Africa Demands That Its Doctors Remain in the Continent

Every year, hundreds of doctors and nurses trained in sub-Saharan Africa leave the continent to join British, French, or Canadian health systems. Kenya trains a doctor in 6 years (5 years of training followed by a year of internship), at a total estimated cost of approximately 66,000 USD in unsubsidized costs. The National Health Service rapidly recruits a growing number of these graduates after their certification. Kenya pays. The United Kingdom benefits.

This mechanism is not new. What is new is that a quantified report attempts to name it, measure it, and propose a strategy against it. The report State of the Health Workforce in Africa 2026, published by the WHO Africa Regional Office, is the first published after the adoption of the African Charter for Investment in Health Personnel and introduces a reinforced perspective on the health labor market — though it is part of an existing biannual series of reports. It accompanies the African Charter for Investment in Health Personnel, adopted under the aegis of the African Union, which commits member states to finance medical training as a strategic investment rather than a compressible budget line.

The Essentials

  • Sub-Saharan Africa has approximately 1.1 health professionals per 1,000 inhabitants, compared to a minimum threshold of 4.45 recommended by the WHO to meet essential needs.
  • The WHO Africa 2026 report integrates for the first time a perspective on the medical labor market, quantifying the gap between training and retention.
  • The United Kingdom, France, and Canada are among the main recipient countries for health personnel trained in sub-Saharan Africa, according to OECD data.
  • The African Charter for Investment in Health Personnel aims to reverse the logic of development aid: finance training without losing its beneficiaries.
  • The stake over the next twelve months: the first implementation mechanisms of the Charter and the national budgetary commitments that will follow.

One Doctor in Four Trained in Sub-Saharan Africa Works Elsewhere

The figure varies by country and profession, but the order of magnitude is stable. According to OECD data on health personnel migration, a significant proportion of doctors born in sub-Saharan African countries work in OECD countries. For certain countries such as Ghana, Zimbabwe, or Malawi, this ratio exceeds 50%. The paradox is brutal: these are precisely the countries that face the most severe health personnel deficits. They export what they cannot afford to lose.

Sub-Saharan Africa has approximately 1.1 qualified health professionals per 1,000 inhabitants. The minimum threshold estimated by the WHO to ensure basic universal health coverage is 4.45 per 1,000. The gap is not a development lag that would narrow over time: it is a structural deficit partly fueled by external solvent demand. Health systems in wealthy countries offer salaries five to ten times higher, comparatively better working conditions, and career prospects that public hospitals in Accra or Nairobi cannot match.

What the WHO Africa 2026 report adds to this known assessment is an accounting. It attempts to quantify not only departure flows, but the net cost borne by training countries and the benefit captured by recruiting countries. This accounting is political before it is statistical: it constructs the argument for reciprocity that development aid agreements have systematically avoided.

What Development Aid Agreements Have Long Sidestepped

Bilateral development aid conventions in the health sector finance hospitals, equipment, vaccination programs. They do not finance retention. For decades, European cooperation agencies subsidized health personnel training in Africa while, in a number of documented cases, allowing their own institutions to recruit the graduates. The contradiction was not ignored: it was convenient.

The United Kingdom adopted in 2004 a code of good practice on the international recruitment of health personnel, revised in 2023, which formally discourages active recruitment from countries identified as having deficits. This list includes several sub-Saharan African states. This code formally applies to private medical placement agencies as well as all recruiters, whether from the public or private sector. Circumventions have nonetheless been documented in practice, and the OECD records each year the gap between declared commitments and actual flows.

France recruits doctors with foreign qualifications outside the European Union, a significant proportion of whom come from North Africa and sub-Saharan Africa, to address medical deserts in under-equipped regions. Canada, whose health system structurally depends on the immigration of qualified personnel, has never claimed to deprive itself of this lever. These policies respond to real needs in recruiting countries. They also create asymmetrical competition: an African state cannot offer the same conditions as a European public employer.

This imbalance structures the problem that the African Charter seeks to address. Its approach is not to close borders or forbid departures — this would be unrealistic and contrary to fundamental rights to mobility. It aims to change the terms of negotiation: make investments in training visible, quantify them, and engage recipient countries in mechanisms of compensation or partnership.

The African Charter Bets on Transparency as a Political Lever

The African Charter for Investment in Health Personnel rests on a simple principle: what you do not measure, you cannot negotiate. Its first pillar is the creation of national systems for monitoring flows of health personnel trained in each country, with disaggregation by qualification level, specialty, and country of destination. This registry did not exist systematically at the continental level.

Its second pillar is budgetary. The Charter commits African Union member states to raise their public health expenditure to 15% of their national budget — the commitment known as the “Abuja commitment,” made in 2001 and respected by fewer than ten countries out of 54. What is new is to explicitly link this objective to the funding line for training and to personnel remuneration. The thesis is that the brain drain of medical professionals is partly a consequence of the chronic underfunding of public health systems, which renders African hospitals incapable of retaining their own graduates.

Its third pillar concerns partnerships with recruiting countries. The Charter proposes a model of “mutually beneficial training partnership” in which countries that recruit personnel trained in Africa contribute to financing training capacity in countries of origin. This model exists on a small scale: certain bilateral agreements between the United Kingdom and countries such as Malawi or Zimbabwe include capacity-building components. The Charter seeks to move from discreet bilateral agreement to claimed multilateral framework.

The political stake is real. Countries that would see their contribution calculated and made public could be incentivized to renegotiate the terms. Or to resist this transparency. The next African Union health conference will be a test of the level of actual political support.

Ethiopia, Rwanda, Senegal: Three Bets on Retention

If the Charter provides a continental framework, several countries have already launched national strategies without waiting for regional validation. Their results are uneven but instructive.

Ethiopia launched in 2019 a national program for rapid expansion of medical training, multiplying the number of medical schools from 13 to more than 40 in less than ten years. The stated objective was to increase the total stock of doctors quickly enough to absorb departures without ending up in net deficit. This volume strategy has limits: the quality of training in new schools is uneven, and producing more graduates without improving practice conditions does not eliminate the incentive to leave. But it shows that a state can treat training as an industrial policy.

Rwanda chose a different approach: specialization and a premium on retention. By targeting critical specialties, by financing training abroad with mandatory return contracts, and by creating centers of excellence that offer working conditions close to international standards, Rwanda has succeeded in retaining some of its specialists trained in Europe and the United States. The Kigali University Hospital Centre receives patients from several neighboring countries for surgical interventions that were previously available only abroad. This quality upgrade is deliberate.

Senegal bet on task delegation and training of intermediate personnel. Rather than aiming to train as many doctors as possible and risking seeing them leave, it invested in clinical nurses, specialized midwives, and community health technicians capable of ensuring primary care in rural areas. These profiles are less attractive to foreign recruiters, more attached to their communities, and less costly to train. This strategy does not solve the problem of doctor brain drain, but it reduces system dependence on their presence.

These three approaches are not mutually exclusive. The WHO Africa 2026 report documents them as complementary examples rather than opposed ones, and identifies the conditions under which each can be replicated.

The Global Medical Labor Market Will Not Slow Down

The external context does not favor retention. High-income countries are aging. Their health systems need personnel in increasing numbers. The OECD projects a deficit of several million health personnel in its member countries by 2030, which creates structural and lasting pressure on training countries. This demand will not rely on explicit recruitment policies: it will manifest through attractive salaries, rapid recognition procedures for diplomas, and facilitated immigration pathways for health professions.

The issue of health personnel moreover joins a broader debate on the dynamics of the global labor market, where the best-endowed countries capture competencies trained elsewhere. This mechanism operates in other sectors, as shown by the literature on precarious workers and structural inequalities in the global economy, but it has particularly severe consequences in health, where a personnel deficit translates directly into preventable mortality.

This asymmetry does not imply that the African Charter is doomed to failure. It implies that it cannot function as a simple goodwill mechanism. For a system of compensation or partnership with recruiting countries to be effective, stronger incentives than moral pressure will be needed. This can take several forms: conditions attached to economic partnership agreements, multilateral financing mechanisms, or coordinated pressure from African states in negotiations on trade in services, where the mobility of qualified personnel is an open subject.

The African Union has more leverage than it has used thus far. The African market represents an investment destination and commercial partner that European countries seek to consolidate. Health can become a negotiating variable in broader agreements, as trade and investment already are. This recomposition remains to be built.

What the 2026 Report Really Changes

Publishing a report is not a policy. The African Charter for Investment in Health Personnel is a framework, not a program. The 2001 Abuja commitments were insufficient to transform national health budgets. Nothing guarantees that this new framework will meet a different fate.

What is different this time is the construction of the argument. By treating medical training as an investment whose return is captured by others, the WHO Africa 2026 report introduces economic vocabulary into a debate that had remained until now in the humanitarian register. This shift is not cosmetic. It changes who is responsible for what. It transforms the problem of medical brain drain from a partially inevitable misfortune into a transfer of value that can be renegotiated.

The practical question that poses itself over the next twelve months is which African states will translate the Charter into concrete budgetary commitments, and which partner countries will accept to open a discussion on mechanisms of compensation. The answer to these two questions will say whether the Charter is a negotiating tool or one more text in a long list of unfulfilled commitments.

What is already known is that countries that have begun to treat this question as a strategic priority, whether Rwanda, Ethiopia, or Senegal, obtain measurable results. The model exists. The question is one of political ambition to generalize it.

Sources

  1. WHO Africa — State of the Health Workforce in Africa 2026 (WHO Africa Regional Office)
  2. OECD — Health at a Glance 2023: data on international migration of health personnel
  3. African Union — African Charter for Investment in Health Personnel (official text, 2025)
  4. United Kingdom Department of Health and Social Care — Code of Practice for the International Recruitment of Health and Social Care Personnel, 2023 revision
  5. WHO — Global Health Observatory: threshold of 4.45 health professionals per 1,000 inhabitants
  6. African Charter for Investment in Health Personnel (WHO AFRO)
  7. UK Code of Practice – NHS Employers (March 2025)
  8. Abuja Declaration 2001 – Wikipedia + HRW
  9. WHO threshold 4.45 per 1,000 – WHO 2016
  10. Cost of doctor training Kenya – Kirigia et al. (Springer, 2006)
  11. OECD – Migration of African doctors (2021)