It is no longer news that Nigeria lost 3,782 nurses to UK alone in year 2021, this is according to figures released by the Nursing and Midwifery Council of UK. Similar figures apply to the other segments of the Nigeria Health sector; a gross loss of skilled man power. Although, several efforts have been made towards reverting this dangerous progression. However, none seems to be working. This progression is gradually creating a defect in the Nigeria healthcare delivery framework; of which it can best be describe as a case of “National Diabetes”.
According to data from World Bank and Nigeria Medical and Dental Council, Nigeria produces an average of 3,000 doctors yearly, and currently has about 35,000 doctors practising, and an estimated doctor - to patient ratio of 4 per 10,000 population. Similarly, data from the Nigeria Nursing and Midwifery Council of Nigeria revealed that Nigeria produces about 12,000 nurses yearly and has a total work force of 250,000 registered Nursing and Midwifery professionals across the country. Despite the above figures, it is estimated that Nigeria will require an additional 149,852 doctors and 471,353 Nurses to meet up its rising healthcare professional need by 2030.
A report by the International Institute of Investigative Reporting, estimated that within a-two year period,(2018-2020), Nigeria lost over 9,000 doctors to UK and other countries. Prior to year 2015, healthcare professionals leaving the country were mainly the junior level professionals. However, over the last 5 years, the dynamics has changed. More and more high level professionals are leaving the country. Considering the existing shortage of high level professionals, if this trend continues unchecked, two grave consequences await the nation. First is the imminent collapse of medical training architecture in the country, and second is the loss of standard of healthcare practise.
While so much has been said about some of the factors underlying the massive exodus of healthcare professionals out of the country, in this review, an analogy of Diabetes mellitus is used to describe the current state of the Nigeria healthcare system. Also, some key recommendations shall be made, which if pursued, is hope to help turn around the state of things in the sector.
Diabetes mellitus is a medical condition characterised by relative or absolute deficiency of insulin leading to impaired glucose metabolism. Insulin is a hormone produced by the pancreas. It facilitates the absorption of glucose into the cell. Logically, in the absence of insulin, glucose becomes nothing but nuisance to the cells. The consequence of this is a spectrum of complications that may eventually kills the patient if no prompt medical attention is sought. As such, Diabetes is often described as suffering in the midst of plenty.
The current situation of the Nigeria health sector looks similar to the above. Glucose in this analogy represents Nigeria healthcare work force, the cells represent the Nigerian population, insulin here represents the healthcare funding and Pancreas represents the Nigeria government. So simply put, national diabetes results when there is an imbalance between healthcare funding and healthcare work force.
Management of this problem requires a multidimensional approach starting with an accurate problem evaluation.
Loss of man power in the health sector can be attributed to several intertwined causes which can be broadly classify into:
a) Nigeria population factor
i. Rapidly increasing population.
ii. Reducing capacity to pay for healthcare.
iii. Increasing prevalence of communicable and non-communicable medical conditions.
iv. Lack of trust in the Nigeria health system.
b) Healthcare professional factors
i. Better job offers at the global market.
ii. Industrial disharmony.
iii. Job Encroachment.
c) Healthcare Incentive factors
i. Poor Remuneration.
ii. Increasing living costs.
iii. Low cost of training.
d) Government Factors
i. Poor healthcare funding.
ii. Crippled healthcare infrastructure.
iii. Defective training architecture.
iv. Poor Healthcare Management.
v. Insecurity.
e) International Medical Market
i. Increased Global Demand for medical skills.
ii. Ease of Migration across international border
1. Rapidly increasing population
Nigeria has one of the fastest growing population in the world with an annual growth rate of 2.5%, and children aged 14 years and below account for 43.39% of the total population. The implication of which is that, about half of the country’s population cannot directly pay for their healthcare needs. This population group also accounts for over 25% of total healthcare usage. This translates into an overall increase in the total healthcare expenditure.
2. Reducing capacity to pay for health
Over the last five years, the Nigeria economy has been plagued with several economic challenges. According to the World Bank 2020, 40% of total Nigeria population now live below the poverty line of NGN137,430 ($381.75) per year. Data from World Bank 2018, estimated over 75% of Nigerians pay out of pocket for healthcare services. As such, a rising poverty index means a falling capacity to pay for healthcare services. Consequentially, this is likely to result in increased use of alternative care services, self-medication, late hospital presentation, and an overall poor clinical outcome. There is also a high risk of increasing prevalence of communicable and non-communicable medical conditions with declining standard of living. This will further put a stretch on the already overstretched healthcare facilities.
3. Increasing prevalence of communicable and non-communicable medical condition.
Poverty, insecurity alongside unhealthy lifestyle choices have contributed to rising burden of communicable and non-communicable diseases with alarming trends, however, the double action of communicable and non-communicable diseases constitute serious impediments to economic development by reducing productivity and slowing economic growth. They also obstruct human development by their negative action on life expectancy, education and socio-economic status in general.
4. Lack of trust in the Nigeria health system
A PwC survey reported that more than 90% of Nigerians believe that the healthcare services in Nigeria is low quality. Most respondents attribute their opinions to personal experiences and the visible state of disrepair in healthcare infrastructure in the country. This has been identified as one of the fuelling factors for the large scale medical tourism out of the country. Locally, it has also been identified as a risk factor for delayed presentation for care, and overall adverse clinical outcome.
5. Better Job offers at the global market
Health worker supply is a term that is used to describe the number of trained healthcare workers who work in a healthcare system or labour market. It is dependent on the number of graduates, and the retention rate of the profession. Healthcare shortage is a growing concern worldwide due to a growing demand that outmatches the supply. The World Health Organization (WHO) estimates that there is a global shortage of 4.3 million physicians, nurses, and other health professionals. The shortage is often starkest in developing nations due to limited capacity of medical schools worsened by loss of personnel to the developed countries. The recent onslaught of the COVID-19 pandemic has also aggravated the entire situation.
Considering the time resource, and financial costs of training of a medical personnel, importation of health work force has proven to be an efficient pathway for most developed countries. Better economic incentives coupled with better working condition is sufficient to entice any healthcare personnel from most developing countries.
6. Industrial disharmony
Strike action in the Nigeria health sector is a day to day occurrence. Most often result following failure of government to honour or implement agreement made with different unions in the sector. This has adversely affected the growth of the sector leading to loss of trust by Nigerians and potential private investors, service disruption, infrastructure decay and disruption of training. To curtail the incessant strike in the health sector, government over the years have implemented several policies like ‘No Work No Pay’ policy and mass retrenchment of striking personnel, all designed to deter industrial action in the health sector. While most industrial actions erupt as a result of renege of government, a few have been attributed to poor handling of some of the grievances by the various bodies in the sector by the hospital’s management.
7. Job Encroachment
Over the last 30 years, in conformity with global practices, several new fields have emerged in the health sector, some with overlapping responsibilities. This often results in job encroachment and inter-union rivalry. Although, it is worthy of note that the global healthcare market has expanded over the years. However, due to the limited investment in the Nigeria health sector, the sector has remained fairly stagnant. The resulting effect is an increased number of personnel competing for a fixed number of space.
8. Poor Remuneration
Remuneration refers to the sum of financial and non-financial benefit that comes with a job. The financial benefit includes salary, bonuses and commissions. While the non-financial benefit includes; vacation, healthcare, housing, education, training and retirement packages, job security etc. Research has shown that the financial benefit is necessary to attract employee, however, it is the non-financial benefit that drives employee loyalty to any organization- the carrot and stick approach.
Over the years, emphasis has always been on the financial benefit with back and forth discussion between different unions and government. The payment structure in the sector limit the extent of financial benefit the government can add to any party without disrupting the entire payment scale in the sector.
The implication of the poor remuneration in the healthcare system is that, average healthcare personnel lacks employee loyalty. And as such, in the presence of right incentives, he leaves the employer.
9. Increasing living cost
Nigeria healthcare workers have been described to as one of the poorly remunerated in Africa. With rising cost of living, the take-home of some average healthcare personnel is barely enough to cater for self or his or her family. In addition, most are required to attend trainings, seminar, pay for licenses and buy textbooks. Aside the basic living cost, most healthcare personnel have a chain of dependent in the family and the society at large. As such, the tendency to embrace an offer with higher financial package is high.
10. Low cost of training
Undergraduate training of a doctor in US and UK cost over $200,000 and $150,000 respectively, aside from accommodation, textbooks and living expenses. Whereas in Nigeria, it ranges from $3,000 to $35,000 from government owned Universities to the most expensive private Universities in the country. In contrary, postgraduate medical training in Nigeria tends to be similar with what obtains in most other countries except for the limitation of poor remuneration in Nigeria.
The low cost of training has a significant impact on the number of doctors and other healthcare personnel produced yearly. Nigeria has the highest healthcare personnel graduates in Africa followed by Egypt and South Africa.
11. Poor healthcare funding
Nigeria budget an average of 3.75% of it 495 billion GDP on healthcare, this is according to the 2021 World Bank report. Data from Nigeria Ministry of Health estimates an annual $10billion infrastructural gap in the Nigeria health sector.
For the year 2022, 4.3% of entire budget amounting to N711.28Billon ($1.72Billion) was earmarked for the Ministry of health, of which payment of salary and other recurrent expenditure account for 73% of total healthcare budget.
It is obvious government alone cannot bridge the huge infrastructural gap in the health sector. There is therefore a need to devise new funding options for the sector. However, crises in the sector, fluctuating government policies and lack of managerial transparency and accountability have been identified as major factors limiting private sector investment in the sector.
12. Crippled healthcare infrastructure
Revising the age-long decay in health infrastructure in the country has been the subject of many debate. This has been largely attributed to government neglect of the sector, alongside poor funding and poor management.
Most healthcare facilities in Nigeria lack conducive working environment for patients and employees. The equipment are either archaic, not available or not functioning. The pharmacy department in most hospitals are in a state of coma. The resultant effect is a massive loss of revenue, overwhelming stress on patients, caregivers and employee, preventable loss of life of patients, and even healthcare personnel.
13. Defective training architecture
The medical training architecture is quite important in replenishing the medical personnel pool of any country. Nigeria still has a significant shortage in the number of undergraduate medical training institutions relative to our medical personnel need. A few persons go abroad to acquire the undergraduate medical training, of which most rarely come back, constituting the indirect personnel loss.
Postgraduate medical training in Nigeria has grown tremendously over the last 50years, with each training body having its own training curriculum, examination and certification model. For example, the residency training programme for doctors, takes an average of 5 to 7 years depending on the specialty, while the school of post basic nursing takes a period of 1 to 2 years.
Recently, the duration of training has been a subject of debate, with some experts advocating for a reduction in the training period in order to facilitate an increased output of the colleges. However, more often than none, due to the peculiarities of the sector, post graduate training often extend years beyond the specified period.
In addition, limited residency placements, limited qualified supervisors, poor healthcare infrastructure, poor funding, hostile working environment and poor remuneration have all been identified as major factors hindering the growth of post graduate medical education in Nigeria.
NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA FELLOWS BY EXAMINATION
(1969-2018)
FACULTY PERIOD
FACULTY | 69-78 | 79-88 | 89-98 | 99-08 | 2009-2018 | total | % |
ANAESTHESIA | 20 | 19 | 24 | 36 | 113 | 212 | 3.5 |
DENTAL SURGERY | 9 | 35 | 30 | 67 | 86 | 227 | 3.8 |
FAMILY DENTISTRY | 7 | 3 | 10 | 8 | 42 | 70 | 1.2 |
OBSTETRICS & GYNAECOLOGY | 84 | 123 | 53 | 149 | 340 | 749 | 12.4 |
OPHTHALMOLOGY | 14 | 44 | 52 | 83 | 239 | 432 | 7.1 |
RADIOLOGY | 13 | 35 | 44 | 79 | 148 | 319 | 5.3 |
SURGERY | 73 | 118 | 83 | 68 | 27 | 369 | 6.1 |
ORL | 0 | 22 | 20 | 34 | 34 | 110 | 1.8 |
ORTHOPEADICS | 8 | 7 | 28 | 48 | 85 | 176 | 2.9 |
Total | 501 | 876 | 706 | 1244 | 2725 | 6052 | 100.0 |
SOURCE: Registrar NPMCN.
An interactive session with a principal officer in the National Postgraduate Medical College revealed a decline in number of applicants, and an increase in number of doctors dropping out of postgraduate medical training. If this trend continues unabated, coupled with an unchecked emigration of specialists, Nigeria may be heading towards a major specialist crisis. This will further cripple the country’s training architecture.
14. Poor Healthcare Management
Leadership in the health sector has been the subject of debate in many forums. However, one thing is certain, fixing the Nigeria health sector requires an innovative, resilient and visionary leadership. Mismanagement by most healthcare managers has been attributed as a major cause of the epileptic state of the health sector.
15. Insecurity
The surge in insecurity in the country has sky-rocketed the number of people leaving the country across all sectors. Healthcare personnel are often a soft target for kidnappers and other criminal element in the society. In fact, healthcare facilities are not spared from the rage of criminals, resulting in loss of lives, fortunes and valuable equipment.
16. Ease of Migration across international border
The International law recognises the right of everyone to leave any country, including their own, and to return to their own country. However, it does not establish a right of entry into another country. Each country has its own criteria to determine admission and expulsion of a non-national. However, due to the global shortage of Healthcare personnel, healthcare workers fall into shortage occupation list in most countries. As such, migration to any country is quite easy compared to other professionals. However, with international migration at an all-time high, government officials, policy makers, NGOs, researchers and international agencies have begun evaluating the human right dimension of migration and the attending consequence on the person, family and the country.
Recommendations
1. There is an urgent need for the government to revisit, review and implement the National Strategic Health Development Plan 2018 – 2022.
SECOND NATIONAL STRATEGIC HEALTH DEVELOPMENT PLAN 2018 – 2022
- Review the country's heath sector finance strategy
I. Ensuring universal health insurance coverage for all citizens.
II. Boast public private partnership in the health sector
III. Boast Investors’ confidence in the sector
IV. Boast user confidence in the health sector
V. Ensure managerial transparency and accountability in the sector
VI. Revitalize existing healthcare infrastructure in the country
VII. Drive economic viability of our health institution
VIII. ICT driven operations and services
- Incorporation of Health workforce development plan
I. identify crisis focus in the health sector and devise effective strategy to mitigate against them.
a) Review the current healthcare management structure with emphasis on transparency and accountability on the part of the leadership.
b) Review the current remuneration structure in the health sector
c) Define clearly job specifications for different categories of healthcare workers.
II. Strengthen and expand the existing health work force training institutions in the country
III. Strengthen and expand the post graduate medical training programme in Nigeria.
IV. Reduce drastically loss of healthcare workforce especially the high level personnel.
V. Strengthen and empower SERVICOM's operations
3. Review migration policies especially for occupations on the shortage list.
4. Improve the security situation in the country
5. Improve economic prosperity for all Nigerians
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