Healing the Brain Drain: Nigeria’s move to stem health workers migration

Recently, President Bola Tinubu approved a National Policy on Health Workforce Migration to manage the exodus abroad of skilled Nigerian healthcare professionals.

As announced by the Coordinating Minister of Health and Social Welfare, Muhammad Pate, the 56-page document presents the national plan to address the dynamics of health workers’ migration, ensuring that it does not compromise the needs of the country’s healthcare system.

Mr Pate described the policy as a major part of Nigeria’s efforts to manage the current health crisis while promoting collaboration with critical stakeholders at national and international levels.

Professor Umar Pate, the Nigerian minister of Health.

Ranked among the 37 countries with critical health workforce shortages in the 2023 WHO Health Workforce Support and Safeguards list, Nigeria has been battling the increasing exodus of its trained professionals.

However, through this policy, the government seeks to address the fundamental problems of health workforce shortage in Nigeria, particularly in rural and underserved areas.

The policy outlines new initiatives such as bilateral agreements and memorandums of understanding (MoU) between the Nigerian government and key foreign destinations of Nigerian health workers.

It stipulates the establishment of training, opportunities for career development, incentives and a conducive work environment.

Also, the policy introduces the creation of a digital registry for migrants in the system, cross-border data-collection on Nigerian health workers, ethical recruitments, research, innovation and equitable distribution of healthcare providers across the country.

This analysis provides a breakdown of these emerging initiatives, and what impacts they may have on the sector and the country.

Trends of migration among Nigeria health workers

Nigeria’s health minister recently revealed that about 67 per cent of Nigerian doctors migrating abroad practice in the United Kingdom and the country now has only 55,000 licensed doctors to serve its growing population of over 200 million.

With 0.363 medical doctors per 1,000 people, far below the WHO recommendation of 4.45 per 1,000 population, Nigeria has continued to lose even more and the uneven distribution in the ratio of doctors to population is worsening.

The doctor-to-population ratio in Abuja is 4.7 per 10,000 population and in Lagos, 4.6 per 10,000 population.

Between 2008 and 2021, 36,467 Nigerian doctors migrated to the United Kingdom, a steady increase from 1,798 in 2008 to 4,880 in 2021.

A larger trend was observed for nurses. Between 2002 and 2021, 60,729 Nigerian nurses migrated to the United Kingdom. There was a consistent increase from 1,393 nurses that migrated in 2002, to 5,543 in 2021.

Highlighting the trend of migration among Nigerian health workers in the policy, data presented shows that 2022 represents the peak of migration of medical doctors as over 3,000 doctors requested letters of good standing from the Medical and Dental Council of Nigeria (MDCN).

The United Kingdom is the destination for 68 per cent of Nigeria’s medical and dental professionals who migrated out of Nigeria through MDCN.

Other destinations are Canada (10 per cent), USA (seven per cent), UAE (five per cent), Australia (three per cent), Ireland (three per cent), Saudi Arabia (one per cent) and Maldives (one per cent)

Proposed MoU

One of the new measures being adopted in the policy is the establishment of a Memorandum of Understanding (MoU) with the USA, UK, Australia, and other key destination countries of Nigerian health workers to align with the WHO Global Code of Practice on the International Recruitment of Health Personnel.

The policy stipulates that there should be an established bilateral or multilateral agreement between Nigeria and foreign agencies trying to recruit health workers in the country.

These agreements will be the basis on which a foreign recruitment agency can engage a doctor, nurse, and every other member of the healthcare workforce.

The new development implies that the government is targeting a more structured and controlled process for migration and the recruitment of healthcare workers by other countries, “ensuring that it is done in a manner that aligns with the country’s interests.”

While it states that the government does not intend to prohibit healthcare workers from leaving randomly, the process may limit the flow of health workers to other countries, as it seeks to ensure that it happens under agreed terms rather than haphazardly.

In response, the National President of the Nigeria Medical Association (NMA), Bala Audu, said the MoU idea is a good initiative to manage the migration of health workers, if properly implemented.

Mr Audu told PREMIUM TIMES that destination countries are expected to make certain commitments before taking Nigerian-trained health workers to serve their health needs.

“From my understanding of the bilateral agreement, it is not bad. It is for countries who come to our country to attract our skilled doctors to have commitments they make.

“The way it appears, you have to give something back in return if you come to take our professionals,” he said.

There have been efforts by the Nigerian government in the past to regulate health workers migration but the conditions have been rejected.

Last year, the House of Representatives proposed a bill to mandate Nigeria-trained health workers to practise in Nigeria for a minimum of five years before they are granted full licenses or travel abroad.

The bill, which passed a second reading, generated heated debates as doctors threatened to down tools, vowing to resist any guise to “enslave” Nigerian medical doctors.

Incentives for health workers

This is the first thematic area of the policy which mandates the provision of “special incentives” for health workers in the country, especially for those who choose to serve in rural and deprived parts of the country.

It affirmed that the government should create easy access to special credit facilities, tax holidays and modalities for special mortgage facilities for healthcare workers to easily own houses, cars, and other essential assets.

The policy stipulates a periodic review of healthcare workers’ salaries, benefits, pensions and allowances, and the provision of adequate equipment and supplies.

It also mandates health agencies to invest in digital health infrastructure (telehealth) in the Nigerian health system and the development of a “return-to-practice” programme with special incentives for health workers who want to return to Nigeria.

Over the years, health professionals in Nigeria have complained of low wages and non-payment of their hazard allowances, among others, which has led to industrial actions on numerous occasions.

In his remarks on the incentives, the NMA President said Nigeria’s effort towards curbing brain drain “depends largely on how effectively the incentives are implemented.”

“On our own side, as leaders in the healthcare industry, we will be reviewing the policy and if there are additional areas we believe will improve the retention of health workers and other providers, we will also dialogue with the government to increase the area of incentive which they may have not been included in the current policy,” he said.

Also speaking to PREMIUM TIMES, the Vice President of the National Association of Resident Doctors (NARD), Kefas Wida, said remuneration is the major reason health workers are migrating and that for Nigeria to retain its workforce, “it needs to adequately address the modalities for incentives highlighted in the policy.”

Mr Wida noted that without implementation, the government cannot stop anyone from migrating, “even if they make the process difficult and tedious with too many bureaucratic processes.”

“People are looking for better remuneration. Anything we are doing that is short of addressing issues around this, we are beating around the bush. This policy is a good one and it is a step in the right direction. But we must address the main crux of the workforce migration, particularly by adequate remuneration,” he said.

On health workers’ safety, security

As Nigeria grapples with armed conflicts such as terrorism and banditry, many health workers have been attacked, kidnapped, killed or displaced from their homes.

Recently, the Nigerian Association of Residents Doctors (NARD) threatened to down tools if the government failed to secure the release of Ganiyat Popoola, a resident doctor at the National Eye Centre in Kaduna abducted in December 2023.

The Safeguarding Health in Conflict Coalition (SHCC) identified 19 incidents of violence against health workers in Nigeria in 2023, and 43 incidents in 2022, compared to 56 in 2021, in which 37 health workers were kidnapped, seven others were killed, and health supplies were looted from pharmacies and health centres.

SHCC reported that between 2016 and 2020, there were 4,094 reported attacks and threats against healthcare in conflict areas across the world. During this period, at least 1,524 health workers were injured, 681 were killed, and 401 were kidnapped.

However, the government, through this policy, seeks to enhance and ensure the safety of health workers serving at all levels of the Nigerian healthcare system.

The policy mandates the provision of adequate security in health facilities for the protection of the health workforce across the board.

Job for returnees, data collection

Unlike the current regulation that prevents returnees from reclaiming their previous positions by banning leave of absence for health professionals moving abroad, the new migration policy permits workers to be rehired if they return to the country within a set period.

Also, the new policy mandates that the existing Public Service Rules guarantee the right of return for health workers previously employed by the government.

This policy allows for rehiring returning health workers, but within a specified timeframe. This means that if workers miss this window, they may face difficulties regaining employment, causing job insecurity.

The government, through the policy, also demands routine cross-border data sharing regarding the licensing and performance of workers migrating to foreign countries which it says should be done “on a quarterly basis.”

The policy recommends that: “The Federal Ministry of Health must regularly report on the trends, patterns, and impact of health workforce migration in Nigeria.

“The report will disclose vacancies, remittances from migrant health workers, and the conditions of Nigerian health workers in their destination countries.”

While this portends to be beneficial to the country and also migrating healthcare providers, routine data sharing and reporting might add layers of bureaucracy, potentially complicating the process for health workers seeking to migrate or return.

The Nigerian government will reintroduce the one-year abroad training programme, according to the new policy.

Capacity development, training programmes

Unlike India and the Philippines, Nigeria lacks a managed migration system and a robust system to train healthcare workers to meet domestic and global demands.

Identifying this deficit, the Nigerian government, through this policy, seeks to improve training and recruitment programmes for health workers to address the situation and contribute to progress towards the Sustainable Development Goals (SDGs) especially on health.

The policy mandates increasing the capacity of health institutions and strengthening the health workforce for “both local and international needs.”

It also stipulates that the government must ensure that existing health workers receive post-graduate degree training and the establishment of more health training institutions to produce additional healthcare professionals of “adequate quality and quantity.”

Presently, there are 400 nursing training institutions, 139 approved Medical Laboratory Science (MLS) training institutions and 37 fully accredited medical schools.

Monitoring, implementation

Monitoring and evaluation is another thematic area highlighted in the policy to institute an evidence-based health workforce migration information system.

This mandates the inclusion of health workforce migration data in all relevant national surveys, including the Nigeria Demographic and Health Survey (NDHS) and facilitates cross-border data sharing on health workforce migration.

Overall, the federal, state and local governments are expected to develop appropriate strategies, plans and guidelines to facilitate the implementation of the policy, while noting that civil society organisations will monitor the implementation and provide feedback to the government on the successes, challenges and solutions.

Meanwhile, Mr Audu noted in his comment that the NMA plans to meet with the government to discuss the policy and implementation modalities.

“I believe we are going to sit with those that have fashioned this policy, to negotiate in such a way that the conclusion will appease those who chose to remain in Nigeria and probably attract whoever has left to come back.

“Implementation is sacrosanct for the policy to have its desired impact,” he told PREMIUM TIMES.