Existential Public Policy – Africa’s Healthcare Sector Brain Drain: Strategies for Retention  

Panel Remarks by Prof. Kingsley Moghalu

Chairman, Africa Private Sector Summit (APSS) and Panelist

Africa Health ExCon 2024 Conference:

Cairo, Egypt

June 6, 2024

Copyright Kingsley Moghalu

1. Introduction: The Challenge

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.

Top Medical Talent “Drainers”

1. UK                   13,909
2. USA                12,692
3. France             10,731
4. Canada           5,888
5. Germany         4,535
6. Ireland             3,056
7. Australia          1,999

Top (Health Sector) Brain Drained Countries in Africa

1. Egypt
2. Nigeria
3. South Africa
4. Algeria
5. Sudan

ii. Causation: What’s Driving the Brain Drain

1. Political instability, insecurity, and weak economies
2. Insufficient investment in public health systems – inadequate equipment and drugs supplies, health insurance, 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.
3. Progressively increasing healthcare needs in developed countries, partly because of  aging populations.  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 didi in 1997. The situation is far worse regarding nurses: England needed 250,000 more nurses in 2008 than it did in 1997.
4. The COVID19 pandemic has massively increased the healthcare needs of developed countries.
5. Recruitment campaigns for health professionals by developed western countries targeting health workers in developing countries.
6. Absence of effective health insurance to cover healthcare costs.
7. Lack of recognition and appreciation. 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.

III.        Consequences of the Healthcare Brain Drain

 Low doctor to patient ratios as a result 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.

1. 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.
2. Inability to achieve Universal Health Coverage.
3. The brain drain of healthcare professionals in Africa threatens the whole spectrum of development.
4. Health tourism, which leads to economic bleeding of financial resources that would have been spent inside African countries, thus boosting the economy.
5. Labour strikes by medical personnel, with disruptive and existential implications for lives and public health in general.

IV.     Retention Strategies

Although reversing the phenomenon of the brain 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.

1. 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.
2. Train multiple times more health professionals. This requires a significant shift in the education 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. Incentive structures need to be created and implemented. These include increased remuneration for public sector healthcare workers, which will in itself 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.
4. The implementation of effective reforms that massively increase health insurance coverage is critical, 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 in particular in 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. A Diaspora Fund 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 if and when purchasing power parity in African countries is factored in.
6. 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.
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 even more directly relevant to the present discussion, it is also outperforming improvements and advances in  health care systems and the capacity of the health workforce.
9. 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.