*Less than 30,000 medical doctors, 150,000 registered nurses nationwide
*Average Doctor-Patient ratio = 1:53,333; Nurse-Patient ratio = 1: 1,066
EVEN before the current health workers’ strike, a visit to public hospitals in Lagos and other parts of the country on a weekday, is an eye-opener. The situation at any of the primary, secondary or tertiary health centres highlights a depressing scenario. One is bound to ask were the nurses, doctors and other health workers have gone, because there are always too many patients and not enough health care personnel around to cater for them. Even during the last Ebola outbreak in the country, health worker shortage was a big threat to the containment effort. In this special report, the immediate and long-term effects , consequences and remedies regarding health worker shortage are highlighted: Excerpts:
By Sola Ogundipe, Chioma Obinna & Gabriel Olawale
IN Lagos, it is not uncommon for patients to sleep in hospital premises overnight or arrive hours before the crack of dawn so as to be at the head of the queue. But even after spending several hours on the queue, chances of being attended to before the close of the day’s work are not often guaranteed as many patients return home without obtaining the treatment they seek.
The problem is obvious. There are too many patients and not enough healthcare providers. Day after day, incidences of attendant effects of health worker shortage are exhibited in excessively lengthy queues, abnormal waiting times, audible patient dissatisfaction at the various outpatient clinics are instructive and an insight into the fact that all is not well with the system. From dawn to dusk, thousands of patients that converge at the hospitals seeking attention for sundry health problems often leave in frustrated annoyance.
This chronic health worker shortage that has prevailed in public hospitals over the years in Lagos and Nigeria as a whole has steadily gone from bad to worse.
On the average, a doctor that should not see more than 30 patients in one day is compelled to attend to average of 100-150 or more patients daily. Sometimes, one doctor is on call for two, three or four days at a stretch. Not only is there a shortage in numbers, there is shortage in specialisation.
The World Health Organisation, WHO, defines a health worker as “all people engaged in actions with the primary intent of enhancing health,” including those paid as “health service providers” and “health management and support workers.”
However, the hospital staff shortage transcends the medical personnel and there are times medical staff needs to carry out administrative work just to keep things going. Even as the government is struggling to contain the unsavoury trend, indications reveal it may be fighting a lost battle.
For chronic health management, the situation is particularly serious. Patients with conditions such as cancer, kidney failure, diabetes, asthma,stroke and coronary heart disease and others requiring specialist attention are worse off. The dearth of health workers is contributing to the death of patients.
Evidence suggests that shortage of healthcare personnel, notably doctors and nurses in the state are detrimental not only to quality of patient care, but also to staff morale, affecting staff retention, patient welfare and weaker standards of practice. Worse still, the loss of confidence and overall failure of the health system is apparent.
High patient-doctor ratio
“Persistent under-staffing leads to a high patient-to-doctor,” stated a commentator on national health issues. “It is largely responsible for the series of frustration, stress, job burnout, poor attitude to work and workplace incivility and higher turnover of healthcare personnel is killing healthcare delivery in public hospitals.
A World Health Organisation publication entitled: “Establishing and Monitoring Benchmarks for Human Resources for Health: the Workforce Density Approach,” notes that it is as difficult to comprehend the extent of the shortage of health workers across the country as it is challenging to contemplate a solution. Going by WHO standards, Nigeria is not on track to meet the very low benchmark of 2.5 doctors, nurses and midwives per 1,000 people.
In Nigeria, Human Resources for Health represent the cornerstone of the health system and no health intervention can be successful without an effective workforce. As one of the eight pillars of the National Strategic Health Development Plan, a skilled and fortified health workforce in the right proportion and combination is essential towards provision of the desired improvement in health indices.
National Health Workforce Registry
In 2011, the Federal Ministry of Health assisted by the World Health Organisation, WHO, and the Centre for Diseases Control, CDC, inaugurated the National Steering Committee for the National Health Workforce Registry and the Committee on Nigerian Public Health Training Initiative, towards establishing a functional human resources information systems and registry to account for and track all health workers in the country.
At that time, WHO Country Representative, Dr. Ruiz Gama Vaz noted that inadequacies in number, mix and quality of human resources for health posed greatest challenges to the nation’s health system’s capacity to deliver effective and equitable health services. Vaz said addressing health workforce shortages, competencies and productivity is a critical intervention to undertake.
In line with current global practice, the National Registry would track all Nigerian Health Workers by capturing routine pre-service training, graduation, work entry and exit retirement as well as attrition.
Initiated by the Federal government in collaboration with the Carter Foundation to improve the quality and quantity of health professionals serving the country, the Health Workforce Registry is expected to monitor a sustainable check and balance system; to monitor progress towards production and provision of real-time data on the availability of required health personnel at all levels of healthcare service delivery.
It is also to provide data for the general management of Human Resources towards optimising production, deployment, utilisation and retention of skilled healthcare workers at all levels in an equitable manner.
But allegations that government has not done enough to address the dire shortage of health workers in the country continue to make the rounds especially as the health workforce crisis is a national emergency.
Findings by Good Health Weekly show that Nigerian health professionals as a whole are unanimous on the issue of health workers’ dissatisfaction, burnout, stress, and motivation that are influencing their recruitment and retention.
“Although the WHO recommends one pharmacist per 2000 population, in Nigeria we have approximately one pharmacist per 12,000 population. This is taking into account that many have died and those who have migrated,” says the Registrar, Pharmacists Council of Nigeria, Mohammed Elijah.
Nursing care, a big challenge
The scenario is as precarious for nurses, the largest group of health professionals, veritable caregivers and the strength of the nation’s health system.
Registered nurses are the hospitals’ workhorses. In providing essential services and health care support, the average nurse’s daily workload to meet up with the clinical requirements of patients is enormous.
The nurse is in charge of new outpatient assessments and monitoring of patients on admission in the wards. The nurse takes the patient’s vital signs including height, weight, pulse, temperature and blood pressure and dispensing of prescribed medications.
Nurses probably develop closer relationship with the patient more than any other healthcare personnel and are crucial to the smooth running of any hospital. They provide or assist in providing services in every imaginable area from the surgical theatre, Accident & Emergency, to the paediatric and labour wards.
Patients requiring surgery, vaccinations, specimen withdrawal, and treatment of fresh wounds or changing of dressings on old wounds, setting up drips, administering regular injections or treatment for ongoing health conditions among dozens of other needs, often rely on the nurse for their care and upkeep.
But the nursing profession has been experiencing persistent shortage for years and is now in dire straits. For close to a decade and a half, the scale of nursing shortage has been termed a global crisis because the supply of nurses cannot meet the demand. The WHO recommends a nurse to a population ratio of 700, but according to the Open Journal of Nursing, 2014, Nigeria has less than 150,000 registered nurses to cater for an estimated 160 million population, giving an average nurse population ratio of 1 to 1,066 people.
Modupe O. Oyetunde of the Department of Nursing, College of Medicine, University of Ibadan, and Olabisi O. Ayeni of the Lagos State School of Nursing, Lagos, in their study entitled “Exploring Factors Influencing Recruitment and Retention of Nurses in Lagos State, Nigeria within Year 2008 and 2012”, found that the turnover rate of nurses in Lagos State Health institutions is higher than obtains in Federal health institutions in the country and also higher than the national average.
The study published in the Open Journal of Nursing 2014, said increment in salary and allowances rated the best influence on recruitment and retention of nurses in Lagos State. The study identified lack of nursing leadership; sense of job security and work environment as major factors influencing recruitment and retention of nurses in Lagos health institutions.
“There is need for adequate human resource planning; increased efforts and formulation of policies that will improve recruitment and retention of nurses in Lagos State of Nigeria,” the study concluded.
Bound by policy
A registered staff nurse at the Lagos State University Teaching Hospital, LASUTH, who simply identified herself as Esther, noted that, ordinarily, the recommendation for maximum number of patients that a nurse can see safely within an eight-hour shift period ranges from 25-30.
“But that is on paper. In practice, providing nursing and care support in a teaching hospital such as LASUTH something else. There are not enough of us, and we sometimes double shift to cope with the thousands of patients that flock here daily. Honestly there is no limit to the number of patients a nurse sees. You just do what is humanly possible,” Esther explained.
Toyin, a Staff Nurse/Midwife at the Lagos University Teaching Hospital, LUTH, Idi Araba, Lagos, tells a similar story. “We are bound by the government policy not to turn away any patient, even when there is no bed space. There are times when there are so many patients at the clinics, even on appointment, it is impossible to attend to them all, so we often ask them to come back the next day. But if someone urgently needs to see the doctor and can’t wait until the following day, we could make an exception. If it is an emergency, we take it on that basis. But no patient is rejected. Every patient is seen.”
In the bid to find solution to the crisis of nursing shortage, the International Council of Nurses (ICN) initiated priority areas, top among which is retention and recruitment of nursing personnel. Experts argue that recruitment and retention of nurses and other health personnel are two human resources functions that require strategic thought and planning for effectual and effective outcomes.
It is argued that successful recruitment begins with proper employment planning and forecasting, however, systemic factors such as constraints in hospital budget; remuneration, practice autonomy, work load, flexible shift, and opportunities for career advancement remain a hindrance.
Worse still, an ageing nursing work force, coupled with decline in the number of nurses graduating from the schools of nursing among other factors are a stumbling block to the availability of nurses for employment.