This study investigated emigration intention of physicians and factors influencing exodus of medical doctors from Nigeria and found that majority of the doctors are not willing to continue practice in Nigeria due mainly to poor remuneration, rising insecurity and inadequate diagnostic equipment and facilities. Although the proportion of physicians who are either not willing or undecided to continue practice in Nigeria is close to 88% of Nigerian doctors previously reported to be seeking work opportunities abroad, the proportion of those who want to leave Nigeria is distantly below the 57.4% emigration intention reported in a study among resident doctors at the University College Hospital (UCH) Ibadan South-West Nigeria. The discrepancies between our finding and those of previous studies may be due to a changing trend in emigration pattern or varying characteristics of the research participants; our respondents were drawn from several institutions in the six geo-political zone of Nigeria and included doctors with varying age distributions, levels of training, qualifications, work experience, remunerations and possibly varying levels of job satisfaction.
Similar to a previous report, UK, Canada, USA, Australia and Saudi Arabia are the preferred destinations of physicians wanting to leave Nigeria. Also, another previous report of migration profile of Nigerians showed UK and the USA as the most preferred and the single most important destinations respectively. This common migration pattern is indicative of strong pull factors present in those UHICs such as high job satisfaction among physicians in USA (91%) and UK (84%), which widely varies with the relatively poor satisfaction found in our study. The high job satisfaction in those countries on the other hand may not be unconnected with the juicy remuneration for doctors in the UK, Canada and USA[23, 24] Australia,[25, 26] and Saudi Arabia. Accordingly, our finding shows that poor remuneration for doctors is a leading cause of physician emigration from Nigeria.
Good pay for physicians is a widely documented determinant of physician job satisfaction,[27–30] and higher pay is known to lower physician migration.[31, 32] Compared to their counterparts in UHICs, Nigerian physicians are poorly remunerated. Whereas a highest-paid public sector specialist doctor on Consolidated Medical Salary Structure Level 7 Step 9 earns about N13,013,213 (US$23,660.38) per annum,[33, 34] specialist physicians elsewhere earned an average of US$326,000, US$144,500 and US$128,500 per annum in USA, Germany and UK respectively as of 2019, and between US$120,000 and US$240,000 in Saudi Arabia, United Arab Emirate and Qatar. The discrepancy between these juicy pays and the paltry physician salary in Nigeria is a strong pull factor for physicians wanting to relocate their professional practice to UHICs and other countries with better pay. Worthy of note among our findings is that physicians in the public sector were two and half times less satisfied than their counterparts in the non-public sector. In a previous study, majority of physicians believed government is unconcerned with mitigating the challenges facing medical doctors in Nigeria. These findings underscore the need for the government of Nigeria at all levels to put in place better incentives to retain physicians and also attract back others from the diaspora. Although doctors may not have chosen medicine purely for financial reasons, earning a decent salary certainly can help to give them and their family a good quality of life.
Our findings show that worsening security situation in Nigeria is among the top reasons the doctors are emigrating. This is in concordance with the negative consequences of insecurity on health workforce motivation and availability,[36, 37] which ultimately adversely affects health service delivery.[38–40] Over the years, insecurity in Nigeria has worsened; in December 2021, majority (79%) of adult Nigerians opined that the country has not fared well in the area of security. The worsening insecurity is attributable to many factors including Boko Haram insurgency, banditry and kidnapping, clashes between herders and farmers, clashes between Nigeria’s security forces and the Biafran separatist group, and militancy in the oil-rich Niger Delta region.[41, 43] The poor response received from the North-East region may partly be due to the paucity of doctors engendered by the protracted insecurity situation in that region.[44–46] The North-East region has been worst hit by Boko Haram insurgency with some 15 million people having been adversely affected due to their activities. In 2014, more than 800,000 persons were internally displaced in the region as a result of the insurgency in Borno, Yobe and Adamawa states. As of the end of 2020, the United Nations Development Programme reported that the region's conflict due to Islamist insurgencies had killed nearly 350,000 people and projected that more than 1.1 million people may die if the conflict continues to 2030. The insecurity situation has led to destruction of more than 40% of health facilities and fleeing of many doctors from the region.[48, 49]
Apart from North-East, every other region in Nigeria has had ugly experience due to worsening insecurity. The severity of insecurity is a clarion call on the federal, state and local governments to address the root causes of the problem by promoting good governance and providing jobs to the millions of educated youths and the unskilled millions of young people, thereby improving the security of the health workforce. It is also pertinent that other stakeholders in security matters such as the traditional and religious leaders sit up to their responsibility of reorientating the youth and their faithful respectively toward a violence-free society. This will not only help in retention of physicians and other health workforces in the country but also in attracting back more to improve the worsening physician population in the country. In a previous report, security was noted as the most important factor influencing the decision to return to Nigeria among the Nigerian health professionals living in the UK.
Further, the fact that inadequate diagnostic equipment and facilities demotivate Nigerian doctors shows how the dilapidated infrastructures and obsolete medical equipment in the nation’s health sector,[51–53] frustrate physicians from achieving professional fulfillment. In Nigeria, modern diagnostic procedures such as Magnetic Resonance Imaging, Computed Tomography scans and other modern diagnostic procedures are still an exclusive preserve of the rich. According to the 2016 National Health Facility Survey, the average availability of basic medical equipment and valid essential drugs in all health facilities country-wide were 32.9% and 34.6% respectively and only about one third of surveyed health facilities received any cash grants to meet their operational costs. These statistics may not have changed much recently considering the nation’s economic recessions of 2016 through 2017 and 2020, and the impact of the COVID-19 pandemic.
Over the years, the paucity of skilled physicians due to brain drain, the inadequate diagnostic equipment and facilities and the underfunding of the health sector have worsened medical diagnostic and treatment challenges in Nigeria and these have in turn fueled medical tourism among the citizens,[51, 52, 57] especially the political class and the rich at the expense of the poor and vulnerable populations. On the other hand, medical tourism has further reduced the revenue for sustaining the country’s local health sector due to shortage of logistics and facilities and lack of trust in medical practitioners. The relationship between diagnostic and treatment challenges and medical tourism in Nigeria has assumed a positive feedback phenomenon, with one driving the occurrence of the other. If the millions of naira spent by some government officials and the Nigerian elites on medical tourism abroad are put into effective infrastructural development and Nigerians are made to receive medical treatments in the country, physicians will feel more professionally fulfilled, be better retained and huge cost of medical tourism abroad will be largely reduced. This will improve the economy and the general image of the nation’s health sector.
Our findings further show that older physicians are more willing to continue their professional practice in Nigeria compared to younger ones. This is probably due to waning interest in emigration at advanced age and more extensive family ties as the family enlarges. Older physicians may prefer to stay back at home to take care of the family and their children and rather support younger ones who may be more willing to travel abroad for greener pastures. The implication of this is that Nigeria is losing more energetic young physicians who are supposed to remain in the country to take over from the aging and retiring ones. With the current trend of physician emigration and the number of medical graduates in the country, Nigeria stands the risk of running unmanageable deficit of medical doctors in the near future. This should be a source of worry to the government of Nigeria and all stakeholders in the country’s health care industry.
In view of the already poor Healthcare Access Quality performance, and poor key health indicators such as high maternal mortality ratio and under-five mortality, emigration of physicians can literally create more life-endangering situation for Nigerians when the health services vanish due to lack of qualified personnel. When there is shortage of physician to provide healthcare services to the people, a number of effects inevitably become evident in the health system, including: unnecessarily prolonged waiting time before consultations, increased workload for practitioners, time constraints on doctor-patient interactions, overworked and stressed practitioners, higher prices for consultations and lower quality of care, ultimately resulting in worsening of the health system.
Beyond weakened health system, physician emigration has negative economic consequences on Nigeria due to loss of return on investment.[62, 63] The country suffers financial losses when domestically trained physicians emigrate because the training of physicians in Nigeria is largely publicly financed. Undergraduate medical education in Nigeria is subsidized with government funds at the public universities which constitute 35 (79.5%) of the 44 accredited medical schools operational in the country. The situation is the same at the postgraduate level since residency training is run mainly at the federal and state university teaching hospitals, funded with government money. According to Saluja et al, LMICs lose US$15.86 billion annually due to excess mortality associated with physician migration to UHICs and greatest total costs are incurred by India, Nigeria, Pakistan and South Africa and by the WHO African region. Over a decade ago, Kirigia et al had estimated that about US$1,854,677 is lost for every doctor that emigrates from a country in the WHO African region. The loss in Nigeria is huge because majority of the physicians obtain their BMD from public universities, an investment that is now benefiting other countries.
To cushion the effects of massive exodus of doctors from Nigeria, there is need to expand medical education to produce more graduates and more pressing need to retain them by addressing the push factors for emigration. Expanding medical education requires a more robust funding of medical schools to enable more efficient admission process, procurement of medical infrastructure for learning and improvement of remuneration for clinical teachers in the medical education system. This will improve the limited numbers and capacity of medical schools in the country which currently stands at 37 fully accredited and 7 partially accredited ones with total carrying capacity of 3,990 per year. To retain physicians from leaving the country, there should be more funding of the health sector to improve on physician remuneration and provide adequate diagnostic equipment and facilities. With allocation of an average of 4.7% of her annual budgets to the heath sector, two decades following the Abuja declaration of the African Union countries to be allocating at least 15% of their annual budgets to improve the sector,[67, 68] Nigerian health sector has been grossly under-budgeted.
Limitations to the study
The authors are aware that inability to operate NMA and affiliated body WhatsApp, Telegram or Facebook platforms due to poor or failed network connectivity during data collection period may have deprived some physicians the opportunity to participate in this study and so made this report not completely representative of the true situation of things, since access to the data tool depended on good internet service. However, these challenges were mitigated by allowing a long window period of one month for submission of responses. Further, the link to the google form was regularly shared on all the identified social media platforms of NMA on two-daily basis throughout the data collection period. WhatsApp and Telegram are not only the common social media platforms of communication of NMA and her affiliate bodies, they are the official media for dissemination of information of the Association and most Nigerian physicians use at least one or two of the platforms. Another limitation is that the link to the data tool was accessible to physicians who have emigrated from Nigeria but remained in the social media platforms of NMA. This challenge was addressed by excluding the responses submitted by physicians in this category during data cleaning before analysis was conducted.