Healthcare systems play pivotal roles in maintaining and promoting the health of populations, while also contributing to the economy, structure, and development of nations. Thus, the instability of healthcare systems is a global health dilemma with implications that undermine the survival and sustainability of these systems worldwide. Hence, health system resilience has emerged as a prominent topic in global health discourse; with emphasis on the fact that resilience is not an action to be implemented but rather a dynamic process of investments and reforms [1, 2, 3, 4].
The diversity of factors that destabilize health systems—including economic crises, climate change, natural disasters, disease outbreaks, migration, conflict, and evolving population—points to the exploration of reasons that leave some healthcare systems more susceptible to instability than others . The emigration of physicians and other healthcare workers from low- and middle-income countries (LMICs) to high-income countries (HICs), colloquially referred to as the brain drain, is a factor that has been a prominent discussion in global health spheres for years—presenting a complex set of decisions and relationships that affect the development of international healthcare systems . Between 2005 and 2015, there was over a 70% increase in Africa-trained doctors who subsequently entered the US workforce with a continual and steady increase over the last half-century [6, 7]. Thus, this emigration creates imbalances and gaps in the LMICs healthcare systems’ workforce—some of which are already struggling with the other factors affecting the stability of health systems. The World Health Organization (WHO) cites workforce as a necessary building block for health systems; yet estimates a projected shortfall of 15 million healthcare workers by 2030, mostly in LMICs who have an average physician density of 17 per 100,000 population as compared to an average of 300 per 100,000 in HICs [8, 9, 10].
Given that sub-Saharan Africa serves as a colossal source region of physicians emigrating to HICs, the WHO estimates that one in four doctors will leave Africa to pursue jobs abroad . Specifically, of the international medical graduates from sub-Saharan African countries practicing in the US, 44.5% are from Nigeria . Studies have listed unrest, safety, and security concerns as major push factors for the move to HICs, emphasizing that LMICs with broad-based unrest are more susceptible to the factors affecting the stability of health systems [12, 13]. Furthermore, increasing unrest and national security concerns in Nigeria in the form of the Boko Haram insurgency, may further drive health workforce emigration . Despite the crippling impact of workforce emigration on LMICs health systems, there are limited studies consulting physicians from LMICs—a seemingly untapped resource—for solution generation. Hence, this study aims to understand the effects of workforce emigration and sociopolitical unrest on the Nigerian healthcare system and to develop an innovative framework for resilience based on physician’s suggestions.
This study used a mixed methods approach with a cross-sectional anonymous online survey targeting Nigeria-trained physicians. Respondents were recruited using convenience and snowball sampling methods in which the primary group of respondents were solicited via WhatsApp, an internationally available messenger platform widely used in Africa. The link to the survey was initially distributed through a WhatsApp group for Nigeria-trained doctors containing 259 Nigeria-trained physicians practicing in the United Kingdom. The group members were encouraged to distribute the survey link to other colleagues, with other Nigeria-trained physicians not in the group solicited via snowball sampling. The inclusion criteria included having attended and graduated from a Nigerian medical school, with the assumption that this target sample would have the most insight on resilience building—with regards to emigration and unrest as destabilizing factors—based on being ingrained in the system right from training. Due to the anonymous nature of the survey and the ability of individuals to forward the link, the total denominator for potential respondents, as well as the response rate, cannot be determined. Prior to the dissemination of the survey, ethics approval was sought from the Research Ethics Board (REB), and approved by the REB of the primary author’s institution.
The survey consisted of three main sections. The first section included demographic questions such as age, gender, place of birth, and medical school. The second section had two separate versions. The first version targeted Nigeria-trained physicians practicing in Nigeria at the moment of data collection. It included both open and closed ended questions regarding job satisfaction, emigration plans, the effects of physician emigration on the Nigerian healthcare system, and reforms the Nigerian healthcare system can adapt to remain resilient in the face of physician emigration and socio-political unrest. The second version targeted Nigeria-trained physicians practicing in countries outside of Nigeria at the moment of data collection. It included both open and closed ended questions regarding current country of practice, factors leading to emigration, job satisfaction while in Nigeria, and job satisfaction in the current country of practice.
Data were collected using the online survey software Qualtrics, allowing respondents to complete the survey at a time and location of their convenience. The survey introduction asked for respondents’ consent, informing them that the survey was voluntary and that the data will remain anonymous. Additionally, the survey included a trigger warning mentioning that the questions about emigration and working in areas of unrest may generate discomfort, and the respondents may pause or discontinue the survey at any moment. The survey link was available for two months, from May 1, 2022, until June 30, 2022. All data were automatically saved in Qualtrics and downloaded into Microsoft Excel upon completion.
Quantitative data were cleaned and analyzed using Stata 17 (StataCorp, College Station, TX, USA) and qualitative data were organized and analyzed by two independent researchers using Microsoft Word. Quantitative data included respondent demographics and other closed ended questions such as a Likert scale for job satisfaction and factors influencing emigration. Qualitative data included open-ended questions such as how Nigeria’s healthcare system has been affected by unrest, suggestions on how Nigeria’s healthcare system can remain resilient in the face of unrest, and means to improve physician retention rate.
The qualitative data were examined by two independent researchers who independently identified the preliminary themes. A codebook was developed and the two researchers independently hand-coded the data. The coded data were then compared to identify all the discrepancies discussed until the two researchers reached a consensus regarding the appropriate code. If no appropriate code was found, additional codes were developed with the consensus of both researchers. The codebook and original themes were then revisited and discussed until the overarching themes emerged.
Figure 1 presents the flowchart of participating physicians. A total of 53 physicians participated in the survey. Four were excluded per exclusion criteria. The final analytic sample of 49 participants included 35 physicians practicing in Nigeria and 14 practicing outside of Nigeria at the time of survey.
The demographic characteristics of the total sample—stratified by location of current practice—are presented in Table 1.
|CHARACTERISTICS||N (%)||PHYSICIANS PRACTICING IN NIGERIA||PHYSICIANS PRACTICING OUTSIDE OF NIGERIA|
|Total||49 (100.00)||35 (71.43)||14 (28.57)|
|29 or younger||19 (38.78)||17 (48.57)||2 (14.29)|
|30–39||26 (53.06)||16 (45.71)||10 (71.43)|
|40–49||4 (8.16)||2 (5.71)||2 (14.29)|
|Female||22 (44.90)||13 (37.14)||9 (64.29)|
|Male||27 (55.10)||22 (62.86)||5 (35.71)|
|Were you born in Nigeria?|
|Yes||48 (97.96)||35 (100.00)||13 (92.86)|
|No||1 (2.04)||–||1 (7.14)|
|Where did you attend high school?|
|Nigeria||48 (97.96)||34 (97.14)||14 (100.00)|
|Other||1 (2.04)||1 (2.86)||–|
|Where is the medical school you graduated from located?|
|Nigeria||49 (100.00)||35 (100.00)||14 (100.00)|
|Location of medical school (city, state)|
|Abuja||3 (6.12)||3 (8.57)||–|
|Benin City, Edo||2 (4.08)||–||2 (14.29)|
|Calabar, Cross River||1 (2.04)||–||1 (7.14)|
|Elele, Rivers||1 (2.04)||1 (2.86)||–|
|Ibadan, Oyo||4 (8.16)||1 (2.86)||3 (21.43)|
|Ilorin, Kwara||2 (4.08)||–||2 (14.29)|
|Iwo, Osun||4 (8.16)||4 (11.43)||–|
|Jos, Plateau||19 (38.78)||19 (54.29)||–|
|Lagos||3 (6.12)||2 (5.71)||1 (7.14)|
|Maiduguri, Borno||8 (16.33)||5 (14.29)||3 (21.43)|
|Port Harcourt, Rivers||2 (4.08)||–||2 (14.29)|
|In what year did you graduate from medical school?|
|2010 or before||5 (10.20)||2 (5.71)||3 (21.43)|
|2011–2015||20 (40.82)||10 (28.57)||10 (71.43)|
|2016–2020||18 (36.73)||17 (48.57)||1 (7.14)|
|2021 or after||6 (12.24)||6 (17.14)||–|
|Did you undergo specialty training (residency training)?|
|No||37 (75.51)||27 (77.14)||10 (71.43)|
|Yes||12 (24.49)||8 (22.86)||4 (28.57)|
|If yes, in which country?|
|Nigeria||11 (91.67)||8 (100.00)||3 (75.00)|
|UK||1 (8.33)||–||1 (25.00)|
|What is your current medical specialty?|
|Family/general practice||18 (36.73)||12 (34.29)||6 (42.86)|
|Internal medicine, (e.g., cardiology, respirology, gastroenterology)||3 (6.12)||–||3 (21.43)|
|Surgery (e.g., plastic surgery, orthopedic surgery)||–||–||–|
|Psychiatry||3 (6.12)||3 (21.43)|
|Obstetrics/gynecology||2 (4.08)||2 (5.71)||–|
|Unspecialized/Medical Officer||17 (34.69)||16 (45.71)||1 (7.14)|
|Other||6 (12.24)||5 (14.29)||1 (7.14)|
The job safety, satisfaction, and emigration intent of physicians currently practicing in Nigeria are presented in Table 2. Regarding overall satisfaction of the current practice, 41% of the physicians currently practicing in Nigeria are dissatisfied to some degree with only one participant stating that they were “extremely satisfied” with their current practice. In addition, half of them mentioned feeling unsafe at work. When asked about emigration plans, all of the physicians currently practicing in Nigeria answered that they have considered emigrating, from 41% answering that they are “always” considering practicing abroad, to only one participant answering that they “rarely” do. Majority of the participants (79%) had concrete plans to emigrate from Nigeria in the next five years. Finally, when asked about confidence in their current practice to withstand the surrounding instability in the long run, close to half of the participants (47%) answered “not confident at all.”
|What state in Nigeria do you currently practice?|
|Akwa Ibom||1 (2.86)|
|Cross River||1 (2.86)|
|How satisfied are you with the overall functioning of your practice?|
|Extremely Satisfied||1 (2.94)|
|Somewhat Satisfied||14 (41.18)|
| Neither satisfied nor
|Somewhat Dissatisfied||10 (29.41)|
|Extremely Dissatisfied||4 (11.76)|
|Do you ever consider emigrating from Nigeria to practice abroad?|
|Do you have plans to emigrate from Nigeria in the next 5 years?|
|Do you feel safe in your place of work?|
|How confident are you that your current practice can withstand the surrounding instability in the long run?|
|Completely Confident||2 (5.88)|
|Fairly Confident||3 (8.82)|
|Somewhat Confident||8 (23.53)|
|Slightly Confident||5 (14.71)|
|Not Confident at all||16 (47.06)|
Emigrated physicians’ country of practice, previous practices in Nigeria, past and current job satisfaction, and reasons for emigration are presented in Table 3. Eight of the fourteen emigrated physicians were practicing in the United Kingdom (57%), three in the United States (21%), and three in Canada (21%). All of them had practiced medicine in Nigeria before emigration with eight (57%) having practiced in more than one state in Nigeria. More than half of them practiced for between five to ten years in Nigeria before emigrating. When asked about the overall satisfaction regarding their practice in Nigeria, six (43%) answered somewhat dissatisfied and five (36%) answered extremely dissatisfied. All except for two emigrated from Nigeria in the past five years and the majority of them (93%) were either extremely satisfied or somewhat satisfied with their current practice outside of Nigeria. Of the list of factors that led to emigration, physician remuneration (93%), socioeconomic state of the country (93%), quality of facilities (86%), and unrest (79%) were most frequently identified.
|Where are you currently practicing?|
|United Kingdom||8 (57.14)|
|United States||3 (21.43)|
|Have you ever practiced medicine in Nigeria?|
|If yes, where/which state?|
|Bayelsa, Rivers, Anambra||1 (7.14)|
|Benue, Abuja||1 (7.14)|
|Edo, Kaduna||1 (7.14)|
|Lagos, Bauchi||1 (7.14)|
|Lagos, Kwara||1 (7.14)|
|Osun, Ekiti, Kwara, Ondo||1 (7.14)|
|Oyo, Adamawa, Osun||1 (7.14)|
|Plateau, Ekiti, Abuja||1 (7.14)|
|How many years did you practice in Nigeria?|
|< 1 year||–|
|1 to 2 years||3 (21.43)|
|2 to 5 years||2 (14.29)|
|5 to 10 years||8 (57.14)|
|More than 10 years||1 (7.14)|
|How satisfied were you with the overall functioning of your practice in Nigeria?|
|Somewhat Satisfied||2 (14.29)|
| Neither satisfied nor
|Somewhat Dissatisfied||6 (42.86)|
|Extremely Dissatisfied||5 (35.71)|
|Which (if any) of the following factors led you to emigrate from Nigeria?
Please select all that apply:
|Physician remuneration (pay)||13 (92.85)|
|Quality of facilities||12 (85.71)|
|Unrest (sociopolitical, civil and other broad–based unrest)||11 (78.57)|
|Personal safety||7 (50.00)|
|Socioeconomic state of the country||13 (92.85)|
|Quantity and availability of allied health disciplines (e.g., nursing, physical therapy, etc.)||2 (14.28)|
|Shortcomings in governance and health services management||10 (71.42)|
|Opportunity for continuing education (residency training, etc.)||9 (64.28)|
|Was the functioning of the health system you practiced in Nigeria affected by unrest (e.g., crises, Boko Haram terrorism, kidnappings, crime etc.)?|
|In what year did you arrive in your current country of practice?|
|Prior to 2017||2 (14.29)|
|Is your current specialty the same as the one in which you trained and/or practiced before emigrating?|
|How satisfied are you with the overall functioning of your current practice?|
|Extremely Satisfied||4 (28.57)|
|Somewhat Satisfied||9 (64.29)|
|Neither satisfied nor Dissatisfied||1 (7.14)|
The pattern of physician movement from medical school location, to location of current practice(s) are illustrated in Figure 2, (A) depicts the movement of physicians currently practicing in Nigeria, showing an overall flow of movement from the Northeast of the country—particularly Borno State where most of the Boko Haram related unrest currently is—to more Southern, Western and Middle-Belt regions; (B) depicts the movement of emigrated physicians, showing initial moves within Nigeria—which follow the same pattern of movement from regions of unrest— to final location of practice outside the country. The numbers of physicians per each state are represented in the location pins.
Figure 3 presents a resilience framework synthesized from the resilience building themes extracted from survey responses.
Suggestions from physician respondents on how the Nigerian healthcare system can maintain and promote resilience amidst the ongoing physician emigration and sociopolitical unrest fell into the following broad themes:
This study aimed to capture Nigeria-trained physicians’ perspectives regarding the ongoing physician emigration and sociopolitical unrest, the impact of the emigration and unrest on the local healthcare system, and key resilience building strategies for maintaining the healthcare system amidst these destabilizing factors. Utilizing a global health equity lens which is anti-oppressive and prioritizes capacity building, we employed an Asset-Based Community Development (ABCD) approach to community-based development which intentionally counteracts the deficit-oriented mentalities which perpetuate and reinforce colonial power dynamics [16, 17, 18]. Therefore, this study represents a response to the call to move decolonization of global health from reflection to action [18, 19, 20, 21].
The resilience framework, which serves to shine light on key issues for consideration by health care policy planners whose aim is to stem mass physician migration, acknowledges that health system resilience is mediated by multiple and cumulative levels of adaptability with the involvement of multiple stakeholders [1, 22, 23, 24, 25, 26, 27]. Quantitative results with regards to plans for emigration and safety concerns indicate that the Nigerian healthcare system is not only currently unstable, but is also vulnerable to future instability in the form of continued progression of sociopolitical unrest and emigration. Therefore, resilience-building efforts should be distinguished from health system strengthening efforts; where the latter involves the health system planning for sudden instability and crises, resilience-building efforts should further include system planning that would also be sufficient to align resource deployment with routine healthcare needs in periods of stability [1, 23, 28, 29, 30, 31, 32].
The themes outlined in Figure 3 can serve as actionable points to tackle the tasks of resilience building, with steps that mirror the key components of the WHO health system framework—particularly health workforce, financing, and leadership and government—which form the building blocks of a health system . Similarly, the WHO put out a toolkit for assessing health system capacity for crisis management, which includes a spate of declarations and agreements relating to strengthening health system capacity for disaster preparedness, further underlining the urgent need for all countries to be prepared to meet emerging threats to public health .
In particular, the emerging themes surrounding utilizing conflict-sensitive approaches to view health as a common good is reflective of the current challenges the Nigerian healthcare system is faced with. Specifically, the Northeast of the country has experienced attacks from the militant group known as Boko Haram since 2011; with the group initially targeting the police and churches, and then expanding to target mosques, schools, hospitals, and banks with bombings, military raids robberies and kidnappings . These atrocities spread from the initial pressure point of Yobe State to the neighboring states of Borno and Adamawa, until a state of emergency was declared in these states in May 2013 . This unrest has led to the internal displacement of inhabitants of the Northeast, as well as emigration from hardest hit regions, which also affects the healthcare workforce as highlighted in Figure 2 (A) above. Thus, these themes can be linked to the WHO Global Health for Peace Initiative (GHPI) which emphasizes using a conflict-sensitive approach to avoid doing harm, to increase project acceptance, and to mitigate risks, under the impression that “there cannot be health without peace, and there cannot be peace without health;” suggesting that health is viewed as a common good by all sides of a conflict, which allows health initiatives to serve as a starting point for bringing people together . Nevertheless, there is more to be explored as to how this can be used effectively in Nigeria’s healthcare system amidst current strains.
The sense of urgency for this study is also palpable due to the potential for fragmented care and limited access—ultimately leading to poorer outcomes—that some argue is perpetuated by the current healthcare delivery model employed in Nigeria. Nigeria operates a pluralistic health care delivery system (orthodox and traditional health care delivery systems), with more focus on the orthodox or “Western” health care model whose care services are provided by private and public sectors . However, the provision of health care in the country remains the functions of the three tiers of government (the federal, state, and local government)—with the primary health care (PHC) system managed by the local government areas (LGAs) with support from their respective state ministries of health as well as private medical practitioners; the secondary health care system managed by the ministry of health at the state level, and tertiary care provided by teaching hospitals and specialist hospitals (with the secondary and tertiary levels also working with voluntary and nongovernmental organizations, as well as private practitioners) [36, 37]. Thus, the complexity of this model can exacerbate the issues surrounding care delivery and access in the current system.
As exposed in this study, physicians—who are major care delivery agents in the healthcare system—believe that the current model of healthcare delivery is greatly lacking in the PHC sector; highlighting gaps with regards to access and health insurance, which drive increases in out-of-pocket expenditure for healthcare. This can serve as a deterrent to the population actively participating in their healthcare, further hindering population health literacy, and leading to poor health seeking behaviors. This illuminates areas for future study and policy reforms which are consistent with the literature around the brain drain and the Nigerian healthcare system deficits ; further highlighting the importance of actively involving the healthcare workforce of LMICs—in this case, physicians—in seeking out innovative solutions for resilience building.
Furthermore, as a product of collaboration, this study highlights physicians trained in Nigeria as a relatively untapped resource in terms of resilience building, who possess a wealth of knowledge and are willing to participate in change. Therefore, regardless of the complexity of the task ahead, the results of this study can assist the stakeholders involved in health system resilience building by striving towards feasible solutions to instability amidst emigration and unrest.
This study has several limitations. First, the sample size is relatively small with only 49 participants included in the final analysis which may limit the conclusions we can draw from the study. However, despite a small sample size, the included participants were quite diverse in terms of their medical school background, practicing location(s), years of practice, and areas of practice. Second, the survey link was disseminated via WhatsApp with the ability for the group members to pass it on to their colleagues. Such convenient snowball sampling is prone to sampling bias. However, there is no database available to reach out to all Nigeria-trained physicians to conduct a randomized study; and the decision to refrain from collaborating with specific medical schools in Nigeria hinges on our goal to capture a wide range of physicians with diverse education and training within Nigeria. Furthermore, considering that the study is mostly qualitative, aiming to capture the challenges and suggestions around resilience building in the face of workforce emigration and unrest, we believe that the themes captured and discussed in the paper are justified. In the future, plans to increase participation by adding compensation and increasing the length of time the survey is available should be considered.
The factors causing instability to healthcare systems globally are complex and diverse, with workforce emigration and sociopolitical unrest being two prominent factors of instability with solutions that are dynamic and variable. Nevertheless, this study suggests ways to maintain and promote resilience by utilizing the suggestions of locally trained physicians and synthesizing a framework for resilience for healthcare systems. The framework unearthed six broad themes: 1) Policy and Politics, 2) Funding and Resources, 3) Organization and Structure, 4) Training and Education, 5) Research and Primary Health, and 6) Health for Peace Initiatives. Some actionable points for resilience building which were developed as subordinate themes were also highlighted.
While the themes around the impact of physician emigration and sociopolitical unrest on the healthcare system are uniquely captured through the perspectives of Nigeria-trained physicians, these challenges—and the recommendations to mitigate them—are not unique to Nigeria’s healthcare system. Therefore, we believe the lessons learned through this study can be applied to other LMICs with similar challenges. Future studies should further develop how each of the six themes outlined here can be adapted with context-specific actionable points involving the participation of the local stakeholders.
ABCD–Asset-Based Community Development
EMR–Electronic Medical Record
GHPI–Global Health for Peace Initiative
HICs–High Income Countries
LGAs–Local Government Areas
LMICs–Low- and Middle-Income Countries
MDG–Millennium Development Goals
PHC–Primary Health Care
REB–Research Ethics Board
WHO–World Health Organization
The survey datasets analyzed during the current study are available from the corresponding author on reasonable request.
Ethics approval was sought from the Research Ethics Board (REB) and approved by The University of Toronto REB; Protocol #42233, low risk. Consent to participate was received from respondents at the start of the survey.
The authors would like to thank the doctors who participated in this study for their great insight, support, and commitment to change. The authors would also like to thank the University of Toronto Department of Family and Community Medicine for providing support in survey collection software (Qualtrics), as well as Chris Sammons for his artistic contributions to the creation of Figure 2.
The authors have no competing interests to declare.
TE formulated the initial research question, design and survey, ethics board application, analyzed and interpreted themes, and served as a primary contributor in writing the manuscript. HL analyzed the quantitative data, served as a second independent reviewer for the qualitative themes as well as a major contributor in writing the manuscript. AS provided support and guidance with the ethics board application and manuscript writing. All authors read and approved the final manuscript.
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