health and well-being. Going back to Alami, a few world financial centres (London, New York, Frankfurt, Tokyo, etc.) have accumulated vast social and political power, which allows them to exert control over wider continent blocs such as Europe, the Americas, South-East Asia, and the global financial system as a whole.

So, if this applies to ‘emerging’ capitalist economies (and increasingly ‘established’ capitalist economies, too – as Stuckler and Basu show), then, I wonder to what extent economies that are not (yet) emerging are being ‘disciplined’.  ‘Hammered’ is probably more like it for these. ‘True public provision of water, energy, housing, transport, health care, telecom infrastructure and education would be a compelling strategic act of redistribution’, says Mason. This redistribution is necessary if we choose people and planet over an economic system that benefits very few and might be dying, according to Mason. How can we enlarge ‘money’ of not yet or non-emerging capitalist economies to actually invest in health and well-being instead of engaging in yet another disciplining act to save capitalism for the sake of the few? Can civil society have a say in this – and if so, how and where?

Hence, when we take off to the Global Conference on Primary Health Care to recommit to strengthening primary health care worldwide, we also commit to restructuring the current global economic order. The Alma-Ata Declaration recognised this need, as well as its urgency, but the current draft Astana Declaration remains silent about it. In this late stage of capitalism, as Mason indicates, we better restructure it ourselves, if we don’t want to end up in a world in chaos. We are currently witnessing the backlash against (neoliberal) globalisation, and it already looks fairly ugly. If we don’t manage to restructure the system ourselves, from the bottom, it’ll only get more ugly, especially as climate change seems to be accelerating in front of our eyes.

Investing in human and planetary health is key to social justice. When we as civil society want to join forces to tackle tax avoidance and illegal (or perhaps more accurately: harmful) financial flows, and lift unnecessary conditions on fiscal space for health spending, and want to get our message across and to the right target groups – it should be with people such as Paul Mason, Ilias Alami, David Stuckler, Sanjay Basu and, not to forget, Kate Raworth.

Bill Gates appears to see the writing on the wall as well. Unfortunately, he draws the wrong conclusions. The opposite would have surprised.  But hey, not everybody can be a Marxist : )

Ooijpolder, Nijmegen (Holland) 

Some 20 years ago, the home base of the Global Health Watch, People’s Health Movement, was founded by grassroots health activists, civil society organizations and academic institutions from around the world to mobilize people for the right to health. Wim de Ceukelaire was one of the founders and present at the launch. ‘Our motivation was the injustice and inequality due to economic and social policies that are imposed on us and that create sickness and death among us’, he said. Today, People’s Health Movement is a world-wide NGO with a presence in around 70 countries.

De Ceukelaire’s words made me think of how we, as civil society, are facing the urgent need to call upon our governments to act in accordance with the right to health for all. The need is given by the present state of affairs, which, in the words of David McCoy, Professor of Global Public Health at Queen Mary University London, is characterized by rising inequality and the prospect of ecological collapse, which are together leading us into an era of unpredictability and political instability.

‘Governance for health is being held captive by private foundations and corporations’, stated McCoy. To the powerful neoliberalist mindset belongs the idea that governments are a threat to corporate liberty, and that humans are driven by the wish to maximize their utility. Furthermore, neoliberals see inequality and social hierarchy not only as beneficial, but also as ‘natural’.

It goes without saying that those who benefit from the current situation are the ones least affected by environmental crises or other human-made disasters. Therefore, they fail to see the connection with the ‘slow violence’ of over-exploitation of the planet that threatens us all.

In my view, the present moment asks for a movement for health and social justice that goes beyond health. The People’s Health Movement is certainly a good start, but, as McCoy suggests, broader coalitions & alliances need to be sought. Along the same lines, Freudenberg emphasizes in his book Lethal but Legal that “harmful consequences of corporations on our society, such as income inequality, subverted democracy, and environmental degradation, have been underemphasized by those working on health, limiting the potential for broader alliances.”

Kate Raworth provides in her book Doughnut Economics the doughnut model of social and planetary boundaries, which serves as an apt visualization for such an enlarged global health thinking.

Raworth urges and guides us to move beyond being addicted to economic growth to being growth agnostic. She shows how to improve humanity’s well-being while eliminating the social shortfall and ecological overshoot, and, at the same time, staying within the ecologically safe and socially just space in which people have the possibility to thrive. For us as civil society organizations working for global health this means that we will need to join forces with organizations concerned with migration, environment, and economic justice, among others. Naomi Klein et al.’s  ‘The Leap Manifesto’ can serve as inspiration.

Tax justice is a good example of how to join forces across the sectors, my colleague Renee de Jong put forth. Tax for carbon and other polluting emissions, a financial transaction tax, a tax on natural resources or on the capital of the 1% richest could be a start to move to a fairer global system based on global public goods such as strong health systems and decent work conditions for health workers.

This blog is adapted from Towards enlarged global health thinking  (published earlier on Wemos). 

More in general, the global health workforce requires serious attention. Due to demographic growth in different regions in the world, an ageing workforce  and an epidemiological transition to chronic disease worldwide, there is a desperate need for more skilled health workers, to contribute to a balanced workforce tailored to countries’ needs. In 2013, approximately 7.2 million more midwives, nurses and physicians were “missing and thus not in action” – and this shortfall is predicted to rise further to at least 12.9 million in the coming decade.  The gap is most obvious in low- and middle countries (LMICs), but has become an issue in other regions as well, including in the North. See for instance Europe, where many health workers have decided to migrate to countries in Northern Europe for employment reasons. This has created inequalities in access to health services.  In sum, the global health workforce crisis is  (or should be) a major issue for the post-2015 development agenda.    The public health community has been convinced of this for a long time, now hopefully also Obama, Cameron and other Xi’s are on board.

In 2015 four important global policy discussions take place that will shape the direction of the health workforce development for the coming decade. First, the relevance and effectiveness of the Code of Practice on the international recruitment of health personnel (WHO Code) will be discussed at the 68^th World Health Assembly in May 2015. Secondly, WHO and the Global Health Workforce Alliance are developing a global strategy on Human resources for health. Thirdly, the future institutional development of the Global Health Workforce Alliance (GHWA), the Global health initiative created in 2006 to raise the global profile and funding of the health workforce, is hotly being debated. Finally, the position of the health workforce within a future 3^rd (Health) Sustainable Development Goal is to be defined.

1. WHO Code

During the first round of reporting on the Code in 2013, the WHO Secretariat informed the Assembly that only 84 designated national reporting authorities had been established and that it had received even less (51) reports. A WHO Assistant Director-Ggeneral admitted during a side-event at the WHA that year that progress was ‘painfully’ slow. We will have to see how Member States will contribute to the second round of national reporting due this year.

Unethical recruitment and inadequate investment in self-sufficiency in high-income countries are crucial contributors to global health workforce imbalances, underlying the continuing relevance of the WHO Code. The WHO Code needs to be properly implemented, including in Europe, and national health workforces need to be developed, nurtured and retained.  Having said that, one should not shy away from also asking the (obvious?) question whether the voluntary nature of the Code detracts from its effectiveness, and WHO should thus move to the negotiation of a more binding instrument to address recruitment and migration issues in the context of a broader HRH strategy. In a joint statement during the Executive Board meeting of WHO, we recommended Member States to consider rescheduling the commitment to report on the relevance and effectiveness of the Code to the World Health Assembly in 2016. This would allow some more time for a proper process, including full consideration of the information gathered through this second round of national reporting. It also would align more closely the processes of Code review and the development of a global HRH strategy planned for this year.

2. Health Workforce 2030. A Global strategy on human resources for health

In 2013, the Board of the Global Health Workforce Alliance facilitated the development of strategic thinking on human resources for health.  8 Thematic working groups wrote a thematic  paper as input for a global strategy; a synthesis report summarizes the papers of these 8 thematic working groups. The Medicus Mundi International  (MMI) network, together with several others, has been following this process closely, providing feedback for further dialogue. Our main critique is that the global strategy mainly mentions  national responsibilities and requirements (multisectoral approaches and labour market analyses) to develop the workforce, but fails to recognise the transnational dimension, international legal frameworks and human rights aspects of health workforce governance. The international moral responsibility and ethical imperative that everybody should have access to skilled health workers providing essential health services is lacking from this strategy. The synthesis paper takes a rather narrow approach: it makes the ‘instrumental’ economic and health security case for investments in the health workforce, but doesn’t recognise the intrinsic value of developing public services for health, the social role of health workers nor the role they can play as change agents in society.

3. The future of Global Health Workforce Alliance

GHWA’s mandate ends in 2016. There is now a debate on how to move forward with a GHWA 2.0. GHWA is currently hosted by (and working in close cooperation with) WHO. Alternative options would be for GHWA to work in close cooperation with other institutions such as the World Bank or the International Labour Organisation, or that it becomes a more autonomous, independent organisation. We think there are already too many global health initiatives, and too much fragmentation and bilateral control within the existing agencies and policies. GHWA should remain closely affiliated with the WHO, so that the latter’s social justice & equity values and health objectives also remain key priorities for GHWA. These aspects could be neglected in case of an “ever closer union with” the World Bank, as the Bank mainly focuses on poverty alleviation and harnessing economic growth.

4. The place of the Health Workforce in the Sustainable Development Goals.

The proposed Health sustainable Development Goal (3) has four suggested modes of implementation. One of them is 3c: “Increase substantially health financing and the recruitment, development and training and retention of the health workforce in developing countries, especially in LDCs and SIDS”. The SDG agenda will be negotiated and decided upon in the coming months  (if God and Mr Putin allow so). There is already much discussion on what a truly ‘universal’ framework implies within international cooperation, and whether  blatant inequalities (as is the case with the workforce) will be redressed. A crucial element will be what comes out of the financing for development summit, later this year in Addis Abeba, Ethiopia. If all goes well, an agreement there should provide the financial means (national and global taxation?) for investment in the workforce in countries that lack an essential level of health workers.

The GHWA board will come together on 25/26 February 2015 to discuss the further process and policy direction for at least 3 of the 4 issues above (except the SDG framework, for which the main action takes place in New York).  WHO will discuss both policy and process during the upcoming World Health Assembly in 2015. It is important to follow these policy debates closely, and to engage with them as much as possible, via a critical but constructive dialogue with all actors involved. A good way to kick off this dialogue is via Twitter. One could approach GHWA and its director Jim Campbell via @GHWAlliance  resp  @Integrare.  The hashtag  #GHWAboard18 could be used to take part in the policy debate during the board meeting itself, from a distance. Many of the GHWA board members  use Twitter as well and could perhaps be contacted. The notes of the 17^th board meeting are also accessible.

Many steps still need to be taken this year to take the various (abovementioned) processes forward. The important thing, as always, is that we walk in the right direction…