Mass emigration is leaving huge gaps in Africa's health sector

After working for six years at one of the top hospitals in Nairobi, Kenya as a pediatric nurse, Mary Wairimu’s monthly salary of 45,000 shillings ($322) only increased by 5,000 shillings. One day in October 2021, she sat at her home and started thinking about her life. “With my experience and years of service, I ought to be somewhere higher even in ranking. But I was still a basic bedside nurse,” the 30-year-old told Devex. “I had the skills and knowledge but I was rotating around the same place. If I am doing this work and I am still getting the same pay, I am still living the quality of life I used to live, why should I be here, why can’t I just leave?” she asked. Her ability to help her extended family had declined as the cost of living increased, and she started considering emigrating to the United Kingdom. The following week, Wairimu spoke to her brother, with whom she shared responsibilities. He agreed to give her a loan to add to her savings and she started her relocation process, which Kenyans colloquially call “journey of hope, immediately. One year later, she arrived in London to start work as a nurse. Across the African continent, medical professionals like Wairimu are making a mass exodus abroad to access better remuneration, a good working environment, and world-class social services, leaving the health sector of various countries across the continent to bear the brunt of health care provider shortage. Critically ill patients suffer as they wait for their turns in excruciatingly long queues. The average physician ratio in sub-Saharan Africa is two doctors per 10,000 people. According to the World Health Organization the region has a ratio of 1.55 health workers — physicians, nurses, and midwives — per 1,000 people, which is below the 4.45 health workers per 1,000 people threshold needed to deliver essential health services. The agency said the staff shortage is responsible for the underdevelopment of African health systems. Of the 55 countries listed in the WHO health workforce support and safeguards list, which identifies countries that are the most vulnerable in terms of health workforce, 37 are African countries. Nine countries, including Nigeria, Tanzania, Malawi and Kenya, are disproportionately affected and it costs these countries up to $2 billion. High-income countries are discouraged from recruiting from these countries. “The continuous outflow of healthcare workers from Africa means danger. It severely threatens patients, the healthcare system, and the entire continent. It will significantly strain the healthcare system, resulting in longer wait times, increased workload on remaining staff, decreased patient access to care, and suboptimal health outcomes,” said Stanley Achonu, the Nigeria country director at the ONE Campaign. Although Wairimu recognized the danger of emigration and the consequences it portends, she argued that health professionals deserve matching compensation for the services they provide. In some countries, such as Nigeria, doctors are owed for several months, forcing them to go on strike in protest. “The agenda is not so much to try to stop migration, but to address the underlying drivers of migration and make it more attractive for people to stay …” --— Dr. Agya Mahat, technical officer, WHO health workforce department Now she makes £26 ($33) per hour and is able to support her extended family as much as possible. “Compared to what I was earning back home, it is such a big margin. You see why we move. I feel empowered,” she said. “I am in a place where I have got access to technology, and research materials. I look forward to more.” A chance at a better life For Olu Joseph, a 30-year-old doctor working in the Accident and Emergency department of a London-based hospital, who left Nigeria in 2022, emigrating — or “Japa” as it is colloquially called — is more about the opportunity of having basic amenities such as functional electricity, security, and potable water. “I am not going to lie that money is not important but I just want to lead a very comfortable life in terms of tangible things that are really basic. In Nigeria, you can’t have access to these without having to pay a premium or fight the system,” he told Devex. In August 2021, Joseph was rounding up his internship at a government-owned hospital when a riot broke out. All the doctors had to jump out of windows and over fences to escape getting hurt. The following day, they had to resume work as if nothing had happened — no one even reached out to know if they were fine, he said. The same hospital also owed them months of wages. “The hospitals do not have standard equipment. Even what you’ve learnt in school, you are not able to practice them, you are having to improvise and make use of substandard equipment,” he said. “You see doctors working on call a whole week because hospitals are short staffed, in the end you become overworked. I have also collapsed in the theater before.” Joseph said he watched his colleagues who had life-threatening illnesses due to exposure to patients because there was no personal protective equipment to work with. The hazard pay, a sum of 5,000 nairas (about $11), is not enough to get treatment. He said that the conditions abroad are better and there are limitless options in terms of specialty. The patients bear the brunt As doctors move to make a more beneficial living abroad, experts say it will adversely affect the health care sector and the patients, who will bear the bigger brunt. Health care access will get delayed which will be burdensome for those with life-threatening conditions that require immediate treatment. Long waits, according to Dr. Agya Mahat, the technical officer at the WHO health workforce department, may push people to resort to the private sector through out-of-pocket payments, resulting in a risk of catastrophic health expenditure and impoverishment. “Health worker mobility patterns are very complex and dynamic; migration is a long-term phenomenon and there is a right to migrate recognized by international instruments,” Mahat said. “The agenda is not so much to try to stop migration, but to address the underlying drivers of migration and make it more attractive for people to stay, particularly in the countries facing the most severe health workforce challenges.” Although some countries, such as the United Kingdom, have placed some 54 countries on a red list of countries not to recruit health professionals from, it has not done much to salvage the situation. “With fewer healthcare professionals available to care for patients, ensuring adequate care and attention becomes increasingly difficult. Consequently, patients may experience medical oversights, delays, or omissions, adversely affecting their health and overall well-being,” Achonu said. Creating a solution To stop the emigration wave, some African countries are working to ban the emigration of health practitioners. Zimbabwe is trying to make it unlawful for other countries to hire its health staff while in Nigeria, a bill to mandate those in medical and dental fields to practice in the country for five years before they can emigrate has passed the second reading. In response, the Nigerian Association of Resident Doctors went on strike to resist the bill. Achonu added that forcing medical personnel to stay without addressing the underlying causes of emigration is pointless, and such a forceful approach attempts to blame doctors for merely seeking an environment that allows them to flourish personally and professionally. Each country will have to assess its situation to come up with strategies suited to its context, Mahat said. “Reducing attrition of health workers requires understanding of the labor market dynamics in each country and using the findings to inform investments in education, employment, and decent working conditions and design appropriate incentives and regulatory interventions. “Focused investments to expand budget space to create funded employment positions and to guarantee fair remuneration and decent working conditions to retain them are the key policy responses that countries in the region should consider on a priority basis,” he said. Wairimu said she is happy to have gone on with the emigration process, however draining and costly, because it is worth it in the end. “All I know is that I am not going back to Kenya to work there. That is for sure,” she said.