Why do Zambian health workers migrate abroad?
The Brain Drain of Zambian health workers
Von David Lusale
As is the case in many other countries, Zambia is severely affected by health workers who migrate to neighbouring countries such as Botswana and South Africa or to overseas. To achieve greater understanding of the factors influencing migration we interviewed around fifty doctors, clinical officers, nurses and district managers in Lusaka Zambia. Their answers indicate that low salary levels and general working conditions are key elements driving migration. With a view to improving the situation indications are hereby provided how health workers can be better retained at their original place of work.
There are 175 million working migrants globally. Among them are many health care providers from poor countries who have migrated to the Middle East, Western Europe and North America. The loss of health care providers through migration abroad impacts negatively on health delivery systems in Sub Saharan Africa in general and Zambia in particular. As more health staff migrate away from the public health sector in Sub Saharan African, more work is dropped on the shoulders of the staff who remain, thereby negatively reinforcing the motivation of the workforce.
According to the recent World Health Report of 2006, the driving forces for migration are manifold and include low remunerations, poor working conditions, absence of career development schemes, civil strife and political instability, fear to contract diseases such as HIV and country policies that encourage labour export like in the Philippines. Due to these factors, about 1,198 Zambian nurses were working in seven European countries. This represents 5% of the total number of nurses in Zambia! Out of 1,200 doctors trained in Zambia since the late 1960s only 391 are practicing in the public sector today. Britain, on the other hand, had, in 2004, a nurse workforce of which 43% were foreign trained. Some 25% of the doctors employed in Canada and United States were originally trained abroad.
Factors influencing migration
In 2006 we interviewed fifty health staff in Lusaka province through a structured questionnaire entailing questions on endogenous and exogenous factors associated with migration. Particular interest was given to salary, working conditions and overseas education. The findings indicate that there are different reasons for migration among the study group. The study shows a relationship between salary and migration of nurses and clinical officers. Salary had little significance in relationship to migration of doctors. Inadequate diagnostic equipment and supplies have a relationship to migration among all the health staff. Long working hours due to shortage of health staff also had bearing on inducing migration among all the study population. The study reveals no relationship between studies overseas and migration.
Adequate salaries are crucially important
The results of our study show that nurses receive an average monthly remuneration of K 1.1m (US$ 229). Also clinical officers receive a monthly salary of K 1.1m (US$ 299). Their remuneration consists of the salary and regular uniform and night duty allowance paid as composite every month. In comparison with other governmental staff like pharmacy technologists, environmental health technologists and radiographers with similar duration of training, the salaries can be seen to be reasonable. Nevertheless, they are low when compared with the monthly food basket requirements estimated to be in the range of K 1.4m (US$ 350) for a family of six, and they do not at all allow meeting the additional costs of decent housing, transport and other basic services like water and electricity. These low salaries are an important factor driving nurses and clinical officers to a “breaking point” and the decision to migrate from the governmental sector and search for new jobs that could pay them a better living wage.
The doctors’ monthly median salary is K 3.9m (US$ 1,361). This compares unfavourably with veterinary doctors in the public sector who earn an average of K 1.8m (US$ 500) more, but at least these salaries are favourable to meet the basic food requirements and other essential requirements in Zambia.
Monetary and non monetary incentives are paid by government since the 1990s. However, their real value relative to the cost of living is not very significant for nurses and clinical officers. On-call allowances of between K 2m (US$ 500) to K 3m (US$ 700) per month are paid to doctors compared to K 0.03m (US$ 7) per month of night duty allowance and K 0.04m (US$ 10) overtime allowance for nurses and clinical officers. Car loans, rural hardship allowances and education allowances for children were extended to all Zambian doctors working in rural districts. Progression training was spelt out for doctors to encourage new graduate doctors to work in smaller districts for two or three years after internship. Thereafter they are eligible for government scholarship study. These have motivated the doctors to remain in the public health sector in recent times. However, the selective incentives have not yet been extended to the nurses and clinical officers to date. These cadres continue to migrate and government and cooperating partners have not yet addressed the matter and are seen to only be “talking the talk, rather than walking the walk!”
Working conditions are important for motivating health workers to perform their tasks. Satisfactory working conditions comprise a clean and safe environment, innovative management, availability of medical equipment and supplies. Besides, it is essential that the staff is not overwhelmed with work. They need to take vacation regularly when required. However, some of the health workers are demotivated by the run down working conditions and heavy work loads. In our study 100% of the doctors wanted improvements to be made regarding the cleanliness and maintenance of health facilities. 80% of the nurses and 92% of the clinical officers formulated similar improvement needs. All the categories of staff identify poor management of human resources as a contributory factor to their issues of leave, accommodation and communication not being appropriately dealt with.
What should be done?
The Government through the Ministry of Health has introduced several strategies to retain doctors in the public sector and to attract all cadres of health care providers to work in rural districts. However, the nurses and clinical officers are currently paid rural hardship allowance of less than US$ 50 as part of salary. Transport, education allowances for their children have not been offered to them yet. Scholarships for studies are not guaranteed for them in spite of serving in rural area for more than three years.
Our work indicates that the Zambian Government should increase wages for nurses and clinical officers in order for them to meet the basic rights of adequate food, shelter, clothing, and communication. The Government should equally improve conditions of employment through the provision of houses or timely house loans, transport or car loans. Such improvements need also to be extended to nurses and clinical officers who are currently excluded.
Schemes for career progression linked to salary increments need to be put in place for all staff categories to facilitate job satisfaction and continuous professional development. The Government should also increase budgetary allocations to health infrastructure in order to have drugs, medical supplies and adequate diagnostic equipment more readily available.
Licensing and regulatory bodies such as the Medical Council of Zambia and General Nursing Council of Zambia should consider only issuing graduate trainees full registration status to practice after the bonding agreement with government is served in the Public Health Sector.
The Government should also endeavour to network with other countries in the region to explore possibilities of importing labour where demand has been met and at the same time to share experiences about which strategies play a role in maintaining health worker motivation in countries where the problems outlined here are also found.
*David Lusale is a Senior Lecturer in Reproductive Health at Chainama College of Health Sciences, Lusaka, and formerly Manager of Administration at Mazabuka District Health Management Board. Contact: firstname.lastname@example.org.