Yeates and Pillinger’s book, International Health Worker Migration and Recruitment: Global Governance, Politics and Policy, provides an acute summary of the role of International Organizations (IOs), both governmental and non-governmental, in shaping global policy in the area of regulation of health worker migration. Their contribution addresses an issue of vital importance, particularly to the Global South, where countries including those of the Caribbean, the Philippines, Bangladesh, and large parts of Africa face grave shortages in healthcare personnel due to emigration. Yeates and Pillinger depart from the assumption that IOs, as actors with their own agendas, can operate autonomously and authoritatively to bring about policy change in this policy area. This premise elevates the study’s analytical lens to focus on actors and processes above and beyond the domestic sphere, away from the so-called ‘methodologically nationalist’ approach characterizing much extant scholarship, to a transnational and multi-relational understanding of policy making.
The study draws on a rich theoretical toolbox that uniquely builds on the tenants of global governance theory, historical institutionalism, as well as historical materialism. The former reflects the authors’ interest in global governance as a collection of formal and informal rules applied across a range of levels, including cross-national spheres, and as a contested process. This is wed with a concern for contextual and historical circumstances, as they come to interact with the material capabilities of actors and contexts in shaping global policy. Concerning the latter, the authors emphasize the special significance of labour as a major historic actor contributing to global health economies.
While the application of precepts following from each theoretical strain is not always clear in the book, leaving a number of key assumptions unspecified (e.g. which types of IOs bearing what material conditions and under what historical circumstances can be expected to affect policy change in one or another direction?), Yeates and Pillinger’s framework emerges as an altogether novel and dynamic approach. This is especially true as applies to the study of health worker migration, which has thus far been limited to a focus on national measures to address worker mobility. Not only theoretically innovative, the book’s period of observation spans across seven decades, allowing for an in-depth, expansive and evolutionary perspective of the developments in this policy field. It is within this timeframe that Yeates and Pillinger trace the origins of IOs’ earliest involvement in the area of health worker migration on the part of the International Labour Organization (ILO), as well as identify three major periods of IO proliferation and engagement in the post-World War II period.
The first phase, taking off in 1945 and ending in 1979, is said to be characterized by a nearly hegemonic role of the United Nations (UN) and ILO specifically. This was a period distinguished by normative concepts such as ‘brain drain’ and ‘fair recruitment’, as well as the ILO’s Nursing Personnel Recommendation in 1977. Yet, it was also marked by a failure of the organization to implement policy, as well as to capitalize on the normative zeitgeist which it itself had helped to create.
With the start of the 1980s, Yeates and Pillinger point to the unfolding of a second phase that pushed forth a neoliberal global policy agenda with a leading role for the International Monetary Fund (IMF), World Bank, and OECD. This brought with it a radical shift in policy goals that led to the marginalization of the UN. It was not until the close of the 20th Century that another major change in the global policy landscape could be seen. As aptly described by the authors, this was marked by a push for more regulation by international development ministries and greater involvement by non-governmental organizations (NGOs) and international non-governmental organizations (INGOs) to address the negative effects of healthcare worker migration through ethical recruitment initiatives. This set the stage for the 2010 Global Code of Practice on the Ethical Recruitment of Health Personnel by the WHO, which helped give the organization a new lease on life in the policy area. Yeates and Pillinger argue that one major design failure of the Code was its exclusive reference to restrictions on governments rather than what is a growing role of the private/commercial sector in worker recruitment. Accordingly, this second phase is characterized by substantial leeway for non-state actors.
The third phase of IO proliferation identified by Yeates and Pillinger is said to have begun in as recent as 2016. This period, currently underway, is marked by efforts to realize Sustainable Development Goals (SDGs), as well as the mainstreaming of international health worker migration and recruitment into the global policy agenda and discourse. It is also defined by a lead role of the WHO, advancing the cause for universal health coverage and emphasizing, alongside the ILO, the urgency of addressing health workforce issues. Crucially, the present phase is also characterized by a multi-stakeholder policy landscape in which IGOs and INGOS are involved in the policy formulation and delivery of SDG goals. In the case of healthcare policy, this has meant a burgeoning reliance on the private sector.
As in the case of any system of periodization, arguments can be made for or against the cutting up of time along certain lines. Given the shift towards greater regulation seen at the end of the 20th Century, for example, the choice to include this within the same phase once dominated by neo-liberal policy seems, at least at first glance, questionable. This said, the real contribution of the book lies not in its delineation of periods, but in the rich details and critical analysis of the events spanning across some seventy years of history. This includes an uncovering of complex relationships between IOs (such as the ILO and WHO), as they complement, compete, and come to dominate certain policy agendas at different points in time. This aspect touches on the need for greater differentiation in our conceptualization of IOs, given the diversity of their governance structures, memberships, ideological leanings, resources and power, not to mention the multitude of actors, hierarchies and institutions residing within each. This complexity is compounded when one considers the various ways in which actors may collide and interact within the current multi-stakeholder period, as IGOs come to incorporate transnational NGOS, the private sector, and local actors into its day to day policy world.
Yeates and Pillinger’s book does a wonderful job at capturing this complexity and identifying some of the main trends within a seemingly infinite universe of actor and issue constellations. Looking ahead, there are many questions small and large that are provoked by the book: in which direction is the global policy wind blowing? And can we hypothesize as to what factors contribute to the rise of one actor type carrying a particular policy banner in place of another? Based on the various changes across the global policy landscape over the past seven decades since the end of the Second World War, it is difficult to differentiate which actors matter the most, when and in relation to which policy field or issue. This book serves as a strong basis for answering such questions, making an invaluable contribution to the study of global governance and transnational policy dynamics affecting international health worker migration and recruitment.
