Southern Africa’s public health services are in a state of emergency. Bad pay and working conditions, plus the impact of HIV/Aids, are bleeding the system of its most valuable resource: people. With the cost of training a general practice doctor estimated to be $60Â 000, and that of training a medical auxiliary at $12Â 000, the African Union estimates that low-income countries subsidise high-income countries to the tune of $500million a year through the loss of their health workers.
Since 2000 in Malawi, more than 100 nurses have applied each year for registration to work abroad. Others have gone abroad without paperwork, and more still have left to work in private clinics or for NGOs in Malawi. With 28,6 nurses per 100Â 000 people, the country has one of the worst nurse-to-patient ratios in Africa. In Zimbabwe, Botswana, South Africa, Namibia and Zambia nurses are moving out at a similar rate.
“We have become a training ground for other countries,” said Martin Mwalukanga, clinical officer in charge at the Ngwerere rural health centre. “If I was given the chance to work overseas where I would be adequately remunerated, then I would definitely go.”
Not all head north. Namibia imports nurses from Kenya, and South Africa draws large numbers of healthcare workers from the region.
African governments are doing what they can to plug the exodus. In Malawi, for example, the Ministry of Health has designed a $278million “emergency human resources programme”. It includes a salary “top-up” of 50% for essential health staff, supported by funds from the British government, and the provision of emergency “stop-gap” volunteer doctors and nurse tutors from overseas.
In Zambia, medical personnel working in rural areas get a hardship allowance — although Alex Mulala, a clinical officer at the Chipapa rural health clinic, says even with the allowance the salary is “a mockery”. He adds: “The government knows that the money we are getting is peanuts. It can’t see you from month-end to month-end.”
In May this year, the Jesuit College for Theological Reflection in Lusaka calculated that the monthly cost of basic needs for a family of six to survive is 1,4million kwacha ($410). An average nurse’s salary is 1,2million kwacha ($351).
But salaries are not everything, said Ibrahim Idana, director of the Queen Elizabeth Central Hospital in Blantyre, Malawi. “The most obvious reason for leaving is that their remuneration is not big enough. They’re told, ‘Don’t worry, you’ll get retirement packages.’ Malawian life expectancy is 37, but the retirement age is 65 — who’s going to live to be 65? People want to live a happy life now.”
In the meantime, northern countries continue to proactively recruit health workers from poor countries to prop up their own public services. One in four doctors in Canada and the United States is from overseas. And while the British government spends millions to top up health worker’s salaries in Malawi, it simultaneously recruits nearly one-third of its doctors from overseas — many from Malawi and other English-speaking African countries.
HIV/Aids redoubles the challenge. Africa is likely to lose 20% of its health workers to the disease in the coming years, with those remaining facing increasing workloads and stress. This undermines efforts to expand the provision of anti-retroviral treatment to people living with HIV and Aids. “As much as we want to scale up, there are no bodies,” said Biswick Mwale, head of Malawi’s National Aids Commission. “People can’t translate money into action when there are no people.”
Caroline Hooper-Box is the media coordinator for Oxfam in Southern Africa. Additional reporting by Helen Palmer and Nicky Wimble