[pic] | COMMISSION OF THE EUROPEAN COMMUNITIES |

Brussels, 12.12.2005

COM(2005) 642 final

COMMUNICATION FROM THE COMMISSION TO THE COUNCIL AND THE EUROPEAN PARLIAMENT

EU Strategy for Action on the Crisis in Human Resources for Health in Developing Countries

TABLE OF CONTENTS

1. Introduction 3

2. Regional Dimensions of the Crisis in Human Resources for Health 4

3. Analysis of Key Issues 5

4. Areas for European Action 8

5. Financing 8

6. Next Steps 9

ANNEX 1 11

ANNEX 2 12

COMMUNICATION FROM THE COMMISSION TO THE COUNCIL AND THE EUROPEAN PARLIAMENT

EU Strategy for Action on the Crisis in Human Resources for Health in Developing Countries

1. INTRODUCTION

IN MAY 2005, THE EUROPEAN COMMISSION (EC) ADOPTED A COMMUNICATION ENTITLED “A EUROPEAN PROGRAMME FOR ACTION TO CONFRONT HIV/AIDS, MALARIA AND TUBERCULOSIS THROUGH EXTERNAL ACTION” – COM(2005) 179. THE PROGRAMME FOR ACTION IDENTIFIED THE LACK OF HEALTH WORKERS IN POOR COUNTRIES AS A MAJOR BARRIER TO PROGRESS in tackling the three diseases and to progress towards MDGs 4, 5 and 6. The Council (24 May 2005) welcomed the analysis in the Action Plan, and asked the Commission to present a Communication identifying innovative responses to the human resource crisis.

The crisis in human resources for health is a global one, with 75 countries having fewer than 2.5 health workers per 1000 population, which is the minimum number estimated as necessary to deliver basic health services( 1 ). The reasons for the crisis in human resources are complex relating to internal and external factors, with lack of training, poor working conditions and lack of incentives helping to push health workers away from the areas with greatest need and better opportunities in urban areas, in wealthier neighbouring countries or in resource rich countries acting as pull factors for migration. Skilled worker migration, which impacts on many aspects of development, is addressed in two Communications on migration from the EC. The first( 2 ) considers the impact of migration on development, the second( 3 ) identifies concrete orientations to minimise the negative impact of skilled worker migration and enhance its potential to build human resource capacity. This Communication on human resources for health, builds upon these concrete orientations.

Africa is the continent facing the greatest shortage of health workers. This Communication draws upon the EU Strategy for Africa( 4 ), which includes proposed actions to accelerate progress towards the MDGs by putting people at the centre of development. However, the focus on Africa is set within the context of the global crisis of human resources for health, recognising the problem in other regions. Asia, as a major producer and exporter of health workers, is facing significant internal health worker distribution problems, which are limiting access to services by poor populations. In the Caribbean, the quality of service delivery is threatened by the migration of health workers to the USA.

This Communication will serve to outline the European Union’s and the European Commission’s coherent and coordinated response to the planned decade of action on human resources proposed by the 57th World Health Assembly (Resolution WHA 57.19), which begins in 2006.

2. REGIONAL DIMENSIONS OF THE CRISIS IN HUMAN RESOURCES FOR HEALTH

In its report on the Challenge of Human Resources for Health in Africa, the Joint Learning Initiative (JLI) on Human Resources( 5 ) highlights the scale of the problem. The impact of the crisis in greatest in Africa, where progress towards the Millennium Development Goals (MDGs) is slowest. The health status in some countries is deteriorating (between 1970 and 1999 life expectancy is estimated to have declined in 17 countries in the region( 6 )). The JLI report highlights that Africa has the highest disease burden per capita of any continent (25% of the global burden of disease for less than 10% of the world‘s population) and yet it has the lowest number of health workers (0.8 workers per 1000, compared to 10.3 per 1000 in Europe). At the same time, 80% of the population has no access to social protection coverage. In addition to concerns about numbers of health workers, there are also serious concerns about the quality and productivity of the existing workforce( 7 ).

High health worker mobility, lack of decent work opportunities, lack of social protection coverage, limited incentives, particularly to work in under-served areas and with poor people, combined with high global demand for health workers, has created a severe crisis in health care provision for the poor. For this reason, adequate training and promotion of decent working conditions and opportunities for health workers requires special attention, if globalisation is to work positively for poverty reduction and if negative impacts on poor people is to be minimised( 8 ).

However, some countries have increased health worker training specifically for the export market. India, the Philippines, Cuba and, increasingly, Indonesia and China, are responding to the global demand from the international market for health workers by increasing health worker production and supporting outward migration. This policy is sometimes pursued despite domestic shortages and inadequate access to services for the poor (the Philippines, which operates a managed migration policy and is the largest source of registered nurses working overseas although its own health service has suffers entire nursing units migrating, leaving hospitals understaffed, and is now facing the problem of doctors retraining as nurses in order to migrate to higher paying jobs, particularly in the USA( 9 )).

There is a global market for health workers, but it is a distorted market, shaped by global inequity in health care provision and the capacity to pay workers, rather than by health needs and the burden of disease.

The current crisis in human resources is an acute manifestation of a chronic problem, with HIV/AIDS and the challenge of delivering ambitious programmes to tackle poverty diseases having exposed systemic weaknesses in health care delivery. The international community’s commitment to accelerate progress towards the Millennium Development Goals now faces a barrier imposed by limited human resource capacity. MDG progress will be difficult to achieve without increased investment in the health workforce. Demand from resource-rich countries for health workers remains high: the Joint Learning Initiative estimates that the USA alone will demand an additional 1 million health workers from the global market over coming years and is likely to look to poor nations, in part, to meet this need. Inadequate long-term human resource planning and domestic production of health workers, coupled with ageing populations in developed countries, will continue to fuel recruitment from resource-poor countries unless there is a significant commitment to address this global inequity.

Turning the vicious circle of under-training, poor retention and migration into a virtuous circle of investment and improved health system performance requires a comprehensive set of actions based on analysis of the key issues. The response to the human resource crisis must start at the country level. This issue was recognised in the Cairo Declaration and Programme of Action, at the International Conference on Population and Development in 1994, which states:

‘The long-term manageability of international migration hinges on making the option to remain in one’s own country a viable one for all people. Sustainable economic growth and equity and development strategies consistent with this aim are a necessary means to that end’ .

Country-level efforts, in turn, must be supported by regional action, for example within the regional integrated markets in Africa that will result from the Economic Partnership Agreements (EPA), and global action to build a comprehensive and coherent international response, strengthening the social dimension of globalisation( 10 ).

3. ANALYSIS OF KEY ISSUES

The management of the health workforce can be considered in terms of inputs (training), ongoing support and supervision (maintenance) and managing health worker attrition, including management of both the push and pull factors causing out-migration. The response to the crisis in the health sector needs to be set within the context of a governments overall approach to public administration, recognising that reform or change in one sector of public administration will have consequences in other sectors.

Years of chronic underinvestment in health worker training has led to limited training capacity in many countries. Some of the under capacity is a consequence of insufficient public investment in the health sector aimed at limiting unsustainable growth in salary (recurrent) costs. However, health worker production has fallen below the levels needed to maintain even basic service provision and a significant proportion of those who are trained leave public service or their country of training without making any significant contribution to health care delivery. For example, only 50 of the doctors trained in Zambia since the 1960’s are still in country( 11 ).

There are a number of issues which determine whether a person will remain in their country of training or work elsewhere( 12 ). Analysis of health worker motivation shows that the high salary differential between rich and poor countries is just one aspect of the decision to change jobs or migrate. Other factors, such as the effectiveness of the health system and working conditions play a part. Increased investment in health and social security is needed if health workers are to contribute effectively to national efforts to improve health. Fundamental changes are needed in health system organisation, in institutional norms and standards, in staff deployment practice and performance management, in monitoring and supervision and in ways of working. Human resource policies which fail to take gender into account may also contribute to the crisis. Failure to recognise family needs, to provide adequate security for women who are working in remote and potentially insecure environments, to develop a workforce which reflects differential client needs related to gender and failure to train and produce an appropriate balance of male and female health workers, can significantly reduce the effectiveness of a health workforce.

As long as the international demand for health workers remains strong, training more health workers with an internationally marketable skill set may simply serve to further fuel the export market. Regulation, as a tool to limit migration, tends to increase the cost of migration to the individual and may be perceived as discriminatory; also, evidence of its effectiveness as a strategy is limited. Evidence from Ghana, which has made significant efforts to retain and attract back workers, suggests that incentive schemes for retention and to encourage health worker return through improved career opportunities and better terms and conditions of service are more likely to produce positive results. Effective incentive schemes must be based on research, analysis and consultation with health workers .

An alternative to training more doctors, dentists, nurses and pharmacists, is to train middle-level and auxiliary health workers. Auxiliary health workers can effectively manage routine problems and reduce the workload for more specialised staff, their training is shorter, focused on a limited skill set, and they are less internationally mobile. There has been under investment and lack of recognition of paramedic staff in the past - countries such as Malawi, where clinical officers and medical assistants were once the backbone of service delivery, provide a useful example of their potential role. Training and recognition of alternative cadres, including realistic prospects for their career progression, is essential but can be a contentious issue for professional groups. The extension of allied health workers functions is sometimes seen as a threat to professional roles. Building strong links with professional organisations and social partners and strengthening civil society’s commitment to finding innovative solutions will be an important part of the political process of addressing the crisis .

Addressing inequality in health worker distribution is also critical. Ensuring a geographic and service level distribution of health workers which better reflects population distribution and need is essential if services are to reach the poorest. Human resource planning needs to be considered within the context of national plans for decentralisation or reform, where responsibility for staff employment may be devolved to the sub-national level. Health workers, particularly the more highly skilled, tend to move towards urban areas where there is the potential to supplement low public sector salaries with private sector work, better access to training and better access to schools for family members. Incentives are necessary to encourage health workers to work where they are most needed. Non-salary incentives, such as improved housing, support for their children’s education and allowances for working in remote or under-served areas, should be considered, based upon an improved understanding of health worker motivation and needs. Much can be learnt from existing experience with the development of retention measures, and facilitation of regional sharing of information is important.

Health Worker Mobility

Health workers move from rural to urban areas, from the public to the private sector, from poor countries to richer countries. Migration within the South makes a significant contribution to brain drain, particularly in Africa. However, it is migration from the South to richer countries with ageing populations and expanding health systems that has attracted the greatest media and political interest.

It has been argued that resource-poor countries are providing a perverse subsidy to health services in resource-rich countries. Calculations based on migration of health workers from Ghana to the UK( 13 ), estimate the saving in training to the UK from recruitment of the 293 Ghanaian doctors and 1021 Ghanaian nurses registered as practising in the UK in 2003/2004 at £65 million for doctor training and £35 million for nurse training. Ghana’s loss includes both the training cost and the opportunity cost of understaffed health facilities. Those Member States that are net importers of health workers should work in partnership with the sending countries to support solutions, addressing both the push and pull factors for migration and helping finance retention policies.

Health worker mobility needs to be addressed through comprehensive national strategies as well as international action. The Health Strategy of the New Partnership for Africa’s Development (NEPAD) highlights the need for countries to ensure effective management of human resources for health by updating their employment and deployment policies, developing flexible career paths, providing supportive supervision and continuing education and fostering motivation and retention strategies.

The impact of HIV/AIDS

HIV/AIDS has compounded the crisis in human resources for health. Levels of ill health in society have risen, increasing the burden of health care and highlighting the limitations of weak health systems. Many health workers will themselves be either infected or affected personally by HIV/AIDS in some way. For example, in Swaziland there is a 7% net loss of health workers per year (50% of that loss being due to HIV infection) and yet if Swaziland is to respond to the challenge of increasing the numbers of people with access to antiretroviral treatment, it is estimated that 103 extra doctors will be needed in the next 5 years, twice the current number of doctors in the country( 14 ). This example highlights another challenge presented by HIV/AIDS: the potential competition for human resources between HIV/AIDS services and other essential service provision.

Developing services which provide access to antiretroviral drugs may take health workers away from delivery of other essential services, including through the recruitment of public employees into NGOs focused exclusively on tackling HIV/AIDS. There is a risk of distorting healthcare delivery in favour of HIV/AIDS interventions at the expense of the delivery of other essential services. The Global Fund to fight HIV/AIDS, TB and malaria (GFATM), recognising this risk, has made a commitment to ensure investments support strengthening of health systems and clinical research capacity, not just the building up of HIV/AIDS, TB and malaria services. The risk of service distortion needs to be effectively managed at the national level through strong national leadership ensuring the additional resources mobilised for HIV/AIDS prevention and care complement rather than compete for existing limited human resources.

4. AREAS FOR EUROPEAN ACTION

European actions are governed by the principles of country-level ownership and leadership. EU commitment to policy coherence for development will further support this principle( 15 ). EU engagement with countries most affected by the human resource crisis will be based on principles of solidarity, recognising that addressing the human resource crisis is a shared responsibility. Actions supported by the EU should be defined by country and regional needs, building political partnership through dialogue and shared objectives.

The EU will engage with the crisis in human resource for health in developing countries at country, regional and global level. The actions set out in appendix 2 (attached) represent a coherent and comprehensive package of interventions, and need to be considered as a whole . The global demand for human resources for health issue dictates that multiple actions at all three levels will be needed if the crisis in the most affected countries is to be overcome.

5. FINANCING

European commitment to move more rapidly towards achieving the target of 0.7% of GNI as ODA by 2015 and G8 commitments to support greater debt relief will make more resources available for development. This represents the greatest potential source of increased investment in human resources for health. The scale of increased financing needed to address the crisis has been roughly estimated by the World Bank and NEPAD: Africa alone will need US$ 500 million in 2006, rising to US$ 6 billion per year by 2011 (these figures are based upon the cost of increased national investment to mobilise an additional one million health workers for Africa, including providing incentives for work in rural or remote areas, the cost of introducing a better skill mix and making more effective use of community workers, and the cost of training and maintaining this workforce). Before countries can make any commitment to increase investment, particularly if that investment is to be financed through increased aid flows, stronger assurances are needed that international assistance will be long-term and predictable and that recipient countries will not be abandoned with unaffordable liabilities.

General and Sector Specific Budget Support

One of the main financing instruments of the European Commission at the country level is budget support. Budget support mechanisms help create the fiscal space necessary for Ministries of Finance to determine national funding priorities. Budget support is particularly effective for supporting recurrent costs such as human resource development. The EC will continue to provide a significant proportion of its development assistance to countries through both general and sector budget support, promoting this as the most effective mechanism for harmonising donor assistance behind national poverty reduction strategies. The EC will strengthen existing aid instruments with the aim of providing increasingly long-term and more predictable support. The EC recognises that Sector Budget Support is an effective instrument for strengthening policy dialogue and harmonising donor support, including project support and global initiative funding, behind national priorities. The EU commitment to increase the volume of development assistance will be complemented by efforts to make aid less volatile and more predictable.

EC budget support is linked to performance indicators which trigger fund release based on achievement of agreed performance milestones; this provides an incentive for progress towards nationally determined objectives. Health and HIV/AIDS indicators are frequently included amongst the indicators for performance monitoring. The EC will continue to support work to develop better indicators of health system performance, through participation in the Health Metrics Network, and will promote the need for an indicator of human resource strengthening to be included as a metric of health system performance and budget support financing.

EU financial support will be provided in line with the principles set out in the Paris Declaration on Aid Effectiveness( 16 ), with the aim of strengthening partner countries’ national development strategies and associated operational frameworks.

6. NEXT STEPS

The EU, in policy dialogue at country level, will seek to ensure that the human resource issue is addressed within the context of comprehensive and coherent sectoral planning and national poverty reduction strategies, with coordinated donor support backed up by UN joint action.

Programming decisions and budget allocations with respect to actions proposed in annex to this Communication will be made in accordance with the structure of instruments determined for the 2007-2013 financial perspectives. The EC will monitor and report on the implementation through the annual and mid-term reviews of country specific instruments, within the context and framework of proposed progress reporting on the Programme for Action to Confront HIV/AIDS, TB and Malaria.

A coherent European response, based on individual Member State and Commission expertise and collective action and reflecting the policy direction set out in the New Development Policy, will help ensure a strong and leading role for Europe in the international response to country led action on the crisis of human resource for health.

ABBREVIATIONS

AIDS Acquired Immunodeficiency Syndrome

ART Anti-Retroviral Therapy

AU African Union

EC European Commission

EDCTP European and Developing Countries Clinical Trials Partnership

EPA Economic Partnership Agreements

EU European Union

GAVI Global Alliance on Vaccines and Immunisation

GFATM Global Fund for AIDS, TB and Malaria

GNI Gross National Income

HIV Human Immunodeficiency Virus

HR Human Resources

HRH Human Resources for Health

ILO International Labour Organisation

JLI Joint Learning Initiative

INCO International Cooperation Programme

MDGs Millennium Development Goals

NEPAD New Partnership for Africa’s Development

NGOs Non Government Organisations

ODA Official Development Assistance

TB Tuberculosis

UK United Kingdom

UN United Nations

WHA World Health Assembly

WHO World Health Organisation

ANNEX 1

References

1. Joint Learning Initiative Strategy Report: Human Resources for Health, Overcoming the Crisis: Harvard University Press, September 2005.

2. COM (2002) 703, 3 December 2002. Integrating migration issues in the European Union’s relations with third countries

3. COM (2005) 390, 1 September 2005. Migration and Development: Some concrete orientations.

4. COM (2005) 489, 12 October 2005. EU Strategy for Africa: Towards a Euro-African pact to accelerate Africa’s development..

5. The Joint Learning Initiative Africa Working Group: “The Challenge of HRH in Africa; March 2004.

6. Sanders D, Dovlo D, Meeus W, Lehmann U: “Public Health in Africa” in Robert Beaglehole (Editor) “Global Public Health: A New Era”. Oxford University Press 2003. (Chapter 8, Page 135-155).

7. Hongoro C, McPake B. How to bridge the gap in human resources for health: Lancet 2004; 364: 1451-56.

8. UN, September 2005: UN Summit outcome document.

9. Joint Learning Initiative. Human resources for health: overcoming the crisis. Harvard University Press,2004http://globalhealthtrust.org/report/Human_Resources_for_Health.pdf

10. COM (2004) 383, May 2004: The social dimension of globalisation – the EU’s policy contribution on extending the benefits to all.

11. Human Resources for Health: Overcoming the Crisis: Report from a consultation in Oslo: 24-25 February 2005.

12. The International Migration of Health Workers: A Human Rights Analysis: Bueno de Mequita J, Gordon M; Medact, February 2005

13. The ‘Skills Drain’ of Health Professionals from the Developing World: a Framework for Policy Formulation. Mensah K, Mackintosh M, Henry L. Medact, British Medical Association, Save the Children UK; February 2005.

14. Wim Van Damme Institute of Tropical Medicine, Antwerp - presentation on the impact of workforce constraints on scaling up of ART

15. COM (2005) 134, April 2005. Policy coherence for development: Accelerating progress towards attaining the Millennium Development Goals.

16. Paris Declaration on Aid Effectiveness, Ownership, Harmonisation, Alignment, Results and Mutual Accountability. High Level Forum, Paris, 28 Feb-2 March 2005.

ANNEX 2

1. Strengthening EU Support at the Country Level

At the country level, the EU will support the implementation of national human resource strategies, within the context of poverty reduction strategies and national health sector policies. Specific actions will include:

- Including human resource issues in Poverty Reduction Strategies and Health Policy discussions . The EU will raise the issue of human resources in health as a barrier to progress on MDGs 4, 5 and 6 in policy dialogue on poverty reduction, to promote broader policy dialogue on the issue and the response by ministries of Finance, Planning, Establishment, Employment, Education and Research. Proposed actions to address the crisis in the health sector need to be considered alongside efforts to reform and strengthen public administration and should also be reflected in country dialogue on human resource planning within the context of national health planning. Related issues of productive employment, decent work and social protection and their role for human resources for health, health worker mobility and poverty reduction will also be addressed in these strategies and discussions. An EU lead agency, either a Member State or the Commission Delegation, will be identified in each affected country to champion the human resource issue in national policy dialogue, working in support of national efforts to harmonise donor support behind national priorities.

- Country level mapping of human resources for health, strengthened human resource policy and planning and agreement on national targets for human resource strengthening. The EU will support national efforts to evaluate human resource capacity, including assessing training capacity and identifying health worker maintenance and retention issues. This information will be used to inform national planning and will be supported by regional analysis to determine complementary regional action, such as inter-country sharing of training resources. Support will be provided for country efforts to strengthen HR planning, based upon globally agreed best practice and drawing upon private sector skills and expertise, where appropriate. Dialogue with professional organisations and medical and nursing trade unions and research institutions will be critical to the success of this process, in order to build consensus on the need to develop and support a workforce which can and is willing to remain in post to serve national health needs. Dialogue will include a focus on the development of incentives through increased training, improved working conditions and clearer career prospects. The role of civil society in this dialogue will be important, to ensure civil society voice informs discussions on improving health and health care and strengthening social security coverage. As part of discussions on monitoring progress towards the MDGs, EU support will promote discussion and research on potential indicators of health system performance and human resource capacity as a metric of progress.

- Support and financing national human resource plans. Human resources represent a long term cost for health systems and effective planning can only take place if there is a reasonable guarantee of long term sustainable financing. The EU will support efforts to increase the volume, duration and predictability of international development assistance. Increased financing through budget support mechanisms is the most effective way to support incentives schemes, decent work opportunities and social protection, retention measures and training and capacity building based upon a comprehensive national human resources for health planning exercise. The EU will support research to identify innovative and effective ways of increasing human resource capacity for health, including evaluations of middle-level technicians, auxiliary and community workforces. Auxiliary staff such as community health workers, in Gambia, South Africa, Tanzania, Zambia, Madagascar and Ghana, have been shown to be cost-effective agents for delivering some basic community health services[1]. The potential of information technology to improve communication between service levels, support distant working and learning and to improve the quality and efficiency of the work environment will also be explored.

2. Strengthening EU Support at the Regional Level

The regional level response to the human resource crisis will differ from region to region. Efforts to define priority regional actions in Africa, Asia and Latin America/Caribbean, are currently underway. The EU will support the mapping, analysis and the technical and political dialogue on human resources necessary for effective advocacy and action. The Oslo meeting on human resources proposed that global and regional action should be coordinated by ‘Platforms for Action’, which should be informed by Global, and Regional Observatories. The Platforms for Action are, primarily, political platforms for advocacy of the issue and for coordination. The ‘observatory’ functions relate to the technical support and analysis necessary to inform decision-making and policy development. A process to develop regional responses to the human resource crisis has already been initiated. A Regional Platform on Human Resource for Health in Africa[2] has been established and an Asian Action Learning Network on Human Resources[3] initiated. The need for Regional Platforms in other regions will be explored. The EU will continue to support this process.

In support of African Regional Action, the EU will back AU/NEPAD leadership and coordination of regional action and will work, within the context of a coordinated Africa Regional Plan, with the Regional Economic Communities in support of the sub-regional responses to the issue, as appropriate.

AFRICA

EU support on human resources for health in Africa is set within the context of the overarching EU Strategy for Africa[4].

Support to AU/NEPAD.

- Support for AU/NEPAD leadership of the African Regional Platform . The global response to the human resource crisis should be informed by a strong African voice, which requires AU/NEPAD leadership. The EC, as part of its strategic support to the AU, will support strengthened AU/NEPAD political leadership and capacity for coordination of the proposed Region Platform on Human Resources. The Africa Regional Platform will be based upon strengthening cooperation between existing regional bodies, with each identifying its comparative advantage in relation to regional action on human resources, working in support of a coordinated Regional Action Plan. The Brazzaville meeting recommended that financing of individual agencies in support of regional action should be based upon an agreed regional work plan to harmonise the regional response.

- Support for a Regional Observatory on Human Resources . The EU will support development of a Regional Observatory for Africa, which will be formed under WHO technical leadership, which will collect, collate, analyse and advocate policy, based on national HR information. The Observatory will be a repository of regional best practice and will produce guidance on HR management to inform national policy. Work should include defining benchmarks for human resource capacity and comparing country performance. The capacity and mandate for this work already rests with WHO and this capacity will be strengthened, with EU support, in order to engage other stakeholders in the process, including supporting greater private sector and civil society involvement.

- Roll-out of Regional Policy Guidelines on Human Resource Planning . The EU will support the roll-out of regional policy guidance on HR planning, to inform national plans of action.

- Identifying opportunities for regional training. The EU will support a mapping of regional resources to back up national action on human resources, which will include addressing the issue of training health workers in the 11 African countries which do not have a medical school. The potential for bilateral agreements within Africa to strengthen training capacity will be explored. Options to support shared regional training resources will be considered.

- Identifying opportunities to strengthen research capacity. Research is critical to addressing the human resource crisis. The EC will continue to support research capacity building: supporting clinical research through works such as that of the European and Developing Countries Clinical Trials Partnership (EDCTP) programme in sub-Saharan Africa; and research on incentives through the International Cooperation (INCO) programme. EU support will include assessing the potential for Regional ‘Networks of Excellence’ and Health Research sites with links to institutions in Europe, and will assess the potential value of this model of support. Innovative approaches to addressing the crisis, for example, through more effective use of information technology and initiatives such as telemedicine or access to major international scientific databases, will also be explored. Engaging local communities in research activities and strengthening the synergy between research and health care activities at local and regional levels will be encouraged.

- Funding for Inter-Ministerial Conference on Human Resources for Health in Africa . The EC will support a conference to bring together the key Ministries with an interest in or influence on health worker training, recruitment and retention, in order to support the development of a broad political consensus on the actions needed at country level to address the crisis.

Support to Regional Economic Communities

- Within the context of the overarching Regional Action Plan on Human Resources, the EU will discuss with the Regional Economic Communities how to address the human resource crisis through measures linked to the process of regional economic integration and the Economic Partnership Agreements. Related issues of economic migration and South-South migration should also be discussed. The aim will be to strengthen and manage the regional market in human resources to mitigate the adverse impact of brain drain, and turn brain drain into ‘brain gain’ through regional agreements on skill sharing and development, recognising the need for policy coherence for development.

OTHER REGIONS

In other regions, such as Asia, where the human resource issues are different due to relatively greater capacity to train and retain health workers, different initiatives will be needed. The Asia Learning Network on Human Resources for Health - a Joint Learning Initiative working group -has identified a number of critical issues for regional action. Despite policies in some countries in the region which are actively promoting health worker export to meet international demand, internal distributional issues exist, and service provision for the poorest remains a significant challenge in many countries. The inequity in distribution of human resources is a critical issue, with health worker shortages in remote or hard-to-reach areas. This is an issue that should primarily be addressed through improved human resource management at the national level. EU engagement on human resources in these cases will build upon existing EU engagement in national health sector policy dialogue, or through memoranda of understanding which seek to balance policies supporting out-migration with policies which address national needs.

3. Strengthened EU Support at the Global Level

An important first step in mobilising a global response to the human resource crisis is acknowledgement of the scale of the problem and the collective responsibility to support an international response. Europe should show leadership in acknowledging and better documenting European recruitment of health workers from resource-poor countries at the same time as strengthening Europe’s internal training capacity. Greater effort to promote decent work an conditions, to invest in social protection and to distribute the benefits of globalisation more evenly are needed at the global level in order to decrease global pressure for health worker migration. EU specific actions could include:

- An EU Statement of Commitment to Global Action and a Code of Conduct for Ethical Recruitment. The EU should respond visibly to the global call for action, and express a strong commitment of support. This will be achieved through the development of a ‘Statement of Commitment’ which will be delivered in response to the global call for action to be launched in 2006. The EC will convene a consensus workshop with Member States to draft and adopt an EU common position. As part of this dialogue, the EU will assess the value and feasibility of EU support for a global Code of Conduct on Ethical Recruitment. There are already examples within Europe of Member States who have developed voluntary agreements to minimise active international recruitment of health workers One of these is the United Kingdom voluntary code to reduce active recruitment from third countries, recently strengthened to govern private sector recruitment, as an attempt to increase its impact. A European approach, if considered to add value, would be applied by Ministries of Health in Member States and would regulate recruitment, preventing active recruitment from those countries which indicate that they wish to better control out migration. European leadership is needed to help build international commitment for more ethical recruitment practices in relation to the global market in human resources for health.

- Support for a Global Coordination of Action. The EU will support international action to address the crisis in human resources and argue for a process based upon networking between existing global agencies, in support of an agreed global work plan. Global action would include: developing capacity to map and analyse the global market in human resources for health and to document national strategies for HR management; providing guidance to recruiting countries for building capacity for greater self sufficiency in human resources; developing research capacity on health worker motivation and incentives. It is anticipated that many of the global actions can be undertaken by existing organisations working in collaboration, and through a clearer definition of organisational roles and responsibilities.

- Mobilising global funding instruments in support of HR Capacity Building. The EU will continue to be active in support of and on the boards of global funding instruments and will work to ensure that these funding mechanisms strengthen national health sector capacity . Funds such as the Global Fund for HIV/AIDS, TB and malaria and GAVI are already committed to channels funds in ways which help build general system capacity at the same time as accelerating action on priority diseases. The EU will continue to use its influence and voice to support these efforts.

- Better EU health workforce planning. The European Union will face increasing internal shortages of health professionals over coming years, as set out in the Commission Communication on the follow-up to the high level reflection process on patient mobility and healthcare developments in the European Union[5]. A concerted European strategy covering issues such as monitoring, training, recruitment, and working conditions of health professionals could ensure that the Union as a whole will be able to meet its objectives of providing high quality healthcare without exacerbating the human resource crisis in developing countries. The Commission has invited the Member States to consider this issue, in collaboration with the health professions, in particular through the High Level Group on health services and medical care. Facilitating internal mobility within the Union can go some way toward ensuring that health professionals are available where they are most needed, but such an approach will need to ensure overall numbers and specialisations of health professionals are adequate, and therefore requires careful and detailed planning and response.

- Promoting circular migration . The Commission Communication on Migration and Development commits the EU to explore issues such as transferability of pension rights and protecting residence rights in the EU of diaspora members who participate in temporary return programmes. Facilitating discussion on circular migration in relation to health will be taken forward as part of an EC/EU working group on human resources that will be established to further develop coordinated European action on human resources for health.

- ‘Networks of Excellence’ in support of health worker training and capacity building. The idea of linking institutions in resource-poor countries to centres of academic, professional or technical excellence in Europe and strengthening North-South and South-South links to build networks which support development of health skills and expertise and research capacity will be explored. Networks of Excellence would attract and help retain highly qualified health professionals and researchers at the national or regional level. Such networks would be an opportunity to address more complex health situations, for example in post conflict countries, where capacity to provide physical care and trauma management for victims of mines, remnants of war or armed violence is needed, but often not available. Synergies between capacity building for research and training of staff for health delivery and care should also be fully explored. As part of the EC Programme for Action (COM (2005) 179) the EDCTP (the EU pilot initiative on clinical trails currently implemented in Africa) should play an integrating role by positively contributing to national and regional human resources plans for clinical research.

- International Volunteers . The EU will consider support to volunteer schemes which are demand-driven, and focus on capacity building and skills transfer . Volunteers are a potential short-term solution to the human resource crisis. However, whilst they may make an effective contribution in support of capacity building and, to a limited extent, in terms of direct service delivery, they do not represent a long-term solution to the HR crisis. They can therefore be no substitute for an EU policy focussed on supporting specific capacity building and skill transfer work.

- Working with the health worker diaspora. The Commission Communication on Migration and Development indicates that Member States will be invited to intensify their dialogue with diaspora organisations, and that the EU could support countries of origin in establishing instruments through which those interested in supporting their home country could register on a voluntary basis. In addition, opportunities to build supportive alliances between these organisations and their home countries, with the possibility of seed financing allocated on a competitive basis, will be explored.

- Strengthen the Social Dimension of Globalisation and promote Decent Work as a global goal for all. The EU will contribute to strengthening the Social Dimension of Globalisation with a view to ensuring maximum benefits for all, including through cooperation with the ILO as well as national, regional and local actors, social partners and civil society organisations. It will also help encourage employment and decent work as a key tool for preventing and eradication poverty. The EU will promote productive employment, equitable economic growth and decent work for all, and for workers in the health sector, in particular as a global goal, thus contributing to improving living and working standards and addressing push and pull factors leading to out-migration of health workers. In this context, the EU should promote increased cooperation between state and non-state actors (NGOs, private sector, trade unions, etc.) to ensure greater effectiveness in service delivery.

[1] Lehmann U, Friedman I, Sanders D. Review of the utilisation and effectiveness of community-based health workers in Africa. A Joint Learning Initiative Paper 4-1. Human Resources for Health Development 2003.

[2] Regional Consultative Meeting on Taking the HRH Agenda Forward at Country Level: 18-20 July 2005, Brazzaville, Congo. Meeting Conclusions.

[3] Workshop on Asian Action Learning Network on Human Resources for Health; 3-5 August, Bangkok, Thailand.

[4] COM (2005) 12 October 2005. EU Strategy for Africa: Towards a Euro-African pact to accelerate Africa’s development.

[5] COM (2004) 301, 20 April 2004. Follow-up to the high level reflection process on patient mobility and healthcare developments in the European Union.