How to reverse the rising tide of brain drain, medical tourism in Nigeria after 60 years

At independence, Nigeria built a health system structured basically along the model of the colonialists. From the 60’s through the mid-eighties, the health system was anchored and led by seasoned health administrators who coordinated the health manpower comprising pharmacists, doctors, nurses, laboratory scientists, physiotherapists, radiographers and other cadres of health workers. Infrastructure from the 60s to about the late 80s were modest but adequate to keep services well above average and a benchmark within the rank of African nations.

One of the most noteworthy development in the health sector remains that the University College Hospital (UCH), Ibadan, was actually rated one of the top five facilities in the Commonwealth.

Indeed, UCH, Ibadan as pioneer set very enviable standards and accomplishments.

UCH since the 1960s through mid-1970s was the ‘Mecca’ of medicine in Africa and indeed medical tourism. It ranked the fourth best university teaching hospital in the Commonwealth where, in fact, Saudi kings came for treatment, queens delivered princes and princesses. Consultants and professors were like deities and appeared infallible. By 1975, it was designated Centre of Excellence in Medicine. A big legacy!

Lagos University Teaching Hospital (LUTH), Idi-Araba made big strides nationally also while University of Nigeria Teaching Hospital (UNTH), Nsukka was renowned for open-heart surgeries.

By mid 1980s, the finest medical teachers were departing to the Middle East and the West and the young physicians they trained were mostly leaving for the West for postgraduate training. Human capital suffered and consequently the quality of research, medical education and patient care outcomes. Infrastructure was decaying from poor funding and management. The few decades that followed witnessed continued downturn in both human capital and infrastructure as well as the resultant spike in human capital flight, brain drain and medical tourism.

Human capital flight refers to the emigration of individuals who have received advanced training at home. The net benefits of human capital flight for the receiving country are sometimes referred to as a “brain gain” whereas the net costs for the sending country are sometimes referred to as a “brain drain”.

Brain drain is defined as the migration of highly trained personnel in search of better standard of living and quality of life, higher salaries, access to advanced technology and more stable political conditions in different places worldwide.

Medical tourism can be defined as the process of traveling outside the country of residence for the purpose of receiving medical care. Nigeria has been losing billions of naira yearly on medical tourism, mostly to India and Europe.

What went wrong and how can the situation be reversed?

A public health specialist and founding partner, Health Systems Consult Limited (HSC), Dr. Nkata Chuku, told The Guardian that medical tourism by Nigerians had been growing over the past decade and had reflected on the persistent under investment in the Nigerian health sector by successive governments leading to a weak health system delivering inadequate quantity and quality of care and consequent erosion of trust in the system by the populace.

Chuku said the country, in 2018, spent 3.8 per cent of its Gross Domestic Product (GDP) on health, less than the five per cent recommended for resource-constrained countries to deliver basic healthcare services. He said out-of-pocket expenses with its high inefficiency and impoverishing effects accounts for over 70 per cent of total health expenditure, the highest in Africa.

The public health expert said that in 2016, Nigerians were reported to have spent in excess of $1 billion on medical tourism; an amount PricewaterhouseCoopers (PWC) estimated could have paid for 3.7 million treatments within the country. This, he said, was about 20 per cent of the total government spend (across all levels) on health.

He said the top four services Nigerians travel out for are oncology, orthopaedics, nephrology and cardiology. Chuku said these are services that could be provided adequately in Nigeria with the right level of investments but the challenge is the perception of low quality of services and lack of trust in the system by Nigerians. “More than 90 per cent of respondents in a PWC survey thought that advanced healthcare delivered in Nigeria was low quality,” he said.

Chuku said the COVID-19 pandemic has shown more than ever the need to strengthen Nigeria’s health system to become resilient and fast-track progress towards universal health coverage. He said making the right investments to reverse medical tourism was critical, especially with the fall in national revenue due to oil prices and COVID-19.

“We now also know that if we don’t fix our system, a situation like COVID-19 may arise and those who need care will not be able to travel irrespective of their level of wealth,”.

The public health physician said the key imperatives for reducing and eventually reversing medical tourism include: creating enabling environment for the private sector to grow and provide specialist services; de-risking the private health sector; entering Public Private Partnerships (PPPs) to turnaround public tertiary hospitals; developing and implementing a national framework for guaranteeing patients’ rights; and strengthen the regulatory agencies for health to improve quality of care.

A Consultant Paediatrician at American Wellness Center and Secretary, Board of Trustees, Nigerian-American Medical Foundation (NAMF), Dr. Adeyinka Shoroye, told The Guardian: “The pragmatic approach to stemming the present serious tide of medical tourism in Nigeria calls into question two or three main issues: human capital, infrastructure and sustainability. Many will argue the major factor is dearth of human capital, some it is deficit in clinical infrastructural. The big question is why are sick Nigerians travelling in large numbers daily to India, Middle East and traditional West seeking medical treatment for highly specialised care?”

So how does Nigeria harness the huge and indeed surplus diaspora human capital to benefit the nation with the current dearth of experts and re-enthrone excellence not only in medical care but also medical school education and research?

Shoroye said: “The idea of visiting physicians in rotations, year-round at the Foundation’s Hospital in about 100 sub-specialties is more realistic as many would want to give back skills. Hence, the human capital challenge is for a long time solved. We are then left with building modern world-class Infrastructure. That is the story of the beginning of the NAMFI Infrastructural project debut in 2020 to complete in 2024-29 in a very pristine and serene location on the Atlantic coast of Lagos-Epe with easy accessibility by road or air to most parts of Nigeria, and serving all of Nigeria, both the rich and poor. This is therefore the new case for modern physical and specialty equipment Infrastructure.”

Former President, Pharmaceutical Society of Nigeria (PSN), Olumide Akintayo, told The Guardian that the enviable status-quo changed about 1985 when the Dr. Olikoye Ransome-Kuit led Federal Ministry of Health (FMoH) pressured the Ibrahim Babangida-led government of the time to enact the University Teaching Hospital Act. He said it was this Act that entrenched a doctor dominated health system by replacing trained administrators with doctors in the leadership hierarchy of the Federal Health Institutions (FHIs).

Akintayo said that apart from instituting doctors as Chief Medical Directors (CMD)/Chief Executive Officers (CEOs) of FHIs, the next in line, who is branded Chairman, Medical Advisory Committee (CMAC) is also a doctor.

The pharmacist said from 1985 till date, the boards of hospitals were geared to have at least eight doctors out of a 13 member statutory board which has only come to entrench a peculiar Nigerian style of healthcare which today positions Nigeria as a health system rated 187th out of 191 systems by the United Nations/World Health Organisation (WHO).

Akintayo described infrastructure in the country’s FHIs as appalling because most of the CEOs, who lacked managerial capacity, are not able to drive business inclined models to preserve the health system.

Akintayo said the only way to get it right was to open the restricted frontiers in the health system, which calls for a holistic reform agenda. “We must return to the days when seasoned administrators and managers of cognate experience to run our health system while all other professionals are made to embrace their specialities and areas of due competence like we see in the climes where best practices are solicited and enforced in public interest,” he said.

On how to reverse medical tourism in Nigeria, a Neuroscience Nurse with a specialist interest in stroke care, Transient Ischaemic Attack (TIA) and management and Member at Large representing the SSOs at the World Stroke Organisation (WSO), Gloria Ekeng, told The Guardian: “Celebrating medical wins and success stories, thus restoring faith in the medical institutions. Reduce brain drain by providing medical practitioners and facilitate training. Encourage Innovation and technology such as telemedicine.

“Encourage private healthcare providers and hospitals to take up the mantle to spur state medical facilities to compete against each other and effect policies that would remove debilitating constraint.

“Provide world class medical services in all tertiary hospitals in the country and Invest in quality medical facilities and appropriate training to operate them Reduce brain drain by providing medical practitioners appropriate incentives and remuneration, encourage opportunities for specialised training.”

Chairman, Pharmaceutical Manufacturers Group of the Manufacturers Association of Nigeria (PMG-MAN), Dr. Fidelis Ayebae, told The Guardian: “This subject needs to be researched deeply to see how other countries managed same when they were faced with the same situation. Ours is worse because it is happening at a time of brain drain, lack of government commitment and investment in healthcare infrastructure.”

A professor of Virology, pioneer Vice-Chancellor of Redeemer’s University and Chairman, Expert Review Committee on COVID-19, Prof. Oyewale Tomori, told The Guardian: “Improve healthcare services at home, provide an enabling environment for healthcare workers to function effectively. Improve generally, infrastructure, facilities and resources for health.

“What went wrong? The environment for the healthcare workers to function maximally deteriorated to the level that healthcare delivery was the route to the mortuary.

“What to do? Improve the healthcare delivery environment and human resources. Improve the remuneration of healthcare workers, revamp health infrastructure and generally improve power supply, and other areas for the wellbeing of the citizens.”

A Consultant Clinical Pharmacist/ Public Health Specialist and National Chairman, Association of Hospital and Administrative Pharmacists of Nigeria (AHAPN), Dr. Kingsley Amibor, told The Guardian: “Medical tourism in Nigeria is the consequence of the loss of confidence of many Nigerians in the health system, which is grossly underfunded. In April 2001, heads of state of African Union countries met and pledged to set a target of allocating at least 15 per cent of their annual budgets to improve the health sector of their respective countries. Close to 20 years after, what is the situation? Many African countries Nigeria inclusive, have not been able to meet that target, with the probable exception of Rwanda and South Africa.

“For Nigeria to reverse medical tourism, the factors that cause medical tourism to thrive in the first place, would need to be addressed. Since underfunding has been identified to be a leading cause, efforts must be made to improve funding of the healthcare sector in the country. Unfortunately, the coronavirus pandemic has adversely affected the nation’s economy, as a result of dwindling revenue from exports of petroleum products. On the long term, the nation must intensify efforts to develop alternative sources of revenue other than crude oil, in order to augment foreign exchange capacity of the country.

“COVID-19 has exposed the inadequacies in our healthcare system, from dilapidated infrastructures, poor staffing of healthcare workers to absence of working tools such as state of the art diagnostic tools and so on.”

On the issue of underfunding of the healthcare sector, Amibor said efforts must be made as soon as the economy begins to recover, to look into the funding of the healthcare sector, vis-a-vis the Abuja Declaration of 2001. “Naturally, such funds would need to be monitored to ensure that they are judiciously utilized for the purpose for which they were allocated in the first place,” he said.

The clinical pharmacist said there is need to employ adequate number of all categories of healthcare workers- nurses, pharmacists, medical doctors, medical laboratory scientists and others to man the various hospitals. “Health professionals who have specialized in various subspecialties and I know Nigeria boasts of several of these, should be sought after. This is one major reason why many Nigerians go abroad to access care, but when they know that they can receive same level of care from specialists right here in Nigeria, they will be encouraged to stay back and access care locally. To this end, it is hereby suggested that government should recruit consultant clinical pharmacists into the various hospitals, because elsewhere in the world, these specialists collaborate with physicians, nurses and others to ensure that the best medications in terms of proven efficacy and safety are given to patients which will reduce length of hospital stay, reduce costs of care and lead to improved quality of life for patients as demonstrated from several studies,” he said.

Amibor said the need to upgrade public health hospitals, especially in terms of aesthetics could not be overemphasised. He said hospital environment should be beautified, attention should be paid to patient conveniences, there must be functional taps and water continuously and convenient waiting areas for patients. He said hospital workers must also be tutored on the need to extend courtesies and empathise with hospital patients.

The pharmacist said government would need to pay attention to the protracted issue of poor salaries and wages of healthcare workers which is a ready excuse for engaging in strike actions, resulting in disruption in service delivery and a major reason why Nigerians go abroad to access care. In other to curb unrest and agitations for salary increment among healthcare workers, Amibor advocated a harmonised salary structure, such that all healthcare workers will be on the same salary scale, each worker will enter the scale based on their profession, period of training, nature of training such as specialist or general cadre and other parameters to be determined by government and workers unions. He said any salary increase for workers should be applied across board to all workers on the salary structure, and this will definitely go a long way to curb unrest and agitation for discriminatory wages increment. He said training and retraining of healthcare workers on a regular basis is advocated in order to build capacity among the workforce.

Amibor said Nigerian teaching hospitals and some others were actually acting as centres for medical tourism in the past but a combination of factors have contributed to their decline. He said teaching hospitals in Nigeria have not been able to meet their mandate because of government neglect, poor funding, dilapidated infrastructures, inadequate staffing and equipment, poor leadership at management levels, disharmony among healthcare workers and incessant strikes by these workers.

The pharmacist said studies have shown that if the teaching hospitals spread across the country were refurbished and made to function optimally, most Nigerians would not need to travel abroad again for medical treatment and brain drain will also be reduced to the barest minimum.

“If all the factors mentioned above are looked into and addressed appropriately, teaching hospitals can certainly be restored to their past glory. The need to rotate headship of the teaching hospitals among qualified professionals from various disciplines should be explored. Where that does not work, the option of using hospital administrators as was the case in the past can be explored. This has the potential of reducing inter-professional rivalry in our hospitals,” he said.

Executive Secretary, National Cancer Prevention Programme (NCCP), Dr. Abia Nzelu, in a statement titled “Nigeria at 60: The Independent Nation With No Independent Cancer Care” said: “…Nigeria is growing old, but tragically, its citizens are dying young. Most Nigerians do not live up to 60. At 60, Nigeria (‘the giant of Africa’) has the world’s seventh lowest life expectancy.”

Nzelu added: “Non-Communicable Diseases (NCDs) are now responsible for over 70 per cent of global deaths each year, with cancer being a leading cause of death and the single most important barrier to increasing life expectancy in every country of the world in the 21st century. This means that Nigeria’s low life expectancy will not change, unless we tackle cancer seriously.”

Nzelu, however, said it is in the area of infrastructure for cancer care that the gap in Nigeria health infrastructure is most prominent.

Nzelu said most cancer deaths are often due to late detection and poor infrastructure but a Comprehensive Cancer Centres (CCC), a world-class, stand-alone tertiary health institution, with all departments focused on cancer care could bridge the gap.

A public health physician and Executive Secretary, Enugu State Agency for Control of AIDS (ENSACA), Dr. Chinedu Arthur Idoko, told The Guardian: “Reversal of medical tourism in Nigeria would be a product of a long term investment in the health sector. These investments will include building and establishment of functional well-equipped hospitals, improvement in remunerations of doctors and other health personnel at par with global standards, institutionalisation of a functional health care financing system.

“All this would create an enabling environment for our medical professionals to thrive for retention of our best of skills here in Nigeria, make available better equipment for training of medical professionals at all levels of their training as well as in their practice, foster International best practices, amongst a wide variety of gains. This will ultimately instill a belief in the system.”

Idoko, who is also an epidemiologist and former Chairman, Enugu State Hospitals Management Board, added: “What went wrong is nothing but the progressive decline in our healthcare industry occasioned by prolonged neglect of the sector. This can however be remedied by a sincere government commitment to doing the necessary and the needful. Everyone, including the medical professionals, also have their role to play towards winning back the lost glory in our institutions.”