The inverse primary care law in sub-Saharan Africa: a qualitative study of the views of migrant health workers

Abstract

BackgroundMany low-income and middle-income countries globally are now pursuing ambitious plans for universal primary care, but are failing to deliver adequate care quality because of intractable human resource problems. AimTo understand why migrant nurses and doctors from sub-Saharan Africa did not wish to take up available posts in primary and first-contact care in their home countries. Design and settingQualitative study of migrant health workers to Europe (UK, Belgium, and Austria) or southern Africa (Botswana and South Africa) from subSaharan Africa. MethodSemi-structured interviews with 66 health workers (24 nurses and 42 doctors) from 18 countries between July 2011 and April 2012. Transcripts were analysed thematically using a framework approach. ResultsThe reasons given for choosing not to work in primary care were grouped into three main analytic streams: poor working environment, difficult living experiences, and poor career path. Responders described a lack of basic medicines and equipment, an unmanageable workload, and lack of professional support. Many had concerns about personal security, living conditions (such as education for children), and poor income. Primary care was seen as lower status than hospital medicine, with lack of specialist training opportunities and more exposure to corruption. ConclusionsClinicians are reluctant to work in the conditions they currently experience in primary care in sub-Saharan Africa and these conditions tend to get worse as poverty and need for primary care increases. This inverse primary care law undermines achievement of universal health coverage. Policy experience from countries outside Africa shows that it is not immutable.

“Why should I have come here?” - a qualitative investigation of migration reasons and experiences of health workers from sub-Saharan Africa in Austria

“…The interview guide included questions regarding migration motives, views on primary health care, changes needed in the country of origin to retain health workers, transnational ties of the migrant health worker, and future plans [ 8 , 41 ]. For the Austrian research, the English guideline was translated into German and French; interviews were conducted in the language preferred by the study participant.…”

“…Pull-factors include better remuneration, better working conditions, and opportunities for professional development in target countries [ 4 - 7 ]. Current studies continue to confirm these factors [ 8 ].…”

“…The Austrian study is linked to others conducted in Europe (Belgium, UK) and Africa (Botswana, South Africa) in the same period, in the same larger context within the larger framework of the HURAPRIM project (EU-FP7) on human resources in primary health-care in sub-Saharan Africa ( http://www.huraprim.ugent.be/ ). The overall aim of all of these studies was to understand why health workers from different regions of sub-Saharan Africa leave their countries of origin [ 8 ]. This paper in particular focuses on the reasons for migration, and the post-migration experiences of health workers who migrated from a sub-Saharan African country to Austria.…”

Stakeholders’ Perceptions on Shortage of Healthcare Workers in Primary Healthcare in Botswana: Focus Group Discussions

“…‘Health workers save lives’[ 1 ] and primary healthcare (PHC) holds the key to improving access to healthcare for underserved communities and reaching the Millennium Development Goals [ 2 ]. Severe shortages of healthcare workers (HCWs) have, however, hampered the efforts of many low-to-middle-income countries in providing universal PHC [ 3 , 4 ]. Promoting the retention of HCWs and developing effective systems for PHC delivery will facilitate improvements in community health and equity, and potentially reduce the total cost of healthcare services [ 2 ].…”

“…Botswana is an upper middle income country with relatively high expenditure per capita on health [ 8 ] and a destination for many health professionals, especially from sub-Saharan Africa [ 3 ]. The country therefore has more health workers per population than many countries in the region [ 8 ].…”