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Brain drain: Can 5-year compulsory service bill curb Nigerian medical doctors’emigration to other countries?

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What the proposed legislation may achieve if passed into law would be to increase the pool of unemployed and disenchanted Nigerians rather than providing solutions to the problem of exodus of medical professionals. Laws and policies that enhance the rate of production of good quality healthcare manpower while promoting the desire and willingness of healthcare workforce to stay back in the country should be the core focus of the National Assembly at this time.

Medical doctors and other healthcare professionals have been “fleeing’’ Nigeria’s shores in their hundreds in search of greener pastures, resulting in brain drain in the nation’s health sector.

The doctors have cited poor incentives, poor work conditions, under funding of the health sector and insecurity as some of the reasons for emigrating to nations with better working environment such as the UK, U.S, Canada, Saudi Arabia, Australia, among others.

Persecondnews gathered that Nigeria is the third country, behind Pakistan and India, with the highest number of doctors that have migrated to the United Kingdom alone in the past few years. Available statistics show that about 13,609 Nigerian doctors have migrated to the UK in the past eight years.

As of November 2021, 8,983 Nigerian trained doctors were working in the United Kingdom, and another 727 licensed in just five months between December 2021 and April 2022, bringing the total to 9,710 with at least 12 Nigerian doctors employed in the UK every week.

The World Health Organisation (WHO) recently released its 2023 list identifying 55 countries as vulnerable to availability of health workers required to achieve the UN Sustainable Development Goal target for universal health coverage (UHC) by 2030, and Nigeria and 36 other African nations are on the list.

“The impact of COVID-19 and widespread disruptions to health services has resulted in a rapid acceleration in the international recruitment of health workers. For countries losing health personnel to international migration, this could negatively impact on health systems and hinder their progress towards achieving UHC and health security,” WHO said in the publication on its website.

Persecondnews recalls that the Association of Resident Doctors (ARD), Federal Capital Territory (FCT) chapter, at a press conference to mark its 2022 Health Week in November 2022, raised the alarm over the imbalance in the ratio of doctors to patients due to exodus of their colleagues.

Speaking on the theme: “Brain Drain and The Health Sector In Nigeria,” the President of ARD-FCTA, Dr Nnamdi Nd-Ezuma, disclosed that in the last 10 months of 2022, over 1,000 doctors had left the country, leaving a considerable gap in the Nigerian healthcare sector.

“We have it on record that we induct 2,000 to 3,000 doctors annually. In the past 10 months, we have had about 1,000 doctors leaving this country. There is an imbalance between our medical practitioners’ demand and supply ratio.

“In Nigeria, we are now taking about one doctor to 6,000 or 10,000 patients. We find it critical to talk about the challenge Nigeria’s sector is facing,” Dr. Nd-Ezuma explained.

Similarly, the National President of Nigerian Association of Resident Doctors (NARD), Dr Innocent Orji, disclosed in January this year that Nigeria has lost about 2,800 resident doctors over a period of two years, adding that the number does not include consultants and other doctors.

Orji noted that the exodus of doctors to foreign countries had continued to weigh down the healthcare delivery and service in Nigeria as one doctor is expected to take care of over 10,000 patients without a commensurate welfare package.

Bill on mandatory 5-year practice for doctors, UK restricts recruitment of health workers from Nigeria
To stem the tide of brain drain in the health sector, a bill by Nigeria’s House of Representatives seeking a mandatory five-year service to the nation for doctors trained in the country before being presented with a practicing license, has passed second reading.

The bill 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 or Dental Practitioner to Practice in Nigeria for a Minimum of Five (5) before being granted a full licence by the Council in order to make Quality health Services available to Nigeria; and for Related Matters (HB.2130)”, was sponsored by a member representing Oshodi/Isolo II (Lagos) Federal Constituency in the House of Representatives, Mr Ganiyu Johnson.

Leading the debate last week at the plenary, Johnson pointed out the bill when passed into law would curtail the influx of Nigerian-trained medical and dental practitioners into foreign countries, adding that “it is only fair for medical practitioners, who enjoyed taxpayer’s subsidies on their training, to give back to the society by working for a minimum number of years in Nigeria before taking their skills abroad.”

Majority of lawmakers supported and contributed to the debate on the bill, stating that the high rate of brain drain in Nigeria is “truly alarming.’’

The bill was passed, read the second time and referred to the House Committee on Healthcare Services by the Speaker of the House, Mr Femi Gbajabiamila, who noted that Section 45(1) of the Constitution has a provision for setting aside fundamental rights for the sake of the greater good of the people.

Less than a week after the five-year compulsory service bill for Nigeria-trained medical practitioners passed second reading, the United Kingdom announced on Monday, April 10, that it had placed Nigeria and 53 other countries on the “red list’’ of countries that should not be actively targeted for recruitment by health and social care employers.

According to the UK, the decision became necessary following WHO’s projection of a global shortage of 10 million healthcare workers to achieve universal health coverage in low- and middle-income countries by 2030.

Medical bodies, stakeholders criticize the bill
However, medical bodies and stakeholders have criticized the proposed bill which would require graduates of the nation’s medical and dental schools to serve out five years in Nigeria before being given a full practicing license.

In a series of tweets on his official twitter handle, the Chairman of the Senate Committee on Health, Sen. Ibrahim Oloriegbe, stated that the bill sponsored by Ganiyu is not enough strategy to address the challenge of brain drain in the health sector as he queried the rationale behind the bill.

“The factors responsible for brain drain are multifaceted and the mere denial of full practice license to medical practitioners as contained in the proposal will never solve the problems but may even aggravate them.

“Besides, it is not only medical doctors that are leaving the country for greener pastures abroad, there are other health workers, as well as professionals in other fields of human endeavours, trained but leaving the country on daily basis for similar purposes. Consequently, focusing attention only on the medical doctors is like curing one of many ailments that are threatening the life of a dying patient without finding solutions to the others.

“In addition, with all due respect, the issues and facts related to granting of practicing license are not understood by the sponsor of the bill, thus, it becomes imperative for me as a stakeholder in the health sector to offer my perspective, this time as a medical practitioner of many years and not particularly as a senator with the privilege of heading the Senate Committee on Health.

“The piece of the proposed legislation at a minimum violates the right to the ‘Freedom of Movement’ (Sec. 41) and ‘The right to freedom from discrimination’ under (Sec. 42) as guaranteed by the Constitution of the Federal Republic of Nigeria (CFRN) 1999, as amended.

“These rights cannot be ordinarily denied by any person or government. Thus, we can’t be seeking legal redress through an illegal procedure.

“A person who is ‘qualified as a Medical Doctor’ cannot be denied a license to practice having been certified qualified, except if he is found wanting in the ethics of the profession. Labour laws will come into play here.

“Furthermore, before the bill can be considered for legislative passage and executives’ approval, the following fundamental issues are important to scrutinise: a) When does the 5-year period start, before or after the housemanship?

b) What sort of license will be awarded to a fully trained doctor instead of a full license to practise under the proposal?

c) Is there going to be a limit in the doctor’s scope of practice, and to what extent are the limits during the five years waiting period? And we need to establish why we are putting such limits; is it for lack of skills, or political expediency?

d) What happens after the five years of denial of rights to practise?

e) Consequently, how will this law advance the quality of clinical services, education, and research in any system, let alone, a crippled one like ours?

“Given the above reasons, it is my considered opinion that resolving the challenge of brain drain in the country’s health sector cannot be achieved through this bill. Rather, we need to address the various factors that make skilled health workers desire to migrate out of Nigeria.

“I, therefore, recommend that rather than enacting laws that will curtail the rights of the citizens to free movement and seek better opportunities through legal means, we should advocate for an improved system that will be very attractive and make medical practitioners unwilling to travel abroad to seek better living conditions.

“That is, we have to make our pastures to be greener so that other people’s pastures won’t be tempting to them. We can achieve this through the following recommendations:

i. Medical students could be obliged to choose between paying the standard market rate for their training or opting for government-subsidized training. Quality education in its real sense can’t be free.

Those who however opted for subsidized training after their qualification would in return be compelled to work in Nigeria for a certain time or refund the subsidies. This is a practice obtainable even in advanced countries such as the UK.

ii. To achieve the goal of a mandatory work scheme, we can enable a system that will guarantee employment opportunities for medical professionals after their qualification and provide inflation-adjusted living earnings for a few years after graduation on the condition that they stay in Nigeria to practice. Apart from providing attractive remunerations, their work environment and career expectations should also be prioritized. Incorporating both measures should give us satisfactory results.

iii. Lastly and importantly, we need to improve our health system with sustainable investments to make it conducive for the various health workers to work. We can be assured of better output only if what we input is in good condition,” he tweeted.

Also ventilating their anger on the bill, the medical students under the aegis of the Nigerian Medical Students Association (NiMSA) described the bill as “unpatriotic and a breach of the fundamental human rights of doctors”.

In a statement signed by its President, Ejim Egba, NiMSA said the proposed legislation is intended to ‘strangulate the medical profession.’

“The search for greener pastures abroad can be reduced by making our land and pasture green, properly equipping our hospitals, better treatment for doctors and the brain drain will be adequately controlled. Rep. Johnson at this point should be steering conversations on medical tourism and not doctor slavery.

“We firmly believe that this bill is not the solution to the problem of brain drain, and we stand against it in its entirety in the strongest possible terms.

“The intention behind the sponsorship of this bill does not take into consideration the root causes of brain drain in Nigeria. The issue of brain drain is multifaceted and requires a more comprehensive approach to tackle it. Instead of trying to forcefully take doctors as slaves, the lawmakers should be focusing on creating an enabling environment that encourages doctors to stay and work in Nigeria.

“The lack of infrastructure, inadequate and inappropriate remuneration, and poor working conditions are some of the major factors driving medical professionals away from Nigeria. These issues need to be addressed if we want to attract and retain our healthcare professionals; make our land green.

“We also unequivocally state that this bill will discourage students from pursuing medical education in Nigeria which will further exacerbate the problem of the shortage of healthcare professionals.

“A better way to bring up the issue of being trained with ‘taxpayer subsidies’ would be to have it optional, the option of paying for medical education at the real cost value, the option of obtaining student loans, and also the option of going for the subsidized medical education with the caveat of staying behind for a certain number of years to ‘pay back’.

“Besides, not all doctors in the country are trained on subsidy; one thing the bill failed to capture. Doctors need to have a choice, even before they start their training so they can make better, informed decisions.

“Additionally, we strongly believe that the bill is arbitrary in nature and totally unconstitutional- it deprives the Nigerian-trained medical and dental practitioners of their fundamental right to freedom of movement by arbitrarily imposing restrictions on their movements against the provision of Section 41 the Constitution of the Federal Republic of Nigeria.

“In conclusion, NiMSA vehemently opposes this bill in part and in one whole. We call on the Sponsor of the bill to withdraw it with immediate effect and seek better ways of finding a lasting solution to the problem of brain drain by consultative collaboration with relevant stakeholders in the health sector coupled with the government’s willingness to address the root causes and underlying issues that drive healthcare professionals away from Nigeria,” the statement said.

Lending its voice to the growing opposition to the bill, the Medical and Dental Consultants Association of Nigeria, (MDCAN), stated that the bill is “not only discriminatory and harsh, but also against the interest of the people”.

A statement jointly signed by the MDCAN President, Dr. Victor Makanjuola and General Secretary, Dr. Yemi Raji, noted that the bill was not only discriminatory and harsh, but also against the interest of the people.

According to the doctors, the bill violates the constitution of Nigeria, as Section 34 (1) b states that, “no person shall be held in slavery or servitude” while section 34 (1) (c) states that, “no one shall be required to perform forced or compulsory labour”.

“We received with a rude shock the news of a bill purporting to make it mandatory for fresh medical graduates to provide services to Nigeria for up to five years before receiving a full registration and license to practice.

“This proposal is such that they would not be able to leave the country until after five years post qualification. It is even more worrisome that the bill has passed through the second reading.

“Healthcare workforce shortage is a global phenomenon that requires international collaboration to address, through well thought-out, fair, and just guidelines. Hence, enacting a law to address such a global issue with a local quick fix is an over kill.

“What the proposed legislation may achieve if passed into law would be to increase the pool of unemployed and disenchanted Nigerians rather than providing solution to the problem of exodus of medical professionals.

“Laws and policies that enhance the rate of production of good quality health care manpower while promoting the desire and willingness of health care workforce to stay back in the country should be the core focus of the National Assembly at this time.

“We hereby convey our total rejection of the Bill and pray that it should be thrown out completely,” the statement said.

MDCAN further stated that it has along with sister associations in the health sector, provided to the appropriate agencies of government useful and practical suggestions on how to remedy the situation, but they refused to their advice.

In the same vein, the President of the Nigerian Medical Association (NMA), Dr. Uche Rowland Ojinmah, disclosed that in spite of the brain drain in the health sector, many qualified doctors are still unemployed in Nigeria.

The NMA President, who stated this during a recent interview on a national television monitored by Persecondnews, called on the government “not to cut the head off to cure a headache”, as he stressed that jobs and good remuneration should be given to the many doctors still seeking employment in the country.

“If everybody is being subsidized, you can not in a discriminatory manner go down to a few people. All that we have come to realise is that doctors are important just like other healthcare workers and the solution is to make a man that is important feel that he belongs to you.

“The pull factors are those things that are outside that are making them go which is not within our control while the push factors are the things within our control that are pushing them out of Nigeria.

“The first push factor is poverty. A newly trained doctor [abroad] is earning about £40,000 (about N22m at official exchange rate) per annum while our own is earning about N3million to N3.6million per annum. A fresh doctor in Nigeria earns in a year what a fresh doctor in the UK earns in a month,” Dr. Ojinmah explained.

He also criticized the heavy taxation policy imposed on doctors in Nigeria, saying “we are treated like we are common and now they are crying that we should be held hostage.”

Meanwhile, the Diaspora Medical Associations in diaspora, DMA has petitioned the National Assembly over the bill, describing it as counterproductive and that it would not achieve its intended goal of addressing brain drain in the country.

The letter titled: “Re: A position statement from diaspora medical associations – Bill seeking to restrict newly-qualified medical doctors and dentists from leaving Nigeria,” was addressed to the Speaker of the House of Representatives.

The body also copied the Senate President, Ahmad Lawan; the Chairman, Senate Committee on Health, Dr Ibrahim Oloriegbe; and the Chairman, House Committee on Health, Dr Tanko Sununu.

The letter was signed by the President, 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.

According to the DMA, the bill sponsored by Hon. Johnson, which passed second reading at the House of Representatives last week, is counterproductive and would not achieve its intended goal of addressing brain drain in the country.

It stated: “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 of care, care delivery deserts the inability to adequately enact health care and public health policy due to lack of manpower and leadership resource.

“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, sociopolitical and economic instability. 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.”

With the various criticisms, condemnations and knocks trailing the House of Representatives’ Bill mandating Nigeria-trained medical and dental practitioners to practice for five years before being granted full licence, will the bill see the light of the day as the 9th Assembly is winding down on June 2, 2023. If passed, will President Muhammadu Buhari assent to it in the twilight of his administration? These are multi-billion questions.

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