Where Have All the Doctors Gone, and Where Are All the Nurses?

The statistics are nothing to sing about. While Africa has nearly one-fifth of the world’s population and assumes 24% of the global disease burden, African health systems operate with a mere 3% of the world’s health workforce.^[1] With only 3.1 physicians for every 10,000 people in Africa (compared to 26.54 in the United States, 40 in Europe, and 85.05 in Cuba),^[2],[3] the continent continues to experience a systemic hemorrhage of a critical human resource: healers who save the lives of their people. As the World Health Organization projects a global deficit of 18 million health workers by 2030^[4] with the shortfall concentrated in Africa and Southeast Asia, the question, where have all the doctors gone, and where are all the nurses is not just a query of global health systems logistics, but a demand for health justice and for the survival, even the thriving, of Africans.

From the 1980s onwards, Structural Adjustment Programs (SAPs) mandated by the World Bank and the International Monetary Fund (IMF) catalyzed a decline in healthcare delivery in African countries by shifting healthcare from a social contract to a market-based commodity. SAPs manifested as deep cuts to public expenditures to ensure debt repayment, and their mandated reforms, particularly labor market deregulation, led to fewer public health resources.^[5] The 1981 World Bank’s Berg Report argued that the public provision of healthcare was unsustainable in Africa, and aligned health aid with these broad structural adjustments.^[6] The report shifted African health systems toward economic efficiency through cost-recovery mechanisms such as health insurance and user fees, and emphasized decentralized and privatized health services to reduce public sector burdens. Globally, between 1990 and 2017, IMF programs were associated with more than 70 additional deaths from respiratory illnesses and tuberculosis per 100,000 people, and privatization mandates resulted in over 90 excess deaths per 100,000 people.^[7] In the African region, structural adjustment was associated with an additional 85.62 child deaths per 1,000 children and 360 maternal deaths per 100,000 live births.^[8] For example, from 1986 to 2010, Kenya experienced an additional 305,000 infant deaths, as compared with earlier mortality rates.^[9] Beyond its impact on healthcare receivers, in countries like Kenya, SAP policies have been related to the exodus of doctors and nurses, as they mandated freezing public health sector recruitments and mandatory staff retrenchments.^[10]

In this sense, the migration of trained health professionals out of Africa is related to coercive socioeconomic push and pull factors. In many African countries, medical professionals struggle with poor infrastructures, chronic underfunding, lack of essential medicines, and stagnant wages.^[11] Many African countries have also experienced severe economic crises, hyperinflation and budget deficits;^[12] and civil unrest, armed conflict,^[13] and political instability^[14] - the good governance trope^[15]- which pushes professionals to migrate. These push factors are met with the pull of higher income countries like the UK, US, Australia and Canada. Experiencing their own aging populations, labor shortages, and escalating healthcare costs, high-income countries attract health professionals from Africa (and other Global South regions) with offers of competitive salaries, advanced research opportunities, and higher living standards.^[16],[17] The missing African doctors and nurses have not mysteriously vanished; they have followed the path of better opportunities. 

While the brain drain is an extreme extractive crisis, some economists reframe it as brain circulation, suggesting that countries that export health workers reap some health dividends and other strategic rewards. Among these rewards are financial remittances, the billions of dollars sent home by migrant workers that often exceed foreign direct investment and official development assistance, and provide a direct lifeline to families and local economies.^[18] According to neoliberal labor market logics, migration can serve as a safety valve for countries struggling with high domestic unemployment; it creates jobs, increases household income, and reduces poverty through remittances.^[19] Further, health professionals who return home often bring back specialized clinical and administrative skills that are limited in their home countries, and health workers who remain abroad often form research collaborations, scientific networks which facilitate the transfer of technology, and social remittances in the form of new medical knowledge and practices.^[20]

Such rationalities still fail to explain the efficiency of these labor extractions. Individual migration should be a rational choice and a guaranteed human right; however, Africa effectively subsidizes the health systems of the Global North, training professionals at great domestic expense only to see them migrate. Their exodus creates a feedback loop in which Africans are denied the right to basic healthcare, while those in the Global North are guaranteed a pool of skilled labor with or without necessary local investments. In Ghana, structural shortages of health workers are caused by limited public sector funding for hiring, which links their migration to poor health system impacts, such as low nurse-to-patient ratios.^[21] The shortage of health professionals in Africa directly erodes health outcomes: essential health services are not provided, preventable diseases are not treated, maternal and child mortality rates remain high, and the capacity to manage pandemics, already weakened by failed market-designed vaccine allocations, collapses. Thus, the active international recruitment of health workers is discouraged in 27 African countries which face pressing shortages of health workers.^[22]                                 

Remittance-led development models, framed as efficient labor market matches, fail when applied to healthcare in developing regions because the human capital loss from the shortage of doctors cannot be compensated for with financial capital. Beyond the clinic, the migration of health workers out of Africa diminishes economic development. The geopolitical landscape of 2025 and 2026 has further intensified the African health workforce crisis, as global instabilities shift critical resources away from public health and toward military and economic survival. Israel’s military actions in Gaza, which constituted genocide,^[23] has not only destroyed Palestinian health infrastructure, but also forced a reallocation of international humanitarian aid, further thinning the scarce resources available for long-term health system strengthening in Africa and other regions. Similarly, the war in Iran^[24] has directly impacted Africa by disrupting fuel supplies and driving up prices for food and essential medicines. This is at the same time that global currency norms are shifting as structural pressures intensify against the petrodollar system and as countries increasingly explore non-dollar oil transactions.^[25] The Trump administration’s maximum pressure campaign against Iran and its support for Israeli operations have prioritized military escalation over global health diplomacy. Its focus on global dominance is at the expense of U.S. commitments to global health security. The efforts of the U.S. to block Cuba’s revenues from medical missions further threaten sovereign health decisions and global cooperation.^[26] The dismantling of these missions further demonstrates the coercive manipulation of the global health market (it is not a free market). The current U.S. policy framework largely views Africa as a strategic site for health, mineral and data extraction, and for military positioning. Ultimately, the geopolitical uncertainties of ongoing pandemic recovery, active genocide, and the grinding war in Iran have undermined global health security. Their economic and human costs ensure that African health systems remain under-resourced, making the pull of the West’s relatively stable (albeit increasingly expensive) health markets irresistible.

The migration of health workers out of Africa to high-income countries and the resulting shortages in health workers in Africa are expected to increase.^[27] This migration shows that toy market design models work perfectly in abstraction or in vacuums, but in reality, they result in health market failures. While liberal economists focus on optimizing matching markets for internal efficiency,^[28] brain drain highlights global systemic failures that the market design framework does not address. For example, the U.S. physician residency match improved the market for American physicians by creating stable, efficient outcomes for individuals and hospitals.^[29] At the same time, the global scaling of this market design, which matches physicians from the Global South to American hospitals, facilitates the extraction of physicians from impoverished countries to rich ones; it is stable in the U.S. because it imposes systemic leakages in developing regions. While the market can be efficient in matching a physician to a high-paying U.S. hospital, it is simultaneously catastrophic for the health system the physician left behind. Thus, the brain drain highlights a form of market recruitment mechanism that can be considered as a continuation of historical extraction or neo-colonialism.

Voluntary consent is a critical assumption of matching markets theories,^[30] but consent in global physician matches is illusory. If the push factors are sufficiently severe, the choice to migrate is not an economic preference; it is a coerced response to market failure at home. A match based on coerced preferences is inherently unstable because it reflects a crisis; the African doctor crisis demonstrates that consent is coerced by systemic failures. When African health workers face structural austerities, poor infrastructures, and low wages at home, their migration to affluent countries is less of a free choice and more of a survival mechanism. Market design models also assume some degree of fairness or equity in free market allocations, but global disparities create power asymmetries that undermine the fairness of the match, and the assumptions fail when one side has all the power. As a result, achieving stability in a rich country’s health market can cause extreme fragility in a developing country’s health system. 

Although market design seeks to make markets thick, or to have many participants,^[31] market thickening depletes or thins African health systems, as health workers are drawn into a pool dominated by affluent countries. This makes the global health market broken and unsafe for African countries because the market match (a doctor moving to the West) violates the participation constraint for an entire continent. If the result of a stable match is the collapse of African health infrastructures, then the market can be considered repugnant. This means that a match is not stable if it results in the death of non-participants (sick people in African countries). As such, the thin African health market is a failed market because it lacks sufficient participants (people are sick and dying) to create efficient outcomes. 

Conclusion: Claiming Equity in a Globalized Health Market

The missing African health workers are symptomatic of a global system that prioritizes the comfort of the wealthy over the survival of the many. Although the international community considers the health workforce shortage to be a humanitarian priority, the gaps between those who need healthcare and those who provide it continue to widen in Africa. The migration of health professionals out of Africa exposes the predatory nature of the neoliberal global health market. While brain circulation theories offer a thin silver lining of health dividends and economic gain, they are a poor substitute for the physical presence of a physician in an African clinic. To suggest that remittances compensate for the loss of a country’s healers is to equate human life with currency. 

The responsibility for these health disparities rests heavily with advanced capitalist countries. For too long, high-income countries have treated Africa’s medical schools as a training ground subsidized by African taxpayers for Western workforces, extracting physicians without replenishing their countries of origin. If the West is to uphold its stated commitments to global health security, it must move beyond the rhetoric of moral recruitment and toward tangible health systems reparations. This means moving from a free market model of health extraction to one of substantive investment in public health, where the clinical match for every recruited health worker out of Africa requires a health dividend paid back into the home country’s infrastructure, including in medical education and retention systems. Health systems reparations are integrated into a holistic reparative framework which includes external debt cancellation. This framework restructures the international financial system to end its predation of African countries, and grants equitable voting power for African countries in global institutions.

All this is not to say that African governments lack responsibility. The migration of African health workers is also driven by internal governance failures and flawed domestic policy decisions. African governments exercise agency in how they prioritize health spending, manage infrastructure, regulate their labor markets, and fulfill their commitments to their people. And yet, the 2001 Abuja Declaration, where African Union member states pledged to allocate 15% of their national budgets to health, remains largely unfulfilled. The time for global health rhetoric has passed. African governments and the international community must enforce the principles of the WHO Health Workforce Support and Safeguards List. The conjuncture reached is clear: we must either design a market that prioritizes collective health or remain complicit in a global health system that thrives on the depletion from the many in the rest of the world to benefit the few in the West. 

The 2024 African Health Workforce Investment Charter is a market redesign tool launched by African governments in 2024 to address critical labor shortages and align investments in health systems across the continent. This policy framework was designed to stimulate multisectoral investment in health workers. To address the projected shortfall of approximately 6.1 million health workers in Africa by 2030, the Charter proposes establishing universal health coverage and expanding equitable access to basic health services across Africa.^[32] To fix broken and thin health markets, the Charter recommends that clinical training be specifically optimized for primary healthcare providers, where the impact on rural and underserved communities is highest. It is too early to determine if the Charter is just another policy paper, or if it represents a shift among African leaders from regarding healthcare as a strain on national budgets, to viewing it as a strategic economic asset.^[33] Global health justice requires that the recruitment of health workers be governed by basic principles of health equity. If the West continues its neoliberal market recruitment model, it leaves the looming deficit of millions of health workers as a monument to global health inequity and to the abject failures of the so-called free market.

Danielle Taana Smith is a Professor in the Department of African American Studies and Professor of Sociology (courtesy) in the Maxwell School of Citizenship and Public Affairs at Syracuse University. Her research engages in global policy issues with an overarching goal of improving the social and economic environment for all, especially those at the margins of our society.  

Endnotes