[pic] | COMMISSION OF THE EUROPEAN COMMUNITIES |

Brussels, 21.12.2006

COM(2006) 870 final

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL

A European Programme for Action to tackle the critical shortage of health workers in developing countries (2007–2013)

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL

A European Programme for Action to tackle the critical shortage of health workers in developing countries (2007–2013)

1. THE POLICY CONTEXT AND SCOPE OF THE PROGRAMME FOR ACTION

In December 2005, the European Commission (EC) adopted a Communication entitled ‘ EU Strategy for Action on the Crisis in Human Resources for Health in Developing Countries’ – COM (2005) 642, highlighting the scale and complexity of the health workforce crisis and arguing for a comprehensive and coherent EU response.

At its meeting on 10/11 April 2006, the General Affairs and External Relations Council (GAERC), adopted conclusions on the EU Strategy for Action. Council called on the EC and the Member States to develop a coordinated EU response in support of country level efforts to address the human resources in health (HRH) crisis (1) (for all references see Annex 2) . The Council also adopted an EU Consensus Statement on the Crisis in Human Resources for Health, stating that:

“ Europe is committed to supporting international action to address the global shortage of health workers and the crisis in human resources for health in developing countries ”.

This Programme for Action (PfA) responds to the Council conclusions and is the product of consultation with EU Member States, taking account of the global analysis set out in the World Health Report 2006. The Human Resources Working Group, formed at the request of the Council to develop the PfA, has defined actions at country, regional and global levels, that will be taken forward by the EU (the EC and the Member States) and those that will be supported directly by the EC.

2. EU ACTIONS AT COUNTRY LEVEL

The EU provides support to strengthen health workforce capacity through bilateral programmes in a number of countries. However, given the scale of the problem, the quantity and quality of support needs to increase and analysis of HRH constraints to health system development assessed more systematically. Whilst some HRH support is provided as part of sector programmes and aligned with national priorities, there remains a need for much greater coordination and for more effective engagement of all the key actors at the country-level, including the private sector and civil society, in support of a strengthened country-level response. The EU, working with other funding and technical agencies, will make a concerted effort to align support at the country-level with nationally defined strategies and priorities, supporting the active engagement of all key stakeholders.

Existing programmes of support are financed in a variety of ways, ranging from general budget and sector budget support, pooled financing of Sector Wide Approaches and financing through multilateral agencies and through project funding mechanisms. The EU will support increased coordination between the EU and other donors in support of country-led planning for health. EU Member States and the EC will provide increased support to country-level efforts to strengthen national health systems, supporting the development of comprehensive and inclusive national strategies to increase the capacity and performance of the health workforce.

Strengthened country capacity will be achieved through the following actions:

2.1. Country level political and policy dialogue and planning

1. The EU will raise the issue of HRH as a barrier to progress towards MDGs 4, 5 and 6 in national policy dialogue on poverty reduction and in discussions on strengthening social governance. This policy dialogue will be strengthened by drawing on EC and Member State expertise and by working jointly with the appropriate technical agencies and experts, to ensure that a stronger evidence-base underpins the policy dialogue. Strengthened stewardship, increased government accountability for MDG progress, increased transparency on service objectives and financing and the promotion of a broad inter-sector policy dialogue by relevant ministries, linked to efforts to reform and strengthen public administration, are important pre-requisites for more equitable and responsive healthcare provision. Related issues of productive employment, gender equity in recruitment, more effective deployment and service delivery, accreditation and recognition of qualifications in the medical field, promotion of decent work and social protection, economic migration and development, tradability of medical services and the role of these factors in human resources for health development and poverty reduction will be addressed.

2. The EU will take forward work initiated on developing an MDG contracting mechanism to link longer-term budget support more closely to MDG progress. Human resources represent a long-term recurrent cost and effective planning can only take place if there is a reasonable guarantee of long-term sustainable and predictable financing. The EU will support efforts to increase the volume, duration and predictability of international development assistance. In addition, the EU will conduct dialogues with governments and the international financing institutions on possibilities for increasing fiscal space for social sector investment.

3. The EU will support national efforts to evaluate, plan for and manage human resource capacity development and to effectively engage civil society and the private sector in the national response. Standardisation of measurement and monitoring of HRH policy, using a set of indicators being developed by the Health Metrics Network, and evidence-based frameworks for HRH analysis and response, being developed by WHO and the Global Health Workforce Alliance (GHWA), will be supported. Support will be provided for research to identify health worker retention and maintenance issues based on workforce motivation studies. Support will be provided to strengthen HR management and planning, based upon globally agreed best practice, drawing upon private-sector skills and expertise. Dialogue with professional organisations, with medical and nursing trade unions, with research institutions and other civil society representatives will be critical to the success of this process. The EU will support consultation and consensus building in order to ensure civil society voice informs national HRH planning. Within the EC and EU health programming, HRH will be treated as a cross cutting issue, to be considered fully in all EU supported health related interventions.

2.2. Capacity building

4. The EU will support research to identify effective and innovative ways of increasing human resource capacity for health, including assessing the appropriate range, cadres and gender balance needed to overcome critical shortages. Research will include evaluations of current workload, recognising that many health workers already perform beyond their defined roles and responsibilities. The potential roles and functions of middle-level technicians, auxiliary and community workforces and evaluation of accelerated training to expand access to services rapidly will be assessed.

5. The EU will support expansion of country-level training capacity, including for human resource management training capacity. The EU will also explore the potential of link relationships between institutions in order to strengthen capacity-building over the long term and to develop south-south and north-south learning communities . Capacity development needs to address individual training needs through the expansion of training facilities, as well as organisational and institutional capacity building for planning, support and management of the health workforce. Research on the effectivenss of task-shifting in order to expand capacity by extending the roles of professional and auxillary health workers will also be explored. Elements that might be included in link programmes are work on training and accreditation of community health workers; task-shifting, delineation of health worker competencies and skill mix; promoting innovative training approaches such as shortening training time; sharing faculty and optimising use of infrastructure; and developing a framework for countries to assess and develop the training capacity of institutions. Developing life long learning, to complement initial training and formal post-graduate training will also be essential.

6. Link programmes between professional bodies and regulatory agencies will be supported in order to build their capacity and support a stronger role for professional associations in the governance and stewardship of quality health services .

2.3. Civil Service reform and enhancing terms and conditions of service

The development of comprehensive incentive packages, including increased salaries and benefits and an improved working environment, linked to a clear and measurable strategy for service improvement and the promotion of decent work, will be an important component of the HRH response in many countries . Incentives for working in under served areas in order to increase access to services for the poor and marginalised also need to be considered. The EU will support necessary analytical work to help address these issues within the context of appropriate national HRH responses. Non-salary incentives, including improvements in the working environment and service efficiency, are considered important for health worker retention. Innovative packages of support which include access to cheap loans, educational allowances for children of health workers and enhanced professional development opportunities will be supported. Salary and other financial incentives need to be developed taking into account broader plans for civil service reform, but recognising the special needs of the health sector. The EU will support analysis or study of the labour market, including assessment of public, private and non-government sector pay scales and conditions and the relationship of these factors with quality of healthcare, in order to establish realistic benchmarks for health workforce salaries . Increased financing for health workers should be linked to clear and measurable targets for improved service performance (productivity), such as increased service utilisation, decreased staff absenteeism and increased client satisfaction.

2.4. Addressing HIV/AIDS, TB and Malaria

The HIV/AIDS epidemic and the increasing burden of TB and malaria have exacerbated the health workforce crisis, increasing the workload on a system already under strain. The particular challenge for health workers in determining their own HIV status and accessing antiretroviral therapy, given the fear of stigma, are acknowledged. The EU will support the incorporation of the WHO’s Treat, Train, Retain strategy within national health and national HIV/AIDS strategies . Policy dialogue will aim to ensure that the health workforce crisis is acknowledged in health sector planning. The EU will continue to support the Global Fund to Fight AIDS, TB and Malaria, to ensure that its Country Coordination Mechanism links the national response to HIV/AIDS, TB and malaria back to the need to build an effective health system that can respond to country defined health priorities.

2.5. Promoting gender equity in health service provision

The EU will support policies which recognise and address gender differences and gender inequalities in the development of human resource for health strategies . Mechanisms to support the role of women in the health workforce, giving particular attention to gender equality issues in matters of education and training, recruitment, salary, career development and decision-making positions will be supported.

2.6. Supporting and strengthening communities

The EU will support policies which encourage both government and non-governmental services to reach out to support community based care and support, as part of national human resource strategies. The shortage of health workers has increased the burden of care being placed on communities, and particularly on women, both in terms of voluntary community work and in terms of informal care within families.

2.7. European technical expertise

The EU will increase coordination of its technical assistance (TA) in support of country programming, identifying expertise for HRH planning. The EU will support greater coordination of access to EU TA encouraging the development of recipient-managed TA pools to allow countries to draw on the most appropriate experience. Mechanisms such as shared programming, monitoring and reporting will be used to make optimum use of the EU 'know-how' in support of country-level planning and programming.

2.8. Post-conflict or fragile States

In countries in conflict or in fragile States, where a government's capacity to plan effectively for national human resource needs is limited, the EU will increasingly work through shadow alignment mechanisms in order to provide more predictable longer-term coordinated support linked to MDG progress. The EC Humanitarian Office will, where appropriate, help to support coordination efforts by active consideration of the health workforce situation in its humanitarian programming. When the country context permits, mechanisms for building national HR capacity, for example by contracting services through NGOs and building national capacity for contracting out services, as piloted in Afghanistan, will be further developed. Effective consideration of human resources issues in the transition from humanitarian support to longer term development assistance is a critical part of the Linking Relief to Rehabilitation and Development process and will be prioritised for attention in transition countries.

3. EU ACTIONS AT A REGIONAL LEVEL

Efforts to define priority regional actions in Africa, Asia and Latin America/Caribbean, are currently underway. Although Africa will be prioritised in the EU response, HRH problems are significant in other regions and the EU response will take account of the need for global action tailored to meet differing regional needs. 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 (2) proposed that global and regional action should be coordinated by ‘Platforms for Action’, bringing together key stakeholders and informed by Global, and Regional Observatories. A Regional Platform on Human Resources for Health in Africa (3) has been established and an Asian Action Learning Network on Human Resources (4) initiated. The need for Regional Platforms in other regions will be explored.

3.1. Political leadership in Africa.

Given the disproportionate impact of the health worker crisis on Africa, the global response to the human resource crisis should be informed by Africa's needs. The EU will work with the AU/NEPAD, the Regional Economic Communities, UN agencies and with regional networks of NGOs and civil society organisations to support a strong African voice in the global response to the HRH crisis. EU support on human resources for health in Africa is set within the context of the overarching EU Strategy for Africa (5) . As part of its strategic support to the AU, the EC will support strengthened AU/NEPAD leadership of regional action. The regional response will draw upon technical networks developed through the work of WHO and the Global Health Workforce Alliance and will help build a regional platform for action.

3.2. Support to African regions

The EU will discuss with the African regions how to address the human resource crisis through measures linked to the process of regional economic integration and Economic Partnership Agreements. Related issues of economic migration and south-south migration will be discussed. The aim will be to strengthen and manage the regional market in human resources to mitigate the adverse impact of brain drain - turning brain drain into 'brain circulation and ‘brain gain’ through regional agreements on skill sharing and migration and development.

3.3. Support for Regional Observatories on Human Resources

The EU will support the development of a Regional Observatory for Africa , which will be a repository of regional best practice and will collect, collate and analyse data, and disseminate information and advocate policy based on national HR information. Work should include defining benchmarks for human resource capacity and comparing country performance. The capacity and mandate for this work rests with the WHO.

3.4. Developing Regional Training Resources, expanding Networks of Excellence and developing eHealth

7. The EU will support a mapping of regional training capacity and explore options to meet country needs by drawing on this regional capacity. The 7th Research Framework Programme (2007-2013) and its Specific International Cooperation Actions (SICA) will support actions to expand training capacity. The EU will support the development of learning networks within and between regions. North-south and south-south links to build 'Networks of Excellence' which support development of health skills, expertise and research capacity will be explored. The EC will continue to support regional meetings to define areas where regional working can add value and will build links between countries for lesson learning, for example the EC is planning a network for human resource information exchange between Portuguese-speaking countries and other similar initiatives will be considered.

8. The potential of information technology to improve communication between service levels, to support medical training, distance working and learning and to improve the quality and efficiency of the work environment will be explored. The Commission, working with the European Space Agency and WHO, has established a taskforce on eHealth for Africa. The taskforce will explore the potential of improved telecommunications to bridge the distance between health workers in rural areas to their peers and specialists elsewhere and to support teleconsultation as well as health sector training and capacity building in Africa. The Commission has provided financing for a series of taskforce meetings that will culminate in an African Stakeholder Conference. The output of the task force will inform the development of EU support for greater ‘interconnectivity’ in Africa - a key component of the EU Strategy for Africa.

3.5. Strengthen regional research capacity

Building research capacity is critically important for retraining academic and clinical research capacity and preventing brain drain. The EU will continue to support research capacity building, including EC support for clinical research capacity development through the European and Developing Countries Clinical Trials Partnership (EDCTP) for sub-Saharan Africa . Engaging local communities in research activities and strengthening the synergy between research and health care activities at local and regional levels will be encouraged.

4. EU ACTIONS AT A GLOBAL LEVEL

With the EU commitment to allocate 0.7% of EU Gross National Income as development assistance by 2015, the EU will be providing over 60% of global development assistance by 2010. EU coordination will help maximise the benefit of this increasing volume of aid and strengthen international efforts to increase the harmonisation and alignment of aid. The EU recognises the need for greater global coordination of the international response to the HRH crisis and is committed to promoting decent work for all, as set out in COM (2006) 249.

4.1. Internal EU action: Strengthening EU health workforce planning and promoting 'Brain Circulation'

9. The European Union will face increasing internal shortages of health professionals over the 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 (6). While fully respecting the subsidiarity principle, a concerted European strategy covering issues such as monitoring, training, recruitment, and working conditions of a sufficient number of health professionals will be developed to help ensure that the Union as a whole will be able to meet its objective of providing high quality health care, without exacerbating the human resource crisis in developing countries.

10. The Commission convened High Level Group on Health Services and Medical Care Working Group on Health Professionals has been charged to consider recruitment practice in the European Union. In this context, it will develop a set of principles to guide recruitment of health workers within the Union and recruitment from third countries, which will seek to minimise any negative impact on health workforce capacity in third countries. The EU will support the World Health Assembly resolution call for the development of a global code of conduct on ethical recruitment.

11. The EC Communication on Migration and Development indicates that Member States will be invited to intensify their dialogue with diaspora organisations. The building of alliances between diaspora organisations and with their home countries will be supported. The EU will explore ways to constructively bring together multiple small-scale diaspora initiatives into more strategic and coordinated actions . The possibility of seed financing for such collaboration, allocated on a competitive basis, will be explored.

12. The EU will develop mechanisms and guidelines for supporting ‘circular migration’ of health workers and will explore issues such as transferability of pension rights and protecting residence rights in the EU of diaspora members who participate in temporary return programmes. Issues of recognition of qualifications and tradability of services in health will also be explored. The EU will consider support to volunteer schemes which are demand-driven, and focus on capacity-building and skills transfer.

13. The EU will explore the feasibility of supporting partnerships between medical institutions in the EU and in the developing world, whereby capacity-building could be provided and interested healthcare professionals could share their activity between the two partner institutions.

4.2. Mobilising funding at the global level for HR capacity-building

The EU will promote in international discussions the importance of long-term predictable financing to address the health workforce crisis as part of international efforts to scale up financing for MDG progress. The EU will continue its dialogue with the IMF and World Bank to identify ways of overcoming macro-economic constraints at the country level which can limit health investment. The EC and EU Member States will continue to be active on the boards of global funding instruments working to ensure increasing alignment behind country priorities to expand fiscal space for necessary investment in capacity-building . Funds such as the Global Fund to Fight AIDS, TB and Malaria and the Global Alliance for Vaccines Initiative are already committed to channelling funds in ways which help build general system capacity at the same time as accelerating action on priority diseases.

5. NEXT STEPS

5.1. Financing

14. The World Health Report 2006 estimates that to meet the investment costs for training an expanded health workforce over a 20-year period, the average resource-poor country would need to increase its overall level of health expenditure per capita by about US$1.60 each year. By 2025, a minimum increase of US$8.30 per capita in the health sector budget would be required to pay the salaries of the expanded health workforce.

15. A key challenge in financing an adequate health workforce will be to create the fiscal space needed for long-term investment through the provision of an increased volume of long-term and predictable aid. Effective measures to accommodate this within the macro-economic constraints and by measures such as de-linking wage bill restrictions for health staff from those of other civil servants will be needed. There is a need to link proposed increases in investment more closely to performance, in terms of improved access to and uptake of better quality services. The possible inclusion of a health workforce indicator in the MDG framework will be addressed to the Inter-Agency and Expert Group on MDG Indicators, responsible for preparation of data, analysis and the monitoring of progress towards the MDGs, enabling the link between financing, HRH investment and MDG progress to be better monitored. The Commission will increase the proportion of its financing provided as budget support and the EU will aim to provide longer-term more predictable financing linked to MDG progress, through the development of an MDG contracting mechanism. In order to monitor the EU commitment to increase financial support for improving the HRH situation, the Commission will, by the end of 2007, develop a framework for capturing and regularly updating Member State and EC supported actions on HR, funded through both bilateral and multilateral channels, and compare EU funding levels with those of other donors and the international financial institutions.

16. In addition to efforts to mobilise resources at the country-level, the Commission will use up to [€40,3 million over the period 2007-2013, out of the €1.060 million] funding available for the entire Investing in People Thematic Programme of the Development Cooperation Instrument, to support catalytic global and regional actions on Human Resources for Health. Catalytic actions such as strengthening the leadership of the AU/NEPAD in developing the African response; supporting the development of regional platforms for action; supporting the engagement of the private sector, civil society and the diaspora in the development of national HRH strategies, through a call for proposal process; and supporting Global coordination of action, through the work of the Global Health Workforce Alliance, will all be considered for funding.

5.2. Monitoring and Evaluation

The EU will support the development of a country level HRH monitoring and evaluation framework, using indicators being developed by the Health Metrics Network and will monitor collective EU action on HRH progress under the planned reporting to Parliament and Council on the European Programme for Action to Confront HIV/AIDS, Malaria and Tuberculosis through External Action.

ANNEX 1

Abbreviations

AU EC EU GHWA HR HRH HIV/AIDS IMF MDGs NEPAD NGO PfA TA TB UN WHO | African Union European Commission European Union Global Health Workforce Alliance Human Resources Human Resources for Health Human Immunodeficiency Virus / Acquired Immune Deficiency Syndrome International Monetary Fund Millennium Development Goals New Partnership for African Development Non-Governmental Organisation Programme for Action Technical Assistance Tuberculosis United Nations World Health Organisation |

ANNEX 2

References

1. Council of the European Union: General Secretariat; 10 April 2006. Document 8359/06. EU Strategy for Action on the Crisis in Human Resources for Health in Developing Countries: Conclusions of the Council of the European Union and the Representatives of the Governments of the Member States meeting within the Council; and EU Statement of Commitment on human resources for health in developing countries.

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

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

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

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

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