A Sustainable and Ethical Future for Health Worker Mobility

[00:00:00] Ben Simms: Thank you, everyone, for coming. It's really lovely to see you. What a lovely location. Goodness me. My name's Ben Sims. I'm chief exec of Global Health Partnerships. And I'm delighted to be part of the organization team today alongside the IOM, the World Bank, the OECD, and the Center for Global Development. And if I could, I just want to applaud Helen and her colleagues for the organization of tonight.

And the applause will get larger because Helen's organized the sunshine and the cocktails in true intercontinental hotel style. We're going to spoil you and treat you, even though we have not a shilling to our name. But never mind. I also want to, as well as thank you, to express solidarity with WHO workforce team. Where are you? We care about you. We applaud you. We recognize what you've been through.

So someone said it so beautifully earlier today, but we are part of your extended family. So please draw on us. Or not draw on us, whatever's most useful. But if you find it useful, then please do draw on us. I've had such a bizarre experience at the World Health Assembly. I'm just going to say it out loud on the grounds that I'll never be quoted. I keep on going into rooms where two things happen. One is, they say, this is the most important thing. The time to act is now. They say with varying degrees of charisma. We have the evidence. We don't need to have that conversation anymore. Every single room I go into, there's that sense of urgency. But I say, there is no health without a health worker. So it is particularly valid, I think, for us in this room to say, the focus on health worker is fundamental to the performance of any health system. So I argue that. I also experience too much consensus. You go into those, particularly the intercontinental. I don't know why I'm being so rude about the intercontinental. It's only jealousy, because they've got all the money, haven't they? But you go in, and there's consensus and people preaching to the converted. And I suppose there's a place for that. But all I can see is the tail and the upper ear of the elephants that aren't being talked about, the elephants in the room that aren't being acknowledged. And I think that in our community, we are better at that. So one of the things I'm most proud of, and my colleague Margaret will talk about, is our APBG report and honest accounts. Let us be honest, this report says, about flows of benefit, in this example, to the UK from the global south. Stop talking about aid. Stop talking about charity. Stop talking about, oh, maybe we'll give you half a shilling, two shillings. Let's talk about the truth of who benefits in this mobile world, in which international recruitment is structural. And so I do encourage honest expression, and let's be provocative, and let's try and really challenge ourselves to tell the truth, and to use that truth to change the way the world is organized. I want to celebrate tomorrow, I think I'm going to celebrate the code, the updated, the revisions to the code of practice on the International Recruitment of Health Workers. Giorgio was talking earlier today, and he reminded us of what was at stake. It could have gone horribly wrong, couldn't it, Jim, everyone? It could have gone horribly wrong, a kind of unraveling of what all the strength of the code, and it didn't go wrong. And so that's something to celebrate. And in fact, much of the wording, I think, we can hope, is that what I meant to say, is a proven, is building on, it's a step forward. It's not as tough as we want. The UK government that benefits so much from the International Recruitment of Health Workers really should be contributing financially, generously, to those health systems that it recruits from. So it's not as tough as we'd like, and that concept of proportionate co-investment isn't as strongly expressed. But it is a tremendous step forward. And many of the ideas we believe in, including the contribution of diaspora, by the way, and the sense of brain share rather than brain drain, many of the concepts of mutual benefit, of acting together, many of the concepts that we care about are in there.

So I'm going to hand across in a moment to our first two speakers. But just to say, we've got a series of contributions from eminent representatives from the WHO, from the government of Philippines, thank you very much. And then I will hand over to Helen, who will then share a panel discussion. We've had some changes. There have been some sort of sad pieces of news. So a couple of people can't be here who we wanted to be here. But without further ado, may I hand over to Manjula Luthria, who is a senior economist at the World Bank. Manjula, we appreciate your engagement and support. The stage is yours. This stage? Or that stage? You can have that stage.

[00:05:50] Manjula Luthria: Hello, hello, everyone. I'm actually embarrassed I don't have a better view. Yeah. We could just tilt. We're just a cozy bunch here. It's great to see so many friends, people we've been on this road with for a long, long time. So hello, hello. Welcome to everybody. And again, a big, big heartfelt thanks to Helen and Anastasia for pulling this off. She makes it look easy, but there's sweat and tears behind this. So again, Helen, thank you very much for organizing.

You know, I was just thinking, given that we are a bunch that knows each other fairly well, we've been in rooms like this for some time. We've sat around. And I think when we visualize a better world in similar ways, I think our frustrations are the same. And so I thought maybe this might be a time to actually, Ben, take a cue from you, challenge ourselves a little bit to think about, how do we move the needle forward? We get that we're stuck. We get that we need to be at a different place from where we are now. How do we get unstuck? And a few thoughts, five or six points. I'm going to make very quickly. And you won't agree with all of them, I'm sure. But that, you know, amongst friends, a little disagreement might just be the thing we need to carry into cocktails. So what gets in the way of our vision of mobility, migration, mobility, being turned into a friend? How do we get it out of enemy country and into, or at least unfriendly country, into it being a friend and fuel for better health outcomes?

And the first thought I had was, so this idea that people move, people move all the time. People move anyway. Skilled people move. Engineers move. Doctors move. Nurses move. Lots of skilled professionals move. Why is health different? This room knows the answer to that. But there's some questions, some unanswered questions that go with this. So the claim we would often make is, well, health is different because health emigration is capable of causing great harm to the places that are deprived of health workers. But when you look for the evidence, it's a lumpy, ad hoc bunch of evidence that actually tries to link emigration to health outcomes. We need to work harder to actually have that body of evidence be compelling. So that's my first request to this room. Could we talk about how we get a compelling case for emigration causing harm in various ways in origin countries? I'm not contesting that. I'm just saying if you were trying to convince someone who wasn't convinced, then that may be an area that we need to be aware that it's not such a mountain of evidence as we would like it to be.

The other really tough question, destination countries. And nothing happens without recruiting countries actually playing ball here. So how are we going to get recruiting countries, destination countries, the rich countries, to pay for something that they get for free right now? This is not easy to convince anyone at a personal level or institutional level to actually pay for something that's available abundantly for free right now. So here, too, I think we need to make the case, both economic and moral. And neither one alone may be enough. But we need to make the case in a much, much stronger way. And we've started to see shoots and seeds of that in Canada, in the UK. And Margaret will speak to that. But this is far from something that the destination countries accept as needing to lean into. So I think that needs more work, that narrative and the evidence.

The third point, I think, is one where I think we really get into really troubled waters, is when, even if you were to assume, wave a magic wand and assume, sorry, I keep tapping that, that both a set of destination countries and origin countries are willing to enter into a partnership, we need better guidance on what's a good partnership model. And again, we have some wishful thinking around it. The WHO has done some work on this as well. They even presented a nice template of what the path to get there is. But there aren't already really good existing models that we can point to. There's a couple of them, but not, again, not enough of a body of evidence where we can say, this is how we're going to start to shift the norms. Because at the end of the day, this isn't law. This is shifting norms. To shift norms, you have to have enough data points to begin to say, ah, do you want to be an outlier here? Maybe you want to fit in, because the norms have changed. That hasn't happened yet. And the WHO has done some work on it. Helen and I are writing a paper as well, trying to distill some good lessons from BLAs. But again, bottom line, not enough. Not enough yet. The few that do exist. I don't think we all have access to them. The good ones are supposed to be the ones in Cuba, for example. I don't think we have great visibility on that. And the others that we do, we can look at, have absolutely no monitoring or evaluation. So again, going back to the evidence, but evidence specifically to say, this is a good partnership because it delivers the following kind of outcome. We don't have enough of that to point towards yet. And so if we're trying to get this needle, trying to move the needle from being stuck at how do we get towards a better model, not having concrete examples to point to is a hurdle.

Another point, and this is perhaps as much a mea culpa for us in the bank and maybe in other places too. If you were to imagine a good partnership, the autocorrect almost immediately in the mind is, so a good partnership is one where a recruiting country that is recruiting skilled workers, nurses, doctors, is then also expanding training capacity. That's what we mean by a good partnership. And that is indeed a good partnership, but it is not the only kind of good partnership that we need, right? In fact, and it's unfortunate that we don't have colleagues from ministries of labor or health from Africa today. We were supposed to. They don't always have a training capacity issue. They actually have an absorptive capacity issue. Now that's where we need to unlock the imagination and think in terms of good partnerships, which don't just add another school, both intensive and extensive margin wise to sort of add another school, yeah, add more seats to existing classrooms. And all those may well be required in several places, but others actually need help with absorptive capacity. And we don't have, to my knowledge, we don't have a single partnership that actually looks at that space, right? And here there may be chances to actually innovate, have some South-South learning and innovation on actually how you might be able to improve absorptive capacity through a mobility partnership. I mean, then you've really hit the sweet spot, right? You get the production side and you get the absorption side. Hasn't happened yet. I think we all need to work harder to get there.

And then a final point, and maybe this is a little bit geeky and nerdy, but I wanted to plant the seed. Even if we got BLAs right, they have partnerships, they have co-investment, mutual benefit, not just on the supply side, but also on the demand side. At the end of the day, we're trying to solve a global problem with bilateral instruments. It's a second best. And we all know if this is the second best we have, let's put all our energies into getting that right. But let's be aware that we're actually trying to solve a global problem with bilateral arrangements. We might actually need to get our heads wrapped around the idea of a global solution, maybe a global fund, a global financing mechanism to think about how you solve global shortages and employment issues. So I will end here. These may be a little bit sobering and depressing, but these are my five or six calls for how we might challenge ourselves and then hopefully be back here in rooms again where we've actually made some progress on these. Thank you for now.

[00:15:50] Margaret Caffrey: Good evening, everybody. And as Manjula said, you should all be turned that way. I'm getting the wonderful view, which is good. That's fine. You can listen and look. So, good evening, everybody. Thank you all for joining us here tonight. Thank you, Manjula, for taking us through some of those very key issues when we talk about sustainable and ethical international recruitment, health worker mobility. So, I've been asked to talk to some of the issues that were highlighted, evidenced in this report. This report is the work of an all-party parliamentary group on global health and security. It builds on a longer cross-party effort. In 2020, Sir Andrew Mitchell tabled the Doctors and Nurses Private Members Bill, which first brought sustained political attention to the ethical responsibility of destination countries.

So, this inquiry, chaired by Sir Andrew, with cross-party support from Becky Cooper, who's a Labour MP, Monica Harding from the Liberal Democrats, and Baroness Prashar from the cross-benches. You took this question forward and looked at how we could have, look honestly at what were the benefits to the UK. So, this work on the report was also triggered by our work in LMICs and our conversations and consultations with governments in source countries on what were some of the issues. Co-investment came out every time. Co-investment in holistic health systems and health workforce was something that was highlighted each time. So, we felt that we needed to bring this further and have this discussion.

It was also triggered by the NHS 10-year plan, which was launched in July 2025, which acknowledged that the current UK levels of international recruitment are no longer possible or ethical to sustain, many of our reflections tonight. So, the inquiry took evidence across three parliamentary hearings, written submissions from various bodies, professional bodies, academic institutions, diaspora networks and associations. We also had roundtables in Kenya and Uganda to listen to what were some of the issues and what were the context, because not every context is the same. So, the question, as Manjula said, was not whether international recruitment should continue because it has been happening for many decades and will continue, but how it should be conducted.

So, what was the honest account, the honest part of this? So, we looked at the health workforce in the UK. Our study particularly focused on the NHS in England. So, we're not talking about the whole of the UK. So, the figures I present tonight are not for the whole of the UK. We haven't established that yet. But we do know one in three doctors and one in four nurses on the UK register are internationally trained. The UK's 10-year plan has a target of reducing recruitment below 10% by 2035. But the UK has not been below that 10% reliance on international health workers for decades since 1990, I think. So, while the target is laudable in terms of how it's achieved, isn't terribly realistic given the numbers we're talking about.

So, when we looked at the benefits that the UK accrued from internationally recruited staff, they were substantial. And by very conservative estimates, worked with our colleagues for the Center for Global Development, the conservative estimate was that the UK had saved, through averted training costs, around 14 billion pounds. That was the cost of not having to train those health workers that they recruited. Doctors, nurses, midwives in the NHS in England. We looked at one year alone in 24 to 25. The figures were up to 1.1 billion. And we know across the 10 major destination countries which WHO has identified, the figures are staggering as well. Even some work that Jim Campbell had done across the 10 major countries, just looking at doctors alone, the figure was roughly 125 billion saved through international recruitment.

We looked at the benefits, but as the title of the report says, we also looked at the costs and the impact on source countries of international recruitment. The costs in source countries are concentrated. As you'll hear from WHO, over half of the global health worker shortage sits in sub-Saharan Africa, where they have the most, many of the most fragile health systems. Recent data by Afro and the report that was just launched recently shows that 46% of health workers across 10 surveyed African countries report an intention to migrate. So as Manjula said, it's going to continue and it will increase. We have intention to work, to leave. UK is among the top three destinations across those countries surveyed.

So the replacement map doesn't work. The inquiry heard evidence from one source country, for example, that trains around 27,000 doctors, nurses, and midwives annually, but loses an estimated 50,000 health workers to migration every year. So out-migration is outpacing training in countries already operating below the WHO minimum standard threshold. Albert will talk from the Philippines' perspective. In fact, I think that status is his, so sorry for taking that from you. But it's worth mentioning again and again and again, because the reality is that health systems are being depleted, while we also benefit, there are also costs. So the case is unambiguous. The UK, and the focus of this report was very much on the UK. The UK is benefiting at scale from health systems that can least afford to lose that. The asymmetry is the problem that the inquiry aimed to examine.

So what did the inquiry recommend and where it lands? The inquiry made seven recommendations, but they converge on a single proposition. If the UK benefits from a global health workforce, it must invest in sustaining it. The principle, which Manjula talked about earlier, is what the inquiry, and Ben mentioned what the inquiry called proportionate co-investment. That is the spine of the report. Everything else follows from it. We have definitions that WHO will provide us with, I'm sure, on what proportionate co-investment. As Ben mentioned, we have it in the resolution. Targeted co-investment is the phrase that is used. We would have preferred proportionate. But we need to keep that in mind as we have these discussions at country level, when we talk about the partnerships and the agreements that Manjula mentioned. We also had in our consultations a very clear message from source countries that the investment needs to be across the whole health worker cycle, as Manjula mentioned as well. The education, employment and retention. Training alone is not enough. Without decent work and retention, source countries continue to train health workers that they cannot keep, they cannot employ.

I won't go into how we're going to operationalise this, because I'm going to leave that to Helen and her panel to explore that. So the question when we leave this room tonight is not whether co-investment is the right principle. The evidence answers that. But we need to make sure that destination countries are leaving this assembly with some co-investment commitments that are specific, predictable and proportionate. These commitments are then operationalised through government-to-government compacts with measurable indicators. And we also need to use the opportunities. We were at a meeting earlier about what are the key events that are coming up that we can advocate for proportionate co-investment. The UK's leadership of the G20 and various other events were mentioned. And I'm sure everybody has events on your calendar. Use those events to make sure that we are highlighting these issues. But once again, if the UK benefits from a global health workforce, the message was clear. It must invest in sustaining it. Thank you very much.

[00:25:48] Ben Simms: Thank you so much, Margaret. I think my favourite moment so far in the life of the report, although Becky Cooper, even today a Labour MP, she was meant to be with us, has published about this report in the House magazine in Parliament. My favourite moment was the Principal Permanent Secretary of Zimbabwe. He picked up the report and he looked at the title and he said, hmm, an honest account. And he absolutely got the point. There is an alternative.

Thank you very much, Manjula. Thank you, Margaret. I now have the great pleasure of introducing Khassoum Diallo from the World Health Organisation. Khassoum, we are very grateful for your leadership as Unit Head of Health Workforce. Thank you for being with us. The stage is yours.

[00:26:42] Khassoum Diallo: Thank you very much to the organisers for this opportunity. And I have five minutes, OK? Five minutes, I want to take one minute to clear the air. Yes, there are some restructurations with WHO. Yes, there is this merger with the academy, etc. But please note that we maintain the core functions and the core mandate and the priorities of the Health Workforce Department. That's something that I want to say. There are some challenges, of course. Second thing is that in that context, so we are very grateful to have now a much bigger team because you all are part of our team now. So that's one of the things. So now our team is not in terms of dozens, it's in terms of hundreds. And let me take this opportunity to thank Jim for his leadership over these years. He has been doing incredibly well. Thank you very much. This minute does not count, eh?

So as you all know, we have had this expert advisory group that advises the WHO Director General on the code, in particular looking at the relevance and the effectiveness of the code. There have been a number of meetings, expert advisory groups, first round, second round, third round, and etc. But let's just focus on the last one because the last one is the one that I believe is very important. And in this, really, there are a number of recommendations that came from that one. And in particular, looking at the sustainable workforce policies and also the strengthening of the evidence, the research, but also the advocacy for the code. And all what you said today goes in that direction. And how do we collectively own the code? And how do we collectively implement? Because this has been generated through this expert advisory group and including some international experts. Including also some experts from other partner agencies. So it is not a WHO recommendation. This comes from the top of the top with regard to those people who have been working in this area and trying to recommend something that is meaningful to the countries based on very strong evidence. That's the other thing. So I just wanted to say that based on this, then there have been a number of recommendations because there is a need to update the code to the latest situation, latest developments. And there are only five. And please remember, we didn't reopen the code. I want to reiterate this sentence. We didn't reopen the code for discussion. If you change one comma of the code, it will take ages. It took six years to agree on the code. So we are not going to reopen the code. So what we are saying is additional text to update the code with the latest situation, latest development. And there are primarily five main points.

The first is to extend it to the care workers because we know that there are many health workers who migrate to take care worker jobs in some countries. And this is one. The second thing is to expand the code to the crisis situation because we know that during COVID, for instance, a number of countries have, let's say, diluted the principles of the code and then tried to be more active in engaging because of the challenges they were facing. And of course, this all global government-to-government bilateral agreements and the co-investment that Margaret just mentioned. So this is central. And of course, the risk mitigation. And the last one is not only in addition to government-to-government, so donor agencies, global health initiatives, and et cetera, are encouraged also to support these efforts. And that's the additional text. Now a few reflections. The first is that we all believe that the best approach to this is government-to-government bilateral agreements based on strong evidence, based also on a multi-sectoral approach. We know health workforce issues are not only health issues. It involves different ministries, Minister of Labour, Minister of Finance, Minister of Education, and et cetera. So approaching it from a multi-sectoral perspective is critical and it is central.

The overall issue around the co-investment, we don't talk about compensation. We talk about co-investment, in particular, the proportionality of benefit. Margaret, you gave some numbers. I'm sure UK does not invest at that level in strengthening health systems of other countries that are sending workers. So even one third of this amount probably is not invested. How do we collectively advocate for this co-investment to strengthen health systems?

The third point that is also new from the expert advisory group is to adopt a flexible approach to the support and safeguard list. What does it mean? Before, we had this list and this is the list, and then we recommend to avoid active recruitment. But we know that with the market failures and mismatches, in some countries, even those countries in the list, have some people trained but who could not find a job. So how do we make sure that we implement flexibility based on evidence that is generated at the country so that those countries who want to express, say, OK, we don't have enough doctors, we don't allow you to go to doctors, but we have oversupply of nurses. Why don't you just focus on nurses in this bilateral agreement? These are some kind of flexibility. The list has not yet been published because we need to explore with Member States how best to implement this flexibility in this context. So, last point. The data is there, the evidence is there. The policies are there, the strategies are there. So the knowledge is there. Why is it still not yet working? We need a very strong political will and strong advocate, but also advocacy alone is not enough if it is not materialized in decisions. We need very strong political decisions. Countries, in particular high-income countries, destination countries, in the top ten destination countries, I was talking to Ben earlier to say, if the top ten destination countries gather and meet and discuss the challenges and make decisions on how to support this co-investment, that would be a very, very big step forward. So I think these are some of the things that we wanted to share. Just a few ideas around that. But let's continue the advocacy. Margaret, you mentioned the G20, the G7, there are many meetings in these countries. Let's try just to make sure that we get to a very strong political will and political decision on that. Thank you very much.

[00:35:11] Ben Simms: Thank you. And if we got those ten countries, maybe we would be edging towards, Manjula, what you were talking about, a global solution to a global problem, rather than a bilateral approach. Kasim, thank you so very much. It's now my great pleasure to introduce Albert Domingo from the Department of Health. He's the Secretary and Chief of Staff, Department of Health in the Philippines. And you might ask, why is it my pleasure? It's my pleasure because the Philippines are providing such leadership and forceful leadership on this issue. And we salute your minister, Ted Harbosa, for his leadership. And we thank him because talking about where the political will come from, I think it is from the Philippines at a ministerial level. Albert, it's such a pleasure to have you with us. Thank you.

[00:36:09] Albert Domingo: Thank you so much, Ben, for the kind words. Oh, yes, all the speakers say... It's like being transported, right? It's like being transported to a different place, looking at a grey wall, and then now suddenly the water is like... But you have this view before you. So thank you so much to our organizers, the Center for Global Development, the Global Health Partnerships. It's my pleasure to see you again. And I did meet a few people who were also with us in London last March. Thank you also to OECD, the World Bank, IOM, and of course to our World Health Organization colleagues.

Margaret already got the data points, but again, it's not so bad to restate it. I come from a country which is one of the world's largest source countries for health and care workers, the Philippines. And my reflections are both on the opportunities and the costs of health worker mobility. In a nation with 115 million people spread across 7,600 more or less islands, our health worker density is only at 21.8 per 10,000 population, far below the SDG target of 44.5. Less than a quarter of our municipalities meet the WHO's recommended density. We are proud to contribute doctors and nurses globally, a testament to the strength of our training institutions and the dedication of Filipino health workers. Yet the out-migration of health workers exposes systemic vulnerabilities.

Nursing is most affected, as Margaret has already given a preview. 47,000 Filipino nurses are deployed annually. But there is also demand for medical technologists, and the demand for caregivers is also rising. The drivers are clear. From the personal perspective, wage differentials, career advancement, and global demand in high-income countries, I'd like to add to my prepared speech that it's also part of the epidemiology of the world. The population is aging. People need someone to care for them. And that is, for me, one of the single most strongest drivers.

Now each year, the Philippines produces nearly 27,000 new licensed doctors, nurses, and midwives. You've heard that number also. But the density remains stuck at 21.8 per 10,000. The costs are high, and this is our honest accounting, so far as the Philippines is concerned. Converted to U.S. dollars, it costs around in the Philippines, but this is probably still cheaper than other countries. A doctor costs 26,000 U.S. dollars, the whole four to five years of training. A nurse costs 18,000 dollars. I tread carefully in saying this because it really sounds like commodities. You want to buy a doctor? 26,000 dollars. A nurse? 18,000 dollars. But that's part of honest accounting. You have to speak to it as it is. There are costs involved. Around 50,000 health professionals migrate annually, mostly nurses. If you do the quick math, 50,000, that's like more or less double what we are producing on an annual basis. And this outflow delays the return on investment in education. It widens service gaps and raises replacement costs. Yes, remittances do strengthen households and the economy. They say in the Philippines around Christmas time, the economy jumps because all of the overseas Filipino workers send back remittances. But the remittances cannot replace the loss of skilled professionals in our hospitals and communities.

Producing, training health workers is not simply a matter of money. It is a race against time. Why? Because every nurse or doctor who leaves represents years of training, investment and experience that cannot be quickly replaced. But if I may add also off script, it is a cycle. We will have periods because of the natural length of our training, especially of doctors, it is always a cycle. There will come a point where there are too many nurses and then suddenly there's a demand and also for doctors and so on and so forth. And the challenge is start. How do we achieve UHC when our workforce is continually depleted and the very foundation of our health system is eroded faster than we can rebuild it? But partially there is an answer. As long as you know how to ride that cycle, then probably you can be successful. It's something that is counterintuitive because not, we used to have this policy that you don't want brain drain so you lock them all up, meaning you keep them in the country. Not in a room but lock them all up in the Philippines. Don't let them go out and use several instruments. But having said that, we would be remiss if we were not to say that the Philippines historically probably has been the leader in trying many things out, trial and error. And this is where artificial intelligence helps me out. I did a quick search on Google because I've heard our minister say, our secretary say that it was in the 1960s. And he's right. Based on AI search I also probed into the websites. I'll just read verbatim to save time. The first large-scale formal international recruitment of Filipino nurses occurred in 1967 to North America, most notably to Canada and the United States. That's why I speak with a North American accent. It is part of the problem. Why is it so easy to export a Filipino doctor or a nurse? Because just pop us right into a U.S. state or in the Canadian territory and we'll be speaking to patients right away. And in the 1970s to the Middle East, driven by post-war hospital expansions and targeted immigration policies. But this is the interesting part. AI was also able to dig this up. While 1967 marks the beginning of formal commercial recruitment, the pipeline's origins trace back to the early 1900s. The timeline below details the history. I'll just go through it quickly because it's a long timeline. 1903, after the U.S. colonization of the Philippines, there was a Pensionado Act of 1903 where Filipino students were funded by U.S. scholarships. Sounds familiar? As early as 1903. And then in 1948, and this is still something which is very much active now, the U.S. introduced the Exchange Visitor Program. It is active. Just this morning, there was an appeal that came into my inbox. There was a Filipino training in the U.S. The way it goes is you can train in the U.S. for around five years and then you have to go back to the Philippines because there is an obligation. It's a 1948 law. And we have scientists, we have doctors appealing directly to me because it's under my watch that can you let me train further because for this gentleman who was appealing, his research takes more than five years. But because of the EVP of 1948, he has to go back to the Philippines. Then in 1967, the formal wave. 1970s, the U.S. Immigration Act of 1965 and the ever-famous H-1 visa. And so on and so forth. And I'll go back to my speech now. But I just had to mention that because the next part of my speech says, Structured bilateral programs like Japan's P-J-E-P-A, Germany's triple win, have provided pathways with language training and rights-based integration. That's why I decided to search. These things are very recent, but as history will show, it's not the first time that the Philippines tried doing this. And maybe that's the reason why we've been burnt, we've been scarred, we've been scalded by all of the errors in the previous decades. Because reciprocity has always been uneven. Too often, the partnerships focus narrowly on recruitment without reinvesting in the sustainability of the Philippine workforce. Success depends on co-investment in training, fair recognition of qualifications, and adherence to ethical recruitment standards. What standards are we going to refer to? That is where the WHO Global Code of Practice helps a lot. It offers a framework. However, as already spoken by our earlier speakers, implementation is uneven. As anyone who is trained in international law knows, the only way countries will follow is if they decide to follow. No one can force each other unless you want to go that route, and we don't want to go that route. I see some heads shaking, yeah, but some have. But anyway, let's not go there. So having said that, it's all about implementation, it's all about monitoring. Even the bilateral agreements that include nice things like technology transfer, scholarships, and reinvestment are promising, but compliance must be monitored. If Ben has been to several rooms where everyone says the magic words of sustainability, we need to act now, and so on, this is my second WHA as a member of a government delegation, and boy, all of the bilaterals I've been to say the same words. Of course I cannot disclose which countries and what the words are, but the formula is like this. We would like to help you out. We appreciate your nurses. What do you need from us? But when we start listing, let's talk further. But that's part of diplomacy. That's part of diplomacy. Sometimes you get it, sometimes you don't. But who's going to monitor that? The thing I notice about bilaterals, and that's why I'm honoring the same tradition between diplomats, is you can't tell others about what happened inside the bilateral relations. It's between country A and us. Because if you break that code of silence, no one's going to approach us anymore. Or our Ministry of Foreign Affairs is going to say, what did you do? What about our other plans for other sectors? So it's very interesting. Key message, the bilaterals just don't do it, or won't do it, at least in the long term. Right now it's probably a stopgap, but we need something better. What about multilateral platforms, such as ASEAN dialogues, opportunities like that? Well, they also need stronger enforcement. The ASEAN, I'm just scanning the room, if there's another ASEAN member state. Yes, they're not here. But anyway, you can always quote me, because everyone in the ASEAN, all member states, share the same frustration. Consensus is much stronger in the ASEAN circle, which means meetings can go on and on. Just like Security Council times 11 members. Everyone has a veto power. If one member state says, we're not so keen on a particular word, we're going to stop. So having said that, that's also an opportunity, but it requires stronger enforcement. You can imagine with all the consensus, then the words are not strong, they're not that enforceable, because just so that we can get over with the meeting, we're going to agree on a lighter and lighter and lighter language. So wrapping up, we call for shared responsibility. Maybe I shouldn't say this. I'm preaching to the choir. It's the same things. Ben, it's the same things. Invest in production and training, ensure data transparency. I'll just skip this paragraph.

I was hoping to meet colleagues, fellow esteemed delegates from other member states. Maybe we will meet them later in the week, because if there is a question on what the Philippines can contribute, no, we cannot match donor funds. We don't have that. We need that, actually. But our experience is where we are rich. Our experience since 1903 offers lessons that other low and middle income countries can draw from. First, you need a national master plan, and by master plan, not something that is just a glossy that you put on the shelf or now in a digital archive somewhere. It has to have items on workforce production, retention, management, and development, and it should consider national realities and the current global workforce situation that keeps on changing. Next, build multisectoral platforms, dialogues that include government, academia, labor, migration, foreign relations, finance. I think this is the multisectoral aspect and partner countries. We have a department of migrant workers because there are 10 million Filipinos at any given time on average everywhere in the world, not just health workers, but that's like already a country in itself floating around the whole world. So we have a department totally dedicated to them. Third, go beyond remittances. Balance mobility with domestic needs supported by structured monitoring and evaluation. Fourth, negotiate strategically. Agreements must secure systemic benefits, training, technology transfer, and managerial capacity, not just recruitment quotas. On a personal note, I just noticed, and my minister, my secretary always says this, it is an interesting soft power that we have. It can be as ridiculous as a joke like you want us to call all the Filipino nurses and then they come home. You want health systems to collapse. Of course, that's not gonna happen. We're not gonna do that, and we can't do that. But whenever we say that, you can see in the room, you can see other member states smiling because they realize it. And often, without naming names, there have been quite a few high-level people from other countries, and also not just from other countries, but from technical agencies. We ride in the elevator. I get surprised. They know how to speak Filipino words, Tagalog words. They have tried adobo. They have tried certain, I see smiles. Maybe some of you have. I did that on purpose because there's always a Filipino worker who has been in contact with them, either domestic help or a healthcare worker, and it's just everywhere. So it's an interesting kind of soft power that we do not want to use to dominate the world but we want to use to just secure the future for our own citizens and to share to other countries, LMICs in particular, on how they can avoid the mistakes that we've had in the previous decades. I just need to say this, establish co-financing mechanisms. It's so easy to put words, to say words, to put them into writing, to have nice photo ops, nice side events, and this is a very nice side event with a nice view. But as the West will say, you have to put your money where your mouth is. You have to put your financing where your words are. And that is something maybe where multilateral institutions, the banks can help us out because we don't have the resources but someone else has and other countries might be interested. So in closing, the Filipino experience shows that health worker migration is both a lifeline and a challenge. To make mobility fairer and more sustainable, we must move from transactional recruitment to genuine partnerships. One where you can look each other in the eye and say this is an honest accounting, this is a proportionate co-investment but we're willing to accept targeted if that will just get the resolution through. Let's just implement it the way it should be which is a proportionate co-investment and we should look at health system strengthening in not just the country that is sending but also the country that is receiving. On a final note, when I was in London, I met the Filipino nurses who are in the NHS and to me that is one concrete example. We are helping strengthen not just the health systems of the Philippines but also the health systems in the UK because you have leading Filipino nurses and doctors over there. That is the path forward, genuine partnership, multilateralism. Thank you so much and a good evening to all.

[00:52:01] Ben Simms: APPLAUSE Thank you so much, Albert. I wanted to say two things before I hand over. One is it was in 1949 that the NHS, I've just been Googling, launched its first formal recruitment campaign and we looked to our empire, of course, and to the Caribbean and it was the Windrush generation that came and helped Britain at that time. And the experience of racism, the challenges that people have experienced in the UK having migrated to the country and including your colleagues, I apologise for that. And so part of our challenge, isn't it, is not just to manage migration in a way that benefits everyone and including those individuals but to treat them well and with respect and to remember to say thank you. And your speech, Albert, I think does represent a significant shift if no-one has noticed it. But the shift is, and we've heard it from Zimbabwe, from Ghana, Kenya, Jamaica, we've been involved in many countries who are beginning to talk with more confidence about the value of what they're contributing to high-income countries. And I think that is a significant shift. It's a political groundswell that will shift the dial in a very exciting way. So I can't thank the speakers enough. And it's now my great pleasure to hand over to Helen Dempster who should really have been up here at the beginning. But it's very nice of you to ask me to do this role. Helen is the Policy Fellow and Programme Co-Director at the Centre for Global Development. And it's been an absolute pleasure working with Helen. Helen, the panel is yours. Thank you.

[00:53:59] Helen Dempster: Hi, everyone. I have the unenviable pleasure of chairing our panel, which stands between you and cocktails and canapes with that view. So I will try and make it as quick as possible. I'd like to welcome up our four panellists to the stage. So Agya Mahat is a Technical Officer at the Health Workforce Unit in the WHO. Please come join me. Be very careful of the chairs. Liz Warn is the Head of the Labour Mobility Division at the International Organisation for Migration.

[00:54:30] Audience: APPLAUSE

[00:54:33] Helen Dempster: I've been informed that we have Dr Angela Nyakundi from the Ministry of Health in Kenya. Thank you so much for joining us.

[00:54:40] Audience: APPLAUSE

[00:54:43] Helen Dempster: And Jim Campbell is the Professor in Practice of Health Workforce at King's College London.

[00:54:48] Audience: APPLAUSE

[00:54:52] Helen Dempster: I'm just going to keep spinning. These are a bit hard to manage. Right. Thank you so much, everybody, for joining us. I very much appreciate you taking time out of what I'm sure is an incredibly busy day to discuss what I think is a very important issue. And as everybody has already said, we already know what needs to be done, and what I really wanted to convene today is a very practical solutions-focused panel. So I would like to start by going through two rounds of questions posed to each of my speakers in turn, and then hopefully we'll have a bit of time for Q&A with all of you before we make sure we get you all outside as soon as possible. So my first question that I'll pass over to Agya, then Liz, then Dr Nyakundi and Jim, is based on your experience, how do we answer this question on the slide? How do we more sustainably and ethically manage health worker mobility going forward? Agya.

[00:55:48] Agya Mahat: Namaste. I think I would first like to take a step back and then first just outline what are the drivers of this international mobility? We are all aware of the push and pull factors rooted in economic inequities, the broader system factors, and then individual choice, as Manjula mentioned earlier. Then there's the labor market and market failures. And we have a very interesting paradox. Like Africa, with the largest burden of disease, greatest shortage of health workers, also faces unemployment of almost 1 million health workers. This was from the latest WHO report released last week. On the other side, a handful of high-income countries, only 10 countries host almost one quarter of the world's workforce. And they are still facing shortage. So there's a paradoxical surplus in Africa and an artificial shortage in high-income countries. And this has got to do with design of systems and how we utilize the available workforce. Now, underpinning all of this is now the demographic shift. The OECD countries are facing a problem of aging population, aging workforce, and now there's a competition between them to attract international workers. So this means that destination countries cannot rely on that particular international worker to fill their gaps because there's problem in retention of those workers also. When we look at the total fertility rate, of OECD countries is below replacement levels. So to maintain the population, you need a total fertility rate of about 2.1, 2.2. OECD countries now has 1.4. So they will rely on international recruitment in the near future. It's not just a structural feature to fill the gaps now. It's going to increase in the future because that's where the population has to come from somewhere else. It's not just health workers. It's population in general. Now, where are the people going to come from? It is going to be from the source countries from the global south. The total fertility rate of countries, 55 countries in the WHO support and safeguard list is almost four. So that is where the future labor force of the world is going to come from. Now, going to ethical recruitment. I think everyone has their own definition, but being from WHO and since more than 190 countries have adopted the WHO Global Code of Practice, we go by the definition provided there, which means that everyone should benefit from international mobility. That is the health system of source country, health system of destination country, and the health workers themselves. For the past 16 years, we've been monitoring the implementation of the code, and we do see benefits. We see benefits to health systems of destination countries. We've heard this before. We also see increasing benefits to health workers themselves. Lots of improvement in health worker rights, welfare, income, equal treatment, and Philippines has been a leader on this. What we don't see enough of to similar account is benefit to source country health systems. This is the biggest critical gap in the implementation of the code that has been consistent across all the five rounds of reporting. There are different reasons for this. The code recommends bilateral agreements because it can be customized to meet the needs of individual countries. However, we don't see it bringing proportional benefits, as was discussed earlier. A number of reasons contribute to this. One is the power dynamics. So who holds the negotiation power? The second is the lack of involvement of health stakeholders in the negotiation process. And then the capacity for negotiation. But now I agree, like Ben said, the capacity of countries to look in the eye with destination countries and to negotiate better is improving, so there is hope there. And I would like to also respond to what Manjula said earlier, that it's not that bilateral agreements haven't worked. They have worked excellently to advance health worker rights, and that gives us hope that now the next step should be increasing investment in health systems because health worker rights also just didn't come on its own. It had to be negotiated, and Philippines has an excellent example of how that could mean for different countries.

[01:01:06] Elizabeth Warn: Right? Thank you very much, Agya. First of all, good evening. And a really great thanks to our hosts and to co-panelists, very much enjoying the session so far and looking forward to a lively discussion. Likewise, before coming to the point about the solution, I think there is one angle that I think we also need to bring up in this conversation, which is we tend to frame this around migration being a zero-sum game for origin versus destination countries. But as Agya was inferring to, many of the countries that we're engaging with as emigration countries are both facing underemployment of health-trained workers and the limited absorption capacity that Manjula was talking about, while at the same time in destination countries, many of these international health workers are underemployed, not utilising the skills that they have for the labour market in the destination country. So I think when we frame this issue, we really need to think from a migration perspective and from a labour mobility perspective where the shortages actually are, how we can address them from the perspective of a labour market analysis, but also to consider, this is the second point, about what the real benefits are for the international health workforce. Now, we've talked a lot about the rights being respected and, of course, as the migration agency, ethical recruitment is a key part of this, but at the end of the day, we're all humans and it's all about agency. So if people are really not living to the potential that they actually have and they're underskilled or they're very highly skilled and working in an occupation that they're not trained for, we're actually doing ourselves a disservice, both for the country that these individuals come from, but also for the destination countries that they're in. And I think although things have changed significantly since the 90s, this is still a significant problem in many countries and it's something that really requires a more concerted effort around recognition of prior learning, upskilling, reskilling and looking at the future labour market needs. Now, when it comes to solutions, from an IOM perspective, we don't see migration as being the problem. Migration is often the outcome of issues where structures and ecosystems have not been created in such a way that creates those benefits. And so, surely, cost-sharing mechanisms are an integral part of that. But I think we have to also remember, and I take experience from the migration world, that many migration agreements are still not being negotiated with this holistic perspective that was being talked about earlier. In countries that we visited, and destination countries included, OECD countries are part of that, the conversation goes much like, yes, we negotiated our agreement, it was our Ministry of Foreign Affairs. Was there a consultation process internally? Yes, but we were only partially engaged or involved late, or perhaps only on certain provisions. That equally happens in origin countries, where the types of involvement of Ministries of Education, of Ministries of Health, of Ministries of Labour, of Ministries of Finance and Ministries of Education doesn't happen at the right time. So then we ask ourselves, why isn't implementation working? And I'll come to the final point here, which is implementation is so much more than what's on paper. And many of us forget that a key part of implementation is having those structures in-country that enable the bilateral discussions that the Philippines excels in to happen regularly, frequently, and with the relevant data behind it. So implementation is certainly not simple, and it's another $100 million question. But even the structures required behind good implementation need to be strengthened as part of those conversations, so that not only the negotiation process is done through a whole-of-government, whole-of-society approach, but the implementation practices that are in place are done so so that you have substantive and systematic implementation over time. Thank you.

[01:05:32] Dr Angela Nyakundi: Thank you very much. Thank you. Thank you very much. First, I'd like to pass on the greetings and apologies of my principal secretary, Dr. Oumar Luga, who would have loved to be here. He really is a champion for the health workforce in Kenya. But unfortunately, he couldn't make it at the last minute, and so I came in. I head the Health Workforce Division in the Ministry of Health in Kenya. And very briefly, I think we would like to give Kenya's perspective on health worker mobility. And maybe start by giving part of the report. We did a health labor market analysis in 2023. I know a colleague from the Philippines said their density was around 20-something. Kenya's is around 30 if you take stock. But truthfully, that is stock, not the ones who are employed. Only 75% of the stock are employed. Therefore, it means that if you look at the actual active density, it's actually less in terms of availability and access to services. And within the same survey, we actually found that 60% of our health workers actually have the intention to migrate abroad. Meaning that if you think about it, it means somebody is at work possibly thinking of sitting for exams, taking language classes, making applications, reaching out to their colleagues outside the country, so maybe they're not even there. Perhaps even our survey didn't go that far in like, what exactly are you doing in preparation for this? In fact, high on the list were doctors and nurses. So that actually tells you how much this labor migration issue, even if we don't think about it as a government, the health workers themselves, as you mentioned agency, they are thinking for themselves. And so when you think about the push and pull factors, I mean they apply. They want career progression. They want to develop their skills. They want better employment. And actually even broader than that, they want better opportunities for their families and such. And so even when we come to the table and discuss bilateral labor migration, even as the source country, you look at actually some of these factors that may go outside the health sector and try to see then, when you're engaging the actors, is it broader than the sector itself in terms of possibly retention? The other thing that maybe is unique to Kenya as well is because the government currently has something, I'll use a Swahili word and then I'll translate, Kazi Maju program. That means work abroad. Where we're actually prioritizing enabling employment abroad and this includes for the health sector. So it means labor and migration are sitting on the table negotiating for migration. Health sector is possibly gasping. But you're in the same government. And so you have to find a way to work together where in as much as you're enabling this employment, you're protecting your health system. But also alluding to what you had mentioned, you find sometimes that when the negotiation is being done, because for us it often is labor agreements, health may not sit in maybe as often as they could or should or may come in later when maybe not much can change. So that then when you're discussing co-investment, it may be within health circles. It may not have gone to labor and foreign affairs who tend to sit. And sometimes the engagements begin perhaps when they are engaging on something else. So that then you come in later like, oh, actually, we could actually engage them. Yeah. So then we look at it that there's still a lot of work to be done. Even strengthening collaboration even within ministries is somewhere that maybe countries could consider if that is the case in your country. And even between now the two countries when negotiations are happening. And even mapping and engaging all the relevant actors. Before you begin the engagement, who should be at the table? Even as you had mentioned, education, labor, finance and such. And then even the frameworks that would make the discussion more of the norm, including these bilateral labor agreements. Are you working within a framework or does it become like a gentleman's agreement? Are they enabling laws and such? And even data. In fact, for us, data is a big issue. To actually know who is living, when they are living. Sometimes it's actually ad hoc. Like a few weeks ago we were, because for us we have a devolved system of government, we were doing some work within the counties. And when we reached one of the counties that has a tertiary level facility, the first thing, it's called a chief officer said, we are losing so many of our senior nurses to some of these countries. And before we even started the work, and he could maybe give you tips of fingers, we lost maybe 10 last week, 32 the other week. But that actual valid data for us to plan is not something that we can say we have. So that you can actually visualize what's happening. We were saying in a meeting just the other week that you actually don't know if somebody is living. If you're at the airport, you wouldn't say, I'm leaving to go to America to work. I could say, I'm going to visit my aunt and just never come back. So you end up using proxies. Like this intention. Those who have asked for certification of their, I mean validation of their certificates and have enrolled for these exams. And then this becomes the proxy data. And then now, sometimes you meet them as diaspora. Later, they've left already. And they meet you in the meeting and say, ah, we left in this year and that year. And so it could be, it's quite frustrating. But you can understand. I mean, it's their right to go. But as a government, it makes it hard for you to then say, okay, we'll use this proxy data and estimate the trends and therefore start getting worried and say, oh, many of our nurses are leaving, perhaps more than the doctors or more than this. And even to bring it down to, for example, where they're employed. Because the way our country works, sometimes you could actually be concerned if they are leaving from one locality more than another because we have a bit of difficulty with crossing over in terms of employment. Meaning it should actually be something also we look at in our planning. If more health workers from a certain region are leaving, it means perhaps our affirmative action may focus on certain regions like that. And maybe to the issue of capacity. There's a challenge with the capacity to develop and implement bilateral labor agreements. The negotiation. Okay, you get all your stakeholders on the table. Does that mean you're going to get this superb BLA? Maybe not. I mean, maybe some of these countries. You said 19 or something. They've been doing this for eons, you know. Now you're just coming to the table. What clauses do you look at? How do you push back? What do you push back for? How should it be phrased? These are some of the issues. And so for us, ideal partnerships. And maybe going to reference this report. I don't know if it's formal or informal. The all-party parliamentary group reports on global health and security. Because what was positive about it was that it actually acknowledged the cost. You know, this is what we are gaining. I don't know if that has happened before. Do countries say this is what we are gaining? And if you can start from there, it means that when you're sitting on the table to negotiate, you can say, okay, if it's to be reciprocate, then how can this be done in kind? You know. And it doesn't have to be sums of money. Because, for example, like Kenya, we know what we want to do in our health system. We have our strategies. We have costed them. It means, for example, we can say, okay, you've taken the health workers. Maybe you can invest in our infrastructure. You can help us, give us research, you know, grants and opportunities, you know, and such. So that then we build our health system as such. So for us, I mean, we say even that true cost of training and that ability, okay, we know what we want. Can really take us, we believe anyway, can take us a long way in terms of bridging the gap that we have seen so far in terms of bilateral labor agreements and the migration of health workers. Thank you.

[01:13:25] Jim Campbell: Good evening, everybody. Good evening. Thank you to our partners in crime for facilitating this debate. I want to pick up on the ethics first. And just tell a bit of a, how do I approach this? And the Undersecretary, Albert Domingo, just to sort of go back into a little bit of history as well. My history, I am 34 years as an international health worker migrant. I have been practicing around the world in terms of my employment opportunities. So I come at it, that's a privilege and opportunity that I've seen. My father was a migrant worker. My grandfather was a migrant worker from Ireland, Northern Ireland. So that gives me the dual nationality of British and Irish. Culture of Ireland is around migration. And I had the pleasure 20 plus years ago of working with the former president of Ireland, Mary Robinson, who chaired the Health Worker Migration Initiative Global Policy Advisory Council. So that was 2006-7. After all the discussions in 2004-5, the MDGs would not be achieved, Millennium Development Goals, would not be achieved unless we stopped some of the brain drain and compensated low and middle income countries for that. And that sort of precipitated then the debates, the discussions, the discussion about a global code of practice. And I was privileged to be at those meetings with Mary Robinson, a group of peers who were absolutely incredible. We were in Kampala, Uganda in 2008, before the code was adopted, having this discussion. So I've been at it for a while. And that's the last few years, with the fantastic team of WHO people, with OECD, World Bank colleagues, Philippines always, always with us, every single step of the way. The Philippines Overseas Employment Agency, that was your predecessors that I used to work with 20 odd years ago, in terms of learning from the Philippines. And the Philippines is diplomatic support, the soft power, it's the technical support, and today it's financial support as well. Philippines hosted these discussions in Manila as part of the expert advisory group, contributing to it. As they grow in terms of things, so hats off, thank you. Let's also remember then that history, the same debate, this history, you said 1967, I think, your AI bot in terms of your intelligence. The debate around who pays for this transfer of labor followed in the early 1970s, the 10 Baguatti Tax. Anybody heard of it, Baguatti Tax, Jean-Christophe? The 10 by 10 initiative, early 1970s, which was that a highly skilled migrant leaving from the Global South into the Global North, for the first 10 years of their career in an OECD, high income country, there should be 10% of their tax should be remitted to the country to subsidize the education, the human capital thing. And guess what happened, people? The high income country said, no, no. Deja vu, we're here all over again. The negotiations on the resolution, which is now scheduled for tomorrow, 15 hours, six different meetings, co-chaired by the Philippines with Germany and others. Guess what they were saying? No. So I want to use the analogy about ethics and sustainability, Lady Justice. We're all familiar with Lady Justice, the scales, the blindfold, the sword and the scales. And it's about how we tip the balance in favor. And we've had this theory, Lady Justice is blind to power and control and everything, that the sword will guarantee the fairness and everything else. But it's not been happening. It's not been happening. Instead, there is very clearly the blindfold is off. And it's in the interest of the Global North that these debates have continuously been challenged, stopped, language weakened. No, no, no, no, no. And instead, so we looked at all this. And let's be honest, there's expert advisory group members, high income, low income countries. We got together informally off the record and said, look, let's change the debate. I've done three expert advisory groups, four rounds of practice. And we said, right, if this is my last one, which was a sort of, let's change the debate. And we said that the debate has to change on one key principle. That this economic transfer, this recognition of human capability moving in different directions, the diaspora as well coming back. Let's recognize that it's not compensation for the loss. It's got to be on the basis of the cost adverted. And that's the discussion. Because if we just say, okay, let's pay the 26,000 or let's pay the 18,000 and everything else. That's too cheap. The actual benefit to the US is 250,000 for a nurse. It's a 10 to 1 scale. Then the 10 years that they work in the US and all the benefits they make. Yes, there's remittances back to the Philippines. But it's about 6% of the total earnings. But the Americans are taxing at 25%. So they've got a 4 to 1 benefit in America just on the tax of that income. And the remittances is personal. It's not government to government. That's an individual choice and should not even be part of the equation. So we said, lady justice, we need to balance the scales. So that's the ethics of it. In terms of the sustainability, I would go back to what my former president, Mary Robinson, was doing. She took, if you remember, the code of practice when it was first being negotiated. Guess what countries were saying? Compensation. No, no, no, no, no. We're not doing compensation.

So it came out that the member state negotiations got bogged down between the scales. No, we're not going to pay for something that's free. No, we're not going to pay when it comes to us. We're not going to compensate anyone. So we took it out of WHO. And it went to a former head of state to have those soft power conversations. Much more reasonable, much more technical. To say, okay, we can do this differently. Let's try to work in a global health partnership. Let's try to work at a global labor market level. Let's try to work something that's ethical, sustainable for everyone else. And I think we're at this moment in time with the disruption to multilateral consensus. We can't get 194, 3. Is it 194, 193, 190? You keep losing member states in WHO. America, Argentina. Who else is going to leave? If you can't get multilateral consensus, let's take the top ten source countries. Let's take a few of the willing top ten destination countries. And let's have some bilateral discussion outside of the formal posturing of prepared scripts, of prepared positions. And let's look at the realities of labor markets, the underemployment, the consequences, the opportunity. Because the global needs the global south to provide health services. Undoubtedly. The global south is a willing contributor to contribute through education. And I think take it out and then do what Mary did. Bring it back when you've got 10, 15, 16, 20 countries who are saying, actually, we can build a new consensus. We can build a new approach. And I look at the undersecretary from the Philippines because we've learned so much from you in the past. And other member states, Kenya, we know others to actually help new ethics, new sustainability for the future. Thank you.

[01:23:07] Helen Dempster: Thank you so much to all of our panelists. I have one final question and you've set it up perfectly for me. So for many years, decades now, we've been talking about the concepts of compensation, mutual benefit, proportionate co-investment. What do all my panelists think about this? And more crucially, what investments are needed to actually improve health workforces in sending countries? And even more crucially, how do we pay for it?

[01:23:34] Agya Mahat: I think we can all agree that there have been benefits, but it's nothing has been mutual. So, you know, you can't like if one side gets the cake and the other side gets the crumbs, it's not mutual benefits. Right. For it to be mutual, it has to be proportionate. And how do we define proportionate will be different by different country context. And these don't happen naturally if you just leave it to market forces or just on their own. So it has to be intentionally designed. And this is why we promote bilateral agreements. So it can be customized and it can mean different things at different countries. So what we are now saying is it has to be intentionally designed that way and it has to be measurable. So when source and destination countries are sitting together, they need to think about what are we trying to get out of this and how do we measure this? Because eventually, based on what we've all agreed on the code, the end goal is that we have to create health systems in both countries that are able to attract health workers and that are able to provide health services to their respective population. If that is the end goal for both, then how is the arrangements within the agreements contributing to it? And how will this be measured? This cannot be a one-time thing because producing health workers takes time, producing strengthening systems takes time, producing results take time. So we do need to think of a medium, a long-term strategy. And as I think many people mentioned before, this has to be a whole-of-government approach. Labor, education, finance, health, foreign affairs, immigration, online. And unless we have it down in paper and say this is what we are going to do and this is how we measure it and we do measure it over time, this is how it will come about. Because co-investment can mean different things in different countries. It could mean education in one, employment in another, quality, accountability in others, or maybe just infrastructure in others. So the main important point is it has to be grounded in the source country realities where source country health ministries state this is what we want, this is our plan, and here is where we want to help you. And then the agreements spell out what exactly is to be done for how long and how it's going to be measured.

[01:26:11] Helen Dempster: Excellent. Thank you. Liz.

[01:26:15] Elizabeth Warn: Excellent question, and thank you for that. I think there's some interesting parallels happening in the broader labor migration world that are useful to reflect upon that are relevant here. The question is certainly about who pays. It's not getting to cost-sharing yet, but there are lots of internal conversations now about who is responsible for paying for what, when will they pay it, and who are they paying it to. Now why do I raise that? Because there's often an assumption in the lower and medium-skilled world that the market will regulate, correct it, address it. But what we see in the broader migration space is when the market steps in, exactly as our colleague from Kenya was saying, this is when we have the abuse and exploitation of the workers that we're serving. So we need different financial models. What do they look like? Still being discussed. What does that mean in terms of safe, fair, and regular migration? Often the conversation becomes very polar and binary in the labor migration space. It's the employer should pay, or it's the recruiter that's doing this wrongly. But ultimately there's lots to be said about shared responsibility across a whole variety of different actors. Governments obviously have a lot of responsibility in the health worker space, but there's philanthropy. There's other spaces in the migration world and other costs in the migration world, including in this area, language. What happens to a worker who now needs to learn German or French or a third language that is not taught in that country? Who pays for that cost and when does the cost start to be paid by the government, not the individual? What about elements that go to soft skill training that are not associated with the health sector specifically? Communications, team building. I was at the World Economic Conference last week in Toronto and there was a lot of conversation around AI as I can imagine in this space. Who pays for that? Where do the costs come from from this part? So I think this conversation is extremely complicated to have because as the health worker context is very specific and has its own dynamics, these conversations are being played out around the mobility world and are having some quite different answers. So some of the thinking is now potentially why do we even need migration in many of these spaces? We have remote work, we have the digital nomads, we have jobs being taken to the individual. Can this be outsourced? So I think when it comes to that conversation about the co-investment we have to go back to indeed the point that we've been making all along which is this is a series of interconnected ecosystems. If the ecosystem itself doesn't work then purely focusing on the cost will not provide you the answer either. Thank you.

[01:29:28] Helen Dempster: Thank you.

[01:29:35] Dr Angela Nyakundi: I think I'm really enjoying the conversation. I'm losing what was in my mind. But I'm actually intrigued by the question about who should pay because when you think, okay, unfortunately, let me step out even of the discussion on labor migration. Some of the principles of course member countries are asked to adopt is government-led. So if we're going to bring the government-led to this conversation, is it government-led engagement? Is it government-led payment? Is it government-led mapping of actors? Then assignment, you know, a mutual, I mean an assignment of responsibilities. I don't know if that's a principle that then we can adopt because you see even in these discussions it's governments that are talking, yeah? So then is it government-led engagement on payment including that if the government is actively engaging in employment as it sometimes does then perhaps they'll take their respective proportions, maybe private sector will, but perhaps at a base principle. Because I find that sometimes in this discussion on labor migration you can be paralyzed by the many unanswered questions. Perhaps one step can be to then just agree, can government then convene people around payment and then maybe move from there, you know. And maybe in terms of something particular I tend to think about in the context of co-investment and where it should go. Because I think at least in Kenya, especially because of the changes in global health financing, we become very particular about what is financed. But because of sustainability. You know, if you come, for example, and say invest in infrastructure or capital investments, it might be safer. Say for example if some health facility in Kenya needs a critical care unit, that might be easier to invest in because it's not only service delivery, it can serve for training. But when you start to engage in, you know, we don't have finances for employment or retention, you see that, we're going back to where we came from, where is this sustainable? So we actually look at, when we look at our strategy, when we've costed it, there's some things that definitely will not be funded by anybody other than government. So even in engagement on co-investment, there are things that are outside, likely outside the discussion. And so we look at them, you know, like going back to like, and I don't know where, somebody has to pay for it, but for example, if we know we need better capacity in research in the context of cancer. And say, let me pick a random country, say Albania is very good at it, and we are engaging with them, can you give us, you know, four scholarships? For example, like in Kenya, we have, we don't have many medical physicists. So you see, when I sit on the negotiating table, I want you to train for me a medical physicist, you know, like that. So we're not looking at it as entirely monetary, but I'm actually looking at my system gaps, different kinds of gaps, and even looking at even how to balance equity. Like, okay, I sit on this table, I need medical physicists in these five regions, this is what I'm going to go to the table with. These five physicists need to come back and find this infrastructure, I'm going to go to the table with it. So that I'm looking at it from a systems perspective, because in fact, building the system, you'll also have to step out of the health workforce bit, and look at the other components, the other pillars towards, you know, realizing universal health coverage, and these are the ones we sit on the table now to engage with, and say, okay, I need, for example, you to build capacity in, you know, supply chain, this is what I'll come to the table with. In line with current government priority, and actually staggered in a way that it builds up on each other. If this year I ask for physicists, the next time I sit on the table, by the time they come back, the infrastructure should be able to support the work that they do. If it's surgeons, it means the theaters need to, you know, like that. So that's actually where we are right now, and I still haven't answered on who will pay, but maybe we can take the first step. Thank you.

[01:33:24] Helen Dempster: Just leave it for Jim. No, no, no, no.

[01:33:27] Jim Campbell: So I'm going to be a bit provocative, it's the end of the evening, we're about to get served a drink. Let's go back, let's name and shame, because I'm no longer at WHO, I'm allowed to do this now. So we're going to, the expert advisory group did fantastic work, we're going to change some of the narrative tomorrow, hopefully with the adoption of the resolution, and then we're inviting WHO and partners to try to push that thing. But meanwhile, when we talk about mutual benefit, the United States of America today, now, having left WHO, is deliberately, intentionally dismantling the Cuba Medical Brigade program, which has been one of the world's most successful mutual benefit programs, between a source and a destination countries, with some issues around the rights of the workers, but over the time, over the years, they've been improved, and so there's been mutual benefit negotiated between those countries, and the U.S. is dismantling that methodologically today. They're going into countries, you haven't got the U.S. giving, give me your poor, give me your wounded, give me your, you know, come to us, give me your data, remove your Cuban investment, and I might give you an American first policy. So let's just talk about mutual benefit. There is a negative out there that we need to call out, but in terms of then, the next thing in terms of the mutual benefit, on a technical level, we need to remove the human capital dominant economic theory of this discussion. So traditionally, it's been a government invests in the education, the capabilities of its workforce, to be contributing through the active labor production to GDP, and this is the compensation mentality. The governments have done early school, primary, secondary, tertiary education, that's the old school human capital thinking, contributing to GDP, but today, in many, many jurisdictions around the world, it's families who are paying for primary school, secondary school, tertiary education, contributing to the human capability for people to flourish, to people to have opportunity, for people, you know, to have a lifestyle and a life itself, which is better than their parents and their grandparents. And that's the reality, is it not, in many, many jurisdictions. It was for my, you know, Irish family connections, that was a mandate in terms of try to do something for your children so they don't have to suffer the same way we did. In which case, this out-of-pocket expenditures, we're into a human capability discussion, a human flourishing discussion, not a human capital debate. And when we start to look at it that way, in creating opportunity for everybody in this world to access health care, to access education, to access things, there are better solutions to do that. And through that, there is, coming back to your point, just basic demography, basic epidemiology. We need to harness the capability of fast-growing populations with countries like the Philippines, Asia, Africa. They are the workforce of the future. We need to harness that. We should be almost begging you in the high-income country, who's going to look after me when I'm old? Where's that workforce going to come from? Africa or Asia. It's not going to come from, you know, the Europeans. We see the OECD PISA survey, 16-year-olds across the OECD countries, across Europe, don't want to work in health care. It's going backwards, it's going down and down and down. So, technically, we need to change the narrative back to human capability, human flourishing, and put out a vision for the future around a global workforce, which people can buy into. Thank you.

[01:37:35] Helen Dempster: Wonderful. Thank you so much, Jim. And I want to thank all of our panellists for joining us this evening. In the interest of time, I'm going to leave our Q&A to some heated discussions over cocktails. I'd like to invite Jean-Christophe Dumont, Head of the International Mobility Division at the OECD, to provide closing remarks. Thank you very much again to our panellists. Thank you, Hélène.

[01:37:56] Jean-Christophe Dumont: I don't know, we have minus five minutes, minus ten, or minus fifteen? No, do you want to take remarks? I have minus something, so I'm going to be short. I don't want to reiterate the thanks, but I would like to join those who have thanked all the partner organisations, Hélène in particular, for putting that together. Thank you very much. I think it's great to hear your leadership. It makes a difference here. I want to blame Jim, because, I mean, yes, you're seated next to me, and I'm sure you look at my notes. I wanted to quote Murray Robinson, but you did it already, so I can skip that. Well, certainly, this is a longstanding issue, and I've also been here for quite some time. I would like to thank all of you. Thank you very much. Well, certainly, this is a longstanding issue, and I've also been here for quite some time. I was part of AGOA with Francis Omaswa from Uganda. I was, yes, at the inception of the code, and since then, we did a lot of work together between WHO and OECD. We produced a regular report monitoring migration flows and trends in OECD countries. So, yes, we have a lot of evidence. I can tell you how many people from your country are working as a nurse or doctor in the OECD country, in which country, and I can look back at 2000 with this OECD WHO data. So, we know much more than before, but it's true that, I mean, I have also the sensation that everything changed, but nothing changed. I mean, 20 years, and we're still discussing the same topic, to be honest, and not 20 years. And I cannot go back statutorily to your old reference, but a brand name came from a Royal Society report in 1963. It was about UK scientists going to the U.S., so I see the diversity of a reference here. But I certainly, there is this sense that, yes, everybody is aware there is an issue. We have the evidence, yes, urgency, and we know what to do, maybe. And yet, we're still discussing it, so something is wrong. Well, maybe what is wrong is this perception of immobility, because I don't think this is true. I think the code has made a huge difference, and I'm a very strong proponent of the code. I think this is one of these international instruments that makes a difference, much more powerful than the global compact on migration, for example. Nothing compares. It has this potential to really deliver. And, indeed, countries have made progress. It's not true that they haven't made any progress. If you look at training capacity, it has more than doubled in most OECD countries in the past 15 years. The problem is that the growth in employment of healthcare workers has increased twice as rapidly as total employment growth. So, yes, there was some progress, there was some investment, there was an attempt to respond, but it was not up to the challenge. There is a problem of anticipation, planning, and long-term vision in a number of OECD countries. And some of these things are being fixed, but it takes a lot of time, and they are not to be fixed everywhere. It's true that there are a few OECD countries where the share of immigrants among doctors or nurses is outstanding. I don't want to name them, but if you look at the International Migration Outlook 2025, you'll find a few countries where it's more than one in two. Not in the UK, 40%. So, you can find worse. So, I think the code made a huge difference, and countries are starting to take into account some of these things. I do think that the revision of the code is a significant step as well. I would mostly focus on two points. One is the enlargement of a focus to care workers, and this is not the same game. We're talking hundreds of millions of people, basically. We're talking a huge number of workers, and for whom the need is going to be increasing probably even more rapidly than in healthcare. So, I think including that in the code makes a huge difference in the scope of the code. I will come back to that in a second. The second thing is this co-investment concept, which is, I don't know who came up with it, maybe you, Jim, I don't know, but a very smart way to take us out of the corner of the compensation discussion. And it's true that there was kind of a blackout on compensation for 20, 30 years, I don't know. I mean, by golly, it didn't make any difference back then. And the co-investment enables, maybe, to make progress. Why? First of all, because there is no automaticity, so that's number one. Second, because it doesn't say co-investment, as the Kenyan colleague mentioned. It's not necessarily about compensation in training. It can be compensation in something else. It can be co-investment in something else. Maybe not in health sector. Maybe it's something else, primary education, secondary education, whatever. So that offers much more flexibility. But I think there is a third argument, which is that it enables to bring in the private sector. So it's not only co-investment necessarily from state to state, but it's also for the employers. Those who are at the end, not only when the health services are private, are making the benefits. So they also need to pay something in this process. Not only the destination countries themselves, the employers in destination countries as well. And this co-investment concept can work. But I think, and I will stop here because I think, let's have a drink. But I think that can work only at one condition. And I'm speaking from the OECD, but okay, I can say that, I guess. We need more WHO, not less WHO. We need more staff working on health human resources. Yes, thank you very much. You've made a compelling argument for the fact that the task remains. But the task remains with a very small team. I mean, it's not to the challenge. So WHO internally needs to make the right decision in terms of investing in human resources capacity. I think that's one. We need a role for WHO. Not only to collect data every four years through the national monitoring system, but to be able, for example, to say, and that was one of my points in this expert advisory group, that the BLA or co-investment mechanism or whatever is WHO certified. That this deal meets the condition or the principle of a code. That would make a huge difference. Because if you don't have the certification from WHO, this deal is no good. If you do have a certification from WHO, that changes the conversation. So having the WHO involved in the process, not necessarily of negotiating anything, but once you have negotiated, does that fit the principle, does that respond to the principle of a code? And if not, what else is missing? And go back to the negotiation. If you want to have a certified agreement. If you don't, fair enough. You don't have to. So I think that would make a huge difference and would enable to bring the co-investment from an idea to something that is really practical in nature. And my maybe last point is, it's in the code, but it's there, but it's not really there. And I think that's a little bit about what Liz said. I think not only we need to do a better job in terms of managing this mobility, but we need to do a better job about brain waste. I mean, there are so many people who have been trained as health professionals that are working in occupations that are below their level of qualification or not in the health sector. Everybody is losing in that case. We need to do a much better job at that. So that's another point. My very last point is that the other condition, and that's also about more WHO, not less. We need real-time data. Just to give an example. Asylum statistics. We have weekly data by nationality for all OECD countries. Weekly data. Why is it not possible to have monthly data or quarterly data for health workers' mobility when they reach a country? I think there is no reason why this is not technically possible. This is possible, and having this real-time data will make a huge difference in terms of planning, but also in terms of the capacity of a country of origin and country of destination to negotiate proportionate deals. Thank you very much.

[01:47:52] Helen Dempster: Thank you very much for coming and thank you for joining us now. Thank you.