Project with Domenick, presented today. It has been great to work with him.

Slides Here. All summer classes end today! 🙂


  • Increasing weight of sub-Saharan Africa in global health as a result of fast population growth

The Challenges

  • Healthcare Workers Shortages and Emigration
    • Sub-Saharan Africa has 11% of the world’s population, 25% of global disease burden, with only 3% of the world’s health workers.
    • ~20,000 African healthcare workers leave annually.
    • 12% of all African physicians are currently in the US, UK or Canada.
    • Each medical professional leaving Africa costs the continent $184,000, the total cost is ~$4 billion annually.
  • Urban-Rural Healthcare Disparities
    • Urban residents have 3x greater access to doctors and 2x access to Nurses than their rural counterparts.
    • Turnover rates highest amongst rural practitioners.
    • Current short-term financial incentives for doctors in rural areas prove to be inadequate and cost significant resources.

ACTORS’ Approach

  • Incentivize rural healthcare practice by financing physician and clinician medical education in return for commitment to work in rural areas.
  • Work with local and national governments to provide better living and working conditions for healthcare workers in rural areas, creating long-term incentives to reduce turnover rates.
  • Strengthen national educational infrastructure by providing education abroad and increasing the number of health professionals.



  • Cooperate with international foundations (Gates Foundation, WHO, World Bank etc.) for funding. Rural doctors can be used to implement international initiatives.
  • Local and regional governments provide housing/medical resources for rural doctors.

Long Term

  • Lower doctor emigration increases taxable income, lessens waste of national education funding.
  • Better rural healthcare reduces economic burden of disease and illness.
  • Human capital accumulates from improved health and education, which enhances the economy

Appendix: policy memo to Nigeria


To:                   Goodluck Jonathan

President, Federal Government of Nigeria

From:               Yuqing Hu

Analyst, Attract Clinicians to Rural Sub-Saharan Africa (ACTORS)

Date:                August 13, 2012

Re:                   Confront the Human Resources Challenges in the Health Sector of Rural Nigeria


The health sector in Nigeria is characterized by wide disparities between urban and rural areas in health status, service delivery, and resource availability. In particular, the rural areas have been persistently suffering from shortages of skilled medical personnel at the primary health care level, and it is largely attributed to the massive emigration of healthcare workers to west and to oil rich nations of the Middle East. However, the current incentives providing allowance and subsidy for rural workers have proven to be inadequate. The purpose of this memo is to introduce a scholarship program run by ACTORS that aims to address the brain drain, and provide recommendations for the government of Nigeria to facilitate the successful implementation of the program.

ACTORS: Attract Clinicians to Rural sub-Saharan Africa

ACTORS’ approach focuses on expanding the medical education, incentivizing medical students to work in (rural) sub-Saharan Africa, and improving the medical infrastructure in rural areas. The core is the scholarship program for medical education that is funded by global health organizations including the World Bank and Bill and Melinda Gates Foundation. It covers the tuition fees for medical students in exchange for their commitment to work for a period of time in rural sub-Saharan Africa. The doctor outflow in Nigeria occurs partly because the low income and unsatisfactory working conditions in (rural) Nigeria cannot help students to recoup their high education costs. When scholarship lowers their costs, graduates’ desire of seeking better pay abroad is thus reduced. It also enables poor students who would otherwise not attend medical schools to receive education, thus enlarge the pool of educated healthcare workers. However, the scholarship program is only a starting engine and it relies on external funding, while ACTORS aims to create a virtues circle that realizes the self-renewal of human resources in the health sector of rural sub-Saharan Africa. To achieve this goal, ACTORS will need the collaboration from the government of Nigeria.


The local and national government of Nigeria should administrate the medical training organization for quality control, establish a fair and efficient mechanism to allocate students to working places and training organizations, provide housing and other benefits for the rural workers, and add resources to the local hospitals or clinicians based on the feedback from ACTORS.

Student Allocation

As the country with the best medical education resources in sub-Saharan Africa, Nigeria relies less on overseas education than other African countries. The medical training can run in three tiers. The first tier is the national level universities: students across the nation who are willing to work in rural areas can apply to ACTORS scholarship. In this process, the federal ministry of education can establish a centralized system, in which the government sets the quota for scholarship students in each region and in each medical school. The quotas should be based on the availability of regional education resources and medical infrastructure, as well as the regional demand for doctors. ACTORS helps design an efficient algorithm such that the centralized system makes the allocation matching the preferences of most students. The second tier is the community level medical training. The government should organize the local medical training sessions, so that the allocated physicians can train their assistants. The second tier multiplies the local capacity for the primary care services. The third tier is the primary and secondary education. The government should improve the enrollment rate for primary and secondary education, since it not only enlarges the pool for eligible scholarship applicants and trainable assistants, the literacy of the Nigerian people can also add to the human capital which can boost the economy.

Quality Control

Since applicants have signed the contract with ACTORS, they are required to work for a period of time in the rural areas. In this period, the government is responsible to pay them salary, and provide other benefits such as housing. However, there involve risks that the rural healthcare workers might break the contract and emigrate, or shirk their duty.

To minimize the risks, there are three ways that the government could do. First, the government can provide the deferred benefits. After the physicians complete work, ACTORS will evaluate their work and confer several different honorary titles according to their service qualities, and report to the local government in confirmation of the completion and the quality. The government then provides different benefit packages to the workers based on ACTORS’ report, and these benefits could be in the form of healthcare insurance, society security and child care subsidy. The healthcare workers have the incentive to do well and comply with the contract. Moreover, since the longer working history is associated with better benefits, they also have incentives to renew the contract and extend their stay in the rural areas. The second way is to increase punishment for breaking contracts. The third way is to value the feedback from rural health workers. As physicians are working, they are responsible for providing feedback to ACTORS, and the advisory board of ACTORS will analyze the feedback and give the local government suggestions regarding the need for infrastructures and medical facilities. The feedback is reliable as it comes from the front line workers. The corresponding improvement of the working and living conditions for those workers can create a feeling of being respected and valued, and strengthen their willingness to stay in the rural area, and also it enlarges the region’s capacity for healthcare services.