The global demand for healthcare professionals is increasing. With Global Skills Partnerships (GSP) industrialized countries want to co-finance the training of health workers in low and middle-income countries - for the domestic and foreign labour market. In the recently published FES Perspective Remco van de Pas and Corinne Hinlopen talk about the challenges and risks of GSPs in the health sector. We spoke with them about their findings.

FES: Why are so many states, NGOs international organizations interested in the concept of GSP?

Corinne Hinlopen: As an NGO concerned with the right to health for all, Wemos is intrigued by the fact that there is an increasing number of collaborations that facilitate health worker mobility, and an increasing interest in engaging in such collaborations. The rise in GSPs are a manifestation of the global scramble for qualified and motivated health workers in a globalized labour market that’s facing enormous shortages. So it’s tempting to try to fill those shortages by moving health workers around, even if this is futile if we do not also invest in more health workers, for everyone, everywhere. 

Remco van de Pas: Due to demographic changes, the growing demand for long-term care services and economic shifts, the health care sector will become one of the main leading economic sectors globally.  This will lead to 40 million health care jobs to be generated by 2030, with demand mostly in high-income countries. This “pull” for skilled health workers causes countries and employers to look for labour forces outside the country and European Union. GSP are a possibility to do this in an ethical sustainable way if they are governed and regulated properly, with the interests of all involved being respected and guaranteed.

CH: Exactly. And the problem is that we do not have a clear picture of who is behind those collaborations, and whose interests they are representing. Many of these arrangements are quite non-transparent. We find that worrisome, because there is actually a lot at stake when facilitating health worker migration: the well-being of the migrant health workers themselves, their labour rights, the position of women health workers especially, who traditionally are more migrant then men, the resilience of health systems in the source countries, to name but a few. And when there’s money to be made in lucrative deals, who will care for those rights and possible negative side-effects? Who will make sure that the migrant workers enjoy a proper induction period? Have equal labour rights to domestically trained carers, nurses, doctors? Receive the same salaries? Are not discriminated in their daily work? And who will prevent that countries become totally drained of precious human resources?

In your paper you say that the notion of GSPs is still contested. What do you mean by that?

RvdP: It is contested because the framing by some actors is that it is a public-private partnership model that generates “a triple win” benefit for all actors involved, such as the labour migrants, the employers, and the governments involved in the source and destination countries. However, from our research we have not seen the evidence yet that there is a sustainable model or exploratory case where this mutuality exists and benefits are distributed in an equal way.

CH: We are concerned that this ‘branding’ of an agreement as a GSP – implying a genuine triple-win model - will be used to legitimize labour migration agreements that do not necessarily pay attention to all the interests involved. And especially the interests of the countries and the individuals who stand to lose most.

The International Council of Nurses says that low- & middle-income countries suffer from ‘brain drain’ of nurses that threatens their public health services. Could GSPs do something about the shortage of health care workers in these countries?

CH: Of course there are ways to achieve this. Imagine a situation whereby a high-income country would like to employ a certain number of nurses and doctors from a particular lower income country that suffers from health worker shortages itself. The destination country could then decide to pay for the training of nurses and doctors to be employed there, but also for a contingent of nurses and doctors that would stay to work in their home countries. Better still, and in many cases very necessary, this donor could work with other donors to create quality jobs in the source country’s health system and guarantee a reliable funding source for those jobs, so that job opportunities are actually available to the new graduates. It doesn’t make sense to train new nurses, doctors and other health workers if there are no jobs for them. It would just create frustration.

RvdP: To take it a step further: yes, in theory, GSPs are able to contribute to solving the shortages. But they should be developed as part of institutionalised, long-term bilateral and multi-lateral health and labour governance mechanisms, including Word Health Organisation’s Code of practice on the international recruitment of health personnel. These governance mechanisms should secure social rights, portability of pensions and insurance, as well sustainable financing to the health and education systems and institutions of origin where the nurses are coming from. Without those mechanisms, there may indeed be a risk for a drain that is not compensated properly.

What other challenges and risks do you see with regard to GSP in the health sector?

RvdP: the main challenge is that public finance carries the risks of those partnerships, and they secure, or even ‘ bail out’  the project and partners when there are difficulties, while at the same time the profits flow to employers and private investors. The risk of the public sector, hence the tax payers, subsidizing private capital is considerable. GSP will only work if there is a clear agreement and monitoring about the shared responsibilities involved and if this is done through a proper social, tri-partite dialogue, with a proper representation by labour unions. 

CH: My main concern is that the proliferation of Skills Partnerships will grow exponentially and unchecked. I’m all for collaboration to solve the world’s shortage of health workers, but we should realize that this resource is not finite. Instead of just moving health workers around, we should also increase our investments in the global pool of health workers. But this requires more patience, a sustainable development vision and more money. That’s why this should be tackled in a more structured and systematic way, bilateral between countries, and multi-lateral in cooperation with the big players, think WHO, World Bank, ILO, and preferably also big global health initiatives such as the Global Fund (to fight Aids Tuberculosis and Malaria), the Global Vaccine Alliance, Pepfar, and the like.

What distinguishes the healthcare sector from other sectors, such as the automotive industry, when it comes to the introduction of GSP?

CH: To put it bluntly: the right to manufacture or own a car is not enshrined in the Universal Declaration of Human Rights. I really don’t care where cars are produced and who buys them. But it’s different altogether with health care, because the right to health has been acknowledged as a fundamental human right. We, humanity, have decided that people have the right to health and that governments have the responsibility to make health care, cure, prevention services available to all, in equal measures. The Sustainable Development Agenda has reiterated this right to health and made it more actionable. So in this day and age, increasing the level of health and preventive care for some (in richer countries), by depriving others (in resource challenged contexts) of the same level of care, by siphoning away their nurses, doctors and other health and care workers, is just not acceptable. That’s why we should carefully monitor this proliferation of GSPs.

RvdP: the health care sector is an ‘artificial’ labour market as its services are not only driven by economic and financial incentives. Health care is a human and social endeavor that is for a large part still done in an informal, reciprocal manner. Without the recognition that (an essential level of) health care is a common good and human right, there is a risk of cherry-picking, meaning that the least complicated and cost-effective health services might become commercialized and privatized, and more complicated or less cost-efficient care, with ‘ difficult’ patients left to the underfunded public sector. So, once we start to see health care beyond its economic merit alone, it is possible to debate on, and decide, how to organize it for the better in Europe and beyond.

What are your three key recommendations to policy makers when designing Skill Mobility partnerships like GSPs?

RvdP: Have an eye for sustainability, make it inclusive including a social dialogue, realize that GSP need to be embedded in a broader multilateral governance effort whereby social and health rights are guaranteed.

CH: Make sure you have the right people around the table, including representatives from health workers, labour unions, health managers, Ministries of Health. Keep an eye on the long-term goal: health for all. Take credit when you have succeeded to truly reconcile the interests of all parties concerned and replicate your success.

Remco van de Pas is a public health doctor, academic lecturer and global health researcher. He is a research fellow at the Institute of Tropical Medicine, Antwerp and research associate at Netherlands Institute of International Relations Clingendael. He teaches on Global Health at Maastricht University.

Corinne Hinlopen holds an M.Sc. in Sociology and Development Studies and a Master’s in Public Health and has extensive public health work experience, in the Netherlands as well as abroad. She currently works as global health advocate with Wemos Foundation where she focuses on human resources for health, health systems, the Sustainable Development Goals and ‘leaving no one behind