Training Without Absorption: Fiscal and Institutional Mechanisms Behind Health-Worker Unemployment in Africa

Background: African health systems face a labour-market contradiction: severe workforce shortages coexist with unemployment, underemployment and unpaid work among trained professionals. Existing syntheses quantify the paradox but do not adequately explain where the transition from training to productive employment fails. Methods: We conducted a systematic review and critical realist framework synthesis of evidence published from 1 January 2000 to 30 July 2026. PubMed was searched using a prespecified strategy and supplemented by citation chasing, exact-title searches and official World Health Organization and World Bank sources. Records were eligible when they examined health-worker unemployment, underemployment, unsalaried work or the fiscal and institutional mechanisms governing employment absorption in African settings. Selection followed PRISMA 2020 and search reporting followed PRISMA-S. A single reviewer completed screening with a structured second-pass verification. Twenty-four sources were appraised and coded against a six-stage absorption pathway. Results: From 171 records identified, 12 duplicates were removed, 159 records were screened, 43 full texts were assessed and 24 sources were included. The evidence consistently located failure at the interfaces between graduate production, professional entry, funded establishment, recruitment and payroll, deployment, and retention. Fiscal-space and wage-bill constraints were the most frequently treated mechanism, followed by training-planning discontinuity, recruitment bottlenecks, maldistribution and weak workforce information. Regional evidence indicates that an estimated 943,000 trained health workers were unemployed in 2024, while country estimates remain heterogeneous and asynchronous. Conclusion: Africa's workforce crisis is not reducible to insufficient training. It is a sequential absorption failure in which population need is not converted into financed labour demand and equitable deployment. Policy should link admissions and graduate tracking to medium-term expenditure frameworks, funded establishments, time-bound recruitment, professional-entry reform, non-state employment and accountable retention strategies.