Managing exodus, shortage of skilled health workers in Nigeria

The World Health Organisation (WHO) predicts a 10 million shortage of health workers by 2030, mainly in low income countries like Nigeria. According to latest figures from the Federal Ministry of Health and Social Welfare, Nigeria has a skilled health worker density of 1.83 per 1000 patients, far below the WHO recommendation. Factors contributing to this include low production of health workers, poor management, and political and economic crises.

Nigeria ranks among the 37 countries with critical health workforce shortages, as contained in the WHO Health workforce support and Safeguards list. Nigeria has 0.363 medical doctors per 1,000 people, far below the WHO’s threshold of 4.45 healthcare workers per 1000 people for adequate health coverage.

Critics say there is a pressing need to holistically address the issue of health workforce shortage in Nigeria, as it poses a significant barrier to achieving the Sustainable Development Goals (SDGs), especially SDG3: “to ensure healthy lives and promote well-being for all at all ages.”

In the backdrop of this scarcity, Nigeria has increasingly been a crucial supplier of healthcare workers abroad. Nigeria was the highest workforce-exporting country in Africa, with the United Kingdom (UK), United States (U.S.), Canada, Australia, and Saudi Arabia as key destinations between 2021 and 2022, second to India, which has 42,966 healthcare workers, while the Philippines is third with 11,021 healthcare workers. But unlike India and the Philippines, Nigeria does not have a managed migration system and a robust system to train healthcare workers for domestic and global labour markets.

The WHO Global Code of Practice on the International Recruitment of Health Personnel was adopted by the World Health Assembly in 2010 to improve international health worker migration and minimise its negative consequences.

In Nigeria, the Federal Government through the Federal Ministry of Health and Social Welfare recently launched the National Policy on Health Workforce Migration, which addresses a critical concern that impacts the nation’s healthcare system. This policy aims to strategically manage health workforce migration to address the fundamental problems of the shortage of skilled healthcare professionals in Nigeria, particularly in rural and underserved areas.

Until now, Nigeria suffers from severe shortages of health workers, stemming from long-lasting issues on the production of skilled professionals and on the difficulty to deploy existing professionals in rural and underserved areas. In this context, the migration of healthcare workers has made these problems more salient. This policy outlines a comprehensive framework to address these fundamental challenges through the lens of a managed migration of the healthcare workers, focusing on improving quality and quantity of training, recruitment, and international cooperation.

The National Policy on Health Workforce Migration in Nigeria is a forward-looking strategy that seeks to strike a balance between the needs of the healthcare system and the aspirations of healthcare professionals. By implementing a holistic set of interventions to develop regular and managed migration systems, the policy aims to strengthen Nigeria’s healthcare delivery, improve health outcomes, and secure the future of the nation’s healthcare workforce.

Key highlights of this policy include: Institutionalisation of an effective well-managed migration of health workers linked to the Universal Health Coverage (UHC) aspirations of the Federal Government of Nigeria; providing meaningful incentives to Human Resource for Health (HRH) who are in the country, especially to those who choose to serve in rural and deprived parts of the country; those in training programmes in the country and providing the necessary equipment and commodities to deliver quality care; recognition that managed migration can play a key role in building capacity of health systems in Nigeria and skill/ knowledge transfer from the diaspora.

The policy also proposes the deployment and application of bilateral and multilateral agreements on recruitment of health professionals, while respecting the freedom of health workers to migrate. Such agreements will provide a basis to favour in-country migration and facilitate circular or return migration for critical skills.

The policy is also supported by real time data. Development and strengthening of a human resources for health registry to support the use of evidence-based policies and provide data for improvement in the availability and international comparability of migration statistics for health personnel in Nigeria.

The policy advances multi-sector and whole of-government approaches to managed migration in Nigeria, by ensuring that the relevant institutions in relevant ministries such as, Federal Ministry of Education (FMoE), Federal Ministry of Labour and Employment (FMoLE) amongst others are involved in ensuring the optimisation of the present health workforce and the production of a future health workforce that is responsive to the needs of the country and the world.

The policy also recognises the role of the private sector as a source of innovation and health as a service. The private sector is involved in the flow and production of skilled health workers and the use of “digital in health” as a way of delivering health services.

Coordinating Minister of Health and Social Welfare, Prof. Muhammad Ali Pate, in his foreword to the National Policy on Health Workforce Migration said: “Nigeria, a nation of diverse cultures, rich heritage, and growing potential, stands at the crossroads of global interdependence. As the world grapples with the challenges of an evolving healthcare landscape, one of the pivotal issues confronting our nation is the migration of our valuable health workforce.”

Pate said the National Policy on Health Workforce Migration in Nigeria marks a significant stride in the country’s journey towards a healthier, more prosperous future. He said this policy is born out of collective resolve to address the complex dynamics of health worker migration, ensuring that the exodus of our skilled healthcare professionals does not compromise the health system’s integrity and the well-being of our citizens.

The Minister said, in line with the Nigeria Health Sector initiative, the policy seeks to manage migration in order to improve the health system for efficient, equitable and quality health service delivery. “Health workers are the backbone of any robust healthcare system. Their dedication and expertise play a fundamental role in advancing the health agenda of our nation. However, the allure of foreign shores, attractive opportunities, and improved living standards have led to a steady outflow of our health workforce,” he said.

According to Pate, “this policy advances multi-sector and whole-of-government approaches to managed migration in Nigeria. It sets forth a comprehensive framework that aims to strike a delicate balance between the aspirations of our health professionals and the urgent needs of our nation. By fostering an environment that supports career development, enhances working conditions, and provides equitable compensation, we hope to create an ecosystem where health workers can thrive and contribute meaningfully to Nigeria’s health system.”

The Minister added: “Crucially, the National Policy on Health Workforce Migration emphasises a collaborative approach in engaging stakeholders across sectors and disciplines. It calls for active partnerships with National and international organisations, governments, and institutions, aiming to channel the flow of migration towards mutually beneficial outcomes while safeguarding the stability of our health system.

“As the country embarks on this transformative journey, let us remember that the true measure of success lies not only in the policies we create but, in their implementation, and impact on the lives of our people. So, I call on all stakeholders to steer our Human Resource for Health towards a future where health workforce migration is managed as a force for positive change, propelling Nigeria towards greater heights of saving lives, reducing both physical and financial pains and producing health for all Nigerians.”

Several studies have shown that health worker migration is driven by labour market forces, including education, working conditions, and pay, which increased during the COVID-19 pandemic. It relates to the movement of healthcare workers within states and Federal Government Health facilities due to lack of job satisfaction and job security.

Indeed, improving training and recruitment programmes for health workers can help address the situation and contribute to progress towards the Sustainable Development Goals on health, gender equality, decent working conditions, economic growth, and reducing inequalities. According to the policy, a managed migration system can be used strategically to make substantive progress towards these goals.

Therefore, the governance of migration refers to rules (formal or informal) that exist to provide oversight of the Health Workforce (HWF) migration process, mitigate the impact of Skilled Health Worker (SHW) migration on health service delivery, and to utilise migration opportunities to boost the supply of healthcare professionals in Nigeria.

These processes shape how state and non-state actors respond to migration, foster cooperation between states, and uphold human rights. The definition is inherent to recognising human rights norms as essential for promoting migration and people-centered health system governance systems. These norms include the right to migrate, fair wages, and proper working conditions for SHWs while protecting access to essential health services and the preconditions for health.

As part of the process for developing a national policy on Health workforce migration, the Federal Ministry of Health with support from the World Health Organisation commissioned a rapid assessment of factors related to the upsurge in the migration of health workers from Nigeria to other countries. The data sources for this assignment included data from the National Bureau of Statistics in Nigeria, National Population Commission, International Organisations: WHO, International Organisation for Migration (IOM), United Nations Population Fund (UNFPA) and Diaspora Associations and Networks. Data were also sourced from National and International Databases like Global Health Observatory of the WHO and the International Migration Outlook from the Organization for Economic Cooperation and Development (OECD) and the Nigeria’s National Health Workforce Profile 2022. Existing policies and other national documents were also consulted namely, the Nigerian Constitution, Public Service Rules, the National Health Policy and Health Act 2014, and other National Human Resources for Health documents.

Surveys and research studies from individual experts, research institutions, universities, and international organisations were also reviewed. Information was also obtained from professional regulatory bodies and professional associations like the Nigeria Medical and Dental Council of Nigeria, the Nigeria Medical Association, the Nursing and Midwifery Council of Nigeria and the National Association of Nigeria Nurses and Midwives, the Medical Laboratory Science Council of Nigeria, and others.

Twenty policy makers were selected from key Ministries Departments and Agencies (MDAs), United Nations, Development Partners, and Civil Society. The questionnaire items enable the consultants to explore the following variables with the policy makers: the severity of the challenge of health workforce migration, reasons for migration, interventions to regulate migration, and policy statements. Other variables include governance, relevant data and monitoring and evaluation.

In conclusion, according to the document, this policy is intended to be implemented by the Federal, States and Local Governments who will develop appropriate strategies, plans and guidelines to facilitate its implementation. Nigeria’s Policy on Health Workforce Migration encompasses a multi-faceted approach aimed at addressing the challenges associated with the migration of healthcare professionals. The implementation modalities are grounded in a combination of regulatory frameworks, capacity building initiatives, and international collaborations.

The policy emphasises the establishment and enforcement of robust regulatory mechanisms to monitor and manage the movement of health workers, ensuring ethical recruitment practices and discouraging brain drain. Concurrently, there is a focus on enhancing the domestic healthcare system through investments in training and education, creating incentives for healthcare professionals to stay within the country. Collaborative efforts with international partners also play a pivotal role, fostering information exchange and mutual support to mitigate the adverse effects of migration.
   
By adopting this comprehensive policy, Nigeria seeks to strike a balance between global mobility and the imperative to strengthen its own healthcare infrastructure and to ensure that the relationships and agreements between Nigeria and destination countries are mutually beneficial to Nigeria, destination countries and the migrating health care workers.
Muanya is a Freelance Journalist, Public Affairs Analyst and media consultant. He can be reached via: [email protected]