Migration of Nurses from Sub-Saharan Africa: A Review of Issues and Challenges

This paper was commissioned by AcademyHealth to “identify and review reports, documents and data relating to nursing workforce dynamics” in sub-Saharan Africa (SSA) with the objective of analyzing, synthesizing, and presenting key information on nurse migration in the region. It reviews trends and impact of nurse migration derived from previously published work by various groups including the Joint Learning Initiative on Human Resources for Health (JLI), the WHO Africa Region (AFRO) report on Migration, International Council of Nurses (ICN) Global Nursing Review Initiative, and reports to the High Level Forum (HLF) on the millennium development goals (MDGs) on the human resources crisis. SSA faces a crisis with human resources for health. The WHO has estimated that though SSA has 25 percent of the world's diseases burden, it possesses only 1.3 percent of the trained health workforce (WHO 2004a, b, c). This situation is linked to an emerging health crisis—for example, it has been reported that life expectancy fell in 17 of the 48 SSA countries due to rising incidence of communicable diseases and the impact of HIV/AIDS (Sanders et al. 2003). It is almost a certainty that health-related MDGs will not be met, and workforce shortages will be a factor in missing these targets. In 2004, a report by the JLI further confirmed the conventional wisdom that availability of trained health workers influences the attainment of health goals and found, for example, that maternal mortality responded best to increases in availability of trained service providers (JLI Report 2004). In relation to shortages, the migration of nurses and other health professionals to developed countries is considered a major contributor to the health crises in SSA. This paper reviews the available information on trends and impact in nurse migration from SSA. This review assessed published and unpublished literature on the nursing workforce situation in SSA. Meeting reports and semiformal publications were solicited from country sources and collated where available. Documents were scanned for relevant information and data on migration, stock and flows, management systems, and contextual issues affecting the nursing workforce; the recommendations and conclusions reached in previous reports were also assessed. One critical finding was that few of the papers reviewed were based on primary quantitative data. This paper attempts to extract relevant content material from these previous studies. “Push and pull” factors encouraging nurses to migrate have been discussed extensively in some of the papers reviewed for this paper (e.g., Dovlo 1999; Meeus 2003; Padarath et al. 2003). These provide a helpful frame in which to assess the overall impact of various factors on trends in migration of nurses. Push factors are influences that arise from within the source country and facilitate a potential migrant's decision to leave. Pull factors reflect actions and omissions of recipient countries that create the demand for, or encourage potential migrants to leave home (CRHCS 2003; Dovlo and Martineau 2004). These factors cover a broad range of issues including income (or remuneration) levels between source and destination countries; job satisfaction and perceptions of the work environment and ability to utilize one's professional skills; the organizational environment and career opportunities as well as workers' perceptions of trust in the management of health services; general political and administrative governance; encompassing bureaucratic efficiency and fairness; occupational risk and protection because of HIV/AIDS and poor availability of protective gear; and the welfare, security, and benefits of health professionals during employment and after retirement. Padarath et al. also suggest that “pushes” exist in both source and recipient countries, but are mitigated by “stick” factors in source countries and “stay” factors in destination countries. “Stick” factors include family ties, psycho-social links, and the potential cost to be incurred to migrate, while “stay” issues include reluctance to disrupt family life and children's schooling, lack of employment opportunities at home, and the higher standards of living enjoyed in the recipient country (Padarath et al. 2003). It should also be noted that one difference between health professions found in migration in SSA countries is that while doctors are usually passively recruited (i.e., look for the jobs for themselves), nurses are usually actively recruited by agents, sometimes for a fee (Dovlo 2006; Mensah, Mackintosh, and Henry 2005)—the role of recruitment agencies is now in itself a significant pull.