Doctoral Dissertation: Analysis of Physician Anaesthesia Workforce Crisis in Nigeria: An Insider's Action Research Written by: Bisola Olabisi Iretunde Onajin-Obembe Role DETAILS Author Name: Bisola Olabisi Iretunde Onajin-Obembe Year: 2020 Title: Analysis of Physician Anaesthesia Workforce Crisis in Nigeria: An Insider's Action Research Document type: Doctoral dissertation Institution: The International School of Management (ISM) URL: https://ism.edu/ images/ismdocs/dissertations/onajinobembe-phd- dissertation-2020.pdf i Analysis of Physician Anaesthesia Workforce Crisis in Nigeria: An Insider’s Action Research Dissertation Submitted to the International School of Management in Partial Fulfilment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY International Business Management By BISOLA O. I. ONAJIN-OBEMBE (MBBS, FWACS, MBA) Paris, France March 2020 ii Abstract There is a crisis of physician anaesthesia workforce in Nigeria. The insufficient surgical workforce including a lack of physician led-anaesthesia care is a major barrier to safe essential and emergency care in Nigeria. The specialist training programmes in the country, have not been able to produce the minimum number of physician anaesthetists for Nigeria while the situation is exacerbated by persistent brain drain. The purpose of this study is to analyse the physician anaesthesia workforce crisis in the 36 States and the Federal Capital Territory (FCT) of Nigeria; to find out the specialist anaesthesia workforce density and conduct a gap analysis between the current workforce and the required workforce by the end of 2030. This study also models a physician diploma in anaesthesia training programme as a potential solution to the workforce crisis. The theoretical framework for this study combines elements of human resource management namely human capital theory, workforce analytics, and strategic workforce planning with workbased learning and transformational change using participatory action research (PAR) carried out by an insider. The approach taken is a mixed method using quantitative numerical data of physician anaesthesia workforce from various sources, along with action research, as part of a multi-method qualitative research design. The participants were intentionally selected for focus group and expert panel discussions. Key findings of the study are a national physician anaesthesia crisis which is alarming in the Northern zones, gross gender imbalance in the anaesthesia workforce and extremely low capacity for specialist training. The physician diploma in anaesthesia is a successful model. Recommendations are based on a systems approach to provide services and training in all the geopolitical zones in Nigeria. This will require a futurist solution such as the formation of a Nigerian Institute of Global Anaesthesia and also providing the appropriate leadership. iii Acknowledgements I am thankful to God for the strength, wisdom, and ability to complete this study. I sincerely appreciate all the vision helpers, teachers, colleagues, and friends at International School of Management that have encouraged me during my study. Thank you. I acknowledge and appreciate Prof. Stanley Smits who triggered my interest in Change Management and inspired me to be futuristic and creative. I acknowledge and appreciate my thesis supervisor, Dr. Tobias De Coning who inspired me through his seminar on leadership of higher education institutions. Both lecturers made me embark on this journey of imagining a better future. I could not have done this study without the management and my colleagues at the Federal Medical Centre, Abuja. I acknowledge the medical director and a visionary leader, Dr. Chinwe Igwilo; the director of hospital services Dr R Felix, the three consultant anaesthesiologists that participated in this action research namely Dr Olagbale Solanke, Dr Emmanuel Ugwu and Dr Olatunde Olawoye; and my four diplomates of anaesthesia namely Dr. Vivian Orjiah, Dr Chioma Ilokanuno, Dr Christopher Ukah and Dr Olugbenga Abolade. These are real people who have allowed me to take part and contribute to their training. I have also learnt from working with my FMC Abuja family. Finally, I sincerely appreciate my husband Olubunmi Obembe and my sons Daniel, Samuel and David who are always supportive of me. I honour the memory of my mother, Folakemi Fasan-Onajin who was alive when I started my PhD but passed on to glory on 16th March 2018. iv Table of Contents Chapter 1: Introduction.……………………………………………………………………. 1 Background...……………………………………………………………………..... 3 Statement of the Problem...……………………………………………………........ 13 Purpose of the Study……………………………………………………………….. 15 Theoretical Framework…………………………………………………………….. 16 Research Questions……………………………………………………………….... 18 Nature of the Study...………………………………………………………………. 19 Significance of the Study……………………………………………………........... 22 Definition of Key Terms………………………………………………………….... 24 Summary………………………………………………………………………........ 26 Chapter 2: Review of Literature…………………………………………………………… 27 Nigeria country profile ……………………………………………………………. 28 History of Anaesthesia in Nigeria………………………………………………….. 32 Academic Departments of Anaesthesia………………………………….……….... 38 Professor Roderick Angus Gordon (1911 – 1998) and Anaesthesia in Nigeria…… 39 The Nigerian Society of Anaesthetists …………………………………….. ……... 44 The Nigerian Healthcare System…………………………………………………... 46 Legal and Regulatory Framework for Anaesthesia Specialists for Training in Nigeria………………………………………………………………………………52 The Physicians’ Postgraduate Anaesthesia Programmes in Nigeria……………… 58 The Current Surgical System, the Constraints and Challenges.…………………… 61 Physician Brain Drain……………………………………………………….…….. 65 Work-based Learning and Brain-based Anaesthesiology Curriculum……………. 74 Resolution WHA 68:15 and Universal Health Coverage …………………..…....... 79 National Surgical, Obstetrics and Anaesthesia Plan………….……………………. 82 Theoretical Framework for the Study…………………………………………....... 84 Chapter 3: Research Design and Methodology………………………………………........ 89 Purpose of the Study………………………………………………………………. 89 Description of the Study Population……………………………………….……… 91 Design Overview and Specific Design Elements ……………………....……........ 91 Action Research Methodology…………………………………………………….. 96 Focus Group and Panel Discussion……………………………………………….. 97 v Advantages of the Chosen Method………………………………………………... 98 Materials and Data Collection ………………………………………………......... 100 Data Processing and Analysis…………………………………………….....……. 104 Validity and Reliability……………………………………………………………. 106 Assumptions…………………………………………………………………........... 108 Limitations of the Study…………………………………………………….............108 Ethical Assurance…………………………………………………………..……… 110 Summary………………………………………………………………...…………. 110 Chapter 4: Findings of the Study…………………………………………………………... 112 Introduction……………………………………………………………………....... 112 Results of the Main Study and Answers to Research Question 1 to 4……….......... 113 Answer to Research Question 5……………………………………………..…….. 127 Result of the Diploma in Anaesthesia Programme and Answers to Research Question 6………….. ……………….………………………..………………........ 134 Focus Group Feedback on the DA Programme…..……………………................... 139 Feedback from Consultant Anaesthesiologist and Trainer (OTO).……………....... 142 Summary of Major Findings..……………………………………………………… 144 Chapter 5: Implications, Recommendations and Conclusions…………………………...... 147 Implications of the Study……………………………………………………..……. 151 Research Significance……………………………………………………………… 166 General recommendations for Future Training…………………………………......167 Specific recommendations………………………………………………………..... 170 Recommendations for Global Anaesthesia Leadership…………………………..... 177 Recommendations for Future Research……………………………………………. 187 Conclusion…………………………………………………………………………. 187 References …………………………………………………………………………………. 190 Appendix...………………………………………………………………………………….225 Appendix A……………………………………………………………………....... 226 Appendix B………………………………………………………………………… 227 Appendix C………………………………………………………………………… 228 vi List of Tables Table 1: Age Structure of Nigerian Population ....................................................................... 30 Table 2: List of Federal Teaching Hospitals in Nigeria ........................................................... 47 Table 3: Location of all Federal Medical Centres in Nigeria .................................................. 48 Table 4: Specialty Hospitals in Nigeria ................................................................................... 49 Table 5: National Orthopaedic Hospitals ................................................................................. 49 Table 6: National Eye and Ear Centres .................................................................................... 49 Table 7: Description of Lancet Commission Global Surgical Indicators ................................ 89 Table 8: Strategic Stakeholders Focus Group ........................................................................ 103 Table 9: High-Level Stakeholders Panel .............................................................................. 104 Table 10: Physician Anaesthesia Provider workforce density per State in the North Central Zone of Nigeria ...................................................................................................................... 113 Table 11: Physician Anaesthesia Provider workforce density per State in the North Eastern Zone of Nigeria .....................................................................................................................