Bulletin of the World Health Organization

Managing brain drain and brain waste of health workers in Nigeria

Article: Stilwell et al. 2004;82:595-600

Nigeria is one of the several major health-staff-exporting countries in Africa. For example, 432 nurses legally emigrated to work in Britain between April 2001-March 2002, compared with 347 between April 2000-March 2001, out of a total of about 2000 (legally) emigrating African nurses, a trend that is perceived by Nigeria’s government as a threat to sustainable health care delivery in Africa’s most populous country. About 20,000 health professionals are estimated to emigrate from Africa annually (1). Data on Nigerian doctors legally migrating overseas are scarce and unreliable, largely because most wealthy ‘destination’ nations like Australia currently make it virtually impossible for overseas-trained doctors to migrate to their countries primarily on the basis of medical skills. Nevertheless, hundreds of Nigerian-trained doctors continue to migrate annually.

Stilwell et al. (2) provided a succinct account of factors influencing migration of health workers from developing countries, and how to manage the complex issues. I wish to extend this excellent article with a focus on migrating doctors from Nigeria. Table 1 provides a summary of three major factors that motivate doctors trained in Nigeria to migrate to work overseas (or de-motivate them from returning), and suggests strategies for managing the encumbrances in the interest of Nigeria’s health system, patients, and doctors. Associated costs for suggested strategies are provided.


Issue Motivation to migrate Suggested management strategies
Short-term Long-term
1 Doctors trained to levels superior to local health realities Doctors complain of ‘brain waste’, and seek better opportunities for professional development in countries with better medical infrastructure Develop basic minimum standards for all district hospitals, and provide emergency funding (average ~ one-off additional grant of $US100,000 per district hospital [= $US 36 million], and additional $10,000/year for maintenance) to equip hospitals to standards that make medical practice rewarding for Develop basic minimum standards for all district hospitals, and provide emergency funding (average ~ one-off additional grant of $US100,000 per district hospital [= $US 36 million], and additional $10,000/year for maintenance) to equip hospitals to standards that make medical practice rewarding for patients and staff; provide inexpensive loan schemes to assist doctors set up private clinics and hospitals, particularly in rural areas, that meet detailed minimum standards ($US1 million) Encourage the establishment of full-fee paying private universities to train doctors for ‘export’ ($0); Intensify training of allied medical staff such as assistant medical officers and community health officers (at an estimated cost of $US5 million/year), whose skills and competences are likely to be more suitable for Nigeria’s current level of health care delivery, particularly in rural areas (3).
2 Poor remuneration In terms of purchasing power parity, Nigeria-based doctors typically earn about 25% of what they would have earned if working in Europe, North America or the Middle East. Emigration is viewed by underpaid doctors as the most effective strategy to address such salary disparities Increase public sector salaries ($US 80 million/year), provide perks for resourceful doctors willing to undertake operational research and/or work on underserved diseases like tuberculosis, and in underserved (e.g. northern) regions, on a competitive basis ($US 500,000/year); Encourage health-based NGOs to incorporate supplemental doctors’ (and other health workers') remuneration into their funding proposals ($US0) Provide non-financial incentives such as sponsorship to attend overseas training and conferences, subsidized housing and transport ($US3 million); develop well equipped centers of medical excellence, where doctors with skill and ambition are able to attract international research grants that would provide professional and pecuniary rewards (US10 million seed grant, then $US500,000 annually)
3 Limited incentives for overseas-based Nigerian doctors willing to relocate and work in Nigeria. Scores of Nigerian doctors currently overseas are willing to return to Nigeria provided appropriate employment opportunities are available. Unfortunately, not only are such opportunities very scarce, there is growing unemployment among registered doctors in Nigeria. Furthermore, there is little enthusiasm by locally based senior medical staff to create openings for overseas-based doctors. Also, accreditation processes tend to be based on the principle of reciprocity, thus disadvantaging overseas-based doctors willing to return (4). Develop incentive schemes to improve attractiveness of return to Nigeria’s health sector for overseas-based doctors, as is currently the case in Thailand and Ireland (5) ($US 80,000/year) Strengthen bi-lateral agreements between the Medical and Dental council of Nigeria (MDCN) and overseas medical accreditation bodies, to reduce the bureaucracy currently involved in accrediting overseas qualifications by the MDCN (US10,000/annually). Provide stimulating environment for intellectual growth, such as ready access to computers, internet, learned journals ($US5 million/year).

The above strategies would cost about $US140 million to commence, and another $US90 million annually to develop and/or maintain, over and above current expenditures in the health and public salary sectors. It is noteworthy that the suggested measures are not necessarily focused on the health sector – the biggest budget item of $US80 million/year is for public sector salary increases. These substantial costs should be weighed against the cost of loss of skilled health care workforce, currently estimated at about $US4 billion/year (1,5) in a continent where one in seven African doctors is trained in Nigeria (i.e. $US140 million/year expenditure Vs. $US286 million/year potential gain, assuming that, in dollar terms, about half of all Nigeria’s skilled workforce loss is medical). Thus, investment in addressing the above primary causes of brain drain and brain waste of medical professionals in Nigeria has favorable cost-benefit ratio. It is also ethically sound, socially responsible, and politically sensible.

References:

  • Raufu A. Nigerian health authorities worry over exodus of doctors and nurses. BMJ, 2002; 325:65
  • Stillwell B, Diallo K, Zurn P, Vuljicic M, Adams O, Dal Poz M. Migration of health care workers from developing countries: strategic approaches to its management. Bulletin of the World Health Organization. 2004; 82:595-600.
  • World Health Organization. World Health Report 2003, Chapter 7, box 7.4 - Health Systems: principled integrated care. Geneva, WHO.
  • Awofeso N. Academic medicine: time for reinvention: encourage overseas based researchers to return to improve academic medicine in the developing world. BMJ, 2004;328:47-8.
  • Pang T, Lansang MA, Haines A. Brain drain and health professionals: a global problem needs global solutions. BMJ, 2004; 324:499-500.

Conflict of Interest: The author has made many unsuccessful attempts to secure employment in Nigerian, and other African, Universities in the past several years.

Niyi Awofeso. Conjoint Associate Professor of Public Health, School of Public Health and Community Medicine, University of New South wales, Sydney 2052, Australia. (email: Niyi.Awofeso@justicehealth.nsw.gov.au)

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