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New Emirates Medical Journal

Volume 1, 2 Issues, 2020
ISSN: 0250-6882 (Online)
This journal supports open access

Open Access Article

Willingness of Medical Students to Practice in their Country of Origin after Studies: A Nigerian Perspective



Onyinye H. Chime1, 2, Chinonyelu J. Orji1, 2, *, Edmund O. Ndibuagu1, 2, Sussan U. Arinze-onyia1, 2, Tonna J. Aneke1, Ijeoma N. Nwoke1, Anselem C. Madu1
1 Department of Community Medicine, Enugu State University Teaching Hospital, Enugu, Nigeria
2 Department of Community Medicine, Enugu State University College of Medicine, Enugu, Nigeria

Abstract

Background:

The availability of skilled manpower at service locations is an important indicator of the strength of the healthcare system and is critical for effective healthcare service delivery in developing countries. The emigration of doctors reported in Africa over the years has tremendously increased in recent times. The health sector in this low-income region has registered a great setback in their health indices following a severe shortage of manpower.

Objective:

This study was undertaken to assess the willingness of medical students to practice in Nigeria after the completion of their medical education.

Methods:

This was a cross-sectional study performed among medical students in Enugu State University Teaching Hospital, Parklane, Enugu, Nigeria. A pretested self-administered questionnaire was used for data collection. Information was analyzed using the Statistical Package for Social Sciences version 22 software. Descriptive statistics were used to summarize and present data. The degree of bivariate associations was measured using the Pearson Chi-Square test at a significance level of p < 0.05.

Results:

The mean age of the respondents was 23.9 ± 3.4 years.The majority were males (58.0%) and a greater proportion of the respondents (83.5%) did not desire to practice in Nigeria after their studies with the USA (29.3%) and Canada (17.8%), being the most preferred countries of migration. Advancement in technology and better remuneration were the most compelling factors for emigration.

Conclusion:

To ensure adequacy and efficiency in the health sector as recommended by the World Health Organization, governments of low-income countries should put measures in place to make medical practice in their countries more attractive to young doctors. Such measures include improved remuneration for services rendered and incorporation of more modern technology into the health care delivery system.

Keywords: Willingness, Medical students, Practice, Country, Migration, HIV/AIDS.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 1
Issue: 2
First Page: 41
Last Page: 48
Publisher Id: nemj-1-41
DOI: 10.2174/0250688202002022005

Article History:

Received Date: 04/12/2019
Revision Received Date: 16/1/2020
Acceptance Date: 24/1/2020
Electronic publication date: 15/07/2020
Collection year: 2020

© 2020 Chime et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Community Medicine, Enugu State University Teaching Hospital, Enugu, Nigeria; Tel: +2348037109273; E-mail:orjichinonyelu@gmail.com




1. INTRODUCTION

Human resources for health remain a vital element of the healthcare system as the quality of health care services depends largely on the performance of skilled manpower [1]. The availability of skilled manpower at service locations is critical for effective health care system delivery in developing countries and is an important indicator of the strength of the healthcare system [2-4]. The role of medical doctors in the maintenance and sustenance of health cannot be over-emphasized, especially in countries where the burden of diseases like malaria, tuberculosis, HIV/AIDS and other non-communicable diseases is a major concern.

The World Health Organization (WHO) recommends the minimum density of 2.3 doctors per 1000 population to achieve the minimum levels of key health interventions [5]. Among the six regions of the WHO, Africa ranks the least with regard to the physician to population ratio of 2.5: 10,000, whereas America and Europe have 20.1 and 33.3: 10,000 respectively [6, 7]. According to the Medical and Dental Council of Nigeria, Nigeria, being the most populous African country, has about 72,000 registered medical doctors with only approximately 35,000 in practice within its shores [8, 9]. The ratio of doctors per population in Nigeria is critically below the recommended standard at 4 per 10,000 population and emigration further places additional strain on the available workforce thereby compounding the already compromised health care deficiency in this region as this number is not sufficient to meet the significant health needs of the people [10, 11].

The emigration of doctors reported in Africa over the years has tremendously increased in recent times [12, 13]. This steady emigration from the developing to developed settings has deleterious effects on both the health and economic sectors of these countries [12-14]. The health sector in this low-income region has registered a great setback in their health indices following a severe shortage of manpower [12, 15]. Medical education around the globe is not cheap. In Nigeria, the government subsidizes medical education to the tune of approximately four million nairas (about $11, 00 USD), this being the highest subsidy in sub-Saharan Africa after South Africa [9]. Resources are lost after doctors trained by the government with tax-payers money in these low-income regions migrate to high-income regions without making a significant difference to health in their countries [5, 12, 13].

Though this emigration is not new, the current trend seems to be alarming. The poor economic situation in Nigeria has made the decisions to pursue better opportunities in developed countries [16]. Between 2001 and 2006 in Nigeria, about 10.000 doctors migrated from the country with an average of 2000 doctors migrating annually over the six-year period [17]. Using this projection, about 36,000 doctors would have migrated from the country from 2000 to 2019. The results of a survey on international medical graduates revealed that a total of 5334 US-based had their medical college in the SSA with Nigeria as the leading country [12]. In 2017, Nigeria's polling agency, NOI Polls, in partnership with Nigerian Health Watch through an online survey revealed that about 9 out of 10 medical doctors in Nigeria were seeking work opportunities abroad [9]. This exodus widens the gap between demand and supply of health services available in this resource-deprived setting since the government is the main healthcare service provider in the country [12]. This further incapacitates health care delivery services in Nigeria.

Among factors influencing this migration, there is the push and pull theory of migration [17, 18]. Push factors are the local components which deter the individual in his locality while the pull factors are the attractants in the developed settings. Poor workers' motivation and perceived job risks are some of the push factors cited in some studies, while the pursuit of a better standard of living and better working conditions was among the pull factors recorded [16, 18]. The objective of this study was to assess the willingness of clinical medical students to practice in Nigeria after their studies and identify associated factors. Findings will provide possible directions for further research aimed at strengthening the healthcare system in order to avert brain-drain and improve retention of doctors.

2. MATERIALS AND METHODS

2.1. Study Setting

This study was conducted in Enugu, a southeastern state of Nigeria. It has a landmass of 7,161km2, with a population of 3,267,837 based on the last national census in 2006 [19]. Enugu state has 17 local government councils [20]. The indigenes are predominantly Christians and are Igbo speaking. The state generally has about 4 doctors per 10,000 population [21]. It has four government tertiary institutions, including two medical students undergraduate teaching hospitals, and in which Enugu State University Teaching Hospital Parklane is also inclusive.

2.2. Study Design, Population and Sampling

This was a cross-sectional study involving medical students of ESUCOM consisting of 3 clinical classes IV, V and VI. The minimum sample size for the study was determined with an expected proportion from a similar study carried out in Bangladesh using Fisher’s statistical formula [22, 23]. The study participants were stratified according to their classes IV, V and VI. The sample size was proportionally allocated to the classes. The total number of students in the clinical classes in August 2019 was 320 and this was used as the sampling frame for the study. The systematic sampling technique was used to select the study participants. The questionnaires were distributed in their classes during free lecture periods.

2.3. Data Collection and Analysis

Data were collected over 2 weeks using a pre-tested self-administered questionnaire. Though the Igbo language is the predominant language of the people in this region, the instruments were provided in English as the English language is the medium of instruction in all institutions of learning in Nigeria. The questionnaire was organized into sections; socio-demographics, willingness to practice in Nigeria and factors associated with willingness to practice in Nigeria. Copies of the self-administered questionnaires were distributed and collected immediately.

Before the study was conducted, ethical approval was obtained from the Health Research and Ethics Committee of Enugu State University Teaching Hospital. Permission was obtained from the school authority. Written informed consents, giving a detailed account of the study objectives were obtained from the participants. Participation was voluntary and confidentiality was guaranteed by non- identification of individual questionnaires.

Data entry and analysis were performed using Statistical Package for Social Sciences version 22 software. Descriptive statistics were used for data summarization and presentation. The degree of bivariate associations was measured using the Pearson Chi-Square test at a significance level of p < 0.05.

3. RESULTS

A total of 188 students participated in the study.

Table 1 illustrates the socio-demographic details of the respondents with a mean age of 23.9 ± 3.4 years. The majority of respondents in this study were males (58.0%) and lived in urban areas (75.5%). The highest number of respondents was 500L, with a proportion of 35.1%. The majority of the participants had their family footing their academic bills (84.0%), while 5.3% enjoyed scholarship from well-meaning individuals and government.

Table 2 shows the willingness to practice medicine in Nigeria, with about 83.5% having no interest to practice in the country. Among people that intend to leave, the USA (29.3%) and Canada (17.8%) were the most preferred countries. Advanced technology (28.0%) and better remuneration (28%) were the top reasons for emigration, while better exposure (8.3%) was the least.

Table 3 outlines the factors which influence willingness to practice in Nigeria; the respondents between the ages of 20-24 (67.7%) years were more willing to practice in Nigeria than other age groups. This was not statistically significant (ꭓ2= 1.509, p = 0.680). Respondents whose families lived in urban areas were more willing to practice in Nigeria than those who lived in rural areas and this was found not to be statistically significant. The respondents who were being sponsored by their families were less willing to practice in Nigeria (ꭓ2 = 4.729, p = 0.317).

Table 1
Socio-demographic variables.

Table 2
Willingness to practice medicine in Nigeria.

Table 3
Factors associated with willingness to practice medicine in Nigeria.

4. DISCUSSION

The mean age of respondents in this study was 23.9 ± 3.4 years which is similar to findings from another study carried out in South-East geo-political zone of Nigeria, with a comparable mean age of 25.5 ± 2.9 years [24] with the highest proportion of respondents being 20 - 24 years. Another study in Egypt, North Africa, among medical students, showed a similar mean age of 20.9 years [25]. This similarity depicts the usual average age of students in medical schools.

This study showed clearly that the majority of the respondents (85%) intend to practice beyond the borders of Nigeria. This may not be unrelated to the high unemployment rate, the heightened spate of insecurity and increasing poverty reported in Nigeria over time [16]. This result is consistent with findings made in studies carried out in Botswana and Serbia, where 69% and 89% of the respondents respectively would want to practice outside their home country [26, 27]. Similar findings were reported in Bangladesh, whereby 51% of the students intend travelling abroad to practice [22]. The similarity can be attributed to the common push factors found among medical practitioners in low-income countries [18]. Contrary to these findings, a lower proportion of students in an Iranian and Pakistani study (42%) were willing to travel abroad [28, 29]. This could be explained by the fact that this Pakistani study may have been conducted among students with probable zeal to serve their country, or the emotional attachment to friends and family, and possible bad experiences with recurring visa denials into the USA and other developed countries [29]. Similarly, religious and cultural values could have been a deterring factor.

Among the countries of intended migration, the USA, Canada and the United Kingdom were distinctively the top choices of the participants of this study. This has also been reported in other studies where these countries topped the choice of practice for medical undergraduates after studies in their home country [9, 29]. The choice for these countries is probably due to pull factors such as better standard of living, opportunities, facilities and remuneration, among other factors [29]. Unlike European and American countries, the desire to migrate to Asia (0.6%) and Africa (1.3%) was reportedly low in this study. This is consistent with findings from a report by the International Organization for Migration, where a diminished number of Nigerians, professionals inclusive, migrate to less developed regions of Africa and Asia [16]. This is attributed to the deteriorating economic realities, security and social disturbance in these countries.

Though not statistically significant, there was a significant difference between the male and female gender that intended to emigrate, with the males (58.6%) having more inclination to leave Nigeria when compared to their female counterparts. This was also the case in a similar study in Nigeria, which showed more males intending to migrate to the developed countries more than females [16]. Studies show that pivotal to their low interest in practicing abroad, there are societal responsibilities and cultural/religious restrictions on women’s movement in some regions of the world. However, a variation was seen in Botswana, where there was an equal number of males and females with regard to emigration abroad [26]. This is probably because 99.1% of the participants were single and yet to have societal, cultural and religious commitments with respect to career pursuit.

Respondents whose families reside in urban areas have more desire to practice in Nigeria than their counterparts residing in rural areas. This is also reflected in the location of their secondary schools as a greater number of respondents who schooled in urban areas desired to practice in Nigeria. The 2013 National Demographic and Health Survey reported that adult literacy level and access to media are higher in the urban than the rural areas [30]. There is a higher chance of those in the urban area of higher socioeconomic status than the rural residents; hence they may not be desirous to go through the rigorous examinations and re-certification exercises required in the western countries before they can practice. Moreover, those people whose families reside in rural areas could be desirous to have their lives and living conditions likened to those of their colleagues residing in the cities. This is however, contrary to findings from other studies. A study about emigration conducted in Nigeria shows that people who reside in urban cities are more likely to be attracted by the economic opportunities of the developed world [16]. A systematic review of literature shows that growing up in rural areas has a great influence on the desire to practice in local settings [31]. Similarly, findings from an Iranian study reported that experience of residing in rural areas, in addition to poor parental education and professional network, could be associated with the reduced desire to practice in more sophisticated regions [28].

Those who are beneficiaries of their families’ income have a clear-cut variation when compared to self-sponsored individuals. It is surprising to note that respondents who are sponsored by their families are more willing to practice in Nigeria than outside its shores. Contrary to this, in a similar Nigerian study, individuals who are dependent on their families in terms of finance and other welfare benefits have more migratory tendency [16].

Among the reasons cited for emigration, advanced technology, better learning opportunities and better remuneration have been cited as the most prevalent. Similar reasons have been cited in a survey report among medical doctors where high taxes and deductions from salary (98%), low work satisfaction (92%), and poor salaries and emoluments (91%) were the major reasons [9]. This low satisfaction resulted from the unavailability of equipment and medical supplies necessary for the management of patients, which in some cases could result in the death of these patients [9]. Better opportunities were also cited as a reason for emigration in this study. The dearth of job opportunities in the country has resorted to doctors paying for employment in some instances [9]. The majority of respondents in the survey are convinced that the government has no commitment to mitigating the challenges facing the health sector in its nation [9]. This is evident as Nigeria’s indices in terms of the proportion of GDP spent on health, despite greater health needs have deteriorated from 109th in 2017 to 167th in 2019 [32]. Similarly, barely 1% of Nigerians have health insurance, which is expected to accelerate progress towards achieving Universal Health Coverage, thereby providing the needed health finance necessary to ensure stability in the health sector [9].

Addressing these challenges, more will change the perception of medical doctors towards emigration. With Nigeria’s population projection for 2018 at a 2.54% growth rate estimated to be about 200 million, Nigeria will need about 460,000 medical doctors to match this population growth [33]. This population growth will directly translate to an increase in the demand for healthcare in the country. With only about 50% of locally trained doctors currently practicing in Nigeria in addition to findings from this study, there is a great need to mitigate against further emigration [9]. If this gap is not closed, the number of doctors remaining left to practice in Nigeria will continue to decrease, resulting in the country having worse health outcome indices than currently reported.

CONCLUSION

This study was conducted to assess the willingness of medical undergraduates to practice in Nigeria and some of the factors that influence this decision. The significantly higher proportion of medical students desirous to leave the shores of Nigeria after their studies is worrisome, with the United States of America and Europe coming on the top of the list of desired destinations. From this study, it is obvious that this trend is still blooming and it poses a threat to the health sector in Nigeria. Given the poor health indices and the low doctor to population ratio, continued doctor emigration will produce even more worrisome health statistics. The urgent need for a reversal is recommended to prevent further deterioration of the economy. The government should put measures in place to make medical practice in their countries more attractive to young doctors. Such measures should include improved remuneration, upgrade to modern hospital equipment and facilities, improved working conditions and increased funding of the healthcare system.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Ethical approval was obtained from the Health Research and Ethics Committee of Enugu State University Teaching Hospital. Permission was obtained from the school authority.

HUMAN AND ANIMAL RIGHTS

Not applicable.

CONSENT FOR PUBLICATION

Written informed consents, giving a detailed account of the study objectives, were obtained from the participants.

AVAILABILITY OF DATA AND MATERIALS

The data will be available and can be assessed at the Community Medicine departmental library of the institution. The questionnaires will, however, be destroyed seven years from the publication date.

FUNDING

None.

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

We sincerely appreciate everyone who has in one way or the other contributed immensely to the success of this study, especially the students who participated, the administrative officers of both the ESUTH-P and that of ESUCOM, will be blessed beyond measures.

APPENDIX 1. WILLINGNESS OF MEDICAL STUDENTS TO PRACTICE IN THEIR COUNTRY OF ORIGIN AFTER STUDIES: A NIGERIAN PERSPECTIVE

Consent Form

Introduction: We are researchers from Community medicine department, Enugu state University Teaching hospital. You have been selected to participate in a study to determine the ‘willingness of medical students to practice in their country of origin after studies: a Nigerian perspective.’

Voluntary nature of participation: Participation in this project is completely voluntary. Thus, though you have been selected, you are free to participate in the programme or to decide otherwise.

Study Procedure: You will be given a questionnaire to be filled immediately.

Risks: There are no known anticipated risks from the study.

Confidentiality: Information obtained from you will be treated as confidential and will not be used against you in any way. In addition, the data analysis and presentation from this study will be aggregate and will not in any way reveal your identity.

Respondent:

I have read and understood the above (or someone has read and explained to me) and hereby consent to take part in it.

Respondent: Researcher:

Name: ……………………………. …… Name: ……………………………………..

Signature……….………………………. Signature: …………………………….……

Date: ………………………….. ………. Date: ……………………………………….

APPENDIX 2: QUESTIONNAIRE

SECTION A: Socio-demographic characteristics

1. Age(last birthday) ……………………………………….

2. Sex A. Male () B. Female ()

3. Academic Level: a. 400 level [ ] b. 500 level [ ] c. 600 level [ ]

4. Area of family residence: a. urban [ ] b. Rural [ ]

5. Father’s highest Education

A. No formal education () B. Primary education ()

C. Secondary education () D. Tertiary education ()

E. Post graduateeducation ()

6. Mother’s highest Education

A. No formal education () B. Primary education ()

C. Secondary education () D. Tertiary education ()

E. Post graduate education ()

7. Type of secondary school attended: a. Public [ ] b. Private [ ]

8. Academic sponsorship by: Family [ ] Self [ ] Scholarship [ ] Others [ ]

SECTION B: Willingness to practice in Nigeria

1. Are you willing to practice medicine in Nigeria after graduation? Yes [ ] No [ ]

2. If not Nigeria, which country do you intend to practice medicine? ………………………………..

3. Which of the following informed your decision to emigrate? (Tick the most appropriate)

a. Advanced technology and learning [ ]

b. Better remuneration [ ]

c. Better standard of living [ ]

d. Better working condition [ ]

e. Better opportunities [ ]

f. Better exposure [ ]

g. No special reason [ ]

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