A Spatio-Temporal Analysis of Migration of Highly-Skilled Professionals from Health Institutions in Nigeria

Emigration and immigration/returning (simply put as migration) of highly-skilled professionals are of increasing concern in developing countries of the world. Emigration of core health professionals from Nigeria have been claimed to be increasing towards the developed North, while immigration/returning of health professionals into the country was believed to be increasing as well, over time. Ironically, virtually no empirical study has been carried out to prove these assertions. The study therefore examined the directions and destinations of health professionals from and into selected institutions in the southwestern Nigeria between 1986 and 2010. On this premise, two tertiary (UCH, Ibadan and OAUTHC, Ile-Ife) and one secondary (AMTH, Ibadan) health institutions were purposively selected, while a systematic random sampling was employed in selecting 348 respondents out of 3,089. The trajectories were mapped over space and time and other data analysed. The findings showed emigration was increasing while immigration/returning of health professionals declined over time. Also, the direction was majorly towards developed North and the destination being the United Kingdom (33.0%), followed by the United States of America (27.6%), Canada (12.0%). Immigrants were majorly from Europe (69.0%), while returnees were from the United Kingdom and United States (33.3% each). The study concludes that the rate of emigration of health professionals is alarming, particularly of the doctors, which if not checked, could affect the health system of the country.


INTRODUCTION
Emigration and immigration/returning (shortly put as migration) of highly-skilled professionals are of increasing concern in developing countries of the world.This is because they are the flows of human resources from countries of dire need to countries where in the case of the former, it is perceived to be plenteous and for the latter, it comes in trickles into countries of dire need; all things being equal (Batista, 2007).However, the perceived gain in both cases is not always adequately gauged, due to certain factors, such as inadequate data and knowledge of the occurrences.
Emigration of highly skilled professionals from origin to destination is the main stream, with the higher volume, as against reverse stream, of lower volume.The former is E-mail: oluabejide@yahoo.comAuthor agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License often referred to as a loss, or a drain; hence, labeled brain drain, while the latter, the reverse flow, though often less known or publicized and comes in trickles, is known as the gain, or brain gain (Adepoju, 2004;Batista et al, 2007).However, a comprehensive study of the brain drain and brain gain in Africa, in particular Nigeria is yet to emerge.This is because no single data source has been able to adequately capture the exact figures of the main stream and reverse flows (de Hass, 2008).Even the available ones are mostly in aggregate forms and the data provided do not tally.Docquier and Marfouk (2006) and Clemens (2007) for instance, gave the estimates of emigrant physicians that were trained in Africa and in particular Nigeria, but, practicing in developed countries.The numbers of Nigerian medical personnel working in the United States and United Kingdom were 8,954 and 3,415 respectively in 2000.For nurses, the US and UK are said to have attracted most of the Nigerian trained nurses.Clemens (2007) also estimated the number of emigrated nurses to be 12,579, or 12 per cent of the total number of nurses in Nigeria as of 2000.Yet, other sources estimated the figure of doctors and nurses trained in Nigeria and working in developed countries of the US, UK, Canada and Ireland in 2005 as 8,805.
The concerns of the study, therefore, is to examine the volumes and direction of migration of highly-skilled health professionals into and out of Nigeria and into and out of the selected tertiary and secondary health institutions in South-western Nigeria over a defined period.However, the study is premised on the assumption that the volumes of migration of health professionals have not been increasing over the defined period among selected tertiary and secondary health institutions.

The Gravity Model
The gravity model is not only used in explaining human interaction from one place to another, based on physical distance alone; but, it also considers the product of two masses, the population sizes of both the origin and destination of the movements in the explanation of level of interaction of two places.The model derives from the Newtonian theories of gravitational attraction between any two celestial masses and was adopted by Geographers to estimate the spatial interaction or movement between any two places (Carey, 1850).Carey (1850) explained that the essentiality of human existence is pivoted on the attractive force that exists between two areas, which is akin to the force of gravity.In other words, there is a force of attraction of people (migration) from a low-populated small city to a high-populated big city.On that note, migration of health professionals are on the contrary to this model, for instance, the attraction of health personnel from developing countries with higher population size to developed countries with lesser population does not obey the gravity model.Also, a potential migrant moving from poor origin and to better destination does not think of the distance separating the two locations but the opportunities.Therefore, the push-pull model could to some extent explain migration behavior of health professionals.

Push-Pull Model
Distance and population alone were adjudged not sufficient in explaining migration behaviour; therefore, Lee (1966) hypothesized the push-pull model.He posited that both the destination and the origin have characteristics that attract or repel migrants; represented by positive and negative symbols, as in Appendix 1. Individuals perceive these characteristics differently; hence, subjectivity plays an important role in their reaction to the stimuli they receive from the outside environ.But, basically, the push-pull model gives an idea of movement of people away from an area emitting 'push' factors/ stimuli to an area with positive stimuli or to an area that 'pull' them towards itself.Without a consideration of people's differences in perceiving the stimuli and reacting accordingly, the criticism levied against the mechanistic nature of the model holds, as it does not allow for individuals' perception and evaluation of the stimuli/ factors.

Behavioural Theory of Migration
In the light of the above, Shaw (1975) modified the pushpull theory, as he presented the behavioural theory that introduces perception and evaluation of humans to pushpull factors.The behavioural theory considers potential migrants' subjective thought, their weighing of the situation of the prospective destination in the light of their limited level of knowledge and information available to them and their personal needs (Shaw, 1975;Afolayan, 2004).Also, the theory depicts human responses to external stimuli or forces that emanate from the environment, as intervening (endogenous) factors or variables that predispose an individual's reaction to external stimuli (exogenous) factors, both at the source and destination.

System Modeling of Spatio-temporal Migration of Health Professionals
The spatio-temporal system of migration of health professionals is perceived the donor/sending country produces the skilled health personnel, who responded to push (endogenous) forces and were unable to be held back by the stick factors; therefore, emigrate.Consequently, their movement results into series of negative and positive effects/impacts, both at the sending and receiving countries.Furthermore, non-migratory forces are in operation in the sending country, such forces are the influence of the natural attrition of health workers, such as the turnout of graduates from different health training institutions.
On the other hand, the recipient/receiving country attracts migrating health personnel because of its pull factors, due to the strong push factors emanated from the donor country.However, counter migration, because of the strong push factors emanated in the recipient country that override the stay factors, hence, immigration/ returning occurs.

METHODOLOGY AND METHODS OF DATA COLLECTION The Sampling Framework
The sampling framework was at two stages.The first stage involved multi-stage random sampling design in selecting two tertiary teaching hospitals each from Oyo and Osun States and one secondary teaching hospital from Oyo State.The second entailed a purposive random sampling technique in selecting the tertiary and secondary health institutions.These are the University College Hospital (UCH), Ibadan in Oyo State and Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile Ife in Osun State, as the two tertiary health institutions and Adeoyo Maternity Teaching Hospital (AMTH), Ibadan in Oyo State, as the only secondary health institution in the sample (Map 1).

The Study Population
The population for the study consisted of medical professionals that are reckoned with internationally as highly skilled professionals.These were classified into four groups.The first comprise doctors (medical and dental), the second nurses, the third pharmacists, and the fourth medical laboratory scientists (MLS).

Sampling Techniques and Sample Size
The sampling techniques were three in number, comprising the administration of a questionnaire, sessions of focus group discussions (FGDs) and in-depth interviews (IDIs).The first entailed the selection of a total number of 348 respondents that were systematically randomly selected from complied lists of the four categories of health personnel in the three institutions for the questionnaire administration.The second technique comprised the organization of sessions of focus group discussions (FGDs) in each of the institutions for each of group of health professionals and indepth interviews (IDIs) that were conducted among members of management in the three institutions.
The total sample size for the study was the representation of the total population of the core health professionals on the lists acquired from the Establishment/ Personnel Unit of the three institutions.The sampling of respondents was approximately 10 per cent of the total population of each category of the core health professionals in both UCH and OAUTHC; but, 20 per cent of sampled respondents in AMTH was selected, due to small population size of the health personnel in the institution.The lists of staff available for sampling was in form of stock; therefore, 10 per cent each of doctors in UCH and OAUTHC was selected; the same for nurses, pharmacist and MLS.But in AMTH, 20 per cent each of these categories of health personnel was selected.

Variables/Measures of Interest
The selected respondents gave information known to them on emigrants.This included number of colleagues emigrated and their destinations.The defined periods were further classified into four phases : 1986-1999, 2000-2003, 2004-2007 and 2008-2010.

Analytical Techniques
The trajectories were mapped over space and time and other data analysed.Also, data were analysed using statistical techniques, of measures of central tendency and cross tabulation.Analysis of Variance (ANOVA) technique was adopted to validate the assumption.

FINDINGS Temporal Trends of Emigration, Immigration and Returning Health Professionals
Table 1 shows emigration of health professionals was generally on the increase, that is, from 435 to 457 and on to 512 respectively between 1986 and 1999, 2000 and 2003 and 2004 and 2007; but with a deep to 414 between 2008 and 2010.
In particular, Appendix 2 shows increase in the volumes of emigrated doctors and pharmacists; but, a decrease of emigrated nurses and fluctuating condition for MLS.Also, ANOVA test buttressed the fact of an increase of emigrated health professionals between 1986 and 1999 (F=0.95; P=0.391), 2000 and 2003 (F=1.51; P=0.226) and 2008 and 2010 (F=2.09; P=0.129), and the decline between 2004 and 2007 (F=4.07;P=0.02) at 0.05 level of significance (Appendix 3).
Table 2 shows 33 immigrants moved in from other countries between 1986 and 2010; compared to larger volumes of emigrated professionals from the institutions.In particular, immigrated doctors and nurses though very few, increased, from 1 to 7 doctors and from 3 to 9 nurses between 2004 and 2010.Also, Appendix 4 shows increase in the volume of immigrated doctors over time in the selected institutions.However, the volume of immigrated nurses between 1986 and 2003 was steady, but declined two times the volume between 2003 and 2007, however, increased with geometric rate between 2007 and 2010.Furthermore, ANOVA test showed the increase was significant, with F=10.111 and P=0.00 at 0.05 level of significance (Appendix 5).Returnee health professionals in the institutions were very few between 1986 and 2010.Table 3 shows majority (72.0%, 82.1%, and 92.3%) of the professionals in UCH, AMTH and OAUTHC reported none of their colleagues had returned.Also, nurses were in the majority, with 70.3 per cent among reported returnees in the three institutions (69.2% -UCH; 19.2% -AMTH; 3, 11.5% -OAUTHC).Moreover, UCH was the only institution that recorded there were returnee doctors (7 -100%) and the four professionals that reported returnee MLS were in UCH (1; 25%), OAUTHC (3; 75%) and none in AMTH.Equally, none of the professionals reported returnee pharmacist in any of the institutions.In summary, though, the numbers of returnee health professionals were low; still, they indicate brain circulation.
Appendices 7, 8 and 9 show doctors and pharmacists in UCH (38.0%) and OAUTHC (31.0%) moved to the US, while emigrated nurses in UCH-40.0%,AMTH-39.8% and OAUTHC-31.9%moved to the UK.The Gulf States were prominent destination for MLS in UCH, with Saudi Arabia, Omar and Dubai recorded 18.2% each, while the Kingdom of Saudi Arabia was the predominant destination for MLS (44.4%) in OAUTHC (Maps 2-5).

Spatial Pattern of Immigration
The immigration of health professionals into the country, in particular to the South-west geo-political zone of the country was majorly North-South, that is, nationals from Europe (20, 69.0%) dominated the flows, as shown on Figure 2 and Appendix 10.Other sources of less importance were the US and South Africa, with 2 (6.9%) nationals each, and one (1; 3.4%) national each from the UK, Australia, the Caribbean, Egypt, and The Gambia.
Again, nurses (17; 85.0%) were in the majority; followed by doctors (3; 15.0%) and one (1) pharmacist that moved into the selected institutions from countries in Europe.Other source countries of less significance for the nurses were African countries, of South Africa (2; 100%), The Gambia (1; 100%) and Egypt (1; 100%), and from Australia (1; 100%) and the Caribbean (1; 100%).Two (2; 66.6%) of the doctors were from the US, while the remaining immigrant doctor was from the UK (Maps 6).

Spatio-Temporal Trends in Volumes of Emigrated Health Professionals
The reasons for the variations in the volumes of the three categories of emigrant health professionals and  among the selected institutions from 1986 to 2010 are multi-faceted.First, the populations of nurses and doctors at any level of health institution; be it primary, secondary or tertiary are always higher than that of pharmacists and MLS.Therefore, the variations in the numbers of the different categories signify, among others the relative proportions of each of the professions in the delivery of health care and services.For instance, the number of nurses employed in any public and private health institutions either doubles or triples that of the doctors and that of the doctors double that of pharmacists, under normal circumstances.
Secondly, the variations are premised on the level of demand abroad for different categories of health professionals and the foreign currency/income they would earn.Doctors are needed for timely clinical diagnoses and surgical operations of patients.Nurses are to administer drugs and carry out other therapeutic plans of treatment to patients in the hospitals/clinical wards; in short, they are in charge of hospitals/clinical wards.Apart from doctors and nurses, whose skills are specialized, the skills of pharmacists and MLS cannot be easily brushed aside, as they are specialists in their own right.In addition, foreign currency/income of health professionals abroad is 'a lot of money'.One of the in-depth interviews with the Chairman of National Association of Nigerian Nurses and Midwives (NANNM) portrays the situation as well: …You see, the motivating factor and reason why nurses move en-mass abroad is because of the financial reward.An average African nurse works 84 hours in a week, while his/her foreign counterpart works for just 40 hours per week.So, when you work there for about six months or one year, you would have made a lot of money in foreign currency.And since the society recognizes/ associates one, based on financial standing, people are forced to travel out (IDI, OAUTHC 2012).
The third possible reason for the decline in the volume of emigrated nurses, but, an increase in the volume of emigrated doctors is the socio-economic and political factor prevailing in Nigeria.Between 1986 and 1999, the military was in charge of the governance of the country; therefore, there were series of harsh economic policies, which led to continuing devaluation of Nigeria currency and incessant strikes (Mbanefoh, 2007).Also, there was an embargo placed/laid on employment during the period; thus, many medical professionals were forced to seek greener pasture elsewhere.In addition, the political environment during the military rule was life-threatening; only few that were ready to go to jail or be assassinated are to confront the junta.These and other factors prompted the massive flight of health professionals from the country, in particular the studied institutions.
In essence, the seeming decline in emigration of nurses became obvious/was noticed during the period of democratic rule in the country, that is, since 1999.This could be as a result of apparent return to decorum in the political cum socio-economic environment; courtesy the civilian government.
In addition, many nurses believed curiosity or the vogue to migrate is a thing of the past.In one of the Focus Group Discussions (FGDs) in UCH, the nurses unanimously agreed that traveling abroad appears as a passing fad in comparison to the situation prior to the 1999 transition to democratic dispensation of the country, Abejide 101 as they stated in their own words: …Many of us had wanted to travel during the military government era, but during the government of Abdulsalam Abubakar, that is, between 1998 and 1999, things changed.Our salary scales were adjusted upwards/changed; our take-home income increased and all pending promotions were attended to.Above all, when Obasanjo became the President, things changed for the better.There is nothing those that travelled abroad did that we have not done.They built houses; we have built ours; they are riding exotic cars; we also ride good cars.Even, some of them envy our position whenever they come around or are visiting.They comment that we look fresher than them.It is common knowledge that they work extra hard over there: running two, three jobs at a time in order to prove their capability and make up for the higher cost of living there compared to that at home.All this has caused most of them to look older than their age (FGDs, UCH 2012).
Notwithstanding, many of the health professionals, particularly doctors were emigrating in larger numbers than before.The increase could have been the result of information/encouraging words that they received from their colleagues abroad.However, the trend is not a new phenomenon, as earlier research listed some of these factors.Mbanefoh (2007), for example, itemized series of socio-economic and political reasons that motivated large numbers of doctors emigrating in the early 1970s and mid 1980s, zeroing specifically on higher pay and foreign currency exchange.At present, the reasons are beyond these, to include lack of modern and sophisticated medical equipment to work with at home compared to the situation abroad, increasing level of specialization in tackling diseases and of new challenges in the field of medicine.Again, an In-depth Interview (IDI) with the Chairman, Association of Resident Doctors (ARD), UCH branch corroborates the above, as: ….Our colleagues are moving out; there is no doubt about that; but, they are doing this because of the challenges we have in the field of medicine.Most of the infections and diseases we diagnose presently have surpassed the use of ordinary 2-D radiological examinations, which can be better diagnosed using 3-D radiological examinations.These were not available in the 1980s and even up to the early 1990s.Besides, the present medical and laboratory equipment are not the same as those we were trained on in the early 1990s.Things are changing very fast in medicine, and we have to catch up with the tide of the events.Why do you think rich people are going abroad?It is because over there, they have many modern medical facilities for their health care and this is exactly what we are proposing for UCH.Note, I want to say loud and clear that all our products here in UCH are good; but, they will come out better, when they have modern facilities to work with and whenever they travel abroad, they are able to put their skills to use.I'm assuring you, UCH is not left behind in striving towards excellence; we are moving.The private suite of the hospital is a testimony of what I am saying, when I said, we are moving forward (IDI, UCH 2012).
In sum, migration of health professionals, particularly, doctors from the country has been on the increase over time and the major destinations for the doctors, nurses and pharmacists have been the UK and USA, while the MLS have been moving to the Middle-East, specifically, Saudi Arabia (Docquier andMarfouk, 2006 andClemens, 2007).Again, there has been a significant decline in the rate at which the nurses emigrate as the country embraced again democratic form of government in 1999, as against what used to be the case during the military regime between 1983 and 1999.

Spatio-Temporal Trends in Volumes of Immigrated Health Professionals
The section presents findings and explanations on the trends of the volumes and directions of immigrated health professionals from source countries into the country and particularly the three selected institutions.The analysis in the section revealed the imbalance of migratory flows between the source country (Nigeria), particularly the studied institutions and the recipient countries.Furthermore, explanations for the low in-flows of the professionals from other countries are deduced from socioeconomic crisis and political instability engulfed the country during the military and civilian government.Perhaps more importantly is the fact that the very low volumes of immigrants in the selected institutions, (and by inference the entire country) showed an imbalance between brain drain and brain gain.

CONCLUSION
In conclusion, between 1986 and 2010, the volumes of emigration of health personnel have been on the increase, while their immigration/returning had recorded very low rate into the country and the studied institutions, in particular.The findings show majority of the core health professionals from the selected health institutions moved out in large volumes within the defined period.Also, it was shown that emigration of core medical professionals, such as doctors and nurses was more pronounced, while few paramedics such as pharmacists and MLS were seldom affected.However, there was decline in the move of nurses between 2003 and 2010, but saw increase in the volume of doctors migrating.The reason for the decline among nurses was as a result of change in government from military to democratic rule, which neutralizes to some level, the push forces.The upsurge in the migration of doctors out of the country was because of obsolete medical equipment and facilities in the institutions under study.Therefore, efforts should be made by government and stakeholders concerned with health issues to provide health professionals with up-dated equipment to work with, hence, reduce their mas-sive outflow.
In addition, within the defined period of the study, the prominent destination was the United Kingdom, followed by the United States and Canada.However, new direction cum destinations emerged in the findings; the Middle East, other countries in Europe, South America and Asia en routes were becoming new course of emigration of health professionals from Nigeria.On the one hand, both the predominant and emerging destina-tions could positively benefit the country, in terms of remittances, if bilateral and or multilateral agreements could be negotiated between Nigeria and the recipient countries.On the other hand, the return of the professionals, though scanty would become a blessing to the health sector, particularly the selected health institutions, if emigrated health professionals domesticate the skills and training they have acquired over time in the host countries.
Finally, the spatio-temporal analysis of migration of health professionals from and into the country has shown the imbalance between the sending (brain drain) and receiving (brain gain) countries.Therefore, the sustainable development of health sector and well-being of the populace in the country would become a nightmare, if the rate of emigration of health professionals, particularly the doctors from Nigeria is not checked.

Figure 1 .
Figure 1.Destination of Emigrated Health Professionals

Figure 2 .
Figure 2. Source Countries of Immigrant Health Professionals.

Figure 3 .
Figure 3. Volume of Returnee Health Professionals from Destination Countries.
Destinations of Health Professionals, AMTH.