WHO red list fails to stem Africa health worker exodus; Zim one of 34 countries on list

Growing migration poses a significant challenge to accessible and quality healthcare services for millions across the continent

By SciDev.Net

It took nearly three hours of sitting, queuing and loitering around Ikorodu General Hospital in Nigeria’s Lagos state before Hadijat Hassan, a retired civil servant, could get the attention of nurses on duty.

The 66-year-old has regularly attended the health facility for health checks since being diagnosed with diabetes nearly ten years ago. But since May, she says, she has had to endure long delays, often while suffering from excruciating pain in her legs as a result of the diabetes.

“I’m not as strong as I used to be,” Hassan told SciDev.Net.

“That’s old age for you. You can get there (the hospital) and meet like 50 people waiting to be attended to.”

“If one deliberately recruits and makes the country suffer because it lacks the required professionals, that’s a crime against humanity.”

Constantino Chiweng, Zimbabwe’s vice president and health minister

In Nigeria, each doctor has an average of 5,000 patients, whereas the OECD average is around 270 patients per doctor.

“They (staff at the hospital) said all of their nurses and doctors have been leaving for abroad,” said Hassan. “Just a few of them are left.”

A senior official at the hospital told SciDev.Net that the management gets notice of resignation from nurses and doctors almost every month.

“Many of them leave for the United States, Canada, United Kingdom and, most recently, Australia,” said the official who asked to remain anonymous.

The Nigerian Association of Nurses and Midwives has reported that Nigeria now has a nurse-to-patient-ratio of one nurse to about 1,160 patients, whereas the OECD average is one nurse to around 114 patients.

Michael Nnachi, the president of the National Association of Nigeria Nurses and Midwives, told SciDev.Net that over 75,000 nurses had left Nigeria since 2017. Nnachi said improved condition of service as well as provision of social security could solve the emigration crisis.

“If you look at the condition of service of health workers generally, you’ll see the difficult challenges complicated by the current economic realities.”

He said inflation in Nigeria compounds health workers’ situations and makes it difficult for people to afford a decent life on their salary.

“Condition of service is very important. And social security. In the workplaces, people need to be assured that their employment is intact and entitlements are paid as of when due.

“Nurses are at the epicentre of healthcare service and should be taken care of to improve the system.”

According to the WHO’s estimates, the world will face a shortage of 10 million health and care workers by 2030. And the numbers are mostly in low-income countries, where health workers are leaving to find opportunities abroad.

Red list

This is despite the WHO’s introduction of a safeguard list to prevent rich countries from poaching healthcare workers from countries where health workers are in short supply.

The list was launched in 2020 to replace the list of countries with critical health workforce shortages contained in the WHO’s World Health Report, and the WHO plans to update it every three years.

The list includes Nigeria, Ghana, Zimbabwe and 34 other countries in the Africa region. Yet according to the UK’s Nursing and Midwifery Council, more than 7,000 Nigerian-trained nurses relocated to the United Kingdom between 2021 and 2022.

Data from the Ghana Registered Nurses’ and Midwives’ Association shows that nearly 4,000 nurses left the country in 2022, while in Zimbabwe, more than 4,000 health workers, including about 2,600 nurses, left the country in 2021 and 2022, the Zambian government revealed.

While the WHO does not prohibit recruitment of doctors from countries in the list, it discourages it.

The WHO recommends “that government-to-government health worker migration agreements be informed by health labour market analysis and the adoption of measures to ensure adequate supply of health workers in the source countries”.

Health sector organisations, however, say it appears to be ineffective in stemming the tide.

For instance, the British government currently flouts the safeguard list by recruiting from these countries. The latest data from the UK’s nursing regulator, the Nursing and Midwifery Council, show significant increases in recruitment of nurses from outside Europe, including countries on the WHO red list.

Nigeria sits in the top three of countries outside Europe, with over 3,000 joining the UK’s official register in 2022.

The RCN said those entering the UK nursing workforce included recruits from 14 countries on a red list of 47 that the UK Government had stipulated should not be actively recruited from.

“The UK list mirrors the World Health Organization, which says these 47 countries face the most pressing health workforce shortages and have been identified as having serious workforce challenges and must not be targeted for systematic recruitment by NHS or independent employers,” the RCN said in a statement when the data was released.

The union added that the increases have led to “concerns that UK governments are becoming heavily reliant” on countries with critical workforce shortages to fill nursing vacancies.

Nurses working in the UK, who spoke with SciDev.Net, say the British government only stops third parties such as agencies from recruiting but allows individuals to apply directly to the NHS or care homes of their choice.

In a revised code of practice issued earlier this year, the UK governmentconfirmed that the embargo was not applicable to “direct application”.

“For the purpose of this code of practice, a ‘direct application’ is when an individual makes an application directly and on their own behalf to an employing organisation,” a clarification posted on the government website read.

However, the WHO, while updating the health workforce support and safeguards list in March, called on countries to respect the list.

“Health workers are the backbone of every health system, and yet 55 countries with some of the world’s most fragile health systems do not have enough and many are losing their health workers to international migration,” said WHO director-general Tedros Adhanom Ghebreyesus.

“WHO is working with these countries to support them to strengthen their health workforce, and we call on all countries to respect the provisions in the WHO health workforce support and safeguards list.”

Nurses dump qualification

Elizabeth Fadziso landed in Heathrow airport after spending about 20 hours flying from Harare to London. For the 30-year-old Zimbabwean nurse, the touch down in the UK in April signalled a fresh start.

She told SciDev.Net that she had hoped to work as an international nurse since she started her undergraduate nursing degree.

This dream, she said, was fuelled by the poor welfare condition of health workers in the country and deficit of advanced medical equipment.

Upon finishing her studies in 2020, she tried to apply for a certificate of good standing from the government, one of the documents required of nurses who want to work abroad. But she met a brick wall.

The Zimbabwean government, as part of efforts to curb the alarming migration of nurses, had stopped issuing the mandatory document. Doctors and nurses in Zimbabwe have long protested this rule that impedes their ability to leave the country.