A doctor in Abidjan (Ivory Coast) (CC Aristidek5maya)
The European Union has, on average, 43 doctors and 99 nurses for every 10,000 people. However, in sub-Saharan Africa, the ratios are vastly different, at 8 and 18, respectively. This discrepancy was reflected in Anesvad and PorCausa foundations’ report “Labor mobility: An opportunity for global health. An African perspective,” which was presented at the end of 2022 in Bilbao. According to the World Health Organization (WHO), around 23 doctors, nurses and midwives are needed for every 10,000 people to provide essential services to a population.
But in Niger, for example, there is a total of 0.2 doctors per 10,000 inhabitants, a figure similar to those of other African countries, such as Ethiopia, Mozambique or Senegal, where the ratio doesn’t even reach 1: 10,000. According to the WHO, 20 countries in the region have fewer than 2.7 doctors per 10,000 people, with an estimated total deficit of 850,000 physicians.
The authors of the report highlight two fundamental concerns: the evident lack of healthcare workers in the countries south of the Sahara, and the high number of healthcare personnel that – unfortunately – choose to move abroad.
“The radiotherapy machine broke (and there wasn’t another one)”
There’s a constant flow of Africans who are leaving their continent every year, but they’re not emigrating illegally. They travel on valid visas with all the necessary paperwork and work contracts. They are the doctors and nurses hired throughout Europe, North America and beyond by public and private health institutions, as documented by experts such as Anna Bono, as well as several studies and reports.
Amid this hemorrhaging, the French government, for example, is drafting an immigration and integration bill in which special residence visas (for thirteen months, renewable only once) would be granted for professionals who are in short supply in the country, including foreign doctors of every specialization, as well as midwives, dentists, and pharmacists. The legislation has prompted pushback and calls for revision, as many fear it will contribute to the burgeoning African exodus. It’s worth noting that the second highest percentage of foreign doctors in France comes from French-speaking African countries, accounting for 16% of the total ( the OECD average is 25%).
African doctors are leaving the continent for various reasons. Perhaps the most important being the difficult conditions in which they are often forced to practice, especially if they are employed by a public health system. Essential medicines, equipment and health supplies are in short supply in many hospitals. It is therefore urgent that African governments, which spend only an average of 5.8% of their GDP on health, invest heavily in improving their systems, whose deficiencies have been exposed by health crises.
“Salary is important, but it isn’t everything. The talent we have here is looking for better conditions to practice their occupation”
“Salary is important, but it isn’t everything. The talent we have here is looking for better conditions to practice their occupation,” says Daniel Mabongo, president of the Cameroon Doctors Union, which sees a third of its specialists leave the country every year. It is “a profession that, let us not forget, is above all a vocation.”
In Uganda, for example, the only radiotherapy machine broke down in 2016 and was not replaced until 2018. And there is only one doctor for every 25,000 people in the country. Even under normal conditions, most of Africa’s hospitals and clinics are struggling, and they suffer from enormous inefficiencies. If an emergency occurs, the situation becomes critical for both patients and doctors. In 2022, the Ugandan doctors and nurses who treated patients during the outbreak of Ebola, a highly contagious disease with a mortality rate of up to 90%, did so in extreme risk conditions, without masks, gloves, and other protective gear, forcing them to have skin-to-skin contact with the afflicted.
Inadequate wages are also leading health workers to emigrate. Those who do not land a job in a private clinic often barely earn enough to maintain a low-medium standard of living. In Zimbabwe, the salary of a nurse on her first contract is about $200: which is too little to live on, even compared to the local cost of living. Like all civil servants, health workers also live in uncertainty, because governments facing economic downturns do not hesitate to suspend their pay for months at a time.
The private sector isn’t much better
Not finding work in their country can lead doctors to accept job offers on other continents, too. Mozambique is a striking case. The country has a total of 2,360 practicing doctors, seven for every 100,000 people, and yet in 2021, in the midst of the Covid-19 pandemic, 200 medical school graduates were unemployed. And in Cameroon, a recent government regulation restricting the recruitment of new med school grads to curb public spending is forcing young doctors to seek work elsewhere.
Nigeria is one of the countries that’s losing the most medical personnel. With a population of more than 210 million, it would need at least 363,000 doctors, but it only has 24,000 employed: one for every 30,000 in some southern states and one for every 45,000 in the north. However, the Nigerian Medical Association maintains that from 1963 to 2019 some 93,000 Nigerians graduated with medical degrees. But in the last eight years, at least 5,600 Nigerian-trained doctors have emigrated to the UK alone. According to a report published in August 2022 by the British government, 13,609 Nigerian healthcare workers, including doctors, obtained work permits in 2021, making Nigerians the second most abundant foreign employees in the country’s healthcare sector, second only to Indians, who account for approximately 43,000 workers.
The U.S. and Middle Eastern countries such as Saudi Arabia, Qatar and Oman are other popular destinations to practice among Nigerian doctors. The situation in the country has degenerated to such an extent that in recent months – as reported by Le Monde – a government deputy from the African country, in an attempt to retain them, presented a bill last April that would force doctors to practice for five years in Nigeria before earning their degrees and the chance to work abroad.
Once the envy of the continent, decades of neglect and lack of investment have destroyed Zimbabwe’s healthcare system
Emeka Orji, president of the Nigerian Association of Resident Doctors (NARD), views the proposed legislation whose advocates claim will fight “brain drain” as “draconian and unenforceable,” and he calls for its immediate withdrawal. He would prefer that “the problem be stopped at its root,” by improving the working conditions and salaries of Nigerian health workers. Doctors do not benefit from insurance or other benefits linked to professional risks, which are aggravated by the lack of protective equipment in public hospitals. But departures are just as high in private establishments, where salaries do not tend to be much better.
The situation in Zimbabwe is also particularly critical. In less than two years, starting in 2021, the country has lost more than 4,000 doctors and nurses, and emigration is increasing: in 2021 and 2022 it doubled compared to 2020 and tripled compared to 2019. The shortage of personnel in public hospitals has reached emergency levels, and in some cases, it has become impossible to schedule appointments. Even some hospitals in the capital Harare are closed due to lack of staff. Others survive by turning to medical students.
Zimbabwe’s public health system facilities were once the envy of other sub-Saharan African countries. Decades of neglect and lack of investment have destroyed the entire system though. In 1992, the first wife of former President Robert Mugabe, Sally, who was suffering from kidney failure, decided to put her trust in a public hospital, which cost her her life. When her husband later needed care, he turned to a private clinic in Singapore.
African heads of state and government, ministers and MPs often receive medical treatment abroad, and the term “medical tourism” was largely coined in relation to their international visits. For the past few weeks, the outgoing president of Nigeria, Muhammadu Buhari, has been in London for dental treatment. And previously, he has spent extended periods in the city to undergo prolonged treatments.
NGOs to the rescue
One might assume that such a detrimental exodus would go against the will of the governments and would provoke reactions among the population, which bears the brunt of the departures. Instead, as it turns out, the governments themselves are signing agreements to regulate the flow of emigration.
The Kenyan government, instead of hiring to make up for the shortage of health personnel, signed an agreement with the British government that allows unemployed healthcare workers to leave to work in the United Kingdom. Those who want to be hired abroad must take an English test. Last year there was a stir and scandal, first with the news that most of the nurses tested had been turned away, and then that the British government was seeking to revoke the agreement because Kenya had been placed on a list of countries with a shortage of health workers, though the agreement was never broken.
Meanwhile, tens of thousands of foreign doctors and nurses work tirelessly, often with heroic dedication, in the countless health centers spread across the continent, even in the most remote, dangerous, and hard-to-reach areas, financed and maintained by NGOs large and small, missionary organizations and other institutions, thanks to which millions of Africans receive health care that they would otherwise be deprived of.
“It is clear that African governments alone cannot solve the continent’s healthcare problems. The only alternative we have is to look for support in the private sector to provide more financing to the government,” says Aigboje Aig-Imoukhuede, president of the Africa Initiative for Governance. A private sector that, it’s worth noting, is primarily sustained by the Catholic Church and all its institutions, which are in fact the groups on the ground solving many of the medical assistance problems close to these populations.
Translated from Spanish by Lucia K. Maher