Trained but unpaid: Africa’s health workforce paradox

A surplus of trained health workers across sub-Saharan Africa hides a troubling reality: thousands remain unemployed or unpaid due to a shortage of funded positions. Aligning training with funded posts and rural deployment could help close gaps in care.

Countries across sub-Saharan Africa report critical shortages of health workers; yet thousands of trained nurses, midwives, and clinicians remain unemployed. Photo: Ezebunwo Omachi

On a humid morning in Freetown, Sierra Leone, Kadiatu* reports for duty at a government hospital. The community health nurse checks patients, administers drugs, and helps deliver babies just as her salaried colleagues do. The only difference is that Kadiatu has not been paid for the five years she has been working as a nurse. “In some facilities, almost everyone working there is a volunteer,” she explains. “Because I am not paid, I have to…find other ways to survive.”

Across sub-Saharan Africa, scenes like this are common. Countries report critical shortages of health workers, yet thousands of trained nurses, midwives, and clinicians remain unemployed, under-employed, or unpaid. Graduation ceremonies grow larger each year, but hiring freezes, capped wage bills, and weak workforce planning mean many qualified health workers never make it to the payroll. Consequently, communities receive insufficient care, while skilled professionals wait, often for years, for a paid post.

This is the region’s health workforce paradox: a surplus of trained workers that coexists with a shortage of paid posts, revealing that training more people alone will not fix broken systems.

Surplus and shortage of health workers

Countries across sub-Saharan Africa have expanded health training capacity rapidly over the past decade, including through private colleges. In 2022, there were 2.6 million doctors, nurses, midwives, dentists, and pharmacists in the World Health Organization (WHO) African region—three times as many as a decade earlier.

But that growth has not been matched by sustained investment in funded posts or incentives needed to deploy health workers where care is most needed. Recent studies suggest that unemployment among health workers across sub-Saharan African may be as high as 24%, based on data from 10 countries.

“Typically, you can go to a health centre and you’ll find mothers queuing for their babies to be immunised,” says Dr George Kimathi, director of the Institute of Capacity Development at Amref Health Africa, explaining that there are not enough nurses on duty to perform the immunisations. “Or the lab doesn’t have a lab technician, but in the same village there is a lab technician who is not employed.”

Amref International University student Naomi Sintamei visits a family in Kilifi County, Kenya, as part of community healthcare provision during her internship. Photo: Amref Health Africa/David Brazier

Kimathi says addressing health worker shortages is not simply about producing more graduates but aligning training to funded demand. At its university in Kenya and within its training programmes, he says Amref focuses on cohorts and skills that support primary healthcare, including nursing and physiotherapy, while advocating with governments to ensure graduates are ‘fit for purpose’ and employable in public and private systems.

Dr Pieternella Pieterse, a research fellow in health systems and human resources for health at the Royal College of Surgeons in Ireland, says public-sector wage bills are tightly controlled and health budgets have not kept pace with population growth or disease burden across sub-Saharan Africa. She notes that “more and more people are currently being trained, but there simply isn’t enough budget available to recruit people [into paid positions]”.

Without sustainable financing for health workers, decent working conditions, and clear deployment pathways, especially to rural and primary care roles, the relatively large investments in education risk being wasted.

Paradoxically, unemployment among trained health workers does not mean that workforce needs have been met. “Even if you recruited every single individual who is currently trained but unemployed, you might still have a shortage,” Pieterse says, referring to published data.

The contradiction exposes a central flaw in workforce policy. Without sustainable financing for health workers, decent working conditions, and clear deployment pathways, especially to rural and primary care roles, the relatively large investments in education risk being wasted.

Shortages are not just about numbers

The gap between the ‘need’ for health workers (usually calculated based on WHO guidance) and the ‘demand’ (the actual jobs available) results in many sub-Saharan African countries falling short of meeting the WHO-recommended 44.5 doctors, nurses, and midwives per 10,000 people. But these metrics can hide deeper constraints. “The word ‘need’ is a little bit problematic,” Pieterse argues. “In many countries, care is funded largely through out-of-pocket payments. Even where workers exist, patients may not be able to afford to see them.”

Posts may exist on paper but remain vacant, especially in rural areas, because of poor housing, insecurity, or limited opportunities for professional progression. Photo: Pixabay

Geography matters, too. Posts may exist on paper but remain vacant, especially in rural areas, because of poor housing, insecurity, lack of schools for children, or limited opportunities for professional progression. In these contexts, shortages persist alongside unemployment among trained health workers.

“When governments invest in basics, including water, power, commodities, housing, and security, health workers are more likely to take and keep rural roles,” highlights Kimathi. “Recruiting and training students from rural areas would also help to improve retention [in rural areas].”

Working conditions and infrastructure are critical for recruitment and retention. In rural posts in particular, facilities must be safe and functional for health workers to do their jobs effectively. Explains Kimathi: “I don’t want to be in a health centre when a mother comes and they require a caesarean delivery, and I cannot do it…because the theatre doesn’t have water or electricity.”

Working without pay in Sierra Leone

Nowhere is the paradox arguably more visible than in Sierra Leone, where an estimated 50% of the country’s health workforce is unsalaried due to insufficient paid opportunities. Demand for healthcare, and the workers who provide it, has remained high since 2010 when an initiative was introduced to make primary care more accessible for mothers and children under five. Yet this demand has not been matched by a corresponding increase in funded positions for health workers.

“Many of us working in the health system are trained, but not paid. In many primary health units, only one person is formally paid; the rest are volunteers.”

Kadiatu, the community health nurse, worked in an unpaid nursing job before completing her formal training. After qualifying, she returned to the same role, still without a salary. “Many of us working in the health system are trained, but not paid,” she says. “In many primary health units, only one person is formally paid; the rest are volunteers.”

She has undertaken further professional training and is preparing to become a state-registered nurse, hoping that a government position will eventually open. But to survive, Kadiatu runs a small clothing business and takes on advocacy work. “I have family responsibilities with my parents and children,” she says. “Volunteering alone cannot support that.”

Pieterse’s research shows this experience is widespread across the country, with unpaid volunteers delivering essential services while waiting to be absorbed onto payrolls. “Waiting to be put on the payroll can be two years, five years… I’ve spoken to people who waited eight years,” she says.

For health systems, this creates hidden risks. Informal payments become normalised; trust erodes. Patients sometimes find that care in public facilities costs more than in private clinics. “Somebody’s going to extract money at the gate,” warns Pieterse of the risk of informal payments.

Health financing falling short

Targets such as the Abuja Declaration’s call for governments to allocate 15% of national budgets to health can help sustain political pressure. But Kimathi says that in practice, most countries across sub-Saharan Africa allocate far below that level, often closer to 6–8%.

He points to stark disparities in health spending between high-income countries that contribute thousands of dollars per person each year to health, and that of low-income countries. “For most governments on the continent [Africa]… you get to USD$70, USD$80, slightly above USD$100 [per capita annually] for some countries,” said Kimathi. In this context, even obvious fixes, like hiring the missing lab technician, become difficult.

“Healthcare expenditure often stays within the physical building of the Ministry of Health. You see administrative costs, travel allowances, and capital city priorities, but not salaries for rural nurses.”

He argues that African countries juggle different priorities and health is always battling with other important needs. “You’ll find in most countries, governments are spending a large proportion of budgets on debt,” he says. “And therefore, they have been given wage-bill ceilings… so they can’t go beyond a certain level of their budgets, including on health salaries, even when services are visibly understaffed.”

Even within health budgets, funding does not always reach frontline services. “Healthcare expenditure often stays within the physical building of the Ministry of Health,” Pieterse says. “You see administrative costs, travel allowances, and capital city priorities, but not salaries for rural nurses.”

Donor funding can complicate matters. External partners often fund training or short-term projects, while governments divert domestic resources elsewhere. The result is more graduates, but no funded posts.

Kimathi points out that smoother labour mobility within Africa itself, with harmonised recognition of qualifications, would allow countries with surplus capacity in certain professions to fill gaps elsewhere, “but only if deployment systems are designed to measure and respond to real workforce need, not just training output”.

The human cost of a broken pipeline

For Kadiatu, the consequences of working as an unpaid volunteer are personal. “When you are unpaid, your commitment is limited by survival,” she says. “I want to serve my country, but I also need to earn a living.” She worries that young people in Sierra Leone are losing faith in health careers. “People turn to business instead. They see that training as a healthcare worker does not guarantee a job.”

Some volunteers, she says, have worked 10 or 15 years without pay. “As long as the system relies on volunteers, there is little incentive for government to change.”

Unpaid volunteers keep fragile systems running in countries like Sierra Leone, but at enormous personal cost to health workers. Photo: Mk_Photoz

Sub-Saharan Africa’s health workforce crisis is not a failure of ambition, but of alignment. Beyond the constraint of funding, coordination is likely to have the greatest impact on matching surplus with shortage of paid healthcare workers.

Kimathi argues that ministries rarely pull in the same direction, yet solving the paradox requires joint decision-making on training, payroll, deployment, and incentives. “If [a country’s] Ministry of Health, Ministry of Education, Ministry of Labour, and Ministry of Finance sit down together… to figure out the best solution to this, we would, to a good extent, start addressing this issue,” he says.

Training more people without funding their future jobs creates a surplus that feels like shortage.

Training more people without funding their future jobs creates a surplus that feels like shortage. Unpaid volunteers keep fragile systems running, but at enormous personal cost. “Financing, deployment, and protection must change first,” Pieterse says.

For Kadiatu, the solution is simple. “If I were employed and paid, I would know my responsibility,” she says. “But without a salary, you cannot depend on volunteering forever.”

Until governments close the gap between classrooms and clinics, the paradox will persist, and so will the queues of patients waiting for care.

*Surname withheld at interviewee’s request