Editor’s Note: This week’s Thought Leadership on Health Piece comes from Nigeria Health Watch Curator, Dr. Ike Anya. Last week’s article about the NOI Polls Survey on doctors emigrating out of the country stirred up a robust debate around the issues facing doctors in Nigeria. Read the piece here. Dr. Anya responds to the conversation with a reflection on his own reasons for leaving and highlights key measures to stem the tide of doctors’ emigration from Nigeria.
In 2000, I was a senior medical officer, part of the pioneer staff at the then new National Hospital in Abuja. My early euphoria at practising at a world class hospital in Nigeria was fast evaporating. So was my joy at the restoration of elected civilian government after the dark years of the Abacha dictatorship.
Having resisted the initial temptation to leave directly after housemanship or after national service, I was beginning to realise that running a world class hospital took more than beautiful buildings and cutting-edge equipment and well-paid staff. Often the lab would run out of kits for tests which we urgently needed for our patients. Asking questions led nowhere. I remember once marching to the Chief Medical Director’s office demanding to see him. When his assistant asked why, I said it was because for nearly a week, the lab had been unable to carry out a particular test which one of our patients urgently needed. Laughing, he asked, “And that is why you want to see CMD? Dr Anya, is the patient your relative?”
This was not dissimilar to some of the nurses on the wards who would say to some of us when we stayed back to complete tasks late into the afternoon “Ah doctor, you are still here? All your colleagues have gone o!”
Many of the colleagues I worked with, doctors, nurses, lab technologists, radiographers, administrators, were dedicated and hardworking, ready to try and make the National Hospital the centre of excellence that it was supposed to be. Others, some of whom had secured their positions at the hospital through connections with politicians, were less so. Some of them would regularly turn up late for ward rounds or clinics or disappear when on call, often without sanction.
With some of my other colleagues I tried to be active in the local resident doctor association and push for changes through that forum. But in a strictly hierarchical organisation like a hospital, in a country like Nigeria where age is revered, there seemed little that we could achieve as junior doctors. Many of our suggestions were disregarded by the management, and there was the fear that being too vocal could affect you in the specialty exams that we all aspired to write.
On the political front, I watched as friends with whom I had debated Nigeria’s ills and the solutions, took up elected positions in the National Assembly and as aides to senior politicians. I was surprised to see how quickly they changed their views. As one said to me when I challenged him, our discussions before the elections were “theory” now that they were in the system, they were facing “practicals”.
I was increasingly disillusioned, and so began to explore career options outside medicine. I liked the way that my friends in the new banks and management consulting would discuss their strategy sessions, where they could suggest new products or new services and sometimes have them adopted. I liked the way a friend who worked in advertising described the friendly collaborative creative atmosphere at his workplace.
Then there was a national resident doctors’ strike. We at National Hospital negotiated with the national executive to be exempt from the strike as we had only just opened and were trying to avoid killing off the new hospital. They graciously agreed and we began to play a mediator role in trying to resolve the strike, since we were in Abuja and knew many of the key government officials who often attended our hospital.
A meeting we had with the then Senate President, weeks into the strike, strengthened my resolve to look for alternatives to a career in medicine or to leave the country. Asked to intervene with the famously stubborn then President, the Senate President said, “Ah, Baba does not want to hear anything about doctors because he feels personally insulted. He says that after he personally pleaded and gave his verbal assurance that the outstanding allowances would be paid, the doctors still insisted on a written assurance. And when that was not issued, they went on strike. He is taking it personal, so he’s not ready to talk.”
I left that meeting in despair that one man’s ego outweighed the suffering that the closed hospitals were causing.
“Gingered” by that incident, I redoubled my efforts to look for alternatives. Eventually I secured a place at the prestigious London School of Hygiene and Tropical Medicine on a Master’s programme and received a partial scholarship. So I sold everything that I had and left. Even then I thought I was only going for a year; I hadn’t resolved not to come back. But the shambolic way in which my request for unpaid study leave played out (story for another day) meant that a month into my course, I couriered, at an expense I could ill afford, a resignation letter. And so, I began to explore other options, and thanks to the wise advice of Professor Kevin Fenton, ended up applying for and beginning specialty training in public health medicine in the United Kingdom.
So what could be done to retain doctors in Nigeria? There has been a lot of debate and research about the retention of health workers in developing countries.
When talking about solutions, it is really difficult. People leave for various reasons, and few, if any, take the decision to stay or leave lightly.
From my personal experience, I would venture to suggest the following as areas to consider. Interestingly, they echo some of the recommendations from the NOIPolls/Nigeria Health Watch recent survey report on the emigration of Nigerian doctors.
- Identify, celebrate and support health workers who are doing a good job. I often say that it is relatively easy to do a good job in a functional health system. Doing a good job in a dysfunctional health system requires almost superhuman effort and we should recognise and celebrate the people who continue to do this, day after day.
- Provide opportunities for frontline workers especially the young and innovative to influence management and policy making at local and national level, and providing them with the skills to do so. A leadership fellowship programme for people like these has been my dream for a long time. Potential sponsors, please call me.
- Ensure that the processes for employment of doctors as house officers, residents or consultants is streamlined, transparent, fair and open.
- Overhaul the training at undergraduate and specialist level, getting rid of the ritual humiliation and including stronger emphasis on ethics and management and understanding the motivation that leads people to become health workers. · Review the recruitment process to allow for opportunities to explore motivation.
- Put in place universal health coverage so that doctors and nurses are not afraid to treat emergencies when they arrive to avoid their salaries being docked when the patient fails to pay. This happened to me.
- Explicitly celebrate the benefits of working in Nigeria, of contributing to building a functional system. When we were in medical school, many of our professors talked wistfully about their days working in the UK and the US, which made us want to do the same. · Foster multidisciplinary working and mutual respect between professionals in the health sector.
- Institute and conduct regular workforce surveys to pick up key issues and use the results to formulate policy at local and national level.
These are just a few of my suggestions and we at Nigeria Health Watch would be keen to hear alternative views and alternative perspectives. We are currently curating this conversation online with the hashtag #BeingADoctorInNigeria. Join the conversation today. You can also send us an email at firstname.lastname@example.org