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CONTEXTAs highlighted by the 2006 World Health Report, Nigeria is one of 36 sub-Saharan African countries in the midst of a health workforce crisis. Inadequacy of optimal numbers of health workers with the appropriate skills-set is most pronounced in the rural and remote regions of Nigeria where 52% of the population live. Mortality and morbidity data from limited surveys of Nigeria indicate greater unmet health needs in rural and remote regions than in urban areas. Spartan living conditions, non-existent rural workforce policies and strategies, and an inadequate number of health staff with skills appropriate to the health priorities of rural areas are several of the many factors attributable to the steady decline in Nigeria's rural and remote health system. Based on 7 years' experience as a public health physician in rural and remote northern Nigeria, the author provides a perspective on factors hindering health workforce recruitment and retention, and proposes approaches to sustainably improving the current unsatisfactory health workforce situation in Africa's most populous nation.ISSUESThis article posits that out-migration of health workers is not a critical contributor to health workforce shortages in Nigeria's rural and remote areas. More important factors include contraction of government health spending as a percentage of GDP despite deteriorating health conditions, public health management systems that operate by default rather than by design, spartan living conditions outside urban areas, inadequate training of appropriate cadres of health staff, limited facilities and medications for effective delivery of clinical services, and burnout of overworked and underpaid rural-based clinicians. Most current health policy and strategy documents in Nigeria do not adequately account for the unique demographic features and health issues which vary according to remoteness from major cities. Addressing rural and remote health workforce shortages in Nigeria should begin with the development of a well-researched national rural and remote health strategy.LESSONS LEARNEDSub-optimal leadership and management at all levels of the public health sector, poverty, low motivation, inadequacy of health facilities and medications for effective delivery of health care, inadequacy of funding to employ qualified health staff, and primitive living conditions constitute major disincentives for skilled health workers to work in the rural and remote regions of Nigeria, and for declining productivity among existing health workers. Practical interventions to encourage recruitment and retention, and to assure improvements in the quality and popularity of appropriately designed training programs for health professionals needed in rural and remote regions of Nigeria are discussed. A need is highlighted for adequate planning and resource allocation to enable a systematic overhaul of encumbrances currently impacting on Nigeria's rural and remote health system. Lessons that may be adapted from successful rural and remote health workforce training and recruitment strategies in Tanzania are discussed.

Improving health workforce recruitment and retention in rural and remote regions of Nigeria