Nigeria: More worrisome state of healthcare system persists as govt ignores rising medical brain-drain

WorldStage Newsonline (EXCLUSIVE)– Nigeria has one of the worst health records in Africa, including the second highest population with HIV and the largest number of deaths from malaria. This report by SEGUN OTOKITI, exposes that the sorry state of the country’s healthcare system is not only the same but more worrisome as stakeholders highlight the needs to start with an acknowledgement by the government that the brain drain is costing the country more than it benefits it in remittances.

It’s again another new year full of expectations and hope of what to get from government in all the critical facets of human needs of Nigerians. Top in these areas of needs is the healthcare sector, which for many years has been beleaguered by the challenge of losing of medical professionals to countries where better welfare conditions exist.

Nigerian doctors

Several reports have supported claim that an average of four medical doctors leave the country for greener pastures daily. This isn’t inclusive of other medical professionals as nurses, paramedics, social health workers etc.

The current Minister of Labour and Productivity last year played down on danger of the phenomenon when he said that the country had enough medical doctors and that their exodus to foreign lands was another means Nigeria was earning foreign exchange. It was a comment that drew him condemnations and accusation of insensitivity from many a Nigerian.

Chris Ngige, Nigeria’s Minister of Labour and Productivity

As the most populous country in Africa and with estimated population hovering around 200 million, Nigeria is no doubt a hotbed of health care needs. However, taking this and the mass outflow of Nigerian medical practitioners of all categories to territories outside the country for better living into consideration, she challenge of making her citizens healthy and sound becomes glaring.

The operating theater at the Okene Zonal Hospital in Kogi State, Nigeria. Image by T.R. Goldman. Nigeria, 2017.

The challenge, according to medical experts and analysts, is not helped by what they consider a meager allocation of about N46 billion to health in then2020 budget, which is just 2% of the over N10 trillion total. This, according to them, serves as proof of near negligence to which the sector is being treated.

It’s an irony, many say, that with relatively good population of medical practitioners in the country, Nigeria is still among countries with poorest of medical care and ravaging health scourge against her inhabitants.

Opinions are not too diverse on why Nigeria is faced with the contradictory fortunes as most of her citizens knock governments at federal, state and local levels for the malady.

Even with what some refer to as fair number of medical professionals, Nigeria is still a far cry from the World Health Organisation’s (WHO) recommended one medical doctor per 600 people. But if most of them had been available for service in the country, the health sector would have been much more boosted.

Findings and experiences of patients and medical practitioners alike reveal that combination of social, economic and environmental challenges are being experienced in the health care sector, ranging from brain drain, poor remuneration, obsolete infrastructure, inadequate medical facilities, underfunding, mismanagement by medical administrators as well as insurgency in parts of the country.

Nature of services in government hospitals across the country

Visits to some of the main general hospitals in Lagos State betray a health system in dire need of expansion and equipping. Aside the fact that they are overcrowded, facilities are far from enough to meet effectively the needs of overwhelming number of patients. Conversely, medical personnel faced with situations as these are often stretched thin to give their best in service delivery. With the overwhelming number of patients they have to attend to daily, they most time get tired with attendant reduction in quality performance.

National Hospital Abuja

An obstetrician with the Ile-Epo General Hospital in Oke-Odo Local Council Development Area (LCDA) of Lagos State, who preferred anonymity because he does not have the authority to speak formally on the issue, relived the daily burdensome pressure mounted on medical doctors in delivering their services. According to him, for effective performance, a medical doctor supposed not to consult with more than 20-25 patients in a day, but that they most times have to meet close to average of 60 on every working day.

Asked why it’s so. Many factors combined, he responded. “There’s first the problem of inadequate hands due to departure of so many medical personnel to foreign lands for better earnings as well as living conditions,” he stated. He added that there are far fewer health institutions than are needed for the number of people in need of their services.

It’s same story of woes and grinding of teeth by patients also. Mrs. Oredeji had come to the Ile – Epo General Hospital for a follow-up treatment of malaria. Spotted hissing and fuming, our reporter engaged her on the reason for her behaviour. She instantly started blasting at the health officials on duty over what she condemned as undue delay in attending to her.

Irrua Specialist Teaching Hospital in Edo State

She claimed to have arrived the hospital over four hours earlier without any hint she would be attended to soon. Asked if the delay she accused the officials of was deliberate, she only replied that there were so many others waiting for consultation but that the officials were sometimes partial in attending to patients.

However, it’s obvious that the woman’s travail points to a problem of heavy population pressure on inadequate facilities. Certainly so many other patients as Mrs. Oredeji must have faced same situation and harboured sentiments as hers.

At the Federal Teaching Hospital, Ido-Ekiti, operations are far more organized and patients more controlled as well as attended, but feelings about the state of health care in the country appear a little mixed. While a senior medical officer in the institution who volunteered just Simeon as a name to mention sees the state of health care services in Nigeria as volatile and ineffectively conceived, a Chief Matron who refused mention of her name attributed politics and insensitivity on the part of key stakeholders in the health sector as the factor affecting quality delivery.

Obafemi Awolowo University Teaching Hospital

According to Dr. Simeon, governments appear at all times to have good and sincere intention to build a purposeful heath sector but are often pulled back by the twin factors of inaction and wrong action, whenever any is taken. “It’s either governments intend pronouncement of seemingly good health policies as mere window dressing or as product of shallow minds, otherwise Nigeria should be in good stead with some of the health measures that have been introduced over the years,” Simeon submitted.

The situations with some hospitals/PHC in parts of Akoko Edo in Edo State perhaps lend credence to Dr. Simeon’s submission. During a visit to that part of the state, some health centres were found to be well supplied with medical kits and physically good operational environment but there were far less than enough personnel.

At one of them, there were only a nurse, an attendant and the gateman. That such a facility is available without government attention and concern is not only embarrassing but attests to recklessness of governments’ administrative indiscipline, said an elderly man who was around at the time of the visit and was forced by what he saw to comment on it.

Dr. Simeon would also add that government policy of massive extension of health care to the rural populace was only met by erecting hospitals and health centres, not with provision of needed manpower and equipment.

In the north-eastern part of the country, the sorry state of the country’s healthcare system is not only the same but more worrisome.

Rising exit of medical professionals

Nigeria’s polling agency, NOI Polls, in partnership with Nigerian Health Watch in 2017, found that most doctors seek work abroad.

Also corroborating the fact of the mass outflow of Nigerian medical practitioners, Mr. Chike Nwangwu, Head of a Nigeria’s polling agency known as NOI Polls, said the trend of doctors migrating to other countries is at an all-time high.

Women and girls are waiting for a fistula repair at Maiduguri’s State Specialist Hospital © Anne Wittenberg/UNFPA

According to him, his agency’s survey shows that 88 percent of doctors are considering work opportunities abroad while reasons for emigrating include better facilities and work environment, higher salaries, career progression and improved quality of life.

Another medical professional, Dr Nwakanma said “From internship days everyone is thinking PLAB (Professional and Linguistics Assessments Board), that’s the exam for the UK, everyone is thinking USMLE (United States Medical Licensing Exam) for the US. It’s part of the system. When you graduate people ask, ‘Where are you doing your residency, the UK or the US?”

Nwakanma disclosed that more than 5,000 Nigeria-trained doctors are currently registered in the UK. Other popular destinations, according to him, include the US, Canada and Saudi Arabia.

“We’re all in this WhatsApp group. Everyone started with a Nigerian number, one year later you see a British number or an American number. Numbers are changing because people are leaving. If I have 10 friends, nine of them are leaving,” he added.

Does Nigeria have enough doctors to ignore brain-drain?

If utterances by key government functionaries, including President Muhammadu Buhari, are to be taken on the face value, it will readily be said that cries of shortage of medical personnel in the country are false alarms.

President Buhari commissions a cancer center build by Lagos State government

Months back, the trio of President Buhari, the immediate former Minister of Health Dr. Isaac Adewole and Minister of Labour and Productivity, Dr. Chris Ngige sparked bitter controversy on the number of medical practitioners in the country and the challenge of health care delivery.

Buhari had said on the matter: “You don’t have to be in (a doctor’s) uniform to be loyal. Others who feel they have another country to go to may choose to go. We will stay here and salvage it together.”

Speaking almost in the same perspective, Dr. Isaac Adewole suggested that doctors who couldn’t find work should turn to alternative careers. “It might sound selfish, but we can’t all be specialists,” Adewole said, adding that some doctors would be specialists, general practitioners, and some would be farmers. He corroborated his position on the matter by saying that the man who sewed his gown is a doctor and that he makes the best gowns. He also said that one doctor to 4088 people in Nigeria is better than other African countries.

Dr Osagie Ehanire, Nigeria’s Minister of Health

Then the Minister of Labour, Dr. Chris Ngige, a medical doctor himself, denied that Nigeria has a medical brain-drain problem and that the country has a surplus of doctors. “We have surplus. If you have surplus, you export… Who said we don’t have enough doctors? We have more than enough. You can quote me. There is nothing wrong in them travelling out. When they go abroad, they earn money and send them back home here. Yes, we have foreign exchange earnings from them and not just oil,” Ngige argued.

But while officials play down the impact of Nigeria’s medical brain drain, advocates are increasingly concerned about the crisis, which they say has both human and economic costs.

They said the country has not got a surplus of doctors by global standards. The World Health Organisation recommends one doctor to 600 people. But continuous migration had further worsened the physician-patient ratio in Nigeria from 1:4,000 to 1:5,000, contrary to WHO’s recommended 1:600.

The low doctor-to-patient ratio is leading to unnecessary fatalities, avoidable deaths, longer wait times, frequent medical errors and a general deterioration in the health of Nigeria’s population.

The National Population Commission (NPC) has projected the current population to be about 182 million at a 3.5 percent growth rate from the 2006 census. This means Nigeria needs 303, 000 medical doctors currently, and at least 10,605 new doctors annually to cover the gaping physician-patient ratio.

The country has about 72 000 medical doctors registered with the Medical and Dental Council of Nigeria, with only approximately 35,000 practicing in Nigeria.

And according to the Mo Ibrahim Foundation, doctors cost an African country between $21,000 and $51,000 to train. Nigeria is one of nine countries who have lost more than $2bn since 2010 through trained doctors who migrated.

Meanwhile countries like the UK benefit. With one in 10 doctors working in the UK coming from Africa, the country saves around $2.7bn by recruiting these doctors.

Aside from leading to a severe shortage of medical staff in Nigeria and disrupting health care services, a report released in August last year by the Mo Ibrahim Foundation estimated that African countries have footed a bill of $4.6 billion in training doctors who were then recruited by the U.K., U.S., Canada, and Australia.

Following Adewole’s comment, Nigerians took to social media to condemn the minister’s claims. They blamed the government for the poor structuring of the medical residency programme in Nigeria, which according to them left many doctors without placements, and for a difficult working environment that has recently seen the health sector plagued by incessant strikes.

The data, according to advocates, cannot be ignored that Nigeria has one of the worst health records in Africa, including the second highest population with HIV and the largest number of deaths from malaria. Although it has significantly reduced its maternal mortality rate since 1990, Nigeria’s is lagging behind other nations.

It’s the opinion of many medical professionals that only greater investment in health will reduce the brain drain of Nigerian doctors. This needs to start with an acknowledgement by the government that the brain drain is costing the country more than it benefits it in remittances.

Problem with Nigeria’s healthcare system

According to the Lagos Ile-Epo General hospital obstetrician, there’s first the problem of inadequate hands due to departure of so many medical personnel to foreign lands for better earnings as well as living conditions. He added that there are far fewer health institutions than are needed for the number of people in need of their services.

Worse still, he lamented there’s great disparity in what medical professionals earn in Nigeria when compared with those of their colleagues in other climes, particularly in Western Europe and North America. He said such better incentives are what are pulling practitioners in Nigeria to those countries. “And who will blame them,” he asked rhetorically.

Another challenge, according to the obstetrician, is the issue of government policies in running the health sector in the country. While the government is sometimes at cross-purposes in initiating programmes and plans aimed at improving the health care system, the policies are more often than not ill-targeted, he said.

He queried the practice by government at federal and state level planting hospitals around without the needed manpower and facilities, or with minimal facilities but without medical personnel in some cases. He blamed the problem on politics and corruption, saying many of such projects are devised to launder money.

Worse still is the fact that in the face of this shortage, many medical professionals are in dire search of job. What an irony and contradiction! There was a reported case of a general hospital in Nassarawa State that has only a doctor consulting with patients.

The doctor was said to have lamented that he sometimes consulted with as many as 300 patients a day, complaining that his own health is at risk on account of overwork and pressure. He felt so relieved to have just four healthcare volunteers temporarily joining him in the discharge of service.

The obstetrician also complained of poor work environment with respect to substandard furnished office; grave shortage of medical tools/machines to work with, particularly in public health institutions; denial of incentives due to them by authorities, and owing of salaries at occasions.

Dr Francis Adedayo Faduyile, president of the Nigerian Medical Association (NMA) recently blamed chronic underfunding for the state of the healthcare system and saying this is leading to the mass migration of doctors.

Dr Francis Adedayo Faduyile, President, NMA

On the Labour Minister, Dr. Chris Ngige’s arguement that it’s normal for a country with surplus of goods and services to export them, Dr Faduyile believes the more doctors are leaving, the more the strain on a system that is already stretched thin.

“If we have any crisis, the health system is weak and will not be able to cope. Unless the government does something significantly different, I think the situation will continue,” he was quoted as saying.

In addition to the woes of health care delivery in the country is the anomaly in the discharge of quality health services to enrollees of the National Health Insurance Scheme (NHIS). Proof of the anomaly was itself made recently in Abuja by no other official than the Health minister, Dr. Osagie Ehanire.

The minister had then warned operators of Health Management Organisation that federal government would no longer accept the failure, as according to him, several complaints of poor quality health care and service delivery had been damaging the reputation of the NHIS.

He added that reports reaching him indicated that an overwhelming percentage of enrollees and health care providers have expressed grave concern over the performance of HMOs, with the areas of concern including but not limited to non-remittance of payments to health care providers, poor customer service delivery and inaccessibility to enrollees at critical moments of need.

After expressing his displeasure over HMO’s poor performance, Ehanire directed them to critically examine their operations and carry out internal reforms within and among themselves. He also urged all stakeholders in the health sector to take advantage of the on-going reforms in the NHIS and engage in frank conversations with a view to addressing the issues that clogged the wheels of the scheme in the past.

Way out of the problem

The Chief Medical Director (CMD) of Barau Dikko Teaching Hospital in Kaduna, Prof. Abdulkadir Tabari in a recent presentation challenged training institutions to come up with relevant courses for consultants to keep them abreast of current development in medicine as a way forward in combating the hiccups in the country’s health system delivery. He also canvassed enabling environment for quality research by trainers and resident doctors.

Nursing mothers waiting to be attended to

He specifically advised that government at federal and state levels should fund projects for rehabilitation and rebranding of hospitals and health centres at least every five years to ensure sustained optimum hospital environment conducive to healthcare service delivery, teaching and learning.

Moreover, to put an end to brain drain in the health sector and improve the country’s healthcare, some medical professionals have advised government to provide more funds, emoluments and incentives to medical practitioners.

Nigerian doctors were likewise advised to participate more in politics so as to change policies affecting them. They were also advised to take on entrepreneurship and more profitable businesses.

These are some of the solutions proffered by medical experts as ways to reduce the mass exodus of Nigerian doctors to other climes.

The movement of skilled workers internationally represents brain gain for the countries that reap their skills and experience and brain drain for their countries of origin, the medical experts reasoned.

Ekpe Phillips, the chairman of the Nigerian Medical Association (NMA), Abuja Branch also advised government to emulate the concept used by India to bring back their medical professionals who migrated to other countries.

Operation at National Hospital Abuja

According to him, India was able to conquer brain drain because they offered an interest-free loan to all their medical professionals abroad. He said the loan was for them to establish whatever facility of their dream in their country.

The Indian government also provided incentives and conducive working condition and their doctors came home. Today, India has joined the list of countries in brain gain! They make a whole lot of money in medical tourism.

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