The results of this study suggest that the level of job satisfaction among resident doctors in the study setting is low but comparable with reports among doctors in other developing countries (Ghazali et al., 2007; Qian and Lim, 2008; Kaur et al., 2009; Malik et al., 2010). The 55.2% job satisfaction recorded in this study is slightly higher than the 46% reported much earlier in a similar setting among resident doctors in Nigeria (Ofili et al., 2004). This may suggest a rising level of job satisfaction, but methodological differences would limit such assertion. After controlling for socio-demographic and other job-related factors, career development opportunities in terms of skill acquisition and professional advancement were the strongest predictor of job satisfaction in this study. This is consistent with reports from other developing countries such as India (Ghazali et al., 2007), Singapore (Qian and Lim, 2008) and Pakistan (Malik et al., 2010) where career development prospects were reported as key motivating factors for doctors in the public sector. This may be because the international competitiveness, sense of worth and the thrill that comes with contemporary skill acquisition that opportunities for higher professional training in developing countries such as Nigeria ensure may independently improve resident doctors' morale. Opportunity for career and skill development can also secondarily improve resident doctors' earning potential both locally and internationally, creating a sense of accomplishment.
Infrastructure for tertiary and quaternary healthcare delivery in Nigeria is poor. This is occasioned by poor and declining total health expenditure (THE) as a fraction of gross domestic product (Central Bank of Nigeria, 2006; Federal Ministry of Health, 2009) and lack of a framework for judicious mobilization of the meagre resources. This has in-turn impacted negatively on infrastructural capacity for contemporary skill acquisition as well as competitive opportunities for professional development and career advancement for resident doctors in Nigeria. The situation was compounded by the abolition in the early 1990s, the hitherto mandatory 1-year overseas clinical attachment for resident doctors in Nigeria on the grounds of financial constraints. This programme was put in place to bridge the training and professional development gaps among resident doctors in the country. The abolishment was carried out despite an inadequate framework for sub-specialty training within the country. From the foregoing, it is plausible to establish a connection between the dwindling career development opportunities occasioned by the abolition of the skill enhancing overseas clinical attachment in Nigeria and the recurrent resident doctors' strikes witnessed in Nigeria in recent times.
Satisfaction with working environment was associated with about 25 times odd of being overall satisfied with job in this study. This tends to suggest that a good working environment is an important source of satisfaction among resident doctors in this study. Working environment has been described as an important variable for job satisfaction (Laubach and Fischbeck, 2007). It is not uncommon for resident doctors in Nigeria to complain of lack of office spaces, call rooms, toilets, furniture and basic work tools. Resident doctors may have to crowd together in a small office, share in the use public lavatories and pass the night in the lounge because of shortage of call rooms. Such working environment can reduce the sense of prestige of any doctor and thus serve as a de-motivator, especially in tropical Africa where studies have shown that prestige is an important “pull” factor into the profession (Orenuga and Da Costa, 2006) and an important reason for not quitting the profession (Mbindyo et al., 2009). Therefore, it is plausible to say that working environment may predict overall job satisfaction by modulating resident doctors' sense of prestige.
Resident doctors younger than 32 years in this study were at least two times more likely to have overall job satisfaction than those above this age. This is in keeping with reports that the relationship between age and job satisfaction among doctors is ‘J’ shaped; with satisfaction being high initially at about age 30 years, falling at about age 35 through 40 years and rising steadily thereafter till retirement (Pathman et al., 2002; Madaan, 2008). Madaan (2008) hypothesized that initial enthusiasm and euphoria of younger doctors on the job may explain the initial high level of satisfaction among them. The author also theorized that expanding social pressures and family responsibilities, larger input–output deficits and increasing job demands may shrink the initial gains and thus explain the decline in job satisfaction at middle age. Gradual acceptance and adaptation was argued as an explanation for the later surge in job satisfaction.
However, the observation in the current study that levels of overall job satisfaction was not significantly different across socio-demographic indices such as marital status, job title, specialty or number of years of residency training may suggest that there are other factors that may explain the lower level of job satisfaction among the older resident doctors in this study. Resident doctors with lower number of pre-residency working experience were significantly more likely to report overall job satisfaction in this study. The widening gap between the conditions of service in the Nigerian service-oriented primary/secondary health sector (mostly run by State governments) and training-oriented tertiary health sector (mostly run by the Federal government) has forced many doctors in State-run hospitals to resign their appointment for the more lucrative training posts in the tertiary centres. Many of these doctors join the residency training programme at an older age, poorly prepared and often settle for any specialty where there is vacancy and not necessarily their preference. As a result, they tend to work under duress, contend with the challenges of relocation, adapt to a rigorous academic environment and oftentimes work under the supervision of much younger colleagues. This scenario may constitute an additional emotional burden on this group of resident doctors and may explain the lower levels of overall job satisfaction among the older participants in this study.
Consistent with pre-existing literature from other parts of the world (Stoddard et al., 2001; Grembowski et al., 2003; Nixon and Jaramillo, 2003), autonomy of practice is a strong predictor of overall job satisfaction in this study. Closely related to professional autonomy and equally a strong predictor of job satisfaction in this study was the alignment of job with personal and professional values (professionalism). Autonomy of practice is related to professionalism because it is a prerequisite for maintaining professional values. In the context of the medical profession, professionalism entails placing the patients' interest above personal interest, high moral and ethical standards, social responsibility and commitment, and integrity and empathy (Halvorsen, 1999; Swick et al., 1999; Wynia et al., 1999; Barry et al., 2000). Physicians will normally require some degree of professional autonomy to be able to provide necessary and high-quality service for patients, make sound clinical decisions and have control over the content and schedule of their work. Such professional autonomy gives a sense of control and responsibility and consequently improves professional self-image and boosts morale. Also, a reasonable control over working time and schedule without affecting income, although not an aspect of patient care, remains a significantly coveted privilege that can drive job satisfaction among doctors (Stoddard et al., 2001). In fact, a controllable lifestyle in spite of the job has been reported to have become a stronger motivator for specialty choice among doctors (Schwartz et al., 1989) and a significant predictor of burnout and job dissatisfaction (Kristie et al., 2007).
In other climes, the main reported factor eroding physicians' autonomy is the introduction of managed care (Schulz et al., 1997; Bates et al., 1998; Linzer et al., 2000). However, in a country such as Nigeria where managed care as a strategy for health care delivery is still at rudimentary levels, there must be other determinants of physicians autonomy in Nigeria beyond managed care. Health insurance and out-of pocket spending contribute about 2% and 70%, respectively, of healthcare financing in Nigeria (Federal Ministry of Health, 2010). There is also a low political will for proper funding of healthcare and a lack of a commitment to equitable allocation of the meagre resources. All these factors combined to create a situation of decay of infrastructure within the health sector. As such, the main impediment to professional autonomy and professionalism among public sector physicians in Nigeria is the inability to arrive at evidence-based clinical decisions and provide high-quality services, due to financial and infrastructural limitations. In the setting of current study, it is not uncommon for physicians to be faced with a situation whereby inability of patients to meet financial obligations hampers the quality of care rendered. Also, infrastructural failures such as power and water supplies sometimes delay clinical procedures, thus impugning on quality of patients' care and frustrating doctors in their bid for professionalism on one hand and control over their work schedule on the other. This scenario is expected to be a source of frustration and de-motivation for the resident doctors. The import of having to work under such circumstance was put succinctly by Mathauer and Imhoff (2006) while examining motivating factors among health workers in Africa that “…health workers overall are strongly guided by their professional conscience and similar aspects related to professional ethos. In fact, many health workers are de-motivated and frustrated precisely because they are unable to satisfy their professional conscience….”
Contrary to common speculations within the Nigerian health sector, more than 90% of the participants in this study reported satisfaction with their salaries. This factor was also not retained as a predictor of job satisfaction in the logistic regression model. This finding is in keeping with the growing body of evidence that non-financial incentives may be superior to wage increase in boosting health worker motivation in developing countries such as Nigeria (Franco et al., 2000; Dielemann et al., 2003; Schmidt-Ehry and Seidel, 2003; Mathauer and Imhoff, 2006). Furthermore, Stilwell (2001) reported that health workers based in rural Zimbabwe exhibited a high level of motivation for excellence despite lack of financial incentives and hard working conditions. Their motivation despite odds was attributed to good leadership, supportive management and certain non-financial incentives. Alihonou et al. (1998) also opined that non-financial incentives and improving structural conditions may be the best way to improve health workers' satisfaction in Benin Republic. Vujicic et al. (2004) also concluded that non-financial incentives may be more effective in reducing health worker turnover and migration in sub-Sahara Africa than wage increase.
Efforts by the Nigerian government to stem recurrent industrial disputes by resident doctors and improve service delivery in the tertiary health sector in the country should include policies geared towards improving the current level of job satisfaction among resident doctors, taking cognizance of some of the key de-motivating factors for resident doctors in this study. Central to most of the predictors of job satisfaction in this study is lack of commitment to funding of the health system by the Nigerian government. In 2005, the THE as a fraction of the gross domestic product was a paltry 8.5% (FMOH, 2009), and the public spending per-capita for health can be as low as USD 2 in some parts of Nigeria (WHO, 2011). This is far below the USD 34 benchmark set by WHO for low-income countries. Compounding this problem is the wide gap between budgeted figures and the actual funds released, as well as judicious use of funds so released. Government will need to increase the THE, and a good way to start is to show commitment to the Abuja Declaration of 2010 signed by all states of the federation to increase the current THE gradually with a view to achieving at least 15% of the annual budget commitment to healthcare and at least 90% budget release by 2015.
Specifically, government should increase funding for residency training in the country by creating a special budgetary line for the programme and to establish a directorate within the National Tertiary Hospitals Commission to oversee and source for fund for residency training programme. These funds should be directed towards the immediate re-introduction of the hitherto mandatory 1-year overseas clinical attachment for resident doctors, a programme that ensures that the Nigerian specialist has not only a thorough understanding of the theory and practice of his specialty locally but is also well grounded in contemporary innovations and developments in chosen field. As a long-term measure, funds should be committed to the strengthening of the existing National Centers of Excellence as well as establishing National Quaternary Mono-specialist Centres to serve as local skill acquisition centres and complement the overseas clinical attachment programme. These steps will provide an adequate framework for contemporary skill acquisition and career development opportunities for resident doctors in Nigeria with positive effects on job satisfaction.
In the same vein, sufficient and judicious funding of health care will improve the state of infrastructure within the health sector. As such, resident doctors will shore up their job satisfaction with the highly valued sense of autonomy and professionalism that opportunity to deploy acquired skills effectively for patient care provides. Also, a predictable state of infrastructural back-up will ensure a reduction in delays and cancellations of procedures occasioned by infrastructural failures and improve job satisfaction through the attendant improvement in sense of professionalism and a better control over work schedule. Similarly, investing in the working environment of resident doctors by providing on-site accommodation, decently furnished call rooms, office spaces, consulting rooms, lounges and cafeteria will improve job satisfaction by fostering a working environment that promotes a sense of worth and prestige deserving of a professional.
There is a need to deliberately increase the health insurance coverage for Nigerians as a government policy. Social welfare services for indigent patients also need to be strengthened. This will drastically reduce the incidence of service gaps due to inability of patient to meet financial obligations of quality service. This will also improve on the satisfaction of resident doctors through the sense of autonomy and professionalism that comes with unhindered ability to make appropriate and timely clinical decisions.
Financial incentives are germane, and the challenges of poor salaries must be addressed especially in an unstable economy such as Nigeria's where inflation is in double digits. However, it should be realized that evidence abounds that increased salaries are not sufficient to solve the problem of low job satisfaction in developing countries but rather a mix of financial and non-financial incentives (Mathauer and Imhoff, 2006). It is instructive that the current study was conducted before the introduction of, in response to recurrent strikes by resident doctors in the country, an enhanced salary package for resident doctors (complete with special allowances such as ‘rural allowance’ to motivate doctors working in rural areas). This reflects that government was assuming that poor salaries were the main bone of contention. The enhanced salary may have quelled the unrest but may not have improved the level of motivation, satisfaction and productivity in the tertiary health sector. A (Awases, 2003) report showed that non-wage incentives may be more effective in retaining quality health manpower in developing countries. Reid (2004) also showed the relative futility of the so-called “rural allowance” as a means of retaining health workers in rural South Africa. Government needs to make it a policy to provide for resident doctors, non-financial incentives such as better working environment, sponsorships for local and international conferences, sponsored holidays, small scale research grants, housing schemes, educational package for children, and recognition and rewards for excellence. There is also a need for government to put a framework in place to address the widening disparity in wages and conditions of service between State and Federal health workers in the overall interest of the nation's healthcare delivery. This will ensure that doctors are not compelled by necessity to join the residency training programme. This will increase the chances of recruiting a crop of enthusiastic and self-motivated resident doctors from the outset.
From the foregoing, it appears pertinent to inject more funds into the Nigerian health sector to ensure industrial harmony and uninterrupted and qualitative patient care. One may ordinarily want to advocate for a speedy increase in the health budget in Nigeria to the prescribed 15% in line with the 2001 resolutions of the Organisation of African Unity (2001). However, unless the myriads of financial drainpipes on the economy of most African countries such as high external debt profile, high budgetary provision for security occasioned by civil unrests (Di, 2005) and high level corruption and mismanagement are addressed, this feat may not be attainable in decades. Government revenue in the world over can generally be improved through increased taxation and specifically for the health sector through tax-funded health budgets. However, the limited tax base in developing countries of Africa including Nigeria limits the use of tax increase as a panacea for healthcare financing. The resurgence of civil and religious unrest in Nigeria has also continued to put pressures on government spending. For instance, analysis of the 2012 Appropriation Bill (Budget Office, 2012) showed that Nigeria' government intends to spend approximately one-quarter of her total expenditure for the year 2012 on security-related issues. Therefore, in the medium term, government of Nigeria needs to develop sustainable alternatives to healthcare financing.
One of the ways to go is to increase revenue base by blocking internal drainpipes on the economy of Nigeria. This will include cutting wastages in government by trimming down the number and the currently bogus allowances and perks of public office holders. Other measures include fighting corruption in several sectors of the economy especially the oil sector and re-vitalizing and expanding the health insurance schemes in the country. Government of Nigeria may also need to improve on her current investment in social welfare and social security for the poorest fraction of the citizenry. Research suggests that a well structured and adequate social welfare and social security system can enhance the perceived legitimacy of government by the people and promote social and political stability in developing countries (Justino, 2003; International Labour Organization, 2008). The wealth redistribution that comes with investment in social welfare and social security schemes has been associated with lower levels of indices of social discontent and insurgency (Ribero and Nuñez, 1999). The import of this is that an early investment in the social welfare of the populace as well as an equitable distribution of national wealth can save the country of the resources currently being diverted to security and social control. While these measures are being put in place, the international communities also have a role to play in the quest for extra funds for the development of healthcare in the developing countries of Africa. Ways to support Africa in addressing her current health funding constraints will include a sustained advocacy for improved debt relief package or outright debt cancellation so that they can divert more of their resources to healthcare financing as well as social welfare packages and responsive social security schemes (Di, 2005). Also, there should be an improved drive towards attracting donor funds with specific targets such as human resource development for health. Such funds can be used to re-invigorate the overseas clinical attachment scheme for instance.
Finally, government of Nigeria will do well by listening more to the people, especially professional groups. The Federal Ministry of Health (FMOH) need not allow declaration of industrial discontent in the health sector to degenerate into strike actions before channels of communication are opened. Such attitude tends to further strengthen the militarization of professional groups. The FMOH must open a communication channel between the Ministry and professional groups in the health sector, as studies have shown that poor communication between government and public sector employees is the key factor underlying industrial actions in many parts of Africa (Mutizwa-Mangiza, 1998). In addition, the FMOH must make it a policy to incorporate key stakeholders in the sector such as the National Association of Resident Doctors (NARD) and other professional bodies in the formulation and implementation of health system policies. This will ensure a smooth sailing of such policies and enhance industrial harmony. The FMOH should also strive to engage the professional bodies and key into their vision for the development of the health sector in the country. A welcome example is the recent bold step of the FMOH to accede to the call by NARD in constituting an all stakeholders committee to review the structure and workings of the residency training programme in Nigeria. The Ministry will do well to ensure and involve NARD in the implementation of the recommendations of the committee.
This is the first study, to the best of authors' knowledge, that made an attempt at providing some insight into the possible factors that may belie the recurrent strikes by resident doctors in Nigeria. The findings of this study should, however, be interpreted with some caution. First, the use of self-reported questionnaires that rely on the sincerity of the respondents is a major limitation. In drawing inferences from this study, the authors assume that job satisfaction is necessarily the motivation for the recurrent industrial disputes engaged by the resident doctors. It is possible that other social and political factors such as inter health-worker rivalry and the quality of leadership skills of leaders of professional bodies and that of the FMOH, which were not assessed, may have contributed significantly to the industrial disputes.
It will be interesting, in a follow-up study, to explore the political, social and other possible contributors to resident doctors' or health workers' industrial unrest and job satisfaction in Nigeria given the political and social turbulence the country has been experiencing. Because only the resident doctors in Ibadan (although the largest body of resident doctors in Nigeria and indeed West Africa) were involved in this study, the findings may not be representative of the entire country. The suggested follow-up study can be conducted in other geographical, ethnic and political settings of the country for validation of present findings and conclusions and therefore further contribute to research evidence and body of knowledge in the subject area.
In conclusion, the findings of this study suggest that job satisfaction among resident doctors in the study setting is poor. This fact may not be unconnected with the recurrent industrial disputes witnessed in the Nigerian health sector in the last 5 years. At the core of factors predicting job dissatisfaction among resident doctors is poor funding of the health sector. To restore satisfaction and possibly stem industrial disputes in the health sector, government needs to sustain current wages while introducing non-financial benefits. Policies geared towards increasing government spending on health especially in the area of human capacity and infrastructural development also need to be adopted.