INTRODUCTION
The emigration of medical doctors from developing countries to more developed countries is very common and is termed “physician brain-drain.” This has been associated with personal benefits to the physicians involved, such as higher education and income, but with resultant negative consequences on the health systems of the physicians' home countries.[1] Brain drain has also been found to significantly hinder economic development in African countries due to the multiplier effect of health on the economy as follows: “poorer health services, insufficient manpower and resources to support institutions of importance to the country; loss of tax and manpower resources; high mortality rate; brain waste, which occurs when health workers end up working outside the health sector or as unskilled labour in the country of immigration; underdevelopment of the nation, and a high level of illiteracy.”[12]
Despite the poor doctor–patient ratio in Nigeria (0.17 doctors per 1000 population), which is far below the World Health Organization's recommendation of 1 doctor per 600 population.[34] Nigerian doctors are known to contribute a significant proportion of the medical workforce in other countries, especially in the United Kingdom (UK) and the United States America (USA).[56] Physician brain-drain, coupled with poor funding of the health sector (4.2% of the total budget in 2019) which have been far below the World Health Organization's recommended minimum of 15%, has led to negative consequences, evidenced by poor health indicators, with Nigeria's health-care system ranked 187th out of 200 nations by the World Health Organization.[789]
This study aimed to assess Nigerian medical doctors' willingness to practice in foreign countries, as well as the possible push and pull factors contributing to this brain drain.
METHODOLOGY
A cross-sectional survey was conducted with the study population comprising all medical doctors attending the Annual Delegates Meeting (ADM) of the Nigerian Medical Association (NMA), in April 2019, where all the 36 states of the federation were represented. A total of 329 medical/dental doctors were selected from a list of doctors using systematic random sampling. A semi-structured self-administered questionnaire was used to obtain the information from the selected respondents. Data were analyzed using the Statistical package for social sciences (SPSS®), version 20, (Chicago, Illinois, United States). The factors considered as priority confounders from a majority of previous studies, as well as factors found to be significantly associated with “willingness to practice in a foreign country” on the bivariate analysis were included in a logistic regression model to control for possible confounding. The level of statistical significance was set at <5% (0.05). All participants in the study signed an informed consent form after a detailed explanation of the purpose and process of the study.
RESULTS
All selected respondents agreed to participate (100% response rate) in the study with a mean age of 41.4 ± 6.3 years (range 29–60), 85.9% of them being males and 75.7% being Christians, as shown in [Table 1]. About 36% of the respondents had medical fellowship, 31.6% were resident doctors, and 16.4% had only MBBS/BDS degrees. As depicted in [Table 2], among the doctors with postgraduate qualifications, a majority were from Family medicine 88 (27.6), while ENT surgeons were the least 1 (0.3). Table 3 shows that the median duration of practice was 12 years and the median monthly income was NGN420,000.000. Most 72.9% of the respondents were willing to practice in foreign countries if given the opportunity [Table 4].
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Table 1: Sociodemographic characteristics of respondents
Table 2: Respondents' specialty of postgraduate training (n=319)
Table 3: Duration of practice and income of respondents
Table 4: Respondents' willingness to practice in a foreign country (n=329)
Among those not willing to practice in foreign countries, 48.3% of the entire population sampled preferred working in Nigeria despite all the challenges and 32.2% were due to family and other personal reasons. Among those willing to practice in foreign countries, the majority 66.3% was due to poor financial incentives/working environment, 46.5% due to insecurity and 38% due to interprofessional rivalry in the health sector [Table 5]. Most 72.9% of the respondents were willing to practice in foreign countries if given the opportunity [Table 4], 29.2% of whom preferred the USA, 25.1%, United Kingdom and 0.4% preferred to emigrate to Japan [Table 6]. The following factors were found to be significantly associated with willingness to practice in a foreign country: geopolitical zone of origin, highest educational qualifications, duration of practice, and average monthly income, as shown in Table 7. On entering into a logistic regression model, all the four factors remained independent (intrinsic) determinants of willingness to practice in a foreign country (P < 0.05) at a 95% confidence.
Table 5: Respondents' reasons for willing to practice in a foreign country
Table 6: Respondents' preferred countries of practice
Table 7: Factors associated with willingness to practice in a foreign country
DISCUSSIONS
The response rate of 100% was not unexpected, as all the respondents were the leaders of the NMA representing their respective states, hence, more likely to consent for such research. The mean age of the respondents was 41.4 ± 6.3 years, which shows that they were doctors in active service who still have a lot to offer. The fact that about 36% of the respondents had medical fellowship, 31.6% were resident doctors, and 16.4% had only an MBBS degree shows that willingness to practice in foreign countries cuts across all hierarchy of doctors. However, this could be because the ADM is more likely to be attended by older doctors due to their experiences in professional associations.
About 73% of the respondents were willing to practice in a foreign country if given the opportunity. This conforms with the findings of a previous Nigerian poll which revealed that 83% of medical doctors who completed the survey were based abroad, but licensed in Nigeria.[9] It also explains the findings of a previous Nigerian study which found that, out of the 468 doctors who graduated from a University in South-east Nigeria from 1995 to 1997, about 40% were practicing outside Nigeria within 10 years of graduation.[10] Another study found that about 86% of Africans practicing in the United States of America were from Nigeria, South Africa, and Ghana.[11] A Ghanaian study also revealed that about 60% of locally trained doctors in the 1980s have left the country.[12] These studies show that medical doctors' willingness to leave Nigeria (and other African countries) and practice in foreign countries has been ongoing for a long time, hence, the need for concerted effort to address this brain drain.
The geopolitical zones of practice in this study were identified as an independent risk factor for the emigration of doctors in this study. This could be related to the fact that there are fewer doctors in some geopolitical zones of the country in addition to the fact that there are variations in job opportunities in some geopolitical zones than others. Insecurity may also be a contributing factor in this regard. A similar finding has been reported from a previous study among medical students who intend to migrate.[13]
The pull factors incentivizing doctors in developed countries were found to include the following: Better salary and other financial incentives (67.2%), better working environment (64.4%), better security (45.0%), and advanced research facilities (51.4%). Similarly, the push factors discouraging doctors from practicing in Nigeria included the following: Poor salary and other financial incentives (66.3%), poor working environment (63.8%), insecurity (46.5%), inter-professional rivalry in the health sector (38%), lack of governments interests in research at all levels (49.5%), and lack of governments interests in doctors' capacity building (62.3%). This is similar to the findings from previous studies.[14151617] Therefore, government interventions to address these issues can go a long way in retaining medical doctors in their home countries. Provision of adequate remuneration, workplace incentives, training of doctors, and security by the government will help to mitigate the problem. Civil society organizations, professional associations of doctors like the Nigerian Medical Association, and the Nigerian Association of Resident Doctors (NARD) can advocate for better legislation, improvement in working conditions/work environment and developing career prospects as well as providing perspectives for training and retraining of the health workforce.[171819]
CONCLUSION
It is a big threat to the Nigerian health system for the majority of its doctors to be willing to leave the country if given the opportunity. Since the common push and pull factors have been identified in this, and other studies, there is a need for governments at all levels to, as a matter of urgency, take evidence-based actions to address the factors responsible for this brain drain like adequate remuneration, workplace incentives, and security of lives and property. Civil society organizations and professional associations of doctors (NMA and NARD) all have roles to play.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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