Africa has a challenge to retain the health workers it needs.

The World Health Organization estimates a global shortfall of 11-million health workers by 2030, with Africa predicted to face shortages ranging from five-million to six-million workers. The shortfall is calculated according to disease burden and health population needs. This is the population’s size and demography together with the prevalence of diseases and risk factors, and type and frequency of health interventions planned or necessary to address the identified diseases, conditions and risk factors.

This shortage is deeply unequal. Many of the 83 countries already below the recommended minimum workforce threshold are in Africa, where in 2022 only four countries (Seychelles, Namibia, Mauritius and South Africa) had more than the recommended ratio of 4.45 doctors, nurses and midwives per 1 000 people. Madagascar, Malawi, Togo, Benin, South Sudan, Chad, Central African Republic and Niger reported less than 0.5 doctors, nurses and midwives per 1 000 people in 2018. In many African countries, it’s difficult to deliver basic services, reduce preventable deaths and achieve universal health coverage.

In contrast, Europe reports a range of 5.43 to 20.0 doctors, nurses and midwives per 1 000 people.

At the same time, wealthier countries such as the UK, US, Canada and Australia are increasingly reliant on internationally trained staff. In 2023 nearly half of new doctors joining the UK workforce were trained abroad.

This pattern is often described as “brain drain”, explained by “push” factors (low pay, poor working conditions) and “pull” factors (better salaries and opportunities abroad).

I am interested in this topic as an international worker: a South African health education researcher working in the UK, where I train healthcare workers and research workforce issues.

In a recent paper I argue that this explanation is incomplete. The “push-pull” framing misses a crucial point: the flow of health workers is not random. It consistently moves from poorer countries to richer ones – a pattern that tracks closely along lines drawn by colonial history.

The term “brain drain” suggests a natural, almost inevitable flow of talent. But health worker migration is not neutral or equal; it is shaped by history, economics and power.

I argue that the pattern isn’t just “brain drain” driven by individual choice. Rather, it’s part of a deeper, unequal global system shaped by colonial legacies – with major implications for health, education and workforce policy.

This shifts the conversation away from blaming individual doctors and nurses for leaving, and towards the systems that shape those choices in the first place.

The three factors at play

My research draws on a decolonial perspective to rethink healthcare worker migration. Rather than treating migration as a series of individual decisions, it examines the global systems that structure those decisions.

Decoloniality argues that European colonialism created a matrix of power that still organises:

• power – who controls resources and labour

• knowledge – whose expertise is valued

• being – who is valued.

Through this lens, I argue that health worker migration looks less like a neutral labour market or unfortunate by-product of globalisation, and more like a continuation of historical extraction. In other words, the same global hierarchies shaped during colonialism still influence who controls and benefits from African resources and labour, whose expertise is recognised, and how international workers are viewed and treated.

Power: First, wealthier countries often underinvest in training their own workforce, then recruit from countries with far fewer resources. This transfers human capital from the global south to the global north. The financial losses are significant: one study estimated that sub-Saharan African countries lost-millions to billions of dollars through the emigration of doctors, while receiving countries saved on training costs.

Knowledge: Second, global hierarchies of knowledge shape professional mobility. Medical education in Europe and North America is often treated as the gold standard, while qualifications from African institutions may be questioned or require additional validation. This reinforces the perception that moving northwards is necessary for career advancement and legitimacy.

Being: Third, many internationally trained health workers face discrimination that negatively impacts on their well being and career progression. They further risk deskilling. As international healthcare workers can be employed at lower levels of employment than they are qualified for, this can result in them losing skills. This reflects colonial dehumanisation and exploitation.

In short, global systems are structured in ways that make leaving more likely and more beneficial to receiving countries than sending ones.

Developing a fairer system

If health worker migration is shaped by structural inequalities, then solutions must also operate at that level.

1. Invest in and retain health workers locally

African governments should address “push” factors by expanding training and employment opportunities, improving working conditions, and ensuring fair pay and career progression, making staying a viable and attractive option. Health professional education should be aligned with local health needs, equipping healthcare workers to first and foremost meet the population healthcare needs of their home contexts.

2. Reform global recruitment and redistribute resources

High-income countries must reduce their reliance on international recruitment by investing more in domestic training. Ethical recruitment codes exist but are inconsistently enforced. There is also a strong case for reparative measures – including financial compensation or investment – to offset the losses borne by countries that train health workers who then emigrate.

More balanced partnerships, such as circular migration schemes (where health workers return home after training internationally) or bilateral training agreements (where the expertise of both countries is recognised, and both contexts benefit), could support skills exchange without permanently draining capacity. But these must include clear pathways for return and meaningful investment in health systems in countries of origin.

3. Recognise and value global south knowledge and professionals

Addressing the “coloniality of knowledge” means recognising the legitimacy of training and expertise developed in African contexts. At the same time, tackling the “coloniality of being” requires confronting racism, bias and discrimination in healthcare workplaces globally.

Moving forward

When African health systems struggle to retain staff, it is not only because of poor national planning. Many of these systems operate in the long shadow of colonial extraction and ongoing global economic inequality.

Recognising this deeper reality opens up new possibilities. A fairer global health system is possible – but only if it no longer depends on Africa’s loss for others’ gain.

Written by Danica Sims, Senior lecturer in Medical Education, University of Oxford

This article is republished from The Conversation under a Creative Commons license. Read the original article.