This interview, conducted by by Nat Thomson, Simmons MSW Candidate, runs abridged in the May 2024 issue of the MPH Monthly.  Corinne Hinlopen is a Global Health Advocate and Policy Researcher with Wemos, a Netherlands based global policy analysis and advocacy non-profit focused on structural change in service of global health justice. 

Corinne, thanks so much for joining us today for our chat. Perhaps to start, could you let our readers know a bit about Wemos?

Wemos is an Amsterdam-based NGO working on the right to health. We are an advocacy group, first and foremost. If we feel that the right to health is compromised somewhere in the world, then we start there, by identifying these situations as a potential area for us to work on. We were founded some 45 years ago by medical students who were studying tropical medicine and international health, and who would do their practicum in low and middle income countries, as their way of getting to know tropical diseases, gaining experience for 1 or 2 or 3 years typically, and then coming back here to The Netherlands. The [students who would go on to form Wemos] concluded that this was a neocolonial way of working; you go there, you get your knowledge, you share some of your knowledge, you contribute to healthcare provision, but then you go back. So these founders started to feel like this was not the right way to go about it. If you want to boost health systems in low and middle income countries, there are different ways to do so, and sending half-qualified students or inexperienced young doctors to these countries and then having them leave [may not be the best approach overall]. We have many topics we work on, such as inclusive health systems, finance for health, human resources for health and access to medicines. 

My particular field is health workers and health worker mobility and migration. Sometimes we work together with health worker labor unions and other health work labor oriented organizations. [Our role with them] is to help to stand up for the appropriate working conditions; the labor organizations do so in a very practical way and we do so in our [advocacy] way. Today, we see shortages of health and care workers, resignations from health and care work roles. Our focus is anyone who contributes to health and care provision [from doctors and nurses to hospice care to pharmacists and beyond]. 

We see that working conditions have deteriorated in the last two decades or so. It’s difficult to pinpoint exactly where the decline started, but we feel it is safe to conclude that the status of health and care workers, surgeons and specialists aside, has declined. It used to be that if you were the village doctor, for example, you were a big person in that village, decades ago. But not anymore, for all sorts of reasons. I don’t know how it is there in the US, but in the Netherlands, the family doctor is the lowest in the hierarchy of doctors nowadays. If you were a family doctor in the ‘70s or ‘80s, you were a figure of importance in the community, but the status of health and care workers has declined, earnings have tended to stagnate and work pressures have tended to increase, for all sorts of different reasons. This tends to mean that people generally are less inclined to become health and care workers. Or those already in the industry are resigning from their work because they feel they can find another career with less pressure and stress, while also earning more, in a different sector or in private healthcare versus public offerings. So, speaking to these [deteriorating] conditions is important in [ensuring that there are people who will fill and stay in these important roles]. It’s important for health and care to be an attractive sector to work in.

When you say low and middle income countries, what countries does that tend to focus on?

Europe and the Netherlands are quite focused on Africa and Asia, specifically Indonesia, based on the old colonial ties. We look at health inequalities and inequities, so it’s sort of obvious that we would work in the lowest income countries and try to understand why they are deprived of good healthcare, or to understand what the specific inequalities present might be. But, we have also done work in the EU which as a union, professes to be a union of solidarity and shared prosperity, which is not the case [in practice]. There are health inequalities in the EU that we look to identify and address. We look to fight these disparities by addressing them through policy change.

What are the forces at play that tend to contribute to these disparities? Would you say it’s primarily capitalistic forces?

Privatization of health care facilities is a factor, but it’s not the only one. It depends on the context of the country. It’s really different in each situation. But I can talk about our ways of analyzing these situations. One of the essences of public health is that you achieve a lot of positive health outcomes by changing policies, not by specific projects or interventions on a small scale for some groups. Bigger and sustained changes are shown to be the most impactful for population health, and health inequalities best addressed with structural changes that benefit those who are most marginalized or in a disadvantageous situation. This is the manner in which Wemos operates; we look at what the “haves” have and what the “have-nots” are missing and we try to figure out what has, in the specific situation, created the disparity and what the accompanying mitigating policy should be to reduce that inequality. Sometimes this involved the “haves” forgoing certain things that might contribute to the inequality present.

Between high income countries and low income countries, the high income countries tend to do development cooperation and inevitably still it’s the low and middle income countries who tend to remain on the losing end. This is on account of the many big geopolitical agreements and [the dynamics of contemporary geopolitics.] Even looking just at tax justice issues, the global tax regimen favors the richer countries. Debt tends to favor richer countries. Lower and middle income countries tend to end up on the losing end, always. So we try to unravel these structural and systemic drivers of inequality. We advocate that they get addressed and eventually taken away.

You had mentioned the topic of migrant health and care workers; could you talk a little bit about how that tends to fit into the philosophy and structures of what Wemos looks to address?

On and off over the past decades, we have had big and small projects focused on international mobility and migration of health workers. This topic ties into the theme of richer countries as well. Because richer countries have more resources, they can spend more on health personnel [than a lower income country]; these workers will see higher wages than Ghana, Nigeria or Zimbabwe, for example. Therefore, people can be attracted to come and work in these richer countries. There is a huge flow of health and care workers who leave their native countries and go to The UK, Australia, New Zealand, Canada, or to neighboring countries in their region, where salaries and working conditions are better. At the same time, the countries that they are from have little money, and this money does not always go towards investments in health systems. 

So their national development tends to follow in the footsteps of wealthier nations, with a primary focus on industry, the market, imports, exports, what have you, instead of health?

Yes. As an example, we did a case study on the nation of Malawi. According to the Abuja Declaration, 15% of a country’s annual national budget should be put towards health, in order to build a strong health system for the population. When we looked at Malawi (this was a couple of years ago already, don’t know if it has changed since then), they spend more than that rate on health, but because the country is so impoverished, it’s still insufficient in absolute terms. So they do their best with the money that they have, but they still cannot provide for their people. And although they do educate enough nurses and doctors, the nurses and doctors that are graduating are then thinking “well, I’m here in a poor country, my pay is rather low, I’m going to go to a neighboring country where the pay is better,” like Nigeria or Uganda. In the quest for a better life and better work opportunities, which is their basic right of course. Such regional mobility and migration flows are very dynamic, and then there are the intercontinental flows as well, to the US, Canada, the UK, Australia, etc. So there is this migration pathway that tends to play out. 

[From the other side,] as a receiving country, once you understand how easy it is to recruit from outside your own country and to not educate your own health and care workers, the richer countries may be tempted to do so on purpose [for cost saving reasons]. Language issues and qualification issues can be taken care of. It can just be quicker and cheaper to recruit from outside the country.

Ah, interesting. Very supply and demand oriented, which I don’t know that I would have ever thought of in that fashion, even though I’ve had doctors, specialists and even friends and family who have migrated in the health industry. You’ve got this almost unlimited supply of workers and unlimited demand in wealthier countries. I’m assuming that beyond recruiting, these people will work for a lower wage as well?

That’s an interesting point. It depends on the legislation in the country they are coming to. It should not be the case [that they are given lower wages] so that is something that the labor unions are rightly very adamant about. Here in Europe, we have this free internal market, meaning we have free movement of goods, services, capital and people. So if you are a fully qualified nurse in Romania, you can apply for a job in The Netherlands and your qualifications will be recognized automatically. Now, even though your qualifications are recognized, and depending on the position you’d like to apply for, you still have to do language tests and you have to update your knowledge and get acquainted with the health system culture. Sometimes people migrating don’t want to bother with these things and will settle for a lower qualified job, for which these skills are less regulated, so they can start right away. So then, you have fully qualified nurses from Eastern and Central Europe willing to work in a lower role in Western and Northern European countries, at lower pay, despite their higher qualification. It’s a huge problem, loss of human capital or as we sometimes call it “brain waste.”

Kind of like when you meet someone who drives a car for a living here in the States, but back home they were a doctor, lawyer, what have you.

Right. And it’s one thing when it happens on its own, it’s another thing when it is actively driven through recruiting practices. This is why a code of conduct was developed and adopted in 2010 by the WHO member states; WHO Global Code of Practice on the International Recruitment of Health Personnel. This Code addresses many different issues, including ethical recruitment and refraining from active and targeted recruitment from countries with critical shortages [of health and care workers]. Many years of negotiation went into its development. Embedded in the code there are provisions and instruments for checks and balances to make sure that the letter and spirit of the code is followed.

An approach in this realm I wanted to ask you about is for states or nations to pay for folks’ degrees with the contingency that they stay and practice where they are needed in said region. For example, I have a cousin who practices as an OBGYN in Kansas; the state of Kansas helped to pay for his degree from a state university with the condition that he practiced rurally in the state, where his services were badly needed.

I have worked on similar projects in a European context, around medical deserts [like you are describing]. For example, if you live in a valley in the Italian Apennines, it will take you at least an hour by road to get to a hospital. It is the same in rural Romania, when roads and bridges are badly maintained. There are many different areas where these medical deserts exist, all with different, but similar, characteristics, and all which require different approaches to getting these areas better served. The kind of agreement you are describing has been implemented in several countries for years now and it does tend to work. But such agreements should ideally be complemented by additional measures so that people will not leave quickly right after their obligation is completed, putting the community back in the same position again. So broadly, this kind of approach can be productive; there are just many considerations to be careful about [in implementation].

One thing that we wanted to ask about was advocacy and maybe how to get the public more aware and involved. Any thoughts on this piece of the puzzle?

The migration and mobility topic can really tend to be over-the-head of the general public. [Through the eyes of the public], it’s more like “I want my healthcare and I would like to have a doctor who speaks Dutch, but if not, then a Romanian doctor will be fine as well,” Getting the general public to consider that Romanian doctors leaving their country to work abroad, in the number that they do, might be an issue for Romanians, In Romania, is a tough one. It’s not really a general public sphere debate, if you will. There are so many other things to concern oneself with, and for people to advocate for, before this one. 

As I hear you describe the nuances and Wemos’ work as an advocacy organization, it occurs to me that the world of public health justice really needs a Wemos type organization at every level, from national, to state, to regional, as an activist body to mind all these intertwined considerations, from outside.

That's a very correct observation. My message, or my plea, to your student readers would be that they take on roles as advocates alongside whatever it is that they may be doing in their position. Those who are the most marginalized and most vulnerable need structural changes, and people who advocate with and for them. Here in the Netherlands we have a woman who is known as the “lung doctor who smokes”. She quit smoking a long time ago and then became a passionate advocate against smoking and the tobacco industry, and so she has become a bit of an icon here. So beyond her practice work, she is highly critical of Big Tobacco, their marketing strategies and their efforts to attract new customers with vapes. She initiates campaigns, appears in the media, and really is the kind of inspiration that I would like public health students to follow and become!

We thank Corinne so much for her time speaking with us!