Editor’s Note: A U.S news politics report that recently trended online showed how Nigerian immigrants have carved a niche in the United States as highly skilled workers. The numbers are impressive, with Nigerians ranking highest in the percentage of immigrants with a bachelor’s degree, at 59%. The applause for this is commendable, yet it also means that as a country Nigeria is consistently and increasingly exporting its skilled workforce to other climes. In this week’s Thought Leadership piece, Dr. Ronald Ikpe, a public health physician, takes a deep dive into the reasons Nigerian doctors are leaving the country enmasse, implications for the health system, and proffers potential solutions to heal, or at least bandage, the deep human resource gash in our health system… before we completely bleed out.
The healthcare workforce is the spine of every health system. Sub Saharan Africa bears 25% of the global disease burden and is roughly about 14% of the world population. It is estimated that this number is being catered to by just 3% of the global healthcare workforce.
There is a growing shortage of doctors in Sub Saharan Africa, and very important to me is Nigeria. This is because I live and work in Nigeria as a medical doctor. According to the Nigerian Medical Association (NMA), we have just about 40,000 doctors practicing in Nigeria and about 80,000 on the register. In 2017, the National Association of Resident Doctors (NARD) estimated that over 2500 doctors were actively seeking greener pastures abroad. Currently this figure may even be more, and it is clear that Nigeria is among the leading exporters of medical personnel globally.
Many reasons have been identified as causes why doctors are leaving the shores of Nigeria daily, commonly tagged the “push and pull” factors. Some of the push reasons are high tax deductions, poor work satisfaction, poor pay, lack of medical equipment, state of insecurity amongst others while some of the pull reasons include ease of integration into the new system, and favorable visa policies.
Lets take a deep dive into some of these issues.
Salaries: Not enough, not paid on time
Salaries are a major push factor for the average Nigerian doctor. In addition to not being paid well, some are owed salaries months on end by their employers, both government and private hospitals. Some doctors are owed as much as seven months at a stretch. I remember being owed for three months once and I complained about it, only to hear that it is the normal thing.
The Nigerian doctor earns on average N150,000 in Lagos, in private hospitals. This price may be more or less depending on the state and the type of facility. I know doctors who earn N60,000 per month somewhere in Owerri, Imo State. I also know someone who earns N30,000 somewhere in Aba before he left the country for the United Kingdom (UK). In government hospitals, the salary might be a little higher.
The twitter post above generated a lot of traction after it was posted.
For locum jobs, its N800 per hour in Lagos and about N250 to N300 per hour in places like Ibadan. So, a grueling eight hours locum shift in Lagos will earn you N6,400 or N2,000 in Ibadan. An uber driver makes more than this daily.
Initially, it was the junior doctors that were leaving, but recently the senior ones, specialists, have joined the train and the top destination right now is Saudi Arabia where they are being paid as high as N1,000,000 to N3,000,000 monthly as salary. The difference is very clear. Who wouldn’t jump at an opportunity to make this type of money working in a sane environment?
Lack of basic medical equipment
Many Nigerian doctors have been called miracle workers as they literally have to work with almost no equipment and still get results. There is often a lack of medical equipment and infrastructure. Issues like lack of oxygen and lack of blood are almost a norm but thankfully companies like Life Bank are increasingly stepping in to bridge that gap. Still, they cannot solve this problem alone. The story of a doctor who died in a hospital where she worked because of lack of oxygen is still fresh in my memory.
It is very disheartening and painful for a doctor to watch a patient die because of flimsy things like lack of oxygen or no sutures. I once had an experience when I went to have my child immunised, and I was asked to buy gloves for N50 without which my child wouldn’t be immunised. It was then it began to dawn on me how bad issues were.
I also remember scrubbing in to assist a surgery and I asked for googles to wear. I was told that there were no goggles. The surgeon and the circulating nurse were wearing googles, and the surgeon quickly told me that he had purchased it, as well as his surgical boots, with his own money as the hospital did not provide any despite several requisitions. There have also been times where surgeons have been forced to use torchlights in the operating theatre due to no electricity.
I agree that some facilities have upgraded a bit, but we are barely scratching the surface. Someone told me that a dog that has cancer in South Africa stands a better chance of survival than a Nigerian with cancer. Even lions have the best of care in South Africa.
No allowances for safety and welfare
The hazard allowance for a doctor is N5,000 in a government hospital and none in most private hospitals. This basically means, if anything happens to a doctor in the line of duty, he or she gets almost next to nothing as a form of compensation. Most doctors feel that the Nigerian healthcare system does not prioritise the safety of its workers. During my houseman year we all individually had to source for Ribavirin after we had a case of Lassa fever. We paid for our own laboratory tests and prayed that nothing happened to us.
Most of the call rooms in hospitals where doctors are supposed to rest during work hours are deplorable. This is aside the poor quality of the call food. The rooms must not be hotel rooms, but they should be able to offer some relief. I know doctors who carry their own bedsheets to work because the call room has none available. Some even go as far as having their own sleeping bags because the foams are bed bug infested.
Recently there has been some reports in the news about doctors that have been attacked in their workplaces and that in itself is incredibly worrisome. Recently a female doctor was said to have been stripped naked at a hospital in Abuja. I felt very sad reading that story as I myself have been a victim of workplace violence all in a bid offer the service that we have been trained for.
Frustration with postgraduate training
With the UK making it easier for doctors to come in, there has been a general decline in specialisation in Nigeria. Even our consultants are also leaving. Postgraduate medical training is required to become a specialist doctor in areas like surgery and orthopedics. In Nigeria it is riddled with a lot of bottle necks.
I passed my primaries in 2013 and by 2018, I was yet to get accepted into a program. I had to travel to different states of the country for interviews. I later learned you need to have strong political clout to get in. I remember being asked to pay N900,000 for a residency slot. During one interview, I saw some of the doctors that taught me in medical school also seeking acceptance into the same training. If this was the case for them, I wondered if there was any hope for me.
Chances are very slim if you are not an indigene of the state where you seek residency training. During an interview in one of the popular teaching hospitals, one of the examiners asked me what state I was from and when I told him, he just laughed, the kind of laughter that instantly told you that you shouldn’t have bothered coming for this interview.
My primaries have expired, and I have no intention of writing another one. Chances of being accepted to a training program are bleak.
We all suffer. Here are some implications of this problem:
Longer waiting times
It is estimated that Nigeria has 1 doctor to 6,000 patients as opposed to the World Health Organisation (WHO) recommendation of 1 doctor to 600 people. The waiting times in most government hospitals have increased as you have fewer doctors to attend to patients. Nigeria has a population of about 200 million and with the current mass exodus of doctors and other healthcare workers, the doctor to patient ratio will worsen if nothing concrete is done.
Physical and mental exhaustion
The doctors who are still in the system are now left to do more work. A tired doctor is a dangerous doctor. There is nothing interesting about seeing over 100 patients daily, then staying back after 4pm to do call duty where you are most likely going to be the only one looking after 20 patients on admission and still cover the emergency ward. I recall with sadness the doctor who died in UBTH after doing some surgeries back to back.
Delivering the best of care in this type of condition is impossible. In some hospitals here in Lagos, some doctors do as much as seven cesarean sections in a day, possibly due to lack of skilled personnel or manpower. The risk of medical errors increases with tiredness and fatigue. Aside the risk of medical errors, it also increases the chances of a suicide by a doctor.
Worsening health indices
With the rising level of communicable and non-communicable diseases alongside the low physician to population ratio, we may soon begin to have worsening health statistics. Care is provided by healthcare workers, and the current massive exodus portends danger for all of us. Even if we leave, our loved ones are still behind and may sooner or later require healthcare that is almost nonexistent.
What can we do to stop the bleeding?
First, the government has to acknowledge that we are in crisis mode. The recent statement by Dr.Ngige that Nigeria has more than enough doctors to cater for the population does not reflect the reality many Nigerians are facing.
Our government must increase healthcare funding. Funding for previous years has been constantly below 5% as against the proposed 15%. There has to be clear roadmap for healthcare strengthening, research and improved service delivery.
There has to be investment into basic infrastructure — electricity, good roads, investing in quality education, and security. This will not only help stem the exodus, it will also attract more professionals back to the country, which may help reverse medical tourism, and turn the brain drain into a brain gain. Nigerian doctors have constantly proven themselves outside the country. Why can’t we give them an enabling environment to thrive?
Hospitals need to be equipped. Post graduate training has to be made more attractive and the training program well structured. Doctors should have better renumeration and working conditions have to be good in order to foster workforce retention.
Doctors that work in rural areas need to be incentivized and given the required equipment to carry out their duties. The Rivers State government seemed to understand this during Governor Rotimi Amaechi’s tenure where doctors in the health facilities in the rural areas were given a furnished apartment to live in with a vehicle. I don’t know what happened to that scheme.
We are all responsible
It is a collective responsibility that lies ahead of all of us. We need to rethink leadership and healthcare delivery in Nigeria to make it work. We need to tell ourselves the hard truths. Brain drain is not the problem but merely a symptom of an underlying disease. Some startups like Doctoora and Life Bank have stepped up to the challenge, but we cannot entrepreneur ourselves out of brain drain. Those that will leave will eventually leave but as a country we have to do what we ought to do.
As my colleague Dr. Ayomide Owoyemi said in this article, we are all Abioduns waiting to happen. We should not wait for the healthcare system to come to a complete halt due to the absence of doctors to provide basic health services before we begin to address the problem. If no one is worried, I am truly worried. This is the time that all stakeholders need to come together and declare a state of emergency.
Are you a doctor with an experience to share about providing healthcare in Nigeria? Drop a line in the comments or on our social media platforms, using the hashtag #BeingADoctorInNigeria.
Author’s Bio: Dr. Ronald Ikpe (Dr. Ron) is the founder of MRI Medic and MRI Media, a healthcare consulting and digital media outfit set up to helping health brands tell their stories on social media. He is the writer of #TalesOfDrRon on twitter, a medical story series dedicated to enlightening the populace on health issues in the most relatable way. He tweets as @ronikpe