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Paradox of doctor shortage in Nigeria




A COUPLE of weeks ago, the leader of the Nigerian Medical Association, Dr. Kayode Obembe called on President Buhari to declare a state of emergency in the Medical sector – this was at a press preview ahead of the NMA’s physician week. As it would turn out, the NMA’s physician week coincided with the three-day capacity development programme for MBBS academic staff of the Nigerian Universities. The MBBS academic staff is a body concerned with the training and production of graduate doctors, whose degrees are titled MBBS in most Nigerian institutions.

It was from this latter meeting that the rather alarming headline “NIGERIA has 277,000 doctor deficit” was brought to our notice by Prof. Folashade Ogunsola, the provost of the College of Medicine, University of Lagos. My fancy was caught by the word deficit which is usually associated with financial matters like the budget deficit, but doctor’s deficit is definitely a new lexicon in medical conversation in Nigeria. Prof. Ogunsola went on to add that there are 35,000 doctors on the ground in Nigeria. The implication of this is that we ought to have 35,000 + 277,000 (totalling 312,000 doctors) in Nigeria in order to meet the recommended Doctor/population ratio of one doctor to 600 lives/persons.

For roundness of figures, the doctor/population ratio is usually stated as the no of doctors per 1000 lives.
UK has a Doctor Population ratio of 2.3 doctors/1000 lives and U.S. 2.8. But the thinly populated but wealthy Scandinavian countries, led by Norway, Sweden and Denmark as usual are leaders with ratios of about 4.5 -5 doctors per 1000 of their citizens. The principality of Monaco, a tax heaven for doctors top the class at 7.1.

Paradox 1: If UK has 2.3 doctors per 1000 of her citizens, with a population of UK currently placed at 65 million, it means UK has some 143,000 doctors on the ground.

Yet UK and U.S. continue to brain drain our skilled doctoral human resources.

Listed below are distribution of Nigerian Doctors in Diaspora.
2000 Nigerian Doctors in the U.S.
1500 in the UK
600 in Canada
500 in post-apartheid South Africa
200 scattered in other African countries like Botswana
100 in the Arabian Peninsula and the Emirates.
100 in the Caribbean islands and Australia
That gives a total of roughly 5000 Nigerian Doctors in Diaspora.

It is paradoxical that some countries like Nigeria with low doctor/population ratio continue to suffer emigration of doctors at all. Even more paradoxical is the fact that these doctors go mostly to countries with higher ratio of doctors per population.

Some of the reasons given are job satisfaction – which is euphemism for better and certain income.

Still even more paradoxical is the fact that with the few doctors on the ground there are many able bodied specialist doctors, surgeons whose training are not being fully utilised – and as a result, a lot of these doctors are living only just above the poverty line.

If I may digress a little bit, over the last five years, we have had fresh Medical graduates roaming the streets trying to obtain placement for housemanship/internship, the final grooming young doctors are expected to have before they are free to practise.

Housemanship is an inevitable part of the curriculum of medical school education. Can Prof. Folashade Ogunsola and her colleagues explain why after 50 or so years of Medical school education in Nigeria, we have a situation where some 500-1000 graduates have to go to the Presidency, state governors, senior presumed influential doctors in the private sector collecting notes, referrals to influence their inclusion in an internship programme? The most important requirements for any clinical training/attachment are patients! patients!! patients!!!. And NIGERIA with its large population in poor environments have large population of patients. Why can’t the medical schools establish internship and residency programmes in satellite state hospitals in Badagry, Igbuora, Igueben, Bida, Ihiala and so on and so forth? With this lack of imaginativeness, there are bound to be doctor deficit.

No doubt, the effects of the low doctor/population ratio are felt the most in the rural area. This is certainly an opening for the NHIS to up its ante or go to the next level as the cliche goes. With easily affordable incentives, the NHIS can reverse the urban migration of doctors with assured rent-free accommodation, automobiles and attractive salaries to doctors, who can operate from these mostly abandoned state/local government hospitals.

These hospitals can now be renamed NHIS hospitals or clinics. This way the reluctant state governments can be drawn into the scheme. Even if all the doctors in Nigeria worked in Lagos State and environs there still will be doctors deficit; certainly less doctor/population ratio than the UK; at 1.04 doctor/ 1000 lives and a far cry from the Scandinavian countries.

I would like to return to Dr Kayode Obembe’s call for a state of emergency in the medical sector; this maybe the way out, but our President and the present administration will be fatigued with states of emergency as he may have to do same in the pharmaceutical sector, education, and, of course, power sector. Some four years ago, the Central Bank of Nigeria (CBN) found it necessary to deny a rumour that it was planning to bail out the oil industry. Yes, the oil industry; after all the CBN had just bailed out the banking sector, where some of the affected banks fly to London, Dubai for Board meetings. If CBN decided to bail out the banking industry and remotely considered bailing out the oil industry why not the health sector.

If the CBN will not bail out the health sector we had hoped that with the actualisation of the National Health Insurance Scheme in 2005, at least some balm on the Health Services Industry was coming. Unfortunately, that has not been the case. What happened to the vision? I get amused when Nigerian NHIS inspectorate officials and some HMO staff go around with arrogance, asking clinics whether they have boreholes, ambulance services before being included in their enrollee panel. Some talk about quality care.

Many doctors licenced by the Nigerian Dental and Medical Council are being disenfranchised. There lies another paradox in the Nigerian health industry. Some HMOs send patients in Ikeja to get specialised attention in Lekki even when such specialists are in Ikeja in the name of giving patients freedom to migrate, when in actual fact the HMOs manipulated them into such ridiculous, stressful trip to another far end of the city – just to do a favour to a friend’s clinic. No patient in Kent (Home country in the UK) is ever sent to Surrey (another Home country) under the British NHS; you see doctors in your locality.

That there is doctor deficit in Nigeria is incontrovertible. There is doctor deficit in the UK, U.S. and even in INDIA. Abuses in the system have compounded our situation.

If all doctors on the ground are engaged, if the concept of the National Health Insurance Scheme is taken to the next level, if the training programme for doctors is more imaginative, the current state of stagnation can be ameliorated.

• Dr John Esangbedo is a Lagos-based gynaecologist

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  • kunzle

    I think the real problem is the inability of the employer (government) to fund medical posts, rather than the lack of space to put the doctors. It would be unacceptable to expect young doctors, who have paid their way (sometimes, up to 8 years of study) through medical schools to work for free, just so that they could complete housejobs and be free to practise without supervision.

    Since the government is responsible for the medical school positions used to train these young doctors, they have to see the process through and fund positions for them to work in also. This is not the responsibility of senior doctors, who are, in reality, also employees struggling to get paid. They can only advise the employer/policy-makers, which is what they have done in this case.

  • kunzle

    I would suggest that the employer (government)/policy-makers include business management in the medical school curriculum, fund training posts in the houseman and resident cadres, and encourage enterpreneurship post-training.

    It should provide startup loans for doctors to start (group) private practices post-qualification, and give tax breaks commensurate with the location of the practice, ie, bigger tax breaks for those serving in rural areas.

    There should be a tightly-regulated referral system, so that HMOs would not, of their own volition, be able to divert patients away from the drainage areas of these practices.

    There should be a travel tax on medical tourism overseas (I know that this may be controversial, since the citizen who can afford it should be allowed to travel to seek healthcare anywhere his money can take him to).

    These steps, I believe, would encourage migration into the underserved areas, and may significantly reduce brain drain.

  • Dunamis2014

    A very well thought out article. It is just too convenient to make the bogus claim of dearth of doctors in Nigeria, without examining some of the reasons for this problem. I expect the powers that be will do something about the current state of affairs in the medical sector in the country in order to forestall calamitous ending forthwith. .

  • tunde008

    There are just not a single good public hospital in nigeria.Our stupid politicians loot money and can not invest in their people but rather prefer to hide it in advanced countries.They can’t build hospitals and equip them,or manufacturing factories that will employ our teeming youths.They openly boast of stolen money on paper.Look at the arabs,see how they vision for their people?Our stupid politicians are busy buying houses in dubai and other foreign lands while no good water and roads in their towns and villages.