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West should compensate poor nations for trained health workers, say advocates

Patients lay down in a corridor of the pediatric area of El Fasher Hospital, North Darfur.
Patients lay down in a corridor of the pediatric area of El Fasher Hospital, North Darfur.
Albert González Farran/UNAMID

Western nations are benefiting from the migration of skilled health professionals trained in Africa. A new report by the UK-based advocacy group Health Poverty Action says that Western countries should pay back the poor countries for the training.

One of the challenges to health in sub-Saharan African countries is a lack of health workers. Africa bears 24% of the global disease burden, but only 3% of the health workers in the world are on the continent.

This shortage is exacerbated by the migration of health workers from African countries to the West, says the report The Health Worker Crisis: an analysis of the issues and main international responses. It uses four case studies to show the impact of health worker shortages in sub-Saharan Africa. It seeks to draw attention to the problem of a too small health workforce and the factors that contribute to the problem.

“Health systems can’t function without health workers. This issue is key in meeting the health related MDGs, achieving UHC etc. Yet this issue often gets sidelined,” said Natalie Sharples, Senior Policy Advisor for Health Poverty Action, to Humanosphere.

A 2006 survey by the World Health Organization identified thirty-six sub-Saharhan African countries as having critical health worker shortages. Norway has the highest density of doctors, nurses and midwives with 361 professionals for every 10,000 people. Conversely, countries like Tanzania, Sierra Leone, Ethopia and Malawi have 3 or less professionals for every 10,000 people.


The shortage of health workers cannot be pinned solely on migration. Sharples cites the DR Congo and Mali as countries where the problems have more to do with the capacity of health systems, than the workers. The report cites that less than 1% of the world’s health expenditure occurs in African countries, well behind what should be spent given the much larger disease burden. However, a decline in health workers can be detrimental to national health systems.

“This is widely recognized, and the WHO Code of Practice came about due to this reason, with recognition that whilst migration  can be both positive and negative, migration from countries with critical shortages is further weakening health systems,” said Sharples.

The two problems converge in the Tete province of Mozambique. Some 2 million people live in the central province, but there are only 63 doctors and 300 nurses. Each doctor treats roughly 30,000 people. With many people living in rural parts of the province, half of population are further than 8 kilometers from a health facility. As a result, the region is doing poorly on a host of health indicators. Matters are made worse by the fact that more than half of doctors from Mozambique leave the country to work elsewhere, says the report.

The government of Mozambique is responding to the shortage by investing in the training of more health workers, with the support of the government of Italy. Some 70% of funding for the Tete Health Training School comes from the government and rest through donors and private funders. The cooperation with Italy is held as a way that governments can work with countries, rather against them. More investments are necessary to improve the quality of healthcare in Mozambique

OECD reliance on docs

“Apart from training we focus on how to retain health workers and motivate them to work in rural areas. This is a much broader question, including building houses for health workers, starting agricultural programs near health facilities, rehabilitating institutions, but also further developing training materials,” said Giulio Borgnoli of the Italian Embassy in Mozambique.

Western countries have benefited from internationally-trained health workers in the past few decades. The WHO said that 25% of all doctors trained in sub-Saharan Africa were working in rich countries that are a part of the Organization for Economic Cooperation and Development. Demand for international workers remains, which has the makings of a crisis as low and middle-income countries continue to deal with their own health worker shortages.

The reason health workers leave has much to do with the situation in their home countries. Better pay was listed as a top reason to leave in a WHO survey. Other leading contributing factors were security, living conditions, a lack of health facilities and limited opportunity. The ability of workers to make decisions based on what they think is best for their families should not be restricted, says the report. Sharples recognizes that the flow of money back into the countries through remittances is significant, but does not have a large impact on the problem of health systems in poor countries.

“There’s obviously an ethical issue in terms of balancing the right to health of populations with the right of the individual to migrate,” she said. “Remittances may be a significant flow but they are private flows so not supporting health systems.”

UK docs by country

The WHO Code of Practice, adopted by the 193 member states of the organization in 2010, called for the protection of migrant health workers while discouraging active recruitment from countries that face critical health worker shortages. Though the ensuing years have not seen adequate enforcement of the code, says the report. Further contributing to the problem is the lack of investment in strengthening the health systems of poor countries, as is recommended in the code.

“We are interested in the arguments put forward that if wealthy countries are benefiting at the expense of poor ones and contributing to global health inequalities, they should compensate them,” explained Sharples.

For recipient countries, they could contribute by compensating countries that trained health professionals. One estimate in the report shows that the employment of 293 doctors and 1021 nurses from Ghana saved the UK government £103 million in 2004. The authors say that part of that savings could have been returned to Ghana and invested in the country’s health systems.

“Destination countries must offer better technical and financial support to source countries to improve their workforce and take the calls to address the ‘push’ factors outlined in the WHO Code of Practice seriously,” concludes the report.


About Author

Tom Murphy

Tom Murphy is a New Hampshire-based reporter for Humanosphere. Before joining Humanosphere, Tom founded and edited the aid blog A View From the Cave. His work has appeared in Foreign Policy, the Huffington Post, the Guardian, GlobalPost and Christian Science Monitor. He tweets at @viewfromthecave. Contact him at tmurphy[at]