Ethical recruitment of health professionals – Madrid, 17th June 2011 Coordinating spaces - The Netherlands example Dr. Remco van de Pas Wemos foundation, The Netherlands On behalf of the Medicus Mundi International network

Current trends in Dutch health sector Demographic changes (23.7 % pop. > 65 year in 2035) Health-adjusted life expectancy inceased to 73y. Increase health care expenditure (25% of income 2020) Health care reform since 2006 Government role changed from steering to safeguarding 1.1 Billion budget cuts public health care (2011) Social protection changes (retirement increases to 67y.)

Trends in the health workforce Due to retirement amount of HCW will not increase Care will become more complex due to chronic illnesses Expected need of extra HCWs in 2025 Investments in education, self-sufficiency, carreer- opportunities and working conditions Immigration of HCW from outside EU: 200 temporary labour permits in 2008, of which 50% from LICs Shift from restrictive towards selective immigration (So called circular - or knowledge transfer migration)

Foreign policy and international development cooperation Change of government early 2011 Migration important topic for current government ODA reduced from 0.8 % to 0.7 % Int. cooperation focus on economic development, less on poverty reduction Thematic focus on water & food security and SRHR Bilateral assistance on health reduced considerably, multilateral investments for health-related MDGs remain (WB, GAVI,UNFPA, UNICEF, EC, IHP+, GFATM, WHO)

The Dutch HRH Alliance Created on initation by Wemos in 2009 Recognizing the challenges on workforce development and international shortages, maldistribution and migration Intersectoral initiative with aim to advocate and facilitate dialogue with government departments and health sector players on HRH related policies Composed of professional associations, labour unions, INGOs and CSOs, academia and independent experts Shared strategic plan, policy papers and media statements, roundtable discussions, advocacy via MP

Implementation of the CoP and the role of civil society 1. Contributing to implementation and monitoring framework developed by WHO 2. Translation CoP, awareness raising at national level 3. Creation multisectoral HRH network and observatory 4. Stakeholder analysis and dialogue facilitation 5. Data-collection, research and monitoring 6. Development of bilateral or multilateral agreements 7. Address health governance, SDH and macro- economic conditions that are root causes for health worker migration

Principles for intersectoral approach on HCW development and migration Right to health in Netherlands and in global context Freedom of movement of health personnel Joint responsibility for health as a global public good Health in all policies and coherence for development CoP on the international recruitment of health personnel Self-regulation via national healthcare governance code Sustainability and (e)quality within Dutch health system

National Government Ministry of the Interior and Kingdom Relations Ministry of Health, Welfare and Sports Minister of Immigration and Asylum policy Ministry of Social Affairs and Employment Ministry of Economic Affairs, Agriculture and Innovation HRH – alliance WHO EU Immigration and Naturalisation Service (IND) UWV Werkbedrijf CIBG KNMG O&R RVZ CEG SER Employer Organizations Health Care Institutions (Employers)Health Workers (Employees) Dutch labor unions and health professional organizations Social Partners Recruitment Offices National International Labor Inspectorate (Arbeidsinspectie) Works Council Agency SzWDGIS EPSCO NZa BoZ ZIP StAZ Abvakabo V&VN Capacity Body Ministry of Education, Culture and Welfare International Affairs (IZ) MEVA Health Council Ministry of Foreign Affairs Advisory Councils Executive Governmental Organizations Inspectorate Agencies Dutch Civil Society Organizations International Organizations IOMWRR Recruitment of Foreign Health Personnel Health Care Governance Commission

Current situation PROBLEM APROBLEM B (SLUITPOST) Shortage HRH Netherlands - Financing of education (pre- service&post-graduate) - Attraction, retention Foreign recruitment PRIMARY ACTIONSSECONDARY ACTIONS – STIMULATING SECONDARY ACTIONS - COUNTERING - Education Fund (specialized)- Knowledge Migration (specialized) - Working permit (non-highly skilled) GOALS (WHO CODE) - Self-sufficiency-Ethical - Compensation -Collection and exchange of data -Guaranteeing rights Solutions / actions

Technical: Lack of qualitative data Responsibilities: MoH is responsible for bilateral agreements MoSE is responsible for work permits MoH is responsible for Opleidingsfonds MoE is responsible for numerus fixus MoFA is concerned with migration and development, but development efforts are targeted at countries with low HDI (not where migrants come from) SER advice on migration, brain drain and health care is not addressed to MoH Information: technical and responsibilities on HCW migration

Conceptual model of policy implementation (Adapted from Bressers, 2004, Spratt, 2009)

Motivation and power StakeholderObjectives/ responsibilitiesMotivationPower Employers- HRM – recruitment at low costs - HRM – quality - Post-graduate education - Good governance, ethical recruitment - Implementation Code ?? ++++ Recruiters- Attract and recruit health personnel -Acquire Hallmark? - ?? ++++ Minister of Immigration and Asylum and IND - Making NL attractive for highly skilled migrants and foreign students needed in the NL - prevent permanent migration of low- educated migrants - More power to the referent (e.g. employer) -Concerned with negative impact of knowledge migration to NL (drain) - + / MoH and CIBG - Quality of care - Accessibility of care - Affordability of care - Power with the market, self regulation / ?? - +++

Motivation and power – continued StakeholderObjectives / responsibilitiesMotivationPower Ministry of Foreign Affairs - Creation of global conditions that serve NL interests - Development cooperation policies - Migration in general (not health in particular) and pro-poor - Coherence between policies regarding developing countries - Piloting managed migration through temporary/ circular migration - ?? - + ?? ++ Ministry of Social and Labour Affairs and UWV - Functioning national labour market - Good working conditions - Professional development - Participation in labour market - Guaranteeing labour migrants rights - Recruitment from EEA first ?? Ministry of Education - Pre-service education of HRH based on planning with VWS and capacity organ- / ?? +++

Motivation and power – continued StakeholderObjectives / responsibilitiesMotivationPower Min. Economic Affairs - Time efficient procedures for attracting highly skilled migrants -++ Insurance companies - Quality of services - Costs of services Professional organizations - HRH quality - HRH motivation (workload, …) - HRH status (nurses, medical specialists) - HRH protection - HRH freedom to move - HRH international solidarity + + / (+) Ministry of Finance - Budget allocation for health and education sector Advisory and inspectorate bodies -SER and WRR: Labour migration does not solve problems - NZa: expand numerus fixus and aio places - Arbeidsinspectie: supervision knowledge migrants CSOs- Health system strengthening in LICs+++

First conclusion of mapping stakeholders and powerrelations Information: Responsibilities are with different actors Motivation: Non-matching interests between actors Stakeholders responsible for implementation code are not highly concerned with the effect of foreign recruitment on health systems in developing countries Interaction: Seemingly difficult to convince actors of value of making links and intersectoral agreements What other Powers can be targets or strategic alliant? Eg Ministry of Finance

Next steps for research and advocacy In-depth qualitative information of motivation and interaction between stakeholders: - Agree general principles in the CoP? -Does the CoP match your goals? -Principles CoP reflected in existing Dutch Code? -Possibilities and limitations implementing CoP in NL? -Ideas stakeholders, roles, powers and responsibilities? -Ideas about incentives, monitoring and enforcement? Writing of a publication and media involvement Round table dialogue with champions of health sector Support data-collection and reporting national focal point Exchange with other alliances and governance platforms

International mobility of health workers - an ethical approach For more information, find HRH dossiers at: