Doctors start planning leaving Nigeria while in medical schools — CMD
Chief Medical Director of the IBB Specialist Hospital in Minna, Niger State, Dr Bala Waziri, talks to CHIKA OTUCHIKERE about the challenges in the health sector and measures governments can take to address them
Brain drain has continued to plague Nigeria’s health sector. In the course of your practice as a younger doctor, did you ever nurse the idea of emigrating?
Most doctors would have nursed that idea for some time. There are certain push factors. Most of us have been getting offers but I just try to weigh it and say ok, let me still stay back in my own country and my people too because, of course, it’s actually beyond us. I was just counselling one of my younger colleagues a few days ago. You know, even at the medical school, some of them had already made up their mind that they were taking the route off immediately after graduation – that they were leaving the country. However, we also tried; I was advising him that it was beyond the money. I was counselling him that we encourage people to go out, get trained, and come back and give back. That is what the minister also said in his interview on December 1, among all the other things he highlighted. He talked about patriotism, that we should be patriotic. The truth of the matter is that our medical education is highly subsidised even as it stands now. I was looking at the current tuition fees for medical students ranging from N82,000 to a little over N90,000. If a student is to receive training in a private setting even within the country, that’s worth millions of naira. I was looking at somebody posting something on tuition fees (outside the country). If for instance, you are going to study at Sheffield (University), that’s in a major city, it’s almost £34,000 for tuition. You know that’s a huge sum of money. So, what we are saying is that, most often, we got it cheap. So, you should also look back by giving back to the country and also assisting our people.
How has what is not popularly called the japa syndrome affected the IBB Specialist Hospital?
It has seriously affected us. In fact, it has affected all the health institutions everywhere and everybody is struggling to maintain their institutions. For instance, here (at IBB Specialist Teaching Hospital), we have to also engage doctors on a local basis to cushion some of these gaps. The other thing is to also encourage the government. I think the Federal Government has also got to that level because even though we talk about japa, there are still many doctors out there looking for a job. That’s the truth of the matter, and they keep coming to you but you are told that there is an embargo on employment. I know at the federal level, they have got what they call a waiver on replacement. When somebody leaves, they can actually be replaced.
Let me give you an example. A job interview was conducted for 70 doctors in Niger State and we could only lay our hands on 15 doctors to come for the computer-based exams. Even after taking the 15 doctors, the attrition rate will be high. Just give them five or six months, and most of them will tell you they are leaving; they will tender their resignation. So, we are encouraging the government to put in place a waiver on replacement. If they leave, then we will also have other people out there to replace them. The issue of teaching hospitals is also another very good initiative because teaching hospitals will want to make people stay back. As a medical worker or medical doctor, after your first degree, you’ll want to specialise in certain areas. So, if that scheme is not available in your institution, of course, people will leave to where it is available even within the country.
Is there any written or unwritten agreement that when a doctor goes out to study under the sponsorship of organisations as you did, they must come back home to practice in Nigeria?
They just encourage you to come back, not that you have anything binding like in some places where there’s what is called a bond so that you even have to sign. But this one (in Nigeria) is more like they encourage you to come back; you don’t need to sign any bond directly. I don’t know what is obtainable there now but when we went, there was not that kind of bond. Of course, there is a caveat to it that when you are done, they encourage you to come back home. But some people could decide to stay back rather than come back.
Medical tourism among the elite is also said to be a major contributor to the poor state of government hospitals in Nigeria and a factor encouraging the emigration of young health professionals to developed countries. What is your take on that?
I don’t think it’s the way people portray it. We still have leaders who assist our local health institutions. I don’t think it’s like that. They also have relatives and they can’t take all their relatives for medical checkups abroad. Some of their relatives still have to come and access public (health) institutions. So, we try to encourage them to look back and try to strengthen our existing health structure. Sometimes, you see them and they will say they have their physicians. State houses also have doctors who sometimes also have personal physicians whom they contact for small ailments. They can make prescriptions but, of course, sometimes just like even the ordinary person, there are certain things you want to access that may be told that they are available here (in Nigeria), and you’ll have no choice but to travel out of the country. For instance, no matter how much you have, a cardiac transplant is not done in the country. If you have a heart problem to a stage whereby you need another heart, it cannot be done in Nigeria. The same thing happens with liver transplant as it is not done in the country. That means if you have the means regardless of your status, whether you’re a president or you’re a director, you want to still be alive then you have to gather money to travel to places where these things are available.
How would you describe the Nigerian health sector?
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The Nigerian health sector encompasses so many things. It is easier to classify them under training, human resources, and infrastructure. So, if you can capture them under these headings, I think that would assist us in covering a wide spectrum of the Nigerian health system. In terms of human resources, you and I know that Nigeria is battling with a raw shortage of health workers and healthcare workers comprising doctors, nurses, lab technicians and others. We have been experiencing mass exodus over the past few years and if you ask some of those leaving, they will give you different reasons why they are leaving. Of course, it’s also generally known the factors that propel people out of the country and the factors that pull them into certain countries and that is what we usually term as pull and push factors.
Some of the push factors are largely maybe, due to the lack of a good enabling environment. Push factors mean within the country, certain things are pushing health workers away and the pull factor means another country is pulling them because of what they have on the ground. So, for us here, a lot of people have attributed it to the enabling environment; they will tell you that the environment is not enabling them to fully practise the skills they have.
Is insecurity also a factor?
Also, maybe the current insecurity most states are witnessing is another example of a push factor. Some areas within the country are witnessing insecurity. Remuneration is also another very important push factor. People feel they are not adequately remunerated. If you look at what some other countries pay their doctors, it’s almost 10 times what they (doctors) are currently earning within the country (Nigeria). But, of course, we all know that it is beyond just the remuneration. Then in terms of enhancing their skills, there are certain skills that you cannot acquire readily within the country; you may have to travel out because they are not available in most of our health institutions. So, sometimes you need to travel outside the country because of the state-of-the-art facilities in some countries to obtain these skills.
For instance, I know I am also one of the beneficiaries of foreign training. I travelled outside the country after my residency programme. I came back home and worked for two years within this hospital then had to travel under the International Society of Nephrology. I had to travel outside the country and it was also to expose me to the state-of-the-art facilities outside the country to equip myself with certain knowledge I may not readily get here (in Nigeria) and come back and give back (to society) what I acquired. The other thing has to do with training which I highlighted in human resources. So, these are just a few examples of the push and pull factors.
Why do some public health institutions in Nigeria lag when it comes to equipment?
On infrastructure, you know if you look at the country many years ago, people will tell you that even foreigners used to come and access our healthcare facilities here. Things were working but over time, these things began to go down because Medicine is quite dynamic – dynamic in the sense that it keeps changing. For instance, there are certain surgeries that can be done through what is called laparoscopy, instead of opening a patient’s abdomen wide rather than just a small cut to achieve what you want. On the screen, the person can watch what you are even doing and you do it with precision. Equipment like that is not available in our hospitals and centres.
For instance, we have heard of people who have gone outside the country to train as interventional cardiologists. But if you come back home, you need what is called a cardiac lab for you to put into use the skills you acquired. In most situations, we do not have a cardiac lab. So, that means you come back home as an interventional cardiologist and you just stay for one or two years without practicing the skill you have learnt, and over time, the skills die down and sometimes, you have to go back for retraining. That is one aspect. The other aspect also has to do with training at the universities which are becoming overstretched in terms of the number of medical students and they cannot accommodate beyond certain numbers because of the infrastructure and because of the human resources they have on the ground. If a university admits 500 students and its limit is supposed to be 200, definitely it knows it may not be able to achieve the result it wants to achieve.
But there’s room for improvement. If you look at it, actually over time, the country has experienced quite a lot of improvement too. For instance, things like a kidney transplant. We do a lot of kidney transplants. You know, kidney transplants have been in the country for quite a while now. Some public institutions have been doing that, it’s just that it’s not as much as the number (of transplants) done in the private setting but what I’m saying is that we have private settings that do quite some kidney transplants. So, instead of people travelling out of the country to Egypt, to India, that has also reduced dramatically. Now, people rather stay back to access these facilities in some of the healthcare centers.
How best can the healthcare system in Nigeria be strengthened or repositioned?
Everybody knows what the country needs to strengthen (the healthcare system). We keep hammering on this. We all know what it takes to strengthen the healthcare system – the same thing we just mentioned about infrastructure. (The government should) just ensure that it upgrades the infrastructure, (and provides) more state-of-the-art facilities. It should also increase the capacity of our universities to accommodate more doctors, and the welfare of our lecturers should be looked into so that they can effectively teach medical students. The government I know probably can look into remuneration to see whether it can upgrade it. That will also assist people in staying back. The other aspect has to do with motivation; after training them (doctors), maybe the government can also motivate them by giving them houses on a mortgage basis. It can also give them car allowances. I think these things were actually in existence before, and the government can do that by bonding them and to some extent, making them stay back a while. The other thing is to go into agreement with other countries. I know it was done during (former president Olusegun) Obasanjo’s era when quite a lot of my classmates moved to South Africa and the government had to contact the South African government and tell them that it (South Africa) was moving most of our doctors and requested an agreement.
