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Social Science & Medicine 64 (2007) 1876–1891

www.elsevier.com/locate/socscimed

Sub-Saharan Africa: Beyond the health worker migration crisis?

John Connella,�, Pascal Zurnb, Barbara Stilwellc,Magda Awasesd, Jean-Marc Braichetb

aUniversity of Sydney, Sydney, AustraliabWHO, Geneva, Switzerland

cThe Capacity Project, Chapel Hill, North Carolina, USAdWHO, Brazzaville, Republic of Congo

Available online 20 February 2007

Abstract

Migration of skilled health workers from sub-Saharan African countries has significantly increased in this century, with

most countries becoming sources of migrants. Despite the growing problem of health worker migration for the effective

functioning of health care systems there is a remarkable paucity and incompleteness of data. Hence, it is difficult to

determine the real extent of migration from, and within, Africa, and thus develop effective forecasting or remedial policies.

This global overview and the most comprehensive data indicate that the key destinations remain the USA and the UK, and

that major sources are South Africa and Nigeria, but in both contexts there is now greater diversity. Migrants move

primarily for economic reasons, and increasingly choose health careers because they offer migration prospects. Migration

has been at considerable economic cost, it has depleted workforces, diminished the effectiveness of health care delivery and

reduced the morale of the remaining workforce. Countries have sought to implement national policies to manage

migration, mitigate its harmful impacts and strengthen African health care systems. Recipient countries have been

reluctant to establish effective ethical codes of recruitment practice, or other forms of compensation or technology transfer,

hence migration is likely to increase further in the future, diminishing the possibility of achieving the United Nations

millennium development goals and exacerbating existing inequalities in access to adequate health care.

r 2007 Elsevier Ltd. All rights reserved.

Keywords: Africa; Migration; Health workers; Recruitment; Impacts; Policy

Introduction

Human resources are central to health caresystems and essential for the delivery of services topatients. In sub-Saharan Africa, especially, failureto invest adequately in health systems and profes-

e front matter r 2007 Elsevier Ltd. All rights reserved

cscimed.2006.12.013

ing author. Tel.: +61 2 9351 2327.

resses: jconnell@mail.usyd.edu.au (J. Connell),

(P. Zurn), bstilwell@capacityproject.org (B. Stilwell),

int (M. Awases), braichetj@who.int (J.-M. Braichet).

sional health education, the rising death toll fromHIV/AIDS and international migration of healthprofessionals are all major factors contributing tothe ongoing health workforce crisis. Acceleratedrecruitment from developed countries, where popu-lations are aging, expectations of health careincreasing, recruitment of health workers (especiallynurses) is poor and attrition considerable, hasintensified this crisis, raising complex ethical,financial and health questions (WHO, 2006a,2006b). In a context of widespread existing health

.

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Portugal 1,258

11,269

17,318

213,331

13,620

1,003

2,832

France

Germany

Finland

Australia

Canada

United States

United Kingdom

New-Zealand

0% 10% 20% 30% 40%

69,813

11,122

Fig. 1. Proportion of foreign trained doctors in selected

countries. Source: WHO (2006a).

J. Connell et al. / Social Science & Medicine 64 (2007) 1876–1891 1877

staff shortages in Africa, migration has furtherweakened fragile health systems. Moreover, thecosts of training health care workers in developingcountries are considerable, hence migration hasbeen perceived as a subsidy from the poor to therich (Save the Children, 2005).

Despite the problems of health worker migrationfor the effective functioning of health care systemsthere is a remarkable paucity and incompleteness ofdata, hence it is difficult to determine the real extentof migration from, and within, Africa, and thusdevelop effective forecasting or remedial policies(Stilwell et al., 2003). Moreover, most of theliterature on health worker migration from sub-Saharan Africa has tended to focus on migrationtowards the United States, the United Kingdom andCanada, or has focused on a particular sub-region(Buchan & Dovlo, 2004; Goldacre, Davidson, &Lambert, 2004; Hagopian et al., 2005; Mullan, 2005;Ross, Polsky, & Sochalski, 2005), while little hasbeen documented on the extent of migrationtowards other countries such as Germany, Franceor Portugal despite its growing significance.

This paper provides an overview of migrationissues in sub-Saharan Africa, examining data fromvarious sending and receiving countries, includingcountries for which little has hitherto been discussedconcerning health worker migration. The paperfurther examines the key impacts of migration, anddiscusses policy options to manage migration,mitigate its harmful impacts and strengthen Africanhealth care systems.

The scope of migration

Highly skilled professionals constitute a growingproportion of migrants, as new technologies enableand promote a global labour market, the produc-tion of skilled workers is inadequate in manydeveloped countries which therefore seek to regulatemigration and recruit migrants according to thedemand for skills. Many OECD countries haveeased their legislation on the entry of highly skilledworkers (OECD, 2005). Countries like Canada,Australia, New Zealand and, more recently, the UKuse migration points systems that favour skills toregulate and facilitate entry. The migration ofhealth workers is a key element of these globalchanges, as health skills are in internationaldemand, within a now global health care chain.

Prior to World War II, the movement of healthworkers generally reflected a flow between devel-

oped countries and a flow from developed to lessdeveloped countries (Mejia, Pizurski, & Royston,1979). However, over the last decades, healthworker migration from less developed to moredeveloped countries has gained importance. Overall,the number of migrant health workers has signifi-cantly increased. In the United States, the numberof foreign trained doctors rose from 70,646 in 1973(Mejia et al., 1979) to 210,000 in 2003 (Mullan,2005). A similar trend has been observed in majorrecipient countries such as Canada, Australia andthe UK. In the latter, the total number of foreigntrained doctors increased from 20,923 in 1970 to69,813 in 2003 (General Medical Council, 2004;Mejia et al., 1979).

While the number of foreign trained medicalworkers in the health workforce has risen, itsimportance varies significantly from one countryto another. In New Zealand and the UnitedKingdom, foreign trained doctors represent morethan 30% of the medical workforces, while compar-able estimates are below 10% for Finland, Ger-many, France and Portugal (see Fig. 1).Nonetheless, in absolute terms, the United Stateshas the highest number of foreign trained doctors,estimated at more than 210,000, followed by theUnited Kingdom (around 70,800 foreign traineddoctors) and Canada (approximately 14,000 foreigntrained doctors).

The immigration patterns of health workers fromsub-Saharan Africa also vary quite significantlyfrom one recipient country to another. WhilePortugal has a low proportion of foreign traineddoctors, its share of foreign trained doctors fromsub-Saharan Africa reaches almost 30% of allforeign trained doctors, which is significantly higher

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0% 15% 25%

Germany

United States

France

Australia

United Kingdom

Canada

Portugal

10% 20% 30%5%

Fig. 2. Foreign trained doctors: percentage of African trained

doctors in selected countries. Source: General Medical Council

(2004), Hagopian, Thompson, Fordyce, Johnson, and Hart

(2004), Canadian Institute for Health Information (2003), Ordre

des Medecins (2004), Carrolo and Ferrinho (2003) and Bunde-

saerztekammer, Aerztestatistik (2003).

J. Connell et al. / Social Science & Medicine 64 (2007) 1876–18911878

than that for Germany, the United States, Franceand Australia, where it is below 10% (Fig. 2).

In recipient countries differences exist in thecomposition of their foreign trained health workers.While South African and Nigerian doctors repre-sent the main source countries in the UnitedKingdom, the United States and Canada, thesecountries do not play an important role in France,Portugal and Germany. (Table 1).

There are estimated to be around 11,000 Africandoctors registered to practice in the UK, mainlyfrom South Africa and Nigeria, representing morethan 85% of sub-Saharan foreign trained doctors inthe United Kingdom (General Medical Council,2004). In comparison, the number of Africantrained doctors in the United States is fewer,amounting to approximately 5500, of whom 75%are foreign trained doctors from South Africa andNigeria. Although both the UK and the UnitedStates have a large number of foreign traineddoctors, 33% and 25%, respectively, of their totalstock, the actual migration of African doctors tothese two countries differs significantly. Thus theUnited Kingdom has more than 11,000 comparedwith 5500 for the United States. Following thegeographical diversification of migration fromAfrica, Canada has acquired a substantial share ofAfrican trained doctors. Numbers are estimated ataround 2000, but mainly coming from South Africa,which represents 84% of all sub-Saharan foreigntrained doctors.

In contrast to the UK, the USA and Canada, thetotal number of doctors trained in sub-SaharanAfrica and practising in France is much lower.Numbers are estimated at 800, about 6% being ofall foreign trained doctors, with the main sending

countries being Madagascar and Senegal, twoformer French colonies, representing approximatelyhalf of the sub-Saharan foreign trained doctors inFrance. However, migration from North Africa issignificantly more important than from sub-Sahar-an Africa (Table 2), and accounts for around 40%of all overseas trained doctors. By comparison tothe USA and the UK, where Asian developingcountries constitute the main sources of foreigntrained doctors, Africa represents for France thepredominant source of migrant doctors from devel-oping countries.

In European countries with a smaller number offoreign doctors, such as Portugal and Germany, themigration flows into those countries vary consider-ably. In Portugal, although the number of Africandoctors is relatively low, around 360, these represent28% of all the foreign doctors. They are mainlyfrom Portuguese-speaking African countries thatwere former Portuguese colonies (Table 1). InGermany the number of African trained doctors issimilar to Portugal, around 310, but they representonly 2% of foreign doctors, from various sourcecountries, mainly from Ghana, Cameroon andSudan (see Table 1).

In other European countries such as Poland,Denmark and Finland, the number of Africantrained doctors is much lower and represents fewerthan 50 individuals in each country. In Poland, themain source countries are eastern European coun-tries (Ukraine, Belarus, Russia, Lithuania) and theMiddle East (Syria, Yemen, Iraq) (Polish Chamberof Physicians and Dentists, 2005), while in Denmarkit is Germany, Sweden, Iraq and eastern Europeancountries (Russia, Lithuania, Poland, Rumania,Bosnia-Herzegovina) (Ministry of Health of Den-mark, 2005) and in Finland, eastern Europeancountries (Estonia, Russia, Poland), Sweden andGermany (Ministry of Health of Finland, 2005).There has also been migration from sub-SaharanAfrica to other parts of Europe including Belgium,the Netherlands, Italy and Spain. Thus, in 2003,doctors from sub-Saharan Africa, mainly fromSouth Africa, accounted for approximately 10%of all foreign trained doctors who registered in 2003in the Netherlands (BIG-register, 2005).

Patterns of health worker migration from sub-Saharan Africa have thus changed substantiallyover the last 30 years. In their 1970s study, Mejiaet al. (1979) found that health worker migrants werefrom a relatively small number of African countries(the larger states of South Africa, Nigeria and

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Table 1

Main sub-Saharan African source countries for doctors in selected recipient countriesa

United Kingdom United States Canada France Germany Portugal

South Africa Nigeria South Africa Madagascar Ghana Angola

69% 40% 84% 31% 26% 34%

(7487) (2158) (1800) (261) (88) (145)

Nigeria South Africa Nigeria Senegal Cameroon Guinea Bissau

18% 36% 6% 17% 20% 17%

(1922) (1943) (133) (147) (69) (74)

Sudan Ghana Uganda Democratic

Republic of Congo

Sudan Mozambique

5% 9% 3% 10% 18% 11%

(564) (478) (63) (87) (61) (47)

Ghana Ethiopia Ghana Congo Nigeria Sao Tome and

Principe

3% 5% 2% 9% 14% 11%

(324) (257) (36) (79) (47) (47)

Zimbabwe Uganda Kenya Togo Ethiopia Cape Verde

1% 2% 1% 8% 13% 9%

(143) (133) (19) (70) (43) (39)

Uganda Kenya Zimbabwe Cote d’Ivoire

1% 2% 1% 8%

(120) (93) (19) (68)

Zambia Zimbabwe Zambia Benin

1% 1% 1% 4%

(88) (75) (13) (37)

Kenya Zambia Cameroon

1% 1% 3%

(74) (67) (27)

Tanzania Liberia

0.3% 1%

(38) (47)

Ethiopia

0.2%

(26)

Other sub-Saharan

African countries

Other sub-Saharan

African countries

Other sub-Saharan

African countries

Other sub-Saharan

African countries

Other sub-Saharan

African countries

Other sub-Saharan

African countries

1% 2% 3% 8% 9% 1%

(86) (83) (54) (69) (29) (3)

100% 100% 100% 100% 100% 100%

10,871 5334 2137 845 337 356

Source: General Medical Council (2004), Hagopian, Thompson, Fordyce, Johnson, and Hart (2004), Canadian Institute for Health

Information (2003), Ordre des Medecins (2004), Carrolo and Ferrinho (2003) and Bundesaerztekammer, Aerztestatistik (2003).aFor each sending country, the proportion and number of foreign trained health doctors is indicated.

J. Connell et al. / Social Science & Medicine 64 (2007) 1876–1891 1879

Ghana) and predominantly went to a few developedcountries outside Africa. Since then migration hasbecome much more complex, involving almost allsub-Saharan countries, including intra-regional andstepwise movement (for example, from the Demo-cratic Republic of Congo to Kenya, and fromKenya to South Africa, Namibia and Botswana),and this has increasingly resulted from targetedrecruitment, by both agencies and governments, asmuch as individual volition. In the context of intra-

regional migration in Africa, countries like SouthAfrica or Botswana are more attractive thancountries like Madagascar or Guinea. Like manyAfrican countries, South Africa is both a recipientand a sending country (Dumont & Meyer, 2004).Migration is now shaped by both market forces andcultural ties, and deeply embedded in uneven globaldevelopment. In contrast to the 1970s, the numberof countries experiencing emigration is substantiallygreater, and the rate of migration from African

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0

10

20

30

40

50

60

2003

Cameroon Ethiopia Ghana Kenya

Malawi Sierra Leone Tanzania Uganda

Congo (RDC) Zimbabwe

2000 2001 2002 2004

Zambia

Fig. 3. Yearly registration of African doctors in the UK. Source:

General Medical Council (2004).

Table 2

North African migrant doctors in France (main countries)

Sending country Number of foreign trained doctors

qualified to practice in France

Algeria 3273

Morocco 805

Tunisia 176

Egypt 148

Total 4402

Source: Ordre des Medecins (2004).

J. Connell et al. / Social Science & Medicine 64 (2007) 1876–18911880

countries has increased and countries like Ethiopia,Angola and Uganda, which had very little emigra-tion of doctors in the 1970s, now experiencesignificant migration of doctors. Various otherreports suggest similar growth in numbers andproportions (Hagopian et al., 2005), while there hasalso been a steady feminization of migration flows(Delorey, 2006).

In the case of the United Kingdom, in 1966 therewere 215 Nigerian doctors representing 1.5% of allforeign doctors, while that figure had grown to 1922in 2003, representing 3% of foreign doctors (Gen-eral Medical Council, 2004; Mejia et al., 1979). Overthe last years, South Africa and Nigeria haveremained the main African sending countries, butthe number of doctors qualifying to practice in theUK from Zimbabwe, Ghana and Zambia hassignificantly increased (Fig. 3).

Relatively similar trends are observed for nursingmigration. In the United Kingdom—the majordestination country for African trained nurses—the number of registered African nurses represented

about 25% of all registrations of foreign trainednurses in the United Kingdom in 2004–2005. Aswith doctors, South Africa and Nigeria remain themain source countries for the United Kingdom, butthere has been also a significant increase in thenumber of nurse registrations from Zimbabwe,Ghana and Zambia over the last 5 years. Inaddition, countries like Botswana, Swaziland, Le-sotho and Sierra Leone, which had very limited orno emigration towards the United Kingdom, arenow experiencing nursing outflows to the UnitedKingdom (Table 3).

The information displayed in the earlier tablesand figures show that for countries in NorthAmerica and Europe the scope of migration variessignificantly, evident, for example, in the differencesbetween the UK and Germany. Moreover, in termsof source countries, although South Africa andNigeria still experience the largest outflow ofdoctors, more countries are involved in migration,despite this continuing to reflect linguistic andformer colonial ties. However, even when thenumber of health workers moving from a countryis relatively small they often represent a largeproportion of the health workforce of thosecountries. Comparing the number of Africandoctors in some significant receiving countries, withthe total number of doctors in those countries andin their countries of origin (Table 4), emphasizeshow migration from countries like Sao Tome andPrincipe, Guinea Bissau, South Africa and Ghana isimportant as the number leaving represents ap-proximately 30% or more of doctors in thosecountries (see also Clemens & Pettersson, 2006).This parallels the situation elsewhere where theactual number of migrants may be small, but theirloss has a disproportionate influence on the nationalstock of skills.

Moreover, outflows of health workers may alsoaffect the availability of a renewed health work-force, as the yearly outflow of health workermigrants is not always compensated by the numberof new graduates. Thus, while the number of nursestrained in Swaziland who registered in the UnitedKingdom was estimated at 81 and 69 for the year2003/2004 and 2004/2005 (see Table 3), the numberof yearly nursing graduates is estimated to bebetween 80 and 90 per year (Kober & van Damme,2006), while attrition and retirement account for thebalance.

Collecting data on the migration of health work-ers is challenging, since the lack of systematic,

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Table 3

Yearly registration of African nurses in the UK (main countries)

Country 1998/1999 1999/2000 2000/2001 2001/2002 2002/2003 2003/2004 2004/2005

South Africa 599 1460 1086 2114 1368 1689 933

Nigeria 179 208 347 432 509 511 466

Zimbabwe 52 221 382 473 485 391 311

Ghana 40 74 140 195 251 354 272

Zambia 15 40 88 183 133 169 162

Mauritius 6 15 41 62 59 95 102

Kenya 19 29 50 155 152 146 99

Botswana 4 — 87 100 39 90 91

Swaziland — — — — — 81 69

Malawi 1 15 45 75 57 64 52

Lesotho — — — — — 50 43

Sierra Leone — — — — — — 24

Total 915 2062 3266 3789 3053 3640 2624

Source: Nursing and Midwifery Council, UK (2005).

Table 4

Summary table for selected African countries

Source countries Total doctors in recipient

countriesaTotal doctors in source

country

% doctors in recipient

country with respect to

doctors in source country (%)

Sao Tome and Principe 47 81 58

Guinea Bissau 74 188 39

South Africa 12,134 34,829 35

Ghana 926 3240 29

Ethiopia 334 1936 17

Angola 145 881 16

Uganda 316 2209 14

United Republic of Tanzania 112 822 14

Zambia 168 1264 13

Nigeria 4260 34,923 12

Zimbabwe 237 2086 11

Mozambique 47 514 9

Cameroon 78 3124 2

Source: General Medical Council, UK (2004), Hagopian et al. (2004), Canadian Institute for Health Information (2003), Mullan (2005),

Carrolo and Ferrinho (2003) (Portugal), Bundesaertzkammer, Aerztestatistik (2003) (Germany) and WHO HRH database (2005).aAustralia, Canada, Germany, Portugal, UK, USA.

J. Connell et al. / Social Science & Medicine 64 (2007) 1876–1891 1881

comprehensive and comparable data means relyingon various sources, with different classifications andmeasurements. In this paper, a major source ofinformation consists of data from professionalassociations and regulatory bodies that maintainregistries of health workers authorized to practice.Data from health ministries and national council ofstate boards of nursing were also used. Registriescan provide detailed information on stocks andflows of migrant health workers in the host country,

though not on whether the people have actuallyentered the country, or taken a position in thehealth sector. This may overestimate numbers ofoverseas health workers within the health sectors,but it does measure losses elsewhere. Alternatively,some registries may fail to capture all healthworkers practising in the country, sometimesbecause qualifications are unrecognized, or includethose who have left or retired. For example, it is notuncommon that, although foreign trained doctors

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are working in the health sector, particularly inhospitals, they will not appear in the register due todiploma recognition issues. Other data sourcesincluding census data, labour force surveys andinformation on work permits are limited because oftheir infrequency, sample size or classificationsystems of limited relevance to health. Few arecomparable between countries (Diallo, Zurn, Gup-ta, & Dal Poz, 2003). A crucial global need issystematic, comparable migration data.

Why do health workers migrate?

Migration is primarily a response to globallyuneven development, but usually explained in termsof such factors as low wages, few incentives or poorworking conditions (Luck, Fernandes, and Ferrin-ho, 2000). Poor promotion possibilities, inadequatemanagement support, heavy workloads, limitedaccess to good technology and even to medicineshave all been regularly cited as ‘push factors’—motivating health workers to leave their country oforigin (Bach, 2003; Buchan, Parkin, & Sochalski,2004; Kingma, 2006; Muula & Maseko, 2006). Suchproblems are intensified in rural areas, where healthworkers feel they and their institutions are too oftenignored, victims of institutionalized urban bias indevelopment policy (Dussault & Franceschini,2006), although health workers may stay in ruralareas, where it is easier to hold other jobs or engagein corrupt practices (Muula & Maseko, 2006).Thirty years ago Mejia et al. (1979) recorded similarconcerns; since then, increased migration hasemphasized the few changes to these characteristicsof poorly resourced health systems. Declininginvestment in health sectors has worsened workingconditions in both origins and destinations (Pond &McPake, 2006; Stilwell et al., 2004). Finally,recruitment, by both agencies and governments,has played a critical facilitating role, so much sothat, in one recent study, 41% of all migrant nursesin Britain had come primarily because they hadbeen recruited (Winkelmann-Gleed, 2006, p. 44).

The morale of those who remain has worsenedand the rise of HIV/AIDS has placed new demandson health workers; as one nurse who had migratedfrom South Africa to the United States observed‘Nurses are emotionally exhausted. They are burntout. I mean if you are dealing with the huge numberof people with a disease like HIV/AIDS it takes itstoll on you’ (quoted in Parker, 2004). Nurses havemigrated from some countries, including Zimbabwe

and Malawi, through concern over inadequatepreventive measures against HIV/AIDS (Chikanda,2004; Muula & Maseko, 2006; Palmer, 2006) orbecause they too have HIV/AIDS (Kober & vanDamme, 2006). Botswana lost 17% of its healthworkforce to AIDS between 1999 and 2005 and inLesotho and Malawi death from AIDS is the largestcause of health worker attrition (WHO, 2006b,pp. 2–3). Civil war in countries such as Sierra Leoneand Liberia accelerated emigration. New factorsincluding lack of security in the workplace, and aworsening political and economic environment,have further intensified the desire to migrate. Insix African countries, both Anglophone and Fran-cophone, it was noted that a majority of healthworkers were despondent about their future in theirhome countries and could see little alternativebeyond migration (Awases, Gbary, Nyoni, &Chatora, 2004). In Zimbabwe there is a correlationbetween migration and economic decline, measuredthrough the inflation rate. Civil unrest, violence andcrime underpinned intention to migrate in severalcountries (Awases et al., 2004; Palmer, 2006).Irrespective of any change in the internationalcontext, all factors encouraging migration in Africa(see Fig. 4) have become more important.

Recipient countries offer real alternatives topolitical and economic insecurity in source coun-tries. A high standard of living with higher wages,better career prospects, good education and a futurefor children are offered in recruitment campaigns,and verified by those migrants established overseas.Health workers often migrate to support familymembers who remain at home and the flow ofremittances from migrants—representing high pro-portions of GNP for some African countries—is amajor source of income for kin. There is growingevidence that individuals choose to become healthworkers because of the possibility of migration,rather than because they value the profession.

Consequences of migration

Migration of skilled health workers has diverseconsequences, from more obvious impacts on thedelivery of health services and the economicconsequences of the loss of locally trained skilledworkers to more subtle social, political and culturalimpacts. Since migrants move to improve their ownand their families’ livelihoods, they are usually thekey beneficiaries of migration. Recipient countriesbenefit from having workers who fill shortages in

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Perc

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Zimbabwe

Fig. 4. Reasons to migrate. Source: Awases et al. (2004).

J. Connell et al. / Social Science & Medicine 64 (2007) 1876–1891 1883

the health care system. Conversely, sending coun-tries and their populations, especially in remoteareas, lose valuable skills unless those skills are an‘overflow’ or are otherwise compensated for. InAfrica neither condition is true, despite somecompensating flow of remittances. Migrants tendto be relatively young and recently trained, com-pared with those who stay. Many leave afterrelatively short periods of work, but long enoughto gain important practical experience. They ofteninclude the best and the brightest (Awases et al.,2004).

Education costs

Training of eventually migrant health workers iscostly, because of the long duration, the high costsof materials and techniques (and the common needfor postgraduate education and training pro-grammes) and is a burden on relatively poor states.However, there have been few estimates of the costsof the ensuing brain drain and a variety ofmethodologies and conclusions.

It has been estimated that because of migrationGhana has foregone around £35 million of itstraining investment in health professionals (Marti-neau, Decker, & Bundred, 2002), hence the financialcosts of health worker migration have been con-

siderable (e.g. Dovlo & Nyonator, 1999; Mensah,Mackintosh, & Henry, 2005; Save the Children,2005). In comparison Save the Children (2005)estimate that the UK has saved £65 million intraining costs since 1998 by recruiting from Ghana.In Uganda it costs about $27,500 to train eachdoctor in Uganda, but this is an underestimate sinceit excludes the costs of training before medicalschool and the remuneration of those involved inthe training programme (Awases et al., 2004, p. 59).Though most such calculations are thus little morethan guesstimates they provide a crude dimension tothe economic costs.

Return migration of skilled health workers isrelatively limited in Africa, though data are scarce,hence benefits from enhanced overseas skills—acompensatory brain gain—are few. However, mi-grant remittances are considerable, though nostudies in Africa presently differentiate the remit-tances of health workers from those of othermigrant groups (Kingma, 2006, p. 199). Theevidence from other regions suggests that theremittances of health workers substantially exceedtraining costs, benefit the private sector and donot contribute to greater equity, new trainingor improved health care provision (Connell &Brown, 2004) a situation that may also be true inAfrica.

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Moreover, where skilled workers leave relativelypoor countries and are replaced, the cost may bevery great, where the costs of both recruitment andsalaries are substantially more than those of localdoctors. In some contexts, despite the cost ofreplacements, they may be less effective because oflanguage and cultural differences, which restricttheir ability to provide health services, contribute totraining and enable sustainability.

Overseas treatment

A further consequence of health worker migra-tion is that of some patients travelling overseas forhealth care. Where such referrals are paid by thestate the cost is considerable. Even where they arenot, as is usually the case, resources are neverthelesstransferred overseas. In a group of six Africancountries referrals have increased at the same timeas health worker migration resulting in ‘an un-precedented increase in both expense of care tofewer people and in the use of foreign currency,which could have been used for other developmentprogrammes or even for the motivation andretention of the country’s health workers’ (Awaseset al., 2004, p. 57). The lack of health personnel maynot be the primary motivation for travelling over-seas for treatment, but it nonetheless represents asubstantial loss of scarce resources. Nigerianshave been estimated to spend as much as $20billion a year on health costs outside Nigeria(Neelankantan, 2003). Even in countries that arerelatively well supplied with health personnel, thecost of referrals is considerable, making the taskof financing local health systems and organizingmore labour intensive preventive health care moredifficult.

Impact on health care provision

The provision of health care may be affectedboth in quality and quantity. Vast amounts ofanecdotal data suggest strong links between themigration and the reduced performance of healthcare systems. Actual correlations between emigra-tion and malfunctioning health care systems aredifficult to make, yet it is implausible that theloss of health workers has no effect on the healthsystem. The link between health workforce den-sity and health outcomes has been clearly demon-strated (Anand & Barninghausen, 2004; Zurn et al.,2004).

In certain circumstances the quantitative outcomeof migration is obvious. In Malawi the recent loss ofmany nurses to the UK has brought the nearcollapse of maternity services even in Malawi’scentral hospitals and meant that only 78% ofministry positions were filled, with 65% of nursingpositions being vacant (Palmer, 2006). In theLilongwe Central Hospital 10 midwives sought tocope with delivering more than 10,000 babies a year,which meant that many births were not attended(Dugger, 2004; Muula, Mfutso-Bengo, Makoza, &Chatipwa, 2003). Proportions of positions filled aremuch lower in countries like Sierra Leone andLiberia. In Ghana 43% of doctors’ posts wereunfilled in 1999 (Afrol News, 28 May 2004). InKenya and Ghana more than half of nursingpositions remain unfilled (Buchan et al., 2004;Volqvartz, 2005). In Zimbabwe by 1997 only 29%of all national positions were actually filled(Chikanda, 2004) even before the most rapidinternational migration. In Kenya staff shortageshave become so critical that at Nairobi’s publicmaternity hospital nurses often care of 60–90patients in a 10-hour shift (Afrol News, 28 May2004) While such data are fragmentary, and oftenrepresent worst-case scenarios, they point to diffi-cult circumstances in many countries and the needfor change.

The outcome of reduced staff numbers is thatworkloads of those remaining become higher, andless likely to be accomplished successfully. In Ghanaand Zimbabwe workloads recently increased inparallel with migration; the workload of midwivesdoubled in 5 years (Awases et al., 2004, pp. 35–37).Many reports, though mostly anecdotal, emphasizelonger waiting times with the implication that thisraises opportunity costs of medical care, and mayalso result in medical attention coming too late. InZimbabwe over a quarter of health workers believedthat longer waiting times had resulted in unneces-sary deaths that prompt attention could haveprevented (Chikanda, 2004). Waiting times wereproblems in four African countries, and some healthfacilities had reduced opening times, especially inrural areas (Awases et al., 2004, pp. 50, 58). InZimbabwe staff shortages resulted in patients beingturned away from public clinics so that staff couldcarry on their private clinics without an excessworkload, with obvious reductions in equity (Chi-kanda, 2004). Health workers themselves stressedthe decline in circumstances that had followedmigration, in terms of such qualitative factors as

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respect for patients and care givers, attention givento patients and general communication betweenhealth workers and clients. Lack of staff also meanta decreased ability to get medication to patientseffectively (Awases et al., 2004, p. 50). In recentyears foreign aid programmes have expanded insub-Saharan Africa, to provide drugs to millionsaffected by tuberculosis and AIDS yet, ironically,these programmes have been hard to implementbecause of too few nurses to administer themeffectively (Volqvartz, 2005).

As a result of stress and higher workloads publicsector staff have tended to neglect public responsi-bilities to work in the private sector (Mutizwa-Mangiza, 1998). The movement of health profes-sionals to the private sector, at the same time asinternational migration, has seriously disadvan-taged the poor, most of whom cannot afford higherprivate sector costs, alongside growing evidence ofless adequate public sector services (Gerein, Green,& Pearson, 2006).

In countries such as Cameroon and Zimbabwethe migration of professionals has made it necessaryfor less or non-qualified people, such as nursesaides, to perform tasks that are normally beyondtheir ability with the implicit risk of misdiagnosis orinadequate response (Chikanda, 2004). In severalAfrican countries ‘young recruits are often left aloneto carry out work without supervision, at the risk ofmaking incorrect diagnoses and prescribing inap-propriate treatment, while unqualified personnel areleft to perform duties that are specialized, andbeyond their scope of practice which may endangerthe lives of patients’ (Awases et al., 2004, p. 58). Inseveral countries patients have reverted to theinformal sector with costly and uncertain healthoutcomes.

The impact of emigration is usually most evidentin remote regions where losses tend to be greater(and where resources were initially least adequate).Consequently, not only has migration had anegative impact on the health care system of sourcecountries, but that impact has fallen particularly onthe rural and urban poor who are most dependenton public health systems. The loss of health workersfrom places most in need emphasizes the ‘inversecare law’. Equity has been reduced further incontexts where health care systems were often farshort of being equitable. Through migration theability to meet the United Nations millenniumdevelopment goals, with their emphasis on superiorhealth status, is receding.

Skill loss

Beyond the brain drain, a further outcome ofmigration can be a ‘skill loss’ when migrants withspecific skills do not exercise those skills. Thismay result from failure to recognize qualifications,discrimination or a preference for jobs with betterwages and conditions. For instance, none of agroup of eight nurses who had migrated fromPortuguese-speaking African countries to Lisbonhad initially been able to find a nursing job, citingracism and the non-recognition of qualifications asthe main reasons. All had therefore taken unskilledwork, such as nursing aides or cleaners, whichoffered neither social security benefits nor long-termsecurity (Luck et al., 2000). In such circumstancesneither health systems nor the migrants make realgains.

Migration thus threatens the effectiveness of thehealth system, because of the net loss of humancapital, since without a balanced mix of professionalskills, appropriately located between regions andfunctions, systems cannot work effectively. In manyAfrican states this is now the situation. Yetparadoxically even if all migrant workers werenow to return to their home countries the systemmight not be able to fund and provide jobs forthem, nor place them in the regions where they aremost needed.

New directions?

The widespread health care crisis in Africancountries, extended and intensified by the acceler-ated migration of health workers, requires animmediate and integrated approach to mitigate thenegative effects of migration and reinforce itspositive effects. Thirty years ago Mejia et al.(1979) argued, firstly, that the lack of good datashould not be used to justify inaction, and,secondly, that the failure of workforce planningcould be attributed to a lack of political will to dealwith the critical problems. Sadly, 30 years later,both conclusions remain valid (Bach, 2004) in acontext of even greater need, where the brain drainhas flourished. Policy options exist to mitigatenegative impacts of migration. Though most mi-grants assert that they do not want to migrate (e.g.Awases et al., 2004), no easy solutions exist toaddress this complex issue. Differentiation betweenpolicy options in sending countries, receivingcountries and both is important.

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Options for sending countries

Retaining existing health workforces

Monetary incentives are the most commonapproaches to improved recruitment and retention.Financial incentives include wages and salaries,bonuses, pension, insurance, allowances, fellow-ships, loans and tuition reimbursement. Providingadequate and timely remuneration is important toguarantee recruitment of motivated and qualifiedstaff. However, developing countries cannot makewages (of health or other skilled workers) compar-able with those of rich world states without a fiscalcrisis. Even doubling local salaries has not reducedmigration, since the income gap remains consider-able between developed and developing countries(Vujicic, Zurn, Diallo, Adams, & Dal Poz, 2004)and other factors are involved. Whilst healthworkers argue that the single strongest influenceon them remaining would be better wages (Awaseset al., 2004, p. 58), improved wages alone will notmeet needs.

Non-monetary incentives like strengthening workautonomy, encouraging career development, pro-viding opportunities for training, adapting workingtime and shift work (for nurses), reducing violencein the workplace and open leadership all potentiallyreduce migration. With the realignment of thecareer structure and promotion based on abilityrather than nepotism, as Zimbabwe was able toachieve in the 1990s, migration slowed (Awases etal., 2004). Wage structures that offer opportunitiesfor significant salary progression encourage reten-tion.

Potential incentives exist outside the healthsector: some Caribbean states have given healthworkers access to loans for housing or cars, atexceptional rates or without deposits, encouragingpotential migrants to remain (while lending institu-tions gain extra customers). For more than half ofGhanaian health workers something as seeminglystraightforward as better day care for their childrenwas a priority (Awases et al., 2004).

In many countries particular measures have beentaken, some with a degree of success, but there hasrarely been a concerted or integrated approach tothe implementation and monitoring of a policypackage, that might multiply single-issue benefits(cf. Palmer, 2006). Such implementation demandseffective management yet these skills may also havebeen lost through migration.

Increasing recruitment capacity

Assuming that some proportion of health work-ers migrate, additional recruitment is critical, butschool leavers now have more options than in thepast, and several countries lack the capacity to trainsubstantially larger numbers. In Malawi nursingschools have a low annual intake ‘because of a lackof hostel accommodation, inadequate classroomspace, too few tutors, insufficient teaching andlearning materials and poor finance’ (Muula et al.,2003, p. 435). Similarly Cape Verde can only accepta new intake of nurses every 3 years, while Swazi-land’s annual output of nurses is below themigration rate (Kober & van Damme, 2006).Countries must give higher priority, and greaterfinance, to the education of health workers, along-side related accommodation, facilities and faculty.

Create a fiscal space for the health sector

Ceilings on public health spending have been aserious constraint to the development of adequateworkforce policies, as they have been for twodecades (Alubo, 1990). Economic restructuring,usually externally imposed, has sometimes meantthe deterioration of conditions rather than thegreater efficiency it sought to encourage. In manyAfrican countries funding for the public healthsector is shrinking in real and relative terms. Due tolow budgetary allocations, public service institu-tions are experiencing shortages of protectiveclothing, basic equipment and drugs and uncompe-titive salaries, since governments have been putunder pressure to reduce public expenditure, andespecially wages (Awases et al., 2004, p. 1). That hassometimes led to simultaneous high unemploymentand high vacancy rates: real incentives to migration.

‘Fiscal space’ must be created to enable recruit-ment in the public sector, where demand is greatestand equity best served. That is largely dependent oninternational agencies recognizing that health con-stitutes a ‘special case’, central to the millenniumdevelopment goals, and requires a productiveworkforce. In itself that would provide a positiveclimate, strengthen morale and enable greater like-lihood of improved structures of governance andmanagement. At the very core of providing aneffective health care system is quite simply an‘improved economic performance, a stable politicalsituation and a peaceful working environment’(Awases et al., 2004, p. 54). That might be obvious

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yet it is hard to be sanguine about positive changesafter a quarter of a century of invocations to change(Ojo, 1990) and where stable economies andpolitical systems are unusual.

Where countries have addressed critical pro-blems, migration has fallen and health systemsbecome more effective. Uganda is one of the fewAfrican countries to have sought more effectivedecentralization of health care (and more generalsupport for regional development) with the outcomethat health workers are less interested in migrationthan in otherwise comparable countries. Since mostsub-Saharan countries have primarily rural popula-tions, rural–urban migration is even more impor-tant than international migration in its negativeeffects on health systems, and because most nationaleconomies strongly depend on the rural sector,effective decentralization and infrastructural sup-port for rural and regional development is at theneglected core of national development.

Raising the status of health workers

Almost everywhere, fewer people are beingattracted to health careers. Wages and conditionsin the public health sector are increasingly seen asdeterrents to entry, and other sectors appear moreattractive (Kingma, 2006, pp. 33–34). Potentialemployees witness the frustrations of health workersand there is a wider range of potential job options.A career in health is now seen as not having theprestige and salary it once had and nursing may beseen as a dirty, dangerous and difficult job whereas‘business’ is the place of income generation,progress and action.

It is no accident that poorly paid, low-status nursesare more likely to migrate than doctors. Introducingthe role of nurse practitioners, intermediate betweennurses and doctors, may offer nurses new status, freshchallenges and better salaries, as has been the case inmore developed countries where nurse practitionersare cost effective and safe (Venning, Durie, Roland,Roberts, & Leese, 2000). In resource-constrainedsettings nurse practitioners can effectively bridge gapsin primary care services. In some African countries,nurse practitioners are now established members ofhealth care teams (WHO, 1996).

Towards the other end of the scale, Malawiintroduced a category of nursing auxiliaries tosupport nurses with preference given to ‘thosealready employed as hospital attendants, cleaners,and people who can demonstrate that, after their

training, they will remain in the same district’(Muula et al., 2003, p. 435). This offers opportu-nities for those who might not otherwise contem-plate semi-skilled employment, and withoutrecognized international qualifications are unlikelyto migrate (Palmer, 2006). Recruiting more men,and midlife women, who are more likely to remainin the country, offers further options, especially ifthe nursing salary becomes the primary householdincome source. Moreover, in an employment con-text dominated by women, in societies where suchgender imbalances suggest low status, opening upopportunities to men might also increase the statusof the profession.

Receiving countries

Given the pressures on public sectors in sub-Saharan African countries, and the very limitedroom for manoeuvre that exists, the onus for a moreequitable distribution of skilled health workers hasgradually shifted towards the recruiting countries,where demand is created.

Raising recruitment and reducing attrition

Few recipient countries have taken effectivemeasures to increase recruitment and reduce attri-tion of skilled health workers, at a time of greaterdemand, either by increasing the number of trainingplaces or improving wages and working conditions(Pond & McPake, 2006). Without an expandednational training capacity demand will continue toexceed supply, but in most receiving countries thereis little prospect of domestic supply increasingsignificantly, and the gap between supply anddemand is widening rather than contracting (Cha-gaturu & Vallabhaneni, 2005). If migration there-fore continues, there are likely to be renewed callsfor ethical recruitment guidelines, adequate codes ofpractice binding countries and/or compensation ofcountries experiencing losses.

Compensation

The economic costs to sending countries, and therecognition that recruitment is accelerating, haverenewed interest in compensation. Compensationcentres on financial transfers from countries that arereceiving, and actively recruiting, foreign health careworkers for government health services (to com-pensate for the loss of investment in training and the

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loss of human capital). During the 1970s there wasconsiderable discussion of the need to and possibi-lity of compensating sending countries (Gish &Godfrey, 1979) but no action was taken and theissue then faded. Even the most simple formulationraises obvious questions of whether there should becompensation from countries that benefit frommigrant health workers but do not actively recruit,what is the situation of migrant health workers inprivate sector employment (as is common) and whoshould pay whom. How any payment might becalculated raises even more difficult questions.Moreover, recipient countries have no great interestin putting in place compensatory mechanisms tocountries supplying skilled labour, arguing thatmigration is freely chosen, markets operate in thisway and there is no means of knowing how longmigrants will stay, despite strong ethical argumentsin favour of restitution (Mackintosh, Mensah,Henry, & Rowson, 2006). Compensation remainsinherently implausible.

Return of the diaspora

Developing countries and international institutionsare putting new emphasis on the potential role of thediaspora in assisting their home countries in someway, There is new recognition of the positive role ofdiasporas in source country development, which goesbeyond remittances, and includes the transfer ofskills, knowledge and technology. Source countrieshave to promote linkages with nationals abroad incooperation with receiving countries (Wickramase-kara, 2003). One example of an expatriate pro-gramme in the health sector is the Ghana–Netherlands Healthcare Project, managed by theInternational Organization for Migration, whoseobjectives are to transfer knowledge, skills andexperiences through short-term assignments andprojects, to facilitate short practical internships forGhanaian medical residents and specialists in theNetherlands and to develop a centre for the main-tenance of medical equipment in Ghana (Wiskow,2005). Ghanaian health workers in the Netherlandscan thus play a key role in the development of thehealth sector in Ghana. Other recipient countriesmight stimulate such cooperative projects.

Codes of practice

With growing awareness of the adverse effects ofhealth worker migration on health systems in

countries experiencing severe shortages of staff,demand for ethical recruitment strategies increased.Complaints from developing countries regardingincreasingly aggressive recruitment campaigns re-sulted in the development of approaches referred toas ‘ethical international recruitment’. From 1999onwards legal instruments were developed to guidedifferent health sector stakeholders in the process ofinternational recruitment. For instance, the Com-monwealth Code of Practice applied principles oftransparency, fairness and mutuality of benefits,among commonwealth countries, and betweenrecruits and recruiters (Commonwealth Secretariat,2004). The UK adopted a code of practice in 2001,later revised, to limit government recruitment ofhealth professionals from developing countries, butthe code did not apply to private recruitmentagencies or prevent the NHS from hiring nurseswho applied independently. Moreover, codes arenot legally binding. Consequently, since the codecame into effect, an estimated 7000 overseas nurseshave registered to work in Britain (Volqvartz, 2005),while some, who would otherwise have chosen tomigrate to the UK, went elsewhere where codeswere absent. Without multilateral codes migrantsremain free to move, the role of private recruitershas been enhanced and recruitment driven under-ground. More collective action on codes of practiceis necessary but seems presently improbable.

Twinning

Twinning, or some form of bilateral linkage,between national health care systems (or particularhospitals, etc.) and overseas institutions may beinvaluable in a number of ways—in contributing toan effective climate for health care, providingtechnological support, enabling quality assurance,improving support and training for key workers andin enabling support to be forthcoming when laboursupplies are severely depleted.

Bilateral agreements

Bilateral agreements offer a policy option formanaging and monitoring the migration of skilledhealth professionals. They can be concluded eitherthrough a formal memorandum of understanding(MOU) between governments or a less formalexchange of ‘letters of intent’ (Wiskow, 2005). AnMOU was signed in 2003 between the UK andSouth Africa with the objective of creating a

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partnership on health education and workforceissues; partnership on time-limited placements andthe exchange of information, advice and expertise.Broadly bilateral agreements combine elements ofboth codes of practice and ‘twinning’ arrangements.

Overseas recruitment

Years ago many overseas doctors and nursesworked in Africa, but such numbers declined partlybecause time spent in Africa was not considered tobe part of a career progression in their country oforigin, and did not enable access to pension rights.Ironically, making such a structure more flexible,and enabling a reverse migration, offers someprospects for human resource development.

More effective regulation, and more ethicalrecruitment, alongside more effective bilateral re-lationships suggest some partial solutions, despitegrowing concern over the ethics of recruitment(Connell & Stilwell, 2006). Several Caribbean stateshave recognized the extreme difficulty of unilateralchange, the futility of ‘Canute-like’ attempts to stemmigration or to significantly change the interna-tional context of recruitment, but have argued for aform of ‘managed migration’ that involves bothregional activities—including the standardization ofnurse certification across the region, creating newmarketing strategies that aggressively sell nursing asa valuable profession, providing more effectivesalary structures—and special incentive schemes toencourage skilled workers to return at least on atemporary basis (and share their skills and ex-pertise). A key component has been the negotiationof new linkages with recruiting countries, in thiscase the USA, where nurses are trained within theregion but the cost of that training is reimbursed bythe USA. This provides a basis for parallel forms ofinternational relationships with sub-Saharan Africa.

Conclusion: the challenges ahead

Almost everywhere fewer people are now beingattracted to health careers. Wages and conditionsare increasingly seen as deterrents to entry as othersectors become more attractive. Potential employeeswitness the frustrations of health workers and thereis a wider range of potential job options. In bothdeveloped and developing countries careers inhealth are now less attractive than ever before,other than as a means to migration. Migration hasinvolved larger numbers of both recipient and sub-

Saharan source countries, and become more com-plex (with step migration within Africa), makingsolutions to resultant problems more difficult toachieve.

African countries can provide more effectivehealth care systems and some, like Malawi (Muula& Maseko, 2006; Palmer, 2006), have made impor-tant steps to do so. They cannot act alone. Sincemigration cannot be ended, and source countrieshave only limited scope for substantial policychange that will improve the number, status andeffectiveness of local health workers, the onus hasincreasingly shifted towards the role of recipientcountries. Migration links sub-Saharan Africa intoa global economy, largely determined by thosecountries that are also the principal labour recrui-ters, hence they must act to ensure that the globalcare chain becomes less inequitable, and that therebe mitigation for losses incurred in sending coun-tries. The notion of ‘managed migration’ needs to begiven some practical basis. Thus far, recipientcountries have still to implement policies that mightslow migration, such as through binding codes ofpractice, or reduce the impact of that migration onvulnerable countries, through supporting trainingcosts or institutions. Even developing an adequatedatabase on migration is extremely difficult.

Sending countries have not always been able todiscourage migration, which is widely perceived as ahuman right. Indeed several remittance-dependentcountries, such as Cape Verde, have not challengedmigration because of its economic role. Tradeunions have supported the rights of members tobetter their circumstances by migration while alsopressing governments to act locally to improveworking conditions. Individual voices in some stateshave even called for the greater export of healthworkers—in pursuit of the ‘Philippines model’—togenerate remittances. Migration is increasinglyembedded in national and international politicaleconomies.

If demand continues to increase in developedcountries, as it is presently doing, as the populationsof developed countries age, demand for health careincreases and local recruitment of health workers(especially nurses) declines, at a time when womenhave increased choices of employment, then theconditions offered to potential migrants and theintensity of recruitment may simply increase. In thelast year even Japan, albeit reluctantly, entered theinternational health care market. There is little signof any presently recipient country taking realistic

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steps to increase national market supply, andany solution requires multilateral consensus ratherthan a national or bilateral approach. Withoutnew directions Africa may thus continue to experi-ence accelerated migration and deterioration in thehealth care of an already inadequately servedpopulation.

Acknowledgements

The views expressed here are those of the authorsand not those of their institutional affiliation.

The authors gratefully acknowledge the contribu-tions of many institutions which have assisted thisstudy. We thank the UK General Medical Council,the UK Midwifery and Nursing Council, theCanadian Institute for Health Information, l’Ordredes Medecins de France, the German Chamber forDoctors, the Polish Chamber of Physicians andDentists, the Finnish and Danish Ministry ofHealth and the Dutch Big Register for providingdata on the stock and flows of international healthworkers in their respective countries.

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