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To assess the impact of out-migration of nurses on the health systems in sub-Saharan Africa (SSA).
The countries of SSA.
Review of secondary sources: existing publications and country documents on the health workforce; documents prepared for the Joint Learning Initiative Global Human Resources for Health report, the World Health Organization (AFRO) synthesis on migration, and the International Council of Nurses series on the global nursing situation. Analysis of associated data.
The state of nursing practice in SSA appears to have been impacted negatively by migration. Available (though inadequate) quantitative data on stocks and flows, qualitative information on migration issues and trends, and on the main strategies being employed in both source and recipient countries indicate that the problem is likely to grow over the next 5–10 years.
Multiple actions are needed at various policy levels in both source and receiving countries to moderate negative effects of nurse emigration in developing countries in Africa; however, critically, source countries must establish more effective policies and strategies.
This paper was commissioned by AcademyHealth to “identify and review reports, documents and data relating to nursing workforce dynamics” in sub-Saharan Africa (SSA) with the objective of analyzing, synthesizing, and presenting key information on nurse migration in the region. It reviews trends and impact of nurse migration derived from previously published work by various groups including the Joint Learning Initiative on Human Resources for Health (JLI), the WHO Africa Region (AFRO) report on Migration, International Council of Nurses (ICN) Global Nursing Review Initiative, and reports to the High Level Forum (HLF) on the millennium development goals (MDGs) on the human resources crisis.
SSA faces a crisis with human resources for health. The WHO has estimated that though SSA has 25 percent of the world's diseases burden, it possesses only 1.3 percent of the trained health workforce (WHO 2004a, b, c). This situation is linked to an emerging health crisis—for example, it has been reported that life expectancy fell in 17 of the 48 SSA countries due to rising incidence of communicable diseases and the impact of HIV/AIDS (Sanders et al. 2003). It is almost a certainty that health-related MDGs will not be met, and workforce shortages will be a factor in missing these targets. In 2004, a report by the JLI further confirmed the conventional wisdom that availability of trained health workers influences the attainment of health goals and found, for example, that maternal mortality responded best to increases in availability of trained service providers (JLI Report 2004). In relation to shortages, the migration of nurses and other health professionals to developed countries is considered a major contributor to the health crises in SSA. This paper reviews the available information on trends and impact in nurse migration from SSA.
This review assessed published and unpublished literature on the nursing workforce situation in SSA. Meeting reports and semiformal publications were solicited from country sources and collated where available. Documents were scanned for relevant information and data on migration, stock and flows, management systems, and contextual issues affecting the nursing workforce; the recommendations and conclusions reached in previous reports were also assessed. One critical finding was that few of the papers reviewed were based on primary quantitative data. This paper attempts to extract relevant content material from these previous studies.
“Push and pull” factors encouraging nurses to migrate have been discussed extensively in some of the papers reviewed for this paper (e.g., Dovlo 1999; Meeus 2003; Padarath et al. 2003). These provide a helpful frame in which to assess the overall impact of various factors on trends in migration of nurses.
Push factors are influences that arise from within the source country and facilitate a potential migrant's decision to leave. Pull factors reflect actions and omissions of recipient countries that create the demand for, or encourage potential migrants to leave home (CRHCS 2003; Dovlo and Martineau 2004). These factors cover a broad range of issues including income (or remuneration) levels between source and destination countries; job satisfaction and perceptions of the work environment and ability to utilize one's professional skills; the organizational environment and career opportunities as well as workers' perceptions of trust in the management of health services; general political and administrative governance; encompassing bureaucratic efficiency and fairness; occupational risk and protection because of HIV/AIDS and poor availability of protective gear; and the welfare, security, and benefits of health professionals during employment and after retirement.
Padarath et al. also suggest that “pushes” exist in both source and recipient countries, but are mitigated by “stick” factors in source countries and “stay” factors in destination countries. “Stick” factors include family ties, psycho-social links, and the potential cost to be incurred to migrate, while “stay” issues include reluctance to disrupt family life and children's schooling, lack of employment opportunities at home, and the higher standards of living enjoyed in the recipient country (Padarath et al. 2003).
It should also be noted that one difference between health professions found in migration in SSA countries is that while doctors are usually passively recruited (i.e., look for the jobs for themselves), nurses are usually actively recruited by agents, sometimes for a fee (Dovlo 2006; Mensah, Mackintosh, and Henry 2005)—the role of recruitment agencies is now in itself a significant pull.
The nurse workforce in SSA is a significant component of its health workforce, perhaps more than on other continents. Nurses constitute 45–60 percent of the entire health workforce with nurses responsible for a broad range of services. Generally, the nurse to physician ratio is much higher in SSA than on other continents. Analysis by Munjanja, Kibuka, and Dovlo (2005) shows nurse to physician ratios ranging between 20:1 and 11.6:1 in Tanzania and Ghana, respectively, to a low of 2:1 and 2.5:1 in Madagascar and Central Africa Republic (Munjanja, Kibuka, and Dovlo 2005).
While the ratio of nurses to doctors may be high, the ratio of nurses to population in SSA tends to be much lower than in most other regions of the world. This is in part a reflection of low availability of resources, but other factors play a part. For example, many countries are unable to expand the workforce significantly even when some supply is available because of fiscal restraints imposed by international loan conditionalities. For example, employment is frozen and staff retrenched especially in from the public sector. A few countries (e.g., Uganda, Kenya) report unemployed health workers but examples from Lesotho and Ghana suggest that lengthy employment processes and lethargic civil service bureaucracy can also reduce the pace of recruitment of health workers (Dovlo 1999).
Another factor impacting on supply of nurses has been the decision in some countries to ban continued training of “enrolled”1 nurses who formed a major component of the health workforce (Munjanja, Kibuka, and Dovlo 2005). A further, relatively new, constraint to the supply of nurses in Africa is a rise in nurse deaths possibly as a result of HIV/AIDS, which may also influence supply through a perception of risk that may deter young job seekers (Tawfik and Kinoti 2001; WHO 2004a, b, c). A recent upsurge in nurse migration has worsened the situation as inflows from training schools are unable to maintain existing poor staffing levels. A WHO study in 2004 showed a general reduction in the availability of nurses with some countries having as much as a 12 percent decline over a 3-year period (Awases et al. 2004).
Adding to this poor supply context is the fact that while most countries in SSA have one or more nurse training institutions, many lack the required number of trainers and training materials and have limited student facilities. This negatively influences the schools' ability to increase the supply of newly trained nurses (Munjanja, Kibuka, and Dovlo 2005). Thus, a complex of factors and influences have affected supply of nurses into the workforce and reduced the ability of health systems in SSA to absorb the impact of nurses' emigration.
The paradox of the situation is that SSA countries with very low concentrations of nurses (ranging from 0.30 to 4.0 nurses per 1,000 population) are supplying nurses to countries in other regions, which already have much better ratios of nurse to population (with densities from 7 to 15 nurses per 1,000) (see Table 1).
Migration has become more significant in SSA due to recent rises in departure of nurses especially from Anglophone2 African countries; there are suggestions that migration from other countries is less pronounced (e.g., a study from Portuguese-speaking Mozambique reported that health worker migration was not seen as a major issue [Ferrinho and Omar 2004]). An examination of data on foreign-trained health workers in Organisation for Economic Co-operation and Development (OECD) countries (recipients) shows smaller proportions found in France and other non-English countries (OECD Ad Hoc Group 2003). While not all of these workers are from developing countries, the data indicate these countries' potential to absorb foreign health workers. In the United Kingdom, some 8.34 percent of all nurses working in the United Kingdom in 2001 were foreign, 21.2 percent of these are from SSA (Simoens, Villeneuve, and Hurst 2005), emphasizing the English-speaking phenomenon discussed earlier.
Accurate and up-to-date information on health worker stocks and flows was very difficult to obtain from the documents reviewed and many SSA countries have inadequate human resources information systems. In Table 1, we have summarized the quantitative situation of nurses in SSA using data from the recent World Health Report (WHO 2006) to build a picture of the shortage situation.
The result shows wide variation in availability of nurses but a generally low level compared with levels in the rest of the world. Some information on workforce stocks derived from Nursing Boards may not be accurate, as until recently some countries only required registration at initial entry into the workforce. Also, source country migration data obtained from verification of qualifications (a requirement by destination countries), provide estimates of intention to migrate and not definitive movement. At best this illustrates trends in the interest of nurses to migrate and suggests their intended destinations.
Registration data related to nurses arriving in recipient countries may provide more accurate data on foreign-trained nurses who come to practice, but again these numbers may not reflect those nurses who take on nonnursing jobs or spend time in “adaptation” before receiving formal registration to practice.
Charting the mobility relationship between source and recipient countries is not a simple linear task. For example, nurses from Africa may first enter the United Kingdom, work for a few years, and then move on to Canada or the United States. Some intra-Africa migration also occurs and Zambia's verification records, for example, show that almost 70 percent of enrolled and registered nurse requests were intended for either South Africa (32.7 percent) or Botswana (32.2 percent). This may not be true for many other countries in Africa. Ghana's verifications between 1998 and 2003 showed that only 0.8 percent of nurses verified for South Africa (compared with 80 percent for the United Kingdom) while in Malawi only 6.5 percent sought verification for other SSA countries (compared with 82 percent for United Kingdom) (Padarath et al. 2003; Buchan and Dovlo 2004; Munjanja, Kibuka, and Dovlo 2005).
Some studies highlight troubling data. For example, between 1999 and 2001, 114 nurses making up 60 percent of the workforce left a single hospital in Malawi; 500 nurses who left Ghana in 2000 made up more than double the number graduating from training schools in the country (Buchan and Sochalski 2004).
The “push” factor of wage difference is one of the most important factors in health worker migration and pay differences between recipient countries and SSA source countries can be very high. For example, purchase parity pay for nurses in Australia or Canada was 14 times that of a Ghanaian nurse, 25 times that of a Zambian nurse, and twice that of a South African nurse (Vujicic et al. 2004). However, when the salary differentials are compared with intentions to migrate, Ghana and South Africa had similar levels of intentions to migrate despite the vastly different salary differentials while Uganda, with similar differentials to Ghana, showed intentions at less than half of both countries (Awases et al. 2004).
The differences raise the importance of the role of nonfinancial factors in improving retention. Studies by Deutsche Gesselschaft fur Technische Zusammenarbeit (GTZ) on nonfinancial incentives in Kenya and Benin suggest that a mix of both financial and nonfinancial incentives were effective in addressing motivation. The research highlighted the potential of using various approaches including group and effort-based awards, team building, career development and transparent promotion schemes, continuing education, and supportive supervision, all supported with staff satisfaction surveys (Mathauer and Imhoff 2004). The 2004 WHO migration study (Table 2), while finding remuneration to be rated highly as a retention factor, also found that nonfinancial factors were very highly rated by health workers among “push” factors influencing a decision to emigrate (Awases et al. 2004).
SSA countries have tried a variety of actions aimed at mitigating the loss of health workers and Table 3 summarizes some of these actions. Financial incentives that were tried include South Africa's “rural” and “scarce skills” allowances aimed at staff working in designated rural areas (it ranged from 10 to 15 percent of annual pay for “scarce skills” and from 8 to 22 percent for “rural location” depending on type of worker and location) (Department of Health 2004). Ghana has introduced an “Additional Duty Hours Allowance” (ADHA) that has significantly increased “take-home” wages for health workers. A separate “deprived location” allowance as well as a transport and housing loan scheme aimed especially at doctors and nurses have also been implemented. Generally, the implementations of the strategies have not been evaluated, although in Ghana, the “ADHA” is thought to have spurred migration of nurses due to dissatisfaction with the disparity between their allowances and that of doctors (Buchan and Dovlo 2004; Mensah et al. 2005).
The low level of supply of nurses in Africa is likely to persist as economic restrictions and the effects of HIV/AIDS limit any expansion in numbers. The internal demand for nurses in SSA countries is further strained by the demand from externally funded global health initiatives, nongovernmental organizations working in the health sector, and disease-specific programs such as TB, which may draw existing staff from regular health services (Kurowski 2003; WHO 2004a, b, c). The basic fact is that currently, Africa has an average of one trained health worker per 1,000 population compared with a world average of four per 1,000, while the estimated minimum required to sustain coverage of basic health services is 2.5/1,000 (JLI Report 2004). Whatever the future holds, even minor losses of nurses to migration will magnify the existing shortages.
Attributable impact of migration is difficult to assess, given the paucity of data and wide variety of other factors that affect health services. However, a basic framework is utilized below to discuss how migration might impact health services.
Staff shortages are the most direct effects of health worker migration and it means that health systems are unable to deliver critical services (CRHCS 2003; Buchan and Sochalski 2004). The loss of key people with critical skills such as educators and specialists can be even more devastating. For example, international recruitment of two specialized anesthetists led to closure of a spinal injuries center in South Africa serving several countries (Martineau and Decker 2002). Financial losses include staff training costs, loss of professionals' contributions to the economy, and the effects on populations denied health services (Dovlo 1999). In Ghana, high nurse migration rates forced the government to significantly increase remuneration despite this having distorted the overall health budget, but the attraction of migration opportunity has brought new entrants into nursing training schools and encouraged establishment of private nursing training schools (Mensah et al. 2005).
Two forms of economic effects are identified based on (i) the lost investment in the training of leavers and (ii) the loss to national gross domestic product
(GDP) of contributions from departed professionals (Dovlo and Martineau 2004). It is suggested, for example, that some $60 m in training investment was lost to health worker migration by Ghana and that doctors leaving South Africa between 1989 and 1997 caused a loss of $5bn (Martineau and Decker 2002). Similar effects may well be ascribed to nurse migration. A third (positive) economic effect arises from remittances made back home, which can be substantial. The level of remittances (by all migrants) is variable—in some SSA countries it is significant, occasionally surpassing official development assistance (ODA) as in the case of Nigeria and as high as 85 percent of the level of ODA to Eritrea (African Union 2003). There are no data available on the specific remittances of nurses. A paradoxical effect is that rising nurse migration generates new incomes for nursing councils, income from issuing verifications, but weakens nursing associations through loss of membership (Buchan and Dovlo 2004).
The issue of HIV/AIDS and its links to migration of nurses is not completely clear. The perception is that HIV/AIDS in SSA may have stoked increased migration of nurses. The pandemic increased workloads in hospitals and changed the kind of skill sets nurses needed to care for increasing numbers of terminally ill patients, including counseling needs and providing antiretroviral treatment. Even without increased occupational risk from HIV/AIDS, high infection rates within the community affect nurses and markedly increased deaths have been noticed in some countries. A South African study reported that 16.2 percent of health staff interviewed were treated for stress-related illness and two-thirds of these had to take sick leave (Shisana et al. 2004). HIV impact has been linked with stress, burnout, absenteeism, and decline in quality (Kinoti 2003; JLI Africa Group 2004; Shisana et al. 2004).
A study of the possible role of HIV/AIDS on staff attitudes found that over 50 percent of staff (range 53.6–85.3 percent) worried about contracting HIV through work-related injury (Awases et al. 2004).
The epidemic in Africa further reinforces all the negative influences impacting the nursing workforce in Africa, seriously undermines morale and motivation, and may be a further factor stimulating migration to “safer” work environments.
The health workforce crisis in Africa has elicited a high level of international attention. There have been a number of policy declarations and meetings on international recruitment of health workers (Commonwealth, ICN, UK-NHS, WHO) some of which have included calls for reparation/compensation for source countries.
A comprehensive and respected international framework is required to moderate losses of critical health workers and to design ways of reducing the impact of this loss on vulnerable communities. At the country level, there are some working examples. For example, Norway was praised for its international recruitment approach based on intercountry agreements covering both private and government sectors and managed by a single government unit (Simoens et al. 2005).
Within countries and internationally, managing the change process of migration will require strong political will and negotiating skills backed by information and data. A critical aspect is to manage “turf” protection and resistance to change from the professions including nursing (WHO 2004a, b, c). There are standard templates for SSA countries to apply to resolve nursing workforce challenges. The papers reviewed made recommendations and called on countries to initiate steps for developing and implementing health workforce plans, however, most of the studies recognize the urgent nature of the crisis and a need to attain quick goals. Drawing from these publications, a range of options can be identified.
Firstly, to urgently increase its workforce of trained health providers in SSA, the potential to introduce new types of workers should be considered. “Health Extension Workers” in Ethiopia and “Community Health Officers/Nurses” in Ghana offer examples of actions to rapidly increase access for communities. These need significant investment in infrastructure and training, as well as development of good supervision and support systems if these mid-level workers are to be integrated with professional-level providers.
Secondly, increasing supply without attention to retention will undermine investments in training. Actions to improve motivation and provide performance incentives especially in rural and periurban poor populations are essential. Public sector pay increases present complex dilemmas in poor countries when particular health workers are singled out for improved pay (Awases et al. 2004). However, governments must provide “a living wage” at the minimum, supported with nonfinancial motivation schemes. An example is the use of debt relief funds from the Highly Indebted Poor Country Initiative (HIPC), which were used to fund incentives in Ghana (WHO 2004a, b, c).
Thirdly, health workforce information systems must be improved to support policy and strategic planning. The Kenya health workforce data project, for example, shows that this is feasible and that the status of the workforce can be monitored effectively (Kenya Nursing Workforce Project 2004).
Fourthly, international arrangements are needed to manage the effects of trade agreements and the labor market on nurse migration from SSA. Modifying the international environment is a challenge to SSA policy makers as effecting retention strategies will be difficult without active cooperation of recipient countries. There is at least a moral case for rich countries to manage the “pulls” attracting nurses from developing countries. International or intercountry agreements offer a way to maintain the rights of health workers while enabling countries to fulfill obligations to their populations.
Finally, there is need for appropriate investments in strategies and to find the evidence to back policies based on commonsense approaches and systematic monitoring and evaluation, coupled with improvements in health workforce management capacity at the national level. SSA countries themselves have to initiate and drive the strategies and actions needed and seek support of development partners. Current efforts appear patchy and uncoordinated possibly due to the lack of capacity to design and pursue reforms. Regional and international organizations in Africa can help in sharing “good practices” and in creating shared technical capacity to support implementation, monitoring, and evaluation. A wider international consensus will enable a fairer playing field and the sharing of Asian and Latin American experiences on the issue of health worker migration.
Ms. Naana Frempong was my assistant on the project and did Internet document searches and reviews in preparation for writing this report. Her efforts are much appreciated by the author.
Disclosures: This review was funded by AcademyHealth.
Disclaimers: The work for this report was concluded well before I joined WHO. The contents of this report do not reflect views, opinions, or otherwise of the WHO or any specific organization. This is a purely independent work.
1Enrolled nurses are subprofessional nurses trained for 2 instead of 3 years and entering nursing with basic primary/middle school certificates instead of secondary school qualifications. In the United States the equivalent would be licensed practical nurses. Several countries have reintroduced versions of these cadres to help tackle the crisis.
2Anglophone countries are those where English is the main, or most commonly spoken, language of European origin; Francophone countries are those where French is the main language; Lusaphone are where Portuguese is the language.