Monday, 2 April 2012

Negotiating global health at the World Health Organization: The case of the Global Code of Practice on the International Recruitment of Health Personnel

Three theses by Remco van de Pas, Wemos
1. The Global Code of Practice on the international Recruitment of Health Personnel (COP) is a successful tool of modern global health diplomacy and demonstrates how health governance with a different network and range of actors can be conducted under coordination by WHO.

The COP has never been intended to be a legal treaty like for instance the Framework Convention on Tobacco Control. World Health Assembly (WHA) resolution 57.19 in 2004 asked the WHO to develop a non-binding code. Despite discussions now and then related to the “brain drain” of migrating health personnel on the financial costs for source countries, the savings by higher income destination countries and the need for consecutive compensation, member states agreed that a non-binding code, a soft diplomatic and legal tool, that outlined the problem is sufficient. The human rights of migrating health workers as well as the right to health (care) of populations, (self)-sustainability of health systems, ethical aspects of health worker recruitment, data and information sharing, monitoring and reporting requirements were eventually all included in the COP.

The development of the COP was done under good coordination by the (former) WHO HRH department, with leadership from both lower and higher income member states like Norway, the Filipinas, South-Africa and Kenya. The Health Worker Migration Initiative, a partnership by Realizing Rights, The Global Health Workforce Alliance and the WHO HRH department facilitated input from CSO, academia and professional associations in shaping the COP that was finally negotiated and agreed upon during the WHA in 2010. The COP should be seen as a ‘dynamic’ document that will remain on the agenda of the WHO, and is able to generate commitment and understanding on the scope, dynamics and impact of migration for countries, including the 57 ones with crucial health workforce shortage. It’s encouraging that both formal national authorities report can be submitted to WHO, as well as ‘other’ stakeholder reports, like CSO or labour unions input.

2. The COP considers (global) health workforce development and health systems, but fails to include other crucial determinants that have an impact on migration and the development of health systems in both source and destination countries.

To begin, the health workforce shortage in Sub-Saharan Africa is only in about 15% related to external migration. There is an estimated gap of 4.5 million health workers to attain the MDGs. In many countries, lack of education opportunities, macro-economic frameworks and fiscal limitations on public expenditure, rapid urbanisation and domestic migration are key issues that limit a sustainable growth of the health workforce in the public sector.

Health worker migration is not only taking place between rich and poor countries; but also from the public to the private sector, from rural to urban areas, from primary to secondary care health centres, from addressing basic “acute” health needs to taking care of “chronic” diseases. Health workforce mobility is taking place within regions (E.g. Europe, Southern-Africa, South-East Asia, and the Middle East). The COP doesn’t provide guidance for these labour, economic, migration and development determinants that are the key structural drivers of health inequity in a rapidly changing world where the division is less so between developed and developing countries, but rather between the have and have-nots between and within countries.

The health workforce becomes a relative scarce public good that within a liberalised labour market will flow where the demand and money is. In that sense, it is prone to mechanisms similar to those of other labour markets, like the garment and electronic industry, where the companies invest where the lowest labour costs are.

From an ethical perspective it’s strange that we “prevent” health systems in the EU countries from recruiting health workers and “protect” our domestic labour market from this cheap labour, while at the other hand we flood” developing countries with expensive technical experts, NGO workers and consultants. Countries like the US, Canada and Australia whose public systems and economies are traditionally build on migrants have understandably different opinions when it comes to accepting health workers willing to work in their countries. Similarly, many health workers from source countries feel also this rather “paternalistic” impediment to migrate. Why can’t they be part of the global economy and build a better living for their family with the remittances send home that can be used for health sector investment? When the time is ripe, they might be willing to return to their home country with all their experiences and skills.

Within Europe, with its demography of an aging population and with low-fertility rates, we’ll probably require in the future migrant health workers to work in cure and care. We have to look forward and also look into benefits and need for future health worker migration, with a focus on sustainability and respecting rights. It must also be clear that in Europe most migration is now between EU countries itself (as a result of the Lisbon treaty) and that these are mostly auxiliary and chronic care health workers and not the “formal” workforce talked about in the COP. In conclusion, the WHO COP itself must be seen in a geo-political context and times where we (and I mean with we here the EU Member States of WHO) need to rethink our rather prescriptive policies on health systems, development cooperation and human rights, while at the same time we show ambivalence via free trade and other preferential (e.g. taxation and export) agreements with low income countries that eventual limit their public sector growth.

Besides a human drain there is an additional natural resources drain and capital flight from the global South to the North that should be considered when talking about “sustainable health systems”.

3. The ongoing WHO reform demonstrates how important global health has become. Member states currently position themselves in what the future role of the organisation should be.

Health and health care have increasingly become globally important over the last decades. While first international health was mainly an issue about poverty-related infectious diseases in developing countries that required assistance by an institution like WHO; it is more and more recognised as a key issue for global stability, security, economic growth and the realisation of human rights and human dignity.

The health care sector alone involves trillions of dollars of expenses and is itself a strong global economic driver. Global health is the arena where a health security (e.g. the prevention of pandemics), an economic (e.g. the impact of the NCD epidemic for countries) and a human rights (see the discussion on health equity and universal health coverage) agenda enforce each other.

Global health has become too important to be addressed mainly under the leadership of the WHO. Is a UN agency that consist of 194 member states the right platform to negotiate global health issues, like health worker migration? From a human rights and democratic viewpoint, I would argue that is still the case, and that WHO should remain the coordinating authority on international health, as outlined in its constitution. It is and remains the unique institution that is authorised to set global health standards and regulations.

However, for several countries WHO should not become too important of a platform for global health diplomacy, and they rather work via bilateral and other multilateral channels, e.g. via G8 or G20 health development frameworks, under the World Economic Forum or via the more than hundred global health initiatives. WHO funding itself is for about 75% dependent on voluntary contributions, which reflect also donor interests, both from member states as well as philanthropies like the Bill and Melinda Gates Foundation. This bilateral influence of multilateral institutions is described as “Trojan Multilateralism” by Devi Sridhar and colleagues.

Instead of a conclusion

Two years after the adoption of the COP, member states are encouraged to send their first implementation report before 31st of May 2012 to the WHO secretariat. This HRH unit of WHO is currently reduced due to financial austerity, reduction of staff and shifted priorities from member states and donors. In times of economic difficulty, domestic public sector cuts and health security concerns like Avian Flu and other viral disease outbreaks, its is not so strange that focus is less on human rights and equity issues. Health workforce migration is hence not in the centre of the global agenda, and many global health initiatives now promote to work via task-shifting and inclusion of informal community health workers.

We should however look beyond current short-term political goals, and consider longer term health workforce requirements for health systems within Europe as well as in countries with crucial shortages. In each member state separately, and at EU level, we should ask to what extend WHO matters for global health policies and norm setting. We might become more dependent on foreign health workers then we can envisage now, hence it is important that we provide WHO with enough resources and mandate to fulfil its tasks regarding health worker migration, regulations and to link this with the structural determinants of health development.

Input by Dr. Remco van de Pas, Wemos, member of the Medicus Mundi International Network, to an Action for Global Health conference in Berlin, 26 March 2012


  • The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis. Edward J Mills et al. in: BMJ (2011)
  • No, British Medical Journal, the emigration of African doctors did not cost Africa $2 Billion. Michael Clemens, CGDev,
  • The WHO Global Code of Practice on the International Recruitment of Health Personnel: The Evolution of Global Health Diplomacy
    Allyn L. Taylor and Ibadat S. Dhillon in: GHG (2011)
  • Stemming the Brain Drain — A WHO Global Code of Practice on International Recruitment of Health Personnel
    Allyn L. Taylor, Lenias Hwenda, Bjørn-Inge Larsen, Nils Daulaire in: NEJM (2011)
  • Advancing the Global Health Agenda
    Ilona Kickbusch in: UN Chronicle, December 2011
  • Trojan Multilateralism: the changing face of global cooperation
    Sridhar D., Woods N. Paper presented at the 52nd Annual Convention on International Studies, 16th March 2011, Montreal, Quebec. 
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