Survey Instrument

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.

Data Analysis

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.

Demographics

The demographic characteristics of the total sample—stratified by location of current practice—are presented in Table 1.

Job safety, satisfaction, emigration intent, and reasons for emigration

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.”

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.

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.

Resilience building themes and framework

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:

1. Policy and Politics
   Regarding policy and politics, respondents drew attention to the effects of poor national security and the lack of healthcare prioritization on resilience building. One respondent commented that “the environment of Nigeria currently is such that it’s like a jungle. Anything hurtful can happen to you [at] any moment and you will find no help, even from the official law enforcement agencies, as they too are completely overwhelmed and generally compromised.” Another stated, “the fear of being kidnapped is rife every moment and the uncertainty of the security apparatus that exists makes daily living and going to work a risk in itself.” This has all led to a palpable emigration of workforce out of the country, as well as a move within the country—from the areas of highest insecurity and unrest. As one respondent noted, “unrest in the North means most doctors pool in certain areas (mostly Southern), and this further skews the doctor-patient ratio.”
   Thus, some of the suggested solutions for resilience building that target the shortcomings of policy and politics include the re-prioritization of healthcare and the formation and expansion of a national health insurance program which they hope will lead to widening access and decreasing gaps in care. Other suggestions include the creation, prioritization, and implementation of national safety initiatives with particular focus on “policies to ensure the safety of doctors and other allied health workers, especially at their places of work.” More accountability in governance and lack of complacency in political knowledge, as evidenced by physician involvement in politics, was also suggested, with one respondent remarking that, “doctors need to begin to forage into politics and mass advocacy to influence and lobby politicians with stolen wealth, and corner it into building and growing the health system.” However, some respondents were of the impression that, “there are good policies and guidelines [already in place], however they are not enforced or adhered to,” going further to suggest that “everyone needs to be lectured on these guidelines so that everyone knows what to do [and] how to do it.”
2. Funding and Resources
   Responses point to the fact that funding and resources are drained by unrest, with one respondent noting, “funding that [could] be directed towards health care is directed towards security….” In addition, shortcomings in terms of policy and governance also emerged as reasons for the apparent lack of funds. Respondents believe that if funding is available for hospital resources, emergency transportation, healthcare workers’ safety and remuneration, resilience of the Nigerian healthcare system would be attainable. Some respondents suggest the, “review [of] costs of care and in turn employee remunerations to reflect the prevailing economic situation in the country [with use of] trade and business owners’ unions to create a united front so that standards can be uniform” and “partnership with more non-governmental organizations,” as innovative ways to tackle the funding deficit and channeling of funds to the healthcare sector.
3. Organization and Structure
   Respondents also highlighted the current void of structured referrals and protocols, with suggestions around the, “standardization of practice with provision of guidelines for each area of practice.” In addition, suggestions highlighted creating a culture that fosters teamwork and responsibility, where roles are defined and considered as a team goal versus the current state described by one respondent as, “the constant back and forth with other healthcare workers for patient welfare, i.e., having to beg other people to do their jobs and many times needing to take on those responsibilities; [for example] doing nursing bedside procedures because the nurses wouldn’t do them.”
   Respondents also suggest the idea of creating opportunities for locums, especially by private sector health practitioners in government health facilities to address the workforce shortage, as well as to foster collaboration between sectors. Furthermore, respondents suggest a shift towards role expansion of allied health in the form of training opportunities like, “train[ing] Community Health Extension Workers (CHEWs)” to “build the capacities of non-doctors in the healthcare system, so they interface with patients at a primary level (with the use of checklists and algorithms) and escalate to the secondary/tertiary level where necessary.” Respondents believe that these will “improve workplace relations and reduce the burden on doctors,” thereby improving the resilience of the healthcare system.
4. Training and Education
   Respondents noted the limited training and educational opportunities as well as the expenses associated with medical education as aggravating factors for emigration. Thus, the need for improvements in residency and career opportunities were posed, with one respondent suggesting, “structured residency training programs with obvious yearly evaluations” as a way to maintain and monitor training standards. Furthermore, suggestions to improve retention revolved around improving wellness amongst staff and addressing the hidden curriculum in the culture of medicine that could lead to “workplace toxicity, [where about] 7 in 10 Nigerian doctors are traumatized by bullying at the workplace [which] definitely hinders productivity and doesn’t allow one to fully learn how to or manage a lot of situations.”
5. Research and Primary Health
   Respondents emphasized the deficits of quality improvement research and the primary health care (PHC) sector as a whole, suggesting ways to address these deficits by bolstering quality improvement research, funding to the primary health care (PHC) sector, population health literacy and health seeking behaviors. One respondent suggests, “research in the country to generate numbers and aid with health education” and another “[the] use of social media [to improve] patient education.”
   Some suggestions revolved around channeling more funding to research and data management with hopes to inspire quality improvement as a resilience building tactic, while others focused on the idea of, “expand[ing] the primary health care scheme and fuel[ing] it with surplus money, thereby creating more jobs for doctors.” As one respondent put it, “we can strengthen our primary healthcare system to build the capacities of non-doctors in the system”, with another remarking that “if the patient burden is slowly shifted to primary health care and preventive medicine, we could reduce the workload of the specialists, and in a way, address the poor doctor-patient ratios.” Furthermore, the theme of e-medicine, telehealth, and Electronic Medical Records (EMR) emerged as ways to help improve data quality, research, and patient health literacy.
6. Health for Peace Initiatives
   Respondents also acknowledged the importance of peace in cultivating health. With the WHO’s conflict-sensitive approach as a means to create a starting point for bringing people together, the theme of, “health as a common good” emerged from the responses [15]. Some respondents mentioned that when health is viewed as a common good by the community at large, “no hospitals or health facilities [are] attacked during uprisings, ensuring adequate provisions of essential resources, [with] physicians outside the hospital ferried to and fro securely.” In addition, others highlighted the importance of a conflict-sensitive approach where health literacy is preserved, with one respondent stating that, “if the perpetrators of this unrest are members of the community, it’s possible to enlighten them on the importance of medical personnel in their communities.”

Limitations

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.