International Health Worker Migration and Recruitment

Global Governance, Politics and Policy

Nicola Yeates, Jane Pillinger

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781317391791
• Edition: 1
• Topic: Politica e relazioni internazionali
• Subtopic: Politica sociale

This book is the first comprehensive study of international health worker-migration and -recruitment from the perspective of global governance, policy and politics.

Covering 70 years of history of the development of this global policy field, this book presents new and previously unpublished data, based on primary research, to reveal for the first time that international health worker-migration-and -recruitment have been major concerns of global policy-making going back to the foundations of post-war international cooperation. The authors analyse the policies and programmes of a wide range of international organisations, from WHO, ILO and UNESCO to the IOM, World Bank and OECD, and feature extended analysis of bilateral agreements to manage health worker migration and recruitment, critiquing the claim that they work in the interests of all countries. Yeates' and Pillinger's ground-breaking analysis of global governance presents an assiduously researched study showing how the interplay and intersections of several global institutional regimes – spanning labour, migration, health, social protection, trade and business, equality and human rights – shape global policy responses to this major health care issue that affects all countries worldwide. It discusses the growing challenges to public health as a result of the globalisation of health labour markets, and highlights how global and national policy can realise the health and health-related Sustainable Development Goals for all by 2030.

This research monograph will be of key interest to students and scholars of Global Governance, Global Public Policy, Global Health, Global Politics, Migration Studies, Health and Social Care, Social Policy and Development Studies. Policy makers and campaign activists, nationally and globally, will appreciate the practical relevance and applications of the research findings.

1 The global dynamics of international health worker-migration and -recruitment policy

1 Global governance, social policy and a new lens on health worker-migration

The last two decades have witnessed a resurgence of academic and policy research on international health worker-migration. Thanks to the cumulative efforts of myriad research projects and programmes to elucidate international trends in the international mobility of health professionals – physicians, nurses, midwives, dentists, occupational therapists, surgeons, pharmacists, pharmacologists, psychiatrists and health administrators – and to chart and assess the diverse measures to manage such flows, we now have a reasonably comprehensive picture of the scale, drivers, dynamics and consequences at the national level of this major social phenomenon affecting most, if not all, countries worldwide.

Yet for all the advances in the state of knowledge in this field there remains a significant void in the otherwise rich literatures that abound on this subject. With nearly all studies focusing on trends in relation to specific countries worldwide and the national measures they put in place to manage health workforce mobility, the main concern of research and analysis has been domestic spheres of policy-making and governance. Thus, it is the national ideational drivers, regulatory institutions, policy actors, processes of policy-making, and the content of national policy and its outcomes that command the overwhelming share of attention. This ‘methodologically nationalist’ orientation has dominated the research field on this topic (as so many others in the social and political sciences) to such an extent that questions about how the governance, politics and policy of this major social phenomenon play out on a transnational scale in cross-border spheres of governance have not been the dedicated focus of extensive research. None of the otherwise rich research literatures on global migration governance, global health governance or global social governance considering the role of cross-border spheres of governance in policy formation policy have attended to international health worker-migration or -recruitment as a field of global governance and policy formation in its own right or as an issue within those wider fields. Nor have studies on national policy initiatives and responses tended to wholly engage with the now-extensive literature on transnational actors as major organisational features in policy formation (Yeates 2018a).

Although this is a significant gap that this book aims to fill, we are not working from a totally ‘blank canvas’. Global institutions have not been the explicit subject of extended research in relation to this issue, though the little analysis of this that does exist has been written from a health planning perspective which is concerned with the practicalities of health workforce organisation, planning and management (hence that literature’s use of the term human resources for health). Moreover, it focuses on just one global initiative – the World Health Organisation (WHO) Code of Practice on the International Recruitment of Health Personnel (WHO 2010a) (e.g. Bourgeault et al. 2016; Buchan et al. 2016; Campbell et al. 2013; Dhillon 2016). This has elicited rich data and analysis which we draw on in the book. Even so, the focus of those studies is very much from a global health perspective, and the wider social and public policy contexts of health workforces as a vital development resource and global issue is largely absent from them. Compared with other areas of social or public policy concerning comparably important ‘global challenges’, this is a notable and lamentable gap in the research field.

As a result, we know far less than we should – or could – about the ‘shape’, nature and characteristics of international health worker-migration and -recruitment from a global governance and policy perspective. The state of knowledge about how state and non-state actors act ‘outwardly’ in spheres of cross-border governance of different kinds to influence or pursue goals and objectives on this issue is all too rudimentary, as is understanding of how different global institutional regimes intersect and what their impacts are. Because of these analytical and data gaps, we do not yet have a full picture of the global dynamics of global policy and governance. Empirically and analytically, these are significant omissions which this book aims to help fill. Because of the salience of health worker-migration as a key contemporary social issue, the dearth of research into these global governance aspects of its dynamics significantly limits in turn our understanding of how the globalisation of health care economies, social reproduction and social development more broadly are unfolding. This means that there are unfulfilled opportunities for theory development in relation to the contemporary condition of the global governance of health, the welfare state, and social restructuring, including the conditions lending weight to certain policy ideas in particular settings becoming dominant or changing. Of significance are the implications of this gap for policy as political practice. Not having a fuller understanding of cross-border spheres of governance as active sites of policy formation and resource mobilisation also means that we do not have a clear picture of the implications of the full force of globalising dynamics in all their varied forms for realising the right to health as a universal and indivisible human right as well as a global development goal. This limits understanding of what opportunities do actually exist to realise those rights and goals.

This state of affairs is even more anomalous because this is a highly active policy field. In 2013 we undertook a short survey of contemporary international initiatives in the field of ‘human resources for health’ (Yeates and Pillinger 2013). We identified a rich, dynamic and complex terrain. It was one that we found to be actively ‘populated’ by numerous social actors, multiple policy spaces and myriad initiatives. We found at least eight multilateral organisations, two global campaign coalitions, and five global forums, partaking in policy-making, standard-setting, technical assistance, data systems, and research on international health worker-migration. We found numerous initiatives of different sorts: normative frameworks for rights-based approaches to migration; voluntary codes on the ethical recruitment of health workers; diasporic initiatives aimed at ‘brain gain’ and development for source countries; data and forecasting on future health workforce requirements; measures aimed at scaling up health workforce capacity, and international partnerships revolving around health worker-migration.

Our finding that there were multiple modes of international cooperation, coordination and integration at work also suggested there is a wider story to be told beyond one of an ever-growing list of actions and projects by international organisations (IOs).¹ Numerous global initiatives were regularly issued and renewed, and followed common identifiable logics, in ways suggestive of systematised knowledge production and resourcing, pointing to the existence of a highly-institutionalised sphere of governance and policy. Such activity was recurrent, even if the forms it took were diverse, over time and across organisations. Moreover, a critical density of activity in the form of projects, partnerships, and policies spanning multiple organisations was apparent. In addition, this highly active, yet complex, terrain was underpinned by a set of universally shared norms that transcended any one country. The right to migrate, to health and to decent work, together with international human rights and trade considerations, shaped myriad policies and initiatives emanating from cross-border spheres of governance. In short, this was more than a set of ad hoc activities: it was a rules-based field shaped by social norms, laws, political and financial resources that were mobilised in various ways, and which cohered, stabilised and gave meaning to the multiple initiatives underway.

Furthermore, the governance structures and policy approaches involved were marked less by overall agreement or unification than by multiplicity, fragmentation and variance. IOs as diverse as the United Nations (UN), World Bank (WB), Organisation for Economic Cooperation and Development (OECD), and International Organization for Migration (IOM) were all active participants in this field. Just as each brought their own approach to social and economic policy so too they brought their own approach and agendas to bear on the question of the international migration of health workers. It is not just that these approaches could be readily identified but that they vied with each other, such that it seemed to matter which organisation is involved in what initiative – not least because it was a guide to what were to become the dominant discourses and approaches in the evolving field. At the time, we looked at a restricted set of organisations and their responses in this field, but we were already aware that more extensive research – both in terms of covering a wider range of organisations and over a longer period of time – would have uncovered a greater number and range of social actors. We were also aware that it would also have brought to the fore the multiplicity of structures and modes of governance shaping health worker-migration. Extended research would, we felt, have identified a far more complex, and ultimately more interesting, way into what was evidently a major global social formation and a ‘new’ realm of global governance, with its own material, ideational, institutional foundations, dynamics, consequences and impacts. In all, the range of initiatives and organisations we found in our initial research provoked our intellectual curiosity to understand better the institutional frameworks in which they were negotiated and the multiplicity of actors, ideas and resources involved. The findings of that short study suggested the additional extensive, in-depth research that has become this book.

Since that time, the global policy field has become if anything increasingly dynamic and ‘busy’. Besides the WHO Global Code (2010a), health workforce availability, universal health care and labour migration issues are all the subject of major global initiatives. The health workforce, including its migration, is anchored into the Sustainable Development Goals (SDGs) (UNGA 2015),² reflecting the now-widely accepted precepts that it is a cornerstone of effective health systems and sustainable development. This ‘mainstreaming’ has supported calls for greater accountability in policy-making at all levels for health impacts on the basis that there are significant public policy consequences of weak health systems for population health and well-being.³ Such global initiatives intersect with on-going global campaigns for universal health coverage (UHC) that are also multifarious in their organisational composition. As the complexity of the initiatives has grown, so too has understanding of the nature of the issues at stake. By way of illustration of this, we invoke the titles of three recent publications which cogently encapsulate understanding of the significance of health worker-migration as one of the foremost global social issues of our time. One report, jointly commissioned by the Global Health Workers’ Alliance (GHWA) and WHO aptly states No Health Without Health Workers (Campbell et al. 2013). The second and third are editorials from The Lancet: No health workforce, no global security (The Lancet 2016) and Health-care workers as agents of sustainable development (The Lancet Global Health 2015). Collectively, these titles convey how international health worker-migration is increasingly understood as a matter of the utmost strategic significance for public health, for human security and for social and economic development for all countries, at whatever their ‘level’ of development, worldwide.

In short, health worker-migration has become the subject of active policy making at the global level and in cross-border spheres of governance involving myriad institutions, actors, ideas and campaigns, but it has not been the direct focus of academic or policy analysis. In this first major study of this issue from this perspective, we elucidate the contours, dynamics and impacts of global governance and policy with regard to highly skilled health worker-migration. The remainder of the chapter introduces the subject of the book at further length. Section 2 sets out the overall aims of the book and defines its scope. Section 3 discusses the salience of our study of international health worker-migration and -recruitment in terms of theory and policy. Section 4 describes the sources of research data underpinning the study and the methods used to construct it. Section 5 explains how the research materials are organised and key elements of the argument on a chapter-by-chapter basis. Section 6 provides a brief note about the terminology used throughout the book and statement about the social values underpinning it.

2 Aims and scope of the book

Our book aims to contribute to filling major analytical and empirical gaps in research on health worker-migration and -recruitment governance, politics and policy with a view to contributing to the research literatures on global social governance and policy more widely. Based on rigorous original research, it presents the results of a comprehensive social policy study from the perspective of its global governance and the social politics of global policy formation. In this, we offer the first extensive and sustained academic global policy analysis of international health worker-migration and -recruitment. We examine in depth the origins, initiation and development of the global governance of international health worker-migration and -recruitment as seen through the lens of the global policy field as it has unfolded over the last seven decades. To this end, we examine:

• the diverse institutions, actors, norms, discourses, policies and practices that constitute global governance and policy in respect of international health worker-migration and -recruitment;

• how this issue is framed and taken up by diverse social actors within institutions of global governance and global policy-making;

• the material, ideational and normative foundations and drivers of the global politics, policy and governance of international health worker-migration, in historical and contemporary settings; including how (and why) these have changed over time;

• how global policy initiatives are addressing (or are attempting to address) the causes and consequences of health worker-migration in source and destination countries worldwide – and their effectiveness in doing so; and

• key issues and priorities for global policies in the light of the SDGs, with a particular focus on diverse and interlocking commitments on health, labour, social protection, human rights and equality, and socio-economic development.

Our study seeks to elucidate answers to questions such as: How and why have cross-border spheres of governance become such important sites of action on international health worker-migration? What kinds of policy approaches and solutions are taken up by global organisations and how have they become instituted in key global initiatives? What are the implications of the overall trajectories we see in this global policy field for the policy space and creative opportunities for transformative solutions to emerge?

As a Social Policy study of the globalisation of international health worker-migration and -recruitment policy, we contest the idea that this phenomenon can be comprehensively understood only from the perspective of health workforce planning or a ‘human resources for health’ perspective. This statement may initially seem counter-intuitive but, we contend, it is only by situating the creation and reproduction of this global policy field within a broader landscape in which questions of power, social justice and social development feature prominently that the structural and institutional features of the global governance of health worker-migration can be fully revealed. Furthermore, just as the roots of health workforce availability and international migration reside outside of the health sector, so we look at global health regimes in relation to other regimes operating in different sectors. Thus, we deploy a multi-sectoral analysis of the global policy field that is cognisant of myriad intersecting socio-institutional regimes that include the health sector but extend way beyond it. Indeed, we argue that it is only possible to comprehend the global governance of this phenomenon using such an approach. It is precisely the intersections among multiple global institutional regimes spanning health and migration, as well as social protection, equality, trade, business and human rights governance, structuring the dynamics of global policy formation in this area in which we are interested. In doing so, we ‘rescue’ analysis of the phenomenon solely as a matter of and for health, to emphasise its wider significance for social provision and as a matter of direct concern to international economic and social development more broadly. In a context where the causes of high levels of health worker-migration that we see today lie in long-term trajectories of uneven and differentiated development, the ‘institutional intersectionalism’ that we show is a central feature of global governance in this area also helps understand the complex and often contradictory pressures on individual health workers to emigrate for work abroad as well as on policy-makers at global, regional and national levels.

Before elaborating the analytical tenets of the study, it is important to clarify what lies within and what outside the scope of the book. Falling squarely within its scope is the sphere of multilateral (cross-border) governance and policy-making as seen through the ideas, norms, laws, rules, and initiatives emanating from IOs such as the UN, WB, OECD and World Trade Organization (WTO). We consider these organisations in depth: they are prominent global policy actors whose role in shaping the contours of this global policy field has never before been mapped. We also include bilateral modes of governance because of the close relationship between bilateral and multilateral modes of governance in migration, trade and development policies. Indeed, bilateral agreements are a prevalent mode of this global policy field, and they have been promoted by major global policy actors over many decades. Such agreements are highly significant in the discursive and institutional rise of ‘circular’ and ‘return’ migration approaches, and they are inseparable from wider currents that are eroding the right of migrants to permanent settlement and the emergence of differentiated (and unequal) migration rights. Our inclusion of bilateral modes of governance allows us to further elaborate on a major theme in this global policy field.

Falling outside the scope of this study are multilateral governance on a world–regional scale. Regional organisations such as the European Union (EU), Association for South-East Asian Nations (ASEAN) and the Caribbean Community (CARICOM), amongst others, are becoming increasingly active and ‘vocal’ in this domain (Yeates 2014a, 2018a; Yeates and Pillinger 2013, 2018). However, they cannot be accommodated within the confines of the book. For the same reason, we do not cover the impacts of global policies on national policy-...