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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 25
| Issue : 3 | Page : 61-66 |
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Brain drain in medically challenged context: A study of the push, pull, and stick factors among a population of medical practitioners in Nigeria
Gabriel Uche Iloh1, Augustine Obiora Ikwudinma2, Ikechukwu Vincent Obi3, Babatunde Abdulmajeed Akodu4
1 Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State; Department of Medicine, College of Medicine and Health Sciences, Rhema University, Aba, Nigeria
2 Department of Family Medicine, Alex Ekwueme Federal Teaching Hospital, Abakiliki; Department of Family Medicine, Alex Ekwueme University, Ndifu Alike, Ebonyi State, Nigeria
3 Department of Health Administration and Management, University of Nigeria; Department of Health Services, AIICO Multishield Ltd., Enugu, Nigeria
4 Department of Family Medicine, Lagos University Teaching Hospital; Department of Family Medicine, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
| Date of Submission | 03-Dec-2020 |
| Date of Decision | 16-Jan-2021 |
| Date of Acceptance | 16-Mar-2021 |
| Date of Web Publication | 20-Nov-2023 |
Correspondence Address:
Prof. Gabriel Uche Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State; Department of Medicine, College of Medicine and Health Sciences, Rhema University, Aba
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/smj.smj_162_20
Background: Globally, brain drain (BD) phenomenon has been an issue for decades in healthcare industry. However, the magnitude of BD syndrome and its impact on medical workforce crisis in a medically challenged environment has been the subject of great interest in the recent years, with apparently glaring effects on the medical workforce. Aim: The study was aimed at describing the push, pull, and stick factors, benefits, and preventive measures for BD among medical practitioners in Abia State, Nigeria. Subjects and Methods: This was a cross-sectional study carried out on 185 medical practitioners in Abia State, Southeastern Nigeria. Data collection was done using pretested, self-administered, and structured questionnaire that elicited information on push, pull, and stick factors, benefits, and preventive measures for BD. The plan to leave Nigeria and preferred foreign countries were also studied. Results: The age of the participants ranged from 26 to 72 (36 standard deviation 8.4) years. There were 159 (85.9%) males. One hundred and twenty-seven, 127/185 (68.6%) study participants had plans to leave the country with the most preferred countries of destination being Canada, United States, United Kingdom and Australia. The most common push factors from Nigeria and pull factors from abroad were similar and included poor income, wages, and salaries in all the participants 185/185 (100%). The most predominant stick factor was family-centric reasons, 126/185 (68.1%). Family and national family remittances were the main benefits, 185/185 (100%) for each while the most common pull factor was higher income, wages, and salaries abroad, 185/185 (100%). The most predominant stick factor was family-centric reasons, 126/185 (68.1%). The greatest benefits were family, 185/185 (100%), and national, 185/185 (100%), financial remittances. The most recommended preventive measures were enhanced income in Nigeria, 185/185 (100%). Young adult age (P< 0.001), male (P < 001), and duration of practice <10 years (P < 0.001) were significantly associated with the plan to leave the country. Conclusion: These findings demonstrates that about 70% of Nigerian medical practitioners plan to leave the country for abroad. The major underlying factors for brain drain include enhanced income in the destination country capacity for financial remittances to the family and nation.
Keywords: Brain drain, medical practitioners, Nigeria, pull, push factors and stick factors
How to cite this article:
Iloh GU, Ikwudinma AO, Obi IV, Akodu BA. Brain drain in medically challenged context: A study of the push, pull, and stick factors among a population of medical practitioners in Nigeria. Sahel Med J 2022;25:61-6 |
How to cite this URL:
Iloh GU, Ikwudinma AO, Obi IV, Akodu BA. Brain drain in medically challenged context: A study of the push, pull, and stick factors among a population of medical practitioners in Nigeria. Sahel Med J [serial online] 2022 [cited 2023 Dec 10];25:61-6. Available from: https://www.smjonline.org/text.asp?2022/25/3/61/389943 |
| Introduction | |  |
Globally, brain drain (BD) and gain phenomena have been an issue of decades in healthcare industry.[1],[2],[3] However, the magnitude of BD and gain syndrome and its impact on medical workforce crisis, especially in resource-poor settings in sociomedical economic development such as Nigeria, has been the subject of great interest in the recent years with threats to stunt the national medical workforce, which has implications for meeting the medical human resources need in the Nigerian health sector.[4],[5]
BD has variously been defined by the academias and different professional scholars with basically the same operational, contextual, and conceptual message. [2,5-7] In the health sector, BD refers to the migration of health personnel in search of better standard of living, higher salaries, incomes, and wages, access to advanced technology, and more stable and secured sociopolitical conditions in different places worldwide.[6] In 2003, the World Health Organization (WHO) observed that the most critical problem that faced healthcare system was the shortage of people who made healthcare delivery system to work.[8] In 2006, the World Health Report focused on global health workforce as a theme.[9] However, in 2018, the WHO reported that Africa has a shortfall of 6 million health workers, which has implications for essential health services delivery, research, and medical education.[10]
The burden of medical BD and gain syndrome differs from one resource-constrained setting to another in varying degrees.[4],[5],[7],[11],[12],[13] In Nigeria, the immensity of BD is disproportionately alarming in the region with urgent calls by individuals, academia, and professional bodies for immediate action to curb the upward trend.[4],[5],[14] In 2015, it was reported in Nigerian national dailies that Nigeria needed 237,000 doctors but has only 35,000[15] with 2000 doctors leaving Nigeria every year.[16] In 2018, the Nigerian Medical Association raised alarm over low ratio of medical doctors to patients[17] in Nigerian hospitals with drones of Nigerian medical doctors emigrating into foreign countries for myriads and sundry reasons.[18]
The role of pull, push, and stick factors in medical BD and gain has been reported in biomedical literature with mixed socioeconomic and medical effects on home and host countries.[1],[2],[4],[5],[6],[7] These factors can be specific to individual countries and even to the individual medical practitioner. However, whether a nation experiences BD or gain depends on a plethora of interacting and intersecting factors such as economic, sociomedical, and political developments among others.[1],[2],[5],[6],[11],[12],[13] Various push factors that encourage emigration of medical doctors from resource-poor nations to developed countries are unfavorable conditions at home countries such as poor salaries, income, and wages;[4],[5],[6],[11] poor working conditions;[4],[5],[6] limited prospect for personal and professional development;[5],[6],[13] social insecurity; and poor political will and leadership in health sector.[5],[6],[12],[13] The pull factors are attractive job conditions that allure the medical professionals, such as higher emoluments, remuneration, and entitlements in the destination developed nations.[1],[4],[5]
In Nigeria, health is on the concurrent list of the Federal Republic of Nigeria due to its benefit to the teaming population of Nigerians, and published research studies on medical BD and gain are not a prevalent research area. However, medical professionals in the region wittingly drift into foreign nations which impact substantially on medical job satisfaction at home.[4] In recent years in Nigeria, BD scourge is particularly acute and disturbing with yearly exodus of medical workforce which takes a large toll on the Nigerian healthcare delivery system whose human resources for health are already suboptimal.[17],[18] Of great interest in Nigeria is that the WHO recommended ratio of medical doctor to patient is yet to be attained and indigenously trained medical doctors are continuously being lost to foreign countries at an increasing rate. In the immediate years, the greatest workforce export in Nigeria is the emigration of Nigerian medical doctors from the nation's healthcare industry and this widens the medical doctor: population ratio gap in the country.[16] The study aimed to describe the push, pull, and stick factors, benefits, and preventive measures for BD and gain in a cross-section of medical practitioners in Abia State, Nigeria.
| Subjects and Methods | | |
This was a cross-sectional study carried out on 185 private and public medical practitioners who participated in Continuing Professional Development (CPD) program organized by the Christian Medical and Dental Association (CMDA), Abia State chapter for medical professionals in Nigeria on November 29 and 30, 2018, as well as during the Annual General Meeting (AGM) of the Association of Resident Doctors (ARD), Federal Medical Centre (FMC), Umuahia, held on December 8, 2018. The questionnaire tool was administered to each eligible medical practitioner once either during CPD program organized by the CMDA or during the AGM. The private and public medical practitioners who participated in the CPD program and the AGM were included in the study.
The sample size was determined using online sample size calculating software.[19] The input criteria for sample size estimation was set at 95% confidence level, and confidence interval of 5. The accessible sample of 300 medical practitioners was used based on the previous summative CMDA, Abia State CPD and ARD, FMC Umuahia AGM attendance registers. This gave a sample size estimate of 169 participants. The sample size calculating software assumed maximum possible proportion of 50% (0.50). To deal with incomplete response to the items on the questionnaire, the estimated sample size was increased by 5% incomplete response proportion, thus sample size = n/1 − incomplete response proportion at 5%. This gave a sample size of 178 respondents. However, a sample size of 185 participants was used for the study. The eligible medical professionals for the study were consecutively recruited for the study based on the inclusion criteria until the sample size of 185 was achieved.
The study instrument consisted of sections on sociodemographic data such as age, sex, and duration of practice; push, pull, and stick factors; and benefits and preventive measures for BD. The plan to leave Nigeria and preferred foreign countries was also studied. The push, pull, and stick factors, benefits, and preventive measures for BD sections of the study instrument were designed by the researchers to suit Nigerian environment through robust review of appropriate literature on BD.[1],[2],[3],[4],[5],[9],[10],[11] The usability criteria for the use of a study tool where there is no existing prevalidated instrument were met.[20] The questionnaire was self-administered since the participants are health literate.
Operationally, the push factors referred to factors that encourage emigration from Nigeria, the pull factors meant attractive working conditions abroad, while the stick factors were reasons for not leaving Nigeria for abroad. The emigration of medical doctors who received medical education, training, and development in Nigeria is referred to as medical BD, while to the receiving country, it is called medical brain gain.
The data generated were analyzed using software International Business Machines Corporation, Statistical Package for Social Sciences (IBM SPSS) version 21, Armonk, New York (NY), United States of America (USA), for the calculation of frequencies and proportions for categorical variables and mean for continuous variables. The Chi-square test was used to test for compare categorical variables. In all cases, a P < 0.05 was considered statistically significant.
The ethical clearance was obtained from Health Research and Ethics Committee of FMC, Umuahia, with reference number FMC/QEH/G.596/Vol. 10/408 dated October 15, 2018. Informed written consent was also obtained from the participants included in the study.
| Results | | |
Of the 185 medical doctors who participated in the study, 110 (59.5%) were young adults (18–39 years), 66 (35.7%) were middle-aged adults (40–59 years), and 9 (4.8%) were older persons aged 60 years and older. The age of the participants ranged from 26 to 72 years with a mean age of 36 (standard deviation 8.4) years. There were 159 males (85.9%) and 26 females (14.1%), with a male-to-female ratio of 6:1. Other demographic characteristic of the study participants are shown in [Table 1]. | Table 1: Age, gender, and duration of practice of the study participants (n=185)
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One hundred and twenty-seven, 127/185 (68.6%), of the study respondents had plans to leave Nigeria for foreign countries, with the most preferred foreign destination country being Canada, 105/127 (82.7%). Other destination foreign countries are shown in [Table 2]. | Table 2: Distribution of the study participants by plans to leave Nigeria and preferred destination countries (n=185)
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[Table 3] shows the push, pull, and stick factors of BD among the study participants. The most common push factor was poor income, wages, and salaries in Nigeria, 185/185 (100%), while the most common pull factor was higher income, wages, and salaries abroad, 185/185 (100%). The most predominant stick factor was family-related reasons, 126/185 (68.1%). The frequencies of other push, pull, and stick factors are shown in [Table 3]. | Table 3: Push, pull, and stick factors of brain drain among the study participants (n=185)
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The greatest benefits of BD were family, 185/185 (100%), and national, 185/185 (100%), financial remittances, while the most recommended preventive measure was enhanced doctors' income, salaries, and wages in Nigeria, 185/185 (100%). The frequencies of other benefits and preventive measures for BD are shown in [Table 4]. | Table 4: Benefits and preventive measures for brain drain among the study participants (n=185)
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Bivariate Chi-square analysis of the demographic characteristics of the study participants as related to plans to leave Nigeria for foreign countries showed that young adult age (P = 0.00001), male gender (P = 0.000001), and duration of practice <10 years (P = 0.00001) were statistically associated with the plan to leave the country as shown in [Table 5]. | Table 5: Comparison of the characteristics of participants who want to leave and remain in Nigeria
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| Discussion | | |
One hundred and twenty-seven (68.6%) of the study participants averred plans to leave Nigeria to work in health facilities abroad, with the most preferred destination foreign country being Canada. This pattern of medical migration is in consonance with previous reports in Nigeria[4] and other parts of developing nations[2],[11],[21] that migrating medical practitioners move to five developed countries, namely Canada, USA, United Kingdom, Australia, and Germany. However, Arabian countries (Saudi Arabia, Dubai, and Kuwait) are becoming new destination countries for migrant Nigerian medical doctors.[4],[16] Admittedly, the exodus of Nigerian trained medical doctors to foreign nations is not new, but it has been on the increase in the recent years with no signs of abetting.[16] Although migrant Nigerian medical doctors are faced with socioeconomic and psychological factors as they embark on “journey of hope,” but demotivating meager salaries and poor working conditions further pushed Nigerian medical doctors to foreign recipient countries.[4],[6],[16] To most Nigerian medical migrants, migration to a greener pasture is a prospect for life, whether it is temporary or permanent due to higher emoluments and job satisfaction in the host countries.[22]
The most common push factor was poor income, wages, and salaries in Nigeria, while the most common pull factor was attractive higher income, wages, and salaries abroad. The findings of this study are in tandem with the reports from other studies in Nigeria[4],[5],[22] and other parts of the world.[1],[2],[11],[21] According to these studies,[1],[2],[4],[5],[11],[21],[22] a complex combination of interactional push and pull factors ignites and perpetuates the decision to embark on migration to foreign countries. The degree of financial and job satisfaction gradients between Nigeria and recipient foreign countries exerts the push–pull factors that underpinned BD from Nigeria to foreign countries with the dazzling roles of advertising and recruitment agencies in Nigeria systematically encouraging and increasing the pull.[3],[4] The push–pull factors are worsened by the warped emolument system for medical doctors in Nigeria which placed the Nigerian-based medical doctors at the bottom of remuneration pyramid when compared with their counterparts in developed nations.[4],[18],[22]
The most predominant stick factor that inhibits medical doctors from leaving Nigeria was family-related and -centered reasons and ties. Although some Nigerian medical doctors contemplate leaving the country, most of them do not want for a variety of family-directed reasons and ties, so they stick in Nigeria healthcare industry with increasing frustrations and hopelessness.[4],[14],[16],[18] The family-related reasons could be a reflection of socio-centric nature of Nigerian family system.[23],[24] There is therefore the need for family-oriented interventional measures to motivate national retention of medical doctors and demotivate the BD syndrome. These measures must be robust to induce medical doctors to remain at home and encourage those working abroad to return home.[22] It is culturally desirable and socially responsible to implement efforts aimed at redressing BD in Nigeria.
The greatest benefits of medical BD were family and national financial remittances. This finding is in agreement with previous reports in Nigeria[4],[5],[22],[25] and other parts of the world[26],[27] that migrant remittances boost family income as well as support national balance of payment, financial growth, and development. However, the benefits of BD and gain in Nigeria are disproportionately skewed to the benefits of recipient foreign countries.[25],[26],[27] Medical doctors in Nigeria should therefore be paid commensurable emoluments to stimulate and endear them to contribute the resources of medical science to rational, safe, and evidence-based healthcare services in the country.
The most recommended preventive measure adduced by the study participants was enhanced doctor's income, salaries, and wages in Nigeria. Understandably, trained medical doctors are needed in every part of the world, but higher income, salaries, and wages and more stable sociomedical and political climate in the developed nations attract medical doctors from Nigeria.[4],[5],[14],[16],[22] Undoubtedly, a sizeable number of medical doctors have left Nigeria and the enormity of BD has reached an alarming level that repositioning the Nigerian health sector for health system responsiveness and performance should be the cardinal responsibilities of the government and organized private sector.[17],[18],[22] These approaches among others are aimed at creating a medical ecological system where the wellness of patients correlates with the wellness of the medical doctors.[4],[28] In this way, the ongoing medical BD in Nigerian healthcare industry can be largely mitigated. Provision of rewards and incentive schemes for national retention of medical doctors, heighten political will, investment and leadership in health, strengthen social security and benefits, and improvement in working and living conditions will favor medical job satisfaction, personal and professional development, growth, progress, and success.
Young adult age, male gender, and duration of practice less than 10 years were significantly associated with the plan to leave the country. The finding of this study could be a mirror of the predilection and cravings of the younger and male medical doctors for financial gains and the desire for higher personal and professional development.[4],[5],[21],[22] The financial picture of medical doctors in Nigeria shows both high and low salaries, income, and wages of medical doctors.[4],[5],[16],[18],[22] The poorly paid young medical doctors in Nigeria wrestle with many personal, family, social, and professional difficulties as they care for increasingly loads of patients in the Nigerian healthcare facilities. Migration of young male Nigerian medical doctors invariably widens the doctor–population gaps in the home country – Nigeria and positively narrows doctor–population ratio in recipient and host countries, thereby draining Nigerian nation of her medical brains amid weakening of the Nigerian healthcare system.[14],[18],[22] Of great prominence in Nigeria is the widespread euphoria of working abroad among young medical doctors and those with years of practice <10 years.[4],[22] The sordid employment opportunities for young medical doctors in Nigeria have made migration for greener pasture abroad a daily chorus.[4],[14],[16] However, if remunerations and working conditions are improved, young and male medical doctors who are still considering leaving Nigeria will have a re-think and stay back in the country to salvage the national healthcare delivery system.
Limitations of the study
The push, pull, and stick factors were based on respondents' subjective responses. The study is on external BD syndrome which involves migration of medical practitioners from Nigeria to other countries.
| Conclusion | | |
Our findings show that majority of the Nigerian medical practitioners plans to leave the country with the most preferred destination foreign nations being Canada, US, UK and Australia. The most common push factors were poor income, wages and salaries in Nigeria while the most common pull factors from abroad were was higher income, wages and salariesthe same abroad. The most predominant stick factor was Family-centered reasons, were the most frequent stick factors while financial remittances to the family and nation were the perceived benefits. These information are vital for effective interventions.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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