Human rights and bill restricting young doctors from practising abroad

About three weeks ago, precisely April 6, 2023, the House of Representatives triggered an outrage with a bill banning fresh doctors from Nigerian universities from travelling abroad to practise or further their education until they have put in five years compulsory service in Nigeria’s health sector. If the bill sponsored by a member representing Oshodi/Isolo Federal Constituency in Lagos State, Ganiyu Johnson (All Progressives Congress) sees the light of the day, only doctors who have practised for five years in the country after graduation would be given licence and allowed to practise outside the country. CHIJIOKE IREMEKA writes on the furore being generated by the proposed law.

Over the years, medical doctors in the country have complained about poor condition of service, lack of equipment to work with and poor state of the country’s medical facilities, among others. The situation, which persists, has continued to be the cause of their incessant strike.

The medical workers complained and have been embarking on industrial action for years in the hope of better working environment in the country. But it appears their demands for better condition of service and provision of necessary tools usually fall on deaf ears as the government continued to treat the issues with kid gloves, making the doctors to seek employment abroad with higher remuneration and better condition of service abroad.

The doctors are further encouraged by the health and care visa given to them easily by the United Kingdom (UK) and other countries, promising them mouth-watery remuneration, accommodation and irresistible condition of service that make it difficult for those that travel abroad to return until they reach the retirement age.

For any doctor that leaves, Nigeria is losing, at least, two to three dependents – father, mother and children, yet the government pretends it doesn’t matter until the doctors’ labour mobility became matters arising in the National Assembly and the lawmakers are now seeking legislation to stop the mobility.

When the medical experts started leaving Nigeria, the government didn’t feel the country was losing her home and best-trained professionals to other countries like America, the UK, Canada, Saudi Arabia, Caribbean Island and South Africa, among others.

The impact became noticeable at a point even as the government pretended that the doctors’ labour mobility wasn’t an issue that should disturb the country, with President Muhammadu Buhari saying in his usual way that anybody who is tired of Nigeria could leave. He made the comment in his reaction to the wave of increasing emigration of Nigerians, especially doctors. Perhaps, the president didn’t know that the same issue would become a subject of hot debate in his administration.

In the same manner, the Minister of Labour, Dr. Chris Ngige said Nigerian medical doctors were in surplus supply, claiming that there was a positive side to the emigration as those who practise abroad were among Diaspora Nigerians who boost the country’s foreign exchange earnings by their remittances back home.

Ngige was quoted as saying: “The medical doctors are surplus in the country. I can tell you this. It’s my area; we have excess. We have enough, more than enough, quote me. There is nothing wrong, they go out to sharpen their skills, earn money and send them back home. Yes, we have foreign exchange earnings from them, not from oil. Those guys go there, they are better trained because of the facilities they have there.

“Eventually, I know a couple of them who practise abroad but set up medical centres back home. They have CAT scan, MRI scan which even the government hospitals cannot maintain. So, I don’t see any loss. Brain drain will only be inimical when, for instance, neurosurgeons travel and we don’t have neurosurgeons here.”

The minister’s comment elicited negative reactions. But a survey shows that many medical doctors are emigrating not necessarily because of the financial rewards abroad but because practising abroad would give them access to better facilities and work environment. It would also guarantee them higher remuneration, career progression, professional advancement, and better quality of life.

The survey conducted by NOI Poll and Nigeria Health Watch last year shows that out of 72, 000 medical doctors registered with the Medical and Dental Council of Nigeria, only approximately 35, 000 are practising in the country. This is in spite of the fact that an estimated 3 000 doctors graduate from the medical schools of Nigerian universities yearly.

The respondents in the survey were medical personnel who practise in Nigeria and abroad. It was discovered that 93 per cent of them flee Nigeria to the UK, where the ratio of doctors to population beats that of WHO recommended one medical doctor to 600 persons.

Also, 86 per cent of the respondents said United States is another target country for medical doctors who emigrate from Nigeria in search of greener pastures abroad. Others are Canada (60 per cent), Saudi Arabia (59 per cent), UAE (29 per cent), Caribbean Island (17 per cent), Ireland (15 per cent), South Africa (4 per cent), Botswana (1 per cent), and Qatar (1 per cent).

Today, the doctors’ emigration has become a major issue in the country, especially as statistics show that Nigeria is short of the WHO’s one doctor to 600 patients standard.

Experts said that Nigeria’s resolve to coerce the doctors with a law to stay back is to the detriment of the patients as legislation would not bring about the passion and desire to go all odds to save a dying patient.

Some stakeholders expressed worry that enacting a law without paying attention to, and addressing the age-long complaints and demands of the doctors will kill the passion to save life as frustrated and hungry doctors who had set their eyes on leaving the shores of the country for better life would routinely pour their frustrations on the patients. The situation may turn medical facilities in the country to mortuaries instead of havens for saving life.

The good intention of the proposed bill to solve the problem of brain drain in the country may not be achieved until the government decides to address the issue permanently by carrying the doctors along.

The bill before the House is seeking a legislation to stop medical doctors from travelling abroad for further education or to practise until they have put in a compulsory services of five years in the country’s medical sector as a way of giving back to the society that subsidised their studies for five academic sessions.

The bill is Titled: A Bill For An Act To Amend The Medical And Dental Practitioners Act, Cap M379, Laws Of The Federation Of Nigeria, 2004 To Mandate Any Nigeria-Trained Medical And Dental Practitioner To Practice In Nigeria For A Minimum Of Five Years Before Being Granted A Full License By The Council In Order To Make Quality Health Services Available To Nigeria; And For Related Matters (HB.2130).

The plenary presided over by the Speaker, Femi Gbajabiamila, passed the Bill for second reading by majority voice votes despite objection from Uzoma Nkem-Abonta on the ground that the move is more like enslavement.

The sponsor insisted that it is only fair for medical practitioners who enjoyed taxpayer subsidies in their training to give back to the society by working for a minimum of five years in Nigeria before exporting their skills abroad.

“Nigeria currently has only 24, 000 licensed medical doctors available in the country, less than 10 per cent of the number needed to meet the WHO recommendation,” Ganiyu Johnson argued. 

According to the President of the Nigerian Medical Association, Dr. Uche Ojinmah, Nigeria requires a mix of 23 doctors, nurses and midwives per 10,000 health services to meet the WHO standard. A large number of Nigerian doctors emigrated to seek greener pastures in developed countries, 5,600 of them have migrated to the UK in the last eight years.

“Now, only one doctor is available to treat 30,000 patients in some southern states while in the North, it is one doctor to 45,000 patients,” he stated. He compared the fees paid in the UK and other countries’ universities to what is paid in Nigerian universities, saying that tuition fees in Nigeria’s public medical schools is being highly subsidised.

According to the NMA president, the tuition payable to study Medicine in the UK ranges between £35,750 and £66,500 annually for four years.

“To study Medicine in United States, one has to pay between $82,000 and $104,000. In Canada, the tuition fees for Medicine ranges between 52,000 CAD to 169,000 CAD, according to the National Centre for Education Statistics.”

Johnson continued: “But contrary to all these bogus Medicine tuitions in the aforementioned countries, in Nigeria, the cost of studying Medicine in public institutions ranges from N40, 000 to N150, 000. Therefore, you will all agree with me that medical and dental education in Nigeria is seriously subsidised. 

“Despite this subsidy in medical and dental’s education, Nigeria still suffers emigration of trained medical doctors and dentists into these foreign countries, where an average Nigerian can hardly afford medical training.

“With the latest mass relocation of trained doctors in Nigeria to the UK, the doctors- patient ratio might become worse, leading to an overstretch of the already limited medical doctors workforce. This might push even more doctors to join their colleagues in a more favourable working environment, resulting in further losses to Nigeria.

“It has also been observed that foreign embassies in Nigeria, particularly those of Britain, the United States, and Saudi Arabia receive on a weekly basis, 20 to 25 verification requests from Nigerian doctors wishing to migrate abroad. This translates into about 1,196 applications a year, while Nigerian people whose resources are being used to subsidise the medical and dental education in Nigeria to train doctors and dentists still suffer from poor health services due to the migration of our doctors and dentists. This is a clear cheat on the Nigerian people.

“In view of the foregoing, this bill, if considered and passed by this Green Chamber, (it) will not only bring about the necessary social justice to the Nigerian people, but also improve the health services available to Nigerians, because Nigerians will be able to enjoy the service of the medical doctors and dentists who were able to get trained with their resources, at least, for the period of five years here proposed before migrating abroad.”

However, since the content of the bill was made public, doctors have been critical of it, saying that it is outlandish and an attempt to enslave them. They vowed to stop the legislators.

For instance, the President, National Association of Resident Doctors (NARD), Dr. Innocent Orji, said: “We consider the bill a total affront to the Nigerian constitution and the laws that guarantee freedom of movement and mobility of labour. The truth is that the idea behind the bill is understandable, but the bill itself is questionable.

“He placed our tuitions side by side with what they pay in USA or in private schools without taking into account what the payments are actually meant for. We know that in some institutions, this payment is composite. When you pay, they give you textbooks and all that, but after what we pay in Nigerian public schools, you still go ahead to buy your own textbooks and all that.

“You pay for your hand out; we don’t have Internet facilities. But in private schools, the payment might cover that. So, it is too simplistic to make that kind of comparison. The other issue is that he said when doctors qualify to practise, they are not going to give them licence until five years. Now, the question is within those five years, what are they exactly going to be doing or do they want to create a pool of unregistered doctors roaming the streets?

“We have always said that there is no ad hoc solution to tackling this challenge. We have told the government what to do; we have said it severally that for the government to solve this problem, they must carry the people involved along. If they don’t do that, they will make a grievous mistake just like the honourable member has made.

“We are totally condemning that bill. We are demanding that it be withdrawn. There is no need for it to proceed to public hearing because that would be a waste of taxpayers’ money. You don’t need to gather people in Abuja to start debating on something that is obviously faulty.”

Also, the Diaspora Medical Associations (DMA), a group representing Nigerian doctors and dentists working outside the country faulted the proposed law.

In a statement titled Re: A Position Statement From Diaspora Medical Associations – Bill Seeking To Restrict Newly-Qualified Medical Doctors And Dentists From Leaving Nigeria dated April 11, 2023 and directed to Gbajabiamila, the group criticised the Bill for being ineffective and failing to solve the nation’s brain drain.

The statement which was also directed to the Senate President, Ahmad Lawan; Chairman of the Senate Committee on Health, Dr. Ibrahim Oloriegbe, and Chairman of the House Committee on Health, Dr. Tanko Sununu, was signed by the President of the Nigerian Doctors’ Forum, South Africa, Dr. Emeka Ugwu; the President, Association of Nigerian Physicians in the Americas, Dr. Chinyere Anyaogu; the President, Medical Association of Nigerians Across Great Britain, Dr. Chris Agbo; the President, Canadian Association of Nigerian Physicians and Dentists, Dr. Nnamdi Ndubuka; and the President, Nigerian Medical Association, Germany, Dr. Al Amin Dahiru.

“We recognise the problems posed by the exodus of Nigerian medical professionals from our health system, including, but not limited to decreased access to health care services, lack of quality healthcare delivery, and inability to adequately enact health care and public health policy due to lack of manpower and leadership resource,” the DMA stated in its statement.

“The major cause of brain drain includes a poor care delivery framework from a failure to invest in the health care to foster a conducive environment. The system does not promote professionalism, growth, work satisfaction, or a high-reliability culture. Other major drivers include very poor welfare packages, high levels of insecurity, limited opportunities for employment, subspecialty training, socio-political and economic instability.

“The majority of these issues stem from outside the health care system and are outside of an individual’s control. Indeed, good governance and commitment to future investment in health care would improve conditions in the country that will allow security, good education for children, improved compensation, as described in the Abuja Declaration.”

The associations also asserted that it would be unproductive to concentrate on only a facet of an issue without adopting a comprehensive strategy for a long-term fix, saying that young professionals leave the country in search of better opportunities as many of them are frustrated by the consequences of governance failures that have progressively worsened over the past 30 years.

“The unfortunate reality is that the health care system is in a state of serious neglect, training and career development opportunities are limited further impairing earning potential. Insecurity is rampant. Equity and justice are lacking for the average Nigerian. The DMA are interested in crafting effective solutions and are willing to participate in fostering solutions to that extent.”

The doctors urged the Speaker to adopt a deliberate and systemic approach to ensure that any attempts at a ‘quick fix’ do not make things worse. The experts also vowed to support reforms and the expansion of the healthcare sector to halt and reverse the brain drain.

The Association of Nigerian Private Medical Practitioners (ANPMP) also called for declaration of a national emergency in the nation’s health sector in view of the proposed five-year compulsory service by the House of Representatives.

The National President of the association, Dr. Kayode Adesola, said declaring an emergency in the health sector would assist in proffering sustainable solutions to attrition of health workers, improve healthcare facilities, and reduce disease burden.

According to him, the proposed bill was ill-conceived and would not tackle brain drain, which is multifaceted and requires a more comprehensive approach to solve. Adesola said the bill would worsen the brain drain in the country because medical doctors do not need Nigerian licences to practise in other countries.

“We have teaching hospitals, general hospitals and primary healthcare centres that are dilapidated with outdated equipment. Political leaders are seeking medical treatment abroad while the citizens are left to suffer in a country that has one of the best doctors in the world. Before, it was the young doctors leaving, but now, the consultants are leaving. Many health workers left because of insecurity, not just poor remuneration or poor working conditions,” he stated.

A former Chief Medical Director, Yaba Psychiatric Hospital,
Dr. Oluyemi Ogun said there was no way the Bill would see the light of the day.

“It will not be signed into law. If it is signed, it will not work. There are plenty legislations that are not being implemented. Hence, this would be one of those.

“It would lead to more corruption, what the law is trying to prevent may be circumvented. How do you train medical personnel and there is nowhere for them to work, yet, you say they should remain in the system. Globalisation has rubbished whatever law they want to pass. People go to medical schools and are not interested in practising medicine. What will they do about such people? It is even basically against the fundamental rights of the doctors. What the legislators want to do is to throw the country into another round of incessant strike,” he cautioned.

A member and former Chairman, Medical and Dentist Consultants Association, National Orthopaedic Hospital, Igbobi, Lagos branch, Dr. Olatunji Idowu, in a statement, expressed dismay at the proposed bill, which he considered as ‘rude.’

“This bill without making any assumptions about the ill intent from the proposal simply lacks the basic ingredients of good faith in the sense that it is both discriminatory and harsh, to say the least and not in the interest of the people. The following reasons underscore our suggestion that a further consideration for the passage of the Bill will amount to a wild goose chase in addressing the challenge of brain drain.

“Our 2022 survey revealed that over 500 consultants were estimated to have left Nigeria over the preceding two years. Along with sister associations in the health sector, we have provided to the appropriate agencies of government both useful and practical suggestions on how to remedy the situation.

“The idea that Nigerian trained medical doctors receive heavily subsidised education is pure fallacy. Tuition has remained part of the fees paid by every medical student, usually higher than that of non-medical students in most universities. The fact that this amount is smaller relative to other countries, especially the developed countries does not amount to subsidy as every graduate who is lucky to get gainfully employed afterwards pay back by earning salaries far lower than their peers in developed countries. The irony is that the generation that had federal and state governments scholarships and meal subsidies on campus are the ones suggesting binding of students, who are self-sponsored.

“In a country with this high rate of unemployment? Worse, the policy is discriminatory as it targets only medical graduates. Education in public schools at all levels is subsidised and as such, the argument that Medical students are heavily subsidised does not make sense to me. What the government, and in this case, the lawmakers, should respond to is indictment of the exodus.

“If doctors are provided with gainful employment, they will not jump ship. Why are the legislators, ministers and heads of public institutions or workers in NNPC not leaving their jobs? In any case, the country will recover its investment through remittances,” he stated.

Solution
NOI Poll and Nigeria Health Watch’s survey recommended that Universal Health Coverage would provide finance necessary to provide a conducive working environment for doctors, and better financing translates to more remuneration, increased training opportunities for doctors, availability of equipment and other consumables.

“Government should not focus on tertiary health facilities alone. It was discovered that both federal and state governments spend capital votes on such facilities to the detriment of general hospitals (secondary health facilities) and primary health care clinics. Focusing on primary and secondary health facilities would also create more job opportunities for medical doctors around the country,” it stated.

To deal with the lack of job opportunities, which have compelled trained doctors to take up appointments in private hospitals and earn pittance, it recommended that the government should activate its plan to establish a central placement for house officers.

“This placement has not taken off yet. Government should commence this placement quickly and ensure that commonly underserved locations are given priority. It would be helpful if this placement is extended to residency and consultancy positions,” stated.

The survey called for stronger public-private partnerships to drive increased investment in the healthcare industry, and possibly better remuneration for doctors which is also a major factor causing them to seek opportunities abroad. The researchers called for increased incentives, tax holidays, among others, to be given to private investors to encourage investment and growth in the healthcare sector in Nigeria.