- Says: FG kick-started the push in the ’70s, when it sacked and evicted doctors from their quarters over a strike
The declaration weeks back by Dr. Ify Adegbulugbe, President, Nigerian Association of Paediatric Dentists, that Nigeria has only 84 paediatric dentists serving her over 200million strong population, set tongues wagging and created a panic. But how true is this and what are the implications for a country bedevilled by a malignant emigration bug called japa Syndrome? Immediate past Senior Special Assistant to the FCT Minister on Health and Hospital and President/CEO, Dr Ejike Oji Community Development Foundation, shares his thoughts with Gboyega Alaka.
About two weeks ago, President Nigerian Association of Paediatric Dentists, Dr. Ify Adegbulugbe came out with a damning declaration that Nigeria has only 84 paediatric dentists serving her 200million population. What are the implications of a situation like this to a country like Nigeria?
This question of emigration of Nigerian doctors has been in the public discourse for quite a while but the truth is it didn’t start today. However, before I go into the main issues, it is good to discuss broadly emigration, the factors responsible for the pull; it is then that we can narrow down to health and its implications.
Emigration of Nigeria’s healthcare personnel did can be traced actions of the government in the past, and recently to population dynamics; and of course the non-availability of good paying jobs in terms of professional developmental ability.
What do you mean when you said ’caused by the government’?
I was admitted into the medical school in 1974, that same year, I had a letter of admission from Howard University in America and also the King’s College Hospital in London; but I decided to stay back in Nigeria and school – because up till the early 70s, Nigeria was a better place to stay and study. They would always tell you that those who left the country to study abroad at that time were people who were not smart enough to compete for admission here. Our schools were wonderful; we were trained by the best of teachers at that time. To give you a simple example, my Pathology teacher at the University of Nigeria, Enugu Campus, Professor Wilson Onuigbo, was one of the best Geographical Pathologists at the time. In my Year IV, I decided to go to King’s College Hospital, London, to do an exchange programme; every year, I went there and spent about three to four months; sometimes six months, and then came back to do another four, five months before I graduated in 1980.
I also encouraged three of my classmates to go with me. We found out that four of us were doing so well that we had more knowledge in certain areas than our English counterparts. As at that time too, Nigerian doctors in training went abroad for one year residency to get broader knowledge of medical practice and acquire up-to-date knowledge. And they always came back, because they had no reason to stay back. However, the first wave of doctors that left the country was occasioned by a rash action of the then Federal Military Government. That was when the military government woke up one day in the 1970s and said they had sacked all the consultants in the hospitals because there was a doctors’ strike. Some of the consultants, who were professors, who had been in places like LUTH all their lives, were given 48 hours to pack out of their residences. Most of them didn’t even have a place to pack to. Some of them had got to a point where they never thought they would leave their environment. Some might even have stayed back to become professor emeritus on retirement, teaching until they were too old to teach. So they had their safety nets and they gave their all to health and medicine at that time.
But because of that sack, majority of them emigrated to Zambia of all places. Some emigrated to Saudi Arabia. In fact one of my uncles, one of the notable endocrinologists of the time, first emigrated to Zambia, and then to Saudi Arabia. From Saudi Arabia, he ended up in the United Arab Emirates. As I speak, the man is in Abu Dhabi. He’s been there for almost 40 years. Some went to Europe and some to America.
What was the attraction to Zambia?
There was this University Teaching Hospital in Zambia that opened its doors and gave them good working conditions. That singular FG action heralded the mass exodus of Nigerian doctors out of Nigeria. Until then, it was mass influx. Once doctors finished training abroad, they returned. Those who went for their one year training abroad always returned home immediately. At worst, they retired and went into private practice, but they never left the country. But suddenly they started staying back. And that trend has continued. The health system got broken. It was as if the military government was fighting the healthcare system. Because of that fight, money was not properly allocated; and that was when the decadence in our health system started coming up. To shock you, in the ’70s, the crown prince of Saudi Arabia used to come to the UCH (University Teaching Hospital) to receive treatment. That should tell you how developed our healthcare system was.
Suddenly we were not progressing anymore. Now, that was the first wave. What happened thereafter was that all those young doctors who were training as consultants, registrars and senior registrars, who were going for one year training abroad, were no longer coming back. Before, we use to have 100 percent returns. But once that purge happened, maybe 50 percent were now coming back. It got to a point that universities had to scrap the one year abroad, because they were now losing their consultants. The result of that action was the degeneration of our health practice. We were no longer in tune with new developments in the outside world. That was the first wave.
What is the second wave?
The second wave of professionals leaving the country that we are experiencing now is a bi-product of the first. As far back as fifteen years ago, I started noticing a very high rise of emigration of health workers. I graduated in 1980; but as I speak, 75 percent of my classmates are outside the country. I am in the country because I worked for an international organisation in Germany for nine years, and then ended up working with another international organisation in the women’s health and women’s rights, as Country Director of IPAS; but I had left the practice of clinical medicine and gone into programming. So even though what I had done had helped reduce maternal mortality and broadened reproductive health services in the country, the fact, however, was that I was not in the clinical rooms. Why did I say fifteen years ago? I noticed that the effects of our population dynamics started showing. There are three things you see in a country and you know the country is in a demographic crisis. Number one is when you have a youthful population. As I speak, 75 percent of our population is under age 35. That means we have a high dependency ratio. The people earning money to support this huge population is less than 20 percent or thereabout. And once you have that, it means your population growth rate is far exceeding your economic growth rate. The second is that once you have that, two things would now happen: you start seeing a flood of your trade professionals (which is the second wave of emigration I was telling you), not just medical professionals, but especially ICT professionals, leaving the country.
In 2010, I was invited by the Association of Nigerian Physicians in America to give a lecture at their annual conference. When I got there, they told me that their members, who trained in Nigeria and emigrated to America were more than 20,000. Now there are many others who were not registered with them. In 2006, I was invited by the Norwegian government to be part of young African leaders’ deliberation on issues of women’s health and sexual reproductive health and rights with their USAID variant called NORAT, and their international development minister to see how the Norwegian government would support issues of women’s health and women’s right in Africa. When I sat down with the international development minister, the first question he asked me was, ‘Dr Oji, how come every single day, 13 commercial sex workers come from Nigeria to Norway?’ So what is going on now is that it is not just highly professional people that are leaving; non-skilled young Nigerians are also leaving the country.
Could it be in quest of stronger foreign currency?
Yes. You would recall that Buhari, as president, brought back more than 20,000 young Nigerians from Libya in his first two years. These were young people of unskilled labour who were waiting to cross the tempestuous Mediterranean Sea to Europe. As at that time, the International Office of Migration (IOM) also estimated that for every 100 young Africans that tried to cross the sea into Europe, 14 were Nigerians. So the country has become so difficult for young people and they’re looking for a place to run away to. The third, which is the second of the two things that happen when you have a burgeoning population, is that nationals start killing nationals based on criminality. Because these young people, who are unemployed, largely uneducated, unemployable, do not have any way to earn a living, so they resort to violent criminality. Criminals will recruit them, unscrupulous politicians will recruit them for electoral violence during elections; and then insurgents will recruit them.
So Nigeria that used to be peaceful became unsafe. That third element started with Oduduwa People’s Congress (OPC) in the South-West, followed by militancy in the South-South, when the young people who felt everything was being taken from the bellies of their earth and they were not getting anything back started kidnapping white oil workers. Eventually they started kidnapping Nigerians; then it went to the South-East where you had kidnapping. That got so bad that for four years, I couldn’t go home. From South-East, it came to Plateau, religious crisis. After that came Boko Haram in the North-East, and then banditry in the North-West. Now no part of the country is spared. See what’s happening in Abuja – One chance. Criminals robbing people in vehicles and pushing them out on motion. These are offshoots of a demographic crisis. So the country is in a demographic crisis.
You’re saying our population is the cause of our problems.
The population is so much that the government does not have enough resources to give the things we used to have easily. Back then, as you’re graduating, there is a job waiting for you; there is a house waiting for you, there is a car loan waiting for you.
Would this be because the government did not take enough precaution to control the population growth at the right time? IBB tried it when he proposed four children per family.
Yes, but he couldn’t enforce it. That was when we lost the opportunity. There are certain baits you would throw and people would fall in line. If the government says we will give free education only to families with four children, and if you have the fifth, sixth or seventh, you’re on your own; people will adjust.
Basically, you’re saying the Japa syndrome is not peculiar to the medicals sector.
No. The reason that of the medical sector is obvious is because globally, health care personnel are in short supply. Also, the population of the world has also grown. In 2007 when we had our last count, we were 140 million, and Britain was just about 65million. In 2023, our estimated population is about 211million. Meanwhile, almost 20 to 30 percent of the doctors we’re producing are leaving. What makes it more dangerous is that the people that are leaving are the specialists; and it takes a long time, a minimum of 12 to 15 years to train a specialist.
Let’s look at the demerits of the emigration of the medical personnel.
First, the waiting time for patients is now so long, especially in the public hospitals. Consequently, patients will not get optimum or quality service, even if they get to see the doctor – because if a doctor is supposed to see 40 patients, he will be forced to see about 100. Automatically, the quality of treatment drops. And this could make some patients begin to feel that they do not have to go to the hospital. They then decide that instead of going to the hospital to spend the whole day and not get the best, they would go to a chemist’s shop, or to laboratories; and the implication is an epidemic of kidney diseases that is now ravaging the country. So the socio-economic impact is huge. Another effect, which is long-term, is that it may create a cycle where future generation of doctors perceive migration as the norm rather than invest in local institutions.
Unfortunately, we’re at that point now, don’t you think?
Unfortunately so. The socio-economic impact is that if you cannot have quality health, then you cannot have quality workforce. Even though there are some diaspora money coming in on account of this emigrations, what they send is only a fraction of what they make there, so the fact remains that Nigeria would have been better off if those people stayed back and contribute directly to the economy
And then of course the young doctors who leave have a better future; they get better pay for their worth; they also have opportunities for advancing their careers. The Nigerian environment is so toxic. Every day, doctors are going on strike for one reason or the other. And then who is at the receiving end? The population.
People are beginning to think the doctors are overdoing it, demanding pay rise nearly all the time, despite being the highest paid in government service.
The thing is that the people that are saying those things should go and make proper comparisons. If a young doctor leaves the country, he has opportunities. The people that are raising those questions, should japa and see whether they would earn the same money as the administrators in foreign lands. Even doctors who emigrate have a waiting time of five to six years or more before they can qualify to work in say the UK or the USA. In between, you get to work like a donkey to be able to build up your professional certification to work. It’s quite unlike in the past. Up until 1984, if you graduated in five universities in Nigeria – University of Nigeria Nsukka, Ahmadu Bello University, UCH, UNILAG, and I think OAUTH; and go to England; you can plug into the system immediately and start working. But after 1984,this changed because the quality of instructions they were receiving had dropped considerably.
So it’s not as if Nigerian doctors who go abroad get snapped up immediately into the system.
Nooo! Some of them, before they leave, which is what I tell them, they take those exams right here. If you’re going to America, there is one they call ECFMG; it is only when you pass it that you will be able to go to America. And when you go there, even if you were a consultant here, they would have to assess you, and you might serve as clinical officer and take their own board exam and pass before you can continue. Sometimes, it may take longer than five years to acquire that certificate; don’t forget that you have to do other jobs to keep body and soul together; as a result of which you’re not able to give that exam 100 percent attention.
Let’s look at the scary declaration that the country has only 84 paediatric dentists? Could there be others that were not captured?
It’s only the Medical and Dental Council that can give you an accurate figure. But even they might not know the actual figure because some people might have even left the country without letting them know. The President Nigerian Association of Paediatric Dentists that say it’s only 84 may also not be completely correct, because she can only give a figure of those who have registered with the association. There might be a lot of people who are not interested in registering with any association and are busy doing their work. Besides, data is still a major constraint in Nigeria. Some may also have registered and paid their dues but left the country in between. Last year alone, over 4000 health practitioners left Nigeria to the UK alone.
What is the way forward or should I say way out of this quagmire?
When it comes to issues of health, there are four ways in which you look at it. First is the leadership. What has the leadership done. The second is the governance structure to implement the leadership’s decisions. The third one is that for a sector like health, you have to look at the architecture- the infrastructure, equipment, and then the workforce, which is what we have been discussing all this while. And then you have to look at financing; and of course monitoring and evaluation. Remember: leadership, Governance structures, service delivery, which is broken into two: workforce and infrastructure. The other two: Finance and Monitoring/Evaluation are cross-curtain of all these other ones. Now, if you look at Nigeria, the greatest bane of Nigerian healthcare sector is improper financing. Nigerians are still spending out of pocket for health service. Nigeria has one of the highest out of pocket health expenditure in the world.
How do you mean?
There is no country where the citizens spend out of pocket and they get quality health delivery. Out of pocket payment is when a citizen falls ill, goes to a hospital and pays out of his pocket instead of via insurance. First, what you pay is usually huge compared to what you earn. If for instance somebody has appendicitis and goes to a private hospital, do you know how much you pay? In Abuja, the minimum in a good hospital range between N550,000 and N1milion. In a public hospital, you pay between N100,000 and N200,000, which is still huge compared to the minimum wage of N30,000. It is called catastrophic medical expenditure. The only way the government can pay and guarantee quality medical c are is through pulled resources, which is Health Insurance.
