on Monday, 11 May 2020.

Dear Colleagues,

Here is a subject dear to my heart and critical for achieving global health equity.

“Health Workers for All and All for Health Workers’ was the slogan of First Global Forum on Human Resources for Health, March 2008, Kampala, Uganda.

The COVID -19 pandemic has once again exposed the global health workforce (HWF) crisis that is characterized by wide spread shortages, mal-distribution and poor working conditions. This HWF crisis was documented by the report of the Joint Learning Initiative on Human Resources for Health in 2004. The HWF shortages have today resulted in a silent scramble to recruit health workers from poor countries by the richer countries. This scramble is inspired by the urgent needed to fill gaps in the scaled up COVID -19 responses and to address long standing HWF shortages.

Visa requirements for health workers have been eased and I have seen recruitment agencies openly advertising for health workers from Africa, Asia and the Caribbean in web posts of some government agencies and in social media. These agencies are convening meetings in poor countries to pirate away health workers who are needed more in their home countries. Significantly, some African and Caribbean countries have formally protested against these clandestine recruitment but have been ignored. These countries have been left to appeal to the patriotism of their HWF to mitigate the dreaded exodus that would cripple health systems during these times of crisis.

This piracy of health workers, left uncontrolled, carries a public health threat to all countries of the world and is untenable. The pivotal role played by the HWF in public health and health emergencies as exposed by the COVID -19 pandemic is sufficient to classify health workers as a Global Public Health Good at par with or ahead of vaccines and drugs. The G20 leaders met recently with the WHO and agreed to collaborate in urgently in developing and equitably sharing new technologies including vaccines and therapies for COVID -19. They should also have included HWF in these discussions and it is regrettable that global support for the HWF agenda has declined. So what is the problem?

Evidence from the UN High Level Commission on Health Employment and Economic Growth ( shows that between 2000 and 2010 there was 60% increase in migrant doctors and nurses working in OECD countries and the increase was 84% for those who migrated to OECD from countries previously identified by WHO with critical HWF shortages. Even worse, there are disturbing unethical stories of these migrant health workers being treated differently from local colleagues in destination countries and are impoverished and dying disproportionately from COVID -19.

These global HWF labour market dynamics are driven by demographic realities of ageing populations in the rich countries who require increasing health services and social care which cannot be met by the local labour market. The WB Global Monitoring Report 2015/16 and the UN Population Prospects 2019 Data booklet show declining working age populations in rich countries and the fact that half of worldwide population growth between2019-2050 will come from Sub-Saharan Africa. The Global HWF strategy 2030 estimates a global shortage of 18 million health workers. It points out that in the face of these demographic realities, rich countries will afford to import the health workers that they need while the poorer countries will not have resources to employ their needed HWF. This imbalance leaves global health security in a perilous state that is not acceptable. Fortunately, we have a solution.

The WHO Code on the International Recruitment of Health Personnel ( was adopted by the World Health Assembly in 2010 following acrimonious debates between Health Ministers from rich and poor countries over unregulated recruitment practices. The Code took six years to negotiate and is comprehensive. The objective is to scale up training and share a global HWF pool guided by the Code using voluntary ethical practices; taking into account the rights, obligations and expectations of source and destination countries and above all of the migrant health personnel. The goal is that countries will use the Code, led by Ministries of Health, to negotiate mutually supportive binding agreements for sharing and upholding the rights of all health personnel.

This is an appeal and a call to action for global solidarity and to all countries to take advantage of the COVID -19 pandemic to refocus attention and effort on the global HWF crisis and the WHO Code. This provides the only solution to move from current conflict to collaboration in our quest to provide a skilled, motivated and supported health worker for every person in every village everywhere.

How do we create a global movement that will make this happen?



Comments (7)

  • Carol


    15 May 2020 at 13:34 |
    Thank you Prof. for this conversation.
    The State of the World's Nursing 2020 report which was released recently actually echoes similar issues. It warns that unmanaged migration can exacerbate shortages and contribute to inequitable access to health services. The report shows that 1 out of 8 nurses practices in a country other than the one where they were born or trained.

    It further shows that many high-income countries in American and European regions appear to have an excessive reliance on international nursing mobility due to ageing health workforce patterns and fewer graduates in those countries.

    To this effect, the report recommends that nurse mobility and migration must be effectively monitored and responsibly and ethically managed. Actions needed include reinforcement of the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel by countries, recruiters and international stakeholders.
    Countries that are over reliant on migrant nurses are encouraged to aim towards greater self-sufficiency by investing more in domestic production of nurses. Countries experiencing excessive losses of their nursing workforce through out-migration are also encouraged to consider mitigating measures and retention packages, such as improving salaries (and pay equity) and working conditions, creating professional development opportunities, and allowing nurses to work to their full scope of education and training.

    So, in summary this indeed is timely discussion.

  • Francis


    15 May 2020 at 13:35 |
    Dear Carol,

    This is very nicely put.

  • Godfrey Sikipa

    Godfrey Sikipa

    15 May 2020 at 13:36 |
    Dear Prof Omaswa,
    Thank you for once again raising the critical issue of Health Workforce. I agree with you that the COVID 19 pandemic is likely to exacerbate the situation. The pandemic has also further exposed the unsatisfactory (sometimes risky) conditions under which our health workers operate. While on one hand it is important for the Global Community to address the piracy practices of the richer countries, I also strongly agree with Carol that "Countries experiencing excessive losses of their nursing workforce through out-migration are also encouraged to consider mitigating measures and retention packages, such as improving salaries (and pay equity) and working conditions, creating professional development opportunities, and allowing nurses to work to their full scope of education and training". There is anecdotal evidence that some of the health workers that emigrate from Africa to other countries would be happier at home if working conditions and other social conditions were better than they are now. I think that we should take heed of the recent assertions of the President of Ghana that we should clean our act and address own shortcomings. We do have the resources to address mot of the issues.

    Godfrey Sikipa
    Chief Executive Officer,
    Compre Health Services.
  • Samkange


    15 May 2020 at 13:40 |
    Dear Francis

    Many thanks for this timely dissection of a very difficult but critical issue. I am humbled to think I can add to your immense and powerful contribution.

    Allow me ta address it in two apparently diametric points of view but which are actually inseparable and which, the one view that the GHWA you founded and which IOM espouses equally well: the concept of the individual health worker who has aspirations and needs expressed in the push and pull factors that result in migration; the second view point which is the compelling conflict between the source and destination nations, each grappling with the need to deliver equitable health services to their populations with the destination countries grappling with local distaste for certain jobs and the ease of providing those services using migrant labour while the source countries have to cope with the cost of generating a health workforce and the ever diminishing capacity (plus political willingness) to offer appropriate retention packages, failure of which provision leads to fragile-to-collapsed health services. In the midst of all this is the most ignoble anomaly: the migrant health worker providing essential health services in one country where they have little to no rights as providers.

    As you stated, 2020 is the Year of the Nurse and nowhere are the anachronisms of our realities as a global community more painful than the stark statistic of 1 in 8 nurses being forced to practice out of the source community.
    I believe both source and destination countries are equally to blame for not implementing the agreed ethical recruitment of health professionals. Covid-19 has exposed what governments on both sides were hoping no one will notice; even our governments in low-to-middle income countries have had to acknowledge our contribution in generating the push factors as much as our deafening silence when our brothers and sisters disproportionately die as Covid frontline workers in countries not of their birth.

    Now, more than ever, we need to strengthen our resolve to commit that every heath worker should be valued enough to be appropriately trained so that they are skilled for the job market (we have, as Africans, every reason to be proud that our nurses go to countries with technology our colleagues have only heard about but proceed to utilise it as if they were born to it - such is our quality of training and preparation for life-long learning); we fall short on the appropriately supported and motivated to make a career of these professionals.
    We have reason to ask for aid, but we should not to seek aid to export our brothers and sisters. Let us only seek aid or assistance to enable and empower our colleagues to serve our people appropriately within our communities. We need political resolve to put a value on our health professionals in our states. Governments need to own up to the social contract; the citizens must hold them accountable in this endeavour. We have the resources to do so; our problem is that we manage the resources badly enough for them to appear insufficient.

    C A Samkange
  • adamson


    15 May 2020 at 13:40 |
    I have followed the discussion with much little to add this far. I was waiting to also read thoughts on African countries which produce nurses and other cadres but fail to provide job postings for them. What are the thoughts from the group?

  • Pius Okong

    Pius Okong

    15 May 2020 at 13:43 |
    Thank you Francis for this eloquent exposure of the critical and eminent threat to the health workforce and the health of the citizens of our countries.
    Governments and the public in general are naturally focused on the immediate personal threats of COVID 19, personal safety etc. There is also understandably much focus on PPEs and to some extent on risk allowances for health workers.

    Strategic matters of a "policy nature" such as health worker migration are remote in the radar of leaders in our countries. Many countries rely on health workers already in service or "volunteers" for case management, surveillance etc. In Uganda, the Health Service Commission (HSC) brought to the attention of Government the dangers of overloading health workers already in service, jeopardizing care for other health conditions but instead recruit additional health workforce. The response to this was positive positive.

    Government made available additional resources to employ additional staff. The Commission has recruited a pool of more than 600 health workers from which the MoH can draw for "instant" deployment. These health workers are engaged on contract basis, this is a much better approach than volunteers. There are still challenges, some not resolved such as welfare of these workers, accommodation, risk allowances etc. As care and surveillance gets more decentralized to regional Referral Hospitals and even Districts, ensuring additional human resources becomes more difficult, but these are discussions ongoing.

    As a way forward:
    Firstly, advocacy to our governments, to employ the health workforce not formally in service in Public, Private and PNFPs for COVID-19 emergency response can be an important avenue to absorb the health workforce locally.
    Secondly, a deliberate engagement of stakeholders to tackle the "brain drain" issue should be pursued, through discussions on webinars, zoom meetings and may be signing petitions to our Governments and corresponding High income country Governments?

    These might be small steps, but worth considering.

    Bets regards,
  • Miriam K. Were

    Miriam K. Were

    18 May 2020 at 07:55 |
    Dear Francis,

    This is a very timely concern as can be seen from the responses given so far.
    It is clear that action is needed both from developed countries that recruit health workers (especially Nurses and Midwives) from developing countries AND the developing countries from which the health workers are recruited.

    I write to comment on the issue highlighted by responses of Carol Natukunda and of Godfrey Sikipa. This is the importance of improving the terms and conditions of health workers in developing countries; especially in Africa. In personal communications with me, a number of health workers who leave our countries have informed me that the push for them to go work out of their countries is the need to finance higher/professional education for their children.

    As it seems that financing higher/professional education for offsprings is a major push factor, countries which health workers leave could help address this problem by setting up scholarships from which the offsprings of health workers could obtain support. Alternatively or in addition, an organisation such as ACHEST can consider setting up and fundraising for provision of a Scholarships Fund from which African health workers could have access for their offsprings so that they do not have to go work out for this.

    With best wishes,
    Miriam K. Were

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