By Thomas
Schwarz
Back from this year’s
World Health Assembly (WHA) in Geneva, I have mixed news and mixed feelings
about the implementation of the “WHO Global Code of Practice on the
International Recruitment of Health Personnel” (1), a topic that was on the WHA
agenda, with a report (2) by the WHO Secretariat to be “noted” by the member
states of the World Health Organization.
The background: Over 50
countries, mainly in Africa and South Asia, suffer from a critical shortage of
health personnel. And in the aging societies of European countries, the number
of people who need long-term care is increasing the demand for health workers.
As the labour market becomes more globalized, the rising demand for staff is
driving migration and mobility amongst health personnel. The recruitment of
health workers from abroad and the related “care drain” of doctors, nurses and
other health workers increases existing inequalities and further weakens weak
health systems.
In 2010, such analysis (3)
led to the adoption of the WHO Global Code of Practice by the World Health
Assembly. Three years later “we still require at least an additional 4.3
million health workers. Still, one billion people world-wide will never see a
health worker in their life. So, three years after Code adoption and having the
Code on the WHA agenda again: Let us take stock.” This is how Anke Tijtsma,
Wemos, introduced a civil society side event to the World Health Assembly (4) organized by the Medicus Mundi
International Network and the European “Health workers for all and all for health
workers” project together with a great number of civil society partners and
co-promoters such as the delegations of the EU, USA, Switzerland and Malawi to
the WHA.
The event was attended by over 80 WHO Member
States delegates, WHO staff and civil society delegates. Starting with case
stories of Code implementation, country leadership and civil society involvement
from source and destination countries and regions, the event led to a general
discussion and overall conclusions on the state of Code implementation and the
management of health personnel migration. As Marie-Paule Kieny, Assistant Director General of the WHO,
admitted, progress in
Code implementation is “painfully slow”. But what are the reasons that “stoking
up the fire for Code implementation” has become such a challenge?
“International recruitment of health personnel”
Do you live in a
country that faces a serious health workforce crisis? And, if yes, do you think
that international recruitment is a key factor for this situation? Or would you
say that action is rather required in fields such as the following:
- establishing effective health workforce planning, education and training, and retention strategies;
- strengthening educational institutions to scale up the training of health personnel and developing innovative curricula to address current health needs;
- adopting measures to address the geographical maldistribution of health workers and to support their retention in underserved areas;
- adopting and implementing effective measures aimed at strengthening health systems, continuous monitoring of the health labour market, and coordination among all stakeholders in order to develop and retain a sustainable health workforce responsive to the population’s health needs;
- adopting a multisectoral approach to addressing these issues in national health and development policies.
And do you expect
international cooperation to support these processes in your country by providing effective and appropriate
technical assistance, support for health personnel retention, social and
professional recognition of health personnel, support for training that is
appropriate for the disease profile of a country, twinning of health
facilities, support for capacity building in the development of appropriate
regulatory frameworks, access to specialized training, technology and skills
transfers, and the support of return migration, whether temporary or permanent?
You know what? It is
all in the Code! This whole list of strategies is directly quoted from it. The “WHO Global Code
of Practice on the International Recruitment of Health Personnel”, despite its
name and besides more specific sections dealing with international migration
and recruitment, provides an overall roadmap for health workforce
development. And, more important, this roadmap was agreed and unanimously endorsed by all
WHO member states in 2010.
One of the biggest
problems with the Code is its title. A simple solution would be to just
informally re-label and promote it as “WHO Code of Practice on addressing the health
workforce crisis”. In the words of Amani Siyam
from the WHO Secretariat: “The Code is a planting bed for many good seeds of
change. Just read it again!”
What cannot be counted does not count...
Dealing with the
global health workforce crisis in a systemic and comprehensive way, as proposed
by the Code, and promoting good practice in various fields related to developing
and retaining a sustainable health workforce has its risks. Health systems are
something “complex”, not easy to deal with. But national policy makers and
international agencies and donors prefer more simple proposals: simple, easy to
implement and internationally funded programs with clear, measurable and
time-bound targets.
What cannot be
counted does not count... and risks neither getting sufficient attention nor
funding. The spirit of our time not only led to the Millennium Development
Goals (and probably their successors), but also to some really strange global
health initiatives such as “One million community health workers in sub-Saharan
Africa by the year 2015” (5). If it was that easy...
What is simple is
wrong, but what is complicated is useless. Criticising unsustainable quick fix
solutions does not prevent us from admitting that one key strategy to address
the health workforce crisis is if fact scaling-up and transforming health
workers education, within a strong health system and based on sound regulation.
At this year’s World
Health Assembly, having followed the rather uninspired official debate in WHA Committee B on the
implementation of the Code, it took me really by surprise that the same Committee adopted,
in an ad hoc exercise (or call it as a result of “guerrilla diplomacy”) led by
Thailand and supported by many countries suffering from a health workforce
crisis, a resolution on “Transforming health workforce education in support of
universal health coverage” (Resolution WHA66/23). (6) The resolution, also
referring to the Code, urges WHO member states “to further strengthen policies,
strategies and plans as appropriate, through intersectoral policy dialogue
among the relevant ministries that may include ministries of education, health
and finance, in order to ensure that health workforce education and training
contribute to achieving universal health coverage”.
This does not sound so
bad, does it? And I was there in Geneva, focusing on Code implementation, and
not aware of what happened next to me. And it would have been so logical: the focus of this
year’s World Health Assembly and of much current global engagement in health is
on universal health coverage. So it makes sense that health workers are identified as a central element of that policy and that the UHC hype is used to refocus attention on the health workforce crisis.
In fact, it makes sense to link
the promotion of the Code with the efforts for scaling up and transforming
health workers education – and, why not, with the current global push for achieving
universal health coverage. If we focus too much on a particular aspect of the
health workforce crisis (migration and recruitment OR education) and the
related policies and strategies, we get lost in fragmentation. So rather let us
admit, that, in its core, it is all about the same. Let us leave our
silos and realize that are stronger walking together.
Code adopted - everything (nothing) achieved
At the civil society
side event to the World Health Assembly various speakers stated that, after the
tough negotiations before and during the 2010 WHA, the
adoption of the Code was for many the end of something instead of its
beginning: At that moment, there was great enthusiasm, but no preparedness to work with the Code, and no
proper mechanisms in place for its implementation. And it also rather looked
then as if those who promoted the Code considered the mission as
accomplished and dropped or downgraded the issue afterwards. This was at least
how the drastic staff cuts at the HRH unit of the WHO Secretariat in 2011 were
seen from the outside.
You can
also see this point differently: During the elaboration of the Code in 2010 the
language was diluted in that the mention of compensation
to source countries for the costs incurred in the formation of emigrated health
workforce was removed. So, when the Code was adopted, it might be that those
countries that expected cash were not happy just to get just kind (words).
Anyhow, mobilization of stakeholders, including civil society, for Code
implementation remained poor in most of the regions and countries. This is
definitely bad news, as Yoswa Dambisya stated in an editorial published right after
the World Health Assembly. He referred to the International Code of Marketing of Breast-milk Substitutes adoped by the
WHA in 1981 (7) and whose implementation
is still a great success: “This provides a lesson on the role of civil society
to galvanise countries into action, particularly with technical support of WHO.
Civil society has kept the code on breast milk substitutes alive and current
and generated pressure within countries to ensure that it is implemented. Is
this possible for the Code of Practice on International Recruitment of Health
Personnel? In theory it is achievable. The loss of health workers in countries
of highest health need is still a concern, and communities and health workers
have an interest in the issue, as it affects their rights and services.” (8)
It is time to
re-politicise the discussion on the devastating effects of lacking health personnel
in poor countries and regions and on the global dimensions of the national
health workforce crises. It is time to denounce and address the economic and
political determinants of poor health and poor social protection, such
as tax evasion and capital flight. Just read the great blog on “Human Resources
for Health – a bottleneck for Primary Health Care?” (9) written by my colleague
Remco van de Pas some days ago.
“It is everybody’s business to
move ahead with the Code”
When Marie-Paule Kieny,
Assistant Director General of the WHO, expressed the greetings of the WHO
Director General to the participants of the civil society side event, she said
that civil society involvement in the follow-up of the implementation of the
Code was well acknowledged by WHO. There was also a lot of praise for the European
civil society organizations that reported last year at the WHO Europe meeting
about Code implementation and the contributions of civil society in their
countries (10) and recently set up the “health workers for all and all for
health workers” project (11) for the
further promotion of the Code implementation in Europe.
Marie-Paule Kieny concluded:
“It is everybody’s business to move ahead with it.”
But what sounds
encouraging can also be a problem: If everybody is responsible, nobody takes
responsibility. If the number of countries speaking at the World Health
Assembly under a specific agenda item is a measure, the Code failed: only 14 countries
took part in the official discussion of the Secretariat’s report, and whole WHO
regions such as Africa (represented by Burkina Faso) and Europe (represented by
Ireland) confined themselves to weak general statements.
So it was good to
hear from representatives of WHO and some countries that they are still
committed to implement the Code and that there are in fact plans and
perspectives to re-launch implementation at a higher level. These plans include
concrete steps that make sense, such as:
- improving statistical tools for national health workforce planning and forecasting based on the OECD observatory;
- improving the “National Reporting Instrument”;
- organizing technical regional meetings.
Key elements not
properly addressed by the World Health Assembly are the on-going lack of
capacities at all levels and the problem that country information on Code
implementation gathered since 2010 through the National Reporting Instrument
developed by the WHO Secretariat is not openly accessible. (12)
Anyhow, even if it is
“everybody’s business” to move ahead with the Code, the main responsible are
the WHO and its member states. It is up to them to show committment, ownership and
leadership on the Code. There is much at stake, as Switzerland stated at the
Assembly: The successful implementation of the Code is a question of credibility
of the WHO, especially as the Code is one of the few regulatory instruments developed
and adopted by WHO over the last years. This directly refers to the statement
by the European “health workers for all and all for health workers” campaign in
the official discussion: “The success or failure of its implementation will be
seen as a case study for the capacity of WHO – and its members – in the field
of global standard setting and regulation. This links the technical issue of
Code implementation with the overall issue of WHO reform and the role of WHO in
global health governance.” (13)
Conclusion of the WHO
Secretariat’s report to the WHA: “The health workforce crisis is a global,
multidimensional challenge. It requires a comprehensive global strategy to
transform the production of health workers, encompassing labour market analysis
as well as the transformation of education and training of the health
workforce, at national and transnational levels. It is essential that countries
wanting to improve access to health care meet the challenge posed by shortages in
the health workforce. Renewed approaches to the health workforce crisis will
therefore be critical for moving towards universal health coverage.” - There is nothing
to add to that one.
Basel, 12 June 2013,Thomas Schwarz, Executive Secretary of the
Medicus Mundi International Network, host of the WHA civil society side event on Code implementation for the European project “Health workers for all and all for health workers” and a broad coalition of civil society partners and co-promoters.
........................
Notes
- WHO Code of Practice: see http://www.who.int/hrh/migration/code/full_text/en/index.html
- The health workforce: advances in responding to shortages and migration, and in preparing for emerging needs. http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_25-en.pdf
- Quoted from the invitation leaflet for a civil society side event to this year’s World Health Assembly: WHO Global Code of Practice on the International Recruitment of Health Personnel: Stoking up the fire for Code implementation. Geneva, 22 May 2013, see www.bit.ly/wha66-code
- See above
- One Million Community Health Workers until 2015 (this is NOT a satire) http://www.medicusmundi.org/en/mmi-network/documents/newsletter/201304
- See http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R23-en.pdf
- See http://www.who.int/nutrition/publications/infantfeeding/9241541601/en/
- No Universal Health Coverage without health workers: Putting the Global Code back into the spotlight. YM Dambisya in: Equinet Newsletter http://equinetafrica.org/newsletter/index.php?issue=148#1
- Published in the MMI “Get involved in Global Health!" blog on 7 June 2013: http://getinvolvedinglobalhealth.blogspot.ch/2013/06/human-resources-for-health-bottleneck.html
- Progress
to date: actions by civil society. Chapter in the WHO Europe policy brief "Implementing
the WHO Global Code of Practice on International Recruitment of Health
Personnel in the European Region” discussed at a technical briefing during the WHO Europe Regional Commitee
meeting in 2012.
http://www.euro.who.int/__data/assets/pdf_file/0013/173020/BRIEF_NRI_annex_060912VeryFinal.pdf - See http://www.healthworkers4all.eu
- Implementation of WHO Code of Practice: Leadership, accountability and capacities are key! Joint statement by Medicus Mundi International, the People's Health Movement and the European campaign "health workers for all and all for health workers" http://bit.ly/11sXMX4
- See joint statement, above
This article is not only well-written, but is informative and calling for action in a very subtle manner. Just one word: excellent!
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