The Critical Shortage of Healthcare Workers in Sub-Saharan Africa: A Comprehensive Review

Abstract
The critical shortage of healthcare workers in sub-Saharan Africa is one of the largest obstacles faced by public health systems in the modern age. This crisis affects almost every facet of public health within the region, including child and adult mortality, maternal health, and treatment of diseases and infections. While several countries have made efforts to address this shortage of medical personnel, mainly through international policy implementations and regional programs, the complexity and scope of this issue makes it extremely difficult to resolve. For the public health systems within sub-Saharan Africa to advance and meet the needs of all citizens, the shortage of healthcare workers needs to be appropriately addressed. This paper presents an in-depth review of the crisis in human resources for healthcare within sub-Saharan Africa by considering the contributing factors, possible implications, and strategies that can be used to address the crisis.
Introduction
Sub-Saharan Africa is the region of Africa that lies south of the Saharan Desert.¹ This area possesses one of the weakest public health systems in the world. Not only are rates of disease and mortality extremely high in sub-Saharan Africa, but a large fraction of the population also lacks access to basic healthcare services.²
The poor quality of healthcare in sub-Saharan Africa is related, in large part, to its critical shortage of healthcare workers. This region lacks an adequate number of doctors, nurses, midwives, laboratory professionals and community healthcare workers.³ This deficit of human resources for healthcare has characterised sub-Saharan Africa throughout history. It persists in the present day because of factors such as a lack of medical graduates,⁴ outbreaks of diseases and infections,⁵ and the emigration of healthcare workers.⁶ 
The shortage of healthcare workers affects almost every facet of public health in sub-Saharan Africa, including child and adult mortality, the quality of maternal healthcare and the treatment of human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS). While many of these public health problems, such as the maternal mortality rate, have been alleviated in recent years, progress continues to be limited by a lack of human resources for healthcare.⁷
Possible strategies to combat this crisis include various task-shifting approaches along with policy changes on the national and international levels. People can also browse this site for the best health care information. The implementation of these strategies will allow countries in sub-Saharan Africa to decrease and eventually eliminate their shortage of healthcare workers, leading to an overall improvement in public health within the region.
The crisis of human resources for healthcare in sub-Saharan Africa is one of the most complex global issues of the modern age. As such, the topic is presented here through a broad lens to provide an overview of all the major elements in play. This paper analyses the current situation in sub-Saharan Africa along with the factors contributing to and implications of the healthcare worker shortage. This review also considers strategies that can be used to address the crisis and discusses the future outlook for the healthcare worker shortage in sub-Saharan Africa.
Present Situation
Numerous public health systems across the world are currently facing a critical shortage of healthcare workers. According to statistics from the World Health Organisation (WHO), there is a growing deficit of approximately 4.3 million workers, including doctors, nurses and midwives, in the global healthcare workforce.³ This shortage of medical personnel is distributed among 57 countries and is present in almost every region of the world.³
However, nowhere is this deficit of human resources for healthcare more severe than in sub-Saharan Africa, where the ratio of healthcare workers to the population is the lowest worldwide.³ As shown in Table 1, 46 out of the 47 countries within this region have significantly less than 2.28 physicians or nurses per 1,000 people, which is widely regarded as the minimum threshold required to deliver basic health services.³ This region of the world also carries nearly 24% of the world’s disease burden while containing only 3% of its healthcare workforce and only 1% of its financial resources for healthcare.⁸

Table 1: List of countries in sub-Saharan Africa and the density of physicians and nurses in their populations.^9,10
Not reflected in the lack of medical personnel on the national level is the uneven distribution of healthcare workers between urban and rural areas within sub-Saharan Africa.³ This issue is most pronounced in Sudan, where the doctor to population ratio is approximately 20 times higher in urban areas than in rural ones;¹¹ across the entire region of sub-Saharan Africa, only 25% of the doctors and 40% of the nurses are based in rural areas, while approximately 45% of the population resides there.³
From the present data, it can be concluded that there is a severe lack of medical personnel within sub-Saharan Africa. This, in conjunction with the unequal distribution of healthcare workers between urban and rural areas, is a substantial impediment to public health within the region.
Contributing Factors
The critical shortage of human resources for healthcare in sub-Saharan Africa is an incredibly complex issue influenced by numerous political, environmental and social forces. However, by analysing data from individual countries and across the region, the greatest contributing factors can be identified as the emigration of healthcare workers, the effects of diseases and infections and the scarcity of medical graduates.
Emigration of Healthcare Workers
Throughout history and in the modern day, healthcare workers have been emigrating from lower-income countries in sub-Saharan African to higher-income countries within North America and Europe.⁶ This pattern of emigration has decimated the medical workforce in several areas. For instance, 70% and 75% of the physicians originally from Angola and Mozambique, respectively, are currently practising abroad.¹² In total, approximately 65,000 doctors and 70,000 nurses from sub-Saharan Africa, which is equal to approximately 28% of the region’s medical workforce, are working internationally.¹²
The outward flow of healthcare workers from sub-Saharan Africa is related to several push and pull factors. The push factors identified by emigrant healthcare workers include low salaries, poor working environments, underfunded healthcare facilities and the lack of opportunities for career advancement.¹³ Furthermore, there is a strong correlation between political instability in a country and its loss of medical personnel.¹² The pull factors for emigration include higher salaries, better healthcare facilities and more opportunities for career advancement.¹⁴ To limit the emigration of healthcare workers from sub-Saharan Africa, it is necessary to minimise the influence of both the push and pull factors.

Table 2: Summary of the push and pull factors for the emigration for healthcare workers from sub-Saharan Africa.^3,12-14
Diseases and Infections
The spread of diseases and infections has directly led to the loss of a significant number of medical workers in sub-Saharan Africa. It is estimated that, since its emergence, HIV/AIDS has caused the healthcare workforce of sub-Saharan Africa to decrease by as much as 20%.¹⁵ More recently, the Ebola crisis decimated the medical workforce of Liberia and Sierra Leone, decreasing the number of doctors by 7% and the number of nurses and midwives by 8%.¹⁶
These significant decreases are mostly observed among frontline workers controlling the spread of disease.⁵ These workers incur the greatest numbers of occupational hazards, such as working with diseased patients and handling infected items.
Lack of Medical Graduates
One of the root causes of the crisis in the human resources for healthcare in sub-Saharan Africa is the scarcity of medical graduates. It is estimated that, on a yearly basis, only 10,000 to 11,000 medical students graduate from the region.⁴ This substantially low number is directly tied to the shortage of medical schools. In total, sub-Saharan Africa contains only 87 medical schools, with an average of 1.8 medical schools per country.⁴ This statistic includes 11 countries that have no medical training facilities at all and 24 with only one such institution.⁴
Moreover, the medical schools that are present in sub-Saharan Africa often lack access to essential resources. For example, a study conducted in 2010 found that a university in Ethiopia had no reliable sources of power, water and telecommunications.⁴ Other medical schools across the region faced shortages of technological equipment and proper student housing.⁴
Implications of the Shortage
The lack of adequate human resources for healthcare has negative impacts on almost every facet of public health in sub-Saharan Africa. Not only does this shortage lead to an overall increase in mortality rates, but it also has an adverse effect on maternal health and the treatment of HIV/AIDS within the region.
Adult and Child Mortality
Mortality rates in the general population of sub-Saharan Africa are among the highest in the world. A male between the ages of 15 and 60 within this region has a 39.1% probability of death, while a female in the same age range has a probability of 33.2%.¹⁷ Similar statistics describe child mortality; the United Nations Children’s Fund (UNICEF) estimated in 2015 that a child born within sub-Saharan Africa has an 8.1% probability of death before the age of five.¹⁸
The extremely high rates of mortality in sub-Saharan Africa are strongly linked to the lack of healthcare workers within the region. Figure 1 shows the density of physicians within individual countries of sub-Saharan Africa compared to the mortality rate of children under the age of five in each country.^9,19 A linear increase in the density of physicians is correlated with an exponential decrease in the mortality rate of children under age five. WHO establishes a similar correlation in its 2006 World Health Report.³
Figure 1: Mortality rates of children under age five compared to the density of physicians in the population. Each point represents data from an individual country within sub-Saharan Africa.^9,19
One possible explanation for the correlation between the healthcare worker density and child mortality rates within sub-Saharan Africa is that the low number of healthcare workers reduces the availability of basic health services, such as vaccinations and antibacterial treatments. Sick children may be unable to access treatments and, as a result, may die of preventable causes. This interpretation is supported by the fact that the majority of the world’s child deaths, and a significant fraction of its adult deaths, are preventable and simply due to a lack of treatment.²⁰ Furthermore, several public health systems in sub-Saharan Africa claim to have closed their treatment centres because they lacked sufficient staff.²¹
Maternal Health
The quality of maternal healthcare within sub-Saharan Africa is the lowest of any UNICEF-defined region in the world.²² It is estimated that 546 out of every 100,000 live births in sub-Saharan Africa result in maternal death.²² This number accounts for 60% of the total maternal mortality within the region, with the other 40% occurring in the period of time immediately after childbirth.²
Much like child mortality, maternal mortality also exhibits a correlation with healthcare worker density. Figure 2 shows the maternal mortality rate compared to the physician density in each country.^7,9 As the physician density increases linearly, the maternal mortality rate decreases exponentially. The same correlation has been found by additional studies conducted across several countries in sub-Saharan Africa.²³
Similarly, studies have found that an increase in the number of deliveries with health professionals present is associated with a decrease in maternal mortality rates.²⁴ However, due to the low number of healthcare workers in sub-Saharan Africa, doctors, nurses and midwives are frequently unavailable at the time of childbirth.²⁵ This is the case in several countries that have an extremely high maternal mortality rate, such as Ghana, where there is a vacancy rate of 57% for the relevant professions.²⁵
Figure 2: Maternal mortality rates compared to the density of physicians in the population. Each point represents data from an individual country within sub-Saharan Africa.^7,9
HIV/AIDS Treatment
HIV/AIDS continues to be one of the most pressing public health issues in sub-Saharan Africa. In 2016, approximately 24 million individuals were living with HIV/AIDS in this region of the world.²⁶ In some countries, such as Botswana and Swaziland, HIV/AIDS patients represent more than 25% of the adult population.²⁷ The issue is exacerbated by the low rates of treatment for this disease; only 54% of the individuals living with HIV/AIDS in sub-Saharan Africa are receiving antiretroviral therapy.²⁸ Figure 3 illustrates the antiretroviral therapy coverage across individual countries in the region.^9,28
Figure 3: Percentage of people with HIV/AIDS receiving antiretroviral therapy in individual countries of sub-Saharan Africa.^9,28
Antiretroviral therapy coverage is also linked to the density of healthcare workers. The countries with the lowest coverage rates, such as Somalia and the Central African Republic, also have the lowest density of healthcare workers.^9,28 Many of these areas have tried to increase their rates of coverage by implementing HIV/AIDS treatment programs.²⁹ However, several of these initiatives have failed due to a lack of resources.²⁹ In fact, many sub-Saharan African countries, like Rwanda, would require an increase in their healthcare workforce by as much as 50% to administer antiretroviral therapy on a national scale.³⁰
Strategies to Address the Crisis
The crisis in the human resources for healthcare in sub-Saharan Africa is an extremely multifaceted issue; it is as much of a medical problem as it is social and political. As such, the crisis can only be fully addressed via a variety of short and long-term strategies on the regional, national and international levels.
Task-Shifting Strategies
Short-term strategies that require minimal resources will likely be the most effective. Ideally, these strategies will be available to all types of public health facilities and will involve no delay prior to implementation. One approach that fulfils these criteria is task shifting.
Task shifting is the transfer of responsibilities from a healthcare worker with a high level of training, such as a physician or surgeon, to a healthcare worker with a lower level of training, such as a nurse or community healthcare worker.³¹ This approach allows staff with less training to complete tasks that otherwise would have been left unfulfilled due to a shortage of staff with more training. This strategy is highly effective in areas where there are significantly more nurses than doctors, like sub-Saharan Africa.³²
Many parts of sub-Saharan Africa have already implemented task-shifting strategies with overwhelming success.³³ For example, in 2004, Malawi began allowing nurses and other healthcare workers to administer antiretroviral therapy, which had previously been provided exclusively by doctors.³³ As a result, approximately 130,000 more patients in that country received antiretroviral therapy in each of the following years. Other studies performed on task-shifting strategies in sub-Saharan Africa have concluded that this approach generally improves health outcomes.³⁴
However, while task-shifting strategies have certainly shown promise, they do have some shortcomings. Most importantly, when a healthcare worker of a lower skill level performs a more demanding task, the quality of the healthcare may decrease. Therefore, task-shifting strategies should not be considered a panacea and must be used in conjunction with other techniques to combat the healthcare crisis in sub-Saharan Africa.
Mobile Workforces
One of the best ways to minimise the adverse impacts of disease and infection outbreaks within sub-Saharan Africa is through the use of a mobile workforce. WHO defines a mobile workforce as a group of doctors, nurses and other healthcare workers of varying skill and training levels that travels to locations in dire need of additional health resources.³ A mobile workforce implemented nationally and internationally within sub-Saharan Africa has the potential to significantly slow the spread of diseases and infections.
However, to prepare for the implementation of this strategy, a variety of tasks must be performed. First, a region or country must gather the healthcare workforce that will constitute its mobile unit. This will require substantial financial investments from public organisations. A successful mobile workforce requires the establishment of adequate support and resources for the frontline workers.³ Last, the ability to easily travel among sectors or districts must be provided to the mobile unit through both the proper means of transportation and the legal freedom of movement.
Policies to Minimise Emigration
To truly overcome the crisis in the human resources for healthcare in sub-Saharan Africa, the emigration of healthcare workers from this region must be minimised. One of the best ways to do so is through large-scale policy implementation. An example of this is the WHO Global Code of Practice on the International Recruitment of Health Personnel, which serves as a policy framework for the ethical recruitment of medical professionals.^6,35 Its main purpose is to address the healthcare worker shortage on the international level. However, compliance with this policy is voluntary, so its actual impact on the healthcare crisis in sub-Saharan Africa is questionable.
To effectively minimise the emigration of healthcare workers, governments must ensure that compliance with the relevant policies is obligatory. A mandatory tax on international healthcare recruitment, for example, can be instated to reduce the loss of medical personnel from sub-Saharan Africa.
Governments can also improve the local working conditions for healthcare professionals to discourage emigration. This can be done through providing incentive programmes for certain fields of medicine or extra funding for private or rural clinics. Such a programme has already been implemented in Mali and has successfully increased the country’s retention of healthcare workers.¹¹ If this type of project can be duplicated by other nations in sub-Saharan Africa, the emigration of healthcare workers from this region will be limited significantly.
Increasing the Current Workforce
Along with limiting the loss of their existing healthcare professionals, countries within sub-Saharan Africa must significantly increase their future healthcare workforce. One of the best ways to encourage people to enter health-related professions is through targeting the field of education. National governments can increase the amount of financial assistance they provide to students entering health-related post-secondary programmes. Additionally, medical school entrance requirements can be relaxed to open this professional pathway to a greater number of students.
Outside of the education industry, governments can increase the retirement age for physicians and other medical personnel. In Ghana, the extension of the retirement age for doctors and nurses from 60 to 65 prompted close to two-thirds of the retired doctors and nurses to re-enter the workforce.⁸
Future Outlook
The future of public health in sub-Saharan Africa largely depends on the number of healthcare workers present within the region in the coming years. While there has been a significant deficit in this sector of the workforce throughout history, the ratio of healthcare workers to the population has gradually begun to increase in the past decade.¹⁰ As shown in Figure 4, a yearly increase in the density of physicians in the population has been observed in 24 of the countries within sub-Saharan Africa.¹⁰ However, the average increase was only 0.01 physicians per 1,000 people.¹⁰ Furthermore, 13 countries have experienced a decline in this ratio,¹⁰ indicating that improvements in some areas may be occurring at the expense of other areas.
Figure 4: Yearly change in physician to population ratios within individual countries in sub-Saharan Africa.^9,10
Diseases and infections are also predicted to have a significantly negative influence on the future of public health within sub-Saharan Africa; research has shown that occurrences of disease epidemics are on the rise.³⁶ This increase has generally been linked to globalisation and the growing prevalence of antibiotic-resistant bacteria.³⁶
In spite of the critical, and in many cases worsening, healthcare situation in sub-Saharan Africa, there has been a minimal response to this crisis from the internal community. Additionally, very few international policy frameworks have been created to address this shortage of healthcare personnel, and the guidelines that have been released, such as the WHO Global Code of Practice, have had a negligible impact because of their voluntary nature. As a result, many countries, such as the United Kingdom, have continued to recruit doctors, nurses and midwives from sub-Saharan Africa at a constant or increasing rate.¹³
In summary, the number of healthcare workers available for a given population size seems to be gradually increasing in some regions of sub-Saharan Africa. However, the growing threat of disease outbreaks and the minimal international response to the crisis create an uncertain future for public health in the region. If the proper regional, national and international strategies are used during the coming years, countries within sub-Saharan Africa may be able to effectively handle and eventually eliminate their critical shortage of healthcare workers. However, without immediate international involvement in the development and implementation of these strategies, the population of sub-Saharan Africa will continue to suffer from a lack of basic healthcare.
Conclusion
The critical shortage of healthcare workers within sub-Saharan Africa is one of the most pressing and complex global issues of the modern age. This multifaceted crisis stems from the interaction of several political, environmental and social forces on the national and international levels and has far-reaching effects, weakening public health systems and reducing people’s quality of life throughout sub-Saharan Africa. Several strategies can be used within individual countries and across the entire region to combat this shortage of healthcare workers. International policies can also be created to address the global factors responsible for this deficit of medical personnel. These actions will allow sub-Saharan Africa to increase its healthcare workforce, leading to better health outcomes and quality of life throughout the region. This, in turn, will help promote the social, political and economic advancement of sub-Saharan Africa.
Key Words:
Sub-Saharan Africa: The geographic region of Africa consisting of the 47 different countries located south of the Sahara Desert^1,9
Public health systems: All public or private organisations that contribute to providing healthcare to the general population³⁷
Human resources for healthcare: The human workforce employed by the healthcare industry, which includes doctors, nurses, midwives, laboratory professionals and community healthcare workers
Global disease burden: The measure of the negative impact of a disease on the general population of a specified region³⁸
Mortality rate: The number of deaths normalised to the population of a certain region
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Cover image source: American Public Media.
About the Author
Saud Haseeb, Canada
Saud Haseeb is a Grade 12 student at Moira Secondary School in Ontario, Canada. His interests include activities such as photography, computer programming and student leadership. However, Saud’s true passion lies in scientific research. He enjoys reading scientific literature and conducting science experiments, and hopes to participate in medical research in the future.