International Cooperation and Development

Promoting sustainable employment in the health sector in developing countries

Brussels1 April 2019

Working for a healthier future

REPORT ofthe Workshop

On the occasion of The Future of Work Centenary Initiative of the International Labour Organisation (ILO), the European Commission Directorate-Gen-

eral for International Cooperation and Development (DEVCO) organised a workshop in Brussels on 1 April 2019 on ‘Working for a healthier future’. This workshop aimed to assess how to promote sustainable employment in the health sector in developing countries, identify key chal-lenges and develop the knowledge base on the topic, in order to better inform practitioners and policy-makers.

This one-day informative, interactive and collaborative workshop brought together more than 60 participants and involved 14 high-level speakers, representing various international organisations and associations, academics and experts. It was a day full of rich and deep exchanges that led to a consensus about the need to understand that health is not only a contribution to human development but is also a motor for economic development. Moreover, the health sector represents a unique opportunity for women

and young people who seek a career in the medical field; therefore, it is important to offer them an attractive pro-fessional environment that promotes decent work.

The workshop was opened by Marietta JAGER, DEVCO Deputy Director-General and closed by Jan PAEHLER, Head of DEVCO Sector Health and Erwan MARTEIL, DEVCO Head of Sector Migration. The debate was mod-erated by Marisol TOURAINE, international consultant and former French Minister for Health, Social Affairs and Women’s rights. The workshop was organised under three separate but complementary themes. The day was organ-ised with three panel discussions, followed by three parallel working groups on:

• Skills development and decent work in the health sector

• Health and demography

• Health, innovation and well-being

Marietta JAGER, DEVCO Deputy Director-General.

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PANEL INTERVENTIONS AND DISCUSSIONS

1. Skills development and decent work in the health sector.

Four speakers intervened in this first panel:

• Stefano SIGNORE, DEVCO Head of Unit Migration and Employment

• Christiane WISKOW, Health Services Specialist, Sec-toral Policies Department, ILO

• Sana de COURCELLES, Executive Director of Sciences Po Paris School of Public Affairs, former political advisor to the WHO Assistant Director General

• Jim CAMPBELL, Director of the Health Workforce Department, World Health Organisation (WHO)

The main issue addressed throughout the workshop was to figure out how and to which extent the health work-force is not only necessary to provide better care to the population but also exploring how the development of the health sector can be an economic opportunity for creating more decent jobs. Reference was made to the High-Level Commission on Health Employment and Economic Growth (ComHEEG)’s report issued in 2016, including its recommendations and the subsequent ILO-OECD-WHO ‛Working for Health’ five-year action plan to implement them. For this commission, the health workforce is a vital

determinant to better address health needs. Sana de Courcelles and Jim Campbell reminded the audience of the reasons why this commission was originally created and of its key findings: investment in the health sector is not only a cost but also a catalyst for social and economic development promoting jobs and growth, especially for women and youth. However, inaction threatens the world’s health security and the attainment of the SDGs, thus it requires an inter sectoral policy dialogue at the highest level, engaging education, employment, finance, migration, gender and health, to address the global shortfall of 18 million health workers, primarily in low- and lower-middle income countries.

Health and social work workforce

Health and social work workforce

Men

Health and social work workforce

Women

Women - % of total employed in helath

and social work

World 3.9 2.0 7.0 69.6

Africa 1.5 1.0 2.0 59.5

Americas 7.6 3.1 13.8 76.7

Arab States 2.8 2.1 7.2 37.8

Asia and the Pacific 2.5 1.6 4.0 58.8

Europe and Central Asia 9.6 3.7 16.8 78.9

Employment in the health and social sector2018: 130 million jobs worldwide; 3.9 % of total employment Health and social work workforce as a percentage of total and degree of feminization by region

Source: ILO calculations on labour force and household survey microdata ILO, 2018

Group photo with the moderator and all speakers.

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There was a consensus among participants to empha-sise the creation of decent jobs in the health sector as an essential condition for achieving the 2030 Agenda: it is an illusion to believe that universal health coverage can be achieved by 2030 without tackling the shortage of health professionals in most developing countries.

Stefano Signore, from DEVCO, highlighted that in order to create millions of jobs in the health sector, it is necessary to change the approach acknowledging that services too can provide employment in developing countries, and not only in the agricultural or industrial sectors. The example of the Philippines is particularly interesting, since this country is training more health professionals than it needs for its own population and can therefore transfer thousands of professionals abroad: this evidence shows how health training can become a business asset. In order to succeed in creating and retaining jobs in the health sector, a few conditions are essential: governments should decide to expand health coverage and invest in this area; they should encourage the emergence of a new skilled workforce and involve the private sector. Stefano Signore recalled DEV-CO’s commitment to facilitate the implementation of these new approaches but also the huge challenge of finding the necessary financial resources.

Christiane Wiskow, from ILO, put forward the point that health employment is not limited to medical or paramed-

ical professionals, but it also includes other occupations such as managers, administrators or cleaning personnel. Moreover, she said, there is a need to adopt a broader approach considering multiplier effects: for one job in the health sector there is the potential to create between 1, 5 to 2, 3 additional jobs in the health sector and beyond. Sana de Courcelles presented the case of the Panzi Hospi-tal in Bukavu (Democratic Republic of Congo), that became the ‘beating heart of the local economy’ and an important contribution towards the area’s development thanks to Dr. Mukwege’s commitment to end violence against women in conflict zones.

Jim Campbell from WHO cited WHO data demonstrating that investment in the health workforce represents approx-imately 50 % of the SDG3 Price Tag to achieve universal health coverage. When factoring in the education budget, the investment in the health workforce reaches as much as 80 %. These jobs particularly benefit women, as 70 % of the global health workforce are women. Decent work and the elimination of gender inequalities in the health and social workforce must underpin national policies.

All speakers insisted that a strong political commitment and appropriate funding are crucial in achieving the goal of improving care for patients while at the same time creating more decent jobs in the health sector, especially in developing countries.

Inequities in access to health careShare of population without access to health care due to health workforce shortages, 2014

Rural - urban divide:Population without access to health care due to health workforce shortages:

52% rural,

24% urban

77% rural population in Africa 2015)

Source: X. Scheil-Adlung et al., 2015

90

80

70

60

50

40

30

20

10

0

Low-income countries

Lower- middle-income

countries

Upper- middle-income

countries

High-income countries

84

55

23

0

Perc

enta

ge o

f po

pula

tion

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2. Health and Demography. Four speakers made a presentation:

• Jan PAEHLER, Head of the Health Sector, DEVCO B4 Unit Culture, Education and Health

• Ibadat DHILLON, Technical Officer, Department of Health Workforce, WHO

• Laurent AUJEAN, Policy Officer, European Commis-sion, DG Migration and Home Affairs, Unit Legal Migra-tion and Integration

• Malik SAMASSEKOU, Advocacy Officer, ARCAD-SIDA Mali, Member of Coalition Plus

This session assessed the opportunities and the challenges of systemic demographic changes including migration between and from developing countries as well as the way to address their implications for the availability of health professionals. Demographic and epidemiological transition will further drive demand for health and social care in a context of global shortages, considering population needs. All participants expressed how politically sensitive this issue is in Europe today. Jan Paehler stressed that governments need to understand that migration can represent an opportunity; many people work in a country different from the one in which they were trained. Circular

migration provides the opportunity to have an additional specialisation. Ibadat Dhillon explained that the reality of migration is by far more complex than what we could imagine. As an example, he mentioned that more and more people move from their country of origin to another to undertake their training, then they move again to another country for work. The movement of health workers is not simply from the Global South to the Global North, there is substantial South-South movement as well as North to South movement. Some countries, such as Cuba, also actively encourage migration of their professionals. Other countries, like South Africa, receive many health profes-sionals thanks to better employment prospects and work-ing conditions.

Laurent Aujean presented the similar findings at European level: 10 to 15 % of health professionals active in the EU are estimated to come from a different country than the one they work in, either from another European country or from a third country. Despite the EU wide recognition of professional qualifications, in a number of EU countries health professionals originating from third countries exceed those from other EU countries. Since there are and will be huge needs of health professionals in Europe, notably because of the ageing of professionals and large replace-ment needs, it is important to focus on attractive training conditions for international students. It remains important

Source: WHO, 2017

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to promote mobility and encourage international solutions and agreements to regulate health professionals’ mobility, either on a bilateral basis (the successful examples of a triple-win agreement between Germany, the Philippines and ex-Yugoslavian countries, is the result of labour unions involvement) or within the framework of regional agree-ments and international standards. In order to avoid a risk of fragmentation, a joint voice is needed; therefore, some participants called for international agreements as a priority. For Ibadat Dhillon, it is important that health stakeholders are involved in the development of bilateral agreements to mitigate the negative effects on source countries’ health systems.

Still, from developing countries perspective, it is necessary to avoid the adverse effects of brain drain. The question is then: what are the relevant incentives to retain health professionals in their countries? The discussion resulted in several outcomes. First, professionals need a positive and rewarding environment, and by investing in health sys-tems, governments give themselves the means to retain their professionals. Second, governments should invest in tailored training matching needs. Third, it is necessary to look at the situation through a gender lens and offer women more opportunities to reach leadership positions in the health sector. Finally, yet importantly, these jobs must be decent, which is often not the case. Christiane Wiskow from ILO emphasised that decent jobs includes good training and career prospects, fair remuneration, adequate social protection, and must be free from dis-crimination and harassment.

Malik Samassekou brought a different perspective to the discussion by insisting on the importance of the role of community health workers. The shortage in health pro-fessionals in the public sector or as private medical prac-titioners makes it unavoidable for associations and NGOs

to step-in. Still, Malik Samassekou considers that even if there were enough professionals, associations would be necessary to help doctors and nurses to get access to the most remote and vulnerable populations, considering both geographical and social factors. In West and Central Africa, 75 % of HIV-AIDS patients do not have access to appropriate treatments: the fight against epidemics involve a change of perspective, by emphasising the role of the community but also the need for task shifting.

Many speakers, both from the panel and from the audi-ence, insisted on one point: it is not enough to invest in training; there is a need to promote training for various professions in the health sector. There is the temptation to focus exclusively on doctors, while nurses, medical assistants, caregivers among others, can per-form many of the required tasks. Therefore, innovative approaches must be adopted and task shifting should be promoted without compromising on the quality of care and availability of specialists.

3. Health and Demography. Five speakers made a presentation:

• Jacques BIOT, Advisor to companies in the field of digital transformation and artificial intelligence, former Head of the Ecole Polytechnique, Paris

• Nick TOMLINSON, Global Health Advisor in the Health Division of the OECD

• Jesus RUEDA RODRIGUEZ, Director International Affairs, MedTech Europe

• Michel GOLDMAN, Medical Professor, Co-director of the Institute for Interdisciplinary Innovation in Health Care, Brussels

• Louis PIZARRO, Head of SOLTHIS, Therapeutic Soli-darity and Initiatives for Health

New technologies and innovations are rapidly trans-forming health organisations, services and oppor-tunities. Professionals and patients would have better care and better health services if they have access to those technologies. Still, the disruption of new technolo-gies in the health sector leads to different and sometimes contradictory realities: some professionals fear that more technology leads to less workforce, while governments may tend to believe that technology is the ultimate solution to all problems. While public-private partnerships could be a solution, they require regulations.

Panel discussion.

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Jacques Biot emphasised that new technologies and innovative approaches would allow developing countries to accelerate the modernisation of the health sector by improving diagnosis and allowing access to remote areas. However, the success of their implementation requires a few conditions, among which is an interdisciplinary approach. New technologies will enable the optimisation of resources and free useful time for professionals. This opinion was shared by Nick Tomlinson, who stressed the challenges of new technologies and highlighted that the access to technology is not equally shared by everyone everywhere. Still, he identified four benefits of new tech-nologies: an improvement in clinical practice, a better system management, a faster detection and response to public health emergencies and support to research and innovation.

Speaking from the MedTech point of view, Jesus Rueda Rodriguez highlighted the need for a systemic change. It is an illusion to believe technologies will solve all the problems in the health sector. They represent new oppor-tunities, indeed, but some of them require a lot of digital knowledge to be used which means different training and maintenance capabilities are required to use these tech-nologies effectively. He stressed that it is important to promote the simplest technologies available which can be used with minimum digital knowledge and financial means in low resource settings.

It is necessary for the developing countries to change their health environment first if they want to ben-efit from new technologies. While many governments believe that the change in the health environment will

come from technology, innovation and new technologies require a mental shift and a different approach based on innovation and structural changes. If these new perspec-tives are not adopted, there would be a real risk of wid-ening the gap between high or middle-income countries and low-income countries.

Michel Goldman was convinced that innovative approaches based on public-private partnerships are crucial in order to address situations in which the private sector is lacking investment incentives. This is essential to address major public health challenges such as antimicrobial resist-ance and development of drugs for neglected diseases in developing countries. He underlined the importance of an appropriate governance and regulatory framework to ensure that the public investment fulfils its objective in these partnerships. More generally, developing coun-tries are facing such dramatic situations that they require innovative approaches rather than the reproduction of what succeeded in richer countries. Louis Pizarro insisted on the need for task shifting as an important innovation, since it leads to new jobs descriptions. He also pointed at the risk of vertical or silo approaches and the need for more cross-cutting policies. He strongly insisted on the point that innovation has to be addressed from a social and human perspective, and that strengthening health systems is an essential objective to achieve sustainable development.

The question of vertical versus horizontal approaches, of sectoral versus multi-sectoral policies, is probably one of the most striking conclusions of the workshop that most of the speakers raised in their interventions.

Many factors are pushing for digital-based health

Patient demands for modern experiences, responsiveness, communications and transparency

Increasingly complex

care needsmake delivering

high quality caremore challenging

Tight fiscal conditions

put pressure on health systems to deliver value

for money

New therapiesand betterresearchrely on our abilityto make better use of data

OECD, 2019

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4. WORKING GROUPS Three working groups extended the debate through smaller groupings of participants and closer exchanges on each thematic topic. Participants were asked to debate around the question: in order to facilitate the creation of jobs in the health sector, which recommendation(s) would they address, first to the European Commission (EC) and the international development community, and second to developing countries?

GROUP 1: SKILLS DEVELOPMENT AND DECENT WORK IN THE HEALTH SECTOR

The participants formulated four recommendations both to the EC and developing countries.

For the European Commission and international development community, the participants recommended to promote a systemic approach by establishing new funds integrating and mixing the different levels of health needs; to strengthen health systems; to support countries’ national health workforce strategies; to support contextualised evi-dence on health workforce challenges and use it for policy dialogue with partner countries. It would help to convince governments that it is worthwhile investing in health jobs.

For developing countries, participants symmetrically recommended to enhance the implementation of national health strategies, to create a status for health and social workers, to implement the WHO Global Code of Practice on the International Recruitment of Health Personnel and to encourage technical and concrete work between experts from different departments.

GROUP 2: HEALTH AND DEMOGRAPHY

The participants recognised potential for greater inter-min-isterial coherence across within countries (e.g. education, health, labour, migration, foreign affairs).

For the European Commission and international development community, participants recommended achieving more consistency between domestic and interna-tional development policies, implementing more systemic and multisectoral policies, having an explicit discussion and strategy (short, medium and longer term) about health workforce shortages and needs, and implementing shorter trainings for professionals.

For developing countries, participants proposed fixing an objective to train enough health professionals to retain them for domestic needs before exporting them, to invest in rural areas, to provide financial and accommodation incentives to attract health professionals and to invest in strengthening the health systems.

GROUP 3: NEW TECHNOLOGIES, INNOVATION AND WELL-BEING

For the European Commission and international development community, the participants identified four grounds for efficient investments: entrepreneurship (local, scaling up solutions, women and youth projects); high education and multidisciplinary training programmes; circular training exchanges north/south/north; new meth-odologies to demonstrate evidence beyond randomised controlled trial (RCT).

For developing countries, the group made two recom-mendations: first, they should support a national and mul-ti-sectoral approach for infrastructure investment in the health sector; and they should deploy a comprehensive data policy, including data protection, ownership, quality and standardisation.

Working group session.

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CONCLUSION

Several converging points emerged from the conclusive workshop discussions, which reflect the recommendations made by the working groups. As a conclusion, they can be briefly summarised as follows:

• First, the need for a political rather than a technical approach: the development of the health workforce has to be supported by a high-level political debate and commitment, and the European Commission should facilitate this process.

• Second, regarding governance, the European Commis-sion as well as governments should embrace a mul-ti-sectoral approach rather than a thematic, vertical one. It is probably one of the most difficult tasks to achieve, but crucially important for a positive change. A mental shift in the policymaking process is needed.

• Third, the need for renewed content of training programmes that should evolve and consider the new opportunities provided by technologies. Task shifting should be promoted systematically, shorter training programmes should be encouraged and realistic and rewarding career perspectives must be offered to health professionals.

• Fourth, reducing inequalities through health workforce policies to be formulated with the objective to address economic, social, gender, territorial or cultural inequali-ties. While health work in general provides great oppor-tunities for women in accessing decent work and gender equality, it is important that women have equal access to opportunities at decision-making levels. Non-discrim-ination and security at work need constant attention and should be addressed from both a prevention and remedy perspectives.

• Last, there is a need to develop a global approach to sustainable employment in the health sector: develop-ing countries will not succeed in promoting a sus-tainable health workforce without investments in strengthening their health systems. The European Commission together with other stakeholders have a key responsibility to support a compre-hensive approach in order to unlock the potential of job creation in the health sector and contribute to the sustainable development of partner countries.

Drafted byMarisol TOURAINE

Moderator

All accompanying documents: Programme, background paper and useful documents here.DEVCO’s Deputy Director General Marjeta Jager’s speech here.Presentations of speakers here. Photos from the workshop here.

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Family Name Name OrganisationAmlaiky Nour-Dine INSERM/CLORA

Astor Evelyn International Trade Union Confederation

Aujean Laurent European Commission

Bärtel Cathrine Havmøller Standing Committee of European Doctors (CPME)

Barthes Anne Médecins du Monde Belgique

Bayès Sara Barcelona Institute for Global Health

Bemelmans Marielle Wemos

Biot Jacques Ecole polytechnique, past president

Campbel James WHO

Carvajal Francisco Mission du Chili auprès de l'UE

Casado Barbara B&S Europe

Chadwick Vince Devex

Concha Carlos Mission du Chili auprès de l'UE

Coomans Yasmina Ecole de santé publique ULB

Couffignal Manuel DEVCO B4, Unit Culture, Education and Health

Cretu Anca EfVET

Culligan Kevin UNICEF

Dalla Riva Donata Medici con l'Africa CUAMM

Darjusch Tafreschi GIZ

Das Sarada Standing Committee of European Doctors (CPME)

De Courcelles Sana Sciences Po, Paris

De Paolis Maria Rosa DEVCO B3, Unit Migration and Employment

Dhillon Ibadat WHO

Diallo Lamine DEVCO B3, Unit Migration and Employment

Diop Thierno Seydou Schuman Associates

Doidin Dimitrescu Constantin

DG Sante

Emrni Boutaina Maastricht University

Fromont Anne UCL

Gamalejeva Jelizaveta Eurideas

Gassier Emilie Croix Rouge Française

Genova Edoardo B&S Europe

Goldman Michel 3IHealth

Gyselincu Xanel Enabel

Heerschap Jean Paul DEVCO B3, Unit Migration and Employment

LIST OF PARTICIPANTS

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Family Name Name OrganisationHendrix Ron DEVCO B3, Unit Migration and Employment

Iturriaga Julene selp

Kakule John Fred ACP Secretariat

Marteil Erwan DEVCO B3, Unit Migration and Employment

Martinez Mar DEVCO B4, Unit Culture, Education and Health

McGinty Mark GOPAcom & B&S

McWeeney Gerry WHO Office at the EU

Mensah Priscilla Hochsccule Bonn-Rhein-Sieg

Mosqueira Irene Danish Red Cross

Ndarugirire Beatrice European Commission DEVCO

Nhlekisana Thembiso Tlotlo Hochschule Bonn-Rhein-Sieg

Oppizzi Matteo DEVCO

Oprisan Ioana DEVCO B3, Unit Migration and Employment

Overeem Marijke self-employed

Paehler Jan DEVCO B4, Unit Culture, Education and Health

Pizarro Louis Soltis

Plonka Beata DEVCO B3, Unit Migration and Employment

Pomatto Valentina Humanity & inclusion (Handicap International)

Proost Tinneke Johnson & Johnson Corporate Citizenship Trust

Reinicke Matthias DEVCO B4, Unit Culture, Education and Health

Riscanu Cornel European Commission

Rodríguez Begoña SOCIEUX+ EU Expertise on Social Protection, Labour and Employment

Samessekou Malik Arcad-Sida, Mali

Scholler Kathrin DEVCO B3, Unit Migration and Employment

Signore Stefano DEVCO B3, Unit Migration and Employment

Singla Siddharth Avocat-Consultant

Tomasina Jacopo EMERGENCY ONG ONLUS

Tomlinson Nick OECD

Touraine Marisol Moderator

Val Elena IOM MHD

Van Renterghem Henk UNAIDS

Vertmann Thor-Sten EU Commission, DG DEVCO

Winter Regina Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ)

Wiskow Christiane ILO

Yildirim Heval Agrinatura

Zerrou Kenzo WHO