Assessing the Challenges of Medical Practitioners’ Retention and Its Implications in a Developing Economy

Abstract

The high turnover rate of medical personnel in Nigeria is becoming alarming as many of them are leaving the country for developed nations for better job opportunities. This has contributed to the shortage of doctors and nurses in the Nigeria health sector. The study’s objective is to crystallise the challenges of health worker retention in Nigeria through a critical literature review. The study used data from previously published peer-reviewed articles published in recognised and credible scientific journals. Relevant information was obtained from these sources, conceptualised, and discussed alongside existing literature. Key findings from the research are attributed to a lack of competitive pay, state-of-the-heart medical equipment deficiency, security, and lack of political will by the government. To this end, there is a need for restructuring of the health sector in Nigeria to address issues relating to poor remuneration, infrastructure, training opportunities, and the well-being of the health workers.

1. Introduction

Nigeria is often hailed as the Giant of Africa due to its population and a strong economy. Moreover, the World Bank has acknowledged it as an emerging market [1]. Nigeria, an African country in the Gulf of Guinea currently has a population of 224,217,577 million people based on a recent report from the United Nations Department on Economics and Social Affairs [2]. The healthcare system, in Nigeria faces challenges such as the quality of public sector health services leading to health outcomes. There is a lack of targeted strategies to reach populations resulting in disparities between the rich and the poor. Insufficient availability of drugs limited human resources and managerial capabilities contribute to the quality of government healthcare services. Also, there is a need for an environment that encourages collaboration between private and public sector providers. Inadequate public funding and inefficient resource allocation further exacerbate these issues. Furthermore, there is ambiguity regarding the roles and responsibilities within the three tiers of government concerning healthcare provision and financing.

Looking back historically modern medical services in Nigeria have their origins in expeditions during the early to mid-century [3].

A severe scarcity of healthcare providers resulted from the colonial deployment of doctors and other medical specialists in the army during World War I, which brought home the necessity for indigenously trained healthcare providers. Only 10–15% of the population of Nigeria had access to contemporary healthcare facilities in 1960, according to Ref. [4] estimates. Foreign donors like WHO, UNICEF, and BTA contributed significantly to the creation and upkeep of medical facilities in Nigeria, but little was accomplished due to the Nigerian federal government’s deceit and apathy [3, 5]. More so, Nigeria had several years of military rule since it gained independence in 1960 from the British and was characterised by poor economic management and a decline in public institutions which made Nigeria’s health system bereft of long-term sustainable development plan characterised by impulses and deviations from what is expected from Nigerian leadership [6, 7]. Realistically, the present state of Nigeria’s health system is far from the minimum standard according to WHO [8], that all members must provide its citizens with the right to enjoy the highest attainable standard of health and provide basic, affordable, and universal healthcare to her citizens according to WHO retention in developing economies through a critical review of Nigeria’s Health Sector. This chapter therefore focused on the concept of health workers retention, migration of medical personnel, possible reasons for migration, strategies for mitigating medical workers migration, incentives, and work environment/infrastructure.

2. Methodology

An inductive approach and a qualitative research approach were both used for the data analysis. The findings of this investigation are based on previously released data. The major goals of the literature review are to extend the scope of potential future research and to offer a critical assessment of the state of the art now. The study follows the guidelines provided by Kitchenham [9] for carrying out a literature review. To find related articles, search terms are utilised. The primary objective of this search is to compile as much relevant research data as is practical to assist with the identified study subjects. It must be noted that only articles published in indexed scientific journals, peer-reviewed, and written in English as well as tertiary sources such as newspaper reports relevant to the subject of health workers retention, and turnover intention were considered for inclusion and exclusion criteria. It is important to highlight that the choice of the papers was based on the evaluation of the articles, information collecting, categorisation of the peer-reviewed works, and identification of empirical research.

3. Literature review

3.1 The concept of employee turnover and retention

The drive for employee turnover is associated with the unsatisfactory and ineffectiveness of policies and existing retention strategies. Retention and turnover can be described as pull-push strategies. Pull factors can be referred to as retention strategies while push factors can trigger or motivate the intention to leave according to Ref. [10]. Workers are an essential part and key to organisational existence. More so, as organisations are experiencing migration of their workforce globally especially their key employees to other organisations, the more organisations are keen on placing priority on the retention of their workforce as opined by Ref. [10].

Employee turnover (ET), as defined by Ref. [11], is the act of leaving a company for one or more reasons, including discontent and unequal access to the company’s resources. ET refers to the migration of personnel away from the company. Employee retention, on the other hand, is a process whereby staff members are persuaded to remain with their organisations for an extended amount of time, according to Ref. [12]. According to Ref. [12], organisations struggling to retain their staff must deal with problems such as additional training for new hires, higher recruitment costs, employees with insufficient skills, and interruption of organisational processes.

3.2 Migration of medical practitioners

The International Council of Nurses (ICN) and the WHO published a cautionary statement regarding the global lack of medical personnel following the COVID-19 pandemic in 2020. Due to its impact on the healthcare sector of both the economy and the overall economy of the nation, which has left the healthcare system in the nation in a precarious position, the migration of medical professionals from Nigeria to advanced nations is of major concern to all stakeholders. Health worker’s migration from Nigeria is a disturbing trend in a country already experiencing critically low medical practitioner numbers and extremely poor health thereby creating a vacuum for those who chose to remain and negatively impacting their job satisfaction and well-being [13].

However, it was not so before independence as extant studies assert that during the era of Dr. Nnamdi Azikiwe in 1924 only three (3) Nigerian students were schooling in the USA and all of them returned home after the completion of their education [14]. After independence, Nigerians abroad were still exhibiting patriotic fervour by returning home after completing their studies even until the 1980s. Nigerian medical doctors that schooled abroad are eager to return home because of adequate employment and a vibrant economy [14].

3.3 Reason for migration

In Nigeria, the major reason for migration is usually an economic factor as the economy was mismanaged by successive governments especially when the military governments were in power between the 1990s and 2000s. Push factors are the low standard of living, political instability, insecurity, excessive workload and stress, low income, inadequate facilities, irregular payment of allowances and salaries, inadequate funding, preferential treatment among health workers, and irregularities during recruitment to mention but a few as asserted by Refs. [15, 16, 17, 18]. According to Ref. [19], the outflow of doctors from sub-Saharan Africa, and specifically Nigeria, started to rise alarmingly over time. The majority of immigrants and foreign-trained medical professionals in Trinidad and Tobago and South Africa between 2011 and 2015 came from Nigeria, which indicates that not all African nations are experiencing migration patterns in their health sectors or are unable to effectively handle their health workforces [8].

The WHO reports that 600 healthcare professionals emigrated from Nigeria on average each year between 2010 and 2016, with roughly 50% of those emigrants travelling to Europe, which was followed by North America and then Africa. Nigerian doctors made up 45.02% of all medical graduates from other countries (IMGs) working in the US who completed medical colleges in sub-Saharan African nations. According to reports, over 9000 medical professionals left Nigeria between 2016 and 2018 in quest of better opportunities in the USA, Canada, and the UK [20].

The Nigeria Medical Association (NMA) expressed regret in 2021 that fewer than half of the more than 80,000 doctors registered with the Medical and Dental Council of Nigeria (MDCN) were actively practising in the nation, translating to a doctor-to-population ratio of 1 between 4000 and 5000, as opposed to the WHO recommendation of 1 doctor to 600 people [21]. According to Ref. [21], the Medical and Dental Consultants Association of Nigeria (MDCAN) expressed regret over the departure of more than 100 medical professionals from 17 Nigerian tertiary health institutions during the previous 2 years. A member poll done a few months later by the association found that over 500 medical and dental professionals had left Nigeria for developed countries in the 2 years prior, with nine out of ten doctors with less than 5 years of work experience departing the country. This unfavourable trend in doctor exodus highlights a serious condition of a long-standing, unresolved issue in the Nigerian health system. The necessity of national action, however, cannot be overemphasised to reverse the terrible trend and avert the anticipated medical professional shortage in Nigeria. Little wonder, a former governor in southwest Nigeria predicted that native doctors would manage Nigeria’s health if Nigeria fails to curb medical workers’ brain drain [22]. He further describes the trend as an emergency and the government must disincentivize the rate at which medical personnel are migrating out of this country.

According to Ref. [23], claims that Nigeria is the most populated country in Africa, has the biggest economy in Sub-Saharan Africa and also has the continent’s highest gross domestic product (GDP). This suggests that Nigeria ought to be facing a brain drain from other nations. Nigeria, the biggest oil exporter in Africa, has a history of poor financial management, including misusing donations from other countries. The mismanagement by the government has affected the development of Nigeria’s strategic sectors including the health sector. Categorically, by Ref. [24], extreme poverty was classified as $2.15 per person per day and the current exchange rate is #768.267 to $1. This suggests an average of #1600.00 per day is available for a low-income earner in Nigeria bearing in mind the minimum wage of #30,000.00 without tax deducted at the end of the month. It is worth noting that this #1600.00 per day includes feeding, transportation, housing, and other expenses.

3.4 Mitigating strategies for medical workers migration—Nigeria in perspective

In the wake of the 2020 COVID-19 pandemic, the WHO and ICN warned about a global scarcity of medical workers. Nigeria has seen an increase in the number of medical practitioners leaving the country in recent years, but there are no obvious efforts to stop or mitigate the harm this trend is doing to the country’s already precarious healthcare sector. Better job opportunities and living circumstances, competitive pay, and the chance for career progression in the destination country are major motivators for Nigerian health professionals to relocate to industrialised nations [25]. Nigeria has not only a severe lack of medical personnel but also a sizable share of the global disease burden [26]. Relocation is becoming an increasingly difficult issue since more and more chronic diseases like diabetes and hypertension are contributing to the spread of infectious diseases like malaria, TB, and HIV/AIDS [27]. Additionally, whereas other countries are responding to the recent COVID-19 outbreak by taking proactive steps to make up for this shortage of health personnel, Nigeria is not acting appropriately because people in control seem unconcerned [28]. The few health professionals’ job happiness, general well-being, and most importantly, their desire to stay in the nation, were all negatively impacted by this gap.

Remittances, one of the most important sources of money influx into Africa over the years, today support the continent’s economic development and standard of living. Nigeria is the nation in Sub-Saharan Africa that receives the greatest remittances [29, 30]. As a result, Nigeria is now a significant source of labour exports to developed nations, particularly from the healthcare sector [29]. This labour is both unskilled and, more crucially, skilled, and professional [29]. The loss of manpower that the healthcare industry experiences and the loss of income that the government invests in training these experts are the results of this ongoing movement of qualified health professionals [25]. Another result of this is that people are now more likely to recommend their fellow countrymen for medical care abroad in areas where these highly qualified doctors have migrated, resulting in a loss of income for the healthcare system [25].

It was recently revealed that Nigeria ranks fourth in the world in terms of the number of medical physicians [31] during the 17th Annual Scientific Symposium and All Fellows Conference hosted by the National Postgraduate Medical College of Nigeria in August 2023. This implies that Nigeria has training medical doctors for the advantage of other countries. However, the factors responsible for pull and push migration are presented in Table 1.

Issues push	Reasons for migration	Suggested mitigating strategies-pull
Disregard for medical employee voice	The medical workforce must be heard by their management whenever issues are raised. They do not care about their yearnings.	They should be given a sense of belonging by listening to them and having a harmonious relationship through communication.
Little or no concern for medical employee well-being	This posits subjective and psychological well-being as criteria for employee mental health. However, stress and burnout as a result of excessive workload on employees can trigger the intention to migrate.	The well-being of employees must be promoted and preserved as it improves performance and satisfaction.
Inadequate medical employee recognition	When employees are not intrinsically and extrinsically satisfied, they can intend to migrate.	Since recognition is a vector for motivation, it can foster job satisfaction.
Absence of organisational citizenship behaviour	Workload that results in stress and job burnout	Encourage organisational citizenship behaviours like altruism, sportsmanship, etc.
Limited/no incentive for overseas medical practitioners willing to work and relocate	Policies & laws are not in place to attract employees in this context back home or not to migrate as employees will weigh the pull options against the push options	Tax holidays can be given to employees in this regard if they relocate back home or given to those that remain to stay.
Inadequate work environment, infrastructure, and Security	Inadequate facilities, Insecurity, and porous environment.	Provision of medical infrastructure, conducive environment, and adequate security

Table 1.

Pull and push factors.

3.5 Employee voice

If the Nigerian government had been listening to the yearnings of medical workers as depicted in Table 1, most of the protests and strikes witnessed in the industry would have been averted [32, 33]. According to Ref. [34], a voice mechanism benefits both the employer and the employee because it has a conflictual and consensual image. Similarly, participation through voice may have a favourable impact on worker quality and efficiency. It could also distract concerns that would otherwise erupt, like in Nigeria. For this study, a collective voice would be preferred as the Nigeria health workers are unionised. According to Ref. [35], voice consists of two components. Employee participation in organisational processes for making decisions and the expression of concerns or grievances at the workplace to management are examples of this. More so because a company still heavily relies on human influence. Since the performance of a company depends on the contributions of the individuals who work there, many organisational executives consider that its personnel are its most valuable asset [36].

Two significant factors influencing employee morale in an organisation are leadership values and style [37]. For workers to be devoted and effective, organisations must encourage them to express their thoughts. To stay a devoted employee, one must feel comfortable expressing their thoughts, worries, beliefs, and statements. However, earlier research has demonstrated that there is consistently a link between the leadership style and the voice of the workforce [37].

3.6 Employee well-being

Our aim in this study is to bring constructs together capable of bringing a paradigm shift to solving or mitigating the identified problem by strongly suggesting connectedness of the effect of happiness (well-being) on productivity while devoting attention to the specific mechanisms through which happiness may foster positive work outcomes. According to Ref. [38] personal characteristics, level of perception, and cognitive variables that may trigger stress are all elements that influence employee well-being in the workplace as depicted in Table 1. Employee well-being is defined as the degree of satisfaction that people have with their jobs and work lives [38]. Managers in this context must create interventions intended at raising employee productivity geared toward the key drivers of employee well-being. This can be achieved through building social relationships at work, making jobs more interesting, and improving the work-life balance of health workers [39, 40].

3.7 Employee recognition

Non-recognition of the value of medical workers is having a devastating impact on Nigeria’s health sector. The level at which Nigerian medical doctors and nurses are migrating calls for an emergency to be addressed [1]. Statistics show that around 11,550 Nigerian-trained doctors are practising in the UK alone, ranking Nigeria as the country with the third highest percentage of foreign medical doctors in the country [41]. Undoubtedly, the need for the Nigerian government to urgently address the issue of migration of health workers cannot be overemphasised. In the last 2 years, over 2800 workers relocated abroad excluding medical consultants and other specialist doctors. It is also sad to note that of the remaining health workers remaining in Nigeria about 74% of them intend to migrate [28]. The implication of this is that Nigerians will have limited access to the best healthcare if nothing is done to discourage the exodus movement of her medical personnel.

One of the panaceas to this problem is the provision of an improved welfare package for healthcare workers. As noted by Ref. [42] posited that one of the reasons why medical personnel usually migrate to developed nations is attributed to poor remuneration and well-being. This is also supported by Ref. [43], who noted that when employees are not satisfied with the pay that they receive in exchange for work performed, the turnover intention will be high. In Nigeria for instance, many health workers particularly medical doctors and nurses are migrating in numbers to other countries because of a lack of competitive pay, lack of infrastructure, and insecurity, as represented in Table 1 [44]. Meanwhile, Ref. [45] posited that if medical personnel are not given the required recognition in terms of their valuable contributions to the well-being of the citizenry and are treated unceremoniously, they tend to lose interest in such an environment, thus, job satisfaction diminishes which will give spur turnover intention.

Additionally, it is evident and almost invariably positive that financial incentives are successful, particularly when linked to behavioural and performance outputs [46]. The value of giving employees non-cash benefits, including acknowledgement and attention, which are typically very effective and efficient, is, however, sometimes overlooked. People enjoy praise and appreciation. Formally recognising someone in a group or coworkers is extremely valuable, even if you only give them an award or commendation certificate [47].

4. Organisational citizenship behaviour

Current research has confirmed that an organisation’s people resources are the most important factor in determining its success. In light of this, employees’ attitudes and conduct toward their work and the organisation have a significant impact on their performance [48]. For an organisation to move from an undeveloped economy to a developing economy, there must be improvements in income growth, health, life span, and the standard of living of the populace [49].

According to Ref. [50], contends that severe personnel ineptitude, malfeasance, and shortage are the root causes of Nigeria’s development issues rather than a lack of natural, financial, or technological capacities. Prior studies in this context have emphasised the absence of motivation, pay increase, and opportunity for growth, research, and development as impediments to the growth of Nigeria’s health sector [51, 52]. However, scant studies underscored the judicious use of human resources which is assumed to be the most important resource that controls other resources in the sector.

Specifically, the management of Nigeria’s health sector is expected to align the strategic objective of the sector stakeholders with the reality on the ground by optimising the use of available manpower through OCB. OCB is defined as individual discretionary activity that, taken as a whole, supports the efficient operation of the organisation but is not explicitly or immediately recognised by the official incentive system [53]. According to Refs. [53, 54], conscientiousness, sportsmanship, civility, altruism, and civic virtue are the five categories that makeup OCB. Altruism involves aiding coworkers or staff members who are experiencing challenges at work, whereas conscientious behaviour involves going above and beyond what is required. More so, courtesy refers to having a polite manner that prevents the creation of problems at the workplace. Nevertheless, sportsmanship refers to having magnanimous behaviours that avoid too many complaints at work. Civic virtue is defined as having behaviours that demonstrate one’s participation in organisational activities [53, 54].

According to research by Ref. [55] on the relationship between job stress and nurses’ intention to leave their positions, it was found that nurses gave their jobs a high level of stress and that factors contributing to this stress included inadequate pay, workplace inequality, an excessive amount of work, a staffing shortage, a lack of promotion opportunities, job insecurity, and a lack of management support as illustrated in Table 1. However, if they could find another work, more than 35% of nurses said they would consider quitting the hospital [56].

The results of the OCB have inspired public organisations to use civic engagement to improve organisational performance [48, 57]. Public organisations must balance maintaining a quality of service that is attainable with meeting the citizens’ growing demands for performance and expectations [58, 59]. Because OCB encourages individuals to go above and beyond officially defined duties, extra-role behaviour may be a crucial element in building organisational responses to such difficulties [60, 61].

5. Incentives for returning and home healthcare workers

One of the panaceas to this problem is the provision of an improved welfare package for healthcare workers. For instance, via strategy, preparation, and the execution of new solutions including both financial and non-monetary rewards for keeping and inspiring health professionals, the chronic shortage of medical professionals in Asian countries was solved. While benefits and compensation, along with the environment of work, oversight, and management, as well as learning and development opportunities, are critical factors in determining whether employees choose to stay in the health sector, previous investigations in that context have found that these factors are also important [62, 63]. This suggests that government commitment to health workers’ well-being will compel them to stay in the country as described in Table 1.

6. Work environment, infrastructure, and security

Effective healthcare service delivery requires a favourable atmosphere referred to as a Positive Practice Environment (PPE). PPEs are needed to foster excellent and decent work that will ensure the safety and health of personnel including patients and their visitors, support quality care to patients, and improve the motivation and productivity of individuals and organisations [64]. Furthermore, PPEs are essential variables such as job and human security, access to adequate equipment, decent staff welfare packages, fair and manageable workloads, and job demand, as posited by Ref. [65]. In a related development, Ref. [66] posited that good infrastructure and equipment drive health workers’ motivation and job satisfaction. The medical personnel’s experience concerning the state of infrastructure and state-of-the-heart equipment to work with is nothing to write home about. According to Refs. [67, 68], they posited that employees are more likely to be engaged if they are provided with necessary support and initiatives. This implies that medical doctors and nurses in Nigeria can be encouraged to stay in the country if they have access to what is obtainable in developed countries in terms of competitive pay, equipment, security, and well-being initiatives as shown in Table 1.

7. Final thoughts and conclusion

Nigerian researchers’ findings corroborate with other researchers in Africa findings based on this context. During this study, we observed that some few African countries were able to curb this migration problem of medical workers and even lured Nigerian medical workers to their home countries. This fact was validated recently when a stakeholder in Nigeria confirmed that countries like Sierra Leone and Gambia are now offering $3000 to $4000 to lure Nigerian doctors which is about three to four times higher than what they earn in Nigeria [69].

What is observed is that there are many causes why Nigerian medical workers are leaving Nigeria which are predominantly triggered by Nigeria’s weak economy and socio-political inadequacies coupled with bad leadership. It cannot be overemphasised that the migration of health workers in Nigeria needs a holistic approach as the problem is multi-faceted. Nigeria leaders must investigate the past when our health workers having trained abroad, come back home to practice. We need a social leadership style driven by emotional and emphatic leadership components that focus on connection, collaboration, and communication. This type of leadership style is needed in this sector to enable a strong relationship and positive work with stakeholders as there is a lack of political will on the part of our leaders to curb this ugly trend.

Recent information gathered identified the root causes of this focus in Nigeria’s health sector which include excessive workload, insecurity, inadequate facilities, and inadequate compensation. Despite the growing and alarming awareness of the devastating consequences of medical workers relocating to good economies, there is scant empirical and qualitative research on how leaders with a social leadership component can bring about a paradigm shift needed in the sector. Moreover, the influence of a high-power distance culture is restraining medical workers from challenging the status quo, as the Nigerian government and employers from the private sector are unworried about the worker’s plight.