When Dr Biira* qualified as doctor in Uganda, she was hopeful about her future. Instead, she faced a common barrier: no job. Despite a huge shortage of doctors, no posts were available. Like many others, she left to work overseas.

Across Africa, talented health workers overcome significant obstacles to train, only to be driven away by unbearable working conditions, low pay, and limited career prospects. Meanwhile, high-income countries aggressively recruit with promises of better pay and career progression.

Health workers have the right to migrate – but the system is broken. Africa must re-negotiate this arrangement and build a fit-for-purpose workforce for the continent on its own terms. 

There is no doubt about the critical role health workers play. As the backbone of strong, resilient health systems, they are the first line of defence against emerging outbreaks, key to achieving universal health coverage, and one of our best bets against the impacts of climate change. Without them, there is no healthcare.

Six million shortfall

Yet Africa, which is home to 18,8% of the global population but 24% of the world’s burden of disease, is critically underserved with just 3% of the world’s health workers. The continent is projected to face a staggering shortfall of 6.1 million health workers by 2030.

Why? As African countries struggle to train and retain health workers, high-income countries underinvest in their pipeline of health workers – relying on imports from overseas. A new World Health Organization (WHO) report underscores this issue – high income countries have 10 times the number of nurses compared to low-income countries – while 23% of nurses in high income countries are foreign-born.

Yet the WHO Global Code of Practice for ethical recruitment of health workers is voluntary and often ignored. Countries on the ‘red list’ from which countries should not recruit, such as Zimbabwe and Nigeria, continue to see active recruitment through private agencies – with the US, UK and Saudi Arabia routinely recruiting, despite claiming not to.

The current system is exploitative and unsustainable and it’s costing lives. Training a doctor in Africa costs between $21,000 and $59,000. Between 2010-18, nine African countries lost $2 billion in investment as trained doctors migrated.

Africa is not the medical school for the world, and it will never be able to build resilient health systems if its health workers continue to be recruited in droves. 

The WHO Code up for review, and long overdue overhaul, and we must see:

Stronger enforcement: The rules should be binding, and the WHO must monitor and penalise unfair practices, including naming and shaming of countries which flout the rules.

Structured and more ethical programs for temporary migration: Exchange of skills and experience for a limited period by design, not by chance. 

Compensation: If high-income countries benefit from workers trained overseas, they must reinvest through training partnerships, training facilities or direct contributions per worker to the affected country.

Yet, a stronger code alone will not fix this problem. The underlying cause is years of underinvestment, now compounded by the freeze on US aid. Africa deserves better.

 Expanded career paths

To this end, people, not diseases, must be at the centre of health funding. A nurse plays multiple roles, treating HIV, vaccinating children, managing chronic illness, and curing TB. Investing in people is a more efficient pathway to better health outcomes. 

Financing is key. We need to create the fiscal space for countries to train and retain health workers. Countries must mobilise more domestic financing and prioritise the health workforce, addressing issues of low pay and poor working conditions to make sure those trained are absorbed and retained in the system.

 A key reason health workers migrate is a lack of training opportunities or because they can’t specialise, so this must be addressed through an expansion of career paths at home. 

In Malawi, where just 43 paediatricians serve a population of more than 20 million, Seed Global Health’s model of partnering with universities and hospitals to train more doctors, nurses and midwives helps – but we need support to not only scale training but to retain skilled providers in the country.

Further, donors and implementers must back African leadership and champion country-led initiatives, which offer more sustainable and long-term solutions to best meet the complex needs of countries in a context specific way. 

Amref Health Africa continues to enhance meaningful engagement and collaboration across sectors to initiate better incentives to motivate, retain staff and also re-attract migrant health workers from the diaspora. This is in recognition of the fact that the continent’s accessible health workforce is the driver of its success.

The Africa CDC has prioritised health workforce development as part of its ‘New Public Health Order’. Now, countries and donors must provide the necessary funding and political support to turn this vision into reality. 

The bottom line is that investing in health workers improves care for populations, but also creates jobs, drives gender equity – 70% of health workers are women – and builds resilience against increasing disease burdens and health emergencies.

The future of global health hangs in the balance. Can we afford to keep haemorrhaging health workers from the countries that need them most? Or will we seize this moment to forge a new path – one that values equity, fairness, and shared responsibility?

The choice we make today will shape the health and well-being of generations to come.

* not her real name.

Martin Msukwa is Chief Program and Innovation Officer for Seed Global Health

Isaac Ntwiga is Director of Health Workforce Ecosystem, Amref Health Africa

Image Credits: © Dominic Chavez/The Global Financing Facility, International Federation of Nurse Anesthetists.