Terms of Reference
I. Background
The Member States of the African Union have long expressed – at regional and global fora - the need to maximize benefits and mitigate adverse consequences with respect to the migration of skilled personnel. See as example, the 1977 UNGA Resolution on “Reverse Transfer of Technology” which called on developing countries to make a thorough evaluation of the “brain drain” challenge; urged developed countries to support the absorption of trained personnel in developing countries; and as a matter of urgency called on Member States and competent international organizations to formulate policies to mitigate the adverse consequences associated with “brain drain”(A RES 32/192). The discussions on “brain drain” have been particularly prominent with respect to the health sector, with the term itself coined due to the loss of NHS doctors to other western countries in the 1950s.[1]
Over half a century later, the international migration and mobility of health workers is accelerating, with patterns of mobility growing in complexity. Data provided by 80 WHO Member States identifies that currently, across countries, over a quarter of doctors and over a third of dentists and pharmacists (unweighted averages) are foreign-trained. The State of the World’s Nursing Report additionally points to one in eight of all nurses globally as practicing in a country different from where they were born.[2] The education of health professionals has also internationalized, with a significant number of individuals moving for education prior to again moving for employment. As illustration, over half of Nigerian International Medical Graduates practicing in Ireland did not study in Nigeria; with Hungary, Romania, Bulgaria and Poland as their leading destinations for education.
Data from OECD countries identifies increasing dependence on foreign-trained health workers, with many African countries serving as important countries of origin for migrating doctors and nurses: e.g. Nigeria, Egypt, South Africa, Kenya, Ghana and Zimbabwe. Demographic pressure is expected to result in increasing demand for foreign health workers in OECD countries. As example, Germany and the UK, respectively estimate health worker shortages to grow to 500,000 and 350,000 by 2030, with both intensifying international recruitment related efforts.
Patterns of health worker mobility are not limited to movement from developing to OECD countries, with substantial South-South and intra-regional mobility. Indeed, Gulf countries and several African countries are themselves important destinations for migrating African health workers. Qatar, as example, with over 90% reliance on foreign health worker, relies heavily on Egypt, Sudan and Libya for doctors, on Ghana and Senegal for nurses, and on Algeria and Libya for pharmacists. Moreover, half of emigrant doctors from Uganda are estimated to have moved within the continent, primarily to East and Southern Africa. South Africa’s leading source of foreign-trained doctors are from Nigeria and the Democratic Republic of Congo. Moreover, over 90% of Namibia’s doctors are foreign-trained with most from other African countries. The temporary mobility, rather than solely permanent migration, of African health workers is also increasingly evidenced.
Over the last six months, in the context of COVID-19, there has been a further rush to fill domestic health workforce through international recruitment of health workers. Countries, particularly high and middle income, have enacted regulatory measures, offered priority pathways for residence and citizenship, and arranged special funds to ease international health worker mobility flows. In contrast, several low and lower-middle income countries, including African Member States, have sought to place restriction on emigration and raised direct concern to WHO. Indeed, African and global commentators have identified the current context as a “global scramble for health workers”.
The issue is one that was specifically discussed at the 73rd World Health Assembly in November 2020, with recognition that strengthened implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel (WHO Code), including targeted support and safeguards for countries with the greatest vulnerability, is necessary for countries to move towards Universal Health Coverage together. WHO Member States in unison committing to ethical principles and practices of the Code, with Member States of the African Region committing to strengthen Code implementation and calling on strengthened investment and cooperation in the area. A key point of discussion was to ensure that health system interests, and associated cooperation, were explicitly considered in discussions on health worker mobility.
African Union Policies
The African Continental Free Trade Area, with the objective of progressively promoting trade in service and movement of persons, as launched in 2019, is an important landmark in regional cooperation. Operationalization of the ACFTA, particularly with respect to the mobility of health workers, requires focused attention on the concerns and interests of health systems and stakeholders.
The AU Agenda 2063, like the UN SDGs, emphasises the inter-relatedness and need for strengthened coherence across sector. As such, Aspiration no. 1 of the AU Agenda speaks to “ A prosperous Africa based on inclusive growth and sustainable development”, with Goal 3 focused on Healthy and well-nourished citizens. A key target of the Agenda is to ensure that “By 2023, all forms of malnutrition, maternal, child and neo-natal mortalities would have been reduced by at least 50% against the background of an expanded access to quality health care and services”. In order to achieve these policy orientations and targets, Africa needs focus on the health sector and the health labour market, including policies related to education, attraction and retention of health workers.
The Africa Health Strategy 2016 –-2030, including focus on health worker mobility, advances the principles that “Health is a human right that must be accessible to all” and that “Health is a developmental input and a result requiring multi-sectoral response”. Improved governance of health labour markets and health worker mobility is a strategic element of the multisectoral responses, with a particular and growing concern regarding the international migration and mobility of health workers and associated impact on the health objectives.
Health worker education, mobility and migration is listed by the Africa Health Strategy (AHS) among the “key emerging issues” and challenges that are “crucial to be addressed”. It covers both health workers’ mobility and migration within and outside the continent. These issues and challenges can hinder the achievement of the Strategic Objective 1 of the AHS: By 2030, to achieve universal health coverage, through adequate national human resource management frameworks to substantially increase health worker training, recruitment, deployment, regulation, support and retention.
Among the strategic approaches, the AHS underscores that a continental mechanism to regulate and better manage intra and extracontinental migration of health workers need to be established. In addition, among other aspects of health human resources management, it points to the need for:
· Strengthened training, recruitment, retention, working and living conditions and health of staff;
· Establishment of continental/sub-regional norms and standards of training;
· Standardization of health professionals’ training, qualification and licencing;
· Strengthening of South-South as well as South-North-South partnerships which support the health sector, based on the WHO Global Code of Practice which aims to provide health worker related support and recruitment-related safeguards with particular focus on the health system-related needs of African Member States.
The imperative to develop a continental mechanism to regulate and better manage intra- and extra-continental migration and mobility of health workers, especially given the context of the Covid-19 pandemic, has never been greater.
An AU Health Practitioner Migration and Mobility Policy can build on and strengthen coherence of policy responses underway across AU Member States and Africa’s 8 Economic Sub-regions, including with respect to sectors of education, foreign affairs, health, interior, labour, as trade, trade. It will be essential to build such policy on a comprehensive understanding of health labor market-related dynamics and policies, through engagement of key sectors and actors, as well as incorporate learning from similar efforts from outside the continent.
An AU Health Practitioner Migration and Mobility Policy hold substantial potential to maximize socio-economic benefits for countries and health workers themselves while at the same time mitigating adverse impacts[3] through a more systematic, evidence-informed, and ethical approach to managing health worker mobility. An explicit policy in the area can also serve to coherently advance the multiple objectives and policies related to the AU Agenda, including with respect to education, health, labour and trade.
The AU-ILO-IOM-ECA Joint Programme on Labour Migration Governance for Development and Integration
The AU Agenda 2063 endorses the Joint Labour Migration Programme as one of the key policy frameworks and strategies aimed at enhancing the management of labour migration in the continent. Aspiration 1 of the AU Agenda 2063 aims at creating a prosperous Africa based on inclusive growth and sustainable development. A key priority area of the Agenda 2063 is on investing in the African People especially the youth, women and children.
The AU-ILO-IOM-ECA Joint Programme on Labour Migration Governance for Development and Integration (better known as the Joint Labour Migration Programme, or JLMP) in Africa is a long-term joint undertaking among the African Union Commission, the International Labour Organization, the International Organization for Migration and the Economic Commission for Africa, in coordination with other relevant partners operating in Africa, development cooperation actors, private-sector organizations and civil society representatives. It is the instrument dedicated to the implementation of the 5th Key Priority Area of the Declaration and Plan of Action on Employment, Poverty Eradication and Inclusive Development, which was adopted by the Assembly of Heads of States and Governments in January 2015 in Addis Ababa, Ethiopia. Its strategy focuses on intra-African labour migration and supports achievements of the First 2023 Ten Year Plan of the African Union (AU) Agenda 2063 and of the Sustainable Development Goals (SDGs) recently adopted by the UN. In addition, the JLMP is a critical instrument of implementing the Migration Policy Framework for Africa (MPFA) and Plan of Action (2018-2030) adopted by the AU Executive Council on 25-26 January 2018 in Addis Ababa.
In order to ensure strong take off the JLMP a Three Year Project (2018-2021), the JLMP Priority, is developed with the overall objective to improve the governance of labour migration to achieve safe, orderly and regular migration in Africa as committed in relevant frameworks of the African Union (AU) and Regional Economic Commissions (RECs), as well as relevant international human rights and labour standards and other cooperation processes. The JLMP Priority prioritizes four specific objectives closely drawn from the JLMP:
Outcome 1: Enhanced effectiveness and transparency of operations of labour migration stakeholders, such as labour market actors and institutions, migration authorities, in consultation and cooperation with workers and employers’ organizations, the private sector, recruitment industry and relevant civil society organizations, in delivering improved labour migration governance services.
Outcome 2: Improved policy and regulatory systems on labour migration at Member State and REC levels, considering its gender dimension and the relevant international human rights and labour standards.
Outcome 3: Multi-stakeholder policy consultation and practical coordination on labour migration and mobility to provide advisory support to MSs’, AU’s and RECs decision-makers; and
Outcome 4: Continental and regional operational leadership and capacity to spearhead/steer the implementation of the JLMP at all levels.
Activity 1.4.2 under outcome 1 of the project aims to provide technical support to the AUC on health workers skills' portability study. To achieve this, ILO is leading and advertising a Joint AU-ILO-IOM-WHO study.
Scope of Work
The AU-IOM-ILO-UNECA Joint Labour Migration Programme (JLMP) is advancing work in “Supporting the development of regional mutual recognition arrangements in African Union identified sectors and occupations”. The present work, includes participation of WHO, and is envisaged within the JLMP-Priority’s Output 1.4,”Labour migration stakeholders in Africa are capacitated to address the skill dimension of labour migration governance.”
A scoping review is required to consolidate relevant information across sectors and countries, as required to advance towards an AU Health Practitioner Migration and Mobility Policy with the overall objective to:
· Strengthen continental health worker mobility governance to advance mutuality of benefits and reducing adverse impacts across countries of origin and destination;
· Provide guidance to Member States and Regional Economic Communities to design well balanced health workforce development and associated mobility-related strategies and policies, which strengthen health systems in achieving the goal health care for all; and to
· Strengthen fair and ethical governance of African health labour markets, with a focus on health worker mobility flows.
The Specific Objectives of the scoping review is to:
· Consolidate available information on contemporary trends and policies related to the international migration and mobility of health workers, including data and information from the 4th Round of National Reporting on the WHO Code; and to
· Provide recommendations on the potential structure and content of an AU Health Practitioner Migration and Mobility Policy.
Methodology and Timeline for the Scoping Review
The scoping review will be informed by:
- A desk review of:
o Relevant national, sub-regional and international regulatory and policy frameworks[4] and recommendations governing the mobility of health workers from across relevant sectors (e.g. health, labour, trade, migration qualifications and skills recognition);
o Data and information on health labour market and international health worker mobility flows, including gender-disaggregated information as available; and Practices, lessons and challenges related to governance of health worker mobility in other economic regions.
A collation of data and information collected by WHO from AU Member States via the 4th Round of National Reporting on the WHO Code; and
Key informant interviews and focus group discussions to gather information and perspective from key stakeholder on challenges and opportunities with respect to international health worker mobility.
o Stakeholder to include representatives of REC bodies, national health authorities, national regulatory bodies, professional associations and trade unions, health worker diaspora groups, and representatives from international organizations (i.e. WHO, ILO, IOM, WTO, UNESCO).
The Scoping Review will be conducted by a consultant in close engagement with WHO and under the guidance of a Taskforce composed of representatives from AUC, Africa CDC, AfDB, ILO, IOM, WHO and the Global Skills Partnership(comprised of ILO, IOM, UNESCO, ITUC and IOE) .
Deliverables
· Inception report including a desk review strategy and standardized questionnaires for key informant interviews: May 2021.
· Mid-term report: August 2021.
· Final Synthesis Report with recommendations on the Structure and Content of an AU Health Worker Migration and Mobility Policy: October 2021.
Follow-up
The production of this mapping will be considered the 1st step of a series of complementary activities. Each one of them will contribute to support the work of the AUC in the future. The African Union is planning to fund raise to ensure additional activities to advance its ultimate aim which is to draft and adopt an African Union Health Practitioner Migration and Mobility Policy. The African Union plans to produce a qualitative survey on labour market needs and imbalances of the health workforce and to establish a continental mechanism/platform to regulate and better manage intra and extracontinental migration of health workers, with a coordinated and coherent approach at national, regional and global levels; and, produce advocacy tools including common policy principles on health professionals’ mobility and migration.
The African Union plans to consider the recommendations included in this study in carrying out advocacy at political levels on strategic health practitioner migration and mobility and associated impact on health , as jointly affecting member states. The African Union would like to disseminate the results and recommendations of this Scoping Review to help Member States to review their policies with a view to strengthen the governance of health worker mobility, as required to strengthen national health systems.
Applicant’s requirements
EXPERTS’ PROFILE
It is expected that the assignment will be conducted by an individual or group of individuals. The criteria for selecting the experts are as follows:
Academic Qualifications
Master’s degree in the field of Public Health, social science, international development, political science, law, international migration law, human rights, international relations, migration or related field.
Technical experience/competencies
i) Minimum international work experience of 7– 10 years;
ii) Demonstrable technical experience in research and drafting in the area of public health and labour migration, mixed migration and human mobility;
iii) Proven previous working experience consisting of substantial involvement in assessments, evaluations, and/or reviews in related areas;
iv) Knowledge of migration governance as well as issues of labour migration and mobility would be an advantage;
v) Knowledge of global, continental and regional policies and initiatives regarding health, labour migration, migration and mobility;
vi) Demonstrable experience in research in/on Africa will be an advantage;
vii) Possession of strong drafting skills; and
viii) Previous working experience with WHO, AUC, the UN (in general) and the IOM and ILO in particular.
Language: Fluency in English and knowledge of other AU languages would be a strong asset.
Other skills/competencies
i) Experience in similar assignments would be an added advantage;
ii) Experience and ability to interact with the WHO, AUC, ILO, IOM, Member States, the RECs governments, social partners and other related stakeholders;
iii) Experience and ability to navigate political processes in highly sensitive settings;
iv) Excellent drafting/writing and analytical skills;
v) Strong interpersonal, networking and presentation skills.
Reporting
The ILO will be responsible for coordinating the work of the consultant, including coordination with HQ as well as partners AUC, IOM, and WHO. The ILO will be the leading agency responsible for incorporation of inputs and comments and validation of the deliverable.
Duration
It is expected that the consultant will complete the work over the period May-October 2021.
[1] See Wright et al, The ‘Brain Drain’ of Physicians: Historical antecedents to an ethical debate, c. 1960-1979. Philosophy, Ethics and Humanity in Medicine, 2008. Available at https://www.researchgate.net/publication/23464809_The_'Brain_Drain'_of_Physicians_Historical_antecedents_to_an_ethical_debate_c_1960-79.
[2] See A 73/9
[3] Working for health and growth: investing in the health workforce. Report of the High-Level Commission on Health Employment and Economic Growth, WHO (2016).
[4] To include but not limited to the WHO Code of Practice in the International Ethical Recruitment of Health Professionals, Working for health and growth: investing in the health workforce. Report of the High-Level Commission on Health Employment and Economic Growth, WHO (2016), Five-year action plan for health employment and inclusive economic growth (2017–2021), WHO (2018), Report of the WHO Expert Advisory Group on the Relevance and
Effectiveness of the WHO Global Code of Practice on the International Recruitment of Health Personnel, WHA (A73/0) 8 May 2020.
How to apply:
Application
Applicants should send their resume, cover letter, two writing samples, and three references as well as daily rate to Mariette Sabatier (sabatier@ilo.org) and Bethelhem Tesfaye Kassa (kassa@ilo.org ) by April 27, 2021