Europe concerned about the mobility of health personnel

How can European countries, the Netherlands included, contribute to the creation of a sustainable health workforce worldwide? What can we do within our own borders, and how can we help ensure countries beyond Europe have the qualified health providers they need to build up their public health systems? But beyond that, how should we address the growing inequality in access to health providers in Europe? These are thought-provoking questions, and the first two are my particular focus at Wemos – but the third one is emerging.

By Linda Mans*

Access to a health provider is an essential criterion of Universal Health Coverage (UHC), a concept (and term) formulated by the World Health Organization (WHO) and defined as access to health care (prevention, health promotion, treatment, rehabilitation and palliative care) for all people without financial risk to themselves. It will also be the theme of the third Global Forum on Human Resources for Health (HRH), held in November 2013. Organized by the WHO and the Global Health Workforce Alliance (GHWA) to highlight the urgency of UHC, the Forum will concentrate particularly on what national and regional parties can do to build a sustainable and fair global health workforce.

The Oslo Consultation on Human Resources for Health for high income countries

A first step in this direction was taken on 4 and 5 September 2013, when representatives of 14 European countries convened in Oslo. Among those attending were WHO, GHWA, WHO/Europe, policy makers, researchers, professional organizations and civil society organizations such as Wemos. As the coordinator responsible for the European Health workers for all and all for health workers (HW4ALL) project, I had been invited to shed light on the role of civil society organizations. In the HW4ALL project, Wemos and organizations from eight other European countries have partnered to raise awareness about the WHO Code of Practice for the International Recruitment of Health Personnel. Efforts include translation of the WHO Code for practitioners and the facilitation of dialogue between the actors involved in training, recruiting, retaining and deploying health care workers. By working together to identify opportunities and avenues for promoting a sustainable and fair national health personnel policy, this multi-stakeholder approach has enabled us to join forces and pool our professional expertise to stimulate policy and activities keyed to this objective.

During the Oslo conference, the central question was how the migration and mobility of health personnel in Europe – which exploded on the back of the economic recession – is impacting the availability of qualified health providers for European citizens. Notably, participants steered clear of any discussion of European funding distribution policy, apparently feeling that financial debates about how public funds should be spent and how much money is needed to support a sound and adequately staffed public health system ought to be left a national affair. However, I doubt whether a discussion limited to purely practical aspects, with no consideration of budgetary responsibilities, will get us very far.

The Finnish delegation explained that a future-proof national health plan will only come within reach if different ministries (health, employment, finance and foreign affairs) can all be brought to the same table. This would enable countries to stake out health personnel policies that are only minimally dependent on international influx, that are geared towards the welfare of an ageing population and that will not crack under austerity measures.

WHO Code of Practice for the International Recruitment of Health Personnel

Representatives from Norway and Ireland demonstrated that the WHO Code of Practice for the International Recruitment of Health Personnel can provide an anchor for a coherent health workforce policy. Both countries have implemented national measures to ascertain how many doctors and nurses need to be trained and in which specializations. In making these countries less dependent on foreign health personnel, these measures also ensure they won’t be exacerbating the global and regional brain drain. Alongside this focus on education and training, these countries are also looking at how to retain their own health personnel, for example through education programmes and salary provisions. And if an injection of foreign health personnel is needed, they make agreements with the countries of origin regarding the duration of stay, employment conditions, training options and workers’ return. Additionally, Norway and Ireland have both adopted foreign policies that aim to help low-income countries strengthen their own health systems, including measures and investments keyed to health personnel. These two member states have played an active role in promoting this topic at the WHO. At home, regular meetings on global public health issues between officials from the respective ministries of health and foreign affairs enable them to coordinate with each other and thus ensure the coherence of their policy interventions.

These examples dovetail with the next step of the HW4ALL project, which will shortly be presenting an online platform where policy-makers at different ministries and health professionals will be able to share examples and experiences of good practices with each other. For example, the retention of health personnel and achieving an equal workforce distribution are a key priority for various European countries. In particular, they are concerned that people living outside urban areas will no longer be able to find doctors as these have all moved to the cities or abroad. Denmark has introduced a system in which during their internship medical specialists are deployed to a particular region for a certain period, giving them a look behind the scenes at different institutions and assuring Danish citizens access to good care. The online platform will offer a space for sharing and discussing measures and interventions like these and for different disciplines and countries to learn from each other.

Fundamental debates on the future of welfare and health care are essential

At Wemos, one of the main questions we are looking at is how we can ensure that everyone in the Netherlands and, indeed, all of Europe, continues to have access to a qualified health provider even in these times of government cutbacks. Already, some European researchers have been sounding the alarm. At the European Public Health Alliance (EPHA) conference that also took place during the first week of September in Brussels, the Romanian State Secretary of Health related how the conditions dictated by the International Monetary Fund (IMF) and the European Commission in 2009 have led to the disappearance of many clinics in rural Romania. What’s more, following salary cuts in 2011, more than 2,000 doctors registered for international recognition of their credentials in order to be able to immigrate and work in Western Europe.

Besides learning from one another’s health personnel policies, Wemos believes financial choices have to be made that reinforce governments’ obligation to provide good health care, both at national level and throughout Europe. This calls for fundamental debates about the future of welfare and health care, centring on the need for solidarity and equal access to care. Crucially, it will also require a coherent approach by the European Commission and EU, and the national ministries of Health, Welfare and Sport, Economic Affairs, and Foreign Affairs. And this is precisely what Wemos is working to achieve.

*Linda Mans, Wemos, project coordinator of ‘Health workers for all and all for health workers’
linda.mans@wemos.nl, www.wemos.nl, www.healthworkers4all.eu/

Economic governance for European health

Governance for (global) health starts at the national level. This concept is elaborated by the WHO in its publication Governance for health in the 21st century. The new governance for health is strongly rooted in concepts like Health in all Policies, multi-stakeholder approaches and democratic decision making for health. But aren’t we fooling ourselves with these trendy approaches? In a sense political philosopher Antonio Gramsci already promoted this governance model when he wrote about an ‘extended state’ that consists of media, civil organizations and labor unions exerting their influence on policy makers and politicians. Extended state actors are crucial in shaping the ‘cultural hegemony’, the social, cultural and political values, that shape society and state governments.  To be clear, the cultural hegemony is not something that emerges by consensus. No, it is shaped by political thinking, debate and ‘sometimes’ bitter fights.

And this is where the comparison between  ‘depoliticized’ multi-stakeholder approaches and Gramsci’s concept of a ‘political society’ diverges. Do the new governance for health and health-in-all-policies concepts allow for the strengthening of political societies for health or is its ‘the-world-is-flat” notion merely a form of dominant hegemonic leadership?

I wonder what Antonio Gramsci would have thought of current governance for health at the European level. Last week, the European state of public health was discussed at the 4th annual conference of the European Public Health Alliance. The title’ Brave new world, inclusive growth and well-being or vested interests and lost generations’ describes perfectly what is at stake. The first day (with an impressive line-up of presenters) focused mainly on health systems reform in European member states, protecting access to services during austerity measures, addressing inefficiencies in health systems, and at the same time investing in sustainable long term (public) health programs. It is the second day that I like to highlight, as here the impact of the current EU economic framework for health has been discussed. This reform of the European economic governance, part of the EU 2020 growth strategy and also known as the European semester, has a thorough and structural impact on public health and health care in all member states. The entire process and mechanisms of this new economic framework and EU macro-economic surveillance can be found in this excellent EPHA briefing from April 2013.

Alongside this European semester, a number of countries (Greece, Portugal, Spain, Ireland) receive financial assistance (bailout funding) from the Troika (being the European Commission, European Central Bank and International Monetary Fund). These countries are subject to specific reforms of their public expenditure and fiscal frameworks. This is typically done under an MoU between a countries government and the Troika. The (first) effects of the economic crisis and related austerity measures on public health outcomes in these and other European countries has been presented in in the Lancet earlier this year, as well as by WHO EURO.

Rita Baeten from the European Social Observatory explained during the conference clearly how the EU macro-economic surveillance has profound impact on the development of national health care systems, without Ministries of Health being involved so far!  It is eventually the European ministries of finance, that within the Economic and Financial affairs (ECOFIN) council ‘recommend’ on the macro-economic structural reforms and fiscal consolidation of countries state budgets. Each year in November an Annual Growth Survey (AGS) is published that gives general guidance for EU member states for measures to ‘ensure financial stability, fiscal consolidation and action to foster growth’. Regarding health care the AGS 2013 mentions “reforms of health care systems should be undertaken to ensure cost-effectiveness and sustainability, assessing the performance of these systems against the twin aim of a more efficient use of public resources and access to high quality healthcare.” Although there is mention that social protection systems should be protected and strengthened, there is no reference to (health) inequalities. Seemingly the principle of reducing social inequalities has to be sacrificed in the times of financial crisis.  

Since 2011 the EC and Council produce Country Specific Recommendations (CSR) on macro-economic sustainability. In 2013, 16 CRS have been made. E.g. for the Netherlands, related to its health system, the following recommendation was made: “Implement the planned reform of the long-term care system to ensure its cost-effectiveness and complement it with further measures to contain the increase in costs, with a view to ensure sustainability. While the plans entails substantial budgetary savings, additional measures are likely to be necessary to fully restore the long-term sustainability of public finances.” An overview of the CSRs and its relation to health can be found in this EPHA policy analysis from Sept. 2013.

 

So, some key questions can be asked about the governance of the European Semester in relation to health:

• What is the legitimacy of Ministers of Finance to “strongly recommend” on the content and reform of the health system at national levels?
• Is the treaty of Europe not breached here; as health systems ought to be under national competency and responsibility of member states, not that of the EU. The treaty on the functioning of the European Union mentions in article 168 the responsibilities of the member states and the EU in protecting and improving public health.
• There seems hence to be a contradiction between different EU policies “fostering sustainable growth” and creating “social cohesion and protection”.
• The transparency of the process is unclear. Where do these recommendations come from? It seems mainly from the EC, probably influenced by the thousands of corporate lobbyists in Brussels, in addition to a selected group of people in and around the ECOFIN council (in which the EUROGROUP is currently chaired by the Dutch Minister of Finance). The European Parliament, national ministers of social and health affairs and civil society groups have had so far little influence in its directions. Partly because the EU economic framework evolves with fast changing targets. Especially the fact that the European Parliament has so little power in relation to the European Semester indicates the “democratic deficit” existing in current Europe.

The European Public Health Alliance has since 2013 analyzed these developments and does it best to be engaged and influence this process. Other European bodies, such as the Social Protection Committee and the Employment, Social, Health and Consumers affairs (EPSCO) Council also have a role in co-legislating the AGS and CSR. More transparency by these bodies and involvement of civil society organizations has occurred, but impact so far has been negligible. Thorough coordination and cooperation between social movements is required as decisions take place both at national and European level. 

Rita Baeten made it clear in her final remarks: “The house of Europe is built on the basis of liberal economic principles such as fiscal consolidation, GDP growth, small public expenditures and an internal open market as to be competitive with other emerging economies”.  In times of economic crisis, we see the true face of the current European Union and its decision makers. It values its economic interests simply higher than social cohesion by and for European citizens (and those that live undocumented in the region).  Moreover, didn’t some economist say ”never let a good crisis go to waste”? We see an assault by those with commercial interests on our social systems, and, at the EU level, we lack the true democratic possibilities to address this. We must demand our national governments and health ministries not only to fulfill their responsibilities in public health and access to health care but also to reform the governance model of the EU, and challenges this structural democratic deficit. The current EC and EU structures favor economic goals over societies’ goals.  How much longer will the European people accept this? The current European cultural hegemony is in crisis. Is there enough mass for an alternative hegemony?

Remco van de Pas, Wemos foundation
remco.van.de.pas@wemos.nl