For much of the past week, Nigeria’s politics has been dominated by a message by president Muhammadu Buhari. But it wasn’t a national TV broadcast, instead it was a audio message released from London, where the president has been away on a medical leave for an unknown ailment for almost two months.

In many ways, Buhari absence speaks louder than his faint message, especially to the state of Nigeria’s healthcare sector.

Nigeria’s political elite have historically shunned local hospitals and instead sought treatment abroad. Famously, in September 2015, Godswill Akpabio, then governor of oil-rich Akwa Ibom state, flew to London for treatment after a car crash just four months after he commissioned a $95 million hospital in his state.

It appeared Buhari might buck the trend when, last year, the government announced that it would no longer pay for medical trips of public officials. But his foreign medical trips, despite a well-funded presidential clinic, suggests even Buhari doesn’t trust local hospitals with his health despite expecting tens of millions of Nigerians to do so.

And Buhari is far from alone when it comes to African leaders skipping out on local hospitals. Zimbabwe’s Robert Mugabe is known to visit Singapore very often for health checks. In fact, since the start of 2016, Singapore has been the 93-year old president’s most frequent foreign destination. Mugabe’s trips have continued despite the lack of resources for local doctors. Back in February, Zimbabwe deployed army medics to work at major public hospitals after doctors went on strike to protest low allowances and bonuses.

In Angola, after a prolonged absence, the government confirmed in May that longtime leader Jose Eduardo dos Santos was away for one of his “regular health checks” in Spain. Despite its oil riches, Angola has largely failed to deliver improved infrastructure to a majority of its citizens. Last year, the country was plagued by a yellow fever outbreak after severe budget cuts for waste collection services. Earlier this month, Patrice Talon, president of the Republic of Benin, admitted to having two surgeries during a visit to Paris.

Indeed, in the last decade, six of the 12 African leaders who have died while in office did so while seeking treatment abroad. Nigeria’s late president Umaru Yaradua died at home in 2010, but only after returning to the country after months away in a hospital in Saudi Arabia.

President Country Died Michael Sata Zambia London (2014) Malam Bacai Sanhá Guinea Bissau France (2012) Meles Zenawi Ethiopia Belgium (2012) Omar Bongo Gabon Spain (2009) Levy Mwanawasa Zambia France (2008) Bingu wa Mutharika Malawi South Africa (2013)

The preference for an international doctor’s appointment is steeped in irony as these leaders often make promises about improving local healthcare a central part of their campaigns while seeking office. But by looking beyond the continent for medical solutions, African leaders maintain a vicious cycle which keeps faith in public healthcare low while channeling substantial state resources to hospitals abroad rather than plug local healthcare gaps.

In many African countries, this reality is all too apparent: according to World Health Organization estimates, with a shortage of 4.2 million health workers, Africa is the region with the world’s second-worst health worker shortage.

In Nigeria, Africa’s most populous country, the shortage will be less severe if the health system could call on the services of the up to 15,000 Nigerian doctors estimated to be working outside the country. But there’s little motivation for doctors practicing abroad to return home with crumbling infrastructure, lack of drugs and poor compensation.