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
Date: 2005-12-12
Institutions: European Commission
Subjects: EU aid, action programme, developing countries, health care profession, health policy, vocational training

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 

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TABLE OF CONTENTS 

1. 

2. 

3. 

4. 

5. 

6. 

Introduction .................................................................................................................. 3 

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

Analysis of Key Issues ................................................................................................. 5 

Areas for European Action........................................................................................... 8 

Financing...................................................................................................................... 8 

Next Steps .................................................................................................................... 9 

ANNEX 1................................................................................................................................. 11 

ANNEX 2................................................................................................................................. 12

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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.  

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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 
the 
international  community’s  commitment 
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 

to  accelerate  progress 

towards 

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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 
social  dimension  of 
globalisation(10).  

strengthening 

international 

response, 

the 

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 

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contribute  to  the  crisis.  Failure  to  recognise  family  needs,  to  provide  adequate 
insecure 
security  for  women  who  are  working 
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. 

in  remote  and  potentially 

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.  

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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 

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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 

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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 
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.  

included  amongst 

the 

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. 

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ABBREVIATIONS 

AIDS 
ART 
AU 
EC 
EDCTP 
EPA 
EU 
GAVI 
GFATM 
GNI 
HIV 
HR 
HRH 
ILO 
JLI 
INCO 
MDGs 
NEPAD 
NGOs 
ODA 
TB 
UK 
UN 
WHA 
WHO 

Acquired Immunodeficiency Syndrome 
Anti-Retroviral Therapy 
African Union  
European Commission  
European and Developing Countries Clinical Trials Partnership  
Economic Partnership Agreements 
European Union 
Global Alliance on Vaccines and Immunisation  
Global Fund for AIDS, TB and Malaria  
Gross National Income 
Human Immunodeficiency Virus  
Human Resources 
Human Resources for Health 
International Labour Organisation 
Joint Learning Initiative  
International Cooperation Programme 
Millennium Development Goals  
New Partnership for Africa’s Development  
Non Government Organisations 
Official Development Assistance 
Tuberculosis 
United Kingdom  
United Nations 
World Health Assembly 
World Health Organisation 

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References 

ANNEX 1 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

11. 

12. 

13. 

14. 

15. 

16. 

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

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

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

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

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

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).  

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

UN, September 2005: UN Summit outcome document. 

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

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

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

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

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. 

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

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

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

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1. 

Strengthening EU Support at the Country Level 

ANNEX 2 

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 

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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  services1.  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  Africa2  has  been  established  and  an 
Asian  Action  Learning  Network  on  Human  Resources3  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 Africa4.  

1 

2 

3 

4 

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.  
Regional  Consultative  Meeting  on  Taking  the  HRH  Agenda  Forward  at  Country  Level:  18-20  July 
2005, Brazzaville, Congo. Meeting Conclusions. 
Workshop on Asian Action Learning Network on Human Resources for Health; 3-5 August, Bangkok, 
Thailand. 
COM  (2005)  12  October  2005.  EU  Strategy  for  Africa:  Towards  a  Euro-African  pact  to  accelerate 
Africa’s development. 

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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 

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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:  

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•  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  Union5.  A 
concerted  European  strategy  covering  issues  such  as  monitoring,  training, 
recruitment, and working conditions of health professionals could ensure that the 

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. 

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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 
trauma 
conflict  countries,  where  capacity 
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. 

to  provide  physical  care  and 

•  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 

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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. 

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