Actions on inequities in int’l recruitment of health workers urged

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Cape Town/Geneva, 20 April (Lauren Paremoer and Nithin Ramakrishnan) – Developing countries are seeking concrete measures to address inequities in the international recruitment of health workers.

A Resolution on the Global Code of Practice on the International Recruitment of Health Personnel is scheduled to be adopted at the 79th Session of the World Health Assembly (WHA79) to take place from 17 to 23 May at the WHO headquarters in Geneva.

This resolution attempts to address structural inequities faced by source countries caused by the uneven progress in the application of the different provisions of the Code.

The Code approved in 2010 by WHA63 is intended to be a core component of bilateral, national, regional and global responses to the challenges of health personnel migration and health systems strengthening.

In ongoing negotiations, developing countries have called for concrete measures such as ring-fenced taxation to address inequities, emerging from the migration of workers. The developed countries continue to oppose.

Ring-fenced taxation is a proposal to address the brain drain from developing to developed countries due to the migration of health workers. According to this concept the tax gains from migrant health works in destination countries are to be used proportionately for the strengthening of health systems in the source countries.

A core group of countries including Bangladesh, Germany, Pakistan and the Philippines are taking the lead in the negotiations for this draft resolution, following the decision made in the 158th Session of Executive Board (EB158).

Currently, the Draft Resolution has 9 preambular paragraphs and 5 operative paragraphs. The draft also proposes an annex that contains certain text additions to the Code of Practice based on the “Box. 2 Recommendations” made by the Expert Advisory Group (EAG) in its report to the EB158.

The first operative paragraph (O.P.1) adopts the annex.

O.P.2 urges WHO Member States inter alia, to strive for sustainable health workforce policies, planning, partnerships, investments and practices that reduce the need for international recruitment and, in parallel, support the strengthening of the health systems in source and destination countries.

O.P.3 urges destination countries benefiting from international recruitment of health personnel to make co-investment arrangements.

O.P.4 and O.P.5 are requests to partner organisations and the WHO Secretariat respectively.

The most contentious issue is O.P 3, where co-investment arrangements are sought to ensure proportional benefits in the health systems and workforce development in source countries.

O.P. 3 states: “ URGES destination countries benefiting from international recruitment of health personnel to establish structured, measurable and transparent co-investment arrangements to ensure proportional benefits in the health systems and workforce development in source countries, [having a  mutual  agreement between both source and destination countries] including, for example, skills partnerships; official overseas development assistance, health, education or other budgets; recruitment fees charged to destination countries or employers; or  other mechanisms related ringfenced taxation of migrant health workers´ income gained in destination countries in line with WHO’s guidance on bilateral agreements on health worker migration and mobility;  …”

According to sources familiar with the discussions, developed countries, in particular European countries, are opposing both the mention of ring-fenced taxation, as well as the entire paragraph urging financial contribution towards source countries. This is despite the EAG report explicitly noting that “High-income destination countries make substantial savings on the costs of health professional education through international recruitment, while the desired investments in low- and middle-income source country health systems have not materialized to yield the expected proportional benefits”.

The WHO guidance on Bilateral agreements on health worker migration and mobility also explicitly calls for investment of financial resources in the country of origin of health workers from various sources from the destination country, for example, official overseas development assistance, health, education or other budgets; recruitment fees charged to destination countries or employers; and ring-fenced taxation of migrant health workers’ income gained in the destination country.

It must be noted that co-investment is already a replacement of the requirement for financial assistance for the source countries to be provided by the high-income destination countries. There are concerns that language of ‘co-investment’ opens inroads to the financialization of public health systems and it is in this context, financial sources like ring-fenced taxation becomes important rather than private or donor-fund investments.

The EAG Recommendations and the Politics of Co-investment

While emphasising the need for co-investment on health workforce development and health system strengthening in source countries, the EAG warns that “demographic shifts and increasingly market-driven mobility of health workers may widen health inequalities and heighten risks to global health security, unless proactive measures are undertaken by both source and destination countries, in line with the principles of the Code”.

Therefore, the EAG called for strengthening of the Code’s implementation, monitoring and accountability. In this regard, the EAG provided two boxes of recommendation: (a) Specific measures for Member States, the WHO Secretariat and relevant stakeholders to ensure the effective application of the Code over the next five years (Box 1); and (b) Additional elements to be included in the Code (Box 2).

Regarding co-investment, Box 1 requests the WHO Secretariat and other stakeholders “to convene source and destination countries to strengthen capacity and negotiation processes and skills to promote co-investment dialogues on the health workforce, including measures to address the drivers of migration in source countries”.

In addition, the Secretariat and other stakeholders are tasked with providing support for developing and evaluating bilateral agreements; providing technical support for capacity development; engaging in research; and otherwise engaging in efforts to strengthen adherence to the code amongst relevant stakeholders.

Box 2 on the other hand proposes the following additions to the WHO Code, with respect to co-investments:

“Member States which rely on international health personnel, irrespective of the pathway of mobility or type of recruitment, are encouraged to partner with source countries on mutually beneficial strategies and targeted co-investments in specific areas of the health workforce and health systems in the source countries. Partnerships, technical collaboration and financial support”

“Donor agencies, global health initiatives and international financial institutions are encouraged to co-invest in priority areas of health systems identified by countries as requiring support, with investments across the entire health worker life cycle (education, employment and retention) to optimize the management and performance of the health workforce and improve population health”.

In language echoing the Lusaka Agenda, Box 2 emphasises the necessity of aligning foreign financial flows with domestic health priorities. However, the reliance on donor funding and international financial institutions, including those pursuing a for-profit agenda, despite research showing the harmful impact of private actors’ financialisation of global health, raises concerns.

These recommendations formed the basis of intense negotiations among Member States. Developed countries, supported by the WHO Secretariat, initially favoured a narrower approach – advancing elements akin to those in Box 2 through a resolution.

However, many developing countries are pushing for a more equitable outcome, highlighting the need for bilateral agreements and financial measures like ring-fenced taxation, quoting WHO guidance.

Can Ring-fenced Taxation Promote Equity?

At the heart of the current negotiations lies a fundamental issue of equity: co-investment in source country health systems.

Each year, thousands of healthcare workers, doctors, nurses, and technicians, trained in low- and middle-income countries (LMICs) migrate to high-income destination countries. While this mobility is often voluntary and sometimes facilitated through bilateral agreements, its systemic consequences are uneven. Source countries bear the cost of training and capacity-building, while destination countries benefit from immediate workforce integration.

The EAG report explicitly acknowledges this imbalance (page 2), noting that destination countries achieve substantial savings in education and training costs, while proportional benefits have not accrued to source countries.

Empirical evidence reinforces this conclusion. For instance, a recent UK parliamentary inquiry estimated that the National Health Service has saved approximately £14 billion in training costs by employing internationally trained doctors and nurses, with £1.1 billion saved in a single recent year.  Similarly, European countries such as Germany have increasingly relied on foreign-trained professionals from other EU member states to address workforce shortages.

Despite longstanding recognition of this imbalance, there is little evidence of structured measures promoting investment from destination countries whether in training institutions, workforce retention strategies, or health system strengthening in source countries.

In this context, ring-fenced taxation has emerged as a particularly contested yet important proposal. Properly understood, this does not imply imposing additional taxes on migrant health workers. Rather, it refers to allocating a defined portion of tax revenues already generated from migrant workers’ income within destination countries toward supporting health systems in their countries of origin, as part of mutually agreed intergovernmental arrangements. This approach aligns with WHO guidance and represents one of several tools to operationalise co-investment in a measurable and equitable manner.

Some developed countries however resist the proposal, citing concerns over sovereignty and fiscal autonomy. While these concerns are not insignificant, they must be weighed against the broader imperative of fairness in an increasingly interconnected global health labour market.

The geopolitical context: Intensification of push factors

These negotiations are unfolding against a challenging geopolitical backdrop. Rising global inflation, energy price volatility, and ongoing conflicts have constrained public spending, particularly in developed countries. Simultaneously, shifts in geopolitical priorities have led to increased defence expenditures, often at the expense of development and health financing.

Regions like the African continent are experiencing cuts to overseas development assistance, much of which was used to support workers in essential programmes like HIV/AIDS care and maternal and sexual and reproductive health services. This has not only resulted in cuts to essential services, but in job losses amongst workers responsible for delivering them.

Furthermore, health workers and health care sites have increasingly become targets of armed conflict. As seen in Gaza in particular, longstanding norms embedded in the Geneva Conventions that define health workers as a protected category of people during conflict have been systematically ignored. This is not an isolated problem, as evidenced by reports of attacks on health and care workers in other ongoing conflicts, e.g. Lebanon, Ukraine and Sudan.

All these contribute to additional “push” factors driving health and care workforce migration from economically and politically unstable countries with overstretched health systems to look for opportunities abroad. This pattern of migration to middle income and high-income countries is likely to continue in coming years.

Consequently, LMICs will forfeit the benefits of investing in health and care worker training. On the other hand, out-migration of health and care workers trained in LMICs will continue to contribute to health system strengthening and expansion of the tax base in destination countries where these workers find employment. In this sense health and care work force migration echoes a similar pattern of subsidisation of high-income countries by LMICs that we see in debt repayments, natural resources and labour.

In this context, while co-investment has become the buzz word, measures like ring-fenced taxation is a strategic necessity if access to health care in source countries needs to remain accessible and affordable.

Source: Third World Network