Harare, Zimbabwe and Lusaka, Zambia — Aspiring nurses are being lured to Zambia and beyond by the promise of lucrative jobs and fewer bureaucratic hurdles.
At a nursing school in Zambia, many of the students aren't from Zambia at all. Michael is one of them. "We are," he says, "over 100 Zimbabweans in a class of 140 students."
More and more Zimbabwean students, like Michael, are pursuing their medical and nursing educations abroad, motivated by better study opportunities, bureaucratic challenges in Zimbabwe, and the rising demand for international health workers in countries like the United Kingdom and United States.
The exodus is likely to worsen Zimbabwe's ongoing brain drain in the health sector, which has already seen significant workforce migration. According to a 2023 report from Harambee Africa International, a Rome-based nonprofit that supports African health care institutions, "in less than two years, starting in 2021, Zimbabwe has lost more than 4,000 doctors and nurses, and departures are on the rise." The report also states that in 2021 and 2022, these departures were twice those in 2020 and three times those in 2019.
Zambian officials who spoke to Global Press Journal also worry that the influx of Zimbabwean students is compromising the quality of education in Zambia, as the growing student population strains medical schools' resources.
Drawn to Zambia
In Zimbabwe, the government funds three-year general nursing training programs -- with a caveat. After graduation, students are required to work for the government for a certain period, typically three years -- a process called "bonding" -- before they can receive their diploma or register with the Nurses Council of Zimbabwe, a regulatory body. But the stipends the government pays during nursing school are low -- and after graduation, the salaries remain low.
Michael, who requested to use only his first name to protect his job prospects, says he chose to study in neighboring Zambia partly to avoid the obligation of working for the government. "I didn't want my diploma to be withheld after completing my studies," he says, "as is happening to those who studied in Zimbabwe."
Shingai Nyaguse, president of the Zimbabwe Senior Hospital Doctors Association, says that bonding is an important part of nurses' training. But in Zambia, pharmacology and nursing graduates don't have the same obligation.
Moreover, in Zimbabwe, despite the mandatory government internship, nursing opportunities are scarce. While the country trains enough health workers, it is unable to employ them, according to a 2020 operational plan from the United States President's Emergency Plan for AIDS Relief in Zimbabwe. Between 2010 and 2019, the Ministry of Health and Child Care recruited only 27% of nurses trained in the country, according to the report.
Michael, who enrolled in a Zambian nursing institution through an agent he found on Facebook, says he also worried about not getting placement in a nursing school.
In Zimbabwe, no private institutions offer general nursing diplomas. Only the Ministry of Health and Child Care offers this course, through its central, provincial and mission hospitals, and these schools offer limited opportunities. Felicity Zvanyadza Gumbo, an associate professor in the University of Zimbabwe's Department of Child, Adolescent and Women's Health, says medical institutions have limited capacity to train. From the thousands of applications they receive, only a few are enrolled, "so chances are, students are already going outside to train because we have no capacity."
The high demand, she says, stems from parental and societal pressure, as the perception is that medical training leads to a lucrative career.
In contrast, Zambia has privately-owned training facilities in addition to government-owned nursing institutions, which means more opportunities to study. "That's why many people are opting to come to Zambia for nurse training," Michael says.
For those who have trained in Zimbabwe and want to work abroad, including doctors, there are more hurdles. In both Zambia and Zimbabwe, nurses and doctors who want to work abroad must work in public or private institutions before the government will issue a letter of good standing. But to control the migration of skilled health professionals abroad, Zimbabwe has cracked down on issuing the letters, says Tryfine Rachel Dzvukutu, deputy general manager of public relations for the Health Service Commission. The increased scrutiny, she says, involves more rigorous checks and documentation to ensure that only genuine applicants receive verification letters.
For Tirivashe Madzinga, a Zimbabwean who is in her sixth year studying medicine at the University of Zambia, the draw was job prospects. Her father was convinced that if she studied outside Zimbabwe, it'd be easier to move abroad. "He was advised that exiting Zimbabwe after earning a medical degree would be difficult," Madzinga says. He foresaw difficulties in getting a verification letter.
Grace, who chose to use her first name only for fear of stigma, likewise pursued a general nursing diploma in Zambia to avoid not only bonding but also the delay in receiving a verification letter.
Eyes on the global stage
Most of the sources who spoke to Global Press Journal plan to find job opportunities abroad. Their ambitions reflect a nationwide trend. A 2022 study published in Globalisation, Societies and Education, a research journal, found that only 43% of the Zimbabwean students surveyed wanted to work in their own country.
Australia has been on Michael's mind. Once he graduates in 2026, he might move there. He believes the move will expose him to more lucrative opportunities. "Also," he says. "I have heard [few] people who complain about racism [there], so I think it's the best."
In addition to losing workforce, another cost for Zimbabwe, says Amos Marume, principal of the Harare Institute of Public Health, is loss of revenue. Students who move to Zambia and elsewhere are taking their school fees and other education expenditures with them.
Enock Dongo, president of the Zimbabwe Nurses Association, believes opening private nursing schools in Zimbabwe will help. He says his organization has lobbied the government to make it a priority. He emphasizes the need for a cautious approach, though, to avoid compromising the quality of education.
Dongo admits that the country doesn't have enough schools to absorb all students who want to study nursing, and he doesn't see any problem with studying abroad. But he encourages those who train elsewhere to come home and contribute to the health care system. "We have provision for those who did nursing outside Zimbabwe to come and register and work at our hospitals," he says.
He acknowledges that the student exodus is pushing the country to do better. "It means that we need to increase the schools of nursing," he says. "We need to increase the number of people that we are enrolling."
The cost for Zambia
Zambia, too, faces consequences from the influx. Fastone Goma, the chief executive officer of the Health Professions Council of Zambia, worries about the lack of enrollment restrictions in his country's institutions, especially private ones. The focus on the quantity, rather than the qualifications, of students has diluted the quality of training in Zambia, he says. "The pass rates for students from medical institutions have declined, indicating a direct correlation with over-enrollment."
Goma adds that the outcomes of the last three licensure examinations, which assess whether medical graduates have the necessary knowledge to practice medicine, have demonstrated the decline. Only about 60% of students passed the exams, he says. The council expects a pass rate of 100%.
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The influx burdens not only teaching facilities but also the hospitals and laboratories where students gain hands-on experience, Goma says. He's calling on the Zambian government to reevaluate its flexible enrollment policies.
Kennedy Lishimpi, the permanent secretary of technical services at Zambia's Ministry of Health, says they will issue regulations concerning the admission of foreign students to Zambian educational institutions, but they must consider the issue carefully. "We don't want to lose the much-needed foreign exchange as a country," he says.
Lishimpi adds that the ministry will soon require private institutions to construct their own hospitals. "A medical university should have a corresponding hospital for practical training," he says. "The current shortage of practical sites poses a significant challenge."
Studies have shown that there is a shortage of clinical sites for nursing students in sub-Saharan Africa, Zambia included, which limits the hands-on experience essential for training. The growing number of students and the existing health care system's inability to accommodate them has led to the wider use of simulations as an alternative to traditional clinical placements.
Meanwhile, while Michael has plans to find work abroad, he doesn't want to leave for good. Eventually, he hopes to return home. "I want," he says, "to be part of the change-makers in the health sector in Zimbabwe."
Gamuchirai Masiyiwa is a Global Press Journal reporter based in Harare, Zimbabwe.
Prudence Phiri is a Global Press Journal reporter based in Lusaka, Zambia.
