There is a global shortage of health workers, and the pandemic is making it worse. An ambitious programme in Rwanda seeks to help Africa in reversing this decline. What will they need to succeed?
By 2030, there will be a global shortage of 18 million health workers and the world will need roughly 80 million health workers to cater for the global population. Health workers are almost always women, and almost always from low and middle-income countries. With such a critical global demand, the question remains: where the supply will come from and what are countries currently doing about it?
In 2018, close to 6,000 nurses in Zimbabwe (around a third of the total number of the country’s nurses in the public health sector) went on strike. During the strike, Zimbabwean authorities sought to fire all striking nurses, while attempting to backstop the health service with unemployed, retired and on-leave nurses. Additionally, the government looked to cancel all official leave of current staff.
By 2020, while Zimbabwe was fighting the COVID-19 pandemic, the Zimbabwe Nurses Association, which has more than 16,000 members, called for industrial action to force President Emmerson Mnanagwa’s government to pay them better salaries. With salaries significantly lower than the living wage, a wage increase was a necessary step to equitable work conditions. Little, however, has improved. This year, the Zimbabwean Nurses Association claims that most nurses earn $53 a month (for perspective, the World Bank’s official poverty index is $1.9 per day).
Back in 2020, strikers met hostility from government agencies. Reports of police in Zimbabwe arresting nurses shadowed strikers’ activities over the three months of the strike. Nurses would eventually win concessions from the government to propose a new pay offer for the health sector and, crucially, for the government to stop paying medical bills for cabinet ministers and senior officials who seek treatment abroad. But two years have passed and still, Zimbabwe’s healthcare system continues to worsen. Against a backdrop of worsening economic crises, uncontrolled inflation, stagnant salaries, widespread poverty and shortages of essentials such as water and electricity, Zimbabwe is haemorrhaging health workers and losing the trust of its citizens.
Health worker strikes are a common feature of many African health systems. South Africa, Senegal, Kenya, Nigeria, and Guinea Bissau, for instance, have all reported frequent strikes over the past few years. The specific reasons for healthcare strikes differ from country to country, but the cause is generally the same—weak and underfunded public health systems.
Decades after African governments pledged to allocate at least 15 per cent of their annual budgets to the health sector, only Rwanda and South Africa have made progress to reach that target. Further, the exodus of capable and willing healthcare workers out of lower- and middle-income countries towards richer nations like the United Kingdom, United States and Australia will continue to mean that the continent’s own health burdens come second to wealthier nations’ health issues. For a newly graduated nurse, it is more profitable to take care of an ageing population in a Western country than young patients in Africa. The Zimbabwe Nurses Association, for example, frequently organizes webinars for health workers seeking opportunities in other countries.
RICH COUNTRIES ARE EXPLOITING A VALUABLE RESOURCE
Healthcare workers are the new oil and the cold war for the next precious resource has already begun. Brain drains are not new for African countries. These persistent emigrations are a symptom of more serious underlying problems to nations within unequal global development. However, COVID-19 has made evident the detrimental implications of these movements.
In April 2020, during the first few months of the pandemic, the European Commission called upon their member states to facilitate smooth border crossings for healthcare professionals and to allow healthcare professionals unhindered access to work in healthcare facilities across member states. Many European countries took this one step further and actively made it easier for foreign healthcare workers to gain employment in their countries. Belgium, Germany, Ireland, and Luxembourg, for instance, fast-tracked applications to recognize foreign qualifications of healthcare professionals. Germany made it easier by reduced language tests for potential foreign healthcare workers. Italy adopted a temporary change to its infamously strict rules on foreign nationals working in public services, enabling temporary licensing of foreign-trained healthcare professionals. In France, non-licensed foreign-trained healthcare professionals were able to work as support staff in non-medical occupations. Recently, also rewarded frontline workers with fast tracked citizenship status. Spain launched urgent, coordinated action for the immediate hiring of foreign healthcare workers willing to work in Spain at the start of 2020, recruiting 400 people in the first few months of 2020. In 2020, the UK introduced the health and care visa with the direct aim to ‘make it cheaper, quicker and easier for healthcare professionals to work in the UK’. The unspoken acknowledgement in wealthier countries, such as across the OECD countries, is that foreign doctors and nurses are key assets for healthcare systems in many rich countries.
With the pandemic still ongoing, healthcare workers are becoming a precious resource as many have sadly passed away, lost their jobs, or left the industry due to burnout. Many wealthy countries, which have arguably mismanaged their pandemic response are in immediate need of more healthcare workers. In the US, it is reported that the healthcare sector has lost nearly half a million workers since February 2020. In March 2021, the International Council of Nurses released the results of a survey of its members, detailing how overstretched staff were as they experienced increasing psychological distress in the face of ever-increasing workloads, continued abuse and protests by anti-vaccinators during the pandemic. They warned that the pandemic risked damaging the nursing profession for generations to come unless governments took immediate action. Long-term impacts on the healthcare workforce are common after outbreaks and pandemics. In Sierra Leone, one-fifth of the entire healthcare workforce died during the 2014 Ebola outbreak. Today, Sierra Leone has fewer than one doctor for every 33,000 people.
With a global strain on health workers, there is a need to expand and train more students. In 2021, the UK’s Medical Schools Council showed that undergraduate medicine courses attracted a record number of applications for entry—an increase of nearly 21 per cent compared to applications for entry in 2020. However, this comes after almost a decade of austerity, cuts to public sector healthcare workforces, and the country’s longest-serving former healthcare minister, Jeremy Richard Hunt, not realizing how long it takes to train a nurse.
A HISTORY OF AFRICAN MEDICAL SCHOOLS
If Western nations fail to invest in the next generation of healthcare workers, what will the future of Africa’s healthcare workers look like? The migration of healthcare workers raises concerns for countries already experiencing various challenges in developing their healthcare workforce as it may further weaken already fragile healthcare systems. The World Health Organization had previously developed a code of practice on the ethical international recruitment of healthcare personnel. However, there are no binding agreements between countries on healthcare workforce, leaving the fate of the international flow of healthcare workers down to national demands rather than international equity.
We cannot talk of medical education in Africa without pointing to its colonial roots. With medical schools already set up in European colonies, they became training sites for African healthcare workers before independence. The emphasis was on training African medical assistants, nursing aides, and field assistants who worked under European doctors, to provide healthcare for European and African civil servants, military personnel, and their families.
In 1960, only 13 medical schools existed in Africa, including one in Nigeria and four in South Africa. After independence, with universities seen as an instrument to give strength, content, and direction to national life, African countries built more medical schools. In 1962, for example, Cameroon requested a WHO mission to advise the country on creating a medical school and went on to host the first WHO/AFRO conference on medical education in 1966. By 1980, there were at least 51 medical schools across Africa. Today, there exists an unequal picture of medical education across the continent despite wider ambitions to bolster African health systems. Africa holds only 1.3 per cent of the world’s healthcare workers while experiencing 25 per cent of the global burden of disease. There is an uphill battle to train more doctors and nurses: eleven countries in Africa lack even a single medical school, and 24 countries have only one medical school.
As such, a new vision of the future of healthcare training in Africa is needed. That future may be starting in Rwanda.
Since 2019, the University of Global Health Equity or ‘UGHE’, a global university based in Rwanda, has been training medical students under its Umusanzu programme. Umusanzu means ‘contribution’ in Kinyarwanda and is billed as a unique medical training programme where students are trained for free and sign an agreement to serve their local communities for a minimum of six years after graduating. This year’s cohort has 42 new recruits from Tanzania, Uganda, and Rwanda. Next year, the programme will be extended to Liberia, Sierra Leone, Malawi, and Lesotho. A central tenet of the programme is its admission of 70 per cent women, a deliberate attempt to increase the number of female doctors in the medical profession. Each student has signed an agreement, not with Rwanda but with their own government. When they graduate, they go back to their home countries and work for a minimum of six years in a public institution in the public sector.
‘The 21st century healthcare provider is a leader, a provider, a researcher, a lifelong learner, a community organizer, and advocate,’ Professor Abebe Bekele, dean of the medical faculty at UGHE, told me in an interview. ‘They feed forward to their own community,’ he added. The training students receive at UGHE is designed to be different from other medical schools; in addition to hospital-related activities they are expected to participate in building the foundation of the healthcare system. The programme will see its first class of doctors graduate in 2025. In that time, as part of the curriculum, students will complete modules in writing and communication, in real world problem solving through collaborations with neighbouring district hospitals, and in learning through community where students learn from community members and community health workers. ‘The plan is to prepare them to be the change agents needed in their own countries,’ Bekele said. UGHE concerns itself not just with training doctors but with training a new class of more rounded healthcare professionals. With 108 students so far in the programme and the first cohort due to graduate in 2025, their goal is to expand to include more and more students from other African countries.
A programme such as the UGHE one relies heavily on strong partnerships and understanding between the African countries that have signed up to the programme. The cohorts of the programme also represent African countries that believe the programme is a valuable way forward. Not only is the Umusanzu an agreement between student and their country, it is also an implied promise the country makes to safeguard the precious resource that is the final doctor. Doctors will emerge into fragile and weak health systems that they cannot strengthen on their own. That will also need strong government leadership to make sure every doctor has the enabling environment to succeed. How each individual government fulfils that tacit promise remains to be seen. This is often challenging for any government. South Africa, for instance, produces more doctors than its public sector can effectively manage. Doctor shortages are common in rural hospitals and clinics because the government often does not have enough money to employ those emerging from its medical schools.
As with all things covering health provision on the continent, questions remain over the long-term sustainability of the programme in Rwanda. Currently, the programme relies on, not only government support, but also charitable donations from international funders. This allows every student on the programme to receive 100 per cent financial aid ensuring that financial capacity is not a barrier to medical education. The landscape of health progress on the African continent is paved with the remains of programmes from international funders where the funding has long since expired. The Rwandan programme hopes to avoid this fate since the programme has strong support from the Rwandan government. An ideal situation, however, would be for other African governments to prioritize public funding of their public institutions, healthcare especially.
PUTTING HEALTH FIRST
While Rwanda’s programme is one example of the ways in which African nations are trying to stem the global imbalance of the healthcare workforce, such a programme is only the first step. Some African countries cannot afford to absorb all health workers produced back into their health systems, a paradox of unemployment amidst shortages in the health system. African governments themselves will therefore need to provide and/or enable wider and more sustained investment in their health systems. In 2015, the African region had an average of 1.3 health workers per 1000 population, far below the 4.5 per 1000 required to achieve the Sustainable Development Goals. Increased training alone won’t be enough to bridge the gap. Better incentives to retain staff and attract workers from the diaspora are equally necessary.
In 2001, African countries signed the Abuja Declaration, committing 15 per cent of their annual budgets on their healthcare sectors. By 2011, only Rwanda and South Africa had reached that target. In 2016, 19 African countries were spending less on healthcare as a percentage of their public spending than in the early 2000s. Arguably, the Abuja Declaration has a long road ahead if countries will be able to reach their target. In the face of external donor funding and economic downturns, the issue is not as simple as reaching the target. As always, more political will needs to drive a culture of putting health first. Only then can a sustainable healthcare workforce be created across the continent⎈
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