Select Committee on European Scrutiny Seventh Report


4 The EU and health workers in developing countries

(28209)
17118/06
COM(06) 870
Commission Communication: A European Programme for Action to tackle the critical shortage of health workers in developing countries (2007-2013)

Legal base
Document originated21 December 2006
Deposited in Parliament5 January 2007
DepartmentInternational Development
Basis of considerationEM of 17 January 2007
Previous Committee ReportNone
To be discussed in CouncilMay 2007 General Affairs and External Relations Council
Committee's assessmentLegally and politically important
Committee's decisionNot cleared; further information requested

Background

4.1 In response to a Commission Communication on HIV/AIDS, malaria and tuberculosis), the Council requested that the Commission consider the more general problem of lack of human resources in health care in developing countries; which it did in its Communication 15774/05 of 12 December 2005. The focus was primarily on Africa, in line with the EU Africa Strategy — where a global crisis (75 countries with less than 2.5 health workers/1000 population) has been exacerbated by the HIV/Aids pandemic — and the primacy of the UN Millennium Development Goals (MDGs),[6] where addressing the crisis in human resources in health is a prerequisite to making progress.

4.2 "Push" factors identified in the developing world include the lack of decent work opportunities and limited incentives, particularly to work in under-served areas and with poor people, and high health worker mobility. "Pull" factors in the developed world include high global demand for health workers, fuelled by ageing populations. Common to both is inadequate long-term resource planning and domestic production of health workers. The Communication proposed EU action at three levels:

—  country level (the main focus): ensuring that human resource issues are adequately reflected in health policy and within the wider development agenda in poverty reduction strategies. Better country-specific problem analysis and support to strengthen human resource planning and management systems, to increase training of appropriate cadres, to improve terms and conditions of service and to provide opportunities for career progression. A major focus on efforts to increase retention and distribution of staff to underserved areas;

—  regional level: strengthened EU support where such an approach adds value in relation to advocacy, information, technical support, sharing best practice, and where appropriate, in developing regional approaches to training and strengthening research capacity; and

—  EU action: development of an EU Statement of Commitment to Global Action (to tie in with the WHA/WHO decade of action on human resources) and a Code of Conduct on Ethical Recruitment (an area where UK leads), better EU workforce planning, strengthening networks of excellence linking EU and developing country training institutions to offer post-graduate training opportunities and work with the health worker diaspora (those from the developing world working in the EU).

4.3 In his accompanying Explanatory Memorandum, the Minister noted that the Department for International Development and the Department of Health had been fully engaged in the development of the Communication. He judged it to be a sound analysis that reflected the long-term neglect of human resources and the complexity of the problem and proposed sensible, comprehensive and pragmatic solutions, building upon limited best practice in a neglected area of development and centring upon country-led efforts. The proposals complemented current UK initiatives organised by the two Departments. The Commission had consulted widely with the African Union and several African regional organisations and donor agencies. Work was continuing in the Development Working Group. His only adverse comment was that the document could have been more explicit in promoting a move to self-sufficiency and health workforce mobility across the EU.

4.4 We agreed that, all in all, this was a good piece of work on an important issue of global and European public policy, but was not in our view one that, in and of itself, warranted a substantive Report to the House.

4.5 The 10-11 April General Affairs and External Relations Council adopted Conclusions on the Strategy and called on the EC and Member States to develop a coordinated response in support of country level efforts to address the crisis in human resources in health (HRH). The Council also adopted a 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".[7]

The Commission Communication

4.6 This present Communication sets out plans for the coordinated response called for by the Council. It notes that the problem of health worker migration, and the role played by rich countries in creating the problem of health worker scarcity in developing countries, especially Africa, has been on the international development agenda for several years: poor terms and conditions create incentives for workers to migrate to seek better opportunities; but little evidence that substantial remittances sent home provide adequate compensation for the impact on health systems, and by implication, the health of the poor in those countries.

4.7 Developed countries are accused of contributing to the problem by recruiting health workers from countries in which health services are understaffed. The issue is difficult to address because the interests of developing countries are not aligned with the interests of health systems in rich countries, who benefit from being able to access a pool of highly skilled labour that they have not had to invest in. Although EU Member States and the Commission already provide support to strengthen human resources for health (HRH) in developing countries, more could be done, and could be based on more systematic analysis of the problem.

4.8 Specific steps for the Commission and EU Member States operating bilaterally include:

—  raising the HRH problem in wider working groups in developing countries, particularly those addressing barriers to achieving Millennium Development Goals concerning child mortality, maternal health, and HIV, TB, and malaria;

—  increasing the predictability and longevity of funding commitments and linking them more clearly to outcomes, through use by the Commission of MDG contracts (long-term budget support commitments intended to finance progress towards meeting the MDGs), and by influencing international financial institutions;

—  supporting national efforts to evaluate, plan for and manage human resource capacity development and to engage civil society and the private sector effectively in the national response; drawing on expertise at the World Health Organisation, particularly the Global Health Workforce Alliance and Health Metrics Network (which aims to improve health by strengthening and aligning health information systems around the world);

—  providing more technical assistance and research that helps developing countries to plan and retain health workforces better;

—  giving more support to develop health worker training capacity, particularly linking developing country institutions with counterparts in EU Member States, and particularly at a regional level in Africa;

—  supporting links between EU Member States' professional associations and regulatory bodies, and those in developing countries;

—  based on solid evidence of what works, supporting reform of HRH employment terms and conditions in public sectors in developing countries, in the context of wider civil service reform steps, in order better to attract, retain and motivate staff;

—  when forming policy, recognising that HIV/AIDS is having an impact on the health workforce both through increased workload, and also because it affects health workers themselves;

—  making sure that the Commission's Humanitarian Office (ECHO) addresses HRH in its policies for fragile states.

4.9 Other steps include: paying attention to gender issues in health workforce terms and conditions; supporting policies that recognise the need to support communities; and providing better coordination of technical assistance to developing countries.

4.10 The document also identifies the need for more EU support to regional institutions. A regional platform on HRH in Africa and an Asian Action Learning Network on HRH have been established. The Programme for Action also proposes support for regional actions by the New Partnership for Africa's Development (NEPAD)[8] and the African Union (AU; the successor to the Organisation of African States)[9] to strengthen the African voice in the response to the crisis. The EU will also try to help African countries to develop regional policies and mechanisms to achieve "managed migration" of HRH regionally, to reduce the negative impacts of migration; and will support collection and use of information and policy materials. The EU will support regional HR mapping and regional meetings. The document proposes the use of innovative mechanisms to address HR shortages, such as support for improved use of information and communication technology to support training and provision of health services. Finally, regional research capacity will be supported.

4.11 The document also identifies specific steps for the EU operating at European and global levels:

—  noting the rising shortages of health workers in Europe, it calls for a concerted European strategy that addresses monitoring, training, recruitment and working conditions of EU health professionals in a way that does not worsen the HRH crisis in developing countries;

—  it supports calls at the World Health Assembly for a global code of practice on ethical recruitment of HRH;

—  it supports action to develop links between diaspora communities and their home countries;

—  it proposes that the EU should develop mechanisms and guidelines on "circular migration" (non-permanent migration between nations). This includes exploring such possibilities as protection of migrant worker pension rights outside Member States;

—  it calls for support to EU Member States' HRH training institutions that wish to develop partnerships with counterparts in developing countries.

4.12 The Programme for Action sets out the following next steps:

—  in the context of the costs of addressing the HRH, the Commission and Member States to start measuring financial support to HRH and benchmark against other donors;

—  the Commission to commit €40 million (£26.9 million) over 2007-13 to a range of catalytic and strategic steps in support of the objectives described above, including investing in leadership development in regional institutions and supporting engagement of civil society and the private sector in responses;

—  using the Health Metrics Network frameworks being developed, the Commission and Member States to improve monitoring of HRH progress for reporting to the European Parliament and the Council.

The Government's view

4.13 In his 17 January 2007 Explanatory Memorandum, the Parliamentary Under-Secretary at the Department for International Development (Mr Gareth Thomas) welcomes the recognition that rich countries must address the domestic factors that attract health workers from developing countries, but must also support such countries to improve their health systems and workforce planning processes and broadly supports the Programme for Action as set out in the Communication. He continues as follows:

"Many of the policies are already in line with DFID policies on HRH, aid effectiveness or strengthening health systems. We are particularly supportive of points about EU support for action in developing countries to improve staff retention; and EU steps to improve sustainability and longevity of support for health systems. However, we think that the Programme for Action is complex and ambitious, and therefore are concerned about the lack of a more detailed implementation plan. We will be advocating for better planning going forward.

"Paragraph 4.1 (1) of the Communication proposes that '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.' We (including the Department of Health) support this proposal.

"We support the plan to develop a set of principles to guide recruitment. These principles will be modelled on those already in place in the UK. In 2001 the UK, uniquely, instituted a code of practice governing the international recruitment of health workers. It proscribes active recruitment of health workers by National Health Service employers and tries to discourage the private sector from doing so. It promotes the labour rights of international staff working in the UK health sector.

"We do not see the AU and NEPAD as implementing agencies in this context but more as providers of political advocacy, accountability and facilitating lesson-learning across member states. Also, actions at regional level should not cut across AU/NEPAD member state responsibilities. The Programme for Action text proposes 'strengthened AU/NEPAD leadership of regional action' and calls for 'a regional platform for action.' We will propose that the Council Conclusions recognise that this slightly ambiguous statement should not lead to the development of additional AU/NEPAD secretariats seeking to direct the actions of AU/NEPAD member states".

4.14 Looking ahead, he says that the Programme for Action will be considered at the May General and External Relations Council.

Conclusions

4.15 The Minister notes the need for what he describes as a complex and ambitious Programme of Action to acquire the necessary focus of a detailed implementation plan, and to avoid the creation of an unnecessary layer of bureaucracy between the EU and Member States and the African partner countries whose endeavours they are trying to support, and will be pursuing this between now and the May "development" GAERC, which will adopt Conclusions on the Communication.

4.16 We are surprised that the Minister says that the Government supports, without qualification, the proposal in paragraph 4.1.(1) of the Communication, for a concerted European strategy on health professionals within the Community. Neither the Communication nor the Minister explains how this may properly be done under Article 152 EC, which provides only for Community action to complement that of Member States and requires, in Article 152(5) EC, any such action to, "fully respect the responsibilities of the Member States for the organisation and delivery of health services and medical care". We should be grateful for the Minister's comments on whether the envisaged strategy may lawfully be adopted under Article 152 EC.

4.17 We should also be grateful if he would write to us before the May GAERC, by which time the draft Conclusions should be clear, to show how his concerns about the Programme of Action have been met.

4.18 In the meantime, we shall keep the Communication under scrutiny.





6   The eight Millennium Development Goals that, in 2000, the UN set itself to achieve, most by 2015: eradicate extreme poverty and hunger; achieve universal primary education; promote gender equality; reduce child mortality; improve maternal health; combat HIV/Aids, malaria and other diseases; ensure environmental sustainability; develop a partnership for development - each with associated targets and benchmarks to measure progress. Back

7   COM (06) 870, page 2. Back

8   The NEPAD strategic framework document, which was formally adopted in 2001, arises from a mandate given to the five initiating Heads of State (Algeria, Egypt, Nigeria, Senegal, South Africa) by the Organisation of African Unity (OAU) to develop an integrated socio-economic development framework for Africa. See http://www.nepad.org/2005/files/home.php for more information. Back

9   See http://www.africa-union.org/root/au/AboutAu/au_in_a_nutshell_en.htm for further information. Back


 
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