Last week, I was in Abidjan, the ‘economic’ capital of the Ivory Coast. I was invited by the WHO to facilitate a dialogue on international health workforce mobility during an inter-sectoral consultation of policymakers and partners in Francophone countries. This consultation feeds into a UN High Level Commission on Health Employment and Economic Growth (UN HEEG). This commission, co-chaired by the Presidents of France and South –Africa, was initiated by a UN General Assembly resolution on global health and foreign policy in 2015, within the context of the need to address the issue of human resources towards robust and adaptive health systems and strengthening global health security. The Commission is charged with ‘proposing actions to guide the creation of health and social sector jobs as a means to advance inclusive economic growth, paying specific consideration to the needs of low and middle income countries’. The Commission will present multi-sectoral responses to ensure that investments in health employment generate benefits across the SDGs. An Ad Hoc secretariat managed by WHO, OECD and ILO provides the support for the commission. A final report will be presented to the UN General Assembly in September 2016. This is the first time that the global health workforce challenge is being discussed at this international political level.
That said, I have in the past expressed my concerns about a narrow labour market approach to health workforce development, hence the irony in my active involvement in the meetings and input to the commission over the last weeks.
The meeting in Abidjan focused on 5 themes: financing and budget space; economic impact; international mobility; institutional reform and governance; and investments in education. The governments present (from Africa, Europe and Haiti) included representatives from ministries of Health and Social affairs. Unfortunately, as is so often the case in international public health meetings, there weren’t that many finance persons or ministries present. When discussing public budgets and economic policies, they would have come in handy, to say the least. Each country had to provide a position and policy recommendations on the 5 themes during the consultation.
In the remainder of this blog, I will focus on the international mobility of health workers – a theme which led to intense discussion among the participants. Firstly, all present agreed that the migration of health personnel is directly related to domestic mobility of health workers. If governments enable decent employment and living standards for health workers in rural areas, this reduces the ‘push’ for personnel to move to the country capital or migrate abroad. Secondly, many had difficulties with the term ‘control’ (‘maîtrise’) of health workforce migration. The mobility of skilled health workers to “greener pastures” (usually high-income countries) is seen as a right to the development and transfer of skills, as well as a source of remittances to the home country, contributing to economic growth. Yet, there are also repercussions on the health workforce of the often low-resource settings of source countries. In an attempt to address these issues, the ‘Global Code of practice on the international recruitment of health personnel’ was negotiated in 2010. Participants recognized its importance, but it was not used as a relevant policy tool in HRH governance by most. At a time with the largest refugee streams globally since World War II, ‘controlling’ migration has become a sensitive topic.
The consultation led to three key messages on international health workforce mobility. First, mobilize the diaspora via agreements between sending and receiving countries, including financial resource transfers to fund health systems in countries of origin; Second, to strengthen cooperation with countries benefiting from the migration of health personnel via investments, such as in education and health equipment. Lastly, there was a call to work towards the international standardization (and recognition) of qualifications and diplomas at the regional level, e.g. in the Economic Community of West African States.
The consultation was successful in eliciting some key policy recommendations and identifying obstacles (also for the other themes) that will find (some) reflection in the final report of the UN-HEEG commission. The consultation would have been richer if also non-governmental entities like NGOs, academia, labour unions, private sector and other stakeholders would have had the opportunity to participate. Also, organizing an exclusive Francophone consultation seems outdated and disconnected from 21st century reality. With modern technology for (simultaneous) translation, it should be possible to organize wider regional consultations, for example a regional pan-African consultation on the topic, especially with the South-African head of state being one of the co-chairs. Lastly, there is increasing recognition that health employment is a key sector for economic growth. However, what kind of ‘inclusive economic growth’ actually benefits public health urgently requires political analysis and debate by researchers and policymakers.
From a diplomacy perspective it is also interesting to note that in 2016 both in France and in South-Africa there have been serious societal tensions on labour law and educational reforms. How do these countries relate their domestic challenges with this foreign policy initiative? In essence it requires us to approach global health workforce development not only from a public health perspective but also from a political economy and foreign policy angle, including the relation between workforce development and security interests.
The adoption of the global HRH strategy: workforce 2030 during the recent 69th World Health Assembly, in combination with the UN-HEEG commission provides the global momentum to commit to the financing of health workforce development at national and international levels. The IMF acknowledges that an alternative to the neoliberal politics is necessary to secure public goods and services. Scholars have provided the evidence that there is a considerable fiscal multiplier of social sector employment. There are already proposals for financial mechanisms to redress inequalities in the global health labour market. The final report of the UN-HEEG at the UNGA in September 2016 will lead to further debate on how to translate this into (international) policies. One can count on IHP to critically analyze this process and to be engaged in the next steps.