A steady outflow of skilled healthcare workers emigrating abroad continues to hamper Zambia’s efforts to deliver quality care. The country is exploring fresh approaches to retain and recruit talent, including improved salaries and better career pathways.
Zambia is exploring fresh approaches to retain and recruit talent. Photo: World Bank/Vincent Tremeau
With a ratio of just one doctor for every 12,000 patients and one nurse for every 14,960 patients—far below World Health Organization (WHO) recommendations of 1 to 5,000 and 1 to 700 respectively—Zambia is grappling with a severe shortage of healthcare workers. The outflow of skilled professionals to neighbouring countries or overseas, driven by factors such as low salaries, limited career opportunities, and challenging working conditions, is a primary contributor to the crisis.
Faced with unfavorable employment—or, in some cases, an inability to find work despite the shortages—many Zambian doctors and healthcare workers follow the path of countless other qualified professionals who trained in the country: they migrate abroad in search of better opportunities.
The ongoing shortage of healthcare workers hampers Zambia’s ability to deliver quality healthcare to its citizens and achieve universal health coverage (UHC). “Overworked staff leads to reduced service quality, which inevitably leads to less-than-ideal care, hindering our progress toward the Sustainable Development Goals (SDGs) and UHC,” explains Dr Oliver Kaoma, secretary general for the Zambia Medical Association.
Zambian healthcare workers emigrating abroad
Kaoma highlights the stark reality of the problem, explaining that Zambia requires 22,000 doctors but currently employs only around 3,400 in public institutions. He says recent data from the Health Professions Council of Zambia indicates employment of 10,000 public and private sector doctors across the country; however, this figure includes workers who have migrated or passed away but retain active licenses.
The shortfall is evident in the number of doctors graduating from universities, and it is exacerbated by the difficulty many of these professionals face securing employment. According to Kaoma, Zambia produces 600–800 doctors annually from 10 medical schools, and an additional 100–200 foreign-trained doctors arrive in the country each year. But only around 500 of these doctors can secure employment in the public sector.
“This means we have around 500 doctors not employed every year,” Kaoma says, explaining that nurses and other healthcare workers face similar problems.
He says the recruitment of healthcare workers is often beset by financial problems. “The government says it has limited fiscal capacity to recruit [healthcare workers].” Private institutions do not fare much better, Kaoma explains, as they keep staffing levels lean and rely on part-time staff to cut costs.
Among those who find work, working conditions can be challenging and healthcare workers are often faced with extra expenses that chip away at their earnings. Kaoma says it is common practice for healthcare workers to cover the cost of relocating within the country. In violation of their employment contracts, many are not paid their gratuities. “This is demotivating, and people opt to seek greener pastures,” Kaoma says.
Going abroad for better pay and conditions
While the Zambian Ministry of Health does not track the number of healthcare workers emigrating abroad and no recent surveys have been undertaken, a 2012 report by the Aspen Institute put the overall emigration rate for qualified health workers at 10%, with nurses emigrating at 9.2% and physicians emigrating at a whopping 57%. Anecdotal evidence suggests that similar emigration patterns continue to persist.
“It’s not unusual for people to find themselves being treated by Zambian professionals in neighbouring countries like South Africa, Zimbabwe, and Namibia.”
An earlier study indicated that the UK, the US, and South Africa receive the highest number of Zambian-born nurses, while the UK and the US employ the most physicians.
Tracy Namakando, who runs Luto nursing agency in Lusaka, says Zambian healthcare professionals migrate to the US because demand for specialised workers is high. Many enter through programs like the Diversity Visa Program or with temporary work visas, such as the H-1B for skilled professionals.
Australia, Canada, and New Zealand are also popular destinations for Zambian healthcare workers as they have strong healthcare systems and offer opportunities for professional growth. These countries have skilled migration programs that allow healthcare workers to gain permanent residency.
Namakando notes that many healthcare professionals work in rural or underserved areas of foreign countries, including in Africa, where better pay enables them to send significant financial support to their families back home—something they often cannot achieve in Zambia. “It’s not unusual for people to find themselves being treated by Zambian professionals in neighbouring countries like South Africa, Zimbabwe, and Namibia,” she says.
Many healthcare professionals choose to emigrate in order to provide financial support to their families. Photo: SolidarMed
Professor Emmanuel Makasa, a Zambian orthopaedic surgeon who has written several papers on the country’s healthcare worker shortage, says the government must take a more active role in managing the migration and retention of healthcare workers.
Zambia is making progress in its attainment of UHC, but Professor Fastone Goma, vice chancellor at Eden University and former dean of the School of Medicine, says the brain drain of healthcare workers is a significant impediment.
He believes the recent recruitment of more healthcare workers, while being a positive move, still leaves a gap. “The government is employing entry-level healthcare workers—what we are missing are the specialised and seasoned professionals who are leaving the country,” Goma says.
Weighing up salary, family, and clinical factors
Judith Muyambwa, a medical doctor who left Zambia in 2020 to move to New Zealand, says the low salary she received at her job in a small rural clinic in the west of the country, equivalent to US$250 a month, led her to leave behind her family of three children and an ageing mother to find a better paying job overseas.
“I know it looks unpatriotic for those of us who leave, but after so many years of studying and suffering, only to get paid a pittance, I had to make the hard decision to leave my family and go somewhere from where I could afford to send money back home,” she says.
A World Bank report estimated that personal remittances from all Zambian workers in relation to GDP was about 0.9% in 2023. The migration and data portal suggests that in 2023, Zambia received US$240 million, mainly from the US and the UK.
Muyambwe is sponsoring three of her sisters to study for diplomas in nursing care so they can join her in New Zealand, and she will be bringing her children and mother to live with her next year. “All of us immigrants do the same thing—it’s about survival and choosing the best living standards for ourselves and our families,” she says.
“All of us immigrants do the same thing—it’s about survival and choosing the best living standards for ourselves and our families.”
However, not everyone shares this view. Makasa stands by a letter he wrote to the BMJ in 2005 in which he outlined six reasons for not wanting to emigrate. One of these reasons was that working in Zambia provided him with early access to surgeries he wouldn’t have experienced so soon in his career abroad.
Makasa, a Fulbright scholar in public health epidemiology, states that “the experience I get in Africa is far richer than that in the UK or US. My logbook shows the number of supervised operations I have performed, and the outcomes of these, and shows how I have rapidly and competently evolved to performing major surgery on my own. I have seen the logbooks of registrars of comparable seniority in the UK and elsewhere, and there is no comparison.”
He adds that though his pay is poor, he has enough money to live in a reasonable house in Lusaka, and with the support of his family and friends he is sustained through the long hours he works.
Today, Makasa says, “I have even more reasons [for refusing to migrate]. If I was ever to live my life again, I would still choose to remain in Africa.”
Jude Bwalya, a physiotherapist, shares a similar sentiment. He worked in the UK for three years between 2009 and 2012 and found that being far away from home wasn’t worth the high salary he was earning.
“Granted, I was earning a lot of money, but I was suffering from bouts of depression. I was missing out on family time—my children were going to good schools, but I was not there to enjoy that with them. My wife was able to stay at home and look after the children, but she was essentially a single mother, and that did not sit right with me,” Bwalya says.
After returning to Zambia, he found employment in a public hospital in Lusaka. “It’s hard, the money is not great, but I am happier to have my family around me.”
Carrots and sticks encouraging workers to stay
To stem the flow of emigration, the World Health Organization (WHO) has earmarked Zambia as having a critical shortage of healthcare workers. Consequently, it discourages countries, particularly those with more robust healthcare systems, from recruiting healthcare professionals from Zambia. This measure is intended to prevent further exacerbation of healthcare workforce shortages in Zambia and encourage efforts by the local health system to retain and develop its workforce.
Aspiring doctors and nurses receiving hands-on training as part of their university studies in Zambia. Photo: SolidarMed
There are, however, limits to the effectiveness of this approach. The UK issued its red list in March 2023 in which it proscribed the active recruitment of foreign healthcare workers from seven countries, including Zambia. The trouble is that private institutions continue to hire Zambian workers.
Kafwa, a recruitment agency helping Zambian medical personnel secure employment with the UK National Health Services (NHS), was forced to officially close its doors due to the release of the red list, but it continues to help nurses get jobs outside of the NHS.
George Muluwe, a gynecologist from Kabwe, a town just outside Lusaka, got help from Kafwa to join a private clinic in Scotland this year. “I understand what the WHO is trying to do, but I was tired of working long hours in poor facilities [in Zambia]. I could not take leave because there was a constant shortage of staff—[there was] no work-life balance,” he says.
In Zambia, the government is trying to bridge the human resource gap and combat the brain drain by employing more healthcare workers. The Ministry of Health reported in September 2024 that more than 20,000 healthcare workers have been recruited in the last three years, including 13,000 in 2022 and 3,000 in 2023. It was also expecting an additional 4,029 from a recruitment drive. This, it says, marks an unprecedented increase in the number of new healthcare personnel working in the country.
“We cannot stop people from migrating, but what we try to do is create a conducive environment for them to stay.”
In the 2022–26 National Health Strategic Plan, Zambia lists mitigating the critical shortage of qualified health workers as one of its three objectives. The Ministry of Health has expanded from 63,057 positions in 2016, including those held by non-clinical staff, to 126,831 positions in 2021. Of these, 48% (63,878) of the positions have been filled, leaving a gap of 52%. The Ministry projects it will have filled 70% of the positions by 2026.
Other efforts being made to retain healthcare workers include the Health Workers Retention Scheme (HWRS), which offers financial and non-financial incentives to healthcare workers, particularly those serving in rural and remote areas, including hardship allowances, education allowances for children, housing support, and vehicle loans. Strengthening community health worker programs alleviates the burden on healthcare professionals and improves access to primary healthcare services in rural areas.
The Ministry of Health hopes that improved working conditions in healthcare facilities—including adequate resources, better infrastructure, and safer working environments—and career development opportunities like continuing education can entice healthcare workers to stay in Zambia.
Perhaps most crucially, the government is working to increase salaries for healthcare workers to make them more competitive.
“We cannot stop people from migrating, but what we try to do is create a conducive environment for them to stay,” Kaoma says.
Local solutions to retain healthcare workforce
Working with the Ministry of Health, SolidarMed is one of several cooperating partners and agencies using non-monetary incentives such as housing, education, and facility improvements to retain healthcare workers, especially in rural Zambia.
Country director John Tierney explains that lack of housing and poor working conditions deter many healthcare workers from serving in rural areas. “We found that, contrary to popular opinion that healthcare workers wanted a lot more money, their main worry was not having good affordable accommodation,” he says.
In 2011, SolidarMed, together with the Hilti Foundation, launched the Ubuntu Homes housing cooperative project. The initiative provides affordable housing solutions through an independent social enterprise. By the end of 2023, five hostels and 120 houses for healthcare workers had been built in several provinces.
Tierney says SolidarMed and the Hilti Foundation will gradually transfer responsibility of these dwellings to an independent social enterprise that will support high-quality maintenance and future growth.
SolidarMed also set up practical training centres that allow prospective doctors, medical licentiates, and nurses to gain hands-on experience alongside their university teaching. The dual-training approach accelerates learning and ensures early clinical exposure.
Looking ahead, Kaoma says government efforts to scale up recruitment should be supported by a diverse portfolio of retention strategies. “We need to be innovative to consider other solutions that might seem radical or that have not been tried before,” he says, citing the importance of establishing broad career pathways in the health sector. “We shouldn’t just look at wards, but outreach in the communities.” People who specialise in public health can work in community facilities, he says, rather than be limited to healthcare facilities.
Makasa suggests a student loan scheme that ties graduates to government jobs after graduation and low-interest loans to help healthcare workers set up medical practices as other potential antidotes to the shortages.
While the issue has global origins, the remedies must be local. “Although there is need for stronger international cooperation, the primary solutions can and must come from within Zambia,” Makasa says.
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