A new book challenges the dominant view arguing that the primary driver of the migration of medical officers to Western countries is neither poverty, nor “the ills of African health systems”.

The book, titled: “The Labor Market for Health Workers in Africa: A New Look at the Crisis” and jointly edited by Tedros Adhanom Ghebreyesus (Minister of Foreign Affairs and former Minister of Health, Ethiopia), Agnes Soucat (Director of Human Development, AfDB) and Richard Scheffler (professor of Economics, University of California, Berkeley), has been officially released last month.

According to the data on the book, African physicians’ migration is estimated between 10 and 15 percent and believed to be much higher than the emigration rate in other fields.

There were about 25,000 African-trained physicians in developed countries 2004. That figure is almost a fourth of the total number of physicians in Africa that year.

Ethiopia is one the major suppliers of physicians to western countries alongside Ghana, Nigeria, South Africa and Sudan, according to the data on the book. The five countries collectively accounted for more than 87 percent of all African physicians in OECD countries in 2004. (See the graphs)

“The number of African-trained doctors working in OECD[Organisation for Economic Co-operation and Development] countries rose by 91 percent between 1991 and 2005. The increase in the number of African-trained physicians working in Africa during the same time frame was comparatively low, at 61 percent”, according to the book.

Regarding the causes for migration, the book claims:

Migration is often blamed for the ills of African health systems, but available studies show a more nuanced picture. Cohort studies in Ethiopia show a relatively low initial desire to migrate, which grows over time. Health workers with higher income and urban backgrounds are more likely to migrate, suggesting that poverty is not the main driver. Instead, the opportunity to pursue higher income may be the primary driver. Higher income plays a role in retaining health workers, as in Ghana. Emigration and rural-urban imbalance seem to be two faces of the same phenomena. Recruiting health workers from rural areas and offering training tailored to local diseases (rather than diseases more common in richer countries) are promising strategies……

The book attests that: “culture also plays a key role in the emigration of physicians”. Elaborating the point, it adds: “In many African countries training and practicing abroad is a mark of success. Medical school faculty measure their success by whether their students are competent enough to practice in the competitive medical environments of the United States and Europe.”

The merit of training lower-level health workers for mitigating migration and the deficiency of manpower in rural areas was re-affirmed by the book as follows:

Almost all health worker retention and immigration studies show that lower level workers are more likely than their higher level counterparts to stay in rural areas and service underserved populations. These frontline workers provide valuable preventive care, such as education on nutrition and sanitation, as well as support to clinical care, such as bathing and feeding patients. Unfortunately many countries are eliminating training programs for frontline workers and focusing on higher level workers. Rwanda recently eliminated training of lower level nurses (Capacity Project 2007). Not only do higher level workers take longer and cost more to train, they are also more likely to emigrate or to serve in urban areas, which already have the highest densities.

Some African countries have been cited for their “tremendous progress” in developing “innovative approaches to managing human resources for health” in the book.

According to analyses presented in the book:

South Africa developed an approach to selecting and training students that led to a rise in health workers in rural and impoverished communities. Ethiopia launched a massive effort to increase the number of health workers to deliver services that contribute to the Millennium Development Goals. It has trained and hired more than 30,000 health extension workers to deliver a basic package of promotive and preventive interventions, including family planning and malaria prevention and treatment. It is also tripling the production of medical officers and doctors trained to address maternal mortality and most illnesses that require referral or hospital care. Ethiopia is also analyzing incentives to reduce emigration of qualified health workers and distribute workers to rural areas.

Ghana increased remuneration of both doctors and nurses. Early data suggest that the pay increases reduced migration but have not affected performance. The Ghana experience raises interesting questions about the fiscal consequences of the salary increase and the pressure it places on the government to boost wages of other public sector employees.”

Yet, the book cautions that: “each country should diagnose its own health labor market issues…. Producing more health workers and paying them more is not always the right answer. There is no one-size-fits-all policy.”

In line with that conclusion, the book expounds:

The performance of health workers is mostly unknown but the few rigorous studies available (Rwanda and Tanzania) paint a bleak picture. Performance is typically associated with skills and training and indeed these factors are critical. Effort is also essential, however, and in some cases determines performance more so than skill. Health workers often do less than what they are capable of doing. Innovations such as performance- based financing, which Burundi and Rwanda are scaling up, can make a difference by aligning financial incentives to producing relevant, quality services. Incentives are not the only answer, and it is important to cultivate intrinsic motivation by selecting students with altruistic or rural backgrounds and encouraging professional and/or public ethos through training curricula.

As part of its analyses of the state of Africa’s health workers’ labor market, the book calls policy makers to pay more attention to the private sector and citing notable practices.

The editors’ noted:

More than half of the health expenditures in Africa are private, and private nursing schools have blossomed throughout Sub-Saharan Africa. The provider/purchaser split is already a reality in countries like the Democratic Republic of Congo, Mali, Rwanda, and Zambia. Yet many countries report only their public sector health workers to the World Health Organization. Many governments only finance public schools and do a poor job of regulating private schools and clinics. Ethiopia’s accreditation of private nursing schools is a good example of how to address nurse deficiencies and shortages. Rwanda’s approach of contracting faith-based organizations engages private providers in the delivery of essential services to the poor. Uganda and Zambia are experimenting with similar programs. Overall the African health labor market is similar to the European market: a diverse mix of institutional models with various degrees of private sector participation in providing and financing services.

The book’s editors also recommended that:

National governments and the donor community should systematically support country-specific analyses of the labor market to understand the binding constraints on both demand and supply sides. The analysis should include wage analyses; discrete choice experiments; institutional analyses; cost and efficiency analyses; analyses of supply constraints; analysis of health worker performance, including measurements of skills and efforts; and impact evaluations of the policies implemented. Only then can countries respond effectively to the human resource crisis.

The 256 pages book – “The Labor Market for Health Workers in Africa: A New Look at the Crisis” – was developed in collaboration with policy makers from Africa. According to the inrodctior notes, “The specific chapters were prepared by, or in close collaboration with, individuals from academia, research centers, and development organizations. The WB-AfDB-Berkeley team collaborated closely with individuals from Harvard University, Cornell University, Johns Hopkins University, the University of Maryland, and the University of East Anglia. Research centers involved include Oxford Policy Management (OPML) Group and CHR Michelesen Institute (CMI).

The book is available on Amazon for sale and on WorldBank’s e-library for subscribers.

[We intend to present this informative and insightful book in subsequent posts – in a manner that don’t infringe its copyright protections – as the book may not be accessible to most of our readers in the Horn of Africa]

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