Gone for good

Sub-Saharan Africa: the medical brain drain

Doctors and other medical professionals migrate for many reasons, but their absence seriously compromises health service delivery

A doctor with a loud hailer shouts slogans during a protest march by senior medical doctors in Harare, on December 4, 2019. – The doctors petitioned the Zimbabwe Parliament demanding improved working conditions and the reinstatement of 448 junior doctors fired for taking part in a two month long strike over low salaries. (Photo by Jekesai NJIKIZANA / AFP)

A brain drain of African medical staff over several decades has significantly depleted the continent’s health services of doctors and nurses. At the beginning of the millennium, approximately 65,000 African-born physicians and 70,000 African-born nurses were working overseas, according to a study by Michael Clemens and Gunilla Pettersson Gelander, published in Human Resources for Health in 2008, representing about one fifth of African-born physicians and one tenth of African-born nurses globally. The number of health workers who migrate abroad varies considerably from one country to another, but figures on the migration of African doctors and nurses to 30 OECD countries, published in a 2016 World Health Organization (WHO) policy brief, suggest that the trend has been ongoing.

Between 2000 and 2011, the number of African doctors who migrated to OECD countries rose by one third to 55,541, whereas the number of nurses more than doubled to 135,970. According to OECD health statistics, Nigeria led the list of African countries whose doctors were working in these countries in 2019, with a total of 10,487 as against 10,318 for Egypt and 9,509 for South Africa. On 25 May 2018, South African daily newspaper The Citizen quoted African Union statistics revealing that 75% of all trained physicians in Mozambique emigrate. The figures for other countries – Angola 70%, Malawi 59%, Zambia 57%, and Zimbabwe 51% – were also alarmingly high.

The trend is corroborated by sources on the other end of the migration flow. An article published on the Mo Ibrahim Foundation website on 9 August 2018, titled ‘Brain drain: a bane to Africa’s potential’, indicated that in 2015, the number of African-trained International Medical Graduates (IMGs) practising in the United States (US) alone reached 13,584, a 27.1% increase from 2005. In 2015, 86.0% of all African-educated physicians working in the US were trained in Egypt, Ghana, Nigeria and South Africa. A WHO report in 2013 warned that the world will be short of 12.9 million healthcare workers by 2035. The largest shortages are expected to be in Asia, but it is in sub-Saharan Africa where they will be especially acute. All regions will be competing for medical staff; and the demand will also be high in developed countries.

In the EU in 2013, the overall shortfall of health workers was estimated at 1.6 million and it was expected to increase to 4.1 million in 2030, according to Jean-Pierre Michel and Fiona Ecarnot, in an article published by the journal European Geriatric Medicine in April this year. African health systems will likely bear the brunt of this shortfall. Africa bears “more than 24% of the global burden of disease, but has access to only 3% of health workers and less than 1% of the world’s financial resources,” says the WHO. In 2011, the British medical journal The Lancet indicated that whereas high-income countries sustained a relatively high physician-to-population ratio, by recruiting graduates from developing regions, more than a half of sub-Saharan African countries were not meeting the minimum. For example, The US Central Intelligence Agency’s (CIA) World Fact book states that in 2017, only four African countries were meeting the WHO standard of one doctor for 1,000 patients: Algeria, Libya, Mauritius and the Seychelles, while Egypt and South Africa were close to it with ratios of 0.8 and 0.82 respectively.

Part of the explanation for this situation is that since April 2001, when African heads of state committed themselves in the Abuja Declaration to allocate at least 15% of their budgets to improving their health sector, by 2014 only four countries (Malawi, Ethiopia, Swaziland and Gambia) met or exceeded the Abuja target, according to a 2016 WHO report, ‘Public Financing for Health in Africa: from Abuja to the SDGs’. South Africa, Namibia, Lesotho, Burundi, the Central African Republic and Kenya were close to the 15% target, but 19 other countries had spent less in percentage than was the case in 2000. The medical staff shortage crisis affects almost every facet of public health, including child and adult mortality, maternal health, and the treatment of diseases and infections. Mortality rates in Africa’s general population are among the highest in the world, with death probability rates of 39.1% for men and 33.2% for women aged between 15 and 60.

UNICEF has estimated that a child born in sub-Saharan Africa has an 8.1% probability of death before the age of five. Africa’s mortality rates are strongly related to a lack of healthcare workers within the region, a situation exacerbated by the uneven distribution of healthcare workers between urban and rural areas. Healthcare workers migrate for a variety of reasons. For many migrants, it is a personal decision. For others, it occurs in the context of cooperation agreements to train staff abroad and it is temporary. This is called circular migration and it is particularly encouraged by the European Union. Other health workers are sent abroad for training by their governments and are supposed to come back and exercise their skills back home, but end up working in European or American hospitals.

Push factors for migration include low salaries, poor living and working conditions, lack of career development opportunities, high cost of living, job and economic insecurity, and lack of social recognition. Some researchers stress a strong correlation between political instability in a country and the loss of its medical personnel. A study from the Universities of Ghana and Alberta (Canada) in 2007 found that push factors for medical personnel included an oppressive political climate, the threat of violence and the persecution of intellectuals.

Doctors tend to a child suffering from severe malnutrition sitting on his mother’s knees at the medical center of the NGO “Bien etre de la femme et l’enfant au Niger (BEFEN, Welfare of the Woman and the Child in Niger) at the Mirriah refugee camp, in the Zinder region of Niger. Mali’s March 22 military coup and the subsequent seizure of half the country by rebels have compounded the already worrying effects of a food crisis across West Africa’s Sahel region. The UN estimates the Mali crisis has forced more than 320,000 people from their homes, with 187,000 seeking refuge in neighbouring countries, including Niger — already in the grips of a new drought that has put millions at risk of hunger. AFP PHOTO / ISSOUF SANOGO (Photo by ISSOUF SANOGO / AFP)

A lack of respect from physicians, and barriers to full utilisation of specialised nursing knowledge in healthcare settings, were push factors for the migration of nurses in a Ghanaian study, according to Delanyo Dovlo, director of health systems and services at the WHO Regional Office for Africa. Another push factor is the HIV/AIDS epidemic. Nurses are particularly stressed by its impact in southern Africa. On the “pull” side, salary plays an important role. According to the United Nations publication Africa Renewal, “on average, surgeons in New Jersey earn $216,000 annually, while their counterparts in Zambia make $24,000”. Another incentive is the possibility to improve skills in the countries of destination, say researchers of the OECD Health Division, in a report on ‘Recent Trends in International Migration of Doctors, Nurses and Medical Students’, published in July 2019. Dovlo also identifies differences in the way that African doctors and nurses are recruited.

“While doctors are usually passively recruited (i.e. look for the jobs for themselves), nurses are usually actively recruited by agents, sometimes for a fee,” he says. Again, the situation varies by country and time periods. The migration of nurses from South Africa is declining, for example, partly due to a slowdown in recruitment from the United Kingdom (UK) since 2006, when new immigration rules allowed foreign nurse work permits only if employers could demonstrate non-availability of staffing from Britain and the EU. Meanwhile, migration flows have continued towards Gulf countries. The United States is the main country of destination for migrant doctors and nurses. Of all foreign-born health workers who practise in OECD countries, 42% of doctors and 45% of nurses practise in the US. The UK is the second country of destination, receiving 13% of all foreign-born doctors who practise in OECD countries, followed by Germany (11%).

This ranking is reversed for nurses, with Germany in second place (15%) followed by the UK (11%). It can be assumed that gaps in staffing significantly compromise health service delivery in sub-Saharan Africa. In Kenya, where the ratios of doctors and nurses to the population are very low (16 doctors per 100,000 and 88 nurses per 100,000), the migration of health professionals reduces the capacity of the remaining staff to attend their patients, note the authors of a paper titled ‘Migration of health workers in Kenya: The impact on health service delivery’, published in March 2008 by the Regional Network for Equity in Health in East and Southern Africa. Countries that invest in the training of health workers suffer financial losses when these professionals emigrate (including the cost of education and training). A 2018 Mo Ibrahim Foundation report on the state of public services in Africa revealed that nine countries lose about $2 billion a year due to doctors and health practitioners leaving the continent.

Destination countries, on the other hand, benefited handsomely. “One in 10 doctors working in the UK come from Africa, allowing the UK to save on average $2.7 billion on training costs, followed by the US ($846.0 million), Australia ($621.0 million) and Canada ($384.0 million). In total, these four top destination countries have saved $4.6 billion in training costs for the Africa-trained doctors they have recruited,” said the Foundation. The recruitment of African medical staff workers by high income countries has been a major concern for global health bodies for more than a decade. At the 57th World Health Assembly in May 2004, participants agreed the international migration of health personnel was “a challenge for health systems in developing countries” and urged member states to develop strategies, including better working conditions, to encourage health professionals to remain in their own countries.

In 2010, the assembly adopted the WHO Global Code of Practice on the International Recruitment of Health Personnel, which, it says, “aims to establish and promote voluntary principles and practices for the ethical international recruitment of health personnel and to facilitate the strengthening of health systems”. One positive element of migration, however, is that African medical staff benefit from new skills abroad, which they can usefully share on returning to their countries of origin. Temporary migration for training and studies, especially when coordinated with support programmes of specialised entities like the Antwerp-based Institute of Tropical Medicine, may bear considerable benefits in designing strategies against pandemics such as AIDS, Ebola and COVID-19, and also boost research. One of the world’s top Ebola specialists, the pioneering Dr. Jean-Jacques Muyembe, practises in Kinshasa and was trained in Antwerp.

Francois Misser is a Brussels-based journalist. He has covered central Africa and Rwanda since 1981 for the BBC, Afrique Asie magazine, New African, and the German daily Tageszeitung . He is the author of several books on the DRC (Géopolitique du Congo, published in 2006 and Le Congo de A à Z , published in 2010, both with Marie-France Cros).

A real threat to national security

Endgame: health after lockdown

African countries must realise that resilient public healthcare systems are a human security issue and vital for stable government

A police officer beats a female orange vendor on a street in Kampala, Uganda, on March 26, 2020, after Ugandan President Yoweri Museveni directed the public to stay home for 32 days starting March 22, 2020 to curb the spread of the COVID-19 coronavirus. – Ugandan authorities have identified 14 confirmed cases of the COVID-19 coronavirus in the country. All borders have been closed except for limited goods and authorised emergency flights. (Photo by Badru KATUMBA / AFP)

On 11 March, the World Health Organization (WHO) announced its decision to classify COVID-19 as a global pandemic. At the time, the number of cases of COVID-19 outside China, where the disease is known to have originated in Wuhan, the capital city of Hubei province, had “increased 13-fold, and the number of affected countries has tripled”. On the same date, the global health watchdog announced that there were more than 118,000 cases recorded in 114 countries, while 4,291 people had lost their lives. A month earlier, on 11 February, the Africa Centres for Disease Control and Prevention announced that several African countries were dealing with suspected cases under investigation, including in Angola, Botswana, Ethiopia and South Africa among others. There were no confirmed cases reported on the rest of the continent.

South Africa was to report its first confirmed case on 5 March, one of a group of people who returned to the country after participating in group travel to Italy. With a number of cases that were later confirmed in different parts of the continent by the end of March, and before South Africa emerged as an epicentre of the pandemic, several countries, including Kenya, Zambia and Zimbabwe, among others, started implementing hard lockdown measures to curb the spread of the virus. On 23 March, South African President Cyril Ramaphosa announced that the country would be put into a nationwide lockdown for 21 days with effect from midnight on Thursday, 26 March. While South Africa had one of the strictest lockdown measures on the continent, if not globally, with a ban on the sale of alcohol, cigarettes and strict curfews, these precautions had something in common with other African countries.

They were all accompanied by strict securitisation measures, with an almost suspension of universally accepted freedoms such as movement and association. Soldiers and police were deployed to the streets on different parts of the continent to enforce lockdown measures. So, the big question is, why did African countries choose this hard security route to control the spread of COVID-19? It appears that these measures were inspired by China’s lockdown strategy, which according to The Guardian newspaper was “brutal but effective”, characterised by a “total shutdown of activity in Hubei province, including all shops except those selling food or medicine”. According to political scientist and international relations expert Zuhal Yeşilyurt Gündüz writing in 2006 in the context of the global health threat posed by the HIV/AIDs epidemic, “securitisation implies the construction of a danger that needs to be changed by quick action and extraordinary, even undemocratic measures”.

Gündüz further explains: “By securitising an issue, public authorities show it as an existential threat, requiring extraordinary measures and justifying actions outside the normal bounds of political procedure. Putting something on the security agenda persuades us of the need to furnish urgent and unprecedented responses, it signals imminent danger and is therefore given a high priority. ” The securitisation response of African governments to COVID-19 is rooted in the disease as an existential threat, which would have claimed millions of people on the African continent if it was not properly managed. According to Amnesty International, poor health infrastructure in countries – even in larger economies such as South Africa and Nigeria – means that the poor and marginalised are at greater risk of dying from COVID-19 related complications due to lack of access to appropriate healthcare and treatment. In most parts of the continent, healthcare infrastructure has not expanded to cater for Africa’s growing population, although private healthcare has thrived, catering to those with the economic means to afford it due to the appalling state of our public healthcare.

Ugandan police officers and members of Local Defence Units (LDU), a paramilitary force composed of civilians, patrol during the curfew after 7pm in Kampala, Uganda, on April, 29, 2020. – Ugandan President on April 14, 2020, ordered the extension of a 21-day nationwide lockdown with a strict night curfew, in a bid to halt the spread of the COVID-19 coronavirus. (Photo by SUMY SADURNI / AFP)

There has been typhoid and cholera, both of which are waterborne diseases, in Zimbabwe in recent years and these have claimed the lives of thousands of people, including in urban Harare. COVID-19 would have been the final nail in the coffin for a country like Zimbabwe with collapsed public health infrastructure if the pandemic had been more aggressive on the continent. Claims have been made that the Zimbabwean government introduced strict COVID-19 preventative measures partly as an excuse to crack down on dissent. According to Amnesty International, there has been a renewed assault on human rights, including the right to freedom of expression in recent months, especially targeting journalists, activists and human rights defenders who have spoken out against alleged corruption and called for peaceful protests. While self-isolation and social distancing were touted globally as some of the best precautions to avoid spreading COVID-19, these measures have not proved practical in Africa’s townships and informal settlements, which are poor and overpopulated.

Many of these also have no access to essential services such as access to clean running water, vital for maintaining hygiene, owing to poor service delivery, corruption and aged water infrastructure. There is no arguing that a healthy nation is a productive one. Countries that have a healthy workforce are some of the most productive economies in the world. After the first world war, on 21 December 1918, The Economist called for “more state involvement to improve public health in Britain”, arguing that “until we all know how to be healthy and strong, and recognise that unless we are so we cannot pull our weight in the boat, … a low standard of health and efficiency will continue to be a drag on the nation’s productive power.” This is equally true for Africa, where improving public healthcare infrastructure would come with economic benefits for the continent. In their paper ‘Why African Countries Need to Participate in Global Health Security Discourse’, published in the journal Global Health Governance in 2011, Hwenda et al argue that “global health security considerations have been increasingly shaping multilateral decisions in the global governance of health”.

They rightly point out that the “African group and other low- and middle-income countries (LMICs) undermine their interest by disengaging from the ongoing global health security discourse, which is increasingly informing multilateral discussion in the World Health Organization (WHO), United Nations (UN) Security Council and elsewhere”. They recommend that African countries “need to consider the potential benefits of participating in shaping the global health security agenda in order to advance their health security interests”. For years, African countries have heavily funded defence and the military at the expense of healthcare, itself a national security issue, with no apparent territorial external threats to their countries. For example, a 2020 Stockholm International Peace Research Institute (SIPRI) report said that “African military spending grew by 17%, rising to $41.2 billion in 2019, over the past 10 years”. The Institute reported that in 2019, the world recorded the largest annual growth in military spending since 2010, rising 3.6% from 2018 to $1.917 trillion.

It is against this background that it is worth noting a 2019 Brookings Future Development report that said – in per capita terms – the rest of the world spends 10 times more on healthcare than Africa. The same report noted that 98% of Tanzania’s funding for HIV/AIDS came from external sources. As the United Nations Sustainable Development Goals have rightly pointed out, good health is essential to sustainable development. Yet, according to the United Nations Development Programme, at least 400 million people in Africa have no basic healthcare and 40% percent lack social protection. It is important, therefore, for Africa to invest in healthcare infrastructure to prepare the continent to cope with its rapidly growing population and future pandemics like COVID-19, and other future transnational diseases.

In some African countries, political leaders would want to have us believe that political activists who demand their right to freedom of expression and assembly are a threat to national security. But the truth is, failure to invest in public services such as healthcare presents the biggest threat to national security. It will take commitment and visionary leadership to build world-class public healthcare in Africa, which will need prioritising to achieve that goal, but as a continent we can build a resilient public healthcare infrastructure if we put our mind to it.

Robert Shivambu has experience mainstream media and human rights environments. His career spans more than a decade in both fields. He is currently a media manager at Amnesty International’s International Secretariat (IS) responsible for the Southern African regional office based in Johannesburg. He previously worked for both PowerFM98.7, a Johannesburg-based talk radio station, and eNCA as Africa correspondent. He has a sophisticated understanding of media and International Relations and he is qualified in both fields with the Tshwane University of Technology in Pretoria and the University of the Witwatersrand in Johannesburg.

A poor prognosis, with some cause for hope

Abuja Declaration: broken promises

African nations have largely defaulted on a 2001 pledge to commit at least 15% of their annual budgets to healthcare

Followers in front of the Yoff Layene Mosque during the Islamic festivity of Korite marking the end of the
Muslim holy month of Ramadan in Dakar, Senegal, May 2020 Photo: John Wessels/AFP

Africa has so far seen controversial and even dramatic policy measures in response to the coronavirus crisis. From Tanzania withholding infection and fatality data as the government pushed conspiracy theories, to Egypt’s clampdown on citizens disagreeing with the government’s handling of the pandemic, to Madagascar’s promotion of a botanical brew as an antidote without following the standard scientific approval steps, the continent has had its share of the blunders that have helped exacerbate the crisis globally. Few, however, have seemed as ironic as Nigeria’s fiscal response at the peak of the crisis.

As the virus ravaged nations, overwhelmed health systems and devastated markets, the continent’s biggest economy announced a steep health budget cut in June, citing a decline in crude oil revenues. The government sliced basic healthcare funding by nearly half, reducing it to 25.5 billion naira ($71 million). The move angered a public already enraged by the government’s earlier plan to refurbish its parliament building with 37 billion naira. Before the pandemic, Nigeria’s entire health sector received 8% of the country’s total budget this year. That figure fell to 6% after the cut.

“This shows what is wrong with our country: poor prioritisation of projects,” Sam Ohuabunwa, the president of the Pharmaceutical Society of Nigeria, told the popular Lagos-based daily, Punch, at the time. “How come the renovation of the National Assembly is taking priority over healthcare and education? It does not make sense to me.” But Nigeria’s typically measly health spending this year is not unique. Kenya proposed to spend only 4% of its total budget on health this year before the pandemic started, and South Africa allotted 11.8% of its budget to the sector.

Besides being relatively low, all three budgets – and many others – share a thing in common: they fall short of a benchmark voluntarily set by African leaders in the Abuja Declaration in 2001, to yearly allocate at least 15% percent of their countries’ budgets to health expenditure. Nearly 20 years after the Abuja Declaration, named after the Nigerian capital where it was signed, many African countries have largely failed to honour it. Their health systems are without needed resources to build and equip hospitals, train and pay health workers and implement health insurance for citizens. The World Health Organization says more than 37% of all of Africa’s health spending comes from out-of-pocket payments.

Now, the COVID-19 pandemic, more than any other crisis in recent history, has shown how grim the situation is across the region. In April, the WHO said 43 African countries had just 2,000 ventilators and 5,000 intensive care beds, while 10 countries had no ventilators at all. Making up just 16% of the global population, Africa bears 23% of the world’s disease burden, yet accounts for just 1% of the total global health expenditure in 2015, according to United Nations and WHO figures. “The COVID-19 crisis and its impact on health and other social policy sectors such as education as well as the economy, has brought to the fore the importance of strong healthcare systems to pre-empt and deal with such global threats,” Kalipso Chalkidou, professor of practice in Global Health, Imperial College London, told Africa in Fact.

The Abuja Declaration was agreed to address the persistent funding problem that had seen health per capita public spending in Africa at a meagre US$70 in the early 2000s. A decade after the declaration, 27 nations had increased the proportion of their health expenditure, according to a 2011 report by the WHO. By 2013, only three countries – Rwanda, Botswana and Zambia – had achieved the 15% mark. By 2014, while the average per capita health spending rose to US$160, more countries (19) were spending less on health as a percentage of their budgets, a follow-up report by the WHO in 2016 stated.

Coronavirus awareness graffitti at Cheikh Anta Diop University in Dakar, Senegal, March 2020 Photo: John Wessels/AFP

According to the report, countries whose health spending fell lower than the pre-2000s figures included Chad, Mozambique, Tanzania, São Tomé and Príncipe, Sierra Leone, Zambia, Rwanda, Senegal, Equatorial Guinea, Zimbabwe, Cabo Verde, Cameroon, Comoros, Benin, Mauritania, Togo, Botswana, Niger and Central Africa Republic. Remarkably, the report found that a country’s wealth did not exactly determine its allocation share to healthcare. For example, while countries with high per capita income (over $10,000) such as Algeria, Botswana, Equatorial Guinea, Gabon, Mauritius, Seychelles and South Africa did not spend as much on health, those with relatively lower per capita like Ethiopia, Gambia and Malawi, surpassed the 15% target.

“Despite increases in fiscal capacity, spending on health has been deprioritised as governments strive to meet other obligations,” the report stated. “In low income settings, the deprioritisation of health in public expenditure tends to be associated with country-level fragility and political instability, poor governance and corruption.” It also found that most countries prioritised high-end care, that is secondary and tertiary levels referral hospitals that treat mostly the middle and upper classes, and committed, on average, less than 40% of health expenditure to primary care that caters for the majority of the continent’s poorest population.

In some countries, the allotted funds were never fully spent due mainly to unpredictable allocations, mismatch between policy and budget allocations, inappropriate budget structures, and under-performing execution systems. As much as 60% of the money remained unspent in Democratic Republic of Congo, for instance. The Nigeria case shows that years after the WHO’s latest report, not much has changed across the continent. Nigeria’s highest-ever public budget share for its health was 7%. A more recent assessment of specific countries in 2019 by a non-governmental group, Africa Health Budget Network, based in Abuja, found that only Burkina Faso (11.03%), Ethiopia (8.1%), Malawi (9.83%), Mozambique (8.35%), Rwanda (8.88%) and Tanzania (9.52%) made some level of progress in trying to meet the 2001 target.

Among all the countries reviewed, only Madagascar reached the 15% goal. “In the face of the current COVID-19 pandemic, health expenditure has nosedived, with many African countries relying on regional and international loans, grants, and donations,” Aminu Garba, the coordinator of the group, told Africa in Fact. By 18 August, Africa had recorded over 1.1 million cases of the coronavirus and 26,346 deaths. Activists and health experts are hoping the COVID-19 experience will provide a new window for Africa’s policymakers to take the decisive step of committing more resources to healthcare.

Chalkidou, who is also the director of Global Health Policy and senior fellow at the Center for Global Development, said with debt at unsustainable levels, they could do so by leveraging innovative and radical ways of generating revenue to not only protect but also to boost spending on health. Also, wealthier nations, although even worse hit by the recession, should do their bit by boosting rather than cutting development aid, she said.

“Radical tax reform, including revisiting fuel subsidies and introducing excise, including tobacco and alcohol taxes, smarter spending, leveraging pooled public procurement to improve procurement of pharmaceuticals where billions are wasted every year in a fragmented and inefficient fashion, and actively exploring underused tools such as debt swaps, must be at the forefront of the policy response,” she said. Response measures should also include governments cutting unnecessary overhead and recurrent expenditures and ensuring judicious utilisation of all loans, grants and donations, Garba added.

 

Ini Ekoutt is the Assistant Managing Editor (News) at Premium Times, an online newspaper based in Abuja, Nigeria. Prior to this, he reported for Next ,an investigative newspaper in Lagos. He has written for IPS Africa and other publications and is a former Wole Soyinka Investigative Journalist of the Year.

The struggle to keep pace

Africa’s collective electricity supply is bedevilled by weak legal frameworks and regional rivalry

An estimated 580 million Africans lack access to electricity, three quarters of the global total. The International Energy Agency (IEA) expects this number to rise as the COVID-19 pandemic stalls efforts to keep up with rising demand. 

Before coronavirus struck, the continent had been making slow progress towards Sustainable Development Goal 7 – Ensuring access to affordable, reliable, sustainable and modern energy for all – but it now stands little chance of meeting this target by 2030.

Despite extensive petroleum reserves, high solar irradiation levels and vast hydropower potential, Africa receives only 4% of global energy supply investment, according to the IEA. This is largely a result of foreign investors’ fears that short-term political considerations will trump long-term policy goals, rendering energy master plans obsolete. Investors’ primary concerns include abrupt changes to the policy environment, unsustainably low electricity tariffs dependent on unaffordable state subsidies, and the poor governance and creditworthiness of state-owned utility companies. A whopping 95% of African energy utilities fail to recover their costs, according to the Energy for Growth Hub, scaring off potential investors. 

Regional cooperation on energy promises potential solutions in three key areas. First, cross-border partnerships increase market size, making projects more likely to attract foreign investment. Second, regional connections enable countries with surplus electricity to share it with neighbours experiencing shortfalls thereby making power supplies more reliable. Third, a regional market can help drive down the costs for consumers if utility companies are mandated to purchase the cheapest available power. All three trends help to promote a shift in the energy mix by maximising the potential of new renewable sources at the expense of older and inefficient thermal generators.  

Power lines leaving the Eskom Duvha power station, some 15 km east of Witbank, South Africa.  Photo: Marco Longari/AFP

Africa’s regional economic communities have already taken steps to integrate through power pools, which enable national utility companies to plan and operate their collective electricity supply and transmission in the most reliable and economic manner given their load requirements. These power pools have the potential to promote investment in new hydropower capacity, reducing power system operating costs by $2.7 billion each year, and carbon dioxide emissions by 70 million tonnes per annum, according to estimates by the World Bank.  

The Southern African Development Community (SADC) was the first regional economic community to connect national electricity grids and form a common market for electricity, establishing the Southern Africa Power Pool (SAPP) in 1995. Rising power demand in South Africa and at energy-intensive mining projects elsewhere in the region helped to attract foreign investment. This led to the creation of the Copperbelt Energy Corporation, a private Zambian electricity generation, transmission, distribution and supply company, in 1997, and Motraco, a joint venture between Mozambique, South Africa and Swaziland to upgrade cross-border transmission lines in 1998.  

This early progress spurred the signing of bilateral contracts between the member countries, followed by the development of a Short-Term Electricity Market in 2001 and a Day-Ahead Market in 2009. By 2010, 7.5% of power generated in the region was being traded across the SAPP, according to the Infrastructure Consortium for Africa. However, this early progress in trading was not accompanied by comparable attention to the institutional environment. SADC failed to establish an independent regulator to oversee compliance with technical codes, regulate prices and promote competition. The weak legal framework and the absence of an autonomous dispute-resolution body undermined the pool’s prospects, according to a report commissioned by the World Bank.   

Regional rivalry also undermined SAPP’s prospects, with SADC energy ministers unable to agree on a list of priority projects, thus missing opportunities to secure new investment in power production during the 2000s.

Uneven development left members overly reliant on Eskom, the utility company in regional hegemon South Africa, which had both the most installed capacity and was the top buyer of surplus electricity. A wave of power cuts in South Africa forced other members of the pool to implement load-shedding from 2008 onwards. Rather than address this challenge President Jacob Zuma mismanaged Eskom, leaving the utility company overstaffed and broke, undermining its ability to honour contracts through SAPP.  

The Economic Community for West African States (ECOWAS) was more pragmatic than SADC when it established the West African Power Pool (WAPP) in 1999. Recognising the chronic energy shortages which plagued the region’s economic engine, Nigeria, WAPP adopted a more pragmatic, two-tier approach. Where reliable connections existed, steps were taken to forge a common market for electricity. Bilateral power purchase agreements enabled Côte d’Ivoire to export surplus energy to neighbouring Ghana, which was grappling with power cuts, and onwards to Benin and Togo, which as small countries had struggled to secure investment in their grids. By 2010, 6.9% of power generated in the region was being traded across this bloc, according to the Infrastructure Consortium for Africa.  

Where reliable connections were lacking, the focus was on linking the hinterland to more developed coastal nations. Thus inland Burkina Faso gained access to power from Ghana and Côte d’Ivoire, while Niger was hooked up to Nigeria. But a number of smaller economies remain left behind, with laggards Guinea, Liberia, Mali and Sierra Leone still busy aligning their systems in the hope of accessing cheaper energy supplies from elsewhere in the WAPP. Other countries have forged their own path. Senegal initially cooperated with Mali and Mauritania to share hydropower from the Manantali dam, but President Macky Sall has since focused on upgrading his country’s installed capacity and grid, eyeing abundant offshore gas reserves. This threatens to leave Senegal’s smaller neighbours Guinea-Bissau and Gambia in the dark.   

While the WAPP’s approach risks exacerbating regional inequality, it has at least developed a more robust framework, including a stronger and more autonomous secretariat capable of promoting priority projects and finalising decisions rather than waiting for national governments to act, according to a report commissioned by the World Bank. ECOWAS also took the critical step of establishing a Regional Electricity Regulatory Authority (ERERA), which became operational in 2011, addressing the lacuna identified in the SAPP.  

The thermal power station of Ivory Coast’s electricity production company Ciprel, a subdivision of French industrial group Eranove.  Photo: Sia Kambou/AFP

In the middle of the continent, the Economic Community of Central African States (ECCAS) has failed to emulate ECOWAS’ dynamism through the Central Africa Power Pool (CAPP), which it founded in 2003. 

Hugely ambitious plans to build new transmission lines required to unlock the vast hydropower potential of the River Congo have yet to move beyond the drawing board, with neither donors nor the private sector willing to tackle myriad political, regulatory, macroeconomic and security risks.  

Greater hope lies in the Eastern Africa Power Pool (EAPP), which was formed by seven Common Market for Eastern and Southern Africa (COMESA) members in February 2005. Although the World Bank dismissed regional energy trade as “negligible” less than a decade ago, investment in new dams and transmission lines promises to make Ethiopia and Kenya major electricity exporters. While Kenya has mastered geothermal power from the Rift Valley, Ethiopia is doubling its installed generation capacity courtesy of the 6,000 MW Grand Ethiopian Renaissance Dam (GERD), which is expected to become fully operational in 2023. Such vast potential convinced the World Bank and African Development Bank to fund a new 2,000 MW transmission line between the two countries, which was completed last year. The GERD promises to lower electricity costs, transform the energy mix and make power supplies more reliable across EAPP.  

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COMESA has also moved to establish common legal, regulatory and institutional frameworks. In 2012, the EAPP established an independent regulatory board to supervise the pool, ensure compliance with electricity codes and technical standards, and regulate the use and price of transmission lines. The regulator also plays a role in enforcing standards and resolving disputes, helping to encourage private investment, thus promoting competition in the pool progressively. For now, the focus is the Day-Ahead Market, but the EAPP aims to move to a centralised trading regime in the next five years, according to the Infrastructure Consortium for Africa.   

[However, Francois Pienaar, Business Development Manager at ESB International and a former consultant to utilities in Ghana, Liberia and Tanzania, worries that “billions spent on interconnections will be wasted” without greater attention to regional integration. Too many African governments focus on short-term objectives, such as subsidising electricity to key electoral constituencies to retain their political support, rather than considering how to address the contingent financial liabilities of national utility companies. Moreover, the energy sector has to vie for attention with competing industries, including the transport sector, beloved by politicians seeking visible projects. 

The outlook is also complicated by COVID-19. “A crisis can often predispose policymakers to undertake more politically risky energy sector reforms”, as Alan David Lee and Zainab Usman note in their World Bank paper, Taking stock of the political economy of power sector reforms in developing countries. Yet Dr Usman told Africa in Fact that “the coronavirus pandemic has dramatically increased fiscal pressures in ways that could make African governments subordinate electrification projects to more urgent priorities.” The strengthening of Africa’s power pools therefore looks to be among the many casualties of the current public health emergency, increasing the number of Africans deprived of access to electricity. 

Nick Branson, Director of Gondwana Risk, advises foreign investors on key African markets and helps African governments to fine-tune their policy objectives. Nick has extensive experience of conducting research across the continent and producing actionable analysis for a range of different audiences. Nick undertook doctoral studies at SOAS, University of London, and previously worked at the think tank Africa Research Institute.

 

Profit and power

A nuclear future for Africa will end up a game of Russian roulette

Russia is becoming increasingly aggressive in attempts to exert its influence in Africa, and nuclear energy is an area in which they are making major inroads. With Africa’s energy deficit and Russia’s comparative advantage in this field, advocates suggest this is an approach which could deliver win-win solutions for both parties. However, this is not a view that is universally held. The debate therefore continues to rage around whether the nuclear approach is simply pragmatic, or whether it is dangerous, unsuitable and a potentially damaging option.

Answering this question effectively requires a nuanced understanding of a number of intricately linked complex factors, namely, the continent’s energy needs; the pros and cons of nuclear energy; how Russian energy diplomacy works in practice, and the strategic rationale for Africa to pursue this avenue. By assessing the current state of affairs alongside past progress and future prospects, a clearer understanding of the potential and pitfalls of this approach is possible. First, it is important to understand the continent’s energy deficit. Despite being home to some 20% of the world’s population, Africa currently accounts for just 4% of global power supply investment. Only 40% of Africans have access to electricity, leaving 600 million people in the dark.

According to the International Energy Agency’s Africa Energy Outlook 2019, the global population without access to energy will become increasingly concentrated, with 90% without access to electricity and almost 50% without access to clean cooking in 2040 living on the African continent.  

The status quo is clearly untenable, especially in light of the continent’s evolving demographics. Simply put, today’s policy and investment plans are still not enough to meet the energy needs of Africa’s growing population. 

With over 1,000 GW of additional power urgently required to address this power gap, the need for cheaper, more sustainable energy alternatives has become urgent. In this context, the search for new sources, partners and strategies is accelerating. Recently, a number of African nations decided to pursue nuclear power industries or are currently considering this option. Africa is largely virgin territory for this mode of energy. Indeed, at present there is only one operational nuclear power plant in South Africa, representing the full extent of the continent’s functional nuclear capacity. However, this is changing fast. 

Russia’s President Vladimir Putin and Egypt’s President Abdel Fattah al-Sisi make a press statement following the 2019 Russia-Africa Summit at the Sirius Park of Science and Art in Sochi, Russia. Photo: Sergei Chirikov/Pool/AFP

However, nuclear’s association with weapons triggers grave concerns about safety. Indeed, for critics, potential for a nuclear meltdown like Chernobyl and Fukushima outweighs the positives of nuclear power, as do the high initial costs and environmental impacts of the nuclear waste produced. African states are expressing a desire to pursue this route, and Russia is expressing eagerness to make it happen, Moscow’s influence on African countries is starting to grow. To be sure, Russia is a major player in the nuclear market. It accounts for 7% of world uranium production, 20% conversion and 45% enrichment of this element, as well as for the construction of 25% of nuclear power plants in the world.  

Russia’s energy diplomacy, which centres on two imperatives – profit and power, is the primary avenue used to achieve this. The Russian government, and more specifically Rosatom, has been used to woo African nations into making deals.  For Russia, Africa is too big to ignore and an important partner in a changing global geopolitical landscape in which it is looking to assert itself as a dominant power. This theme was strongly emphasised during the 2019 Russia Africa summit in Sochi, which was billed as the start of a new era of Russo-Africa relations.  

Understanding Russia’s broader strategic aspiration in Africa requires understanding the broader geopolitical context. Historically, Russia and many African countries’ leaders share close ties and existing relationships to lever as a result of the assistance Russia offered during the time of African independence and the Cold War. African states are of strategic interest to Russia in terms of the geopolitical support they can offer – African states comprise the biggest geographic voting bloc across a multitude of global diplomatic, security and economic institutions and organisations. 

There is a broader economic imperative behind this rapprochement, too. As Aailya Vayez notes in her August/September 2020 paper on the evolving nature of Russia-Africa relations for The Republic, “the looming prospects of shrinking national natural resource reserves have extended into the country’s nuclear sector, with uranium reserves in shortage. Uranium extracted from African countries, such as Egypt, South Africa and Namibia, has become a significant raw material for Russian nuclear companies. This has gradually pushed Russia to become an importer of many raw minerals.” 

Russia’s President Vladimir Putin and Egypt’s President Abdel Fattah al-Sisi make a press statement following the 2019 Russia-Africa Summit at the Sirius Park of Science and Art in Sochi, Russia, on October 24, 2019. Photo: Sergei Chirikov/AFP 

Meanwhile, African countries see Russia as a partner that is not morally, politically or otherwise prescriptive. Russia’s trade and investment in Africa without conditions or imposition of ideals means that African countries view Russia and the related relations in a positive light – opening the way for further economic interactions.  

For African countries that lack financing to enhance energy infrastructure, the value proposition around nuclear is clear. Rosatom provides cheaper products than its competitors, is ready to loan money for construction and take care of the disposal of nuclear waste, and, in the conditions of constant blackouts, the continent needs uninterrupted, environmentally friendly and inexpensive electricity supplies as never before. 

However, Russian engagement is not without risks. What African economies stand to gain in terms of huge investments into cheap and reliable electricity, increased access to global markets and economic opportunity, may undermine governance and lead to a potential loss of institutional oversight.  

The recent headline grabbing nuclear deal proposed between Russia and South Africa is a clear example of the secrecy and lack of transparency associated with such transactions. It was only after strong pushback from South African civil society, independent media and robust institutions that the deal (which made very little commercial sense) was aborted.

However, other countries with less sophisticated systems and weaker institutions may be less lucky and fall victim to such malfeasance. Building nuclear plants with Russia would also open up those African nations to the vagaries of energy diplomacy relations with the country, which if evidence with Europe is anything to go by, could carry disastrous consequences. Indeed, if things turn sour, political displeasure could be expressed in unconventional ways – as was evidenced when Russia shut off gas supplies to Europe during the winter of 2015. Load shedding via Russia may become a reality for African countries who fail to manage their arrangements pragmatically and who enter into lopsided, unfavourable deals. For average citizens, the opacity around these government-to-government contracts should be carefully monitored.  

Then there is the issue of debt. To contextualise, over the past 20 years, Moscow has written off $140bn to foreign borrowers, of which $20bn came from African states. The persistent pushing of expensive nuclear projects in countries with a bad credit history suggests that there may be a political motivation overriding economic calculations. African countries need to be careful of ending up on the wrong side of exploitative practices, which are not mutually beneficial and could saddle them with unanticipated budgetary consequences. A more streetwise approach is therefore needed.  

Finally, there are concerns around the capacity of African states to manage these entities and questions on whether nuclear is actually fit for purpose. Insufficient infrastructure and a lack of human resources are key constraints which would hobble the success of such endeavours. Deep technical skills and experience is required to run such reactors, and unfortunately these are not in high supply on the continent.

In theory, if managed sensibly, nuclear energy could be a game changer for the continent. Indeed, the peaceful use of nuclear energy could act as an instrument to achieve national, African (Agenda 2063) and international development goals such as the UN Sustainable Development Goals (SDGs).  

However, there are a number of important caveats to this. Given the dangers associated with this mode of energy, sound governance and management will be needed to prevent sub-optimal societal and economic outcomes. Here, co-ordination and sequencing will matter, as will the need to “strengthen relevant bodies responsible for nuclear governance on the continent, improvement of national-level legislation on nuclear safety and security, and promotion of public debate on these issues”, as noted by the South African Institute of International Affairs’ (SAIIA) Atoms for Development project.    

In the absence of these measures, gambling on a future in nuclear will end up being the equivalent of a game of Russian roulette – both literally and metaphorically. The rewards may simply not be worth the risk.  

RONAK GOPALDAS is a director at Signal Risk, an exclusively African risk advisory firm. He was previously the head of country risk at Rand Merchant Bank (RMB) for a number of years, where he managed a team who provided the firm with in-depth analysis of economic, political, security and operational dynamics across sub-Saharan Africa. He holds a BCom degree in philosophy, politics and economics (PPE) and a BCom (Hons) from the University of Cape Town (UCT). He also has an MSc in finance (economic policy) through the School of Oriental and African Studies (SOAS) in London.

 

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