International migration of Africa-born health workers: a scoping review of drivers and policies, 2010–2024

Abstract

Background

Africa faces a critical shortage of human resources for health (HRH), crucial for improving population health. We described drivers of and policies to manage the migration of Africa-born HRH from source (African) countries in Africa to destination (non-African) countries.

Methods

We conducted a scoping review, using the Arksey and O’Malley framework, using data from peer-reviewed articles (2010–2024) and gray literature from institutions like Africa Centers for Disease Control (CDC) and World Health Organization (WHO). We used push–pull theory to identify economic, professional, social, and political drivers, and WHO’s HRH Workforce 2030 policy levers framework to identify policies at national, regional, and global levels. We focused on targeted migration policies—those aimed at strengthening health system resilience and health worker density in Africa (mitigating brain drain), ensuring ethical recruitment practices by destination countries, and upholding the individual right to professional mobility—based on the WHO Global Code of Practice on the International Recruitment of Health Personnel.

Results

Of 335 citations, 65 articles were relevant. Key push factors included inadequate pay, limited professional growth, and political instability; pull factors included better remuneration and career opportunities abroad. Return migration to Africa was influenced by high costs of living, discrimination, and deskilling. Source countries have focused on economic reforms and improving working conditions. However, destination countries should adopt ethical recruitment and strengthen destination country HRH training. Regional bodies like Africa CDC should harmonize HRH practices, while global actors like WHO should enforce ethical recruitment and fair compensation.

Conclusion

Multiple drivers influence migration of Africa-born HRH. Recent changes in the US government’s global health funding will likely intensify these drivers. Targeted innovative approaches, including repatriation programs and public–private partnerships, offer the potential to improve HRH retention in Africa while protecting individual rights to mobility.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12960-026-01093-9.

Highlights

• Economic, professional, social, and political factors drive migration of Africa-born HRH, with key push factors including low pay and poor working conditions, and key pull factors including better remuneration and opportunities abroad.

• Return migration is influenced by high living costs, discrimination, and deskilling in destination countries.

• Health reforms in source countries and ethical recruitment practices by destination countries help curb migration.

• Regional bodies like Africa CDC can support training and retention initiatives, while global actors like WHO can support policy enforcement on fair recruitment practices.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12960-026-01093-9.

Background

Human resources for health (HRH), defined as individuals working toward the improvement of population health, have notably shifted out of Africa—a trend colloquially described as “brain drain” [1]. Africa bears over 20% of the global disease burden, accounting for the loss of 629,603,271 disability-adjusted life years, equivalent to US$243 billion in lost income in 2015 [2]. However, Africa has only 3% of the world’s HRH with an average density of 1.55 physicians, nurses and midwives per 1000 population, well below the World Health Organization (WHO) threshold of 4.45 health workers per 1000 population needed to achieve universal health coverage (UHC) [3, 4].

Africa struggles to retain HRH while for all intents and purposes, it subsidizes HRH training for high-income countries; an estimated one-fifth of Africa-born physicians, approximately 65,000 physicians, migrate to high-income countries within five years of completing their medical training [5]. In addition, low- and middle-income countries (LMICs) lose $2.8 billion per country annually (adjusted to 2022 US dollars) due to physician migration to high-income countries and subsequent excess mortality associated with the loss of physicians [6, 7].

Migration of skilled HRH, especially doctors and nurses, out of Africa began in earnest after the 1970s oil and debt crises and the subsequent structural adjustment programs (SAPs) instituted by the World Bank (WB) and International Monetary Fund (IMF) in the 1980s and 1990s [8, 9]. SAPs had deleterious effects on the health sector including suspension and/or mandatory early retirement of HRH, privatization of the health sector, and underinvestment in public health infrastructure [9]. The HIV/AIDS pandemic further worsened health indicators making many African countries unattractive for HRH with some switching professions, opening private health practices, or migrating to high-income countries [8, 9]. The most affected African countries included Nigeria, Ghana, Ethiopia, Sudan, and Liberia [10, 11]. Key destination countries for Africa-born HRH included the United Kingdom and the United States for those from Anglophone African countries [6, 10–12]; France and Belgium for those from Francophone African countries [13]; Portugal for those from Lusophone African countries [14]; and Saudi Arabia and the Gulf for those from Arabic-speaking African countries [15, 16].

Globally, countries have been cutting health budgets due to financial instability occasioned by the 2008/2009 financial crisis and the 2020 COVID-19 pandemic [17]. Despite these declines, there has been increased demand for skilled HRH due to aging populations and epidemiologic transition to chronic and non-communicable diseases. Hence, the migration of Africa-born HRH is not expected to abate in the near future [18, 19]. We, therefore, conducted a scoping review to identify the drivers and policies to support targeted migration of Africa-born HRH aimed at mitigating brain drain, ensuring ethical recruitment practices by destination countries, and upholding the individual right to professional mobility—a call supported by the Africa Centers for Disease Control’s (Africa CDC) new public health order for the continent [20]. We defined ethical recruitment as policy framework that discourages active recruitment from countries facing critical health workforce shortages while promoting bilateral reciprocity—where destination countries provide technical or financial support to mitigate the loss of human capital [21]. While the drivers of HRH migration from Africa are well-documented, this scoping review adds a novel and critical lens to drivers and policies that lead to circular and return migration of Africa-born HRH.

Methods

Study design

We conducted this scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses—Extension for Scoping Reviews (PRISMA-ScR) checklist [22] (Appendix A). We utilized the five-step Arksey and O’Malley framework that involves (1) the identification of the research question(s); (2) the identification of potentially relevant documents; (3) the selection of documents for analysis; (4) data charting, and (5) summary and report of the results [23].

Research questions

The two key research questions were: (1) what push and pull factors (defined below) have contributed to the migration of Africa-born HRH, and (2) what policies support targeted migration of Africa-born HRH out of and back into the continent.

Theoretical framework

We utilized two theoretical frameworks: the push–pull theory and WHO’s global strategy on HRH workforce 2030 policy levers framework. The push–pull theory has been widely used to describe the factors that cause individuals to migrate to and from different countries [24, 25]. We defined source countries as African countries from which Africa-born HRH migrate and destination countries as non-African countries to which they move [26]. Push factors were defined as characteristics of source countries that induce migration; pull factors were defined as qualities of destination countries that attract migrants [27, 28]. Push and pull factors were further grouped into economic, professional, social, or political drivers [27].

We utilized the WHO’s global strategy on HRH workforce 2030 policy levers framework which holistically organizes HRH policies and accounts for training and health sector dynamics (Fig. 1) [29]. We organized policies into five categories, according to their intended impact on (1) society, (2) HRH production, (3) inflows and outflows, (4) maldistribution and inefficiencies, and (5) the private sector.

Fig. 1.

Policy lever framework for health labor markets adapted from WHO’s global strategy on HRH workforce 2030 report [29]

Search strategy

We searched PubMed, EMBASE, EBSCO, Ovid-Medline, Global Health, and African Index Medicus for peer-reviewed papers published between 1 Jan 2010 and 31 Dec 2024 to give the most current understanding of the migration of Africa-born HRH (search strings in Appendix B). We conducted a gray literature search on the migration of Africa-born HRH by reviewing a range of non-peer-reviewed sources, including government reports, policy briefs, non-governmental publications, and other relevant documents to capture a comprehensive view of migration trends and HRH issues.

Document screening and selection

We included original, peer-reviewed research studies and gray literature on the migration of Africa-born HRH. We included articles published in English after 2010 and excluded those that did not meet the inclusion criteria based on study dates. We excluded articles focusing on HRH born outside Africa and those focused on intra-Africa HRH migration. We excluded preprints, conference abstracts, editorials, letters to editors, commentaries, interviews, and correspondence.

We also conducted a search of gray literature directed at major regional and international institutions involved in HRH management (e.g., WHO, Africa CDC, World Trade Organization (WTO), European Union (EU), and Organization for Economic Co-operation and Development (OECD)). First, we conducted targeted institutional web searches by navigating the internal publications and policy repositories of these organizations using standardized keywords (e.g., ‘health worker migration’, ‘retention’, ‘Africa’). Second, we used targeted Google searches to capture reports hosted externally (e.g., site:who.int “health worker” migration Africa).

The main author (BW) screened all the titles and abstracts, removed duplicates, created a final list of selected articles, and reviewed all full-text articles identified from the search to see if they met the inclusion and exclusion criteria. When the full text was not found or articles did not meet the defined criteria, they were excluded. At each stage—title review, abstract review, and full text review—BW compared included and excluded articles and resolved discrepancies were resolved through discussion and consultation until 100% consensus was reached. We iteratively revised the extraction and analysis plan as we reviewed the literature.

Data charting—extraction, analysis

We extracted the following data items: bibliographic information (author, title, year), country, study design, cadre, push factors, pull factors, and policy interventions, according to the data extraction instrument (Appendix C). Extracted data were organized in a database using Microsoft Excel.

Synthesis of results

We grouped the findings based on push and pull factors and policy interventions and presented the results as a narrative. We grouped push and pull factors into economic, social, professional, and political drivers for the migration of Africa-born HRH, and the policy interventions into national, regional, and global policy categories, depending on the scope.

Results

Article selection

The search strategy yielded 335 citations, 325 from database searches and 10 from gray literature searches. After removal of 82 duplicates, 253 articles were assessed for eligibility. Of these, 65 articles met our inclusion criteria (Fig. 2). Eligible articles evaluated mainly on doctors (29/65, 45%), multiple HRH cadres (21/65, 32%) and nurses (9/65, 14%). Most papers focused on HRH at the Africa continent level (26/65, 40%); studies at individual-country level were from South Africa (9/65, 14%), Ghana (7/65, 11%), Nigeria (3/65, 5%) and Sudan (3/65, 5%).

Fig. 2.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for article selection

Push and pull factors affecting out-migration of Africa-born HRH to non-African destination countries

Economic factors, especially inadequate remuneration, were key push factors for migration of HRH out of Africa (Table 1) [16, 27, 28, 30–56]. Source countries were largely unable to employ and deploy HRH due to limited fiscal space in the national budgets. This created an environment in which HRH were pulled into destination countries with better remuneration packages and employment opportunities.

Table 1.

Push and pull factors affecting out and return migration of Africa-born health workers

	Migration out of Africa		Return to Africa
	Push factors	Pull factors	Push factors	Pull factors
Economic	• Poor remuneration/pay • Inability to supplement income • Low health labor market demand • Poor economy; high levels of poverty	• Better remuneration/salary • Opportunities for supplemental income • High demand for health workers • Stable economy in destination country	• High cost of living	• Low cost of living • Improved economic conditions
Professional	• Poor work environment • Lack of job security • Limited professional development • Lack of continuing medical education • Poor quality, non-standardized postgraduate education • Unavailability of the specialty of interest • Lack of research funding • Corruption • Lack of respect • Harassment	• Better work environment • Speedy registration, licensure • Professional stability • Research funding • Access to advanced medical technologies • Better education opportunities	• Deskilling • Poor working conditions • Exploitation • (Visa-limited) time restrictions • Lack of licensure and/or registration • Tough professional competition • Obligation to return to source country • Patriotism/commitment to source country	• Desire for impact or to use expertise in source country • Preference to work with underserved communities in source country • Possibility of circular migration—free movement between countries
Social	• Poor living conditions • Societal expectations to maintain certain lifestyle • Concerns over family and children's future • Lack of acceptance in source country’s local communities	• Better lifestyle • Self-actualization • Esteem • Desire to settle abroad (based on TV shows, reports from relatives/other professionals abroad)	• Racism • Discrimination: Racial/gender based • Lack of family support especially if family visas are denied • Religious reasons • Difficult weather esp. winters	• Familiar physical environment • Family ties • African “lifestyle”, i.e., culture, norms • Willingness to help one's own people • Fairer weather
Political	• Lack of appreciation by source government • War, conflict	• Political stability/peace • Pathway to citizenship, asylum • Familiarity with language, religion (incl. colonial ties)	• Political instability • War, conflict	• Political stability • Potential for dual citizenship/permanent residence

HRH Human Resources for Health

Professional push factors revolved around poor work environments, limited opportunities for continuing medical and postgraduate education, and insufficient research funding [16, 27, 28, 30–46, 49–54, 56–59]. Overall, destination countries pulled Africa-born HRH due to better work environments and professional development opportunities.

Social push factors revolved around poor living conditions for HRH who were often concerned about maintaining societal expectations of standards of living for themselves and their families [27, 28, 36, 38–41, 43–45, 50, 52–54, 56, 58]. Most were pulled into destination countries with better living standards and prospects for social advancement.

Lastly, HRH cited political factors such as war, conflict, and lack of respect and appreciation by source governments as major push factors out of Africa [27, 31, 44, 45, 47, 52–54, 56]. HRH were pulled to politically stable destination countries—often those with similar colonial, linguistic, or religious ties.

Push and pull factors affecting return migration of Africa-born HRH to source countries

Drivers for the return migration of Africa-born HRH were often mirror opposites of the factors that pushed them out of Africa (Table 1). Among economic factors, the high cost of living in destination countries often pushed Africa-born HRH back into Africa [28, 36, 41, 45, 49]. The return to source countries was much easier if the source countries had made significant economic improvements or had increased HRH salaries [16, 28, 36, 41, 45, 49, 54, 60].

Professionally, Africa-born HRH reported deskilling, defined as engaging in menial tasks for which one is overqualified [57], restrictions on professional licensure and registration, and work-based exploitation as major push factors out of destination countries [16, 28, 36, 41, 45, 49, 53, 54]. Africa-born HRH were often pulled back to their source countries to work with underserved communities due to a strong sense of patriotism and desire for impact [28, 36, 41, 45].

Socially, racism, discrimination, and limited family support discouraged Africa-born HRH from continuing to work in destination countries [28, 36, 41, 45, 53, 54]. Africa-born HRH returned to source countries due to the more conducive culture, societal norms, and weather [28, 36, 41, 49].

On the political front, push factors out of destination countries included war or conflict (e.g., Africa-born HRH moved out of Ukraine due to the war) [45, 53, 54]. Africa-born HRH returned to source countries due to improved political stability in the source countries—or other African countries if their home countries were not politically stable [31]. Some cited opportunities for circular migration where they could easily travel between source and destination countries (e.g., dual citizenship or permanent residence status) as an incentive to engage with, and eventually return back to Africa [18, 32, 61].

Policies

Using the policy levers framework from WHO’s global strategy on HRH workforce 2030 report, we mapped out policies to support targeted migration of Africa-born HRH [29] (Table 2). We organized the policies at national (source and destination country), regional (e.g., Africa CDC, regional bodies based outside Africa like EU, OECD) and global levels (e.g., WHO, WTO).

Table 2.

Policies to address migration of Africa-born health workers

Policy lever	Level	Policies	National		Regional		Global
			Source country	Destination country	Africa CDC	Regional bodies outside Africa	WHO	WTO
National planning	On society	• Improve economy [60]	x
		• Promote political stability [13]	x
HRH production	On infrastructure and material	• Conduct detailed mapping of health workforce including those in destination countries [62]	x
		• Improve health systems (e.g., planning, leadership) [1, 41]	x
		• Improve work environment [53]	x
		• Develop targeted migration program to train and export HRH [62]	x
	On enrollment	• Enroll and train rural, disadvantaged high school graduates and deploy in underserved areas [1, 54]	x
		• Involve the private sector HRH training [17, 62]	x
	On selecting students	• Enroll and train rural, disadvantaged high school graduates and deploy in underserved areas [1, 54]	x
	On teaching staff	• Train new cadres of skilled HRH that can be deployed to underserved areas (e.g., clinical associates, pharmacy techs) [54]	x
HRH inflows and outflows	To address migration and emigration (Source country)	• Close wage gap through financial incentives (e.g., increased salaries) [1, 17, 18, 41, 48, 53, 63]
		• Allow dual practice for HRH to supplement incomes [64]	x
		• Consider compulsory service requirement before exit [1]	x
		• Provide professional development opportunities and specialty training [64]	x
		• Allow flexible workhours [30, 39]	x
		• Monitor migration of Africa-born HRH [16, 60]	x		x
	To address migration and emigration (Destination country)	• Limit hiring from countries with poor health worker-to-population ratios [9, 18]		x
		• Adhere to ethical guidance/codes of conduct on HRH recruitment [9, 18, 43, 65]		x
		• Revise immigration laws to rationalize hiring of migrant HRH [9, 18]		x
		• Increase number of domestic trained HRH [9, 18]		x
		• Develop cost-effective ways to educate HRH (e.g., innovation grants) [9, 18]		x
		• Leverage diverse health worker cadres to achieve an optimized and diversified skill mix [18]		x
		• Compensate African countries for the cost of training HRH [18]		x
	To address migration and emigration (Regional bodies)	• Develop a regional repository of Africa-born HRH based within and outside the continent [60, 66]	x	x
		• Monitor migration of Africa-born HRH [16, 60]	x	x
		• Establish bilateral agreements to regulate registration of overseas physicians [9, 18, 26]	x
		• Translate medical degree and license equivalents across countries [32]		x	x
		• Develop comprehensive guidelines on Africa HRH training, recruitment, migration, return, and collaboration / sharing during crisis (e.g., pandemics) [66]		x
		• Partner with funding institutions to support HRH training and retention (e.g., PEPFAR, Fogarty) [45]		x
		• Incorporate WHO Global Code of Practice on the International Recruitment of Health Personnel into national laws, policies [16, 43, 67]	x	x	x		x	x
		• Increase publicity of the WHO Global Code of Practice on the International Recruitment of Health Personnel [16, 67, 68]					x
		• Clarify definitions and articles in the WHO Global Code of Practice on the International Recruitment of Health Personnel to better address HRH migration [16, 67]					x
		• Include governance structure to WHO’s Global Code to manage HRH migration [16, 67]					x
		• Include sustainable, binding financing system to WHO’s Global Code to reimburse source countries for HRH losses [16, 67]					x
		• Allow Africa-born HRH work permits only if employers demonstrate non-availability of local staffing [1, 61]			x
		• Issue temporary visas to Africa-born HRH to encourage return to source countries [1]			x
		• Support high-income country HRH regulation in both public and private health systems [1, 61]			x
		• Promote self-sufficiency in HRH training and deployment to remove incentives for migration [1, 18, 61]			x
		• Enforce ethical recruitment practices in member countries [1, 18, 61]			x
		• Structure policy strategies on integration of migrants in international labor markets [9, 69]						x
		• Develop work-place anti-discrimination policies (race, gender, etc.) [9, 69]						x
		• Enforce legal actions against racial discrimination at the workplace and civil society in general [9, 69]						x
		• Enforce fair recruitment of Africa-born HRH using the WTO’s General Agreement on Trade Services [69, 70]						x
		• Improve mechanisms of diploma recognition for Africa-born HRH [71]		x			x	x
	To repatriate Africa-born HRH based abroad	• Implement re-integration policies for Africa-born HRH returning to the continent [53]	x
		• Establish public–private partnerships to help returning Africa-born HRH negotiate repatriation challenges [53, 60]	x
		• Implement low hurdle registration and licensing requirements for returning HRH [58]	x
		• Promote active return of destination-country based Africa-born HRH [1]	x	x
		• Support re-integration of returning HRH (e.g., short-term housing, children’s education) [53]	x
		• Identify and support reliable local partners to engage destination-country based HRH (e.g., local medical associations) [15, 53]	x
		• Facilitate medical service trips and donations to health agencies (in-kind and financial gifts) [60]	x
		• Support circular migration policies to encourage free return of HRH (e.g., through dual citizenship, permanent residence) [18, 32, 61]	x
	To attract unemployed HRH	• N/A
	To bring HRH back to health sector	• N/A
HRH maldistribution and inefficiencies	To improve productivity and performance	• N/A
	To improve skill mix and composition	• Shift routine tasks to lower cadres [8, 9]	x
		• Import HRH (e.g., physicians from Cuba) [54]	x
	To retain health workers in underserved areas	• Hire staff with strong community ties [1]	x
		• Implement targeted recruitment of HRH from underserved populations to improve retention [54]	x
		• Train new cadres of skilled HRH that can be deployed to underserved areas (e.g., clinical associates, pharmacy techs) [54]	x
		• Incorporate eLearning programs to encourage HRH to remain in rural areas [17]	x
Private sector engagement	To improve quality of training	• Involve the private sector in HRH training [17, 62]	x
	To manage dual practice	• Allow dual practice (moonlighting) for HRH to supplement incomes [65]	x
	To enhance service delivery	• N/A

Africa CDC Africa Centers for Disease Control, WHO World Health Organization, WTO World Trade Organization, N/A not applicable

Policies on national planning

National policies to support economic improvements and political stability have the potential to reduce out-migration of Africa-born HRH and promote the return of those outside the continent. For example, from the late 1990s onward, South Africa observed a net return of HRH due to improved economic performance and political stability [49, 54].

Policies on HRH production

HRH production policies address enrollment, selection, and training of HRH. This involves detailed mapping of the health workforce within and outside the country to understand the number of HRH required for an effective health system [62, 63], tailored selection and training strategies including training high school graduates from rural areas who are more likely to be retained in underserved areas [54], encouraging private sector involvement in HRH training [62], and establishing targeted migration programs to facilitate training and export of HRH [62].

Policies to manage HRH inflows and outflows

Multiple country, regional, and global actors have been involved in the management of HRH inflows and outflows (Table 2). Although we did not identify policies to attract unemployed HRH or to bring HRH back to health sector, repatriation policies came up as a new category not initially identified in the policy lever framework.

Source-country policies

Some source countries have reduced HRH migration by closing wage gaps for HRH through financial incentives (e.g., increased salaries) [1, 17, 18, 41, 48, 53, 64], allowing dual practice (moonlighting) for HRH to supplement incomes [65], allowing flexible workhours [30, 39], providing professional development opportunities and specialty training [65], and considering compulsory service requirement before exit [1]. For example, in 2007, South Africa introduced the successful Occupation Specific Dispensation (OSD) policy, raising HRH salaries relative to those of counterparts in destination countries to attract and retain HRH in public health facilities [1, 49, 54, 64].

Repatriation policies

Voluntary repatriation policies, not outlined in the original framework, came up as a new category during our literature review (Table 2) [66]. Short-term repatriation, typically less than one year, allows a range of opportunities ranging from remote assistance (fundraising, advocacy, knowledge or technology transfers) to in-country support (clinical practice, teaching, establishing clinics) [15, 53]. Long-term repatriation, including permanent return, allows for highly engaged Africa-born HRH to share expertise and resources from abroad [15]. Circular migration, a hybrid of short and long-term repatriation, allows Africa-born HRH especially those with permanent residence status or dual citizenship to spend a considerable proportion of the year serving the health systems in Africa [8, 9, 18, 61].

Destination-country policies

Destination countries are often seen as not doing enough to stem the migration of Africa-born HRH [1, 12, 67]. Therefore, policies in African countries cannot succeed without the participation of destination countries, often high-income countries (Table 2). Such policy discussions require multisectoral collaboration with government, providers, payers, patient groups, and training institutions in both source and destination countries.

Short-term policies may include adhering to ethical guidance and codes of conduct on HRH recruitment and revising immigration laws to manage the migration of Africa-born HRH [9, 18, 43, 67]. This includes bilateral recruitment agreements between source and destination countries, as well as WHO Global Code of Practice on the International Recruitment of Health Personnel. Long-term policies include implementing cost-effective approaches to train additional HRH in destination countries, and compensating African countries for the cost of training HRH who migrate to destination countries [1]. For example, in 2003, United Kingdom signed a memorandum of understanding to manage HRH recruitment from South Africa, successfully halting active government-to-government recruitment and stemming the outflow of healthcare workers from South Africa to the UK [54, 68].

Regional, global policies

Multilateral policies have been recommended or implemented at Africa CDC, WHO, EU, OECD, and WTO to manage the migration of Africa-born HRH into and out of the continent (Table 2).

Africa CDC

The Africa CDC has begun to play a crucial role in Africa’s public health agenda by supporting HRH training and retention initiatives [69]. Partnerships between Africa CDC with funding institutions could prove useful in managing HRH migration. Prior to 2025, US President’s Emergency Plan for AIDS Relief (PEPFAR) supported HRH production of over 300,000 new health workers through a wide range of in-service trainings [12, 54, 70]. After 2025, PEPFAR—now part of the US Department of States’ Bureau of Global Health Diplomacy—transitioned toward country-led ownership which is expected to shift HRH production and retention [71]. The National Institutes of Health’s (NIH) Fogarty mechanism has been instrumental in training Africa-born HRH in research [72]. Similar partnerships in collaboration with Africa CDC can be leveraged to train, attract, and retain Africa-born HRH.

European Union (EU) and Organization for Economic Co-operation and Development (OECD)

Economic zones such as the EU and the OECD have a role to play in managing Africa-born HRH migration [1, 8]. This includes regulating work permits, issuing temporary visas to facilitate HRH return to source countries, and funding initiatives in member countries to improve self-sufficiency in HRH [1]. For example, the “Framework for action on the health and care workforce in the WHO European Region 2023–2030”, adopted in October 2023, focuses on retaining, recruiting, and protecting EU health workers through improved working conditions, mental health support, and fair pay [73].

World Health Organization (WHO)

The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted by the World Health Assembly in 2010, provides guidance and voluntary international standards for recruitment of health workers to improve the consistency of national policies and discourage unethical recruiting practices [21]. However, it has been criticized as weak and ineffective due to the voluntary nature of participation, inadequate political support and policy direction, limited publicity, limited incorporation into national laws and regulatory frameworks, and limited resources, areas which need to be addressed to stem migration of Africa-born HRH [67, 74, 75].

World Trade Organization (WTO)

The WTO has a role to play in rationalizing HRH migration by developing policies, strategies, and legal frameworks to improve the recognition, integration, and protection of Africa-born HRH in the destination countries [75, 76]. For example, while WTO’s General Agreement on Trade Services (GATS) can be used to enforce fair recruitment and compensation of Africa-born HRH in destination countries, it is limited in this context because it focuses on liberalizing the temporary trade of services rather than regulating the permanent employment markets, labor rights, or ethical health system safeguards required for Africa-born HRH.

HRH maldistribution and inefficiencies

Policies to manage HRH maldistribution and inefficiencies focused primarily on improving skill mix/composition and retaining HRH in underserved areas but not on improving HRH productivity and performance (Table 2).

On improving skill mix/composition, source countries addressed shortages occasioned by HRH migration by shifting routine tasks to lower cadres [8, 9] or importing HRH from other countries (e.g., physicians from Cuba) [54]. To retain Africa-born HRH in underserved areas, countries have implemented strategies such as targeted training, selection, and recruitment of HRH from underserved populations to improve retention [54], hiring staff with strong community ties [1], training new cadres of skilled HRH that can be deployed to underserved areas (e.g., clinical associates, pharmacy techs) [54] and incorporating eLearning programs to encourage HRH to remain in rural areas [17].

Private sector engagement

There was a paucity of literature on the role of private sector engagement on targeted migration of Africa-born HRH despite private sector’s potential to support governments in training, deployment (including dual practice), and service delivery (Table 2). In some source countries like Ghana and Cameroon, the private sector has been involved in HRH training [17, 62]. Other countries like Ethiopia officially endorse dual practice to supplement incomes for HRH, thereby improving retention [65].

Discussion

Migration of Africa-born HRH is complex and driven by a myriad of economic, professional, social, and political drivers at individual, institutional, and system levels. Inadequate pay, poor work environments, limited prospects for professional advancement, and political instability are key push factors that draw Africa-born HRH to better opportunities abroad. Conversely, Africa-born HRH return due to high living costs, discrimination, deskilling, improved economic and political conditions in Africa, cultural ties, and opportunities for impact or circular migration. While our findings align with the “push–pull” framework, our review highlights a contemporary shift toward circular and return migration based on a desire to return home, not just economic gain [13, 24, 28, 60].

Policies at national, regional, and global levels have been proposed or enacted to address drivers leading to the migration of Africa-born HRH. Some source countries, such as South Africa, have managed to reduce out-migration and promote return due to economic improvements and political stability [54]. Although such large-scale policies might be challenging to effect, smaller scale HRH-specific policies such as improving salaries, offering dual practice, and targeted selection and training of HRH to work in rural/underserved areas can address economic push factors and improve retention. Of note, formal return-of-talent programs, such as South Africa’s African Health Placement (AHP) initiative and similar efforts in Ghana and Zimbabwe, have had limited success in encouraging Africa-born HRH to return for short- or long-term stays [1, 54]. These costly programs have attracted few returnees, particularly when underlying drivers like political instability remain unaddressed.

In destination countries, ethical recruitment practices, revised immigration laws, and cost-effective strategies to train local HRH are critical [18]. For example, bilateral agreements, such as the UK’s memorandum with South Africa, have demonstrated success in regulating recruitment and mitigating HRH outflows [54]. Long-term measures, including compensation for training costs incurred by source countries and development of targeted migration programs to train and export Africa-born HRH, may also be considered [1].

Multilateral, rather than bilateral, agreements may be better suited to regulate Africa-born HRH migration due to the complexity of managing diverse source and destination countries [20]. At the regional level, Africa CDC is well-positioned to harmonize training, licensure, registration, and skill transfers across African countries especially during crises and pandemics [20, 60, 63]. Africa CDC should develop a concierge service unit to lower barriers to the return of HRH [32]. Some of its ‘concierge’ functions might include translating medical degree and license equivalents across health systems in Africa, matching diaspora offerings with needs of source countries, and simplifying regulatory processes for travel. Africa CDC should expand the use of AVoHC Net, its online new web-based tool to facilitate rapid deployment of standby workforce for public health emergencies across Africa, by including Africa-born HRH outside the continent [60, 63, 77]. By proposing a stronger role for the Africa CDC, our study calls for regional harmonization to prevent the “patchwork” of agreements from exacerbating health workforce inequities [78]. EU and OECD countries can implement policies to reduce dependency on Africa-born HRH by supporting fair recruitment practices, increasing local HRH training capacity, regulating temporary visas to facilitate circular migration, and providing funding for HRH development in source countries [75, 79].

Global institutions like WHO and WTO need to play a more prominent role in managing migration of Africa-born HRH. Many of the papers we reviewed echoed concerns that the voluntary nature of WHO’s Global Code of Practice on International Recruitment limits its effectiveness. Integrating the Code into national laws and providing robust governance, financing, and enforcement mechanisms would strengthen its impact [16, 18, 74, 80]. WTO can use trade agreements to enforce ethical recruitment, ensure fair compensation, and establish legal frameworks to protect Africa-born HRH against discrimination and exploitation [34, 55, 79].

Voluntary repatriation policies, a new category from our review, offer an innovative approach to encourage the return of Africa-born HRH [53, 60]. Short-term returns enable knowledge transfer and capacity building, while long-term or permanent returns ensure sustained contributions. Circular migration, supported by dual citizenship or permanent residency, provides flexibility for Africa-born HRH to work across borders. Incentives such as streamlined licensing, competitive remuneration, and professional development opportunities can be used to make repatriation more attractive.

The private sector appears largely untapped, based on the paucity of literature on its role in addressing migration of Africa-born HRH. While the private sector has been used to support training and dual practice, as seen in Ethiopia [65], its contribution to enhancing service delivery and mitigating HRH migration remains underexplored. Public–private partnerships can be used as a policy tool to incentivize private sector investments in rural/underserved areas and to augment government efforts in HRH training, deployment and retention, potentially reducing migration pressures among Africa-born HRH.

International funding mechanisms (e.g., Global Fund) and philanthropies (e.g., Gates Foundation) hold significant untapped potential in addressing the migration of Africa-born HRH. For example, the Global Fund will invest over US$900 million to train and deploy community health workers between the 2024 and 2026 [81]. The Gates Foundation has made strategic health system strengthening investments with a particular focus on HRH development in source countries [82]. Similar institutions can play a critical role in promoting better working conditions, enhancing HRH development, strengthening health infrastructure, and advocating for policy reform making source countries a viable option for HRH.

This study has several strengths. First, we explored a wide range of economic, professional, political, and social drivers of Africa-born HRH migration which we used to identify policy interventions for both source and destination countries. Second, we utilized the WHO policy levers framework to systematically analyze Africa-born HRH migration. This approach enabled us to identify gaps in existing policies and provide a structured foundation for developing multilevel, evidence-based solutions that align with global health strategies and regional priorities. Third, we identified repatriation policies as an innovative approach to encourage return of Africa-born HRH from destination countries.

We acknowledge several limitations to this work. First, we focused on English-language articles, potentially introducing geographic bias and excluding relevant non-English studies. Since a substantial proportion of the articles (26/65, 40%) focused on HRH at the Africa continent level, we believe we have adequately accounted for perspectives from non-English speaking countries. Second, although the search strategy for our scoping review was comprehensive, this was not a systematic review, and we may have omitted relevant peer-reviewed and gray literature. Third, this analysis was not intended to be quantitative, therefore we did not rank the relative importance of migration drivers or prioritize the effectiveness of policy interventions in mitigating the movement of Africa-born HRH. Fourth, the use of a single reviewer for title/abstract screening and full-text review which may have introduced selection bias. Fifth, we did not assess cross-cutting interdependencies between drivers, a potential area for future research. Finally, we did not review intra-Africa migration of Africa-born HRH as this was outside the scope of our paper. This would have provided additional insights into regional migration trends and the impact of intra-continental mobility on health systems within Africa, which may require separate exploration.

Conclusion

The migration of Africa-born HRH presents challenges and opportunities for source and destination countries. Addressing the economic, professional, social, and political drivers of migration through targeted policies at national, regional, and global levels is essential. The current changes in US government global health funding will likely be push factor for Africa-born HRH, as economic constraints and resource shortages exacerbate conditions that drive migration. Now, more than ever, collaborative efforts involving governments, regional bodies, and the private sector, including innovative repatriation programs and private–public partnerships, are critical to achieving sustainable solutions and strengthening health systems across Africa.

Abbreviations

Africa CDC

Africa Centers for Disease Control and Prevention

AU

Africa Union

EU

European Union

HRH

Human Resources for Health

NIH

National Institutes of Health

OECD

Organization for Economic Co-operation and Development

OSD

Occupation Specific Dispensation policy

PEPFAR

U.S. President’s Emergency Plan for AIDS Relief

WHO

World Health Organization

WTO

World Trade Organization

Author contributions

JJ and MP conceived, designed, and supervised the scoping review. BW implemented the study, developed the data extraction tool, curated the data, conducted the formal analysis, and wrote the original draft. JJ and MP reviewed and revised the manuscript. All authors approved the final draft for submission.

Funding

None.

Data availability

No datasets were generated or analyzed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Patient and public involvement

Patients and/or the public were not involved in the design, conduct, reporting, or dissemination plans for this research.

Disclaimer

Funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The views expressed in this article are those of the authors and do not represent the views of the WHO.

Competing interests

None declared.