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.
Brain drain is detrimental to the Nigerian Health Sector. Source: https://www.youtube.com/watch?v=Sk10v2FZBxk
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.
We need to revisit the medical internship system in Nigeria. Photo Source: hotels.ng
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.
Nigeria needs to retain its doctors for a better health sector. Photo Credit: Nigeria Health Watch
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.
Such a fantastic piece on the current state of the national post graduate medical training!
In the past 3 years, the effect of the incessant strike actions and lack of slots for internships and residency alike seems to have gone unnoticed by the government and also regulatory bodies like NMA.
Segun, I totally agree with your assessment and recommendations. In addition, I also think that the geographic variation in the distribution of health workers in the country need to be addressed to guarantee effectiveness.
This is a shamefull disgraceful blight on the profession as we ignore the plight of the young ones our. own Medical Generation Next. I have a personal experience with a young graduate trapped between the connected and the confused.
As with almost medical everything in Nigeria we fail to plan for our medical graduates and consequently plan to fail them when they seek housemanships without which they are useless as doctors to themselves and legally unemployable in society as they cannot register fully or even do NYSC which itself is now becoming another high hurdle to jump. It is a sad but necessary research study to see what victims of No Housejob Disease are forced to get up to during the forced timeoup in the career they and families invested so much finance and hope. What is the long-term fate of a Delayed housejob victim? Since medicine began House job has been a mostly painful right not a privilage. House job merely completes training interupted by graduation. Nigeria and NMA et MUST ensure they do to graduates what was done to them in the past an automatic housejob. No pulling up of the ladder or selective housejob.
Solutions in addition to those mentioned in the excellent article include
1 There requires to more burden on each Med School to find places for its graduates
2 No new graduates should be recruited for housejobs anywhere until the backlog from the previous year have been taken
3 The all clear on late housejobs must be given by the. BODY RESPONSIBLE FOR REGISTERING NEW AND OLD DOCTORS. This will immediately solve the backlog. not senators seeing admission for favoured pikin and eliminate any waiting beyond 1 year if all temp reg must submit where they are doing housejob and those without or waiting are on a waiting list i would be simple to fix them before any newer grad comes to reg for temp reg.
Thanks Dr Marinho,
I agree that more burden should be placed on the medical schools as well. I also agree that the MDCN needs to remove the barrier as this is not their fault but the nation’s failure to plan (including MDCN as a major stakeholder). Your other suggestions on clearing a backlog by a school before taking on new candidates is also valid.
We must eliminate favoritism and engender equity in our medical training programs again.
Regards’
Olusesan Makinde
I want to thank you for bringing this horrible plight of some of our young colleagues at the end of their medical school training to public attention. I too have been so concerned about it that I decided to make it the issue of a keynote address I would delivering at the 50th Annual General Meeting and Scientific Conference of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) which will hold in Ondo, early October this year. Titled THE INTERNSHIP IS AN IMPORTANT COMPONENT OF MEDICAL EDUCATION, the lecture which will be delivered under the auspices of the Frontiers In Medical Education, draws a comparison between my experience as a pre-registration house office at the Lagos University Teaching Hospital in July 1969 and the experiences of some of our colleagues in recent times in the same capacity. It contains a lengthy discussion on the way forward in addressing a number of the horrendous differences which were highlighted in the paper.
Dear Dr Briggs,
Many thanks for also thinking about this sir. The medical profession is being desecrated daily because our leaders have failed to plan for us. Pre-registration medical graduates in dire financial situation are engaging in private practice ahead of internship training. Some of them barely survived through medical school and have learned only medicine all their lives. In the absence of internship slots, they still need to survive and become forced “quacks” as they have not been licensed to practice yet.
We need to help them turn this around. We also need to advocate to more private hospitals that have the capacity to take on this responsibility as a corporate social responsibility. I hope you can include this last statement in your discussion at SOGON.
Regards’
Olusesan Makinde
Dear Prof Briggs
Is there a link to your lecture for the public to access. It will be insightful. Meanwhile, has your recommendation been implemented yet?
Thank you
I wish to add my voice in this discourse and thank you for bringing forward to attention this plague in our health system which requires urgent attention before corruption takes over and by this I mean Quakery. Like you said, entry into medical school is usually celebrated , likewise the taking of the Hippocratic oath as a qualified doctor. You correctly captured the reasons for the problem of internship in our country to inadequate number of institutions for training, establishment of teaching hospitals by states thus churning out doctors without commensurate expansion of the secondary tier health services, nepotism in the filling of the few spaces and the incessant strike actions in the health sector. I want to add to your suggested solutions, that a stakeholders conference or workshop on this might throw up Nigerian solution to this. It is not long ago when federal medical centres were included in training of house officers. We can look at rotational internships using private hospitals/teaching or specialist hospital collaborations to bridge the requirements for internship. By this I am suggesting that if the requirements are programmed in modules, the internee can acquire such supervisory skills from different hospitals and clinics under approved Consultants. This can be further fine tuned. This way, these young doctors can shop around for the modules in different hospitals.
Thanks for your beautiful and germane article.I can agree no more with your submissions.
I believe the MDCN should lead the effort in reversing the situation,like the council of legal education solved the backlog issues in Law School some years ago.
They should put a moratorium on admission into medical schools which have backlog,and hold the institutions accountable for their graduates.
Secondly,it’s time we instituted an electronic selection system of placing candidates for internship as is obtainable in other countries.
Like you rightly pointed out this requires a buy in by all relevant stakeholders.
Thank you for addressing this very important issue. The state governments, I believe, can do more to address this menace. Many state governments do not appoint consultants to their secondary centers and as such they cannot be accredited for internship programs. Secondary medical care is almost non existent in many states. State governments need to do more!
Worked in the Hospital setting for 15 years (UPTH), before my present job as Admin/ supplies officer in SPDC
This challenge could be handled by setting up a centralized medical body to serve as a melting pot for all graduating medical students before transiting for House job. This central body will play the buffer. Screen/select and ensure postings are strictly on merit. We can begin by setting up a think tank to work out the modalities. They should be given a free hand to do their job and come up with relevant structures with government legislative approvals.
Dear Collins,
I do not think that we need to form new structures and organizations to manage what you have just described. Should it be necessary, that can be added to the responsibility of the Medical and Dental Council of Nigeria which regulates the medical profession. However, it will not be an easy task to accomplish since these institutions are independent and some are private.
In any case, there is no reason why we should be churning out more medical graduates per year than the number we can take on for Pre-Registration training in the country. We should actually have an excess of the internship slots because we should assume that more people are training outside the country and will return upon completion of their training programs.
Part of the problem rests on how the Medical training program is structured. It cuts across two Ministries: Ministry of Health and Ministry of Education. Like almost everything in Nigeria, they do not communicate or set goals together. This is responsible for the problem we are seeing now and will continue to be until they sit at the table and work together.
Regards’
Sesan Makinde
This is a very thoughtful and insightful article.
while I do not claim to provide solutions to the obvious problem, these are my comments:
In the state-owned teaching hospital where I work, there is a considerable shortage of interns and plenty of patients. Conversely, in many federal government owned teaching hospitals, there is a surplus of interns and very few patients; these interns become glorified vampires, learning few clinical skills relevant to a developing society such as ours.
My suggestion is that just like the NYSC, interns should be placed in a common pool and posted according to some pre agreed guidelines with the federal government being responsible for their remuneration and the hospital for accomodation and call duties.
Dear Lydia,
Thanks for your comment.
It might be necessary to confirm that the shortage of interns at your institution is not because your institution cannot take more due to limited budgetary provisions. I am aware of interns that have spent the entire one year period as supranumerary (volunteer) physicians in state owned tertiary health facilities during which they received no penny from the institution. Not even an accommodation space. The acceptance to complete the houseman-ship without pay was done by these frustrated doctors just to be able to complete the training, beat the 2 year hurdle and move on with life. Not all young graduates have families that are that buoyant.
Like I pointed out in the article, what is the role of state governments in establishing tertiary health facilities when their major responsibility according to the national health system is to provide secondary level care? Asking the Federal Government (FG) to be responsible for the payment of medical interns is like asking the FG to take responsibility for the shortcomings of the state governments. We often assume wrongly that the FG has an unlimited basket of funds to tap from.
The common pool that you advocate can be the responsibility of the Medical and Dental Council of Nigeria. However just like NYSC which is plagued with its own challenge, posting medical interns to unfamiliar terrain will have some backlash.