1.1 BACKGROUND TO THE STUDY
Nigeria is a country greatly endowed with a lot of resources ranging from natural, human, material, financial and information resources, such as a typical organization needs to have in place for its effective, efficient and proper functioning. But in the midst of these plenty, it is still, backward technological, underdeveloped, sickly and impoverished. The neglected Health Sector in Nigeria is a typical example of mismanagement of resources, lack of priority and respect for the rights of citizens to health, squandering of a mandate by our leaders, complacency of the electorates to call their leaders to order and say enough is enough. The resultant effect of that is a vicious cycle of health sector that will continue to dwindle and worsen off and increase migration of health workers to other countries where their services are needed and valued (Magashi 2007).
This condition could be accounted for based on the lack of the technical knowhow or lack of technological expertise and machinery to tap into these resources, and maximally utilize them, for the optimum benefit of the citizenry and development of the country as well as the dearth of health professionals in the health sector as a result of migration. Knowing that the health sector is an integral aspect of the Nigerian society, it cannot be left behind in the pursuit of national development.
Migrations have ever since been one of the most important phenomenons of human civilization. It was very evident that this exodus had a strong effect on the economic and military (human) potential both of origin and receiving countries (Huges, 1970). On the other hand, it is also evident that if these favorable developments are to take place, the country of origin must contain a sufficiently large nucleus of scientists and retain at least a minimal scientific and economic potential before their expatriate scientists can contribute to its further development or be enticed back home (Boulier, 1999). If people are a country’s principal asset, then their health status defines the course of development, and their health characteristics determine the nature and direction of sustainable human development. In the absence of this, not only will the scientific and technical system of the country continue to deteriorate owing to the loss of trained human resources, but also all capable students will inevitably be forced to specialize abroad and remain there forever ( Iredale, 1999; Castanoz-Lomnitz, 1998).
So likewise is the movement of intellectuals like university lecturers and researchers from one national setting to another, ranging from permanent relocation to short-term visits or exchange programs, which facilitates the dissemination of knowledge and the broadening of cultural horizons. However, when one nation becomes a substantial net exporter of academic talent, and health professionals a “brain drain” condition is said to occur. The presence of this condition suggests that the provider nation is at risk of depleting its natural supply of intellectual talent and efficient health care delivery (Gedamu,2002).
Brain drain or skilled labour migration is not a recent phenomenon, but over the last few years it seems to be increasing, causing much concern. Brain drain or skilled labour migration according to the United Nations definition is defined as a one way movement of highly skilled people from developing countries to the developed countries that only benefits the industrialized countries.
Stenman (2006) describes brain drain as a large emigration of individuals with technical skills or knowledge from one country to another usually for better conditions of service and good living environment. These factors are germane for man and his family. The former serves as a means of livelihood while the latter makes life convenient for him and his household. Thus, every professional is interested in both. That is why he subjects himself to the rigor of academic activities in institutions of learning from the elementary stage to the highest level. At the end of his study, he looks for where the best salary and conditions of service can be obtained around the world.
UNESCO sees brain drain as an odd form of scientific exchange among states that is characterized by a movement in one direction, which inevitably flows to developed countries(http://www.sudaneseonline.com/cgi-bin/enews 2008). It also extends the destination of these scientists to other parts of the world. Nevertheless, it could be observed that brain drain is not only flowing to one direction. It is an affair that involves different nations of the world (http://www.answers.com/ topic/braindrain. 2008). It also include the crop of people who travelled abroad for training and acquired the necessary skill needed in their fields of specialization and stay permanently (Aredo 2008).
This menace of human capital flight seems to be an issue of concern to scholars across the globe; because its occurrence defiles ideological affiliation of countries worldwide as well as their level of development. In respect of ideological background, brain drain affects both socialist and capitalist nations. Socialist countries like Cuba and Russia would have been exempted from the problem, judging from the fact that they strive to build societies based on equality and humane values of living. They are not known for accumulating personal wealth but for using knowledge, skills, talents and whatever resources available to make their countries better places for entire citizenry. The paradigm being that the arch rival of capitalism is expected to make its countries free from brain drain (Mghanga 2008). But the reverse is the case. The problem of brain drain is worse in some socialist countries than many capitalist states (BCC News 2002; Goodman 2007)
When a highly qualified professional chooses to leave his own country for another, he does so for one or several legitimate political or economic reasons: peace and security for himself and his family, job satisfaction, education, better pay and conditions, a higher standard of living, etc. Throughout history, countries and centres of academic excellence which offer these attractions have received the largest numbers of professional migrants and these have, in turn, made substantial contributions, not only to the economic growth of their host countries, but also to the scientific and technological advancement of humanity.
Technologies, scientific thoughts and design methods are stored in human brain. They are only accessible to the individual involved. When such persons depart from their countries, their brains, skills and knowledge which can be used to develop their countries go along with them. Thus, their nations remain underdeveloped (Pei 2008).
In Nigeria today, brain drain has become a serious issue. Many professionals from all the sectors of Nigeria’s socio-economic environment have gone to practice abroad. The health sector seems to be one of the worst hit, Mohammed Yaro Budah, a pharmacist and Fellow of the Pharmaceutical Society of Nigeria (PFN) captured the scenario: “I dare say that the health sector has suffered the greatest brain drain compared to other sectors. This has led to a dearth of specialists in the various fields.” Nigeria has the highest population in the continent; Nigeria alone loses more health workers than other African countries combined. Some estimates put the number of Nigerians outside at one out of every five black doctor in the United Kingdom. In the US it is about one out of every 10. The story is also not different in other European and American countries (Guardian, 2005). According to an interview with Business Day, Osahon Enabulele, National President, Nigerian Medical Association (NMA) in 2013, “Most of these doctors are presently working in the United States, Britain, South Africa, and other neighboring African countries where medical personnel are treated better. In addition, there is a disproportionate concentration of medical personnel in urban areas because they find remote areas unattractive, despite the huge disease burden such as malaria, tuberculosis, typhoid fever etc. in rural communities. Official statistics show that there is one doctor to every 6,400 patients in Nigeria. This falls far short of the World Health Organisation (WHO) standard of one doctor to every 600 patients and is a grave threat to the physical and mental wellbeing of the country’s populace. To meet the WHO benchmark, Nigeria needs to have 283,333 doctors, measuring by a 170 million population base. This means that the country needs 283,308 additional doctors at present. Although the total expenditure in health amounts to 4.6% GDP, financial managerial competency, besides inadequate funding , remains a major problem. Current statistics show that health institutions rendering health care in Nigeria are 33,303 general hospitals, 20,278 primary health centers and posts, and 59 teaching hospital and federal medical centers (Menizibeya 2011). This represents a huge improvement in regards to the last decades; nonetheless, health care institution continues to suffer shortage.
Now what impact could the exodus of such number of knowledge workers have on the health sector and more importantly on the overall national development? This issue becomes pertinent when we consider the fact that only a healthy worker is productive. In other words, a productive nation cannot be built on the foundation of an unhealthy workforce, according to Berger and Messer (2002) they view health as a form of capital, such that health care is both a consumption good that yields direct satisfaction and an investment good that yields indirect utility through increased productivity, fewer sick days and higher wages.
Not far from the issue is the contention of low budgetary allocation to the health sector as Adejugbe (2013) observed that government actually allocated 6.04 per cent to the Health sector in the 2013 budget, as presented to the National assembly, in the sum of N279.23Bn . This is a far cry from the 15% recommended by the World Health Organization (WHO) and the agreement signed by several African heads-of-state in 2001 (of which Nigeria is a signatory) to budget a minimum of 15% to the health sector in developing countries due to the problem the sector is facing and its importance to the well being of the populace. Could this be behind the heavy incidence of brain drain in the health sector?
Migration of health staff out of the country is an important issue to consider which also could be behind the heavy incidence of brain drain in the health sector. Highly qualified nurses and specialist doctors have been mainly involved in migration to other countries. In the year 2005, 2600 nurses migrated to UK, 2050 migrated to USA. Other countries of importance to migration are Ireland, Australia, and Canada. Some nurses have migrated to other parts of Africa
Data from nursing and Midwifery council shows that they received a request from 3194 nurses in 2008 for seeking employment outside Nigeria. * African Boards (An addition of figures for Ghana, Botswana, South Africa, and other African countries. This new classification was started by the Nursing Council from the 2006 data generation year) ** Other Boards (An addition of figures for Australia, New Zealand, British Columbia, and Prince ward Islands.)
A large number of medical doctors have migrated to UK, USA, Ireland, Denmark, and Australia. The trend of migration is more towards USA, UK, then other parts of Europe. It is difficult to have a total number of actual migrants, however using proxy data like requests for certificate of good standing it appears that 2,989 Nigerian doctors migrated in the year 2006 and 2,341 migrated in 2005. In 2007 the number of doctors migrated increased to 3,567 (Table 1.2).
To buttress the fact above, the table below shows the number of doctors who made efforts to leave Nigeria to practice abroad. Overwhelming evidence show that till date health professionals are still migrating to developed countries. The increase of Nigeria migration to developed countries seems to equal a slow death for Nigeria socially, economically, culturally and health wise. It is against this backdrop that the researcher seeks to investigate the impact of brain drain in the health sector on national development.
.1.2 STATEMENT OF THE PROBLEM
The health system in Nigeria has been in persistent decline over the past few years, with resultant poor performance and the enduring burden of disease and poor health indicative of the alarming health status indicators as reported under the 2003 DHS Survey. The health sector in Nigeria is facing majorly human resources for health crisis with the mal-distribution of the available workforce, and the increasing brain drain resulting in shortage of critically needed health professionals. The health sector recognizes that human resources are critical in the provision of quality health care. Evidence points to the fact that areas with lowest concentration of health professionals have the worst health indices in the country. Since the year 2003 Nigeria has embarked on a process of reforming her health sector like the HSR (health sector reform) initiated in 2004 during the second term of the President Olusegun Obasanjo, with Professor Eyitabo Lambo as the Federal Minister of Health.. The reform aimed at significantly improving the health status of Nigerians and reversing the high prevalence of maternal and child mortality, which is currently among the worst in the world. A major challenge to the implementation of the reforms and the achievement of the Millennium Development Goals (MDGs) is the shortage of human resources for health. WHO (2006) defines human resources for health as “those who promote and preserve health as well as those who diagnose and treat diseases. Also included are health management and support workers, those who help to make the health system function but who do not provide health services directly” Human resources are the heartbeat of health service delivery. This is evidenced by the fact that health worker numbers and quality are positively associated with immunization coverage, increased outreach of primary health care, and maternal, neonatal and child survival. The health workforce determines health outputs and outcomes, drives health systems performance, and commands the largest share of health budgets.
The major challenge Nigeria faces is how to ensure availability and retention of adequate pool of competent human resources in their right mix to provide health care in areas where their services are in most need. This is a challenge complicated by many global and disease burden issues, such as global changes in health trends, shifts in health needs and demands, declining resources, changes in global economic, political, and technological situations. Additionally, these issues include the Health Millennium Development Goals (HMDGs), the global initiatives to fight HIV/AIDS, tuberculosis and malaria, and the polio eradication campaign have implications for human resources for health. Shortages of health workforce are widespread and supply of health care professionals and other service providers are inadequate to meet requirements. Coupled with the above is the uneven distribution of competent health workforce who deprive many groups access to life-saving services, a problem exacerbated by accelerated migration in open labor markets that draw skilled workers away from the poorest communities and the country as a whole . As an important element of national security, public health not only functions to provide adequate and timely medical care but also track, monitor, and control disease outbreak. The Nigerian health care had suffered several infectious disease outbreaks year after year. Hence, there is need to tackle the problem in the Nigerian health care system, with regards to methods of medical intelligence/surveillance.
Addressing these challenges require sufficient health professionals and inter-sectoral cooperation and action since in many instances the precipitating factors are outside the direct control of the health sector.
The migration is already causing a lot of havoc to the country and the growth of its health care system, because according to the recent statistics from the WHO regarding Nigeria’s health status is disturbing; the average life expectancy at 54 years is below the global average, maternal mortality is 608 per 100,000 live births, twice as high as South Africa’s 300 per 1,000 and almost 10 times Egypt’s 66 per 1,000. Besides, only 3% of HIV-positive mothers receive anti-retroviral treatment. According to Omeruan et al. (2009), the major challenges of Nigeria healthcare system have been largely due to the decades of neglect, thereby endangering Nigeria health status and national productivity. Men, women, children, and especially the core poor die from avoidable health problems such as infectious diseases, malnutrition, polio, guinea worm, measles, complications at pregnancy and childbirth, because the health sector suffers from the dearth of qualified healthcare personnel and regulations, as Nigeria’s promising doctors, pharmacists, nurses and other health professionals continue to leave Nigeria to apply their services more profitably in other countries. Nigerians are being denied quality healthcare services, especially those in the rural areas. Between 2005 and 2012, Nigeria‟s HDI value increased from 0.434 to 0.471, an average annual increase of about 1.2% (HDR, 2013). However, health spending as a proportion of the federal government expenditures shrank from an average of 3.5% in the 1970s to less than 2% in the 1980s and 1990s (FMOH, 2004). Nigeria was ranked 187th among the 191 United Nations member states in 2000. That same year, Nigeria spent 4USD per capita on health, below WHO’s minimum benchmark of 14USD per capita for developing countries (WHO,2000). By 2002, total health expenditure was a dismal figure of 4.7% (WDR, 2005). In 2012, total health expenditure as percentage of GDP stood at 5.3%, ranked 153 out of 187th countries and territories. High profile individuals, especially the political class, continue to fly abroad on regular basis for medical treatment, further widening the inequality in accessing healthcare services. Increase in government expenditure and growth in per capita output in Nigeria do not speak for increase in social welfare and health status in particular.
A significant number of Nigerian health professionals also migrate to Europe and USA and other parts of the world in search of better remuneration, better, advanced and modern facilities and equipment, and better working environments. Within the country health professionals are moving away from the sector to other more attractive sector.
The increase of Nigeria migration to developed countries seems to signal a slow death for Nigeria socially, economically, culturally and health wise. In view of the above, the researcher articulates the following research questions.
- Has the brain drain in the health sector affected National development?
- Has the budgetary allocation to the health sector contributed to the brain drain in that sector?
- What strategies should be adopted to reduce the incidence of brain drain in the health sector?
1.4 OBJECTIVES OF THE STUDY
The general objective of this study is to systematically study the brain drain in the Nigerian health sector and to find out how it has affected the health status of the citizenry and equally the development of the country. The specific objectives are to:
(1)To determine whether the brain drain in the health sector affected National development.
(2) To ascertain whether the budgetary allocation to the health sector has contributed to the brain drain in the sector.
(3) To identify the strategies that could be adopted to reduce the incidence of brain drain in Nigerian health sector.
1.5 SIGNIFICANCE OF THE STUDY
The significances of the study are great and enormous since to a great and large extent, it marks the beginning for other researchers who would want to carryout research on the subject matter. So the study has both theoretical and practical or empirical significance. From the theoretical view point, the study will add to the knowledge already accumulated on the subject matter. By clarifying and facilitating the understanding of an important issue, it will serve as a foundation for further research and inquiry. The theoretical significance is also seen when the theory of motivation as propounded by Abraham Maslow is considered. The study makes input to the relevance of the theory in establishing the reason behind the mobility of labour out of the country. One of the most popular theories of motivation is the “hierarchy of needs” theory espoused by this psychologist Abraham Maslow (1970). The theory rests on three major assumptions: first, is that human beings have many needs that are different in nature, ranging from biological needs at the lower level to psychological needs at the upper extreme; second, “individuals are in a constant state of motivation, never achieving a state of satisfaction except for a very short time. Man is, therefore, motivated by constantly unsatisfied and changing needs” (Pratt and Bennett, 1979: 27); third, these needs are arranged in a hierarchy, so that lower level needs must be satisfied, before higher level needs arise or motivate people.
On the empirical level, this study provides insight and understanding of a practical issue. The study will be useful to the government, the health sector, the academia and the general public. It should facilitate the formulation and implementation of policies geared towards reversing the trend of brain drain in the health sector.
1.6 SCOPE AND LIMITATIONS OF THE STUDY
This research focused on brain drain and its effect on national development. It looked at the causes and tried to identify strategies to address it.
Primarily, it focused on the health sector and tried to study the impact of brain drain on the delivery of health care services. It should be noted that the health sector is wide. Thus the scope was narrowed down to four federal hospitals where the data needed for the research was drawn. These hospitals are viz: University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu State University Teaching Hospital, National orthopedic hospital Enugu, federal Neuropsychiatric Hospital Enugu. All in Enugu.
This study had some limitations and challenges. There was the difficulty of making frequent visits to collect data in an unfamiliar place (the researcher has never stayed in Enugu). Another constraint was the unwavering stance of the managements of the hospitals who marshaled out elaborate protocols which must be followed in order to administer instruments of data collection to their staff. The researcher followed them to the later, but had to patiently and persuasively educate many respondents on the significance of the study before they could dutifully attend to the questionnaires.