Publication Date: February 28,2015
Authors: Ronald Labonté, Amir Attaran, Ivy Bourgeault, Gail Tomblin-Murphy, David Sanders
On March 2, Uganda’s High Court will rule on a request by the country’s Institute of Public Policy Research (IPPR) to stop the planned export of nearly 300 health workers to Trinidad and Tobago.1 The IPPR argues that the deal is “unconstitutional, irrational, illegal, un-ethical and contrary to both the national interest and public health policy.”
As part of a bilateral agreement, Trinidad and Tobago has been assisting Uganda to exploit recently discovered oil fi elds. In return, Trinidad and Tobago requested Ugandan health workers to fi ll gaps in its own health workforce, to which Uganda agreed.1 In the process of asking and agreeing, both countries have violated the 2010 WHO Global Code of Practice on the International Recruitment of Health Professionals and commitments under international human rights law.
The WHO Code was drafted in recognition of the fact that density of health workers is crucial for improvements to health. Article 5.1 calls on member states to “discourage active recruitment of health personnel from developing countries facing critical shortages of health workers”.2 Uganda faces a critical shortage, with less than a third of the WHO recommended minimum number of health workers. Trinidad and Tobago, which has ten times as many physicians and almost three times as many nurses per citizen, does not face a shortage (table).
Both countries have ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR), Article 12 of which addresses the right to health. This article requires countries to do everything possible to permit their citizens to progressively realise “the enjoyment of the highest attainable standard of physical and mental health”.
Although progressive realisation has been made in both countries, the under-five mortality rate in Uganda is still three times that of Trinidad and Tobago, while the maternal mortality rate is 3·5 times higher in Uganda than in Trinidad and Tobago. One reason Trinidad and Tobago outperforms Uganda is that skilled health workers attend almost 100% of births, compared with only 40% in Uganda (table).
Despite this fact, amongst its health-worker requests Trinidad and Tobago is asking for more than 100 Ugandan midwives and 40 public health nurses, another contravention of Article 12.1
Trinidad and Tobago’s comparative success is also attributable to its spending 23 times more than Uganda on health per capita. More than half of its health spending is public, by contrast with Uganda, where spending is more than 75% private. The portion of Uganda’s budget allocated for health consistently remains between 6 and 10% each year, well below the 2001 Abuja target of 15%.6 Uganda’s weak GDP, low taxation, and low public spending translates into unfi lled health positions, and complaints that public wages, when paid, are too low for health workers to earn a decent livelihood.7 That many health workers are keen to accept Trinidad and Tobago’s off er is no surprise. Uganda needs to substantially increase funding for public health, while Trinidad and Tobago needs to abandon its request for Ugandan health workers.
Uganda’s High Court decision should support the IPPR’s landmark request for an injunction. The court should also rule that the Ugandan government’s attempt to export health workers violates Uganda’s own constitutional right to health. This would cause Uganda to appropriately comply with its international obligations under the ICESCR and the WHO Code, and would put teeth into what has so far been exhortatory talk alone.
We declare no competing interests.

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