TECHNICAL REPORT

Niger J Paed 2013; 40 (2): 112 –118

Paediatric Association of

Nigeria (PAN)

Paediatrician workforce in Nigeria

and impact on child health.

DOI:http://dx.doi.org/10.4314/njp.v40i2,2

Accepted: 8th August 2012

Abstract Objective: To determine

the number and distribution of

paediatricians in Nigeria. It also

aims to determine the association

between paediatrician workforce

and under five mortality (U5MR)

and immunization coverage

across the six geopolitical zones

of the country.

tal settings, mostly tertiary centres

(344=88%). Lagos State had the

highest number (85; 17.9%) of

practicing paediatricians followed

by the Federal Capital Territory

with 37 (7.8%) paediatricians.

More than two thirds of the pae-

diatricians (336; 70.6%) were

practicing in the southern part of

the country. The average child:

p a e d i a t r i c i a n r a t i o w a s

157,878:1for the country. The

North East zone had the highest

child-to-paediatrician ratio

(718,412:1) while South West had

the lowest ratio (95,682:1).

Higher absolute numbers of pae-

diatricians in each zone were asso-

ciated with lower U5MR

(Spearman ρ=-0.94, p=0.0048),

accounting for 84% of the variabil-

ity among zones. Higher ratios of

child-to-paediatrician were signifi-

cantly associated with higher

U5MR (Spearman ρ=0.82, p=0.04,

Ekure EN⁽

⁾Esezobor CI

Department of Paediatrics, College of

Medicine of the University of Lagos/

Lagos University Teaching Hospital,

Lagos, Nigeria

Email: ekaekure@yahoo.com

Balogun MR

Department of Community Health and

Primary Care, College of Medicine of

the University of Lagos, Nigeria

Methods: The part II fellowship

examination pass list of the West

African College of Physicians and

the National Postgraduate Medi-

cal College and the register and

financial records of the Paediatric

Association of Nigeria were

searched for the purpose of the

study. Using a structured ques-

tionnaire, personal and profes-

sional data was obtained from

members at the 2011 Annual Pae-

diatric Association of Nigeria

Conference or via the Associa-

tion’s website, email network and

phone calls to Departments of

Paediatrics in institutions (private

and public) across the Country.

Data on the paediatricians resid-

ing within Nigeria was then ex-

tracted from the comprehensive

database and subsequently ana-

lyzed. Population data, mortality

and immunization rates were ob-

tained from the National Popula-

tion Commission census and their

most recent National Demo-

graphic health survey in Nigeria.

Correlations were drawn between

number of paediatricians and

U5MR and diphtheria-pertussis-

tetanus (DPT) vaccine coverage.

Results: There were 492 practic-

ing paediatricians in Nigeria at the

end of year 2011, comprising 282

(57.3%) males and 210 (42.7%)

females; 476 (96.7%). Majority

Woo JG

The Heart Institute and Division of

Biostatistics and Epidemiology,

Cincinnati Children’s Hospital Medical

Center

Mukhtar-Yola M

Department of Paediatrics, National

Hospital, Abuja, Nigeria

Ojo OO

Lagoon Hospital, Lagos

Emodi IJ

2

Department of Paediatrics, University

of Nigeria Teaching Hospital, Enugu,

Nigeria

linear R =0.73) and marginally

with lower DPT coverage by geo-

political zone (Spearman ρ=-0.77,

2

p=0.07, linear R =0.59).

Omoigberale AI

Conclusion: The study reveals that

the number of paediatricians in

Nigeria is grossly inadequate with

a huge child-to-paediatrician ratio.

There is also an uneven distribu-

tion of the paediatricians with

higher numbers in the southern

states. Zones of the country with

lower child-to-paediatrician ratios

also experienced lower U5MR.

There is a need to train more pae-

diatricians in Nigeria and promote

an even distribution of the paedia-

trician workforce

Department of Paediatrics,

University of Benin Teaching Hospital,

Benin City, Nigeria

Ezechukwu C

Department of Paediatrics, Nnamdi

Azikiwe University Teaching

Hospital, Nnewi, Nigeria

Olowu AO

Department of Paediatrics, Ogun State

Teaching Hospital, Sagamu

Ogala WN

Department of Paediatrics, Ahmadu

Bello University Teaching Hospital,

Zaria, Nigeria

Key words: Paediatrician, work-

force, child-to-paediatrician ratio,

under-5 mortality, immunization,

childhealth, Nigeria

Esangbedo D.O

Paediatrics Unit, Providence Hospital,

Lagos, Nigeria

(

84.7%) worked for the govern-

ment with 97% of them in hospi-

1

13

Introduction

Paediatric Association of Nigeria Conference in Abuja,

Nigeria. In addition, the registration and financial re-

cords of the Association were reviewed for more names

and personal information of paediatricians in Nigeria.

We also obtained the names of all who had passed the

part II fellowship examination of either the West Afri-

can College of Physicians or National Postgraduate

medical college from the two Colleges. Various paedia-

tricians located at different parts of the country were

thereafter contacted by the PAN secretariat either per-

sonally or by telephone to verify obtained information

about the paediatricians. We also contacted Nigerian

paediatricians in Diaspora for additional verification of

our database. After compiling the list of all paediatri-

cians in Nigeria which included Nigerian paediatricians

in diaspora, it was circulated via electronic mails to all

members of PAN for corrections or additions. This proc-

ess helped us to identify and exclude the paediatricians

who had died and those who were retired. Data collec-

In Nigeria, UNICEF and WHO reported infant and un-

der-five mortality rates as 88/1000 live births and

1

43/1000 live births respectively by the end of 2010.

About half of global under-five deaths occur in only five

countries: India, Nigeria, Democratic Republic of the

Congo, Pakistan and China. India (22 percent) and Nige-

ria (11 percent) togethe₂r account for a third of all under-

five deaths worldwide. Immunizations are one of the

most cost effective public health interventions known to

man because vaccines save lives and promote child sur-

vival. WHO-UNICEF estimates for Nigeria show that in

2

required 3 dose of the combined diphtheria, pertussis

and tetanus (DPT3) vaccine usually given at 14 weeks

009, the_rp_d roportion of 1 year-olds who received the

1

of age was only 42% and national DPT3 coverage rate

for any single year has never risen above 60% in the last

twenty years. By the end of 2010, only two countries in

sub-Saharan Africa – Malawi and Madagascar are re-

ported to be on track to achieve Millennium Develop-

ment Goal 4 which is reduction by two thirds between

st

tion was censored by 31 December 2011.

Data analysis was restricted to paediatricians residing in

Nigeria. Except when noted, all analyses conducted in-

cluded only paediatricians in active practice, regardless

of the type of practice (clinical care, public health or

administrative).

1

than five years

990 and 2015₃, the mortality rate in children younger

Crucial to improvement in the health indices of any

country is her health manpower. For child health the

highest level of care is provided by paediatricians. They

not only provide promotive, preventive and curative

services, they also help train the country’s needed man-

power in child health. The quality of life of a child could

be improved by access to a trained paediatrician. The

current number of paediatricians residing and practicing

in Nigeria is not known. Secondly, the distribution of

the available paediatricians in the country is also un-

known and this may have huge implications for service

delivery. Determining such data will not only inform

current recommendations but will provide basis for fu-

ture projections of workforce requirements and tracking

of trends. Therefore the objectives of this study were to

determine the number and distribution of paediatricians

in Nigeria and correlation between the number and child

health indices such as U5MR and DPT3 vaccine cover-

age.

Population and Demographics

Data were analyzed for the country as a whole, the six

geopolitical zones, the 36 states and the Federal capital

territory (FCT). The zones and their component States

are: North Central (Benue, FCT, Kogi, Kwara, Nasa-

rawa, Niger and Plateau); North East (Adamawa,

Bauchi, Borno, Gombe, Taraba and Yobe; North West

(

Kaduna, Katsina, Kano, Kebbi, Sokoto and Jigawa);

South East (Abia, Anambra, Ebonyi, Enugu and Imo);

South South (Akwa Ibom, Bayelsa, Cross-River, Delta,

Edo and Rivers); and South West (Ekiti, Lagos, Osun,

Ondo, Ogun and Oyo).

The total population of Nigeria was estimated using the

National Population Commission figure of 167 million

for the year 2011 and assumed that 45% of the popula-

tion is <15 years old based on_,₅Nigeria Demographic and

4

Health Survey (NDHS) 2008. Estimates of the popula-

tion by states as at the end 2011 were based on projec-

tions from the National Population Commission 2006

census at 3.2% annual growth. The U5MR (per 1000

6

Methodology

live births) and the DPT3 vaccination coverage for each

of the six geopolitical₅zones of Nigeria were obtained

from the NDHS 2008. These population values were

used to calculate the ratio of children <15 years to the

number of paediatricians in each state, each geopolitical

zone and the country as a whole.

Definition: A paediatrician was defined as a doctor who

had passed the part II paediatric fellowship examination

of either the West African College of Physicians or Na-

tional Postgraduate Medical College or has been duly

certified by an equivalent body from other countries.

Paediatrician Count

Statistical Analysis

A structured questionnaire requesting for data on name,

sex, current practice location, fellowship obtained, year

of fellowship, area of interest/subspecialty, telephone

number and email address was distributed to ordinary

members of Paediatric Association of Nigeria (PAN) via

email and subsequently at the January 2011 annual

Data were analyzed using Microsoft Office Excel 2010

and SAS version 9.3 (SAS Institute, Cary, NC, USA).

Categorical variables were summarized as frequency,

mean, percentage or ratio. Ecological (zone-level) asso-

ciations between childhood mortality, DPT vaccination

1

14

coverage and ratio of children/paediatrician were

with 3% of them working as non-hospital based public

servants. Assessing the distribution by level of care hos-

pital showed that 88% (344) worked at tertiary hospitals

while 11.3% (44) and 0.8% (3) worked in secondary and

primary level hospitals.

conducted using Spearman rank correlations due to the

small number of zones (n=6). Curvilinear relationships

were observed that suggested linearity on a natural log

scale; therefore, the child-to-paediatrician ratio was

natural-log transformed and regressed upon mortality

2

and DPT coverage by zone, with adjusted R and p-

Private sector: Sixty nine paediatricians who worked

exclusively in the private sector were located primarily

in ten states of the Federation and the FCT. The largest

concentration of these paediatricians was in Lagos State

with 42 (60.9%) and Rivers State with 10 (14.5%). Pae-

diatricians primarily working in the private sector make

up 46.7% and 31.3% of the paediatricians work force in

Lagos and Rivers States respectively. FCT had five

while each of the other eight States had three or fewer

privately practicing paediatricians.

values presented from those models.

Results

General

There were 492 paediatricians in Nigeria as at the end of

2

(

011. This consisted of 282 (57.3%) males and 210

42.7%) females giving a male female ratio of 1.3:1.

Retired paediatricians numbered 16 (3.3%) leaving 476

96.7%) actively practicing paediatricians in the work

Practice location and geographical Distribution

(

force. A large proportion of the paediatricians (90%)

received their fellowship from either the National Post-

graduate Medical College or the West African College

of Physicians.

State distribution: Figure 1 shows uneven distribution

of the paediatrician work force in the 36 states and FCT

with Lagos State having the highest number (85=17.9%)

of practicing paediatricians followed by FCT with 37

(

7.8%) paediatricians. Yobe State with a children popu-

Primary employment setting

lation of 1, 240,795 had no paediatrician.

A large proportion (403=84.7%) of the paediatricians

worked for the government with only 69 (14.5%) work-

ing primarily in the private sector and 4 (0.8%) with

international agencies.

Regional/Zonal Distribution: More than two thirds of

the paediatricians (336=70.6%) were practicing in the

southern part of the country. Figure 2 shows an uneven

distribution among the six zones with the South West

having the highest number of paediatricians (152) fol-

lowed by the South South zone (114); within zones,

there is also an uneven distribution by state.

Government: Majority (391=97%) of the paediatricians

employed by the government worked in hospital settings

Fig 1: Number of practicing peadiatricians in the 36 States and FCT.

Population and Demographics

had much fewer paediatricians. Figure 4 illustrates

states, zonal and National child-to-paediatrician ratios.

Five states in the South and two from the North zones

had child-to-paediatrician ratios below 100,000 but no

state in the country had a ratio lower than 25,000.

Twenty two states (59.5%) had ratios above the National

children per paediatrician ratio of 157,878. The smallest

ratio was in FCT with 26,659 children per paediatrician

while the highest ratio was in Bauchi state with

2,487,313 children per paediatrician. Neither the number

There were 476 documented paediatricians practicing in

a population of 75.15 million children less than 15 years

of age. This equaled a National ratio of 157,878 children

per paediatrician.

States: Figure 3 demonstrates the number of paediatri-

cians by state and population. Lagos and Kano states

had the largest populations but Kano state unlike Lagos

1

15

of paediatricians in each state (Spearman ρ=0.23,

mapping of the child-to-paediatrician ratios by zone.

p=0.17) nor the ratio of children per paediatrician

(

Spearman ρ=0.15, p=0.39) was correlated with the total

Fig 5: Mapping of average children per paediatrician ratios in

the six Zones in Nigeria

population of children <15 years in each state.

Fig 2: Distribution of Paediatricians in the six geopolitical

zones of Nigeria.

Legend

>

≤

600,000

400,000-600,000 Yellow

200,000-400,000 Light green

200, 000

Red

Fig 3: Actively practicing paediatricians by State and

population.

Dark green

Under five mortality and DPT vaccine coverage

Higher absolute number of paediatricians in each zone

was associated with lower under U5MR (ρ=-0.94,

p=0.0048), accounting for 84% of the variability among

zones. Higher numbers of paediatricians were not sig-

nificantly associated with higher DPT3 coverage by

geopolitical zone (ρ=0.60, p=0.21).

Higher child-to-paediatrician ratio was significantly

associated with higher U5MR (ρ=0.82, p=0.04, linear

2

R =0.73) and marginally lower DPT coverage by geopo-

2

litical zone (ρ=-0.77, p=0.07, linear R =0.59). However,

a curvilinear relationship was observed between the

child-to-paediatrician ratio and the childhood health

outcomes, so the natural-log transformed ratio was re-

Fig 4: Average ratio of children<15years/paediatrician – Na-

tional, Zonal and in the States of Nigeria.

2

gressed against the outcomes (Figure 6). Adjusted R

values from these models indicated that 80% of the vari-

ability among zones in U5MR (p=0.01) and 82% of the

variability in DPT3 coverage (p=0.008) are explained by

the log of child-to-paediatrician ratio in each zone.

When under-five mortality figures for each zone from

Nigeria Multiple Indicator Cluster Survey (MICS) 2011

7

report were used for the correlation rather than the

NDHS 2008 report figures, findings were similar

(

data not shown).

Discussion

Total number and trend/ College contribution/

population ratio

Zones: There were wide variations in the average child-

to-paediatrician ratios in each of the six geopolitical

zones with a trending towards lower ratios in the South

zones as shown in Figure 4. The North East had the

highest average ratio (718,412:1) while South West had

the lowest average ratio (95,682:1). Figure 5 shows

There were 492 paediatricians in Nigeria as at December

st

3

1 , 2011. The establishment of two postgraduate medi-

cal Colleges in the country has contributed greatly to

this number as 90% of the paediatricians obtained their

1

16

training from these Colleges. The number of paediatri-

cians currently practicing was however 476. WHO re-

ports 55,356 physicians in Nigeria by end of 2010 with a

physician population ratio of 4 per 10,000; less than

Postgraduate Medical College (1972-84) showed that

the College had produced a total of 145 Fellows during

the period. Of these 36, 34, 27 and 13 respectively were

in internal medicine, obstet₁r₂ics and gynaecology, gen-

eral surgery and paediatrics. Also from March 2008 to

march 2012, the pass rate in paediatrics at the part I ex-

aminations of the National postgraduate Medical Col-

lege has remained below 33% with the lowest rate being

12.7%. This indicates that outflow from the programme

is also a problem with a similar trend in the West Afri-

can College of Physicians. To improve the paediatric

work force in the country, obstacles to a faster pace of

completion of the Fellowship programme need to be

addressed by the Colleges, training institutions, trainers

and the trainees.

8

their recommended 1 per 600 population. Our data

shows that practicing paediatricians in the country are

less than one percent of the physicians in Nigeria. The

absolute number of paediatricians in Nigeria diminished

beside the national child-to-paediatrician ratio of one per

1

57,878 children less than 15 years thus revealing inade-

quate supply of paediatricians. In contrast, the Ameri-

can board of pediatrics reported a ratio of 1400 c₉ hildren

to one paediatrician in the United States in 2011.

Fig 6: Relationship of zonal child: paediatrician ratios and

child related outcomes

Gender

When the Paediatric Association of Nigeria was inaugu-

rated in 1969, the founding c₃ore members consisted of

1

ten men and one woman. This gender ratio has

changed drastically with women constituting 42.7% of

the paediatrician workforce of Nigeria compared to 9%

in 1969. This trend is also exp₁e₄r_, i₁e₅nced in other countries

such as Japan and the USA.

For Nigeria, this is a

healthy trend as its society is very diverse in culture,

languages and religious inclination which reflects in

client’s physician gender preferences.

Setting of Practice - Government/Private

A large proportion (87.5%) of paediatricians in Nigeria

is employed by the government at tertiary institutions

where they provide specialized care for children and

engage in teaching paediatrics at both undergraduate and

postgraduate levels. This result is consistent with₆find-

1

ings in other low and middle income countries. Al-

though these centres of employment are designated terti-

ary, some primary care is often still provided by the pae-

diatricians. In addition, these paediatricians from the

tertiary institutions are involved with primary level of

care through advocacy, voluntary work or as consultants

to the private sector and international agencies focused

on child health. Although only 14.5% of the paediatri-

cians work primarily in the private sector, it is notewor-

thy that the two cities with the highest number have high

wealthy populations. Lagos State is the major economic

hub of the nation with most industries, national and mul-

tinational organizations. This has resulted in an in-

creased presence of large private medical practices, mul-

tinational companies and Banks with employee health-

care facilities that attract paediatricians to the private

sector thus complimenting the efforts of government in

providing health care.

The reason for the mismatch of paediatrician growth and

population growth in Nigeria is multifactorial. One of

the known workforce challenges is international migra-

tion. Incidentally, Nigerian paediatricians registered

with the Ameri₁c₀an Medical Association (AMA) in 2003

numbered 427. It is also important to note that not all

paediatricians in the USA are members of AMA.

Hagopian et al reported that more than 23% of Amer-

ica’s physicians received their medical training outside

the USA and that 5,334 of them were from sub-Saharan

Africa with₁₁86% originating from Nigeria, South Africa

and Ghana.

Also, a slow process in the training path-

way for paediatricians may partly explain the shortage.

This could be either due to inadequate enrolment of doc-

tors or low percentage of graduations from the training

programme or both. However, entry into the paediatric

residency training programme in Nigerian institutions is

very competitive with more applicants than available

training positions in the institutions. A review of results

of the examinations for Fellowship of the National

Geographical spread- State/Zones

There was an uneven distribution of paediatricians

across the country with states in the south having more

paediatricians than states in the north. The pattern of

distribution of the paediatricians from our data is proba-

bly a reflection of the educational situation in the

1

17

country as a whole. For example In the year 1999, the

rate of participation of 14 year-olds in schools in the

south of Nigeria was 85% while the northern zones had

of their children, access to a health facility or health

professional was listed only 15% of the time among

rural dwellers. Thus, in planning public health interven-

5

only about₇40 percent except for the North-Central with

tions, other concerns should be addressed besides access

to facility and/or professional.

1

7

1percent. Also the presence of a teaching hospital in a

state contributed to more paediatricians in that state. All

the states with ten or more paediatricians had teaching

hospitals while only 26.3% of the states with less than

ten paediatricians had teaching hospitals. Similarly,

there is a wide variation of the child-to-paediatrician

ratio across the states with more than 90 fold variation in

some instances. Factors other than the educational at-

tainment and presence of public-funded tertiary hospi-

tals may also explain the wide variations between states

and between zones. The economic activity and affluence

of the state may also have an influence on the number of

paediatricians per state. For example, states such as La-

gos, Rivers and the FCT which have huge economic and

political activities have the highest numbers of paediatri-

cians and the largest pool of paediatricians in the private

sector, reflecting the high purchasing power of the resi-

dents. The FCT also enjoys a relative lower population

which makes their child-to-paediatrician ratio more fa-

vourable. In contrast states with low gross domestic

products such as Yobe, Zamfara and Taraba had the

lowest number of paediatricians. This is not limited to

paediatricians alone. Nigeria’s health workforce profile

for 2007 similarly reported that health workers are

poorly distributed and in favour of urban, southern, tert₁i-₈

ary health care services delivery and curative care.

Like other high cadre professionals such as lawyers and

engineers, paediatricians may be attracted to states

where their services could be paid for. This trend of un-

One of the strengths of this study is that a detailed and

comprehensive method for identifying and locating pae-

diatricians in Nigeria has resulted in the first national

census of paediatricians. Further, the present study was

able to correlate paediatrician distribution with popula-

tion distributions and childhood outcomes in all areas of

Nigeria. Despite the significant strengths of this study,

some limitations should be noted. First, we relied on an

estimate that 45% of the population in all states is under

age 15, which is the national proportion. State and zone

level estimates of child-to-paediatrician ratios would

change somewhat if this assumption is inaccurate. Sec-

ond, relationships between paediatrician distribution and

child outcomes are assessed at the broad geopolitical

zone level, not at the level of the individual, or even the

states. Thus, we are not able to determine whether indi-

vidual children experiencing specific outcomes saw a

paediatrician or not, or even had a paediatrician nearby.

We are also limited in our ability to determine whether

the presence of paediatricians in an area of the country is

a cause of improved outcomes among children, or is a

surrogate measure for other important factors.

Conclusion

1

6

even distribution is in keeping with reports from WHO

Paediatricians are grossly inadequate in Nigeria with

huge child-to-paediatrician ratios. There is also uneven

distribution of the paediatricians with higher numbers in

the southern states with either teaching hospitals or in-

creased wealth. Zones of the country with lower child-to

and is not peculiar to Nigeria or developing countries.

Developed countries with data on paediatric workforce

have reported simila₉r_,₁f₉indings with a leaning towards

urban or large cities.

-paediatrician ratios also experience lower childhood

To improve the paediatrician distribution across the

states and zones in the country, the state governments

should sponsor doctors for postgraduate training in pae-

diatrics and have these doctors work for the state after-

wards. This does not have to be limited to indigenes of

the state in question. The state governments should also

encourage paediatricians to come to their states for sab-

batical leaves by providing good working and welfare

conditions. PAN can be a focal point for such partner-

ships. Providing adequate security is however para-

mount in view of the recent security challenges in the

country.

mortality rates and higher DPT vaccination coverage.

Postgraduate medical training Colleges including both

trainers and trainees and the government have roles to

play in reducing the high child-to-paediatrician ratios in

Nigeria.

Authors’ contributions

The study was conceived by all the authors except WJG.

Data was collected by all authors except BMR and

WJG. EEN and WJG analyzed the data while EEN

wrote the initial draft of the manuscript. All authors re-

viewed and approved the final manuscript for submis-

sion.

Impact on child health

Conflict of Interest: None.

Funding: None.

Our data suggest that areas of the country with lower

child-to-paediatrician ratios also experience lower

U5MR and lower DPT3 vaccination coverage. How-

ever, other multiple factors such as living standards,

wealth, cultures and beliefs, education and urban resi-

dence also simultaneously impact both the paediatrician

distribution and health outcomes. Indeed, in the recent

survey of parents’ reasons given for lack of vaccination

Acknowledgement

PAN gratefully acknowledges the assistance of Dr.

Ekopimo Ibia for manuscript editing and Emmanuel

John for data entry.

1

18

Paediatric Association of Nigeria Executive Committee Members 2010 - 2012.

Ekure EN

Omoigberale AI

Ezechukwu CC

Olowu AO

Ogala WN

Esangbedo DO

Esezobor CI

Balogun MR

Mukhtar-Yola M

Ojo OO

Emodi IJ

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