10 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)
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| Legal base | — |
| Department | International Development
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| Basis of consideration | Minister's letter of 20 March 2007
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| Previous Committee Reports | HC 41-xvi (2006-07), para 5 (28 March 2007) and HC 41-vii (2006-07), para 4 (24 January 2007)
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| To be discussed in Council | May 2007 General Affairs and External Relations Council
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| Committee's assessment | Legally and politically important
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| Committee's decision | Cleared
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Background
10.1 This Communication builds on a December 2005 Communication
that looked at the problem of lack of human resources in health
care in developing countries. The focus is 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),[24]
where addressing the crisis in human resources in health is a
prerequisite to making progress.
10.2 "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).
10.3 When we considered the Communication on 24 January, we noted
that, in his accompanying Explanatory Memorandum, the Parliamentary
Under-Secretary of State at the Department for International Development
(Mr Gareth Thomas) welcomed the recognition that rich countries
must not only address the domestic factors that attract health
workers from developing countries, but also support such countries
to improve their health systems and workforce planning processes.
But while broadly supporting what he described as a complex and
ambitious Programme for Action set out in the new Communication,
he said it needed 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. He said he would be pursuing this between now and the
May "development" GAERC, which will adopt Conclusions
on the Communication.
10.4 As to the proposed "pull side" counterpart —
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
— we were surprised that the Minister said that the Government
supported this proposal without qualification. Neither the Communication
nor the Minister explained 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".
10.5 So we asked for the Minister's comments on whether the envisaged
strategy may lawfully be adopted under Article 152 EC, and for
him to tell us, before the May GAERC —by which time the
draft Conclusions should be clear — how his concerns about
the Programme of Action had been met; and in the meantime retained
the Communication under scrutiny.[25]
The Minister's first letter
10.6 When we considered his 20 March letter, we set out in full
the Minister's response to our question about whether Article
152 EC provides a legal base for the proposed strategy because
we could not understand parts of his explanation and were surprised
that he had not given an explicit assurance that the Government
would carefully scrutinise the proposal when it was made to ensure
that it was lawful, proportionate and consistent with the principle
of subsidiarity. We said that we should certainly wish to satisfy
ourselves on each of those points when the proposal is deposited
in Parliament and asked him to ensure that his accompanying Explanatory
Memorandum fully sets out the Government's view of all three issues.
10.7 We were also not reassured by his other comments. We were
not able to understand any more clearly than hitherto, beyond
generalities, what the roles of the AU and NEPAD were to be —
particularly, what the phrase "hold their member states to
account on steps to address the human resources crisis in the
context of regional markets and economic migration" meant.
10.8 As for an implementation plan, all we had so far was that
the Commission would be asked to report progress on the devising
of one before the year's end. What, we asked, would the Minister
do if, come December, the progress report were to show that a
convincing implementation plan was not in prospect?
10.9 We understood that the Presidency was aiming for the adoption
of Council Conclusions based on this Communication, and had no
wish to hold up further detailed work towards this end. But we
did not yet feel sufficiently assured about these issues, both
legal and political, to feel able to clear the Communication,
and therefore continued to retain it under scrutiny.[26]
The Minister's further letter
10.10 In his letter of 16 April 2007 the Minister responds as
follows:
LACK OF IMPLEMENTATION PLAN
"You have asked what I will do if, in December of this
year, the progress report shows that a convincing implementation
plan is 'not in prospect'. The Government is committed to ensuring
that there is an appropriate implementation plan. It must describe
the concrete steps that would be taken in support of the Communication's
expressions of intent.
"As I noted in my letter of 20 March, the draft Council
Conclusions state that, 'The Council calls on the Commission and
the Member States to develop a joint implementation plan and a
framework to monitor EU action on human resources, as set out
in the European Programme for Action, while taking full account
of these Conclusions, and requests the Commission to report by
December 2007 on the progress of all EU action towards solving
the human resources for health crisis.'
"The development of the implementation plan is underway.
On 28 March the Commission set out its intent to consult Member
States fully and have a draft ready for wider discussion by September
2007. The Government will be heavily involved in supporting the
Commission to develop a sensible plan, drawing on our experience
of addressing the health worker crisis in Malawi and Sierra Leone.
If the Government's efforts to guide this process do not result
in a satisfactory plan, the Government will raise the issue in
the relevant Council meetings. If this does not bring an appropriate
response, we will request a discussion at the next relevant Ministerial
meeting (likely to take place in spring 2008)".
AMBIGUITY ABOUT ROLE OF THE AU AND NEPAD
"You asked for more detail about the roles of the African
Union (AU) and New Economic Partnership for Development (NEPAD).
"The African Union is mandated to work towards better
cooperation and policy coordination amongst its member states.
It also cooperates with various relevant regional networks to
ensure a coordinated regional response.
"The European Commission supports this work by providing
financial assistance. €55 million has been allocated over
five years. The intention is to finance actions that the AU would
like to undertake but cannot pay for. Some of this financial support
will be used to build the capacity of the AU unit responsible
for regional health work, which will deal with the human resources
for health crisis. This would include additional personnel to
help the AU to achieve its coordination role, consultant time
with the same objective, travel costs and financing for coordination
meetings.
"For example, this support helped to fund the inter-ministry
meeting of 48 African countries in Botswana on 2-4 March. At this
meeting, senior government officials discussed regional actions
that need to be supported if Africa is to respond effectively
to the human resource crisis. The outcome of this meeting will
be presented to African Health Ministers at the AU Health Ministers
Conference on 11th April in South Africa.
"It is also very important that African countries clearly
articulate their need for support, and their expectations of the
international community in responding to the human resources for
health crisis. The AU facilitates this articulation by coordinating
inputs from member states on the human resource crisis and communicating
it to the international community.
"NEPAD is a strategic framework for development in Africa,
developed by the African Union. It seeks, amongst other things,
to develop partnership between African countries, and accelerate
regional and continental integration, in pursuit of the Millennium
Development Goals.
"You also asked for clarification on how the AU is to
hold its member states to account on action to address the crisis
in human resources for health. The AU does this by helping member
states to draw up and agree targets and benchmarks. It then applies
political support and pressure to member states to reach these
targets.
"For example, the African Health Ministers Meeting in
South Africa on 11th April will endorse the role of
the AU in defining clear regional benchmarks (such as a minimum
health worker to population ratio) on health workforces. They
are expected to agree to define regional benchmarks on rates of
access to health services that are themselves heavily dependent
on effective staffing of health systems — such as skilled
attendance at birth. The AU will scrutinise progress towards these
targets. By monitoring this regularly, the African Union will
help to ensure that its members collect and report the relevant
information.
CONSISTENCY OF THE CONCERTED EUROPEAN STRATEGY WITH ARTICLE 152
EC
"The Committee wanted assurances that the Government
will carefully scrutinise the proposal when it is made to ensure
that it is lawful, proportionate and consistent with the principle
of subsidiarity. I am happy to give such an assurance.
"As I noted in my letter of 20 March, the concerted European
strategy refers to an existing process being led by the High Level
Working Group on Health Services. The Government will ensure the
proposal is made available to Parliament for scrutiny. This is
likely to be handled by the Department of Health".
Conclusion
10.11 The Minister has now provided the clarifications and
assurances that we have been seeking, for which we are grateful.
10.12 We now clear the Communication, at the same time reminding
the Minister, and his counterpart in the Department of Health,
of our expectations with regard to the further scrutiny of, especially,
the legal aspect of any proposal on a "concerted European
strategy " on EU health service professionals.[27]
24
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
25
See headnote. Back
26
See headnote. Back
27
See headnote. Back
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