If health is truly wealth, as the popular saying goes, does Africa have any chance of escaping mass poverty and low rankings in the human development index that measures the quality of life of the world’s peoples? This is an existential question for the continent because its health systems are collapsing, worsening the quality of life of millions of Africans who do not have adequate and quality healthcare because the continent’s doctors, nurses, pharmacists, laboratory scientists and other health professionals are fleeing abroad in search of greener pastures. Real development is not just about GDP growth numbers, but more about GDP per capita and human development issues such as the availability of quality healthcare and Universal Health Coverage, education and skills, nutrition, potable water, and life expectancy.

Africa, which has only 3% of the world’s health workforce despite being 18% of the world’s population, has suffered a massive “brain drain” – a one-directional migration of skilled human capital that benefits only the receiving countries – for several decades. The problem has become acute, progressively getting worse as the years have gone by. And it isn’t going away soon. While the brain drain is a challenge for the continent across the board, it is most profound – and its impact heaviest – in the healthcare sector.

Consider: 65% of Egypt’s doctors work abroad. A total of 9,000 Nigerian doctors left Nigeria between 2016 and 2018 to work in the UK, USA and Canada. In Nigeria we call this the “japa” syndrome. Between 1986 and 1995, 61% of the entire graduates of one medical school in Ghana had migrated to other countries for work. A decade ago, an Ethiopian official lamented that there were more Ethiopian doctors in the United States city of Chicago than in Ethiopia.

When we look at Africa’s health workforce, what we see most vividly and immediately is a map that divides Africa and the developed world between the “brain drainers” and the “brain drained”. Fifteen of the world’s fiscally wealthiest countries have 55,000 African doctors working in their health systems – and this does not include nurses and other healthcare professionals. And there is anecdotal evidence that these numbers are a conservative estimate. The top “brain drainers are UK (13,909), USA (12,692), France (10,731), Canada (5,888), Germany (4,535), Ireland (3,056), and Australia (1,999). Conversely, Australia is the country that suffers the least brain drain the world. The top brain drained countries in Africa are, in ranking order, Egypt, Nigeria, South Africa, Algeria, and Sudan.

The health workforce brain drain is caused mainly by a combination of political instability, insecurity, and weak economies, on the one hand, and insufficient investment in public health systems. Inadequate equipment and drugs supplies, health insurance, low worker pay (African healthcare workers earn between $200 and $500 a month on average, while their counterparts in developed countries earn, on the average, 3000% more) all combine to create very difficult working conditions. Progressively increasing healthcare needs in developed countries, partly because of aging populations also drive the brain drain, as the laws of demand and supply kick. In the UK there was a 38% increase in new registrations of foreign doctors in 2002 compared to 1993 – a decade. England needed 25,000 more doctors in 2008 than it did in 1997. The situation is far worse regarding nurses: England needed 250,000 more nurses in 2008 than it did in 1997. More than 75,000 nurses are estimated to have left Nigeria in 2017.

The COVID19 pandemic has massively increased the healthcare needs of developed countries. Recruitment campaigns for health professionals by developed western countries targeting health workers in developing countries, and the absence of effective health insurance to cover healthcare costs, all contribute to a potent, irresistible mix of “incentives” for the brain drain phenomenon. There also is a lack of recognition and appreciation of the healthcare professions. The importance of health workers and the healthcare professions is not explicitly recognized, appreciated, and incentivized in the governance of most African countries. This also includes non-financial aspects of recognition and reward including the value attached to scientific research, the impact and publicity of publications in professional journals etc. This, combined with poor working conditions, creates an urge to leave our countries to work in developed countries where the uniqueness of the medical and healthcare profession is recognized in different and innovative ways.

The brain drain has had disastrous consequences for African countries. There is low doctor to patient ratios because of staff shortages. The World Health Organization recommends a ratio of 1 doctor to 600 people, but in Nigeria the ratio is a paltry 1:9000, while in South Africa it is 1:3198. Doctors in training (interns, Residents) now carry most of the workload burden, resulting in lack of adequate supervision, overwork, and burnout, with dangerous implications for health outcomes. Most African countries have been unable to achieve Universal Health Coverage. Moreover, the brain drain of healthcare professionals in Africa threatens the whole spectrum of development. Health tourism, which leads to economic bleeding of financial resources that would have been spent inside African countries, thus boosting the economy, is another major consequence of the brain drain. And labor strikes by medical personnel, with disruptive and existential implications for lives and public health in general, are a reality of life in countries like Nigeria.

Although reversing the phenomenon of the brain drain will take time even in the best of scenarios, it is such an important threat to the well-being of the citizens of African countries that it ought to be a number one priority of public policy and governance. Unfortunately, this is not the case. Few African countries prioritize healthcare. Without evident political will to reverse the brain drain, especially in the health care sector, the future of most African countries is bleak. A state exists to enable the welfare and prosperity of its citizens, for them to thrive and not to merely exist. Without health, most individuals will not live fulfilled and economically productive lives.

Against this background, the following strategies must be adopted to begin to stem the impact of the healthcare sector brain drain. First, fiscal investments in improving healthcare systems must become an evident political priority. In 2001, member countries of the African Union pledged to allocate and invest 15% of their national budgets on health. Only Eritrea, Mauritius, and Seychelles have met this target. Without such a level of investment, and with such investments allocated and spent efficiently and effectively with monitoring and evaluation of outcomes, healthcare cannot take off in African countries. Private healthcare providers simply cannot fill the gap, as their services are costly for poor populations. Second, we must train multiple times more health professionals. This requires a significant shift in the education policy. We need to shift the curricula of tertiary institutions to prioritize science and technology, in particular medicine and health sciences. Nurses and laboratory technologists are critical in this context. Third, incentive structures need to be created and implemented. These include increased remuneration for public sector healthcare workers, which will also incentivize more people to study medicine and the other medical sciences such as nursing, pharmacy, and so on. There should also be additional incentives for healthcare workers who work in mostly underserved rural areas. Fourth, we must massively increase health insurance coverage, as viable health systems must have a working health insurance policy to subsidize their costs, including compensation for medical workers.

Fifth, African countries need to establish and invest in comprehensive Diaspora return strategies, focused on the healthcare and education sectors. The brain drain crisis cannot be addressed without a direct engagement with brain drained Africans and with an attractive proposition too. IGET proposes a Diaspora Fund that would pay Diaspora returnees 50-75% of the compensation they earn in developed countries, for a fixed period of 5 years. This strategy would appeal to patriotic Africans who wish to return to and work in the continent but cannot get over the realities of their financial needs. These kinds of Africans would accept some “discount” on their compensation abroad when purchasing power parity in African countries is factored in.

The newly established World Health Organization (WHO) and World Bank Pandemic Fund

could be adapted for this purpose. However, with $500 million at this time, it may be too meagre

to meet the diaspora return funding needs of larger countries that have been the greatest victims of the brain drain such as Egypt, Nigeria and South Africa. Nigeria alone would need at least a $500 million Fund for this purpose.

Sixth, investments in skills training for healthcare industry remote work could create a brain gain in which trained and skilled African workers work partly for industries abroad remotely, earning hard currency, in addition to supporting medical care at home. Conversely, “brain drained” medical personnel abroad can deploy the technology of telemedicine to support health systems at home in Africa. Seventh, the productivity base of African economies must be improved so that a general improvement in living, working and professional conditions can help retain a significant portion of health workers. This will require adequate electricity, improved security, and the availability of housing and educational opportunities. Eight, slow down population growth. Population growth is outstripping not just economic growth in many African countries, but also outperforming improvements and advances in health care systems and the capacity of the health workforce.

Finally, African countries need to engage more effectively with the World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel, which aims to make such recruitments more “ethical” and ensures the oversight or involvement of national health authorities. But most African countries have yet to engage seriously with this framework as part of a holistic strategy to address their brain drain challenge. In the WHO Global Code of Practice 4th National Round of Reporting published in March 2022, only 8 African countries had submitted their national reports on the implementation of this framework in their respective countries.

African countries cannot afford to merely lament the brain drain, with little or no strategy, public policy, or tangible action. That’s simply admiring the problem. The brain drain is admittedly a difficult challenge, one not amenable to a quick fix. This is the case also because migration, whether for political, economic or other reasons, is an intrinsic part of human history. And we have seen no evidence of Francis Fukuyama’s famous phrase, the end of history. But we must begin to mount a serious response to the phenomenon in Africa. Without a viable health workforce, effective healthcare delivery can’t happen. And without healthcare, a basic human need, any talk of development is a pie in the sky.

References

Mark Green, “Africa’s Healthworker Brain Drain”, Wilson Center Blog Post, May 23, 2023, www.wilsoncenter.org/blog-post/africas-healthworker-brain-drain.

Alfred Olufemi, “There Won’t Be Enough People Left: Africa Struggles to Stop Brain Drain of Doctors and Nurses”, The Guardian (UK), August 14, 2023.

World Health Organization Global Code of Practice on the International Recruitment of Health Personnel: Fourth Round of Reporting, June 2, 2022, who.int/news/item/02-06-2-22.

Delanyo Dovlo, The Brain Drain and Retention