Editor’s Note: This week’s Thought Leadership Piece is by guest contributor Olusesan A. Makinde, a Physician and Chief Executive of Viable Knowledge Masters, a Nigerian research and consulting company. He writes about the growing challenges that medical students in Nigeria face today when trying to find places to train for their internship and offers pragmatic solutions.
Admission into any medical school across the world is usually not an easy feat and when it happens, is celebrated with much fanfare. Admitted students often represent the top echelon of high achieving academic performers in the secondary schools from which they graduated. These brilliant students are usually unaware of the rigorous training ahead of them, with only a proportion of those that start eventually completing the race.
Nigeria, like several other developing countries, has a poor doctor to population ratio compared to developed countries, with only 38.9 doctors per 100,000 people as at 2012* (*The reference comes from the 2013 National Health Workforce Profile report which is not available online but the linked WHO report contains similar information). The poor physician to population ratio has been worsened by the continued emigration of physicians in search of greener pastures abroad;, a situation that has been termed “brain drain”. Although there have been several international initiatives to discourage the recruitment of doctors from developing countries; these need to be complemented by in-country efforts that will make traveling abroad less attractive to physicians. Limited specialist training opportunities in developing countries are one of the main reasons driving brain drain in countries like Nigeria.
Over the last 10-15 years, another growing problem has surfaced. Medical students are completing their training and finding it difficult to get internship slots for the compulsory one year pre-registration training, known as their Internship or Housemanship. The situation has become so bad that some medical graduates spend up to five years wandering across the country in search of continuously dwindling opportunities. Yet, the rule remains that if a physician has not begun housemanship in two years after completing training, he or she will need to rewrite qualification exams. It is discouraging to have family and friends contact me in order to facilitate placement for internship for their wards, in the mistaken belief that as a “senior” in the profession I will have access to internship opportunities for them.
As a medical student in the late 90s, we had intermittent screening periods where those who excelled were selected for the few training slots available in the teaching hospitals. However, lately, the stories we hear about the recruitment process for the few available slots are disheartening. A place on the internship scheme, it is alleged can now be secured by getting letters from senators, governors or other prominent political figures rather than through merit.
The incessant health worker strikes also have a detrimental effect on the internship training positions. Anytime there is an industrial action, the periods of industrial action do not count for the medical interns thus prolonging their training period beyond the one year contract and preventing others from beginning their own training. Medical schools are also springing up and producing more graduates beyond what the sector can currently absorb for internships and more medical students are receiving training in Eastern Europe and Asia, and coming back to Nigeria to complete the internship programme.
To make matters worse, there has been no corresponding expansion of secondary health facilities to provide more training slots. Many state governments seem to be more interested in establishing new teaching (tertiary) hospitals rather than providing secondary healthcare in their states. The cost of building and maintaining these specialist hospitals weighs significantly on the states’ budgets, which leads them to abandon their primary responsibility of providing secondary care. It is concerning that even though the problem has persisted for a while, every year the backlog increases, and those that ought to lead in tackling the challenge seem unprepared to do so or are unaware of their responsibility.
In 2014, I participated in the National Human Resources for Health (HRH) Strategic Plan development exercise. This activity was supported by an international development organization with an interest in human resources information systems. As such, the meeting seemed to have been biased towards the approval of an HRH information system for the country rather than an HRH strategic plan.. Neither the Ministry of Education, National Universities Commission, Medical and Dental Council of Nigeria, the Nursing and Midwifery Council of Nigeria, Pharmacists Council of Nigeria, Medical and Laboratory Science Council of Nigeria or any training institution was invited to the event.
A consultant had been engaged in order to develop a new strategic plan without an assessment of the previous strategic plan (2008 – 2012) which had expired with almost no implementation. There was a clear bias for the interests of the development partner. A few of the good heads present pointed out the poor planning of the activity and the need for a wider stakeholder engagement especially with the Ministry of Education and the accreditation and training institutions or their representatives in order to develop an HRH plan for the country. It is my honest opinion that such poor and biased planning of activities will continue until Nigeria begins to take responsibility for its own plans and strategies rather than depend on development partners to fund the planning for the future of the country.
The difficulty in securing internship slots by young medical graduates is likely to influence their future career plans. As internship slots get more difficult to come by, residency/ post-graduation training opportunities also dwindle. Difficulties in securing these opportunities for career development will probably negatively influence new medical graduates and they will continue to seek better opportunities outside Nigeria. The high rate at which Nigerian doctors are accepted into training programs in the most advanced countries in the world today is a testament to the capability of graduates from our medical schools. However, Nigeria needs to get its act together if it is to be the “Giant of Africa” when it comes to retention of medical doctors in its health system.
In proffering a solution to the “no internship slot” crisis, it is necessary for a broad-based stakeholder engagement which will include the Ministry of Education, accreditation agencies, training institutions and state hospital management boards. There should be a target to accredit more secondary health facilities to accept medical interns. As a last resort, an embargo or reduction in admission quota should be placed upon medical schools until the backlog is sorted out.
It is also time to consider a more transparent process for recruitment into these internship roles, not just in medicine, but also in pharmacy and other health professions that require such programmes, to ensure that merit and fairness are the bedrock of filling these very scarce positions.
The inability to commence internship immediately upon graduation is tantamount to an internal “brain waste” and the Government of Nigeria needs to do something about this urgently. The experience of these newly qualified doctors will certainly shape their motivation and future career pathways, and at the moment, the growing army of disillusioned young doctors does not look promising for the future of the Nigerian health system.