FUNMILAYO AREMU reports on the cost of training a doctor, the technicalities of the training, the reactions of doctors to the bill seeking to mandate them to practice in Nigeria for five years before they are granted a full licence and the solution to the brain drain in the health sector.
On April 6th, Nigerians woke up to the news of a bill, ponsored by an All Progressives Congress (APC) lawmaker from Lagos, Ganiyu Johnson, seeking to mandate medical practitioners to practise in Nigeria for a minimum of five years before they can travel abroad.
The intendment of the bill is to “amend the Medical and Dental Practitioner’s Act, Cap. M379, Laws of the Federation of Nigeria, 2004, to mandate any Nigeria-trained medical or dental practitioner to practice in Nigeria for a minimum of five years before being granted a full licence by the council in order to make quality health services available to Nigeria.”
Johnson said the bill is part of the measures that will curb the mass exit of doctors in the country, as no doctor will be given a full licence until after five years. However, oneof those who spoke against the bill, a lawmake from Abia State, Nkem Abonta, called it offensive, saying that such a law is not obtainable in any clime. But in his reaction Abonta’s observation, Johnson argued that such a law would enable doctors to give back to their society. He argued further that the government has invested so much money in training doctors and the least they (doctors) can do is to practise for five years before they leave the country. The bill was put to vote and a majority of the lawmakers supported it.
The bill may not come as a surprise to many as more skilled hands across various sectors seem to be leaving the country by the day. It will be recalled that the Nigerian Medical Association (NMA), in October 2022, said the population of registered doctors had gone down to 24,000 bringing the doctor-patient ratio to 1:5,000, conflicting with the World Health Organisation (WHO) recommendation of 1:600. This may come across as quite worrisome as the issue of public health is of utmost importance to humans, regardless of locations or countries.
The bill has since generated mixed reactions from Nigerians, especially among doctors and medical and dental associations. While many Nigerians have said the bill was a deviation from the real problem, very few commended the lawmakers for finally paying attention to the crumbling state of the health sector.
How we feel about the bill
The question on the minds of many is whether or not this bill is a step in the right direction and if it will improve situations in the health sector. The NMA President, Dr Uche Ojinma, in his reaction to the bill, described it as dead on arrival. He said the lawmakers were not trying to find a solution to the problem but are trying to restrict the movement of doctors which is contrary to the international labour law. He also challenged the lawmakers to make laws that will stop medical tourism.
Speaking with Sunday Tribune on the bill and its implications, the president, Medical and Dental Consultants’ Association of Nigeria, Dr Victor Makanjuola, knocked down the proposed saying it would not solve any problem in the nation’s sector. According to him, “the intent of the bill is misguided, not properly thought through and doesn’t have the potential to stop the brain drain among physicians,” he had declared.
An orthopaedics consultant with the Federal Medical Centre, Abuja, Dr Ganiyu Aremu, who also spoke to Sunday Tribune, labelled the bill as a forced journey into slavery. Resting his argument on the back of the constitutional guaranty of freedom of movement, Aremu said the bill is a violation of the doctors’ fundamental human rights.
“It is against the constitution which stipulates that every citizen should have freedom of movement,” he posited. “You cannot force anybody to stay in the country. Forcing someone to stay in the country for five years after graduation means you are also forcing that person to work. Whether the wage you give him is satisfactory or not, he will be forced to stay.
“Why are doctors being targeted? Are they the only ones leaving the country? Can doctors work without nurses, Pharmacists, physiotherapists, and other allied professionals in the country? We cannot! So, if the doctors stay, who will do the work of nurses, pharmacists, physiotherapists and others?” he queried.
He also pointed out the greater danger inherent in the exodus of consultants and specialists who ought to train young doctors, concluding that the lawmakers are barking up the wrong tree with the bill.
“The group of doctors that are being targeted is very wrong because this is the group of doctors who must work under the supervision of consultants. If the government is now targeting the young doctors, meanwhile the consultants are moving in droves, does it not occur to them that a time will come when even the young doctors that you are forcing to stay will not have the senior ones to supervise and put them through the ropes of the industry?”
Another doctor who shared his thoughts on the matter with Sunday Tribune is Dr Solomon Obekpa, a gastroenterologist and board member of the Advocacy for the Prevention of Hepatitis in Nigeria (APHIN). Obekpa, stated that the lawmakers are putting the cart before the horse by not directly addressing why doctors are leaving the country.
According to him, proposing such a law “shows how unexposed and ignorant our lawmakers are. It shows that they do not know what the problem is. In my opinion, they are putting the cart before the horse. You need to address why doctors are leaving. Nobody wants to leave a place where he or she is a first-class citizen.
“I think they are ignorant because they think we are trained for free. We pay more fees than other courses at the university. So how can you tell us not to travel?” he queried, further reinforcing the argument that Nigerian medical doctors paid their way through their programmes.
The cost of training a doctor
But a critical justification made by the proponent of bill is that the government has invested a lot in the training of doctors in the country. But how true is this claim? Does government invest anything in the training of medical doctors? Are medical courses subsidised in any way? What is the cost of training a medical doctor in public and private universities in the country compared to the cost obtainable in the United States and the United Kingdom?
According to the Students Mirror, in Nigerian private universities like Madonna, Afe Babalola University, and Igbinedion University, medical students are required to pay N2 million to N3 million per year. At Babcock University, the school fees for Medicine and Surgery for freshers is N3.5 million while old students pay N4 million, and at Bowen University, medical students are required to pay school fees of N3.5 million. These fees include tuition, development levy, course registration fees and others.
Meanwhile, in Nigerian public universities like the University of Ibadan, the school fees for Medicine and Surgery range from N60,000 to N150,000, depending on the year. According to the Students Mirror, the current school fee at the University of Lagos College of Medicine for new students is N69,500.
At the Obafemi Awolowo University, Ile Ife, the school fees for the current academic session are N159,000 for new students and N151,500 for returning students.
Alternatively, it was discovered that it is rather expensive to study medicine in the United States of America and the United Kingdom. Upon research, the following was discovered to be the average fee for the 2022/2023 academic year in medical schools across the USA, according to Shemmassian Academic Consulting.
The tuition fee is categorised into in-state tuition and out-of-state tuition. In-state tuition rates are the rate students pay to attend a university or college within their state of residence while out-of-state tuition refers to the rate students pay when they apply to universities outside their state of residence.
For in-state public medical schools, the average tuition is $41,000 per session which is about N19 million at the official dollar to Naira exchange rate and about N30.3 million at the black-market exchange rate.
For out-of-state public medical schools, the average fee is about $65,000, which is about N30 million at the official exchange rate and N48 million at the black market.
Similarly, for the in-state private medical schools, the average fee is about $67,000 which is about N30.8 million at the official rate and about N50 million at black market rate.
Lastly, the average fee for out-of-state private medical schools is about $68,000 which is about N31.3 million at the official rate and N50.3 million at the black-market rate.
At Brighton and Sussex Medical School in the UK, students from the UK are to pay £9,250 for the 2023/2024 academic year, which is roughly N5.3 million at the official rate and N8.6 million at black market rate.
For international students at the same school, the tuition fee is £42,000 which is approximately N39 million at black market rate and N24 million at the official exchange rate.
According to TC Global, “The tuition fee to study medicine varies from one university to the other, and in a famous university like the University of Glasgow, tuition fees will be around £47,000 per year. At the same time, in a university like the University of Oxford, the tuition fee will be around £36,710 per year, and at the University of Cambridge, the tuition fee will be around £ 52,000 per year. At the University of Aberdeen, the Medicine course is offered for five years, and the tuition fee will be around 39000£ per year.
“There are also universities like the University of Edinburgh and the University of Manchester where the tuition fee will be much lesser when compared to the other universities. At the University of Edinburgh and the University of Manchester, the tuition fee will be around £137,280 and £133,435 for six years.”
With this in mind, it is quite obvious that medical tuition is way more expensive in the USA and the UK than in Nigeria. Sunday Tribune, however, found out from doctors if the fact that medical school is relatively cheap in the country justifies the intent of the bill.
To this, Dr Mufutau Bioku, a Consultant Urologist from the Federal Medical Centre in Abuja opined that the difference in medical school fees of Nigeria and other developed countries should not be compared in isolation.
He said: “Sincerely, nobody has come out specifically how much subsidy a medical trainee enjoys annually. It is true that tuition fee is cheaper compared to what is obtainable in UK or Canada or SA. But we can’t look at the amount in isolation. What does the amount give you? For example, how many medical students per cadaver? How well-equipped are our Physiology and Biochemistry laboratories? And how rich are our physical and e-libraries? Are they comparable to the ones in developed countries?
He noted that despite all these challenges, Nigerian doctors are still one of the best trained in the world, adding that it is “mainly due to our natural tenacity and adaptability to all conditions and circumstances. To me, in concrete terms, medical education is subsidised but at the expense of infrastructural deficiency or poor facilities.”
Dr Obekpa, on the other hand, believes that cheap or subsidised education is the responsibility of the government to its citizen. He also noted that all courses in Nigerian universities are cheaper than what is attainable in developed countries.
According to him, “In developed countries, students are granted loans which they pay back after school. We don’t pay as much here in Nigeria, but I see it as the responsibility of the government to its citizens. Why are doctors being singled out? We have a lot of courses at the university, why only doctors? Education is subsidized for everybody. A lot of people also go to the private universities. The government is only doing its duty. What else have they done for us? Nothing!”
He added that “The lawmakers should lead by example, let everybody learn to sacrifice, they should use their salaries for the masses. The cars that some lawmakers drive can pay the salary of a doctor for 10 years. Doctors cannot even afford to buy them. They only tell the poor people to give back and it doesn’t apply to them.”
Technicalities of training a doctor.
As Dr Aremu pointed out that new doctors require training and supervision from specialists and consultants even after graduation, Sunday Tribune went ahead to examine what technicalities go into the training of a medical doctor.
The President of the Medical and Dental Consultants’ Association of Nigeria, Dr Victor Makanjuola explained that a lot goes into training a doctor.
According to him, “Every aspiring doctor has to write the Secondary School Certificate Examination, Unified Tertiary Matriculation Examination (UTME) and must be in the top five per cent or top one per cent of the highest scorers in UTME to get into medical schools, and having done that, they will have to spend about six years, plus or minus, due to some disruptions in the academic calendar, after which they will go through a mandatory one-year internship whereby the focus will be on acquiring clinical skills necessary to practice independently, all these are global practices.
“Post-house job, they still have to do the mandatory one-year National Youth Service for those who are less than 30 years old, to give back to the country. After this, they will now come in for residency training and to get into a good residency program, you will have to pass a qualifying exam we call Primary. Those who succeed will now look for placement for a residency program, each of those residency programs will run for about four to six years, after which they become specialists.
“After becoming a specialist, there are some things we call Sub-specialisation, you might have to go to a centre for one year or six months for Sub-specialisation training for you to become a super-specialist so to say in the management of a disease of one part of the body. In all, we are talking of about 13 to 14 years of investment in an individual’s life in becoming a specialist,” he said.
Also speaking with Sunday Tribune, A Consultant Urologist from Federal Medical Centre, Jabi, Abuja, Dr Mufutau Bioku said both in time and conent, the medical training all over the world is rigorous. He stated that the minimum length of time for undergraduate training is six years without ASUU strike.
He further added that, “As a medical graduate, you are issued with provisional licence by Medical and Dental Council of Nigeria. Then you undergo internship (housemanship) for one year before becoming a fully registered doctor and you are issued a full practicing licence. Once licensed, the doctor must now proceed for mandatory youth service unless he/she is qualified for exemption.
“For Postgraduate training, otherwise referred to as Fellowship training to become a Specialist, Doctor must pass the Primary examination. This is a necessary pre-requisite. The Fellowship program is even more rigorous and the duration of training depends on the area of specialisation. It may vary from six years to eight years,” he said.
Merits or otherwise of the bill
With all these being said, is it safe to say the bill has no merit whatsoever? Dr Makanjuola revealed to Sunday Tribune that the only merit this bill has had is that it has drawn attention to the problems bedevilling the health sector.
According to him, “The bill has no merit other than drawing attention to the problems that we have been drawing the government’s attention to in the past two years. Different organisations, medical-related organisations; MDCAN, NMA, have been calling the attention of the government to the growing rate at which medical doctors, other healthcare workers, nurses, and pharmacists are leaving the country in droves. If there is any benefit at all, it is just that of publicity of a problem that has been lingering and that we have been calling the attention of the government to. Other than that, there is no benefit.”
On the faults of the bill, Dr Makanjuola pointed out that bill not only infringes on the rights of doctors, but is targeted at the wrong doctors and will spell nothing but disaster for the health sector.
According to him, “The basic human rights of Nigerians should be championed by the National Assembly and the members of the National assembly, this bill is attempting to withdraw the rights of upright members of the society. One is the right of the person to be free from slavery or servitude, two is the right to not be discriminated against, and three, the right to not be coerced into any forced labour. These rights are in the constitution of Nigeria, this bill will be taking away those rights from medical doctors and it is quite shocking that a member of the national assembly that should be conversant with these rights, with the constitutional provisions is proposing a bill that will take away fundamental human rights of medical doctors.
“The bill is not properly thought through because the person believes that young doctors probably form the bulk of the medical service providers in the health sector, but he doesn’t understand that at the early stage of the career, and one is still under some form of supervision by more experienced doctors, who are also leaving the country in droves.
“We have reported that in about two years, from 2020 to 2022, over 500 consultants have left the country. That is a major concern for us and should be for the country. While the bill is trying to tie down inexperienced medical doctors, we will continue to haemorrhage from the other end, those that are to supervise them.
“The honourable also tried to justify the bill by saying the country has invested so much in training these people and they are now leaving the country. What he doesn’t understand is that the country has invested so much in every Nigerian, including himself. Every Nigerian that went through public university or polytechnic, any tertiary institution in Nigeria, the country has invested so much in every one of us and we shouldn’t discriminate against one group while others are not being subjected to the same rules.
“Most Nigerians who went through university actually paid for their education, the fact that the cost is small relative to other countries does not equate to subsidy. Similarly, our income is also small or minute compared to those in other countries who pay heavily for their university education,” he said.
He also revealed that the country has invested in every citizen who went through public universities in Nigeria.
“It will spell a total disaster for the health sector because it has the potential to aggravate the migration of medical doctors and other health workers from the country. The tendency is that people will think even if the bill doesn’t go through now, it may go through in two to three years and then more doctors will want to leave before the bill becomes operational.
“So, I foresee a situation where in the next six months to one year, we are going to lose many more doctors and nurses to the developed countries, more than what would have happened if this bill did not come up at all. there is going to be a scramble to leave before any such bill can become law. So, rather than help the system which is the intention of the honourable member of the house, the bill is going to have the opposite effect of even making things worse by depleting our workforce even faster than we can replace them,” he stated.
Dr Bioku also believes that the bill is a recipe for persistent crisis in the health sector as he described the bill as an anti-doctor policy.
Dr Obekpa also added that the bill is not in any way addressing the real problems of the health sector which he pointed out to be poor remuneration and infrastructure.
Consequently, Sunday Tribune spoke with doctors on the solution to the problems ragging the health sector.
The MDCAN president highlighted the security of lives and properties, having a vibrant economy, increasing the remuneration of doctors and improving the state of infrastructure in the hospitals as the solution to the brain drain in the health sector.
He said, “If we have a secure country, many more people will stay, if we also have a vibrant economy, many more people will stay. Another push factor is poor income. Most Nigerian doctors earn about 10 times less than what their counterparts in developed countries earn, having the same level of skill. That is the reason many people leave. If the government can improve the average income of doctors in Nigeria, it definitely not 10 times more than what it is currently, maybe two to three times more, or just show some interest in increasing the remuneration of doctors in Nigeria, many people will rather live within their country than to face the uncertainty of living in a new land.
“Another thing is the working condition and the state of infrastructure in the hospital, are some of the things pushing people out of the country, which is within the capacity of the government to improve. These are some of the things that could help in retaining more of our health personnel in Nigeria,” he advised.
Dr Bioku believes that the solution to the Japa syndrome in the health sector is that the government at all levels do everything to retain and increase its human resources for the sector.
He added that “the government must equip its hospitals, improve remuneration for doctors and other healthcare workers and address insecurity in the country. Our political leaders should also be made to patronise our public hospitals.”
For Dr Aremu, asides from better remuneration and improving the state of infrastructure in the hospitals, giving incentives to doctors and encouraging intramural practices is another solution that can be explored by the government.
According to him, “Some of the people running away are not leaving because of money. If we have a functional system where we work and can practice the skills we have acquired over the years, a lot of doctors will stay in Nigeria. They can also give doctors incentives. During the previous administration, doctors were sent to the US, UK and other countries for some training, given allowances, and their flight and accommodation paid for.
“Another way to incentivise doctors is to encourage intramural practices whereby doctors can bring in their own patients, treat them privately and pay the hospital what is due for the treatment and can keep whatever he or she earns from that without the hospital looking at whatever has been collected from the patient. These are some of the things that are done in other parts of the world. There are a lot of ways to give incentives to the doctors,” he said.
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