Since completing her midwifery training three years ago, Aisha*, a 27-year-old midwife and mother of three children under 5, has been working in a bustling primary health-care center in Kano State, Northern Region, Nigeria.
She says she loves her work, but life has been harder since a recent devaluation of the naira, Nigeria's currency.
"I haven't been paid for two months," Aisha says. "I receive 76,540 naira [approximately $48] a month, despite taking on more responsibility in my health center. I often don't receive my salary on time."
This situation has prompted Aisha's interest in finding a better-paying job, either in one of Nigeria's urban areas or in the United Kingdom.
Aisha's situation is not unusual. About 80% of the nurses and midwives in Nigeria say they would be willing to leave, or ja pa ("escape" in Yoruba) for better job opportunities in other countries. Between 2017 and 2022, more than 57,000—about 30%—of the country's nurses and midwives left Nigeria. The United Kingdom was their top destination.
About 80% of the nurses and midwives in Nigeria say they would be willing to leave for better job opportunities
To address the challenges spurring this emigration, the Sydani Group, a health consulting firm, conducted a national survey of 197 nurses and midwives in primary health-care facilities across Nigeria's 36 states and the Federal Capital Territory of Abuja from November 2023 to June 2024. This survey was part of a larger research initiative that included interviews with policymakers and a review of projects implemented to improve the country's health workforce.
Of the 197 health workers surveyed, 50% were between 36 and 60 years old and 89% were women. The average age was 38 years for females and 34 for males. Both had, on average, 13 years of working experience. The health-care providers surveyed mentioned factors such as higher remuneration (34%), better career development pathways (31%), and the availability of good infrastructure and basic amenities (16%) as key motivators for considering emigration.
Salaries and Financial Support
The need to increase the salaries of nurses and midwives—and to ensure that these essential health workers are paid on time—is pressing. Some of those surveyed at primary health-care facilities earned as little as $20 per month, and 79% earned between $20 and $150. Many reported that their salaries often arrive late. To address emigration, the national government should review the medical and health worker salary scales and enforce the implementation of these federally mandated salaries by state governments.
State governments manage about half of Nigeria's overall health budget and most of the funding available for primary health care. It is therefore imperative that state governments undertake proactive measures to improve the social welfare of nurses and midwives by paying salaries on time and by offering hazard pay to health workers serving rural areas or more precarious zones.
Other incentive packages that address access to credit and health insurance should be developed and implemented to encourage nurses and midwives to work in rural areas. Some states have begun to offer rural incentive programs for midwives, including access to health insurance and hazard allowances. Several midwives we interviewed said that access to credit for small loans would incentive them.
Health-Care Facilities: Understaffed and in Disrepair
Eighty percent of midwives reported experiencing extreme work overload in their facilities, primarily because of inadequate staffing.
Up-to-date information on the unaccredited institutions, training programs, production capacity, and quality of learning is needed. Nigeria has approximately 350 nursing and midwifery training institutions—including nearly 100 schools created since 2018—that enroll nearly 30,000 graduates, up from 14,000 in 2018, annually. As of 2022, 218 (62%) of these training institutions were fully accredited.
In addition, the federal and state governments should undertake measures to support the renovation of dilapidated health training schools, ensuring they are adequately equipped with necessary training materials—including medical equipment and updated computer systems—to enhance the quality of education.
Frontline health workers express concerns not only about their salaries but also over the "demoralizing" conditions at primary health-care facilities. More than half (52%) of the nurses and midwives surveyed said that the lack of essential drugs—including antibiotics, antimalarials, and oxytocin—and equipment at their facilities is a problem. The facilities are often small, cramped, and out of date, requiring new roofs and equipment. Solar energy systems are also a priority because electrical blackouts and brownouts are frequent. Nearly one-fifth (19%) of those surveyed have general fears for their security.
Many nurses and midwives view their work and chosen professional as noble but feel demotivated and demoralized. Poor salaries—coupled with ill-equipped primary health-care facilities—make them feel undervalued.
A Path Forward: Funding the Health Sector
Pursuant to Nigeria's new health Sector-Wide Approach, the government should ensure that financial and technical support is provided to increase the number of primary health-care facilities from almost 9,000 to more than 17,000 by 2027. Funds should also be provided to ensure that existing facilities are renovated and equipped with essential amenities such as water, power, and a more conducive work environment.
Maternal mortality rates have plateaued in the last several years, especially in sub-Saharan Africa
The Basic Health Care Provision Fund, established in 2014 to improve access to primary health care by supporting the operational costs of primary health-care facilities, receives an annual grant from the federal government of Nigeria, private-sector donations, and grants from international donor partners. The fund has been plagued by problems, primarily a lack of funding from the federal government and mismanagement at various levels. The federal government develops and coordinates national policies and health worker training, but management and financing of health facilities is the responsibility of state-level ministries of health and local government authorities.
The existing accountability and monitoring system should be strengthened to promote the effective and judicious use of allocated resources by stakeholders at the local government and facility levels.
Midwives Save Lives
Maternal mortality has decreased globally in the past two decades, but rates have plateaued in the last several years, especially in sub-Saharan Africa. Most causes of maternal death can be prevented if women have access to high-quality obstetric care with a qualified health professional—a nurse, midwife, or other skilled birth attendants. According to The State of the World's Midwifery Report (2021), trained midwives can provide 90% of maternal and newborn health services, but Nigeria needs more of them.
As of March 2023, the country's maternal mortality ratio of 1,047 deaths per 100,000 births is the third highest in Africa—and one of the highest in the world. The country is plagued by a dearth of health workers and currently has fewer than 200,000 midwives for a population of 217 million. To meet the World Health Organization's recommendation of 44.5 midwives per 10,000 people, Nigeria would need to train and deploy nearly 700,000 additional nurses and midwives.
To stem the emigration of midwives in Nigeria, collaborative efforts among the government, local, and international development partners, and health-care workers are imperative.
Recommendations to the country's federal, state, and local governments include setting up mechanisms—and funding—for full implementation of the national health workforce strategic plans and the policies already in place, including the 2020 National Human Resources for Health Policy and the Human Resources for Health Strategic Plan, 2021–2025. These policies are often underfunded and under-implemented at the national and subnational levels.
Our survey demonstrated the tremendous value of listening to the voices and stories of health workers. Nurses and midwives told us that they want better salaries and incentive packages and better working conditions. Governments at all levels can gain important insights by ensuring that the voices of health workers are heard, and mechanisms should be put in place to regularly collect input from nurses, midwives, and other frontline health workers.
To stem the brain drain—and ensure that midwives are there to save lives—donors need to support national and state-level priorities—including the Basic Primary Health Care Provision Fund, and the implementation of both existing strategies and policies and the development innovative solutions to the health workforce and primary health-care challenges in Nigeria.
*Aisha's name has been changed to protect her privacy.
