Over 75,000 nurses, midwives exit Nigeria in 5 years over poor pay, welfare, others

By Tumininu Ojelabi Hassan

The mass exodus of health professionals in the past years to advanced countries is gradually deteriorating the quality of healthcare in Nigeria. Lack of welfare, poor renumeration and hostile work environment among others have been cited as the reasons for the brain drain in the health sector.

According to the National Association of Nigeria Nurses and Midwives (NANNM), over 75,000 Nurses and Midwives left the country in the last five years in pursuit of greener pastures.

Within one year (April 1, 2022 to March 2023), 3,383 Nigerian-trained nurses and midwives were licensed to practice in the United Kingdom while 10, 639 nurses and midwives currently practice in the UK. This is based on a recent report from the Nursing and Midwifery Council (NMC), the regulatory body responsible for nursing and midwifery in the UK.

In an interview with our correspondent, the state secretary, NANNM Lagos Council, Oloruntoba Odumosu attributed the factors responsible for the mass exodus of nurses to poor renumeration, unfriendly work conditions, unsophisticated medical facilities and the Economic situation among others.

“The reasons nurses are leaving is attributable to a lot of factors, some are within the control while some are outside the control of what is happening in the country. There are pull factors pulling people away and there are also push factors pushing nurses away. One of the key issue is renumeration, the way nurses are paid compared to the demands of the job and the roles.

This is due to the fact that many people are leaving and government is not able to replace nurses at the rate at which they are leaving. It means that those, who stay behind have to carry much more workload. Their job becomes more precarious and the pay becomes abysmal. Even those who do not wish to leave become more easily frustrated and eventually pushed out of the system,” he stated.

Aside the aforementioned reasons, lack of investment, uneven distribution of resources and power are other factors crippling the health sector.

“The second thing is that, we don’t have a good level of investment in the health sector across board. The Abuja declaration recommends that in every country, at least 15 percent of the annual budget should be invested in healthcare. Nigeria has never crossed the single digit. Nigeria has not invested in healthcare. Many years of underinvestment in the health sector means that, the infrastructures within this sector are already decaying, people have to use archaic equipments to work and the environment is not very friendly for workers. For an average nurse, you are working within a very frustrating environment. The power dynamics within the health sector unfortunately does not also distribute responsibility and power evenly among the stakeholders within the health sector, which means that most of the time , the nurses who are supposed to be at their duty post for 24 hours caring for patients do not have the leverage to demand for the kind of equipments and resources they need to perform their roles. No restrooms, they don’t have places to take their proper break, there are hospitals where water is not running or cleaning is not done properly. People who have to stay there for long hours bear the brunt of it. Unfortunately, they are not the ones in the position to make critical decisions on how resources are distributed,” he said.

“Another good example is the fact that, ordinarily by the way the healthcare system is designed, 70 percent of the health care interventions should be done at the primary healthcare level. 27 percent of the healthcare interventions should happen at the secondary level and only three percent should happen at the tertiary level. Prevention is better than cure, you need to take health care closer to where people are.

But the reverse has been the case, we have huge amount of money being devoted to tertiary institutions, tertiary facilities and secondary facilities, meanwhile thousands of primary healthcare centers are deserted, poorly funded and poorly resourced, some of them don’t have light, thereby taking delivery with lantern.

Which means that the management are not setting their priorities right. These are some of the things that make the healthcare system in the country a bit frustrating. We have situations where we have different salary structures, doctors are going on strike, this means that the government is not putting premium on the health system in the country,” he added.

With regard to the economic situation of the country, Odumosu stated that the absence of structured healthcare financing and lack of reward for nurses in Nigeria as opposed to other countries, where nurses are recognized, well rewarded and prioritized are other factors contributing to the brain drain in the country.

“Also, the situation of the country, in terms of the economic prospects of the county is also a factor. Anyone, who is being tasked with much work and labour will definitely leave, when they don’t see a bright future for themselves. In countries where nurses are traveling to, it is because the government has placed a premium on healthcare and nurses are properly rewarded.

They see their future secured in those climes, that is why they keep leaving and they will continue to leave, unfortunately, until the government is ready to do what is right for the health sector. We expect that the implementation starts as soon as possible so that more funds can be mobilized to ensure that healthcare financing is much more structured,” he said.

He lamented over the harsh working condition in the profession, which has resulted in chronic illnesses as well as the demise of many nurses.

“The health and education sector need a state of emergency. We are losing our members every now and then and many of them are coming down with chronic illnesses like hypertension and diabetes because of the level of stress they go through,” he revealed.

He further revealed NANNM’s efforts towards mitigating the impact of the brain drain on its members through calls for mass recruitment. However, he noted that challenges in terms of years of professional experience and retaining nurses are degenerating the health sector.

“It is affecting us and we get more complaints from our members on the impact of the exodus. Some of the things we have been doing is to make calls for mass employment, for example in Lagos state, through some of the interventions, there have been mass requests and recruitments at the primary healthcare level and health service commissions.

Also, we want to put an exit replacement policy in place, which the governor has given approval for employment of nurses, so at least when people leave now, the adverts will be placed to replace those that have left.

The challenge with it is that, we need to get enough nurses to meet up with the quota. People can’t be equated one for one. For a nurse with 10 to 15 years of experience, you can’t equate that person with a fresh person you are just employing. The level of experience on the job makes a whole lot of difference. If you lose someone, who has done 20 years and replace with someone that just graduated, the system is not going to improve.

While we appreciate those interventions, they are not adequate to cater to the needs of the health sector. When they place job adverts, they get people but in the next six months about 100 people are also resigning. The problem is not being able to recruit, it is about being able to retain those people they have recruited. Policies must be directed towards retaining, not just opening up the recruitment process because in the next five years if this trend continues, the health sector would have a critical decline of mid level managers of doctors and nurses.

We would have just people at the tail end of their career and those who are just coming in. The middle man, who are the engine room of the system won’t be there again. People won’t stay long enough to be promoted or to gather enough experience which will be a serious capacity issue for the healthcare system to deliver optimally,” he stated.

To fix the issue of brain drain in the health sector, Odumosu urged the government to declare a state of emergency in the health sector. Aside this, prioritizing the welfare of nurses, proper remuneration and provision of healthcare facilities are crucial.

“Essentially, if the government want nurses to remain in the country, they need to declare a state of emergency in the health sector and listen to the issues that are befalling different health professionals, especially nurses, who constitute more than 50% of the professional healthcare in the system anywhere in the world. Ensure that you prioritize their welfare, they are properly remunerated, they have input in their workplaces, facilities are provided, provide services that support them and we won’t have this level of exodus,” he said.

“The global report of 2022 states that there is a total of 5.9 million global shortage of nurses, and 85% of this exists in Africa. So if the shortage is more for Africa, imagine the shortage for Nigeria, when they say Africa, Nigeria’s population is the highest. The same place where we have the most shortage of nurses is also experiencing the highest level of attrition.

“You can’t leave people in a precarious work environment and deny them right of migration. Workers will definitely look for places, where they labour is best rewarded. What any responsible government should do is to sit down and say, how do we ensure that we can provide decent work for the nurses, and make sure that they are well supported in their role.

For us a country, it is a huge economic loss when you train graduates and they are dying of preventable illnesses, because the healthcare system is not resourced. It is a double drain. A drain on the amount of money people shell out for the abysmal healthcare they receive. When a family manages to enjoy some level of upward social mobility, one illness can wreck the whole family and put them back in poverty. Prioritizing healthcare and education is key for any country serious about its development.

So many nurses have chronic illnesses because they have to work longer hours, especially, those, who are at the local government closer to people. If you have a population of 27 million in Lagos state, hypothetically you have eight thousand nurses and all of a sudden, it decreased to six thousand. Those six thousand have to care for the 27 million population, which means people’s well-being is being sacrificed for the system to continue to run,” he elaborated.

Odumosu raised concerns over the privatisation of the public health sector despite the level of poverty and hunger in the country. Adding that hiking the price of services in government hospitals is a callous approach to solving the issues in the health sector.

“We are weary about the kind of solution the government wants to declare in the health sector. Everyone has access to the data in terms of the level of poverty and hunger in Nigeria as we speak. The use of public-private partnership as a silver bullet to solving the problem of healthcare system in Nigeria is fundamentally faulty in the sense that the government must first of all have a different ideological approach to health. It must be seen as a social service you owe as a responsible government to your people and not a profit-making venture, because in a situation where the government’s approach is to privatise public facilities that poor people in Nigeria are already struggling to afford its services, if they tow that line, it makes the job of the health workers more precarious because we understand what it means to work in the private sector in Nigeria where there are no strong labour regulations.

When such service becomes privatised and overhead interest becomes profit, the service becomes out of reach for the common people. The situation is already happening in public health facilities. If people want to invest privately in the health sector, it is welcome but to begin to sell governments hospitals built by taxpayers money and then overshooting the price of these services can only be a callous way to approach the problem within the health sector,” he said.

He emphasized the need to reach bilateral and multilateral agreements with countries experiencing shortage of health workers while ensuring a win-win situation for both parties.

“Apart from the fact that there is need for government to invest in the health sector, it is also not out of place to have bilateral and multilateral agreements with countries that are also in shortage of healthcare manpower especially nursing. We have countries like Philippine and some other countries, who have bilateral agreements that require countries like UK and U.S to invest in countries in which they are actively recruiting from, so that we are able to produce above the required number of nurses that our economy accommodates.

For instance, they invest in the country by building schools, giving scholarships and providing facilities, maybe out of 250 people, they would employ 100 people. These people will practice in their country for five years, then they are required to return to the country they migrated from and work for five years, bringing some level of international expertise and knowledge to their home country, so it is a win-win situation.

In our own situation, we train nurses here and they work for the international market without any compensation and agreement that ensures that the country is not at loss. If any government is serious, there are ways to carve out policies that ensure that we are not losing in the whole equation and see how we can meet up with our own domestic needs in healthcare,” he advised.

He further suggested other solutions to reduce the brain drain while decrying the segregation of nurses in the leadership structure of the health sector.

“More Nurses should be sponsored through in-service trainings towards improving in their specialized roles, allowances should be improved and paid to nurses, special mortgage, tax exemption, single digit car loans should be made available for them. Ensuring that nurses are within the structure of leadership in the health sector.

Since 1962, nursing has been in the university. Today we have nurses with doctorate degrees, we have professors of nursing. Almost 70 percent of nurses are now graduates, but there are situations where we don’t have nurses as permanent secretary, or commissioners of health, or in leadership roles in their hospitals.

What it means is that, when they are not within the leadership structure, you will see a situation where the system halts their progress. Administrative role in the health sector should not be limited to just one professional group, you don’t have to be a surgeon to manage a hospital, you don’t need clinical skills for administrative duties. Once they are able to attain the level of education and expertise needed to carry out this role, it should be liberalized and opened up to everyone so that the interest of all professional groups can be captured with how the system operates, or else you create a lopsided system that would ensure that the system itself does not favour anybody.

Even though we have had just one professional group at the helms of affairs almost across board, they are also leaving because they are not enjoying the system,” he said

He shared his thoughts on the recent statement released by NMC concerning the suspected widespread CBT exam fraud at Yunnik Technologies Test Centre, Ibadan. He demanded that the full weight of law is applied on the perpetrators, adding that the incident will expose other nurses to more scrutiny and discrimination.

“It is quite an unfortunate development, the association is not involved in processing accreditation of these kinds of facilities. They are independent actors and we have no regulatory responsibility over that. Our advocacy is that, when such things happen, the full weight of the law is applied, especially, in those kinds of institutions to ensure that they do not have the capacity to embarrass the country in this manner again or to compromise exams that are meant to improve the lives of health professionals. The receiving countries will become a bit more circumspect in the way they look at results from Nigeria, it will expose them to more scrutiny. Nigerians who travel already experience an abysmal level of discrimination due to a certain image of the country. This will just add a new layer of discrimination, when such news go round, employers will become a bit more weary,” he said.