The benefits of community health workers, how to entice doctors to rural areas, matching supply to demand, and the role of civil society are just a few of the topics we’ve been discussing this week at the Third Global Forum on Human Resources for Health in Recife, Brazil. The Forum is the biggest international event dedicated to the health workforce, with over 2,000 people including government Ministers, officials, NGOs, Trade Unions, health workers and academics in attendance.
And it’s timely. According to a report launched by the World Health Organisation at the event, the global shortage of health workers is even more critical than previously thought, and is set to rise from 7.2 to 12.9 million by 2035, with the most acute shortages to be felt in sub-Saharan Africa.
Yet, one issue that has been lurking at the side-lines, the proverbial elephant in the room, is how we should address the huge global health inequalities caused by the migration of health workers from poor to rich countries. This movement has drained some of the world’s poorest countries of their health workers, with devastating consequences for the people who need their care. Africa bears 24% of the global disease burden, yet has only 3% of the health workers with which to fight it, and the financial loss to sub-Saharan Africa is estimated to be in the billions.
The recognition that the health systems of the poorest countries are undermined by the recruitment of their health workers by high income countries is not new. Back in 2006 researchers Mackintosh and Mensah estimated that the money saved by the UK through the recruitment of Ghanaian health workers may have exceeded that which they gave to Ghana in aid for health. Various initiatives and codes including the 2010 Global Code of Practice on the International Recruitment of Health Personnel have been established to address exactly this issue. Yet while the Code provides guidance on ethical recruitment, the rights of health workers and strengthening health systems, one obvious element is missing; that of financial compensation. During the negotiations, some source countries did make calls for its inclusion, but these were ignored.
It would be wrong to say the Third Global Forum completely overlooked the brain drain. I heard it mentioned a few times, and one side session was dedicated to the issue of migration. Yet overall, from what I heard (and with several side events happening at once it’s true that I didn’t hear it all), my impression is that the issue of compensation as a response to the brain drain didn’t get anywhere near the attention it deserved.
So what’s the problem? Whenever I’ve spoken about it this week, the response seems to have either side-stepped the question or raised concerns. Those concerns mainly fall into the following categories:
- It’s complicated: Yes it is. There are numerous questions about what compensation would look like in practise. Firstly, who should be compensated? Not all health workers are trained at public expense and with the economic crisis the lines between source and destination countries are becoming increasingly blurred. How do we calculate how much is owed? Should it be based it on the costs of training the health workers or an estimation of the value of their work? How should this be administered? For example through bilateral transfers or a fund. There are many legitimate questions about the practicalities of compensation, and if we are to adequately address the issue, further robust research is certainly needed.
- It’s the choice of the individual to migrate, not the countries they migrate to: Well, migration is certainly a right. But when you are a health worker faced with low pay, limited training opportunities, sub-standard working conditions, a lack of medicines and an overwhelming workload, it does call the notion of choice into question. This also ignores the fact that a number of countries, including the UK for a number of years, pursued an active policy of recruiting from abroad as a cheaper alternative to adequately resourcing their own workforces.
- It is anti–migration: There are concerns that drawing attention to the brain drain feeds an anti- immigration agenda. These sit alongside fears that an obligation to compensate could result in restrictions on migration, and therefore remittances, and punish those who wish to exercise their right to migrate. I can certainly see why this might be a worry, and as a former immigration advisor and advocate for migrant workers, this is definitely something I want to explore further. I do however reject the idea that the call for compensation inevitably fuels the anti-immigration agenda. In contrast, highlighting the enormous contribution that migrants have made as doctors, nurses and surgeons, providing vital lifesaving care when we are most in need, seems to me the antithesis of any anti-immigration rhetoric.
- It is dangerous to talk about compensation when the public is already sceptical of aid: Now this I just don’t understand. Surely scepticism about aid stems from a misunderstanding about the direction in which resources flow? No wonder people are sceptical if, at a time of austerity when public services are being cut, benefits are shrinking, and the majority of British people are being punished for the actions of the wealthy few, the idea that we are handing out aid to other countries and getting nothing back continues to be peddled. Exposing this myth of who is aiding whom and highlighting the numerous ways that wealthy countries benefit at the expense of the poor – from the exploitation of natural resources to inequitable tax and trade policies – can surely only help to make the case that the UK must do more to fulfil its international obligations.
- It is unrealistic – The UK and other wealthy countries’ will never agree, therefore we look silly asking for it: Well, it’s not an easy ask certainly. But campaigning is not just about tackling the things you know you can easily win. Sometimes we have to take on bigger issues that shift the parameters of the debate, even when concrete progress can seem far away. Ignoring something because we think those in power won’t like it makes us complicit in the problem, which feeds into the final point;
- It’s politically sensitive: It certainly is. And I would hazard a guess that this is the real reason for its absence. Of course destination countries don’t want to have conversations that are potentially expensive. And, as above, when these counties are currently providing aid – however inadequate in terms of their real ‘debt’ – to both governments and NGOs it’s easy to see why this is an uncomfortable conversation to have. But as civil society isn’t our role to challenge power, not let it dictate our actions?
It’s very clear there needs to be greater research, evidence and thinking on this issue of compensation, and I am a long way from believing I have all the answers. But I am sure that we cannot continue to ignore the huge global health inequalities or pretend they are inevitable.
It is unacceptable that the health systems of the poorest countries suffer due to the actions of the richest. It’s time to revive the debate about compensation. It’s just a shame we didn’t really get started in Recife.
For more information on the health worker crisis read our report here.
Click here to act to end the health worker crisis.