Of the global shortage of 10 million health care workers needed by 2030, more than half, or about 6.1 million of the shortage, is in the African region, according to the WHO. In high-income countries, international recruitment is often used as a stop-gap solution, resulting in a reliance on migrant health workers who constitute 46% of nurses and 64% of doctors in some settings. This reliance perpetuates inequities and places further strain on developing countries that are already grappling with workforce shortages while continuing to lose their health workers to migration.

Between June and July 2024, Public Servicees International (PSI) conducted a survey among its affiliates to examine the challenges and opportunities that health and care sector unions are facing on the issue of health workforce migration. Thirty-nine unions in 35 countries representing both origin and destination countries of migrant health workers responded to the survey. The findings from the survey provided the evidence that PSI, as an independent stakeholder, submitted to the World Health Organization (WHO) during the 5th Round of reporting on the implementation of the WHO Code of Practice on the International Recruitment of Health Personnel (WHO Code). The evidence, as well as recommendations from the report, are referenced in this article.

Challenges Post-Pandemic

The COVID-19 pandemic underscored the vulnerabilities of health workers. Praised as essential, many health workers faced intensified workloads, mental health challenges, and unsafe working conditions. PSI survey revealed that 45% of respondents believe health workers are now more vulnerable than ever. Temporary gains in recognition during the pandemic have been rolled back, leaving many workers unprotected and undervalued.

Unethical Recruitment Persists

Despite the existence of the WHO Global Code, unethical recruitment practices persist. Many unscrupulous private recruitment agencies exploit migrant workers, charging them exorbitant recruitment fees and committing acts of fraud and misinformation thereby leaving migrant health workers buried in debt and trapped in a vicious cycle of exploitation. There were also reports of private recruiters actively recruiting in countries that fall within the WHO Health Workforce Safeguards and Support List. PSI findings indicate that only 19% of countries fully comply with the WHO Code, with many countries failing to monitor or enforce its principles effectively.

Community Health Workers are filling the gaps

Community health workers play a vital role in addressing workforce gaps and in delivering primary health care especially in underserved areas. In middle-income and low middle-income countries, community health workers are predominantly women, who are often poor, racialized and marginalized women. They are undervalued, they work without formal recognition, receive very little compensation and have limited access to training and to social protection.

The importance of Collective Bargaining

Collective bargaining agreements have proven to be effective in improving salaries, benefits, and working conditions for health workers. Through collective bargaining, unions are able to negotiate for better conditions and win health workers’ rights, thereby improving workforce retention and strengthening quality and delivery of health services. According to the PSI survey, such agreements strengthen occupational safety in 60% of cases and improve retention in 76% of cases. However, migrant workers, particularly those on temporary contracts, are frequently excluded from these agreements, leaving them vulnerable to exploitation.

Recommendations: Towards Building a Strong and Sustainable Health Workforce (PSI, 2024)

1. Global Social Responsibility and Funding of Public Health Services

PSI advocates for health as a fundamental human right and a public good. Governments must prioritize funding of public health services as prerequisite to ensure universal health coverage. PSI has been documenting evidence of the impacts of healthcare privatisation in increasing health inequalities, depriving patients and care recipients of access to quality health care, staff reductions and deteriorating working conditions for health and care workers often resulting to high attrition rates, staffing shortages, as well as out- migration. Public funding of universal health care systems is crucial to address health inequalities and achieve universal health coverage. This includes investments in the health and care workforce that prioritises people over profit. To support low-income countries, high-income countries must provide technical and financial assistance, including debt relief and fiscal space to expand health budgets.

At the heart of health care systems are the health and care workers, the majority of whom are women and many are migrant workers. Despite their valuable contributions, they remain undervalued and unrewarded, enduring poor working conditions, low pay, discrimination, and limited access to training and career advancement. Genevieve Gencianos

2. Strengthening the WHO Global Code

The WHO Global Code must be strengthened to ensure full compliance and robust monitoring. Multi-stakeholder awareness-raising and social dialogue can help build the support for the active implementation of the WHO Global Code so that it directly promotes migrant health and care workers’ rights and supports efforts to strengthen quality health care systems of all countries. In this regard, it is essential that all relevant stakeholders, in particular health and care sector unions, are actively involved in consultation processes to implement and inform reporting on the WHO Global Code, including in the conduct of Health Labour Market Analysis.

3. Guaranteeing Labor Rights

Labor rights for all health workers, including migrants and temporary workers, must be safeguarded. This includes the right to freedom of association and collective bargaining. Expanding union representation and involving trade unions in national health workforce planning are critical steps. PSI findings reveal that only 7% of unions were consulted in national reporting under the WHO Global Code, highlighting a significant gap in the WHO Code implementation.

4. Bilateral Labor Migration Agreements (BLMAs)

Government to government BLMAs must be designed to promote ethical recruitment and to protect the rights of migrant workers. BLMAs that are grounded in human rights, core labour standards, the ILO Fair Recruitment Guidelines and the WHO Global Code principles, and supported by social dialogue, can be effective tools to guarantee the rights of migrant health and care workers, ensure fair and ethical recruitment and mitigate the negative impacts of migration on health systems.

5. Promoting Social Dialogue at all stages of the migration cycle

Social dialogue is essential for shaping rights-based, gender-responsive and sustainable labor migration policies. Governments, employers, and unions must work collaboratively across all stages of the migration cycle. PSI research shows that 72% of respondents identified social dialogue as a priority for workforce sustainability. Effective dialogue can enhance worker protections, improve retention, and ensure equitable health policies.

6. Building Alliances with Civil Society

Along with social dialogue, building coalitions between trade unions and civil society in addressing the global health and care workforce crisis, including movement-building around issues of health equity, labour rights, gender equality, climate, tax and economic justice are crucial to defending universal access to health and care systems in both the global North and the global South.

Conclusion

The global health workforce crisis is symptomatic of an on-going crisis of equity, lack of decent work and the systemic underfunding of public healthcare systems. Addressing this requires a bold, systemic and holistic approach. PSI’s comprehensive strategy --underscoring decent work, gender-responsive and rights-based migration policies, fair and ethical recruitment, fundamental labor rights, and sustainable public funding -- provides a roadmap for achieving universal health systems that leave no one behind. By placing health workers at the center of solutions, we can build resilient, equitable, and quality healthcare systems that uphold the human right to health for all.

Reference

• PSI, 2024. Read the full report, Strengthening the WHO Global Code of Practice on International Recruitment of Health Personnel: Evidence and Recommendations, Public Services International (PSI), September 2024. https://publicservices.international/resources/publications/full-report-strengthening-the-who-global-code?id=15480&lang=en