Dr. Nnamdi E Ojimadu of the department of Family Medicine, Jos University Teaching Hospital and an advocate of human resources development, bares his mind in this post. He birthed the idea of a national health summit designed to address the problem of brain drain which eventually held in the nation's capital. This article appears in the Jos Journal of Medicine. Permission to re-publish has been granted by the author and the editors.
Human Resources Development For Health: Key to Achieving Millennium Development Goals.The great majority of Nigerians have had minimal or no improvement in their health status in the last few decades despite an increase in the number of health workers or professionals trained each year. There is rather a deterioration of health status shown by the increase in infant mortality rate (110/1000), under 5 mortality rate (190-205/1000) and maternal mortality rate (800-1000/10,000): one of the highest in the world,
1 reduced life expectancy and a higher incidence of malnutrition, rapid dissemination of HIV/AIDS, and the emergence of other diseases. Malaria affects 300-500million people every year and 80% of these live in sub-Saharan Africa, 25% of whom will be Nigerians. Malaria kills 1-1.5million people every year – 90% of these deaths occur in sub-Saharan Africa. About 3000 African children die of malaria every day and one African child is lost to the disease every second. Achieving the Millennium Development Goals may remain a mirage in Nigeria, except health care systems are able to offer quality services that are accessible to vulnerable population groups. This of course depends on availability of a well-trained, rationally deployed and sufficiently motivated workforce operating in an enabling environment. There is a need for quality undergraduate and postgraduate training and adequate incentives. Health workers’ performance, however, is also influenced by an array of other factors.2
All over the world Nigerian health professionals have distinguished themselves. The question then remains; why is the nigerian health system in such a deplorable state, with such a huge human resources? Environmental factors cannot be excused from the reasons responsible for the ailing health system. HIV/AIDS, tuberculosis, malaria and other communicable diseases are placing additional burdens on the health workforce. Almost two thirds (64%)of all the people living with HIV/AIDS are in sub-Saharan Africa including Nigeria.
Unfortunately the country is ill equipped to deal with the situation. For example, there is only an average of 0.8 health workers per 1000 population in Africa
In 2002, Nigeria had a nurse population ratio of 1: 20,700 people as against the 1: 1,000 which WHO recommends. To achieve the Millennium Development Goals, the minimum level of health workforce density require by WHO standard is 2.5 health worker per 1,000 people. In contrast there are 10.3 health workers per thousand in Europe and 9.9 in the USA.3, 4
The International Community seeks to address the health needs of the developing countries through the Millennium Development Goals (MDGs).
This includes:
Ø Eradicate extreme poverty and hunger
Halve the proportion of people living on less than a dollar a day and those who suffer from hunger
Ø Achieve universal primary education
Ensure that all boys and girls complete primary school
Ø Promote gender equality and empower women
Eliminate gender disparities in primary and secondary education preferably by 2005 and at all levels by 2015.
Ø Reduce children mortality
Reduce by two thirds the mortality rate among children under five
Ø Improve maternal health
Reduce by three quarters the ratio of women dying in childbirth
Ø Combat HIV/AIDS, Malaria and other Diseases
Halt and begin to reverse the spread of HIV/AIDS and the incidence of malaria and other major diseases
Ø Ensure environmental sustainability
Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources.
By 2015, reduce by half the proportion of people without access to safe drinking water.
By 2020’ achieve significant improvement in the lives 100million slum dwellers.
Ø Develop a global partnership for development
Develop further an open trading and financial system that includes a commitment to good governance, development and poverty reduction- nationally.
Address the least developed countries’ special needs, and the special needs of landlocked and small Island developing states.
Deal comprehensively with developing countries’ debt problems.
Develop decent and productive work for youth.
In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.
In cooperation with the private sector, make available the benefits of new technologies – especially information and communications technologies 5
The MDGs can improve the health status of the country but this will only be a reality when three important issues are addressed viz: as brain drain, strikes and low moral among health workers.
The issue of brain drain
There are conflicting data on the exact number of Nigerian doctors outside the country. About 20,000 health professionals are estimated to emigrate from Africa annually.6 Today it is thought there are more Nigerian physicians in the USA and UK than in their own country .7 Though having the highest population in the continent, Nigeria alone looses more health workers than other African countries combined. Some estimates put the number of Nigerian doctors outside at one out of every five black doctor in the UK. In the US it is about one out of every 10. The story is also not different in other European and American countries 8 Another account estimates that over 23% of US physicians received their medical training outside the United States, with most (64%) coming from low or lower middle income countries. This group includes more than 5000 doctors from sub- Saharan Africa, which represents 6% of all doctors practicing in sub- Saharan Africa now. Almost 86% of these Africans practicing medicine in the United States come from Nigeria, South Africa, and Ghana, and the vast majority was trained at 10 medical schools.9 Data available on emigration of Nigerian nurses indicates that among 2000 African nurses legally emigrating to work in Britain between April 2000 – March 2001 about 432 were Nigerian.6 A 2003 statistic of registered nurses in the UK showed that Nigerian nurses topped the list.8
Studies focusing on why skilled health professionals emigrate have identified two broad categories: the ‘push’ and ‘pull’ factor.10 11 12
a) Push factor –
Furthering their career
Improve their economic or social situation
Insufficient suitable employment
Lower pay
Unsatisfactory working condition
Poor infrastructure and technology
Persistent shortages of basic medical supplies
Lower social status and recognition
Repressive governments
Lack of opportunity for postgraduate training
Under funding of health-service facilities
Absence of established posts and career opportunity
Poor remuneration (Nigeria-based doctors typically earn about 25% of what they would have earned if working in Europe or North America.) 6 and conditions of service, including retirement provision
Government and health-service management shortcomings
Civil unrest and personal security
Lack of fulfillment in practice
b) Pull factor
Opportunity for further training and career advancement
Higher living standards
Better practicing conditions
More sophisticated research condition
The attraction of centers of medical and educational excellence
Greater financial rewards and improved working conditions
Availability of posts, often combined with active recruitment by prospective employing countries
Human Resources Development for Health
The health reforms required for achieving the MDGs demand a careful attention to making use of resources, especially human resources. This approach includes utilization of health care workers and their education and training and the evolution of a strategy that will improve the health system.
There must be a pragmatic approach that involves a more proactive management of the workforce. This will involve a change of attitude through orientation of the workforce. This change is not limited to a particular cadre but cuts across borders, affecting administrators, and health professionals, especially doctors, who are often in the leadership role. The new orientation will focus on enabling all health workers to see themselves as individuals responsible for the quality, efficiency, and effectiveness of the health system.
Human Resources for Health (HRH) as a whole will require a close collaboration between the ministry of health, health care providers, colleges of health and educational institutions and professional associations. The individual strengths and capabilities of each group should be mobilized so that HRH issues can be tackled jointly.
Professional associations can make valuable contributions to strengthening, change of attitude and continuing education of health professionals, medical audit and monitoring systems.13
Much as the effort of the Federal Ministry of Health in her Health Sector Reform Programme (HSRP) is commendable, a more realistic approach is needed. It is not enough to outline programmes or talk shop about HSRP, NEPAD and MDGs. What is the impact on the common man, and what challenge is it to the average health worker? A highly motivated work force is needed to meet the challenges facing the Nigerian health system.
Policies are made without carrying along the health work force. If anything, the health worker who is in the frontline and is confronted by day-to-day challenges should be part of the policy-making process. As a matter of importance and urgency there is a need for a national health summit to address fundamental issues clogging the wheel of progress of the nigerian health system.
The following issues need to be addressed in order to find a solution to strikes and brain drain:
Ø Improved systems performance
Ø Capacity development
Ø Better remuneration packages
Ø Adequate work incentives
Ø Better training of health workers
Ø Personnel policy
Ø Create enabling environment for the provision of health services
Ø Management of data and performance
No doubt this reform will place a financial constraint on the government with regard to funding the health services. The Department For International Development (DFID) should make good its pledge to increase aid to Africa’s health sector. This has been implemented in Malawi (ranked 198 out of 198 by WHO), with 1.13 doctors per 100,000 [2003population] where a six-year 100million pounds programme to support Malawi’s health sector included investment in better training and higher salaries for doctors, nurses and other health workers.11 If this is replicated in Nigeria (ranked 187 of 191 member states in 2001), it will have a significant impact on her health system. During the G8 summit in 2005 the developed countries especially Britain demonstrated a renewed concern and determination to increase grants to solve the crisis the African health sector is facing.13 Countries like Nigeria can benefit from support World Bank, Global Fund and DFID to build HRH.
Brain drain has its pros and cons as it has for many enhancement of their personal and family economic fortune. The developing countries have served as training grounds for health professionals for many years. It is therefore disturbing when their potential contribution to health development in their countries is lost. Some of these doctors currently overseas may be willing to return to the country provided there is an enabling environment and adequate work incentives. Unfortunately some of those willing to return and help develop the health system have either been denied opportunities or subjected to discouraging accreditation procedures.6 Despite the scarcity of health professionals there is still high rate of unemployment. This has resulted in some new graduates waiting for years before getting places for internship or job placement. These factors will continue to encourage the emigration of health workers.
The way forward
The individual’s freedom should not be restricted as this amounts to human right abuse. Instead efforts should be made to retain health professionals by creating an enabling environment for medical practice in Nigeria.
Housing loan schemes should be provided, payable over a period of 25 years. This will go a long way to reduce the efflux of health professional
Car loans such that a doctor will be able to afford a new car.
Incentive for rural practice- health workers who practice in rural communities should be remunerated higher than those in the cities in order to retain them and attract more health workers. This will help reduce infant, under-five and maternal mortality rates. Instead of hiring foreign doctors who are paid in dollars despite their limitations in communication and inadequate exposure to tropical medicine, indigenous doctors should be recruited to such places with similar incentives. The hard currency paid one expatriate is enough to make five Nigerian doctors comfortable in any part of the country.
Regular in-service and short-term training courses on Basic Life Saving Skills (BLSS) and Advance Life Saving Skills (ALSS) could be organized on regular basis as Continued Medical Education (CME) for health workers in rural areas.
Recreational facilities can also be created in such rural environments as one of the incentives for health workers.
Consideration should also be made about the schooling of their children. This will open up the rural areas for rapid development as good schools and other social amenities will follow. This will attract teachers and businessmen to such areas.
Regular water and power supply should be ensured by way of sinking boreholes and power generators for constant supplies in areas that do not have electricity. However, electricity-supplying body should endeavor to extend their services to such areas.
We can develop friendly policies and create incentives that can attract or encourage the return of health professional based overseas.
Nigeria as the giant of Africa should be able to improve her health status with the staggering potential at her disposal. To this end Human Resources Development For Health should be given adequate attention to reduce the impact of brain drain in the health sector. Hence the noble goals of the MDGs can be achieved when the three tiers of government in this country, the private sector, Non-Governmental Organizations and the International Community realize how much they owe the people of Nigeria - an efficient, effective and quality health care system that works.
To realize this noble goal a National Health Summit that will bring together all the key players in the health sector to brain storm on the issues raised above and find an enduring solution to the challenges facing the sector is being organized.
The Millennium Development Goals are achievable and realistic.
References:
1. Habte D, Dussault G, Boostron E, Pearson B. Education of professionals and the human resources crisis in Africa: Medical Education Resources Africa (MERA). March 2003, pp. iv-vi.
2. Okeahialam T C. The Nigerian child and the Millennium Development Goals. 37th Annual General and Scientific Conference: PANCONF 2006, Jos Nigeria.
3. Addressing Africa’s Health Work Force Crisis: An avenue for action, Abuja Declaration
4. Human Resources for Health: Overcoming the Crisis. Report from Consultation in Oslo 24th – 25th February 2005.
5. WHO Millennium Development Goals. Report of Secretary –General. A57/270 (31 July 2002)
6. Stilwell B et al. Managing brain drain and waste of workers in Nigeria. Bulletin of the World Health Organization
7. Pearson B. The brain drain: a force for good? Medical Education Resources Africa (MERA). January 2004)
8. Okumephuna Chukwunwike. The Ever Green Story of Brain Drain. USA/Africa Dialogue, No 669: Brain Drain (The Guardian, Thursday, May 5, 2005)
9. Hagopian A, Thompson M T, Fordyce M, Johnson K E, Hart G L. The migration of physicians from sub-Sahara Africa to the USA: measures of the African brain drain.
www.human-resources-health.com/content/2/1/1710. Chen L C, Boufford M. Fetal Flow – Doctors on the move. New Engl J M 353;17 Oct. 27 2005, pp. 3850.
11. Ahmad O B. Managing medical migration from poor countries. BMJ vol 331. 2 July 2005, pp 43.
12. Fifth-Seventh World Health Assembly [22 May, 2004] A57/VR/
13. Alwan A, Homby P. The implication of health sector reform for human resources development. Bulletin of WHO vol. 80 no. 1 Geneva.
14. Loss of health professionals from sub-Saharan Africa (Lancet vol. 365 May 28, 2005).
