Health Worker Strikes in Africa: Tactical Reactions Are Not Enough

Strikes by health workers have become a recurring feature of many health systems across sub-Saharan Africa [1, 2]. Although often framed as isolated national crises, these events expose deeper structural deficiencies in the governance of public health systems and labour relations [2, 3]. Based on the case of Mozambique [4], this editorial argues that both governments and health professionals tend to favour tactical responses, such as legal threats, dismissals, public appeals, or one-off negotiations, instead of adopting long-term strategies that could promote stability and trust. Overreliance on tactics, while politically expedient, perpetuates fragility and fails to break the cycle of confrontation. The Mozambican experience is not unique. Similar reactive and fragmented responses were documented during the prolonged health worker strikes in Kenya and Nigeria, where institutional weaknesses and the absence of structured dialogue exacerbated the crisis [5, 6]. Mozambique has witnessed successive strikes involving doctors, nurses, and other health workers since 2013. These actions have often followed a similar script: governments respond tactically, aiming to suppress unrest, while underlying causes remain unaddressed. At the same time, health workers failed to build durable platforms for negotiation. Their mobilisations have focused on immediate demands related to pay or conditions, without broader engagement with structural reform. Like in other countries, this limited scope, combined with state resistance, has entrenched a dynamic of short-term escalation, and temporary resolution and recurrent conflicts [5, 6]. The 2013 doctors' strike in Mozambique is particularly illustrative. It began with specific demands from a small group of physicians but accelerated after the government refused to acknowledge the legitimacy of their grievances. Rather than engage in structured dialogue, authorities employed coercive measures, including dismissals and public accusations. These responses intensified mistrust and triggered wider participation from other professional groups [4]. In the absence of institutional mechanisms for collective bargaining or conflict resolution, further strikes followed in subsequent years. More than a decade later, the situation remains unresolved. Similarly in Kenya, Nigeria, South Africa and other countries, authorities have frequently relied on legal instruments, court injunctions, suspension of salaries, or deployment of military personnel to contain health worker protests. Although such responses may achieve short-term order, they rarely result in sustainable agreements. In parallel, the fragmentation of professional associations, the lack of coordinated leadership, and the absence of institutionalised grievance mechanisms prevent workers from engaging in long-term negotiation processes. In many settings, labour relations become reactive rather than constructive [1, 3-8]. This editorial argues that what is missing is a strategic approach to health workforce governance. Labour unrest in the health sector should be seen not as an operational inconvenience but as a signal of systemic failure [1-3]. Sustainable responses must recognise health workers as essential public servants who require safe conditions, fair compensation, and meaningful participation in institutional decision-making [1, 3-8]. Moving forward requires a shift from crisis containment to long-term investment in systems that support dialogue and accountability [1, 3-8]. In Kenya and Ghana, for example, efforts to implement collective agreements and broaden stakeholder participation have contributed to more stable labour relations, despite uneven progress [6, 9]. In Mozambique, lessons from the 2013 strike include the importance of involving social actors such as religious leaders, professional associations, and media in dialogue processes [4]. However, implementation gaps persist in all settings, and fragile institutional environments often undermine continuity [2]. This view is also supported by recent evidence from pandemic contexts, where health worker strikes also revealed underlying governance failures rather than isolated responses to crises [3]. First, governments should establish legally protected and institutionalised frameworks for social dialogue. These include permanent collective bargaining committees, sector-specific labour tribunals, and independent mediation structures. The purpose of these bodies is not simply to avoid strikes, but to promote continuous and structured negotiation between state and workforce. Second, human resources for health planning must be aligned with national fiscal policies and employment capacity. Many strikes are linked to a mismatch between the number of trained professionals and the public sector's ability to recruit, retain, or promote them. Planning must therefore be based on reliable data and adapted to the realities of labour markets and national and regional needs. Third, investment in leadership is essential. Health administrators, union representatives, and civil society actors must be trained to engage constructively in negotiation processes. Credible leadership - authentic, distributed and participatory—is critical to moving beyond adversarial relationships and building trust. Fourth, countries should develop transparent and responsive grievance redress systems. These mechanisms must be accessible to health workers and capable of resolving disputes at an early stage, before escalation occurs. Beyond the national level, the absence of a regional or global debate on health worker strikes is notable. Despite the scale and recurrence of labour actions across Africa, organisations such as WHO and the African Union have not developed specific guidance or frameworks to support governments and health workers in managing disputes. This silence limits the exchange of experiences and prevents the development of regional norms or collaborative strategies. It also reinforces the perception that labour conflict is an internal matter, disconnected from broader health system performance or resilience. Mozambique should therefore be viewed as a microcosm of a continental problem. Across Africa, health worker strikes reflect a pattern of over-reliance on tactical responses and underinvestment in strategic governance. Until this imbalance is addressed, cycles of disruption will likely continue. The editorial calls for action not only at national level, but also at regional and international levels. A structured conversation on labour relations in the health sector is urgently needed. Governments, professional associations, unions, and development partners must engage in serious dialogue on how to prevent and resolve conflict. This includes recognising that health worker strikes are not exceptional. They are indicators of chronic governance failures that demand institutional reform. Only through long-term planning, inclusive negotiation, and system-wide strengthening can African countries build the foundations for more resilient, equitable, and harmonious health system. We thank the Fundação para a Ciência e a Tecnologia (Science and Technology Foundation) for funds to Global Health and Tropical Medicine Research Centre (Grant No. UID/04413/2020) and Associate Laboratory in Translation and Innovation Towards Global Health (Grant No. LA/P/0117/2020). The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report.