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.
- 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
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.
- 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