2,000 doctors leave Nigeria yearly -Enabulele, CMA President

In this interview with Mudiaga Affe, President of the Commonwealth Medical Association and former President of Nigeria Medical Association, Dr. Osahon Enabulele, talks about the brain drain in the Nigerian medical sector and the endless conflicts between government and healthcare practitioners, among other issues.

Embarking on strike has become a recurring decimal, especially in the health sector, what is your position on this?

For as long as the superintending government continues to pay poor attention to the welfare and development of those in the health sector, particularly those in the medical and dental practitioners, by failing to implement their collective agreements, issues like this (strike), which does not help the progress of the health sector in the country, will continue to happen.

The health sector is critical to the development of the country, the human capital resources in the health sector are critical to the productivity of the nation, so, for as long as government and its agencies do not up their game by being more responsive and proactive to the issues that concern the health workers and workers generally, we would continue to have strikes.

They must guaranty appropriate working conditions for their workers and it is a situation of getting people to appreciate their roles and responsibilities in ensuring that there is consistent delivery of healthcare services in our country.

Some members of the NMA are currently on industrial action and the government has dragged them to court, do you consider it a recipe to resolving the dispute?

It is going to be counter-productive at the end of the day because it is a wrong action by the government. It is not a solution to the resolution of industrial disputes because it is believed that they (government) are just trying to use their might to muzzle a legitimate struggle by those who have been so oppressed in terms of non-fulfillment of promises made to them by the government from earlier discussions and negotiations.

So, for me, it is better to always be on the negotiation table that reports to self-help or means that seek to undermine the process and create more bitterness, suspicion, and distrust. Rather than explore means that would further aggravate the situation by going to the court to stop a legitimate struggle, they should resort to negotiating with those who feel that they have been shortchanged, oppressed, and are not accorded their due wages.

Some state governments have refused to pay their health workers for as long as 19 months. Some others are 10 months, six, and four, and this shows that some states are irresponsible. I think rather than resorting to what I call ‘strong-arm practice’, the government should embrace dialogue and negotiations, and if they do not have the skills to negotiate they should look for skilled negotiators to negotiate for them.

The Federal Government has given directives to chief medical directors to enforce the no-work no-pay rule, will this move compel the striking medical doctors to return to their duty posts?

This move clearly shows that they do not have a good understanding of the situation on the ground. As I said, using such instrumentalities is a sequel to using strong-arm practice to muzzle down a legitimate struggle for better working conditions by a people that have been so suffocated by years of un-sustained promises spilling into months of unpaid salaries and denial of appropriate working conditions. So, those kinds of prescriptions are meant to protect those in government.

To protect those who do not see the need to keep to their obligations. The question I am asking is: in implementing the no-work no-pay rule, where were you when people were not being paid for working? In other words, if you are implementing the no-work no-pay rule you should be courageous enough to implement the no-pay no-work rule as well.

So, it cannot just be a unidirectional thing where because of the availability of the instrument of power you seek to use that to undermine a legitimate struggle. It will not work because these people (striking doctors) are expressing their legitimate legal rights and appropriate working conditions. It will only aggravate the situation because now they are saying it is no-work no-pay, but it is ineffective.

The people are saying we do not mind if you implement the no-work no-pay rule, it is your headache, but for as long as you refuse to pay us our legitimate wages, we would remain in the trenches. The prescription is archaic which has been used to suffocate legitimate struggles, but they may meet their waterloo this time because the people are saying you cannot owe us for 19 months, for instance, and you expect us not to cry out. It is something that is not going to help the early resolution of the current impasse.

I think that the government should be more responsible in embracing a negotiation table and be more sensitive to the needs of workers rather than allowing it to become conflagrations. Today as I speak to you a lot of people are moving out of the country in the face of the implementation of the no-work no-pay thereat, so, how has that solved the problem? The workers no longer care about your no-work no-pay policy as long as you have failed in your responsibility to keep to the agreement that you swore to implement. I think people should call the government to account and people should own up to the fact that the government cannot be implementing such bourgeois prescription unilaterally without the constructed frameworks and opportunity for workers to get adequate compensations for working judiciously. You cannot be implementing the no-work no-pay when people have not been paid for the work that they have done for several months­­­­­- that is not justice.

A few days ago there was a video clip of how Nigerian doctors were jostling in Abuja to fill up vacant positions in Saudi Arabia. As an organisation, do you find this embarrassing?

As President of Commonwealth of Medical Association, superintending over situations in the 54 countries that make up the Commonwealth of Nations; and also a past President of the Nigeria Medical Association that superintendent over thousands of Nigerian physicians between 2012 and 2014 and currently Coordinator of the National Medical Associations in the African region. So, I clearly understand the challenges of the poor working conditions in the continent and even Nigeria and why medical and other professionals are moving to jurisdictions where they consider as more embracing, ambient and accommodating to their professional preoccupations.

I consider the trending video as embarrassing to the Nigerian state and that government should see it as a wake-up call to put in place appropriate working conditions to address the socio-economic imbalances in our country and ensure the resolution of the security challenges in the country. It is not now only on account of poor working conditions, but increasingly because of the rising spate of insecurity across Nigeria. Right now there is nobody who feels safe in Nigeria because as you wake up from sleep you hear that your neighbour has been kidnapped and they are almost closing-on on you.

I mean, if you have the opportunity you would want to go to a safer and more secure environment. More so for medical professionals who have struggled through thick and thin, through a very rigorous and tortuous path to become who they are now practicing their trade in Nigeria. They may not want to remain in the Nigerian environment because yours to continue to exert certain responsibilities and you should be able to do that in a safe and secured environment. So, beyond the issues of working conditions, the spate of insecurity is another issue and it is not clear what we expect in our country.

Already in Africa, the continent has every reason to stop brain drain by doing the needful by creating the enabling working conditions for their workers. In health, for instance, the African continent accounts for about 25 per cent of the disease burden in the world. Simply put, of all the diseases in the world, Africans contribute 25 per cent of that burden. You would expect that those who have the highest-burden would need to ensure that they have the appropriate workforce to attend to those in need, those who are challenged by these diseases burden, but it will surprise to note that Africa has only three per cent of the global health workforce- you can see the disparity.

So, Africa does not only have reasons to conserve the low percentage of healthcare workers in Africa, but to produce more and put in place retention mechanisms that will motivate them to remain in their country, but they are not doing that. Rather they are bringing out policies that do not encourage the healthcare workers to remain in their country. Look at what is happening in Nigeria today, till date the hazard allowance is N5, 000 monthly in the face of the COVID-19 pandemic.

To date, healthcare workers, including medical and dental professionals, are not appropriately rewarded for what they do. Whereas, other countries in the face this COVID-19 period, are coming with better policies to attract healthcare workers from Nigeria. These people are now coming to Nigeria to recruit our medical professionals. You cannot blame those countries because they are trying to improve their own country. Where they are attracting these healthcare workers from should be the one that should be challenged by putting on the ground those necessary factors to ensure that their workers remain.

Today as I speak to you, Nigeria requires an additional 250, 000 doctors to meet up with the global requirement that will attend to the population which is put at about 200 million persons. To meet up with this number of doctors, Nigeria would need to produce much more than they are producing now from the training institutions.

In your estimation, how many Nigerian doctors are practising overseas?

Well, I cannot give an exact figure. I can only give what has been provided by either regulatory bodies in these countries or by their associations (Association of Nigerian medical professionals in those countries). Recall that Nigerian medical professionals do not only to go Europe, or the West, some of them are even in Africa. It will amaze you that some Nigerian medical professional is immigrating to Gambia, Uganda, and Ghana. For the ones that we can readily put our hands-on, the body in the UK for instance, we have over 8, 000 registered doctors and this figure varies from month to month and year to year.

As we speak, there are over 3, 000 doctors in Nigeria that may be planning to move to the UK by going through their examination processes on a month-to-month basis. The figure keeps increasing. In the United States of America, it should be in a region of over 5, 000. There are also Nigerian doctors in Canada, Saudi Arabia, Australia, Germany, and many other countries. Every year, the Nigeria Medical and Dental Council puts the yearly estimation of Nigerians who are going abroad at nearly 2, 000.

When you put all these together, you can estimate that the figures are very humongous. So, it is the responsibility of everyone to ensure that this matter is addressed with the commitment and right political will and not through retrogressive policies that do not encourage anybody to remain in the country.

What are the issues to be addressed?

Fundamentally, the socio-economic issues need to be addressed. Every doctor, like every Nigerian, will need to have the economic power to attend to his needs. Do not forget that doctors also have children/dependents to cater for like every other Nigerian. The economic power of Nigerians and healthcare workers must be attended to because of the appropriate wages that should be addressed because in these whole migration issues there are fringe factors. I have been discussing the issue of brain drain in Africa and indeed the commonwealth since 2004 and that is over 15 years ago. What bothers me is that the issues are still the same.

The drumbeats are only changing but the drums themselves are essentially the same and different players are beating the drums at different times and everybody is revolving in the barber’s chair with no movement forward. So, we need to get this thing clearly understood in terms of what is pushing our doctors and other health workers away from Nigeria. Specifically, they are the issue of poor working conditions, uncompetitive wages, insecurity, dwindling economy, training opportunities, and lack of employment. Today, Nigerian doctors are largely unemployed because the employment stage has been frozen. You hear of people getting waivers to be employed, even in the medical sector where people move in at different levels on a day-to-day basis. Why tie down the hands of those who are managing the institutions? You will have to go to Abuja to get a waiver to recruit- this does not make sense.

It makes that you do not place value on the continued delivery of healthcare services at the different levels. Those factors that are pushing them away must be sufficiently addressed and the motivational factors put on the ground to encourage them. It is not something that should be addressed with kid gloves. They must engage these in a full crisis mode and ensure that the issues are collectively addressed. Even though I do not think I should be mentioning this, the government of General Ibrahim Babangida, addressed some of these issues by putting on the ground a new wage structure which to a large extent addressed the movement of healthcare professionals to other countries.

The time has come for the government to sit down again on the table and ensure that the appropriate working conditions are put on the ground through negotiations. The N5, 000 hazard allowance, for instance, should be reviewed and tied to the inflationary trend in our country, just like workers’ wages should also be tied to the inflationary trend in the country without the need to be negotiating all the time and embarking on strike actions. As long as inflation is rising your wages should also appreciate. Again, in the era of government not paying their workers for several months in the case of Abia (17 months), Imo (10 months), Ondo and Ekiti (10 months), and many other states, there must be punitive measures against those governments. Those who are owing are now even implementing the no-work no-pay rule, this is absurd.

A lot of doctors have been accused of receiving salaries from the public sector while they also practice privately, why is it so?

There is nothing that offends their rights from engaging in private practices in their spare time. Everybody has the right to undertake his endeavour outside the official engagement. What I frown on and what the medical profession frowns on, is engaging in private practices during official time slated for government work. It is not acceptable in terms of our code of conduct and medical ethics and expectations from physicians. But to deny them the opportunity of expressing themselves in other vocational endeavours outside their official working hours is an infringement on their rights.

There is nothing stopping anyone from embarking on that outside the official hours, but the medical and dental council have come up with some prescriptions as to what kind of practices physicians at different levels should undertake during unofficial government hours. It is known to the code of medical ethics and it is the responsibility of the physician to observe those codes and not be seen to be infringing on them. In a nutshell, the appropriate laws allow physicians to undertake their vocational endeavours during their unofficial government hours and they frown on those who undertake private practices during the official government hours.

President Muhammadu Buhari is always in the UK for medical attention, as a leader of a medical association, are you worried, if yes, have you protested against this recurring issue?

It is not only the union, I have issued statements on this on Facebook from the day he made the first trip to the UK as President. I felt traumatised that we have a President that came based on promises that they were going to reverse Afro-medical tourism, but who now is advancing Afro-medical tourism. I felt very embarrassed about that kind of narrative and I blew the lead in 2015 to tell Nigerians that it was wrong and that country now has a provision that restricts the use of our commonwealth or taxpayers’ resources to finance foreign medical trips by political officeholders. I had reasons to call on the British government in the past to tell the Nigerian president to return home. It was a headline story in a British newspaper.

What is embarrassing is that even in the face of COVID-19 when we thought it would create some repentance amongst our political leaders to stay in their country to develop their system in preparation for any future pandemic, the reverse is now the case because soon after the international borders were opened for travels, our political office holders started travelling abroad again for foreign medical cares which are clearly against the expectations of Nigerians with lessons learnt from COVID-19. So, it is not right to have this continuously because it was shocking to the sensitivity of the Nigerian people that what is on the ground is only good for some of us while our political leaders will continue to fly abroad to attend to themselves.

If you provide a healthcare system for your people, it should be good enough to take care of them. It clearly shows that government needs to be more sincere and paying attention to the healthcare system for the Nigerian people than saying one thing and doing the other. It is not to say I am against any person travelling to any part of the world to get their healthcare needs, they have the right to do that with their resources, but as long as you are using the Nigeria resources, it negates your responsibility as a government official or political office holder and it does not inspire anybody. It is a disservice to the healthcare development system in our country.