BACKGROUND Despite a global recognition from all stakeholders of the gravity and urgency of health worker shortage in Africa, little progress has been achieved to improve health worker coverage in many of the African human resources for health (HRH) crisis countries. The problem consists in how policy is made, how leaders are accountable, how the World Health Organization (WHO) and foreign donors encourage (or distort) health policy, and how development objectives are prioritized in these countries. METHODS This paper uses political economy analysis, which stems from a recognition that the solution to the shortage of health workers across Africa involves more than a technical response. A number of institutional arrangements dampen investments in HRH, including a mismatch between officials' tenure in office and program results, the vertical nature of health programming, the modalities of Overseas Development Assistance (ODA) in health, the structures of the global health community, and the weak capacity in HRH units within Ministries of Health. A major change in policymaking would only occur with a disruption to the political or institutional order. RESULTS/CONCLUSIONS The case study of Ethiopia, who has increased its health workforce dramatically over the last 20 years, disrupted previous institutional arrangements through the power of ideas-HRH as a key intermediate development objective. The framing of HRH created the rationale for the political commitment to HRH investment. Ethiopia demonstrates that political will coupled with strong state capacity and adequate resource mobilization can overcome the institutional hurdles above. Donors will follow the lead of a country with long-term political commitment to HRH, as they did in Ethiopia.