A renewed agenda for HRH, with some grey areas

The Third Global Forum on Human Resources for Health has just concluded, and I have finally arrived at home, quite happy that the issue of human resources for health had a space of renewed attention within the international community, but also that a renewed agenda has been forged and a consensus has emerged in this area (see "Recife Political Declaration on Human Resources for Health"). As often occurs to me when I walk out of large international discussions, however, I left the Forum with a few question marks in my head, related to the actual meaning of the consensus emerged.

Everybody, for example, agreed that there is an established consensus on the fact that political will is essential for HRH development. I always feel lost in this statement, as I keep asking myself  which kind of political will we are referring to? For me the critical question is: if this political will actually existed, would it incorporate the equity dimension? As the equity dimension cannot be assumed as a natural part of any political will, it seems to me that saying that the latter is central leaves the political issue undefined.

In addition, the political will of a Minister of Health can do little when confronted to broader determinants such as the lack of development in rural areas, or a low negotiating power with regards to migration or, even more substantially, fiscal space constraints. Can health systems in low-income countries be expected to do substantial changes out of political will, or should this issue be strongly linked to aid levels and fiscal space discussions (which were not prominent at the Forum)? Or can southern European Health Ministers truly invest in their health workforces in the frame of the constraints posed to them by the Fiscal Compact?

The challenge of the growing health workers migration was also prominent at the Forum and acknowledged as an area of consensus. However I wonder if one can truly say that there is also political consensus on the need to implement the WHO Code of practice on the International Recruitment of Health Personnel: emerging countries committing to Universal Health Coverage are obviously expanding their health services and are therefore, in some cases, hunting - also abroad - for health workers to staff their new facilities (I think of Brazil but the US may go in the same direction). On the contrary, other countries perceive the remittances sent back home by their health workers abroad as crucial (it is the case of Philippines, but also of some African countries), although I am not aware of any conclusive evidence saying that the value of those remittances overweight the negative impact brain drain has on the health system. This leads to a paradoxical situation where Canada, with a nurse/patient ratio of over 8 /1000 affirms that they do not have enough (and look for them in the Philippines, with a bilateral agreement), while the Philippines, with a nurse/patient ratio of 1.7/1000 affirm they have a lot, and are therefore ready to export them, as was suggested in the session dedicated to migration. In this complex political environment, more tricky issues connected with brain drain phenomena - like for example compensation to countries of origin, or the internal brain drain from the public sector by NGOs and by vertical programmes - remain out of the picture.

Another consensus statement which emerged from the Forum relates to the need to strengthen community and mid-level health workers, their full integration within health systems in the frame of task-shifting processes. The prevailing reasoning behind this statement seems to be that lower cadres are more cost effective. Cost effectiveness must of course be a central part of the debate, but not alone, and I wonder if an appropriate addition would be to think how it is also ensured that these cadres become agents of social change. More and more, in fact, these health workers will have a role as promoters of equity, dealing with the prevention of non-communicable diseases and the social determinants of health, and they should be able for example to critically understand the impact of food and tobacco industry on health.

Other "grey areas" for me include the stewardship role of the state in promoting human resources for health for Universal Health Coverage, or the role civil society is called to play in this frame. Question marks remain in my head...

Giulia De Ponte, Amref Italy, advocacy coordinator of the Health workers for all and all for health workers project (HW4ALL), was in Recife at the Third Global Forum on Human Resources for Health. Other voices of HW4ALL project members from Recife: presentations by Linda Mans ("A sustainable health workforce starts at home") and Remco van de Pas ("Towards sustainability in financing HRH"), blog "The Health Worker Crisis" by Nathalie Sharples and blog "Time to blossom? Renewed partnership of WHO and GHWA" by Linda Mans.