Working Towards an Improved African Health System

Wednesday, 5 August, 2009 - 11:40

Doctors, nurses and midwives are essential role-players in Africa’s attempts to overcome the unrelenting force of HIV, and all of the necessary support demanded by such a task should be made available to them as a top priority. In this article, Jonathan Mundell, writes that African health workers continue to be overworked, underpaid and often unappreciated, despite the fact that they form the foundation of the continent’s fight against HIV/AIDS

African health workers continue to be overworked, underpaid and often unappreciated, despite the fact that they form the foundation of the continent’s fight against HIV/AIDS. Without these health workers, Africa’s efforts to stem the tide of the epidemic would be futile. All plans developed to address the issue of HIV/AIDS in Africa are very much reliant on a well-oiled (or even partially oiled) health system, and the functioning of this system largely depends on the people who are working on the ground, on the front-lines, in the communities and with the people affected by the epidemic. Doctors, nurses and midwives are essential role-players in Africa’s attempts to overcome the unrelenting force of HIV, and all of the necessary support demanded by such a task should be made available to them as a top priority. This has unfortunately not been the case, as the state of the African health worker, and consequently also the African health system, is somewhat bleak.

A report released by the World Health Organisation (WHO) in 2006 estimated that the African continent possesses 14 percent of the world’s population, 25 percent of the global health load, but a mere 1.3 percent of global health workers (2). The report also revealed that the world is facing a shortage of more than four million health workers. Results from a study conducted by the Joint Learning Initiative suggest that countries should have an average of 2.3 healthcare professionals per 1 000 people. The report revealed that of the 57 countries that fall short of this threshold, 36 are in sub-Saharan Africa. In order to achieve the Millennium Development Goals (MDGs), it has been estimated that just 2.5 health workers are required per 10 000 inhabitants. Africa continues to fall well short of even this rather modest target, however, with the health worker/population ratio standing at less than one health worker per 10 000 residents (3). Two of the key questions that need to be posed then, is why is there such a shortage of health workers on the continent, and what can we do to address this issue?

A quest for greener pastures leaves the health system stretched

The current human resource crisis in the African health sector is very closely related to the appalling working conditions that the African health worker must endure, as well as the dismal state of many African health systems. This crisis is driven by a number of factors, of which migration is central, and a good starting point in an attempt to better understand the underlying factors behind the current health worker shortage. For the health sector, the continuous migration of health professionals from Africa to richer countries has for some time raised concerns of a medical ‘brain drain’, which desperately needs to be plugged. It is estimated that in sub-Saharan Africa, 13 272 physicians have emigrated to Australia, Canada, the United Kingdom and the United States (4), and this has had a severe impact of the health sector in many countries. The emigration of skilled persons from their home countries has affected developing countries worst. These countries contribute tremendously to the training of professionals, but many of these professionals then emigrate to contribute to the economies and improve the health sector of already developed nations, leaving their home countries in desperate need of skills and experience to run the systems that form the structure of society.

This unfortunate cycle is particularly evident in Africa, where the health system has been brutally affected, largely due to a lack of staff. This shortage of skilled health workers has significantly increased the workload for remaining personnel, who face prospects of little career advancement, fewer training opportunities, stress, frustration and ultimately burnout. These factors push more and more health workers away from the public service sphere, often to emigration, perpetuating this vicious cycle. Health workers emigrate for a variety of reasons, including economic motivation, a quest for a better quality of life, poor working conditions, poor workforce planning, a declining healthcare service, and the seeking of further training, experience and upgrading of qualifications. As these health workers embark on a quest for greener pastures, the African health system becomes progressively more and more stretched, placing increasing pressure on remaining health workers.

Plugging the medical ‘brain drain’, and working towards an improved health system

Despite the fact that thousands of qualified health workers have been leaving Africa for better opportunities in more developed countries, essentially dismantling the African healthcare system, little has been done to improve the situation for remaining health workers or for the health system in general. Efforts desperately need to be made to retain and support the current health workers and substantially expand their workforce. Policy recommendations are broad-based and emphasise the need to approach the health worker shortage from local, regional, national and international levels. Policy makers need to consider global dynamics, such as active recruitment of health workers by industrialised countries and the effect of globalisation. In addition, it is also necessary to tackle the issue on a national level, involving governments and implementing incentives for health workers, for example. From a local perspective, it is critical that factors such as the dangerously high workloads and the effects of HIV/AIDS on the health sector are addressed.

During the 5th International AIDS Society (IAS) Conference on HIV Pathogenesis Treatment and Prevention, which was held in Cape Town in July 2009, experts emphasised the importance of the decentralisation of health systems and of task-shifting. According to Jacqueline Bataringaya, IAS Senior Policy Advisor, “There are serious deficiencies in our health systems and without addressing the weaknesses, we cannot upscale…Yet, we need an additional one million doctors, nurses and midwives in Africa.” (5) Task-shifting and the increased use of community health workers have repeatedly been raised as two of the possible avenues to address the severe health worker shortages, but up to now neither strategies have been implemented to the degree that is so desperately needed. Delegates at the IAS conference made a call to funders for an increased focus in developing the African health system, but Michel Kazatchkine, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, very promptly responded that a substantial portion of the Global Fund budget has been allocated to increase numbers of health workers in developing countries.

It remains a problem that African governments need to respond to - with or without what they deem “sufficient” funding. The current state of healthcare systems around the African continent, particularly the working conditions of health workers, is disgraceful. Since the health sector has the most influence on how Africa progresses in fighting HIV/AIDS, the primary focus of governments, when deciding where and how to allocate funding, needs to be on the considerable improvement of a system that is gradually disintegrating.


(1) Jonathan Mundell is a Director at Consultancy Africa Intelligence (
(2) The WHO report
(3) Sambo, L.G. (2007). Message of the Regional Director on the Occasion of World Health Day 2006: Working Together for Health. African Health Monitor, 7 (1), pp 1-3.
(4) Mills, E.J., Schabas, W. A., Volmink, J., Walker, R., Ford, N., Katabira, E., Anema, Joffres, A., Cahn, P. & Montaner, J. (2008). Should Active Recruitment of Health Workers from Sub-Saharan Africa be Viewed as a Crime? The Lancet Journal, February, pp 4.
(5) “Where to find a million Nurses?



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