Cairo — If health is wealth, as the 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?
Real development is not just about GDP growth numbers, but more about GDP per capita and about human development issues such as the availability of quality healthcare and ‘Universal Health Coverage’, education and skills, nutrition, safe water, and life expectancy.
Africa’s health systems are collapsing, worsening the quality of life of millions of Africans who do not have adequate and quality healthcare. Doctors, nurses, pharmacists, laboratory scientists and other health professionals are fleeing abroad in search of greener pastures – a massive ‘brain drain’.
Africa has only three percent of the world’s health workforce despite being 18 percent of the world’s population. The one-directional migration of skilled human capital benefits only the receiving countries and has persisted for several decades. It is progressively getting worse, and it isn’t going away soon. Emigration of skilled talent in many sectors is a challenge across Africa, but the loss is most profound – and its impact heaviest – in healthcare.
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Consider: 65 percent of Egypt’s doctors work abroad. Nigerian lost doctors 9000 doctors between 2016 and 2018, most of them for work in the United Kingdom, the USA and Canada. In Nigeria we call this the “japa” syndrome from a Yoruba word meaning “to run” or “to flee”.
Between 1986 and 1995, 61 percent of the 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.
The importance of health workers and the healthcare professions is not reflected in the governance of most African countries. This includes non-financial aspects of recognition, appreciation and reward, such as social status and the value attached to scientific research or to publications in professional journals.
Africa and the developed world are divided 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 even more nurses and other healthcare professionals – and these numbers may be conservative.
The top ‘brain drainers’ are the UK (13,909), USA (12,692), France (10,731), Canada (5,888), Germany (4,535), Ireland (3,056), and Australia. (1,999). The top ‘brain drained’ countries in Africa are, in ranking order, Egypt, Nigeria, South Africa, Algeria, and Sudan.
A combination of political instability, insecurity, weak economies and insufficient investment in African public health systems adds impetus to the movement of skilled practitioners to Europe and North America. Inadequate equipment and drugs supplies and low worker pay are also factors. African healthcare workers earn between $200 and $500 a month on average, while their counterparts in developed countries earn, on average, 3000 percent more.
Many wealthy nations have failed to invest adequately in educating their own potential healthcare workforce. Aging populations in fiscally richer countries put additional pressures on their systems. This makes Europe and North America increasingly dependent on other countries, especially in Africa, to fill the gap.
In the UK there was a 38 percent increase in new registrations of doctors from abroad doctors from 1993 to 2022. 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.
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 mix of incentives for recruiting skilled workers from abroad.
The brain drain has had disastrous consequences for Africa. The World Health Organization recommends a minimum ratio of 1 doctor to 600 people. In Nigeria, the ratio is a paltry 1 to 9000, while in South Africa it is 1 to 3198. Doctors in training – interns and residents – now carry most of the workload burden, resulting in lack of adequate supervision, overwork, and burnout, with dangerous implications for health outcomes.
Africa has been unable to achieve Universal Health Coverage, and the low status of healthcare professionals in Africa threatens development more generally. Labour strikes by medical personnel, with disruptive implications for lives and public health, are a reality of life in countries like Nigeria.
Reversing the brain drain will take time even in the best of scenarios. It ought to be a number one priority of public policy and governance, but 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.
The following strategies must be adopted to begin to stem the impact of the healthcare sector brain drain:
1. Financial investments in improving healthcare systems must become a political priority. In 2001, member countries of the African Union pledged to allocate 15 percent of their national budgets on health. Only Eritrea, Mauritius, and the Seychelles have met this target. Without such investments allocated and spent efficiently and effectively, with monitoring and evaluation of outcomes, healthcare cannot take off in African countries
2. We must train multiple times more health professionals. This requires a significant shift in our education policies. 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.
3. Third, incentive structures need to be created and implemented. These include increased remuneration for public sector healthcare workers, which will also encourage more people to study medicine and the other medical sciences such as nursing and There should also be additional incentives for healthcare workers who work in mostly underserved rural areas.
4. 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.
5. 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. I proposed, as a presidential candidate in Nigeria in 2019, 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 meet their financial needs in their home countries. Nigeria alone would need a $500 million fund for this purpose.
6. Investments in skills training for healthcare industry remote work could create a brain gain in which highly educated Africans 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.
7. 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.
8. 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.
9. 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. Most African countries have yet to engage seriously with this framework as part of a holistic strategy to address their challenges. In the WHO Global Code of Practice 4th National Round of Reporting published in March 2022, only eight African countries had submitted their national reports on the implementation of this framework.
African countries cannot afford to merely lament what is admittedly a difficult challenge, not one not amenable to a quick fix. Migration, whether for political, economic or other reasons, is an intrinsic part of human 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.
Kingsley Moghalu, a former Deputy Governor of the Central Bank of Nigeria, is the President of the Institute for Governance and Economic Transformation (IGET) and Chairman of the Board of Africa Private Sector Summit. He is scheduled to give the 5th Annual Arthur Mbanefo Lecture at the Arthur Mbanefo Digital Research Center, University of Lagos, at 11 am, Tuesday, June 11th.
