Retention of skilled health workers in Africa: the migration–governance–environmental nexus

Introduction

The retention of skilled health workers (SHWs) in Africa is far more than a logistical or budgetary hurdle; it is a profound human capital crisis that threatens the very foundations of continental development and global health security. Sub-Saharan Africa remains the epicenter of a global health workforce paradox. While the region bears nearly 25% of the world's disease burden, it is served by only 3% of the world's health workers, a disparity significantly worsened by the persistent emigration of skilled professionals (Joshi et al., 2023). A recent scoping review highlights that African nurses and other health professionals are increasingly migrating, reducing workforce-to-population ratios and undermining national life expectancy (Adam et al., 2025).

The World Health Organization, 2022 identifies inadequate remuneration, poor working conditions, corruption, political instability, and limited career progression as key drivers of this mobility. Yet, as we move further into the 21st century, it has become clear that migration is not merely a relocation for economic gain; it represents a profound social transformation shaped by governance, institutional capacity, and community expectations (Castles, 2018). Corruption, in particular, functions not merely as a background governance weakness but as a direct driver of attrition: budget leakages and nepotistic promotion pathways erode professional trust in the state and are treated throughout this paper as a central, rather than incidental, determinant of mobility (Chivandire et al., 2024; Mutswiri et al., 2025). In Africa, weak political institutions and inequitable resource distribution amplify attrition, while stronger governance frameworks can stabilize retention (Ali, 2019; Nzimande et al., 2025).

Environmental change adds a modern, urgent layer of complexity to this crisis. Climate shocks such as droughts and floods intensify resource scarcity, destabilize rural livelihoods, and increase patient loads in under-resourced facilities (Anayo, 2024). Countries with lower institutional capacity face greater challenges in adapting to these stresses, leading to higher staff attrition rates among those on the front lines of ecological collapse (Castro Lopes et al., 2017). Despite growing attention to these population-environment linkages, there remains limited exploration of how social, political, and environmental factors jointly determine health worker mobility. This study addresses that gap by situating retention-focused Human Resources for Health (HRH) strategies within the broader migration–governance–environmental nexus. In doing so, the paper deliberately narrows the “social” dimension of this nexus to governance and institutional capacity — the specific structural mechanisms substantiated by the reviewed literature and the Delphi panel — rather than treating “social” as a diffuse catch-all category encompassing unexamined cultural or demographic factors. Drawing on comparative insights from Eswatini, Lesotho, Nigeria, South Africa, Zambia, and Zimbabwe, the study highlights both successes and shortcomings of current approaches and offers recommendations for integrated, multidimensional strategies to advance Universal Health Coverage (UHC).

Problem statement

Despite growing recognition of the role of social, political, and environmental factors in shaping global migration, there remains limited exploration of how these interconnected forces affect the retention of skilled health workers in Africa. Existing studies often isolate financial incentives or professional development as solutions, without adequately addressing the broader systemic drivers of mobility, such as governance weaknesses, climate shocks, and institutional transformation. This gap in the literature constrains the design of effective, sustainable HRH strategies. By situating retention within the migration–governance–environmental nexus, this research seeks to illuminate the multidimensional determinants of health worker mobility and propose integrated approaches that strengthen health systems and advance Universal Health Coverage (UHC).

Research objectives

This research pursues the following objectives:

• To analyze how social, political, and environmental contexts intersect to shape health worker migration in Africa.
• To evaluate the strengths and limitations of current HRH retention strategies across Eswatini, Lesotho, Nigeria, South Africa, Zambia, and Zimbabwe.
• To propose integrated, multidimensional approaches that embed governance reforms, workplace improvements, and climate resilience into HRH retention policies.
• To contribute to global migration scholarship by situating African HRH retention strategies within broader debates on human mobility and institutional transformation.

Conceptual framework

The conceptual framework for this study illustrates how multiple, interconnected drivers shape skilled health worker migration and retention in Africa, ultimately influencing progress toward Universal Health Coverage (UHC). This framework is visualized across four main domains: Migration Drivers (Push and Pull Factors); Social, Political, and Environmental Contexts; Retention-Focused HRH Strategies; and Outcomes (see Figure 1). It is important to clarify that the Migration–Governance–Environmental Nexus is not a pre-existing, universally accepted theoretical model. It is the central conceptual contribution advanced by this study, synthesized inductively from the reviewed literature and triangulated through the Delphi consensus reported in the Findings section (Table 1).

Table 1. Reflective insights from the three-round delphi consensus (n = 14 African scholars), organized by manuscript theme.

At the heart of this framework is the recognition that the health worker is not a static unit of labor but a social actor. Their decision to stay or leave is mediated by the “Environmental Change Nexus,” where climate shocks interact with institutional readiness. For example, environmental scarcity does not automatically lead to migration; outcomes are mediated by governance and social cohesion (Freeman, 2017). When governance is weak, environmental stress acts as a “threat multiplier,” accelerating the decision to emigrate.

Methodology

Consistent with the perspective-paper format of this article, the methodology below is not presented to generate new primary empirical data in the manner of a systematic review, but to make the authors' interpretive and narrative synthesis process transparent, reproducible, and auditable — in line with recommended practice for reflective and position papers in global health (Khalil and Alameddine, 2020). The study, therefore, remains, in form and intent, a perspective piece: its contribution is conceptual and interpretive (the Migration–Governance–Environmental Nexus), not a statistically generalizable result.

This study adopts a comparative, interpretive, and narrative synthesis approach to examine retention-focused HRH strategies. Rather than generating new empirical data, the methodology emphasizes integrating existing literature, policy documents, and collaborative reflections from African scholars in Eswatini, Lesotho, Nigeria, South Africa, Zambia, and Zimbabwe. This approach is particularly suited to addressing the multidimensional nature of health worker migration, which is shaped by layered social and political contexts.

To ensure transparency and systematic reproducibility, this narrative synthesis followed a structured literature retrieval protocol. The Google Scholar database was comprehensively searched to support the authors’ narrative perspectives. The search string applied across titles and abstracts utilized combinations of Boolean operators: (“health worker” OR nurse OR physician) AND (“brain drain” OR migration OR mobility OR retention) AND (governance OR corruption OR institution) AND (climate OR environment* OR drought OR flood); (“health workforce”) AND (“climate change” OR drought OR flood OR resilience) AND (Africa); (“health workforce”) AND (retention) AND (governance OR corruption OR accountability) AND Africa; (“health workforce”) AND (retention OR migration) AND Zimbabwe. The authors replaced Zimbabwe with Nigeria, Zambia, South Africa, Lesotho, or Eswatini to repeat the search for each country of interest.

PRISMA flow diagram

Inclusion and exclusion criteria

Studies were included if they were published between January 2015 and May 2026, focused empirically or conceptually on human resources for health (HRH) in the target nations, and explicitly analyzed non-economic (structural, environmental, or administrative) drivers of mobility. Purely clinical studies, or papers evaluating temporary migration outside the continent without feedback loops from the health system, were excluded. The literature search yielded 2,221 unique records; screening of titles and abstracts excluded 1,388 articles (see Figure 2). Full-text evaluation of the remaining 339 records resulted in the final retention of 39 peer-reviewed empirical studies and 12 national/regional policy frameworks for detailed qualitative narrative synthesis (see Figure 2).

The table below lists every source retained for synthesis (matching the References list), classified by country/regional focus and primary thematic contribution. Classification was performed at the level of title and abstract content and is intended as an indicative map of the corpus rather than a definitive coding.

Expert co-design and ethical protocols

To triangulate secondary data with ground-level institutional realities, the authors engaged a purposeful sample of 14 senior African public health scholars and HRH planners (South Africa: 3, Nigeria: 3, Zimbabwe: 2, Zambia: 2, Lesotho: 2, Eswatini: 2) with a minimum of 10 years of experience in regional health governance. Collaborative reflections were collected through a structured three-round digital Delphi consensus protocol (Dalkey, 1972; Hsu and Sandford, 2007) between January and March 2026. Each round was administered through a secure, password-protected online survey platform; summarized results and areas of disagreement from each round were circulated back to panelists before the next round, allowing positions to be revised and consensus to be iteratively refined. Because this process involved professional peer reflection on public policies rather than patient-level clinical data, it was granted an exemption from full institutional review board (IRB) review, though strict ethical protocols were maintained: all participants provided written informed digital consent, all data were de-identified to prevent institutional backlash, and findings were validated through a member-checking workshop.

Analytical approach

The analysis proceeds in three stages: Contextual Mapping, which identifies the social, political, and environmental drivers of health worker migration across the selected countries; and Strategy Evaluation, which assesses the strengths and limitations of current HRH retention interventions, including financial incentives, professional development, workplace reforms, and regional collaborations. The authors then synthesize and integrate the findings, situating them within the broader migration–governance–environmental nexus to highlight gaps, opportunities, and policy implications for advancing Universal Health Coverage (UHC).

Results and findings

This section synthesizes the retained corpus of 51 sources (39 peer-reviewed empirical studies and 12 national/regional policy frameworks; Table 2) alongside reflective input from the 14-member Delphi panel of African scholars. The findings are organized under four themes: (1) Governance, Institutional Capacity, and SHW Retention; (2) Environmental Stressors and Climate Change Shocks as Threat Multipliers; (3) The Migration–Governance–Environmental Nexus; and (4) Evaluation of Existing Retention Strategies. Table 1 summarizes the reflective insights contributed by the Delphi panel under these same four themes; these reflections are integrated narratively within the corresponding theme below rather than treated as a separate, parallel set of findings.

Table 2. Overview of the literature corpus retained for narrative synthesis (n = 51).

Theme 1: governance, institutional capacity, and skilled health worker (SHW) retention

Governance emerged as one of the strongest determinants of skilled health worker retention across all six countries. Weak governance reduced workforce confidence through delayed salaries, poor career progression, inadequate supervision, political interference, and institutional corruption. This institutional decay directly accelerates health worker emigration by undermining the fundamental professional efficacy of the workplace. In countries with weak public-sector governance metrics, systemic leakages in health budgets lead to chronic shortages of essential diagnostic equipment, personal protective equipment (PPE), and basic pharmaceuticals (Chisholm et al., 2021; Zhanda, 2023). This forces skilled professionals into severe moral distress — the psychological suffering resulting from knowing the correct clinical action but being blocked from executing it by systemic resource depletion. Furthermore, nepotism in clinical promotions, delays in payroll disbursement, and the politicization of institutional leadership positions create a pervasive sense of professional disillusionment, shifting the decision to migrate from a choice for personal enrichment to an act of professional self-preservation (Gajewski et al., 2017; Chivandire et al., 2024; Masiu and Motlamelle, 2025). Although financial incentives were widely implemented, they were frequently undermined by weak institutional capacity, inconsistent implementation, political interference, and inadequate accountability mechanisms. Across the six countries, governance effectiveness consistently moderated the relationship between financial incentives and retention outcomes. Governance, therefore, acts as the central mediator through which other migration drivers influence workforce retention. The Delphi panel independently reached the same conclusion, framing it more starkly: “financial top-ups cannot purchase morale in a system that is otherwise broken, since allowances are meaningless if workers are simultaneously forced to work without electricity, clean water, or basic medicines”. Panelists further characterized institutional corruption — particularly nepotism in promotion pathways and budget leakages — as a direct psychological push factor, and persistent payroll delays as an implicit signal of structural exclusion that erodes workers’ sense of being valued by the state (see Table 1).

Zimbabwe vividly illustrates how prolonged economic instability and governance challenges weakened the effectiveness of bonding schemes and rural retention programs (Taderera et al., 2016; Mashange et al., 2019; Chikanda, 2024). Despite government investment in compulsory service and rural allowances, deteriorating infrastructure, delayed remuneration, and declining institutional confidence continued to encourage outward migration (Mashange et al., 2019). The human element in Zimbabwe is characterized by “professional exhaustion”. When governance fails, environmental stress acts as a threat multiplier; for instance, the 2023/2024 El Niño-induced drought left over 60% of rural health outposts in peri-urban areas like Epworth without reliable groundwater (UNOCHA, 2024). The resulting lack of clean water compromised basic clinical sanitation, driving multidrug-resistant hospital-acquired infections, amplifying push factors, and accelerating the exit of exhausted nursing staff (Mani et al., 2024; Mutswiri et al., 2025). In this context, migration is often viewed not as a choice for wealth, but as a flight from a system that no longer allows for professional dignity or personal survival.

Similarly, Nigeria's National Health Workforce Strategy (2019–2024) has faced implementation challenges due to inadequate financing, fragmented governance, and inconsistent policy implementation (FMoH and SS, 2024). Healthcare funding fluctuates around 5% of the national budget, far short of the 2001 Abuja Declaration target of 15% (Eneh, 2022; African Union Commission, 2001). The widespread phenomenon popularly referred to as “Japa” reflects more than standard labor migration; it represents declining confidence in institutional capacity to provide professional development, security, and career progression. Originating from the Yoruba word meaning “to run, flee, or escape a desperate condition,” Japa has transcended colloquial slang to become a recognized sociological framework describing a collective psychological rupture between skilled professionals and the state's socio-political framework. Hardship postings and rural allowances provide only minor financial compensation (Okoroafor et al., 2021) but are completely ineffective against existential threats to personal safety, which are exacerbated by severe localized security threats along the Sahel corridor, where rural health facilities remain highly vulnerable to banditry and insurgencies. This literature-based reading of Japa is corroborated directly by the Delphi panel, who described the decision to emigrate among younger cadres not as a routine job search but as a collective psychological rupture — an institutional flight toward professional dignity, security, and self-preservation rather than a purely economic calculation. Panelists likewise observed that the Global North offers a predictable professional future that the home state cannot guarantee, reframing migration as an active flight from systemic instability rather than a simple pursuit of higher wages (see Table 1). This sociological dimension is developed further under Theme 3 below.

In contrast, South Africa demonstrates how stronger institutional arrangements — including the Occupational Specific Dispensation (OSD) policy — have improved retention through structured career pathways and salary reforms (George and Rhodes, 2012). Evidence indicates that the OSD boosted salaries, improved job satisfaction, and reduced attrition among public-sector nurses (Labonté et al., 2015). Nevertheless, governance improvements alone have not eliminated migration pressures, particularly among specialized cadres (Minko, 2025). Inequitable resource distribution and climate-related stresses in rural provinces continue to drive migration among younger professionals seeking global mobility (Anayo, 2024). While stronger institutional frameworks enable South Africa to better stabilize its workforce than its neighbors (Ahmat et al., 2022), the allure of the Global North remains a significant challenge, proving that structural resilience must look beyond salary adjustments.

This governance deficit is echoed across the remaining study countries, where scale and geography intersect with institutional capacity. In Eswatini, workplace reforms and governance frameworks have been pursued (Dlamini et al., 2023), yet the small workforce size makes the system highly sensitive to migration pressures (Anderson et al., 2021). When extreme water scarcity in the Lubombo region pushes water availability below the critical clinical safety threshold of 20 L per patient per day, it compromises neonatal ward hygiene and forces staff to manage outbreaks without basic running water, rendering financial rural allowances completely irrelevant. In Lesotho, bilateral agreements and training investments are consistently undermined because mountainous facilities suffer from inadequate infrastructure, medicine shortages, and unreliable utilities (Government of Lesotho, 2019; WHO, 2022; Mostafa et al., 2024). Intense alpine winters and flash flooding isolate rural clinics from medical supply chains for weeks, causing critical stockouts of life-saving antiretroviral (ARV) therapies. This causes severe professional frustration, turning the “pull” to neighboring South Africa into an irresistible alternative (Mostafa et al., 2024). In Zambia, where rural posting allowances are utilized (Shen et al., 2017), financial incentives fail because climate-induced agricultural collapse destabilizes local communities. This causes sudden surges in patient-to-worker ratios in under-resourced district hospitals, proving that a health worker's life is inextricably linked to the ecological and institutional health of the community they serve (Manda et al., 2023; Osuigwe, 2026).

Collectively, these findings demonstrate that governance influences migration both directly, through employment conditions, and indirectly by shaping institutional resilience against ecological shocks. Consequently, sustainable health worker retention cannot be achieved through isolated financial incentives alone without concurrent improvements in governance, structural accountability, and climate-proofed infrastructure.

Theme 2: environmental stressors and climate change shocks as threat multipliers

Environmental change emerged as a cross-cutting determinant of skilled health worker mobility. Rather than acting independently, climate-related events amplified existing institutional weaknesses, thereby accelerating migration decisions. Across all six countries, climate-related events — including prolonged droughts, flooding, water insecurity, and food shortages — were consistently identified as indirect drivers of migration. Unlike conventional migration theories that emphasize economic incentives alone, the reviewed evidence demonstrates that environmental stressors primarily function as threat multipliers, amplifying existing weaknesses in health systems. The Delphi panel framed this pattern with particular clarity: ecological shocks “break the back of underfunded clinics,” precisely because climate stress does not act in a vacuum but exploits pre-existing infrastructure deficits. Panelists further noted that moral distress escalates sharply when water scarcity falls below basic safety thresholds, leaving health workers to watch preventable outbreaks spread, and that seasonal isolation from medical supply chains is best understood as an infrastructure failure amplified by weather rather than a discrete climate event (see Table 1).

These environmental stressors reduced workplace safety, increased workload, and diminished professional satisfaction, thereby strengthening migration intentions. Environmental change, therefore, operates indirectly by weakening health system resilience rather than acting as an isolated driver of migration (WHO, 2025). The evidence demonstrates that climate change does not independently cause migration but interacts with governance failures, poor infrastructure, and fragile health systems to produce cumulative pressures on skilled health workers.

The localized manifestations of these environmental stressors across the six countries highlight how ecological shocks exploit specific systemic vulnerabilities:

Zimbabwe: Severe drought interacts with collapsing infrastructure and chronic medicine shortages. Prolonged dry spells dry up local water tables, leaving clinics without running water, which directly compromises basic infection control and forces staff to work in unhygienic environments.

Lesotho: The country's rugged mountainous terrain creates severe transport barriers, which interact with unreliable electricity and isolated facilities. Flash floods and heavy snow isolated medical supply chains for weeks, forcing rural health workers to manage critical emergencies without power or essential therapeutics.

Eswatini: Acute water shortages directly lead to severe sanitation problems in health centers. Lacking the institutional capacity to truck in emergency water supplies, clinics see compromised hygiene in neonatal and surgical wards, raising patient infection risks and driving acute professional distress among staff.

Zambia: Declining agricultural productivity due to shifting rainfall patterns has triggered widespread food insecurity, leading to an increasing patient burden at the facility level. Malnutrition-related admissions surge, placing extreme strain on understaffed district hospitals and causing severe burnout among health workers.

South Africa: Climate-related pressures are heavily concentrated in underserved rural provinces. Persistent water restrictions and heatwaves in deep rural clinics expose stark provincial resource inequities, accelerating both internal and international migration of younger, globally mobile professionals.

Nigeria: Severe seasonal flooding interacts with regional insecurity and widespread climate displacement. Inundated transport routes disrupt the delivery of basic medical supplies, while concurrent climate-driven displacement forces health workers to operate in highly insecure, overwhelmed frontline facilities.

Theme 3: the migration–governance–environmental nexus

The core theoretical contribution of this study centers on the empirical verification of the Migration–Governance–Environmental Nexus. Rather than acting independently, governance weaknesses and environmental stress interacted to shape skilled health worker mobility. The findings demonstrate that climate shocks intensified workforce shortages, primarily in areas where governance capacity was already weak.

The systemic operational pathway of this nexus moves from institutional failure to professional flight through a compounding structural chain:

Poor governance → Poor infrastructure → Poor disaster preparedness → Unsafe working conditions → Migration.

Conversely, an effective institutional framework disrupts this pathway, building a resilient cycle that safeguards the frontline workforce:

Strong governance → Better adaptation → Better retention.

South Africa demonstrated this interaction more effectively than Zimbabwe or Lesotho because stronger institutions buffered environmental shocks. While rural facilities in South Africa still experience severe climate pressures, its robust institutional arrangements, structured career pathways, and superior public sector capacity allow the system to adapt far better than its regional neighbors. In contrast, in Zimbabwe and Lesotho, where institutional frameworks are fragmented and underfunded, even minor environmental shocks trigger immediate failures in the health system. This interaction forms the migration–governance–environment nexus proposed in this study, illustrating that health worker retention is fundamentally dependent on how governance structures mitigate or exacerbate ecological disruptions.

This nexus is further substantiated by the sociological dimension of migration decision-making captured in the Delphi consensus. Panelists consistently described the decision to emigrate, especially among younger cadres, not as a routine job search but as a collective psychological rupture — an institutional flight toward professional dignity, security, and self-preservation rather than a purely economic calculation. Panelists further noted that the Global North offers a predictable professional future that home governments cannot guarantee, reframing migration as an active flight from systemic instability rather than a simple pursuit of higher wages (see Table 1). This sociological evidence strengthens, rather than stands apart from, the governance–environment interaction described above: it is precisely because governance and ecological failures compound one another that migration acquires this psychological character of rupture and flight, rather than remaining a discrete economic calculation.

Theme 4: evaluation of existing retention strategies

To address the study's second objective, this section shifts from country-specific profiles to a comparative evaluation of specific retention interventions implemented across the region. The Delphi panel's overarching judgment on this body of interventions was blunt: “economic band-aids cannot cure structural hemorrhages”. The strategy-by-strategy evaluation below repeatedly bears this out.

Financial incentives

Financial mechanisms have been widely deployed across the region to offset low public-sector pay, primarily targeting rural or hard-to-reach postings. In Zimbabwe, this took the form of rural allowances; Zambia utilized specialized rural posting allowances; and Nigeria implemented direct financial top-ups and hardship allowances.

Strengths

When consistently funded, financial incentives provide immediate economic relief to health workers, temporarily reducing the financial pressures driving outward migration and demonstrating an initial ability to attract staff to underserved rural clinics.

Weaknesses

These strategies suffer from severe operational limitations. In Zimbabwe and Nigeria, economic instability, high inflation, and governance fragmentation frequently delayed disbursements, eroding the real value of the allowances. Furthermore, financial incentives failed completely to offset non-monetary push factors, such as unsafe working conditions, severe medicine stockouts, and lack of clean water. Consistent with this, the Delphi panel concluded that rural incentives carry an implicit expiration date wherever climate-proofing is absent, since no hardship allowance can retain a worker once the surrounding community faces agricultural and ecological collapse (see Table 1).

Bonding schemes

Mandatory service requirements and bonding schemes have been used to secure public sector returns on educational investments and are heavily relied upon in Zimbabwe and Lesotho.

Strengths

Bonding schemes create a predictable, guaranteed baseline supply of newly qualified health professionals for rural and public facilities, temporarily filling critical staffing vacancies in historically underserved areas.

Weaknesses

These schemes face major sustainability challenges. They act as coercive rather than voluntary retention mechanisms, significantly lowering long-term job satisfaction. In Zimbabwe, deteriorating working conditions, lack of basic clinical tools, and low institutional confidence meant that health workers frequently left the public system immediately upon completing their compulsory service, viewing the bond as a hurdle rather than a pathway to long-term domestic employment. The Delphi panel captured this dynamic directly: bonding schemes “produce captive workers, not committed professionals,” since coercive retention strategies generate only a temporary, disgruntled workforce that exits the public sector the moment mandatory service concludes (see Table 1).

Professional development

Structured career pathways, continuing medical education, and access to specialized training represent long-term retention tools, prominently emphasized in South Africa and Nigeria.

Strengths

In South Africa, the implementation of the Occupational Specific Dispensation (OSD) created clear, transparent career pathways and salary growth linked to professional advancement, thereby significantly improving job satisfaction and reducing public-sector attrition among nursing staff. The Delphi panel emphasized that this success reflects a broader principle: retention is best understood as an ongoing investment in institutional accountability rather than a one-time policy signing, and the OSD succeeded specifically because structural career progression was backed by a durable institutional framework (see Table 1).

Weaknesses

Implementation remains highly fragmented. In Nigeria, despite strategic policy frameworks, actual access to professional development is severely constrained by inadequate financing and institutional nepotism. Furthermore, in rural provinces across both countries, professional development is often undermined when facilities lack the staff to cover for workers away on training, leaving remaining staff heavily overworked.

Regional collaborations

Supernational frameworks and ethical codes — such as those championed by the World Health Organization (WHO), the Southern African Development Community (SADC), and the WHO Global Code of Practice on the International Recruitment of Health Personnel — aim to regulate international health worker migration.

Strengths

These regional and global frameworks provide a unified platform for bilateral agreements, foster intergenerational collaboration, and establish clear ethical benchmarks that discourage the active, predatory recruitment of health professionals from highly vulnerable, red-listed states.

Weaknesses

These instruments are non-binding and carry no enforcement mechanisms. High-income countries in the Global North continue to attract specialized cadres through fast-tracked visa pathways, bypassing the spirit of the WHO Code. Regional bodies like SADC lack the financial and legislative power to equalize working conditions across member states, leaving resource-constrained countries highly vulnerable to losing their workforces to wealthier neighbors. This assessment matches the Delphi consensus almost verbatim: panelists judged bilateral ethical codes “toothless in a competitive global labor market,” since non-binding recruitment guidelines are easily bypassed by high-income nations through fast-tracked visa pathways (see Table 1).

Synthesis of interventions

Across all countries, interventions focusing solely on economic incentives demonstrated only temporary effectiveness. Long-term, sustainable retention was achieved exclusively where financial incentives were accompanied by comprehensive governance reforms, supportive and safe work environments, accessible professional development, and robust institutional accountability.

Integrated synthesis

The synthesis demonstrates that skilled health worker migration in Africa is driven by the interaction of governance failures, institutional capacity, environmental stress, and professional aspirations rather than by economic incentives alone. Across the six countries, governance moderated the impact of environmental shocks, while climate-related pressures amplified existing institutional weaknesses. Countries with stronger governance structures, such as South Africa, demonstrated greater workforce resilience despite continued migration pressures, whereas weaker institutional settings experienced compounded effects of political instability, environmental stress, and professional dissatisfaction. These findings collectively support the proposed Migration–Governance–Environmental Nexus Framework and provide empirical justification for integrated retention strategies.

Discussion

The migration–governance–environmental nexus and institutional transformation

The findings underscore that HRH retention strategies must be situated within the migration–governance–environmental nexus. Skilled worker migration is not only a response to poor pay but to wider institutional transformations (Castles, 2018). In this context, institutional transformation is operationalized specifically as the evolving structural relationship between the healthcare professional and the state apparatus — mediated by transparency, public safety, and professional dignity — rather than as a broader, unspecified social phenomenon. This narrower framing directly reflects Theme 1 and Theme 3 above and the governance-focused evidence base underlying them. As younger professionals increasingly view migration as a pathway to career advancement, retention strategies must acknowledge these generational aspirations (Baluku et al., 2018).

Environmental change and HRH retention

Environmental change is no longer a peripheral issue but a primary driver of attrition, as demonstrated throughout Theme 2 and confirmed independently by the Delphi panel (Table 1). Climate shocks exacerbate resource scarcity and strain fragile health systems (Anayo, 2024). In rural areas, declining agricultural productivity reduces community resilience, placing additional burdens on under-resourced facilities (Okoli et al., 2024).

However, environmental scarcity does not lead to conflict or migration in a vacuum, as it is mediated by governance and institutional readiness (Freeman, 2017). Countries with proactive adaptation policies are better able to retain health workers by ensuring service continuity and protecting workplace conditions (WHO, 2022). Conversely, in settings with limited capacity, environmental stress amplifies the “push” factors (Mutswiri et al., 2025). This aligns with research suggesting that migration is a profound social transformation shaped by economic and ecological contexts (Castles, 2018).

Governance, corruption, and institutional capacity

Weak governance, corruption, and limited career progression consistently undermine retention efforts. While financial incentives provide short-term relief (Witter et al., 2017), they fail to address the systemic drivers rooted in governance and environmental change. Countries with lower institutional capacity, such as Lesotho and Zimbabwe, are less able to adapt, leading to higher migration rates (Atte, 2021). This confirms that environmental scarcity interacts with institutional readiness to shape health outcomes (Gemenne and Blocher, 2017; Mutswiri et al., 2025; Nishimura, 2015). Corruption specifically — nepotistic promotion and budget leakage, as detailed in Theme 1 and Table 1 — functions as a direct psychological push factor rather than a secondary background condition, a distinction this study treats as central to its contribution.

Regional and global frameworks

Retention strategies remain fragmented across the continent. Platforms such as the SADC Labour Migrations Action Plan and the WHO Global Code of Practice offer opportunities to harmonize policies and align with ethical recruitment standards. Yet, these frameworks are frequently underutilized in national workforce planning (Khalil and Alameddine, 2020). Regional collaboration offers the only viable path to harmonize policies and build collective resilience (Bhanye, 2025). As detailed in Theme 4 and Table 1, the Delphi panel judged these instruments to be toothless in a competitive global labour market — a judgment consistent with the WHO Code's non-binding status and its documented circumvention by destination countries (Chikanda, 2024).

Policy implications and targeted recommendations

To ensure maximum administrative execution, the generalized policy guidelines have been structured into targeted matrices that map specific strategic pathways to their respective responsible institutional stakeholders (see Table 3).

Table 3. Targeted matrices that map specific strategic pathways to their respective responsible institutional stakeholders.

These targeted pathways operationalize the Delphi panel's core recommendation that retention functions as an ongoing investment in institutional accountability rather than a one-time policy signing (see Table 1).

Strengths and limitations

Strengths

This study offers a comprehensive, multi-country perspective on retention in Africa. By situating HRH within the migration–governance–environmental nexus, the research fills a critical gap in the literature. The interpretive, narrative synthesis approach allows for a layered understanding of how governance and climate pressures interact with workforce mobility. Furthermore, the integration of regional frameworks, such as the SADC Action Plan, enhances the relevance of these findings for international policy debates. The explicit integration of a structured three-round Delphi consensus (Table 1) with the literature-based narrative synthesis is a further methodological strength: it allows the study's central nexus argument to be triangulated across two independent evidence sources — published literature and expert reflection — rather than resting on literature alone.

Limitations

The study is limited by its reliance on secondary data sources, which may constrain the depth of real-time, country-specific insights. The comparative scope, while diverse, cannot fully capture the heterogeneity of all 54 African nations. Additionally, the interpretive methodology emphasizes synthesis over statistical precision. The thematic classification of retained sources in Table 2 is indicative rather than definitive, since narrative synthesis categorization inherently involves interpretive judgment. Future research should include broader ecological determinants such as urbanization and biodiversity loss.

Recommendations for future research

This study already demonstrates — through both the literature synthesis (Theme 3) and the Delphi consensus (Table 1) — how social, political, and environmental determinants interact through the Migration–Governance–Environmental Nexus; future research should then move beyond establishing that this interaction exists and instead focus on quantifying its magnitude and testing its predictive validity. Priority directions include: (i) longitudinal, multi-country studies that track retention and attrition rates against governance indices and climate-shock indicators over time; (ii) mixed-methods designs that pair quantitative workforce data with qualitative narratives from health workers and communities to capture the lived realities of migration and retention; and (iii) intervention studies that test whether climate-proofed infrastructure investment measurably improves retention outcomes independent of financial incentives.

Conclusion

The retention of skilled health workers in Africa is inseparable from the wider dynamics of migration, institutional transformation, and environmental change. While financial incentives and bonding schemes provide temporary relief, they cannot counteract systemic drivers such as weak governance, inequitable resource distribution, and climate-related stresses.

Skilled worker migration reflects collective responses to fragile institutions and environmental scarcity — a reading that the Delphi panel independently confirmed by characterizing migration as a psychological rupture rather than a routine job search (see Table 1). By situating HRH strategies within this broader nexus, it becomes clear that sustainable solutions must be multidimensional. Integrated approaches that combine workplace reforms, professional development, and governance accountability with climate-resilient infrastructure are the only way to stabilize the workforce and strengthen health systems. Ultimately, addressing this intersection is not only a health-sector priority but an institutional imperative, ensuring that Africa's health systems remain resilient and capable of delivering equitable care amidst a global transformation.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Goran Miladinov, International Union for the Scientific Study of Population, France

Reviewed by: Louis Ako-Egbe, World Health Organization—Country Office for Liberia, Liberia

Judy Mbekelu, African Forum for Research and Education in Health(AFREhealth), Ghana