Each year 20,000 healthcare personnel—doctors, nurses and midwives—emigrate from Africa to Europe and North America: more Beninois doctors now work in France than in Benin. Yet because of the disastrous health situation in Africa, a million more health workers will be needed there by 2015 to achieve Millennium Development Goals (1).
African healthcare personnel have become a pillar of strength for health systems in the North. Europe, the United States and Canada have neglected to train and retain adequate numbers of doctors, nurses and midwives to meet the growing needs of their ageing populations, and are forced to recruit from abroad. Britain will need 25,000 more doctors and 35,000 nurses between now and 2008, according to estimates; the US will need a million more nurses between now and 2010.
Recruitment from abroad seems to be a cost-effective and simple solution to a shortage of healthcare workers. In seeking personnel from Africa, rich countries save on the cost of training, which is about 10 times higher at home than in Africa. Another advantage is that African health workers are more flexible—prepared to work for less money and more willing to work night shifts and overtime.
This migration of qualified professionals represents a major loss to their countries of origin in healthcare capacity and economic and social costs. It is enough to measure the training costs: since 1999 Ghana has lost $67m in health system investments because health workers emigrate once they have completed their training.
These workers are easy prey for northern economies. The continual drain of human resources from Africa, combined with decades of harsh economic policies, has led to chronically underfunded health systems. Staff in such countries are paid meagre salaries (the purchasing power of a Nigerian doctor is 25% lower than that of a doctor even in eastern Europe). They work in insecure areas and have heavy workloads, but lack the most basic resources, including insufficient drugs or medical equipment; they have little chance of career advancement.
The impact of this chronic underfunding, together with high levels of emigration and the worsening impact of the Aids pandemic (2), has led to a rapidly mobile health workforce ready to seek better opportunities elsewhere. It is easy for recruitment agencies and diaspora networks to entice health professionals from Africa to developed countries with offers of higher salaries and better working conditions, selling a new employment paradise in the North. But healthcare professionals also move from rural areas to the cities and from the public to the private sector, seeking to optimise the quality of life for themselves and their families, and making the most of their work opportunities.
This brain drain has terrible consequences for Africa, where two out of three children die from diseases that could easily be treated or prevented. Of the 1,200 doctors trained in the 1990s in Zimbabwe, only 360 remain; 600 out of the 800 doctors trained in Ghana between 1993 and 2002 have emigrated and 66% of them now work in Europe or the US. The infant mortality rate in Ghana is 1 in 10, against 1 in 200 in France; there are nine doctors for 100,000 people against 335 for 100,000 in France.
Dr Abdoulaye Bagnou, coordinator of the prime minister’s cabinet in Niger, says that his country has lost all its experts in certain areas. “We can’t choose the right equipment. We have difficulties planning and cannot get support from technicians. This effects our capacity and we can’t recruit new staff. The World Bank and the International Monetary Fund control our expenses.”
Several African countries have decided to take action and their initiatives show that it is possible to reverse the brain drain and improve health systems by investing in healthcare personnel. In Uganda, the ministry of health started meal payments for doctors in 1996, followed by a 60% increase in salaries in 2001. Malawi managed to convince Britain’s Department for International Development, the World Bank, the Norwegian Agency for development cooperation and the Global Fund to fight aids, tuberculosis and malaria to fund a major increase in personnel. This means 40-50% higher salaries, new cadres of health workers, modified training modules more suited to context, and six times as many graduates in medicine and nursing.
Ghana is another dynamic country. With the help of the International Organisation for Migration, it launched a recruitment programme to offer financial incentives for health personnel who return home after working abroad. Recruitment offices were set up in Ghana’s chief embassies to improve contact with likely candidates. Ethiopia is desperate to make changes. It has morbidity and mortality rates among the highest in the world, and an acute and chronic shortage of doctors and nurses. Twenty thousand women without nursing qualifications have been trained in maternal and child health and will soon be sent to rural areas in an attempt to make 19 health schemes work. In Zambia, healthcare personnel are being offered such incentives as financial bonuses, housing loans and contributions to their children’s education, to encourage internal migration towards more remote areas. In 2005, 66 doctors accepted these.
Failure to coerce
Research by Save the Children UK and Medact (3) shows that many of these positive retention policies were introduced because of the failure of coercive reforms in the 1990s. These included taxing those migrating to work abroad, withholding diplomas from health workers until they completed their agreed bond time of one or two years, and failing to add their names to public payroll lists until they completed two years’ work in rural areas. The result of these measures was to encourage migration and increase tensions between health workers and government; many countries have had to deal with staff strikes and more absenteeism.
In most inefficiently resourced African health systems, ineffectively supported health workers have to charge fees just to have some resources to keep the basic health services functioning. This has led to tension and eroding trust between health workers and poor communities who either avoid seeking care or wait until they are seriously ill to do so, leading to high levels of unnecessary deaths among women and children.
Some rich countries have adopted codes of good conduct, but these have until now had limited impact. The codes prohibit recruitment from target countries and protect the rights of personnel within the host country. All African countries are on this list of targeted countries. But codes of good conduct have not been made law in Britain and some other Commonwealth countries and their application is dependent on government goodwill. In practice, codes of conduct have not prevented developed countries from continuing to recruit African personnel through private agencies.
Need to invest
When launching the World Health Report “Working Together for Health” in April, Louis Michael, the European commissioner for development and humanitarian aid, said: “It is essential to invest in health worker training”. He added that it was necessary to put more resources behind effective human resource strategies and highlighted the contradiction between member states who pretended they were increasing development budgets while draining poor countries’ resources for their own needs. He warned that if long-term strengthening measures were not taken immediately in sub-Saharan Africa’s health sector, international community investments in health would have only limited effects.
According to the Commission for Africa, between $1bn and $6bn will be necessary from 2006, and as much as $7.7bn from 2010, to make up for the lack of African health professionals. To date few donations have been pledged to help developing countries fill their personnel gaps.
Training this additional pool of healthcare workers is essential, even though it will take six to eight years to produce results. Urgent short-term measures are necessary: successful measures include increasing salaries and introducing financial incentives for service in remote areas. It is vital to convince the IMF, the European Union and other international institutions to loosen economic regulations to allow African countries to improve their expenditures on health.
Dr Ntaba, Malawi’s minister of health, said: “I would like to bring to the attention of the international donors that it is impossible to deliver quality care with $12 per person per year (4). It is poverty that underlines this situation. If donors respect their promises, they should spend 0.7% of their GDP. This would have a significant impact on poverty in developing countries.
It is unrealistic to analyse the present human resource crisis without relating it to poverty issues. To be able to attain the Millennium Development Goals, we urgently need significant investments in both human resources
(1) Eight Millennium Development Goals were agreed at the United Nations Millennium Summit in September 2000 (see http://www.dfid.gov.uk/mdg/). But the World Health Organisation (WHO) says $22bn would be needed to achieve the goals and the international community has never invested that much. Return to text.