By Sola Ogundipe, Chioma Obinna & Gabriel Olawale
In 2014, when the Federal government ordered the sacking of 16,000 resident doctors across the Federation, there was a huge outcry not only from the medical community, but from the entire health sector. The decision was not only considered drastic, but ill advised and potentially catastrophic because resident doctors a.k.a. trainee doctors, constitute the main support force and backbone for medical practice in the public sector.
Seasoned medical experts take a critical look at the challenges of training, employment and distribution of medical personnel, particularly doctors and recommend a multifactorial approach as solution. Excerpts:
As an institution established to promote higher standards for specialised medical and dental practice in Nigeria, the National Post Graduate Medical College of Nigeria has its work cut out.
Since it was established in 1979 by Law CAP N59 LFN 2004 for the conduct of medical examination after training in the various specialised branches of Medicine and Dentistry, the College has been constantly under pressure to accredit more amd more training institutions across the country for the purpose of residency training for the sole purpose of producing enough doctors for the country.
A former National President of the Nigerian Medical Association, NMA, and the current Registrar of the College, Prof. Oluwole Ayoola Atoyebi, laments the dearth of medical doctors in the country, but observes that in addition to the problem of shortage of medical personnel, their distribution is an even bigger challenge.
Atoyebi, who was one time Provost, College of Medicine, University of Lagos, however accepts that the issue of inadequate personnel is global. But even though very few countries in the world have met the minimum standard set by the World Health Organisation, WHO, the magnitude of the problem in Nigeria is in a class of its own.
“In America and Europe, they have not met the required standard of one doctor to 500 people. But in Nigeria, we have one doctor to almost 20,000 people. There are two categories of doctors, the general duty doctors who just qualified, finished their internship and can practice, and the specialists. What we do here, in this College, is to produce specialists,” he says.
Too few specialists produced
Right from the beginning, the number of doctors in Nigeria, even at general level has been insufficient for the population because the number of doctors produced in the entire Colleges of Medicine across the country is less than 3,000.
Atoyebi, who should know better, puts it succintly. “We are not producing enough specialists yearly. For instance during our convocation in September 2014, we produced only 247 specialists in different areas. Some specialties experience acute shortage than others.”
But what is probably more worrisome is the imbalance in distribution of doctors, insufficient as they are. When probed, the Registrar confessed: “Overall, there are just about 30,000 actively practicing doctors in Nigeria, out of which no less than 6,000 are in Lagos alone compared to a place like Taraba State where there are less than 50 doctors overall. The remaining doctors are distributed across the other 34 states plus the FCT, Abuja.”
Investigations reveal that a number of factors ranging from low turn out of trained doctors from the few accredited colleges of medicine in the country, to brain drain, amongst others are actually responsible for this shortage.
“Doctors are not commodities,” Atoyebi remarked. “You can just be producing doctors like you are in factory. For the fact that they are to be dealing with human beings warrants their proper drilling. Also, there is limited number of institutions to be accredited just as there is limited number they can train because the number is pegged by the Medical and Dental Council based on the facilities and number of teachers.
Essentially there is a limit to the numger of doctors that can be trained by a medical institution at a particular time.
According to Atoyebi: “It usually varies from 50 to 200. But quite a number of medical schools cannot graduate more than 50 at a time. Even the maximum allowable for any institution is at the University College Hospital, UCH, Ibadan, being the first medical school. The maximum the institution has been allowed to admit in a year is 200.”
Brain drain palaver
External and internal migration of doctors is a big issue. The big issue is that the nation is not retaining even the small number of doctors it produces because of brain drain.
“Not less than 10 per cent of doctors produced in this country over the last 10 years have migrated to other countries in the quest for greener pasture. The payment in Nigeria compared with standard of living is not encouraging. Also, many doctors migrate due to inadequate facilities, and the large numbers of doctors who migrate because of inadequate facilities are specialists,” Atoyebi explained.
On internal migration, he asserts that many doctors have moved from the north east to Abuja and its environs while others opt to go to Lagos.
To improve the situation, the medic calls for committed political will to ensure teaching hospitals are built with the right facilities.
“If institutions are not equipped with the right facilities we can’t produce more because the number is pegged based on human resources and facilities. The shortage is usually a facilities problem.
“We have been asking that government should make sure that each medical school is funded by the Tertiary Education Trust Fund, TET Fund, to have Clinical Skills Stimulation Laboratory, CSSL so that many people can practise on inanimate object, this way more numbers can be taught on stimulators so they would have become expert on stimulators before they come to see actual human being, because if you are going to teach them on human beings it will take a longer time because you can only teach one person at a time as you have to guide him so that he will not injure the patient.
But if we have stimulators, practise on those is easy because simulators cannot die, they just stimulate humans. So the students will have perfected what they want to learn before moving to human beings. So when they now move to human beings the facilities should be upgraded to that capacity. That way, more doctors can be produced both at under graduate level and post graduate level.
“At post graduate level, we have made several moves to the Ministries of Health and Education for the TET Fund because we want a clinical skill and stimulation laboratory to be provided here so that more specialists can be produced.”
Poor job evaluation & payment
Internal migration is just as big a problem. To prevent or minimise it, the Post Graduate Medical College once pushed for what was described as “rural posting allowance”, but the proposal was messed up by the time it was approved.
“The Salaries and Wages made nonsense of what we proposed. The amount given to motivate people to practise in rural areas must be reasonable and attractive enough to encourage people to opt for rural areas. If you say because it is rural area you are just given him N5, 000 extra, that will not motivate anybody to move there. There is need for incentive for doctors.”
Atoyebi urges that to prevent external and internal migration, there should be good facilities and good pay. Reward and sanction system must be in place and also the admission process should be controlled.
“It is saddening that here in Nigeria we don’t use our data very well. For example if you go to Ministry of Health, probably they might not be able to tell you how many radiologists they think we need in the country. Nobody is working on that. If we determine such, we give incentive; those who want to move to areas where we are experiencing shortage will get special dispensation.
“It is gloomy that in this country we don’t do job evaluation and payment; in America, doctors don’t earn the same, what we are concerned about in Nigeria is the level. Payment should be based on evaluation. It is what you do for the system that ought to determine what you get. For instance, neurosurgeons that operate on the brain ought to get more money than someone who works on the breast.
“We should also be able to control the admission process, if we know that we have enough surgeons and fewer gynaecologists in teaching hospitals, when they want to take in people, they should correct that. But the leg work has to be done first. Evaluate what the needs in those areas are and make sure you admit more people.
Need for incentive
“Second, give incentive. You must create attraction to some areas, but people may be looking for some area of specialties that they may not need to wake up at night or do so much if they know that at the end of the day they are paying the same thing.
“I will advise that as a nation, we should take the issue of health serious. We should not take it with word of mouth saying health is wealth. We need to put it into action, get correct database and plan very well and make sure we have not only adequate number of doctors produced but make sure we know the area of need more and work towards that. There are many areas that never had a doctor within five kilometres radius in this country. That should not be. We should be able to create incentive, produce enough, distribute them well and encourage them.”
No resident doctor has been recruited in Lagos in 3 years
— Dr. Tope Ojo, Chairman, NMA, Lagos State branch
Looking at issue of shortage of health worker I do like to put it in political perspective, I have two reasons I always advance in respect to this which is inability to be fulfilled individually and professionally.
You are in a country where a health worker cannot boast of a living wage, you cannot boast of very good condition of service and this is not alien to Nigeria. Shortly after independence around 70’s people were enjoying a robust package which were not only applicable to doctors. These included a car loan, house loan among others. But this is not applicable again, we are now experience a state of dead infrastructure. We have not been able to get continuous power supply in this country over the years, bad roads and even access to health facilities even as a health provider, this are personal things that when you are growing up in life you want to graduate and leave like normal human being but this is not guarantee at all.
Second, our people are unable to practice their profession to the fullest. There are a lot of things in terms of revolution that have occurred in medicine, and this is not available in our country. For instance when you are looking at surgical specialities, it has gone beyond opening people up a times, there are now facilities that can conduct the proper examination without tiring people. Many years back Lagos State can boast of 20 Magnetic Resonance Imaging, MRI machines, but now in the whole of Lagos I don’t think we can boast of five. And when you are comparing this number with the population of Lagos State we all know what it means. Even practising the profession you cannot help your patient maximally.
So how do will now juxtapose this with what I call a political decadence? It is the failure of leadership that is responsible for all of this, and the only people to be held responsible are our political leaders that have deceived Nigerians over the years. When you look at it government still spend a lot of money to train our graduate but at the end you don’t have them staying back and this can be attributed to poor governance over the years.
This is a very serious problem and until we start to see it from political perspective, and be a vanguard of change and join the train of people that will say enough is enough, regardless of your political party, the situation will continue to get worse.
In the past three years in Lagos State, the government has refused to recruit resident doctors because of their rancour with doctors employed in the State and their Association.
The implication of this is very glaring. Accreditation will be withdrawn, the medical school will collapsed, this simply means that the institution is going to collapse because the patient here in Lagos State University Teaching Hospital has been subjected to long waiting time.
Also there are cases of people who have being waiting for surgical operation for almost 18 months even up to two years now.
Insecurity, poor job satisfaction to blame— Dr. Osahon Enabulele, VP, Commonwealth Medical Association
REASONS for health worker shortage in health facilities in Nigeria are legion, in the view of the Vice President, WAR, Commonwealth Medical Association, Dr. Osahon Enabulele.
They include poor health human resource development plans; inadequate training infrastructure and health facilities to support the production of health human resource; migration of health workers (particularly medical/dental practitioners) due to insecurity and poor job satisfaction, particularly as a result of uninspiring workplace conditions, poor health infrastructure and equipment, inadequate remuneration and welfare conditions.
Enabulele who is the erstwhile President of the Nigeria Medical Association, NMA, argues that the attractive remuneration, better security guarantee, better incentive packages, conditions of service and workplace conditions in developed countries, such as United States of America, United Kingdom, Germany, Australia, etc., greatly encourages migration of health workers from developing countries, particularly countries in Africa, Nigeria inclusive.
“In terms of the appropriate numbers recommended by the World Health Organisation, a country is expected to have a minimum number of the various categories of health workers to cater for the population of the country. For instance, the recommended ideal doctor : patient ratio is 1:600, even though for developing countries the minimum is usually taken as 1:1000 (doctor-patient ratio).
In Nigeria, an average of 2, 500 medical doctors are produced annually. However, this is grossly inadequate considering the average doctor- patient ratio of 1:6300 in Nigeria.
“To address health worker shortage, there is need to address the identified factors responsible for Health worker shortage in health facilities in Nigeria, particularly by increasing the number of training infrastructure without compromising quality and standard; instituting a more efficient and effective health human resource development plan and Personnel Management System; improving the morale and job satisfaction of health workers by constantly improving their incentive package, remuneration and welfare conditions to be in tune with their professional calling, job roles and economic realities; effective resolution of conflict areas, particularly with regard to role conflict through proper designation of job roles; improved security of health workers; and institution of a transparent performance reward system,” he asserted.
No common platform for medical personnel to thrive— Dr. Olurotimi Odunnubi, MD, National Orthopaedic Hospital, Igbobi, Lagos
ADDRESSING shortage of healthcare providers requires planning and projection. For instance if the country need 12,000 doctors over the next five years there will be need to create avenue for such in terms of training.
But after training them, how to retain and distribute them so that they can cover the Nigeria population is another issue because there is freedom of movement. When you train people and they have better offer somewhere else, you can’t stop them.
In the face of this shortage, there are some states without a single specialist doctor and they are not even looking for a specialist. There are states in this country where the only specialist is at the Federal Medical Centre, FMC.
There are so many Nigerian doctors outside the country, and one way of fast tracking development and quality healthcare is to attract them back to the country. Many of them want to come back but want improved infrastructure in place first. Government can provide incentive which was what India did, like giving them land or tax relief maybe for five years because they have the skills but they are working in different environment from what exists here.
For a skilled surgeon to practice successfully, you need all those supportive services that ensure you are still providing that high level care. The diagnosis that will almost explain what the patient problem is even before going into the surgery is required and to acquire those equipment require a lot of money, they don’t really need to bring that money out of their pocket, just like government did for agriculture and industry, providing special bank for them, you can provide fund or special bank in which the interest rate will be low, the operational rate now is about 26- 30 per cent if you make special concession like maybe single digit interest rate that will encourage people to take loan from such special bank to develop healthcare.
Government should also pursue idea of encouraging various specialists to come together and provide a platform because the days of unit specialist is fading away. Gradually one man hospital which is what we have in a lot of private hospital in the country is going out of fashion. There is need for collaboration to minimise risk.
In service delivery, time is of essence, if somebody is ill, he wants to get back to his state of good health as early as possible, because for every minute he is ill, is a loss of revenue to the family and larger society. When you don’t have the right personnel to provide the specific care he needs, he wait his turn, there are some hospitals where people wait for elective surgery, and these are surgeries that are not emergency. They have to wait for upwards of six months or nine months.
The surgeon cannot do more than a certain number per day and there are not enough surgeons so they need to wait for that special care. These are basic problems that happen when you have shortage of qualified medical personnel, and in the course of waiting for service sometimes other problems may develop, for instance, anaemia.
Normally for most people is not dangerous but while you are waiting, you can develop complication, obstruction which can be life threatening.
No hospital is exempted— Prof. David Oke, CMD, LASUTH, Ikeja, Lagos
THE Chief Medical Director, LASUTH, Prof David Oke, admits that there are shortages in all cadres of healthcare professionals in all health facilities in the state. “No one will deny that it does not have enough. LASUTH is not exceptional in Lagos State. We are only hoping that the incoming government will look into it and we are now doing task sharing and task shifting with the little number that we have.
“The inadequate number is understandable because of the wage bill. And that is what we are saying that it has to be factored in by any incoming government to judiciously use the money they have.
There is no hospital anywhere in the world that is having enough health workers and Nigeria is no different. As much as possible the government is aware of it and they have mentioned to us that they will tackle it.
“Shortage of health workers is one of the priorities of the new government coming into Lagos State. Right now we have consultants, resident doctors, pharmacists, nurses and others but I cannot give you the numbers because I am out of the hospital.”
In the view of
Dr. Olufumilayo Bankole, who is the Acting Medical Director, Isolo General
Hospital, Lagos, the staff strength of the hospital dropped from 550 to 409 over the last two years, while patronage is on the increase.