This is a guest post by Dr Ayodipupo Sikiru Oguntade.

Shortage of medical manpower has been a perennial problem in Nigeria since pre-independence. The first college of medicine was established in Ibadan in 1948 and its first intakes graduated with degrees from the University College London. The first medical graduates from Ibadan was in 1960 and shortly thereafter, the Ashby Commission on Higher Education in Nigeria in 1960 recommended the establishment of more training institutions, including medicine. This led to the establishment of the medical program at the University of Lagos and later the three regional universities. Since then, there has been establishments of other colleges or faculties of Medicine across the country.

Presently, we have 37 medical and 9 dental schools with an annual turnover of 2550 medical doctors and 175 dentists. Yes, one in 48 applicants get admitted to study medicine or dentistry and the doctor-patient ratio in the country is 1: 5,200 with an estimated Nigerian population of 190milllion people. We presently spend about 800 million USD annually on medical tourism and our President was in the UK for medical care for over 95days! No wonder of our high infant – under five and maternal mortality – indices, the low life expectancies and the proliferation of quacks!

So, let’s look at the matter critically. What are the root causes of the poor quality health care, the trouble with medical training, the health sector and how do we proffer solutions?

The causes of poor health care in Nigeria are multifactorial. Poor healthcare funding is a fundamental cause of poor healthcare delivery. The national healthcare expenditure in 2016 was 221.7billion naira out of 6.08 trillion naira with a per capita health expenditure of 90 and 118 USD in 2012 and 2014. The attendant lack of health infrastructure, vaccines, investment in logistic management information systems for drug delivery and abysmally low national health insurance make accessibility of health care a challenge for most Nigerians.

Also, imbalance in healthcare funding among the three tiers of government is another militating factor against health care delivery. Several local governments and states have practically abdicated their responsibilities to citizens’ health and the local government primary healthcare centres and state general hospitals are in dire need of rejuvenation. This puts tremendous strain on federal hospitals and staff which are largely tertiary health facilities that are not intended or designed to treat simple ailments like malaria or attend to simple obstetric cases.

Another problem is the inherent corruption that has pervaded many government establishments, including hospital managements. One hears in the news of several litigations involving hospital administrators and the government. The internally generated revenues (IGRs) of several hospitals are shrouded in secrecy and not within the public domain. Most hospitals squander their IGR and depend on the government for day-to-day running costs. Insufficient scarce resources are mismanaged by administrators. Thus, making provision of valuable health services in such settings a challenge.

Another factor is the gross imbalance in staff disposition in various government hospitals. Many hospitals have non-clinical staff with unclear job description other than the well-known government feeding bottle – welfarism – displayed in employment processes in other parastatals. This is counterproductive because valuable economic resources that should have been used to develop human capacity in the health sector is spent on salaries and remunerations of unproductive staff. A certain hospital in Nigeria is reputed to have up to two thousand non-clinical staff!

Universal health insurance is still a mirage despite several calls by the Nigerian Medical Association and other groups in the Nigerian health sector. Universal health coverage and insurance guarantees subsidized, free and affordable healthcare for all Nigerians. However, the government has not hearkened to this call, probably due to the financial implication of such policy. But, this is hypocritical given that the same government has given instructions several times to hospitals in the country that no Nigerian must be denied access to quality health care in an emergency for the first 24 hours. Policies like this without financial commitments are bound to fail and are generally seen as political talks which lack any seriousness. Many Nigerians are still denied quality healthcare even in dire emergencies due to lack of funds. Moreover, in most government hospitals, there are no free emergency packs to use over critical cases while relations source for funds for care.

Another factor is the incessant strikes and industrial actions that have been the bane of the health sector in the last couple of decades. This is tied to poor conditions of service, and inter-professional rivalry. The year 2014 has been described as the year of strikes. In that year, the National Association of Resident Doctors went on strike that lasted more than 2 months, that resulted in the sack of her members, the Joint health sector union went on strike for more than a month, while the Nigerian Medical Association also called out her members in solidarity industrial actions. Sadly, all the striking workers were paid during the months that several lives were lost. Recently doctors in LAUTECH Teaching Hospital, Osogbo were on strike, protesting several months of unpaid salaries. How a government can afford to neglect a critical sector is unfathomable!

The government’s unpreparedness and lackadaisical attitude to resolution of the perennial strike actions in the public health sector leave much to be desired. Several committees have been set up to find lasting solutions to the industrial disputes in the health sector but alas! none has been fruitful. The government’s lack of will to enforce discipline, encourage sound professional attitudes and follow up on financial commitments with several unions in the sector is a fundamental driver of the industrial crises.

Postgraduate medical education in Nigeria is poorly funded, poorly organized and shrouded in controversies. Despite having the largest force of postgraduate resident doctors in sub-Saharan Africa, the country still suffers critical man power shortages in several disciplines, which is exaggerated by the disparity in manpower across the socio-political zones, the urban-rural divides and federal-state-local government divides. Resident doctors are poorly paid, overworked and put under enormous strain while being victimized for errors of judgment that are bound to occur in such situations. The lack of clear job descriptions especially for those in laboratory medicine has put those in that specialty at loggerheads with laboratory scientists.

More so, the curricula of the postgraduate colleges are too disparate and not in tune with global aspirations and best practices. The examination fees and update courses fees in many specialties are too exorbitant and not within the each of the poorly paid resident doctors who form the bulk of medical personnel in the teaching hospitals (about 6,000 at the last count). Furthermore, due to the work pressure faced by the resident doctors and the irregularity in payment of their meagre salaries, many are unable to sit for their postgraduate exams at appropriate time, thus, spending extra years in training with attendant incapacity of the hospitals to absorb fresh candidates for residency training from the labour market. Also, the former practice of government sponsored clinical fellowship in more developed foreign countries to learn new skills has been grounded to a halt during the transition to civilian rule in the late 90s.

Despite these challenges, the Nigerian health sector is still a force to reckon with in Africa. The cost of medical training in Nigeria is very cheap compared to Ghana, Sudan, the US, the UK, and several other countries. For example, the cost of medical training in Nigeria is 5, 130 USD per student (according to the NUC which is subsidised by the government), 12,500 USD in Ghana, 70,000 to 90,000 USD in the Caribbean, 15,000 USD in Sudan, 208, 310 USD in Canada and 230,456 USD in the US. Thus, Nigerians are actually at a better advantage in terms of cost of medical training. However, the stumbling block has been the inability of the available medical schools to accommodate up to 80% of applicants every year. Thus, many Nigerians are still denied the opportunity of medical training due to the benchmark used by the NUC for accreditation of medical schools so that the available facilities for learning are not over stretched.

The current population of Nigeria is 192,207,088 as of Thursday, August 3, 2017, based on the latest United Nations estimation. There are about 35, 000 doctors practicing in the country out of the 87,000 registered in the country. About 24,500 doctors are in urban areas while about 10,500 doctors are serving rural communities where about 153.8 million Nigerians live presently. This translates to doctor/patient ratio of 1:2,353 in the urban areas and 1:14,647 in the rural areas. This is in stark contrast to the WHO standard of 1:600. At the present state of medical training and available human resources, Nigeria will need to train about 285,000 more doctors over the next 95 years since our medical schools produce only about 3,000 doctors annually. This is a daunting task given the fact that we cannot afford to import doctors with our present economic reality.

Sadly, in a recent poll published in several national dailies on 4^th August, 2017, 80% of Nigerian doctors have plans of leaving the country for the developed world. How a government will spend so much to subsidise medical education and fail to productively engage those graduates, thus, allowing them to leave the country in droves, leaving the populace critically underserved, is still beyond me!

The reasons advanced from the polls were:

• High taxes and salary deductions
• Very low work satisfaction in Nigeria
• Poor salaries and emoluments
• The knowledge gap in the medical field between Nigeria and the developed world
• Poor quality of practice.
• Poor relationship among colleagues
• Inadequate opportunities for career growth
• Poor working environment
• Lack of proper infrastructure
• Poor treatment by government
• Insecurity

Nigeria’s 2017 budget allocated a paltry N304b, representing 4.3% to the health sector, contrary to the recommended 15 percent by African Union countries in the 2001 Abuja declaration, which commits member nations to improve national health budgets.

The good news is that the panacea to solving the challenges that have beleaguered the Nigerian health sector is within our reach and is achievable. There is a need to sensitise stakeholders at all levels on the magnitude of the problems. The government has a large role to play in policy directions, setting priorities and health care funding. There is an urgent need for universal health coverage and health insurance, so that Nigerians do not have to pay out-of-pocket for health care. Quality health care is a fundamental right of everyone in the country and government’s funding of healthcare has to improve dramatically if we are to meet the targets for the United Nations’ sustainable development goals.

Government may look at the health care model in the UK and the US. In the UK, healthcare funding is through the NHS which derives her funds from tax, while in the US funding of healthcare is by health insurance companies who are regulated by the government. The UK model is particularly attractive if we can re-orientate the populace on necessity of quality tax and its payment, also government must be transparent in the administration of funds. However, the recent revelation about the corruption and mismanagement of funds by the NHIS in Nigeria is a cause for concern.

The available health personnel in the country’s health sector can be deployed by the government through a central mechanism to needed communities and specialties. It is a waste of public fund for the government to have spent billions of naira on medical education and postgraduate medical training only for the trained personnel to leave the country for greener pastures after their training.  Presently, more than 40,000 Nigerian doctors are abroad, thus constituting massive brain drain and looming healthcare disaster in the future. The government must engage the services of the trained doctors after their training. The distribution of the personnel should be by a board under the purview of the three tiers of government so that no community is marginalized in the allocation of human resources.

The conditions of service for public health workers should be improved and made at a par with their counterparts in places like Egypt, South Africa and some of the Asian countries. Government must fund the hospitals and see the investment in health care as a worthy one. Corrupt hospital administrators should be prosecuted and forensic audit of the hospitals should be conducted annually to detect corrupt practices. Also, government officials must patronize government hospitals and not waste public funds for their medical tourism.

Furthermore, the curricula of the postgraduate medical colleges need to be reviewed to reflect current global standards of care. Specialties of critical need should be developed by regular in service training of healthcare personnel and clinical fellowship abroad when necessary. Also, inter-professional rivalries should be investigated and work descriptions should be well detailed in the scheme of service. Hence, each healthcare personnel should be given the chance for professional advancement within the scheme of service. And adequate remuneration of healthcare staff and continued engagement of government with health workers’ unions will facilitate resolution of perennial strikes in the health sector. This will also build trust of the people in the hospitals.

Work environment should be friendlier and paternalism in healthcare delivery should be discouraged. Doctors and other health personnel should not see themselves as demi-gods. The attitude of health workers to patients has to improve, if the view of the populace on service delivery by the hospitals is to improve. And there is no need for patients to queue for hours in the hospitals or even sleep overnight on the corridors in order to see a doctor on time. If health human resources are judiciously spread and allocated and the model of primary health care works – in which basic health services are provided by middle level health staff like community health extension workers and public health nurses – the specialist hospitals will not be overstretched and quality health research can be done in these places without distraction while delivering quality health care.

Finally, it is my hope that the different stake holders in the country’s health sector will hearken to the calls and plights of the country’s residents.

This article has been slightly edited by Abdulghaniy Kayode Otukogbe. The facts, opinions, views or positions expressed or established in guest posts represent that of their writers and not necessarily of www.edusounds.com.ng.

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