Globalization, with its focus on production and trade has led to increased international demand for high skilled labor. Brain drain is the preponderance of the migration of highly skilled educated persons from developing and less industrialized countries to developed and industrialized countries (Nadja, 2009). This phenomenon creates problems for source countries already struggling to cope with poor healthcare systems that barely meet local healthcare needs (Mills, Kanters, Hagopian, Bansback, Nachega, Alberton, Au-Yeung, Mtambo, Bourgeault, Luboga, Hogg and Ford., 2011). The World Health Organization (WHO) African region continues to experience loss of a sizeable number of skilled health professionals (physicians, nurses, dentists and pharmacists) to Australia, North America and European Union (kiriga, Gbari, Nyoni and Muthuri., 2006). He further stated that there are three categories of emigrants, namely;
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Scientific trainees (Master’s Degree (MSc.) and Doctor of Philosophy PhD.) who go overseas for training but fail to return upon completion of their studies.
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Health professionals who train in developed countries, return upon completion of their studies, and then emigrate after working for some duration.
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Health professionals who train in local institutions but emigrate upon completion of their studies or working for some period of time). (Pg: 1).
The developed countries are actively trying to attract skilled talent through offering a range of incentives and institutional mechanisms (Commander, Kangasniemi and Winters., 2004). The emigration of professionals especially from third world countries such as Nigeria, is not a new or unusual phenomenon. However, the emigration occurring within the healthcare workforce, especially doctors, appears have an alarming dimension at even a cursory glance (Adebayo, Adebayo, Adufe, Ayanfe, Buowari, Egwu, Efosa, Amoo, Oduyemi, Igbokwe, Fagbule, Agbogidi, Ebguchulem, Kwuduwei, Kanmodi and Ogunsuji., 2019). A myriad of push and pull factors determine why a skilled professional emigrate. The unfavorable attributes of the push factors are present in the underdeveloped countries which compel high skilled migration to the favorable pull factors of developed nations. Typically, the causes are economic, socio-political, demographic or ecological (world Economic Forum, 2017). The push factors occur in countries where education has not been commensurate with national needs and where talents and ability to perform have gone unrecognized (Mugo & Kamara, 2006). In another dimension the push factors in the developing nations are caused by the policies of the international monetary fund and World Bank such as the structural adjustment program that increased government spending in social programs thereby increasing high skilled emigration in developing nations (Nadja, 2009).
The medical and healthcare profession will be the scope of this study because much attention has been placed on the glaring loss of medical and health professionals and its implications on the underdevelopment of the Nigerian health sector, which has some of the poorest health indicators in the world, and the resultant effect on the capacity to fight diseases and provide lifesaving interventions. The management of this brain-drain is difficult for several reasons; firstly, there continue to exist strong reasons for health workers to migrate to recipient countries (the pull factors) and equally strong reasons to emigrate from source countries the ‘push factors’ (Pang, Lansang and Haines., 2002). Medical practitioners are often regarded as an important component of the social and economic sector of a country because they contribute toward the market for consumer goods and the political, social and economic stability of country. In other words, the health of a country’s population is the key for the economy of a nation (Hagopin et al., 2005). Various factors have been ascribed as being responsible for the emigration of medical doctors from Nigeria, including poor remuneration, hostile workplace environment, limited career progression or opportunities for skills development, amongst others (Dzvimbo, 2003). It is believed that low remuneration is the main reason why doctors in developing countries emigrate, leading to call for higher remuneration for health professionals in developing countries (Edward, 2014). It is difficult to determine the average salary of doctors in Nigeria, yet a newly employed doctor in the Nigerian federal civil service earns less than 250,000 naira ($694 US dollars) monthly while a fresh specialist trainee under the National Health Service in United Kingdom earns averagely $3600/month ( BDI, 2019). Therefore, it is attractive to move to other countries where they will receive greater monthly financial benefits for their services such as the UK, and USA (Mercy, 2019)
The migration of medical and health professionals in Nigeria deserves critical attention due to its future implications or adverse effects which under-develops the health sector, directly impacts socio-economic development outcomes and creates greater inequality among vulnerable populations. To that, this study intends to examine the adverse impact of medical migration and underdevelopment in Nigeria’s health sector and propose rational government polices peculiar to the Nigerian locality to minimize migration of medical and health practitioners.
1.2 Nature of medical and healthcare system in Nigeria
The healthcare system in Nigeria consists of public and private sectors. The public healthcare system provides about 20% of the population with healthcare, and it is structured along the lines of government (Nigeria operates a three-tier federal system of government, consisting of Federal, State, and Local Governments, with the State and Local governments being semiautonomous with each operated as determined by the government (or organizational) level, and with considerable overlap between them (Uzochukwu, 2017). He also opined that Healthcare at state level also includes support to local health centers, and sometimes the concurrent building and running of health centers in under-served rural areas. Furthermore, in states where the state government has established medical schools, healthcare at the state level also includes tertiary healthcare services, with the establishment of university teaching hospitals and medical research centers.
In furtherance to his assertions, tertiary health services are provided predominately by the federal government through the network of teaching hospitals and specialist hospitals, but several states manage and finance tertiary health care facilities within their state territories and the federal government through the Federal Ministry of Health is primarily responsible for overall stewardship and leadership for health and provision of tertiary health care. In Nigeria, the Federal Ministry of Health is made up of the Secretariat with eight departments; five agencies, including the National health Insurance Scheme and National Primary Health Care Development Agency; five vertical control programs; federal health institutions (comprising teaching hospitals, federal medical centers and specialist hospitals); three research institutes; and professional regulatory councils and boards for the various professional health disciplines (Uzochukwu, 2017). In addition, the development partners also provide resources to the Federal Ministry of Health through the Federal Ministry of Finance. He also noted that Federal responsibilities include setting standards, formulation of policies and implementation guidelines, coordination, regulating practices for the health care system and delivering services at tertiary care level. Specific diseases and specialized services are provided at the tertiary hospitals and health care in Nigeria is financed through different sources, including tax revenue, out-of-pocket payments, donor funding, and health insurance, both social and community. Financing agents in Nigeria include the federal government and its parastatals, state and local governments, and insurance companies. The government is responsible for the provision of quality health services to the citizens, but evidence suggest that households through out-of-pocket spending continue to be the major source of health financing in Nigeria (Uzochukwu 2017).
Although states allocate reasonable budgets to their health sectors, there is evidence of erratic or lack of release of the allocated budgets and, Accountability has been noted as a key element in implementing health sector reform and strengthening health system performance In Nigeria, accountability and transparency is one of the weakest areas of the public finance system, especially at the LGA level (Uzochukwu, 2017).
The main categories of human resources for healthcare are doctors, nurses, midwives, laboratory staff, public health nurses, public health nutritionists, and community health and nutrition workers, including community health officers, community health extension workers and community health assistants. Health care workers are paid by the level of government where they work, though there are some exceptions where professionals working in tertiary facilities are employed by the state. Primarily because healthcare is on the concurrent list4 of the Nigerian constitution, the governments at each level can establish and run healthcare facilities, depending on their resources. In practice, the three tiers of government and the private sector have established primary health centers and health facilities all over the country. Most of these centers are staffed by health personnel, ranging from nurses in the smaller centers, to nurses and doctors in some of the larger centers. However, these centers have failed to deliver adequate healthcare to the populace, especially in the rural areas for which primary healthcare was supposed to provide coverage. Due largely to a lack of political will, underfunding, understaffing, corruption, poor management, and public perception of an unsatisfactory quality of services, most Nigerians refuse to access and utilize the services of the primary healthcare center (Abdulraheem, Olapipo and Amodu., 2012), preferring to use secondary and tertiary Health facilities. These facilities, situated in urban and semi-urban centers, are therefore forced to receive and offer primary healthcare services because they are better staffed and equipped, thus putting serious pressure on both human resources and healthcare facilities, especially at the secondary healthcare level. A lack of clearly defined roles and responsibilities between the different tiers of government, and between the public and private sectors of the healthcare system causes further difficulties for efficient healthcare delivery (Welcome, 2011), with some states preferring to delve into establishing tertiary health facilities (which is much more capital intensive) while neglecting their primary responsibility of properly funding and running secondary health care facilities; probably because establishing these tertiary facilities gives them more political capital.
The healthcare system, just like most Nigerian institutions, face a lot of challenges, resulting in a system that fails to meet the healthcare needs, let alone the aspirations, of the Nigerian population. The WHO has placed Nigeria among countries with low density of skilled workforce because Nigeria’s health workforce is grossly inadequate due to poor funding, bureaucratic restrictions and the brain drain phenomenon (Alkali & Bello, 2020). This failure of the Nigerian healthcare system is blamed on many factors, identifying the “inadequacies in the community or primary healthcare services” as the most important (Asuzu, 2004). Like other stakeholders, he calls for reform in the system, as there has been little progress despite decades of primary healthcare policy implementations in Nigeria. Nigerian healthcare workers work in some very challenging working environments which often leads to frequent industrial action in the healthcare system in the midst of unsatisfactory working conditions (Oleribe, EziemE, Oladipo, Akinola, Udofia and Taylor., 2016). The cause of Nigeria’s health workforce crises is influenced by several factors including missed salaries, deteriorating health facilities, poor welfare and divisions among health workers, but most important of all poor health leadership (Adeloye, David, Olaogun, Auta, Adesokan, Gadanya and Iseolorunkanmi., 2017). For example, the low motivation of healthcare workers and poor quality of service delivery is juxtaposed with most of the Nigerian population’s failure to trust public hospitals for their history of poor services and poor facilities, and believing that private practices were expensive (Olu Ogurin and Akerele., 2007). Medical products, drugs and vaccines are either unavailable, or the available ones are too expensive, or substandard with some reports claiming that over 70% of drugs dispensed in Nigeria are substandard (Raufu, 2002).
Some of these challenges have been blamed for the continuing loss of Nigerian doctors through international migration (Uneke, Ogbonna, Ezeoha, Oyibo, Onwe and Ngwu., 2008), which, combined with insufficient production of medical and healthcare graduates, leading to a severe dearth of human resources for health in Nigeria. The resultant effects on the healthcare sector are glaring: health centers lacking basic facilities, hospitals that serve mainly as consulting clinics, a primary healthcare system that is prostrate, human resources for health that are poorly remunerated and motivated, and a health system that has failed to adequately cater for the healthcare needs of the Nigerian population (Welcome 2011).
Overview of Abia State Health System
Abia State is in the southeastern region of Nigeria and consists of 17 local government areas (LGAs) and 292 political wards, with a population of 4.5 million people in 2019 (Abia State SBS, 2019; Nelson et al., 2020). The Abia State Ministry of Health is responsible for healthcare policy and administration in the state. Through the local government health authorities, the Abia State Health Care Development Agency is responsible for issuing and implementing policies and guidelines for primary healthcare service delivery across the 17 LGAs. The Hospital Management Board oversees secondary healthcare provision. Other major public health entities in the state include the Abia State Health Insurance Agency and 11 health training institutions.
In Abia State, healthcare services are provided and accessed at primary, secondary, and tertiary health facilities. There are 1,496 healthcare facilities (1,245 public, 236 private, and 15 faith-based). Among these are 687 public primary health facilities, 236 private health facilities, and 33 hospitals.
Underdevelopment and the medical system
In all societies, the quality of healthcare is associated with a nation’s political and economic development. Hence medical and health underdevelopment is inextricably linked to a nation’s economic underdevelopment. Transparency international in 2011, observed that one major problem of the weak medical and health sector in Nigeria is corruption- a misuse of entrusted power for private gain. It occurs when public officials, who have been given the authority to carry out goals, which further the public good, instead use their position and power to benefit themselves and those close to them. Corruption is a pervasive problem affecting the Nigerian health sector. Evidence abounds on the negative impact of corruption on health and welfare of Nigerians, Work Related Stress (WRS) among medical which is been argued as a factor associated to emigration of medical and health workers in Nigeria.
The medical work related stress is the harmful physical and emotional responses that occur when the requirements of job do not match the capabilities, resources, or needs of the worker in the work environment (Etim, Bassey, Bassey, Ndep, Iyam and Nwikekii,., 2017). The Hospital work stress is characterized by stressors like; work over load, under – staffing, use of redundant equipment, poor promotion, poor managerial relationship with staff, poor working environment, excessive/prolonged working hours, etc. a detailed study by Etim, Bassey, et all., (2017) demonstrates that there is significant relationship between work – related stress on healthcare workers and service delivery, work over – load and increase in work stress, and poor managerial relationship/support and staff attitude to service delivery.
From the foregoing, corruption can be arguably linked as an associate factor of underdevelopment contributing to the weak health care systems in the country. It takes states health care systems and at least passable local infrastructure to improve public health. However, decades of neglect have rendered local hospitals, clinics, laboratories, medical schools and health talent dangerously deficient. What this means is that despite all the public health sector reform, the health sector could not produce the desired result (Anaemene B, U 2016)
1.3 Statement of the problem
While scholars disagree on factors responsible for manpower deficiency in developing countries, some attribute the upsurge to the transnational movement of skilled manpower to a number of potential attractions present in the host countries’ economies. Among these are employment opportunities and a higher standard of living than those available in the migrant’s home country (Odunsi, 1996). According to the World Health Organization report (2004), searching for an adequate standard of living is the root of decisions to migrate by an increasing discontent with the existing job or living conditions, workers skeptism about career advancement, poor management, work overload and burnout, wage difference and political instability which are among the push factors for migration.
In analyzing the dynamics of migration, Odunsi (1996), attributed the decision of Nigerian medical and health professionals to emigrate to multiple factors; prominent among these are higher educational opportunity, opportunity to fulfill occupational and professional aspirations, unavailability of employment opportunities at home, political and socio-economic instability, inconsistent and unfair recruitment policies in public sectors, improper method of evaluating diplomas and among others. In a study about the declining nature of primary health care in Nigeria, Abdulraheem et al., (2012), pointed out, that a lack of political will, underfunding, understaffing, corruption and poor management, affect the productivity of medical and health workers in Nigeria.
A detailed research by Eriki, Oyo-Ita, Odedo, Udoh, Omaswa, and Kadama., (2015) outlined the main factors underlying human resources for health and medical challenges in Nigeria include:
(a) Insufficiently resourced and neglected health systems;
(b) Poor human resources planning and management practices and structures;
(c) unsatisfactory working conditions characterized by heavy workloads, lack of professional autonomy, poor supervision and support, long working hours, unsafe workplaces, inadequate career structures, poor remuneration, poor access to needed supplies, tools and information, and limited or no access to professional development opportunities; and
(d) Internal and international migration of health workers. (Pg: 3)
In addition, The cause of Nigeria’s health workforce crises is influenced by several factors including missed salaries, deteriorating health facilities, poor welfare and divisions among health workers, but most important of all poor health leadership (Adeloye et al., 2017) Organization for Economic Co-operation and Development (OECD) data identified Nigeria as the leading African source of foreign-born nurses practicing in OECD countries; and one of the three leading African sources for foreign-born physicians citing Inadequate infrastructure, poor working conditions and poor compensation packages as major factors contributing to the emigration from the country of a sizeable number of surgeons, physicians, nurses and other medical professionals (Eriki, et al., 2015). For example, health workers in Nigeria typically earn about 25% of what they would earn if they were working in North America, Europe or the Middle East.
Despite sound policies and interventions to develop the Nigerian health sector, Timothy, Irinoye, Yunusa, Dalhatu, Ahmed and Suberu, (2014) outlined several challenges that continuously undermine the progress and achievement of universal access to health care. The scholars mentioned some of the factors that affect the overall performance of the health system to include; inadequate health facilities/structure, poor human resources and management, poor remuneration and motivation, lack of fair and sustainable health care financing, unequal economic and political relations, the neo-liberal economic policies of the Nigerian state, corruption, illiteracy, very low government spending on health, high out-of-pocket expenditure in health and absence of integrated system for disease prevention, surveillance and treatment, inadequate mechanisms for families to access health care, shortage of essential drugs and supplies and inadequate supervision of health care providers are among some of the persistent problems of the health system in Nigeria.
The Emigration of health practitioners in Nigeria deserves critical attention due to its future implications or adverse effects which directly impacts socio-economic development outcomes and creates rapid health decline among vulnerable populations. Thus this study intends to examine the undeveloped sectors in Nigeria’s health system caused by medical migration for propose pragmatic policies peculiar to the domestic environment to minimize the migration intentions.