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

Background: Many 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. Aim: To 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 setting: Qualitative study of migrant health workers to Europe (UK, Belgium, and Austria) or southern Africa (Botswana and South Africa) from sub-Saharan Africa. Method: Semi-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. Results: The 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. Conclusions: Clinicians 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. ©British Journal of General Practice.