Consultation to Draft guidelines on monitoring the implementation of the Global Code on the International Recruitment of Health Personnel Action for Global Health1 contribution
The Who Global Code on the International Recruitment of Health Personnel is the first major international recognition of the truly global nature of the health worker shortage and the role that unregulated migration is playing in undermining the right to health for all. The Code of Practice promises to have a significant impact on the deplorable shortage of health workers in low-income countries.
However the voluntary nature of the Code leaves it to the risk of dilution or being ignored. The need, not just of monitoring –as included in the Code itself-, but of common standards and clear guidelines for this tracking is, therefore, essential. Without a way to assess the implementation of the Code, the document would be useless as we wouldn’t be able to know in which level it would be having any impact.
If a periodic reporting to WHO is the only way we have, till now, to foster Member States to implement the Code, the reporting guidelines must be as defined and concrete as possible, with low levels of ambiguity or subjectivity, in order to really avoid any dilution and be sure we are getting a meaningful assessment and implementation.
With this aim, Action for Global Health wants like to share the following observations to the draft:
The article 2.3 asks destination countries to compensate source ones with cooperation, in different ways, to strengthen their health systems. The compensation is the only way to stop the plundering that the developed states hiring from developing ones is. However, any compensation must be additional -if not the Code wouldn’t have any impact in increasing human workforce globally- and fair. If not, we would move just from “stole” workforce to “buy it cheap”. Nevertheless, it is not easy to define what “fair” means or to establish any criteria to measure compensation.
1 Action for Global Health (more at www.actionforglobalhealth.eu) is a network of European health and development organisations advocating for the European Union and its Member States to play a stronger role to improve health in developing countries. AfGH takes an integrated approach to health, based on gender equality and women empowerment, and advocates for the fulfilment of the right to health for all. One billion people around the world do not have access to any kind of health care and we believe that Europe can do more to help change this. Europe is the world leader in terms of overall foreign aid spending, but it lags behind in the proportion that goes to health.
Our member organisations are a mix of development and health organisations, including experts on HIV, TB and sexual and reproductive health and rights, but together our work is organised around a broad approach to health. AfGH works to recognise the interlinkages of global health issues and targets with a focus on three specific needs: getting more money for health, making health care accessible to those that need it most and strengthening health systems to make them better equipped to cope with challenges and respond to peoples' needs
Starting by the additional aspect of the compensation:
Where to find it: Page 9, question 2.3: “If you are a destination country, do you undertake or encourage measures aimed at strengthening health systems in source countries?(…) _Yes_No If YES, please describe such measures and what level of government is responsible for implementing them.” Alternative wording: Page 9, question 2.3: If you are a destination country, do you undertake or encourage measures aimed at strengthening health systems in source countries?(…) _Yes_No If YES, please describe such measures and what level of government is responsible for implementing them.” TO INCLUDE THE FOLLOWING SUBQUESTION: If YES, please describe if such measures have increase as a consequence of this Code or under the umbrella of any bilateral, regional or multilateral agreement”
Regarding what is and what is not fair, WHO recommends investing the 50% of health ODA in health system strengthening and the 25% of it in workforce. This suggestion could be a starting point to assess if donor countries are doing their part on the joint efforts to end with the shortfall of HRH and make health systems more attractive to workers.
It is not easy, knowing the complex nature of the HRH crisis, to determine which foreign aid is supporting in any way health workforce. However, it is possible set up which investment is having a direct impact on it. That is why we request WHO to include another data appendix only for donor to track HRH ODA. Even any tracking can’t be totally exact, common standards, even giving approximate amounts, will allow us to establish trends and comparisons.
The way HRH ODA is calculated must be established in a open process, involving donor and partners countries, as well as NGOs and other actors, but, as a starting point we consider that HRH ODA tracking must include those CRS code related to HRH (12181, 12281, 13081), plus the percentage of sectorial budget support that goes to health staff and the amount of money that goes to other type of projects that have direct impact on HRH retention (e.x. the construction of houses for rural doctors).
The Code, in the article 5.6, asks Member States to develop both health systems and health workforce in a sustainable way. Regarding this point we want to add two considerations:
1) Even there are different standards and criteria used by ME to identify if they are facing a shortfall and in which level (e.x. we can’t compare the Spanish Shortfall with the Malawian one), it is needed to identify ME deficit to allow asses the impact of measures undertaken to increase the share of domestically trained HRH and work toward the self-sufficiency, be able to identify trends and comparisons among countries; as well as to assess if, globally, we’re moving forward to match demand and offer of HRH.
Where to find it: Page 9, question 2.4. “As policy matter, does your country strive to meet its health personnel needs with its own human resources for health as far as possible? _Yes _No” Question to include: 2.4 “As policy matter, does your country strive to meet its health personnel needs with its own human resources for health as far as possible? _Yes _No If NO, please describe which is the estimated deficit and which are the criteria used to calculate it. ”
2) Even the article 5.6 asks to “continuous monitoring of the health labour market” and there is a reference in the guidelines to those element that are keeping countries to strengthen human resources for health; we consider that, knowing the impact that it has haven in the past2, it is worthy to ask specifically about budgetary difficulties.
Where to find it: Page 10, question 2.5. “…What constraints does your country face in its efforts to increase the share of domestically trained health personnel in the health workforce?” Question to include: 2.5 “…What constraints does your country face in its efforts to increase the share of domestically trained health personnel in the health workforce? TO INCLUDE THE FOLLOWING SUBQUESTION: If your country is facing health budget cuts or ceilings to health expenditures, are these measures impacting on health workforce shortage or on the fulfilment of the Code?”
AfGH and its member organizations believe that the maximum responsible of health planning, policies and delivery are the Ministries of Health. We encourage WHO to consider a stronger recommendation to Member States to leave on hands of MoH the National Authority intended to report. In case this authority ends in other Ministries involved, as Migration, Labour or Cooperation, the final aim of the Code, ensure that health personnel are available everywhere and to everyone, will be diluted to the prejudice of others as “migration control”; there could be also the risk that the foreign aid aspect would be highlighted without taking into account that is essential to work toward national self-sufficiency and policy coherence.
Taking also into account that some Ministries are facing several weaknesses on their capacity to plan or implement HRH policies, be the national authority could help them to strengthen themselves.
Where to find it: Page 5: “The Code does not specify the type of organization that should serve as the national authority (…) It is recommended that such organization should have a strong interest in health workforce issues, be sustainable, have the capacity to build intersectoral action, and possess adequate information technology communication means.” Alternative wording: Page 5: “The Code does not specify the type of organization that should serve as the national authority (…) It is recommended that such organization should have a strong interest in health workforce issues, be sustainable, have the capacity to build intersectional action, and possess adequate information technology communication means. Currently department in charge of national planning of human resources for health, within Ministries of Health, could play this role.”
The whole document makes, when coming to assess fair labour conditions of foreign health workers, the distinction between “domestically trained” and “immigrant”. Even when this distinction is suitable if we want to assess how much benefit richer countries are getting from employ HRH trained by southern countries, is not so useful talking about labour conditions. The aspect that determines how they are treated is, not only where they have gotten their university diploma, but their nationality, as it is shows in several studies3.
2 AfGH and Stop Aids Campaign (2010), ‘The IMF, the Global Crisis and Human Resources for Health’ 3 AfGH (2011) ‘Addressing the Global health workforce crisis: Challenges for France, Germany, Italy, Spain and the UK’
Where to find it: Page 8, question 1.1: “If No, please describe how the legal rights and responsibilities of migrant health personnel differ from the domestically trained health workforce… Page 8, question 1.2: “… possibilities as the domestically trained health workforce in terms of employment and condition of work?” Pag 8: question 1.3: “Do migrant health personnel enjoy equal opportunities as the domestically trained…?” Pag 8: question 1.3: “If NO, (…) on the basis of equality of treatment with the domestically trained health workforce…?” Alternative wording: Page 8, question 1.1: “If No, please describe how the legal rights and responsibilities of migrant health personnel differ from the domestically trained or national health workforce… Page 8, question 1.2: “… possibilities as the domestically trained or national health workforce in terms of employment and condition of work?” Pag 8: question 1.3: “Do migrant health personnel enjoy equal opportunities as the domestically trained or national …?” Pag 8: question 1.3: “If NO, (…) on the basis of equality of treatment with the domestically trained or national health workforce…?”
Lastly but not least, we would like to highlight the need also for guidelines to other stakeholders willing to report on the implementation of the Code. Count with a report framework would make easier receive meaningfully contributions but, mainly, would allow WHO and those following this process to identify any potential conflict of interest; especially when talking about contribution from recruitment agencies or other private sector actors.
Don’t hesitate to back to us in case you are interested in discuss this document deeply, writing to [email protected]
Action for Global Health members: