Perspective

Healthcare workers are expected to provide care under demanding circumstances. In Nigeria, many doctors operate within a fragile labour protection environment characterised by workforce shortages, recurrent industrial disputes and inconsistent enforcement of employment safeguards [1]. These challenges have implications not only for the well-being of doctors but also for the stability and performance of the health system.

Workforce shortages and systemic pressure
Nigeria faces a severe shortage of healthcare workers. Estimates suggest that the country has approximately 0.29 doctors per 1,000 population, with the National Association of Resident Doctors reporting a ratio of one doctor per 9,000 patients in some tertiary institutions – a density substantially lower than the WHO recommendation of 1.7 doctors per 1,000 population for universal health coverage and far below the global average [1, 2]. The WHO African Region Health Workforce Report 2024 classifies Nigeria among countries with low health worker density and low production capacity, requiring intensified efforts to expand workforce training and retention [3]. Such workforce deficits place considerable pressure on available doctors, particularly in tertiary hospitals where resident doctors often undertake prolonged on-call shifts. Available evidence indicates that Nigerian doctors frequently work shifts exceeding 24 hours in understaffed facilities with inadequate equipment and inconsistent remuneration [1, 4]. These prolonged shifts, while common in resource-constrained settings, routinely exceed safe limits established by occupational health standards and contribute to measurable harm.

Excessive workloads have measurable consequences. Studies among resident doctors in Nigerian teaching hospitals have reported high levels of burnout, emotional exhaustion and work-related stress. In some settings, burnout prevalence has been reported in more than half of surveyed doctors, with prolonged working hours and limited staffing identified as key contributing factors [5–7]. Workplace stress has also been associated with poorer perceived health among doctors and reduced job satisfaction [7]. A 2025 study among healthcare workers in Lagos found that boosting employee engagement presents a robust strategy to address burnout, emphasising that both male and female healthcare workers experience comparable burnout levels in high-demand settings [8].

Migration and workforce attrition
Labour dissatisfaction and challenging working conditions have contributed to a sustained outflow of Nigerian doctors to high-income countries. According to the Federal Ministry of Health’s State of Health of the Nation Report 2024, approximately 3,974 doctors migrated internationally in 2024 alone, seeking better opportunities in countries such as the United Kingdom, Canada and Saudi Arabia [2]. This represents a significant spike from previous years – data from regulatory bodies show that 3,419 doctors requested letters of good standing in 2023, while 3,047 did so in 2022 [2, 9]. The United Kingdom (UK) has emerged as a major destination, with Nigerian-trained doctors consistently ranking among the largest groups of international medical graduates registering to practise in the country [10]. The UK General Medical Council register shows Nigerians as the fourth-largest group of internationally trained doctors in the UK, with 15,692 Nigerian-trained doctors – representing 28.5% of Nigeria’s current domestic workforce – to serve its 69 million people, a population less than one-third the size of Nigeria’s. This means a single high-income nation holds more than one-quarter as many Nigerian-trained doctors as Nigeria itself, while caring for fewer than one-third the population  [11, 12].

The implications of this migration are substantial. Nigeria already experiences a critical shortage of health professionals, with a skilled health worker density of 1.83 per 1,000 population – far below the WHO recommendation of 4.45 per 1,000 for adequate health coverage [13]. Continued outward migration further weakens service delivery capacity, particularly in rural and underserved areas [14]. The loss of trained personnel also represents a significant economic cost, given the public investment required to train medical professionals [11].

Industrial disputes and labour conflicts
Industrial disputes have become recurrent features of Nigeria’s healthcare sector. Over the past decade, nationwide strikes involving doctors and other healthcare workers have been triggered by disputes over unpaid salaries, hazard allowances and working conditions [15–24]. These conflicts highlight deeper structural tensions within the health workforce.

Government responses have ranged from negotiations to legal interventions. On January 9, 2026, the National Industrial Court sitting in Abuja granted an interim injunction restraining the Nigeria Association of Resident Doctors from embarking on any form of industrial action from January 12, 2026, following an ex parte application by the Federal Government [25]. While maintaining continuity of care is essential, such legal restrictions can also generate concerns among healthcare workers regarding the protection of labour rights and the balance between public health priorities and workers’ welfare. It is important to acknowledge that industrial disputes also disrupt patient care and can lead to avoidable deaths. While strikes are a legitimate tool for workers to demand fair treatment, they inevitably harm patients who depend on continuous care. Sustainable reforms must therefore prevent disputes from reaching the point of strike action, addressing grievances before they escalate to service disruption. This tension between worker rights and patient welfare is not unique to Nigeria; it is a challenge that requires balanced policy responses.

Occupational safety and workplace risks
Beyond remuneration and workload concerns, healthcare workers in Nigeria also face occupational risks. Evidence suggests that burnout among healthcare workers may be linked with exposure to workplace violence and unsafe working conditions [26]. The COVID-19 pandemic further highlighted vulnerabilities in occupational safety systems, including shortages of personal protective equipment in some healthcare facilities [27]. Emerging concerns regarding insecurity in certain regions have also entered national discourse. According to the Safeguarding Health in Conflict Coalition, 35 health workers were kidnapped in 15 incidents in Nigeria in 2024, compared to 24 in 18 incidents in 2023 [28]. In Katsina State alone, 83 health workers have been kidnapped over the past eight years, with 16 killed by abductors [29]. These incidents contribute to perceptions of profound insecurity and reinforce calls for stronger institutional protection mechanisms. A 2025 study in Northern Nigeria found that 50% of nurses reported verbal abuse and 19.1% experienced physical violence or sexual harassment in the past year, with inadequate training on workplace violence and limited knowledge of reporting procedures identified as significant predictors [30].

Awareness and utilisation of labour protections
Nigeria’s labour framework includes several statutes intended to regulate employment conditions and dispute resolution, including the Labour Act (Cap L1, Laws of the Federation of Nigeria 2004) and the Trade Disputes Act (Cap T8, LFN 2004). The Labour Act specifies provisions for hours of work, overtime, sick leave and termination of contracts, while the Trade Disputes Act establishes mechanisms for resolving industrial disputes through conciliation and the National Industrial Court [31, 32]. However, awareness and utilisation of these protections among healthcare workers remain limited.

Medical training in Nigeria traditionally prioritises clinical competence while offering minimal structured exposure to employment law or labour rights. Consequently, many junior doctors enter professional practice with limited knowledge of available legal protections or grievance procedures. Hierarchical workplace cultures, fear of retaliation and lengthy litigation processes further discourage formal complaints [33, 34].

The increasing use of short-term employment arrangements has added another layer of complexity. Reports of casualisation within the health workforce describe growing reliance on temporary contracts that lack comprehensive benefits and formal grievance mechanisms [4]. Such arrangements may further weaken the practical enforcement of labour protections. “Casualisation” refers to the practice of employing workers on temporary, short-term contracts rather than permanent positions, often denying them benefits such as health insurance, pension contributions and job security that accompany standard employment.

Comparative perspectives: Labour protections in low- and middle-income countries (LMICs)
The challenges facing Nigerian healthcare workers are not unique; they reflect broader patterns across low- and middle-income countries where labour protections often exist in principle but fail in practice.

In Ghana, health worker density stands at approximately 41.92 per 10,000 population comparable to Nigeria’s 18.3 per 10,000 but still insufficient for population health needs as many experienced specialists are leaving for opportunities abroad and underserved areas continue to experience critical shortage. [13, 35]. Ghana has experienced similar challenges with health worker retention and migration, though its relatively smaller population and more concentrated health infrastructure have allowed somewhat better workforce distribution [35].

In Kenya, the doctor-to-patient ratio is approximately 1:5,263 which is five times less than the WHO-recommended ratio of 1-1.7:1,000 [22]. In 2024–2025, doctors in Kiambu County engaged in prolonged strikes citing labour rights violations such as chronic salary delays, lapses in medical coverage, stagnation in career progression, excessive working hours, irregular procedural transfers and illegal halting of union dues remittance. The author stated that salary payments sometimes arrive over 30 days late and the non-implementation of 2024 incremental salary adjustments contributed to their grievances [36]. Nairobi County health workers have similarly protested withheld arrears and unfair promotions, with the Nairobi City County Health Reforms Task Force reporting that 300 nurses resigned in 2023 citing poor working conditions, low and delayed salaries and the search for “greener pastures” [37].

In South Africa, which has a relatively higher health worker density of 41.2 per 10,000 population, the Public Service Coordinating Bargaining Council (PSCBC) has served as a mechanism for resolving wage disputes, though provincial protests and health sector strikes have continued to disrupt services [38]. South Africa’s experience demonstrates that even with stronger institutional frameworks for collective bargaining, healthcare worker dissatisfaction can still manifest in industrial action when wage negotiations deadlock or implementation lags.

In India, the world’s largest democracy and another major source of health worker emigration, resident doctors have faced similarly grueling conditions. Despite the 1992 Uniform Residency Scheme capping duty hours at 48 hours per week and 12 hours per day, institutions routinely push doctors into 70–100-hour workweeks without adequate rest [39]. In 2025, the United Doctors Front filed a writ petition before India’s Supreme Court seeking enforcement of these limits, arguing that continued violation of duty-hour norms breaches fundamental rights under Article 21 of the Constitution [39]. A Parliamentary Standing Committee on Health and Family Welfare has recommended adopting aviation-industry-style safety protocols for resident doctors, mandating fixed rest periods and monitored duty rosters [40]. India’s experience illustrates that even with explicit legal protections, enforcement gaps can perpetuate unsafe working conditions – paralleling Nigeria’s challenges.

These comparative examples demonstrate that labour protection failures in healthcare are systemic across low- and middle-income countries, driven by common factors: insufficient workforce investment, weak enforcement mechanisms, hierarchical workplace cultures and the global pull of higher-income destination countries. However, they also reveal that coordinated policy responses such as Kenya’s county-level health reforms, South Africa’s bargaining council structures and India’s judicial interventions can provide models for addressing these challenges.

Lessons from international contexts
Evidence from other healthcare systems suggests that stronger labour protections can contribute to improved workforce retention and job satisfaction. For example, systematic reviews of the United Kingdom’s National Health Service indicate that supportive work environments, fair remuneration and structured working-hour regulations are associated with improved morale and reduced staff attrition [41, 42].

These comparisons highlight an important point. The existence of labour laws alone does not guarantee protection. Effective enforcement, institutional accountability and supportive organisational cultures are equally essential. In Nigeria, the gap between legal provisions and practical implementation remains the central challenge.

Reform Imperatives
Addressing labour protection challenges in Nigeria’s health sector requires coordinated reforms. Several measures warrant consideration.

First, medico-legal and labour rights education should be integrated into undergraduate and postgraduate medical training. Such training would equip healthcare workers with a clearer understanding of employment rights and dispute resolution processes under the Labour Act and Trade Disputes Act.

Second, healthcare institutions should strengthen internal grievance mechanisms that allow workers to raise concerns safely and efficiently, reducing the likelihood that disputes escalate to strikes that disrupt patient care.

Third, enforcement of occupational safety standards must be prioritised to protect healthcare workers from workplace hazards, including violence and insecurity. This requires not only institutional protocols but also collaboration with security agencies to address the kidnapping and attacks that have targeted health workers in conflict-affected regions.

Fourth, workforce planning policies addressing remuneration, staffing levels and working conditions are essential to improving retention and reducing outward migration. The Federal Ministry of Health’s National Policy on Health Workforce Migration, approved in 2024, represents a step toward managed migration, but implementation must be matched with domestic investment in working conditions [43].

Finally, institutional culture must shift from expecting silent endurance to supporting professional wellbeing. Nigerian doctors are often expected to demonstrate resilience and self-sacrifice regardless of working conditions. While dedication to patients is admirable, normalising hardship as part of medical professionalism risks perpetuating unsafe and inequitable work environments.