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
This was indeed an insightful article for me – thanks for the articulation.
With regards to the suggested solutions I wish to observe that, the central driver for change in our health care delivery system is the patient!
If patients in Nigeria responsibly begin to demand for quality care, whether paid for out-of-pocket, or through health insurance, the health care facilities would gradually be forced to focus on quality care delivery – which rests squarely on the personnel (Nurses, Lab scientists, Doctors, even the cleaners!). At the moment health care services are perceived (by patients) as a favour done/provided to patients, and so anything goes.
The banks in Nigeria are not at their best at the moment, but there is clearly a viable traction in this direction. The customer can always move his/her money to other banks if unsatisfied with the services provided by a particular bank. So their is a consistent effort (competition) by the banks, geared towards increasing quality of customer services/care. This has also been helped by the policy environment.
We need similar focus in our health system, but the patient is the key in this effort. Unfortunately majority of the patients seeking care in majority of the public health facilities, are un-informed!
Thanks again for this insightful article.
Development of the healthcare industry in Nigeria, by private investment, is frustrated by the all embracing, poorly financed health insurance scheme that makes investment for profit very unattractive to the private investor! Overseas centres of healthcare tourism are possible due to the profit motivation which encourages investment. Nobody will invest in a situation where all services are regarded as primary care with capitation of N750 for over seven years! That cannot promote high quality medicare services and, surely, not healthcare tourism! Ik. Onyiah, FRCS.
Wow! “Mr.” Ik Oniyah, this is true. It should be noted that some of our private individuals such as Aliko Dangote have started to give their support to the healthcare system in the nation by investing. Do you think this move has a possibility of improving the quality of healthcare delivery in our country?
Btw, I must commend your achievement (FRCS). I hope to get there very soon by God’s grace.
Finally, the nail has been hit squarely in the head.
The main problem of the Nigerian health sector are the patients themselves… the average Nigerian!!!
I have NEVER heard of a scenario where Nigerians ask of their leaders, a decent health system, or better access to healthcare and fight for it. I have never heard of a demonstration or industrial action by the labour groups fighting this vital cause.
We rather, keep walking around like zombies, licking our wounds, basking in the cocoons of our ignorance, and requesting a golden coin from politicians in return for a thumbprint at the polls.
A healthy nation is more likely to progress in other spheres of the economy. You cannot expect the best from a nation with sick individuals and no plans to nurse them back to health.
Till Nigerians on the streets re- order their priorities, the health sector is going to continue down the path of shame.
My only grief is that in the future, judging by the rate at which we are plummeting in a free fall to the ground, health workers would be a scarce resource in the Nigerian health system. We would be cast back to the era of quacks masquerading as doctors and committing heinous crimes under their disguise. Herbalists, mechanics, electricians, illiterates, to mention few, would ride on our ignorance and exploit us.
That future is here already… We just are turning a blind eye to it.
A very good article that articulates the frustration that drives many to leave and it is not just in doctors. I also agree with your recommendations on the way to resolve the challenge. I believe that the most critical element is ensuring that doctors have the tools to work with, that people receive decent wages and that the overall environment is made conducive to the practice of medicine.
Insightful write up. Nigeria has a lot of problems particularly and many of us have collectively contributed to encourage mediocrity directly or indirectly. The challenges in the health sector are not limited to it but a reflection of the society in which we live. However, in the various positions we hold, we can decide to do what is right and not to follow the bandwagon. Let’s join hands together to make Nigeria and the health sector functional.
Thank you Ike for your insightful story. Remember, I was one of the DTM&H 2002 set that came back to Nigeria. My experience in Nigeria 10 years after is captured in my book “Maximizing the benefits of foreign education” published in 2012.
Thanks to Governor Okowa, I am now Permanent Secretary, Delta State, Ministry of Health, Asaba.
My recommendation is that you take one of your suggestions and pilot the application in the smallest location possible e.g. a political ward or a health facility. Then share the results whether positive or negative.
I launched a project titled “Adopt Your Own Village” in 2010. A bit about it was presented at the Faculty of Public Health Conference at Telford in June this year by Dr. Eni-Olotu. That is one way I manage to motivate myself in spite of the numerous challenges. I really hope others can do the same.
The amount spent overseas, treating one person , can easily establish a first class centre to take care of many more citizens here. Did Nigeria reap any benefit from the overseas treatment for “radiculopathy” several years ago? Most well organized counties would Import the experts (many of whom are Nigerians) and also the needed equipment for the treatment of their vips so that such equipment and expertise may be used to treat other citizens who may have similar problems but may not afford the overseas cost. I am just sounding “Common Sense!”. Joe.
This is an insightful piece. It does appear that what we are facing in the health sector is just a fallout of the state of our country generally. It is difficult to name one sector that is doing well. The situation is complex.
I used to habour hope that perhaps if people like Dr Ike Anya found themselves in positions where they could directly influence policy or act to effect the needed changes in the health sector, then our problems would be solved. But those hopes are no longer as strong since this article exposes how people change when they get into the corridors of power as exemplified by his friends who ended up as aides to politicians.
The system does change people, especially when they are isolated in their ideals or ideology. It would require a critical mass of like-minded changemakers to get into influential positions at about the same time. There are a few steps that could be taken in the interim, as outlined in the article, but those would be a drop in the ocean.
The problem is systemic.
A well-informed article.
I am amazed, frustrated and disgruntled at the way our hospitals in Nigeria are been run.
The patient are ill-informed about their rights. Even when they do, in Nigeria, its very had for people to win a case against the government, so people just stay back, considering the time and resources they will put into such struggle.
Our very problem in Nigeria is that a few health workers who belief in a better healthcare system get frustrated and walk away.
When you keep walking away, who will change the system.
For health sector to be redefined, the policies and structures must be redefined, and for such to happen, only like-minded individuals can do the same.
Even when this equipments and resources are provided, the leaders of such sectors siphoned it and force the patient to buy with their underprivileged resources.
Spirit of service is too low.
My suggestions are that we need people who belief and want a better healthcare system to start working their way to political offices, they must resist any financial temptations at any point in their pursuance of such goal, when we do have such persons, they must ensure supervision, evaluation and re-evaluation at every stage of government projects.
Take for instance, the servicom, they should beable to identify those things that are the rights of the patient and published at every point of services not to tell patient to lay a complain which they dont know which and which is their right. e.g buying of syringes which are fully provided by government; buying of hand gloves; buying of gauze; buying of all other materials. If patients must pay a dime for it, it should be for the sake of compensating the shortage supply by the management. And these shortage must be calculated by servicom and made available. I say this because, a patient rushed into the ER unit or in the ward, a nurse or doctor will sit down and write an invoice for a patient to go and buy so, so and so. Piece of gauze which was supplied by government for free is sold for 200#, and the patient may need 5 packs for just one wound dressing because, there are too small.
To solve a problem in Nigeria, talking can not solve it, we all who think we have the knowledge have to start acting.
Well where is our president at the moment? I think that is a clear reflection of the priority healthcare delivery is accorded in Nigeria. I mean a “whole”government of Nigeria cannot even spare us the ignominy of our number one citizen being treated outside the country. # our mumu don do!
This thing called quality healthcare can be demystified if there are real reforms to allow private capital to invest. That’s how “gsm” was introduced and despite all the infrastructural challenges to doing business in Nigeria, it remains the biggest ICT market in subsaharan Africa. Healthcare has always been a commodity in Nigeria and if we think laterally, we can democratize it across the country.