The Migration of Skilled Health Workers from Low-Income to High-Income to countries: The Health Workforce Shortage in sub-Saharan Africa
HIC – High Income Country
LIC – Low-Income Country
OECD – Organization for Economic Co-operation and Development
SHW – Skilled Health Workers
WHO – World Health Organization
Health Worker Shortage in sub-Saharan Africa
The evident shortage of health professionals within countries with the weakest health indicators and its effect on their capacity to combat diseases and provided interventions has attracted global attention(1). The health system in Africa, especially among countries in sub-Saharan Africa, has faced significant challenges and has been particularly impacted by the migration of skilled-health personnel(2). This critical shortage affects several aspects of public health within the region including disease treatment, child mortality and maternal health(3).
The migration of highly-educated health professionals in search for a better life and career opportunities within country (i.e. rural to urban migration) and across international borders, mainly from low-income countries (LIC) to high-income countries (HIC), has become of increasing concern(4, 5).
The deficit of skilled healthcare workers(SHW) in sub-Saharan Africa has chastised the region in the past decades(3). About 20 million highly-trained professionals were reported living in OECD countries in 2000, a 70% increase since 1990(4). Of these skilled professionals, two-thirds immigrated from LIC(4). Since then, migrant nurses and doctors working in OECD countries have increased by 60% in the past decade, as reported by the WHO(6). The WHO appraised a worldwide deficit of over 4.3 million health personnel in 2006(3, 7, 8), of which 2.4 million were doctors, nurses and midwives(7). LIC was the worst-affected with 57 countries facing severe shortages, of that 36 were in sub-Saharan Africa(7). The ratio of health workers to population size is the lowest in sub-Saharan Africa, with most countries averaging significantly less than 2.28 health workers per 1000 persons (minimum threshold for basic health service delivery)(3), compared to 24.8 per 1000 person within the OECD countries(2). The WHO projects future acceleration in the migration of skilled health professionals with a continued disparity in the demand and supply of health workers(6) on source and destination countries.
The shortfall of healthcare workers in sub-Saharan Africa is a multifaceted problem influenced by several social, environmental and political factors, however, the emigration of health professionals is one of the largest contributing factor(3). This hefty outflow of health professionals from the region is associated with several drivers.
Drivers for Migration
Drivers of skilled health worker’s(SHW) migration are complex and dependent on a range of push and pull factors(9). For instance, demand for health services, institutions developed in origin versus destination countries, licensing and certification policies for foreign-trained professionals in receiving countries, and immigration policies in both sourced and receiving countries, most of which do not consider the necessity of the health workforce(9).
Need in destination countries
As a major public health need, international migration first surfaced in the 1940’s with the emigration of European professionals to the United States and United Kingdom(5). By 2000, shortages of nurses and doctors were reported in numerous OECD countries(7). To address this, recruitment of health professionals from overseas was an attractive short-term solution(7). Aspects in the increase in migration of SHWfrom LIC to HIC can be attributed to this “quick fix” to unanticipated needs of the health workforce in HIC, due to delayed effect of training additional doctors and nurses(7). Overseas professionals play a major role in the health workforce of HIC(9). International migrant destination countries have become heavily reliant on foreign-born and trained skilled health professionals to fill gaps in physician, specialist and nursing roles(9). According to the WHO Migration of Health Workers 2014 report, about 37% of registered physicians in the UK are foreign-trained, with 26% in both the United States and Australia and around 22-24% in Canada(9).
Why health workers leave their country (push and pull factors)
Factors that drive migration of SHW largely coincide with that of skilled professionals overall, from potential migrants perspective(7). Poverty, lack of economic growth, discrimination, inequality, and political repression often fuel the migration of highly-educated personnel(4). The “brain drain” can be categorized by the emigration of skilled professionals and the emigration and retention of college graduates in HIC(4). Despite the shortage of skilled professionals in LIC, the main impetus for overseas migrant is a combination of social, psychological and financial factors and family choice(5) resulting in both temporary and permanent migration(2) . Limited post-graduate training and career opportunities, underfunding of healthcare facilities and infrastructure, partial investments in health service management and quality(2, 3), coupled with de-stimulating working conditions, poor wages(2, 5), civil unrest and personal safety(2, 3, 10) reflect the push factors that fuel these “journeys of hope”(5).
Skilled health professionals migrate in pursuit of higher education and financial improvement(5), however, remuneration differences across countries although vital is not the determinant pull factor(7). The possibility of prosperity for themselves and a secure and improved future for their families is a significant determinant of migration(7). Prospects of advanced training and professional development(2, 5), the allure to research and medical centers excellence, increased remuneration awards, and availability of posts are common pull factors
(2). The recognition of pull and push factors continue the disparities in migration between HIC and LIC, offering a greater pull towards OECD countries(5).
Outcome of Migration
The debate on the impact of health worker migration on sourced countries and the obligations on receiving countries has and continues to be controversial(11). In the past decade, health workforce emigration has been under scrutiny due to apprehensions on its impact on sourced countries(9). Substantial policy and academic research on the increase in outflow and its effects have attracted worldwide attention(9).
Impact on origin country (brain drain)
The scarcity in adequate health professional has led to the incline in mortality rates, adverse influence on child and maternal health and HIV treatment in sub-Saharan Africa(3). The substantial high mortality rates in the region are strongly associated with the shortage of healthcare workers(3). The WHO ‘Working Together for Health Report’, indicated a correlation in the increase in physicians with a decline in children under-5 mortality rate(3, 12).The link to health worker availability and under-5 mortality can be attributed to the shortage of health workers resulting in a reduction in health services and treatment availability, like vaccinations. In sub-Saharan Africa, the quality of maternal health is the poorest among all regions(3). Similar to child mortality, studies have shown that an increase in healthcare workers is correlated with the decline in maternal mortality rate(3). However, due to the low density of health professionals in the region, physicians, nurses and midwives are often absent during child delivery(3). This is seen in several countries with exceptionally high maternal mortality, like Ghana with a vacancy rate of 57% of health workers(3). HIV/AIDS remains a major public health concern in sub-Saharan Africa, an estimated 24 million individuals were living with HIV/AIDS within the region in 2016(3, 13). The countries reporting the lowest rates of antiretroviral therapy coverage also reported a significant shortage of health workers, like Somalia(3). According to WHO, Africa endures over 24% of the global burden of disease, with access to only 3% of health professionals(14, 15).
Countries with the lowest need of health workers have the largest workforce, while countries with the highest burden of disease make do with a significantly smaller health workforce(15).LIC has invested in the education and training of their health professionals; migration of these skilled workers translates to finances and resource to receiving countries that did not pay the cost to educate them(5, 14). According to Edward Mills et al, research looking at this financial cost in nine countries in sub-Saharan Africa (Ethiopia, South Africa, Malawi, Nigeria, Tanzania, Kenya, Uganda, Zimbabwe and Zambia) reported a loss of approximately USD$2.1 billion from emigration of health workers in receiving countries(14, 16). Another study found that the financial loss of Africa’s health workers to HIC amounted to USD$3 billion to the UK, $850 million to the US, USD$620 million to Australia and USD$380 million to Canada(14).
Migration and Global Health: The Way Forward
International movement is neither the only key contributor to healthcare deficits in LIC, nor would its decline singlehandedly address the global health workforce crisis(7). However, it is true that high SHW migration rates in sub-Saharan Africa exacerbate and further weakens their delicate healthcare system(7). The global market for health professionals is rather distorted as HIC address their shortage of health workers through the recruitment and migration of health personnel(8), sustaining their high physician-to-population ratio(14), and shifting the shortage from HICs to LICs(8) increasing worldwide inequities. The ‘Global Code of Practice on the International Recruitment of Health Personnel’ adopted in 2010, was the WHO policy framework to globally tackle the health workforce crisis(8, 14, 17). However, the code is a moral guide, that encourages its application into member states national practice rather than an enforceable legal tool where compliance is mandated and monitored(8, 14).
Overall, I respect and agree with the rights of health professionals to migrate and seek opportunities, as such I believe both origin and destination should address the drivers that encourage health workforce migration. To address the contributing factors on the deficit of SHW, destination countries should increase education training and capacity and prevent excessive dependence on migrant health workers(7). Additionally, OECD countries should be more efficient with current health workforce by developing and adopting more advanced roles like nurse practitioners and physician assistants, task-shifting, enhancing integration and improving retention of the health workforce(7). Origin countries need aggressive retention policies with a special focus on rural areas, as there is a link between internal and international migration(7). With the movement of SHW from rural to urban areas increasing and more international migrants relocating from urban areas, it fuels the shortage in rural areas(7). However, improving retention will be challenging, as LIC cannot close the financial gap with HIC(7), improving remuneration, working conditions, equipment’s, addressing unemployment, facilitating professional development and scaling-up health workforce training(1, 7), providing incentives, research budgets and research facilities and enhancing overall quality of life and safety(2) will aid in minimizing the outflow of health professionals.
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13. Prevalence of HIV, total. The World Bank. 2016. Available from: https://data.worldbank.org/indicator/SH.DYN.AIDS.ZS?view=chart.
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16. Mills EJ, Kanters S, Hagopian A, Bansback N, Nachega J, Alberton M, et al. The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis. BMJ. 2011;343.
17. The WHO Global CODE of Practice on the International Recruitment of Health Personnel: Implementation by the Secretariat. World Health Organization
Health Systems and Services Cluster; Department of Human Resources for Health;
Health Workforce Migration and Retention Team; 2010.
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