Lawmakers in Nigeria are discussing a bill that could stop physicians from emigrating directly after graduating from university. By prolonging the doctors’ licensing process for five years, it would be possible to address the chronic shortage of health workers the country is facing—or at least that’s what one part of the House of Representatives hopes.
Nigeria has recorded startling rates of health workers’ emigration. In the last eight years, 5,600 physicians have left the country for the United Kingdom alone. Baba Aye, Health and Social Sector Officer at Public Services International (PSI), estimates that at one point, there was a daily average of 50 doctors leaving Nigeria. The intensity of the emigration has weakened the system and pushed health care away from the reach of patients.
Not long before the discussion in Nigeria caused an uproar of discontent among physicians’ professional associations, the World Health Organization (WHO) issued an updated version of the Health Workforce Support and Safeguards List. Among the 55 countries singled out as most precarious in terms of health workforce, 37—or 40, counting Djibouti, Somalia, and Sudan, which are officially members of the WHO’s Eastern Mediterranean regional office—are in the African region. Nigeria is, unsurprisingly, on the list.
WHO’s health workforce mechanisms lack teeth
The list is one of the instruments for the implementation of the WHO Global Code of Practice on International Recruitment of Health Personnel, a mechanism that in theory should rein in high-income countries’ tendencies to resolve their own health workforce shortages by recruiting health workers from the Global South. In practice, this hasn’t been the case.
For example, although Nigeria was on the 2020 version of the WHO Support and Safeguards List, the UK did not stop recruiting physicians and other health workers originating from there. They did announce they would stop proactively recruiting from countries on WHO’s list—just as they did this time—but the UK effectively continued to rely on the import of health workers to mitigate its own staff shortage. During the time when the UK was formally not proactively recruiting from Nigeria, the count of Nigerian-trained doctors practicing in Britain passed 11,000. That makes them the third-largest group of international medical recruits in the UK, right behind doctors from India and Pakistan.
The WHO’s members are not bound to abide by the Global Code. Rather, the rather optimistic expectation is that what is written in the Code will inspire recruiting countries to approach the process in a spirit of solidarity, respecting the needs of countries in the Global South. In reality, high-income countries tend to work around the meek limitations, putting their needs over everyone else’s.
Corinne Hinlopen, Global Health Policy Researcher at Wemos, points out that some countries from the Global South might prefer to be off the list despite their own staffing needs. It is somewhat easier to deal with locally trained health workers being employed abroad than facing their unemployment at home. This is the case with the Philippines and Indonesia, for example, from where many migrant health workers originate.
Baba Aye echoes Hinlopen’s considerations on the bizarre situation faced by many low-income countries, where large numbers of health workers are unemployed and staff shortages abound, but there is no capacity to absorb workers in workplaces. According to him, this has to be looked at in the context of structural adjustment programs forced on many countries in Africa, the debt burden they are shouldering, and the illicit financial flows which strip them of any chance for building strong public health systems. “Policies imposed by the International Monetary Fund, for example, limit the space for local employment and improvement of working conditions. This means less health workers are present when outbreaks of Ebola or other diseases happen, and then the people pay the price,” he says.
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Hinlopen and Aye agree that WHO health workforce mechanisms have been of some use until now, although they are definitely not enough to provide a clear break from the current problems. “Ideally, the WHO would do more. But in practice, they have very little space for maneuvering, as they try to introduce changes without rubbing too many member states the wrong way. Many members of the WHO would prefer not to see the organization going down this road,” says Hinlopen.
Concrete solutions to extreme staff shortages like the one faced by Nigeria will, therefore, depend on steps taken by governments both in the Global South and in the Global North. The need remains for high-income countries to acknowledge their role in bleeding out the South’s essential workforce. This acknowledgment should go beyond formalities. Governments in the Global South should be granted the space to actually develop their health systems instead of resorting to emigration bans. “That means addressing the debt load, stopping illicit financial flows, and creating better jobs in health care, adequately paid jobs. There is no alternative to building quality public health care delivery,” says Baba Aye.
People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here
