Addressing health worker migration in Africa

Introduction

Over the past two decades, the African region has seen significant growth in health workforce development following concerted efforts and investments made by governments, donors and other stakeholders to expand the training and supply of health workers. By 2022, the number of educational institutions had expanded to over 4,000, enabling the annual training of more than 255,100 health professionals.^1–3 Notably, there have been increases in the training of doctors, dentists, nurses, and midwives, with women comprising 65% of the nurses and midwives, and 28% of medical doctors. ¹ This development has led to a rise in the workforce to approximately 5.1 million health workers in 2022. This represents a significant increase from 4.3 million in 2018 and a substantial rise from 1.6 million in 2013, effectively tripling the number of health workers over a span of 9 years. The density of sustainable development goals (SDG) 3.c.1 tracer occupations - medical doctors, nurses, midwives, pharmacists and dentists, also increased. In 2022, the density rose to 27 health workers per 10,000 population, up from 23 per 10,000 in 2018 and 11 per 10,000 in 2013. This upward trend highlights the progress made in improving access to healthcare services and addressing the critical shortages of health workers that have historically beset the region.^1,4

However, the region is still struggling to meet the SDG indicator threshold of 44.5 medical doctors, nurses, and midwives per 10,000 population. In 2022, Cabo Verde, Eswatini, Ghana, Mauritius, Namibia, South Africa and Seychelles were the only countries in the region whose density had exceeded the SDG 3 index threshold. Furthermore, the region continues to face a shortage of competent and motivated health workers, with an estimated deficit of 6.1 million workers by 2030 which could account for 52% of the global shortage. ⁵ Of this shortage, 5.3 million are for the SDG 3.c.1 tracer occupations. This projected shortage may be further exacerbated by the increased levels of health worker migration, which has once again become one of the continent’s most pressing health sector challenges.

This paper explores the state and drivers of health worker migration in the African region, drawing on published literature and data from the National Health Workforce Account (NHWA). It offers an overview of the persistent yet pressing health system drivers and their impact, as well as the global guidance on managing the international recruitment of health workers. Lastly, it outlines recommended actions for countries to effectively monitor and manage health worker migration.

State and drivers of health worker migration from Africa

The migration of health workers out of countries in Africa has been a challenge for decades. The African region has borne a significant share of the international mobility of healthcare professionals, predominantly from low- and middle-income countries. This trend has been driven by the escalating demand for health workers in high-income nations and the dual challenges of an ageing workforce and population. As shown in Figure 1, at least 34,653 doctors of African origin have been reported to be employed in nine high-income countries, accounting for nearly 10% of the total headcount of doctors in the African region as of 2022. ⁶ OPEN IN VIEWER

Within the African region, approximately one out of every 10 doctors or nurses is employed in a country other than their own. ⁴ This out-migration of healthcare workers to high-income nations intensified during the COVID-19 pandemic. Furthermore, it is estimated that around 42% of the region’s healthcare professionals have plans to relocate to another country in the future, with the United Kingdom, the United States, Canada, Ireland, and Australia being the most sought-after destinations. ¹ The ramifications of this emigration of highly competent health workers to destination countries, termed “brain drain”, can be severe, depriving nations of their most qualified and experienced medical personnel, impacting the quality and accessibility of healthcare services.

There has been a significant outflow of health professionals from their domestic markets compared to existing stocks. ¹ Figure 2 shows a concentration of countries with high migration, particularly in Southern and West Africa for doctors, and West and East Africa for nurses, including Zimbabwe in the south. Furthermore, some nations with a low density of the current healthcare workforce exhibit a disproportionately high proportion of medical professionals practising abroad, e.g., the Central African Republic. Additionally, another group of countries which demonstrates a higher share of doctors working overseas generally have lower levels of educational requirements to qualify as a nurse, exemplified by Madagascar, the Democratic Republic of Congo, and Burkina Faso.OPEN IN VIEWER

Nigeria’s healthcare workforce has faced significant outward migration in recent years. In 2022, over 3000 doctors (more than 3% of doctors in Nigeria) requested letters of good standing from the Medical and Dental Council of Nigeria to facilitate their migration. Additionally, 11,838 nurses and midwives (8112 nurses representing about 5% of nurses in Nigeria and 3726 midwives, representing about 2% of midwives in Nigeria) migrated in 2022. The trend extends to the pharmaceutical sector as well, with about 4% of pharmacists (n = 751) migrating in 2021.^7,8 Healthcare worker migration is not limited to Nigeria. In Kenya, 5628 nurses requested letters of good standing to migrate in 2024 alone. In Uganda, the emigration of doctors has increased by 16% over a 3-year period, with the majority of doctors requesting certificates of good standing to migrate. ⁸ Zimbabwe has also experienced significant outward migration, with 2080 nurses requesting letters of good standing to migrate in 2021. ⁶

The health workforce in Ghana and Zimbabwe has been grappling with a worrying surge in employee attrition, primarily driven by out-migration. In Ghana, before the COVID-19 pandemic, the voluntary turnover rate stood at around 4%. However, published evidence revealed that more than 3000 professional nurses and midwives left the country in 2022, with the United Kingdom, United States, Ireland, and Canada being the primary destinations. ¹ This trend has accelerated in subsequent years, with the attrition rate between 2021 and 2023 being nearly three times higher than previously recorded. The situation has reached critical levels, as the number of nurses seeking verification of their good standing to facilitate their migration has risen from 2678 in 2020 to 6208 in 2022 - a 232% increase within just 2 years. ¹

A similar pattern is unfolding in Zimbabwe, where an accelerated rate of out-migration was observed in 2021, with the United Kingdom, United States, and Australia being the main destinations. Evidence shows that one in every five doctors and nurses trained in Zimbabwe is now employed by the National Health Service in the United Kingdom, making Zimbabwe the second-largest source of African health workers in the United Kingdom, surpassed only by Nigeria. ¹ Prior to the pandemic, Zimbabwe had a relatively stable annual rate of around 3.6% of nurses requesting letters of good standing to facilitate their migration. However, this proportion almost doubled to 6.5% in 2021. In response, the Zimbabwean government has implemented administrative measures to address this out-migration, successfully reducing the rate to 3.4% by September 2022. ¹

This context underscores the urgent need to address the factors driving healthcare worker migration from various African countries, in order to strengthen local healthcare systems and ensure the provision of quality medical services to their populations. These factors are fundamentally market forces linked to wage differentials and working conditions, and are a large-scale and growing phenomenon.

The migration of healthcare workers from lower to higher income nations, often referred to as “brain drain” has been a long-standing and contentious issue in the global health landscape. ⁹ This trend is driven by a complex interplay of “push” and “pull” factors. ¹⁰ The “push” factors in many African countries include low salaries, poor working conditions, limited career advancement opportunities, and a lack of adequate resources and support for healthcare professionals, driving health workers to leave. ¹¹ Conversely, the “pull” factors include higher salaries, better working environments including career advancements, and more advanced healthcare infrastructure and technologies, attracting health workers to destination countries.^10,12 These disparities in opportunities and working conditions serve as powerful incentives for healthcare workers to seek employment outside their home countries. Although this provides an opportunity to apply approaches to optimize the utilization of existing health workers, it ultimately undermines the capacity of local healthcare systems in Africa to deliver quality services to their populations and adequately respond to public health emergencies. ¹³

In many low-income and lower-middle-income countries in the African region, the growth of the supply of health personnel through education has outstripped the labour market capacity to absorb new graduates, sometimes resulting in the paradox of coexistence of unmet population health needs with unemployment among health workers. This is evident with nearly 30% of graduates remaining unemployed or underemployed after a year of graduation, attributed to a 43% shortfall in public sector budgets and underutilized private sector potential.^1,4

In some contexts, the governments of source countries are viewing international migration as an opportunity to alleviate unemployment pressures among health workers and indirectly benefit the economy through remittances. However, this may exacerbate pre-existing health workforce challenges in the source countries, as the departing workers are often experienced and specialized, making them more expensive and time-consuming to replace through the training system. Some also accept jobs abroad below their skill level, particularly in adult and social care settings. This represents not only a loss for health systems but also a significant underutilization of their abilities. To address this issue, source countries could explore strategies to incentivize the retention of experienced health workers, such as offering competitive compensation, improved working conditions, and opportunities for professional development. ¹⁴ Additionally, they could work to strengthen their domestic health workforce through enhanced training and education programmes, ensuring a sustainable supply of skilled healthcare providers to meet the population’s needs.^4,15

WHO guidance on health worker migration

In 2010, the World Health Assembly represented by Ministers of Health from all WHO member countries adopted a Global Code of Practice on International Recruitment of Health Personnel^9,16 following 6 years of negotiations amongst the countries on measures to manage the migration of health workers and share skills ethically. Article 5 of the Code focuses on health workforce development and health systems sustainability with Article 5.1 specifying that “Member States should discourage active recruitment of health personnel from developing countries facing critical shortages of health workers.” ¹⁶

To operationalize this provision, WHO maintains a Health Workforce Support and Safeguards List 2023 that identifies countries facing particular workforce vulnerabilities to be prioritized for safeguards, support and investment.^17,18 A country is included on the list if its health workforce density is less than the global median of 49 doctors, nurses and midwives per 10,000 population or its Universal Health Coverage (UHC) index is less than 55 out of 100 index points. Globally, there are now 55 countries on the list, with 37 in the WHO African region. ¹⁸ Wealthier countries are strongly discouraged from conducting active international recruitment from the safeguard list countries unless under a negotiated bilateral agreement. ¹⁷

However, active international recruitment of health workers continues to escalate, despite the existence of the WHO Code and Safeguard and Support List. ¹⁸ These guidelines, intended to protect the rights of health workers and source countries, are not being adhered to. Recruiting countries, at times, aggressively pursue international recruitment, often through the use of recruitment agencies that target potential candidates on social media, at workplaces, and on billboards. Some health workers have fallen victim to exploitative labour schemes, facing deplorable working conditions and having to surrender a significant portion of their earnings to their recruitment agents. Additionally, certain source countries, frustrated by their inability to employ and retain trained health workers amidst staffing shortages, are tacitly encouraging the emigration of their healthcare professionals. This systematic undermining of efforts to protect health workers highlights the need for stronger international cooperation and accountability measures to ensure ethical recruitment practices.

What can countries do to manage health worker migration?

Currently, the mechanisms for tracking the migration of health workers in African countries are weak, mainly due to limitations in the health planning and workforce information systems at various administrative levels to track the labour market dynamics.^19,20 Consequently, the exact magnitude of brain drain is not known, which has the potential to impede the progress towards achieving UHC and ensuring overall health security in the region. The lack of reliable data not only makes it challenging to quantify the scale of the problem but also hinders the development of evidence-based policies and targeted interventions to address the issue effectively.

Drawing on the available evidence, countries in the African region can take action. Countries can pursue mutually beneficial bilateral or multilateral agreements with destination countries to optimize the management of international migration of health workers. Furthermore, ways of harnessing the potential benefits of migration health workers in improving health systems in partner countries, and ensuring the labour rights of migrant workers are protected, should be explored. The World Health Organization has developed guidelines to assist countries with these processes. ²¹ The Support and Safeguard List specifies that Government-to-Government health worker mobility-related agreements are permissible for listed countries, provided they:

(1) Are informed by a comprehensive health labour market analysis and include provisions to ensure an adequate domestic supply of healthcare professionals.

Furthermore, African states should conduct a thorough health labour market analysis and use the findings to plan the production, funding, employment and retention of a sufficient number of health workers to meet their population’s health needs. The analysis should also explore the contextual factors and policies that inform health workers’ choices of working locations and their perspectives on working conditions. Additionally, exploring potential incentives to encourage the return of migrant health workers is essential.

Evidence from the above should be applied in developing local policies and systems for improving working conditions in the health sector to alleviate the pressures that compel health workers to seek opportunities elsewhere and encourage migrant health workers to return. This may entail offering comparative and better remunerations and benefits, enhancing working environments and retention packages, providing career development and advancement, and ensuring they have the necessary tools to carry out their duties effectively. Countries can cultivate a more appealing and supportive setting for health workers by attending to these factors.

Improved regular monitoring and reporting of health worker flows in and out of the country through national human resource information systems, profiling, state of health workforce reports, and the National Health Workforce Account is also vital. This information can be used to develop targeted strategies that address the specific needs and challenges of the health system, and health workers and track implementation of agreements between countries.

Dialogues amongst internal stakeholders and between countries to agree on a mutually beneficial mechanism of skills exchange and proportionate investment, as well as measures to address unethical practices, are also critical in ensuring collective ownership and actions for improved health outcomes.

Conclusion

The African region has made progress in health workforce development, yet significant challenges remain. The projected deficit of 6.1 million health workers by 2030 underscores the urgency for targeted actions. Addressing health worker migration through strategic agreements and protecting migrant workers’ rights can mitigate the impact of this trend. Comprehensive health labour market analyses and contextual policy explorations are necessary to inform effective workforce planning and retention strategies. Encouraging the return of migrant health workers and fostering international cooperation can further strengthen local healthcare systems. By implementing these measures, the African region can move closer to achieving the SDG targets and ensuring sustainable, high-quality healthcare for its populations.