By Henry Uche
Minister for Health and Social Services, Dr Muhammad Ali Pate, in this monitored interview on Channels TV, speaks on a wide range of issues affecting the health sector including health workforce policy on migration, brain drain among others.
In 2015 about 233 doctors left Nigeria; in 2016, 279 left; in 2017, 475 left; in 2018, 852 left; in 2019, 1347 left; in 2020, 833 left; 2021, 932 left for UK alone, what is happening?
Answer: Well, this policy is really about the health workforce, about doctors, nurses, pharmacists, scientists and others who contribute to service delivery in any health system. Health workforce is a lifeblood of any health system, and I have to acknowledge that this landmark policy approved by the President in Council, has reverberated not only all across Nigeria and Africa, but also globally; among Nigerians in diaspora, as well as at home and among friends of Nigeria. And I want to acknowledge all those who worked tirelessly to bring it to fruition: The multi stakeholders group that includes different sectors, civil society, professional associations, that had made input into this policy that has now come into fruition. The issue of workforce migration is a global phenomenon. It’s not only in the health sector, but as you mentioned, but it is also in education and other sectors. In the context of Nigeria, there is a global workforce shortage.Western countries face significant shortage of human resources, and they are recruiting from developing countries like Nigeria. In Nigeria, it’s acute. I think we have less doctors to a population ratio than many countries of our size, including large countries like India. The distribution of the health workforce is a challenge. Many of them live in cities- Abuja, Lagos and a few other hot spots, and training them is something that needs to happen. And recall that upon assumption of office, we expanded the training of health workers, medical schools, nurses schools, pharmacies as well as other scientists, to expand the training as well as the conditions of service, including the infrastructure in our health sector, hospitals, federal hospitals, cancer, equipment, all of those were to improve the enabling environment for them to be able to enjoy what they are doing. But that doesn’t mean that professionals can’t seek to travel abroad, either for training, for personal reasons or for family reasons. This policy strikes a balance between the needs of the professionals to seek for where they can advance and improve themselves, and the need of the health system to deliver quality services to Nigerians. We don’t expect this trend to disappear overnight, but how can we, as a government balance these two competing priorities? That’s why this comprehensive policy was developed, and the President took the bold step to confront the issues in a very systematic way and approved this in Council. And it will go a long way in addressing this critical challenge that we face in our Nigerian health sector.
I think we have the distribution of those who have been trained over the last five years and who have left. I think you will find that almost 17,000 have been trained over the last five years. More than half of them have left. So the younger doctors tend to be trained, and they leave because there’s a demand elsewhere. They want to be better trained, and they see the challenges that we face as a country. So this policy is to try to address that. We retain to provide the services that Nigerians need, while, in a way, make it easier for those who have left to be able to come back and over time, for our health system to be one that, in a way, provides less push for them to leave, despite the pool that they have from the more advanced countries that are using them as economic migrants. To some extent, they are professionals. And I admit that there are many reasons why doctors left.
How many doctors are practicing in Zamfara state alone?
I think I can tell you nationally, the doctors that we have, and if you give me time, we will have the breakdown. We have a registry of health, of course, the medical and dental council that licenses every professional also has a distribution across the 36 states, not only of doctors. The Midwifery Council has theirs for nurses, midwives, community health workers, because every health professional is licensed and you don’t license somebody who is not a professional.
I’m picking some Zamfara specifically as an example of how bad our health sector has been. I’m not sure we have up to 50 doctors in Zafara state, while our doctors are hot cake in other parts…
They’re well trained, I think we have a good system for health worker training. Our universities are doing a great job. I was trained here. I went and worked in different places, different countries, different universities, and I’ve never felt second to anyone, and many of my professional colleagues outside this country, they can beat their chest. They do a great job. And so they are attractive, they speak English, and that is something that we should cherish and we should be proud of. And we should also remember that the majority of healthcare workers remain in Nigeria. They serve in Nigeria, and they’re intrinsically motivated to provide care for Nigerians. The few that left have various reasons for leaving, and we cannot stop them from leaving. But what, as a government is the responsibility that we have? That is what this policy is all about.
What are the specifics in this policy, how would the japa syndrome within the medical sector, especially for migrating doctors reduced?
It is a five-pronged policy. One is about incentives. How do you provide non monetary incentives as well as monetary incentives to allow folks who are healthcare workers to serve in rural areas, more to be enabled, whether it is accommodation, whether it is credit facilities for cars, for mortgage or other mechanisms that will make their lives comfortable so that they can remain and serve. How do you recognize those who have served in rural areas? Doctor that serve in Zamfara for instance, for three years, should have been recognized for that, versus some who serve elsewhere. So that is on the incentives front. Also dealing with the allowances and salaries and all of those packages of service, and that is something that we would work with Service, Incomes and Wages Commission and the other relevant agencies of government to see that there are improvement. The second part is capacity development. That is a training of doctors. The training of those doctors, not only domestically, but also how do we improve it by exposing them to basic class training elsewhere, in terms of training abroad, opportunities.
How do we expand the schools of medical education, nursing, pharmacy to double and maintain the quality the way and manner they are? How do we maintain continuous professional development so that they will continued to grow, and the pathway that they can be getting, the actualization that they need over time. How do we use digital technology to enhance what they do and allow them to learn using tele-health, tele – education in this day of zoom? How do we enable that? That’s what the capacity development. The third part of it is about health diplomacy and promoting ethical recruitment practices. The recipient countries that recruit our professionals, should they not have some responsibility to help us expand the training, because the trend on health worker migration is continuous and it’s not going to stop tomorrow, UK will need Nigerian doctors. 67% of our doctors go to the United Kingdom, and 25% of NHS workforce are Nigerians. So does the UK, for instance, want to consider expanding the pre- service education? Can we have corridors that allows us to have a compact that you take so but you also help us train more so we will replace them. That’s in the realm of health, diplomacy and ethical recruitment. And when they are recruited, how do they get compensated and treated fairly? There are other elements which have to do with research, data and evidence. So as we refine and implement this, how do we learn as we go? How do we keep the registry, and finally, the governance of it. How do we work where federal government only recruit certain doctors? States do, the Private sector does, and all of that. There is an important element also that I would like to mention: The work life balance of the health professionals, including their mental well being, the security of where they live, those who are living in challenged areas, how do we improve that for them and the younger doctors? How do we ensure that, in fact, their decent work environment and also working hours that are fairly reasonable without disrupting patient care? Those are all elements that encompass this policy measure that the government has now put in place which will proceed with the implementation.
Is there a policy document to back this?
There is, and that policy document is available, and it’s called Health Workforce Policy on Migration.It is a policy of managed migration. It has a forward, the background, the various chapters, all that I have laid out for you, including those who have been consulted in development of this policy, up to its approval yesterday by the President in council. On the ministry’s website, we’re streamlining, because it’s a large document, so it is easily downloadable, it’s available document and has gone through iterations of consultations with key actors, with key professional bodies, with workers from all across the country, as well as other ministries for the federal government. For instance, whether it’s the Ministry of Justice, Ministry of Labor, foreign affairs, Ministry of Education. It’s a whole of government approach to deal with issue, and on one hand, focuses on health, but it’s connected to wider effort of the Nigerian government to deal with the problem of migration, which goes beyond health which you alluded in your earlier remarks. How we harness this potential as a country that has a lot of youth, some of whom are in school, are learning and have high aspirations…we think we’re the country of the future. How do we harness this demographic potential, including in the health workforce, but also potentially in other areas where the digital technologies, academia and many others.
Will this policy document come into effect on the practitioners?
It is available as of yesterday, and it will be online tomorrow. It’s already there, part of it have been implemented. I mentioned, for instance, the training and retraining, when I mentioned the digital transformation, I mentioned the physical infrastructure, whether it’s at the primary care level for the frontline health workers, or the hospitals. When I mentioned all of those elements, they retrain 120,000 frontline health workers. We have retrained 10,000 already. So as we were developing the policy, those that made sense, we have tested it- so it’s been implemented. There are facets of it. For instance, when I mentioned credit lines for loans, for mortgage, for health workforce, that has to be developed, and that requires us to convene with the financial sector to work out the modalities, the risk profiles, and how that can be made available in the current economy that we have. And, of course, with the professional bodies, whether it’s NMA or the health professional bodies, but there are elements of it that we would have to work overtime. It is not just a document that is gathering dust on the shelves, but we’re about action, and we have been taking very tangible actions under the leadership of the President to advance the health sector overall, and not forgetting the key ingredient of the health sector, which is the health workforce, whether they are doctors, nurses, pharmacists and all other kinds, and we’ve engaged repeatedly with them in the context of this policy.
This is just an administrative document. There is a national health Act of 2014, which a lot of people say is so outdated, it’s 10 years old, but this policy, if it doesn’t have a force of law, then there is also a challenge to it, isn’t it?
Well, I think you have to be very clear that there are laws. The National Health Act you referred was 10 years in making. It took from 2004 to 2014 when it was enacted and signed into law by President Goodluck Jonathan, it took eight, nine years before elements of it were implemented. When this administration came, we started implementing that Act, and that is what we are proceeding with. Now, there’s a policy and there are institutions and how we behave as leaders within that context also matter. The intent is there. The consensus has been built. The resources have been mobilized. Will all actors behave in the way that they should? We certainly hope, in the light of the President’s vision for our country, that all actors will pull together, whether federal government, state governments, private sector, to make sure that we have a robust health system, because it will benefits everyone. So I am confident that if we continue in that line, the Act exists, the National Health Act that provides a governing framework for the health sector. We signed a pact in December which was unveiled by the President for the Health Sector Renewal Investment Initiative. We have various policy instruments, here; we identify the problem, and we are solving the problem, some through appropriation, which will continue to be improved, and some through behaviors and incentives to even some national actors to compliment. And I just mentioned the retraining of frontline health workers. That is something that is happening, and it’s mobilized by the federal government and the states are collaborating with us, and that will make a difference to the health workers that are in the areas, but also to the services that they deliver.
What are you offering Nigerian doctors if you want them to stay?
You narrowed it to the doctors. What about the health workforce which is a tapestry of all kinds of exceptional health professionals: Doctors, nurses, midwives, pharmacists, laboratories, scientists and others that are serving the population? To your question I will say, let me understand a little bit better economics, because the UK GDP is very different from the Nigerian GDP. The purchasing power of the pound in the UK is different from what it is today. The taxi ride in London is very different from what it is in Abuja. There are other things beyond monetary compensation that is of value to individuals. This is our country. We have a moment in time that we can rebuild it and make it great. And there are difficulties that we will have to walk through, and there are sacrifices that we have to make through. If I had looked purely on the basis of economic terms, I wouldn’t leave the compensation that I was entitled to, sitting and doing probably half of what I’m doing currently to do that. But I came because I know that there is a meaning. This is a country that has educated me. This is where my family is, my relatives, and I got my education in this country and have an opportunity to serve. So there are doctors, many of them, all over the world that are juggling these issues, and we cannot force the answers on them. Everyone will have to reach conclusion. But I tell you, there are doctors that are leaving the United States, coming back to Nigeria to set up practice in here, but it’s meaningful to them. I know those, some that left the UK doing sophisticated, fantastic jobs in oncology that are setting up practices in Lagos, my colleague, the Minister of State, has a phenomenal practice in Chicago. He is here running around, doing the work that we need to do to rebuild this country. And there are many other folks like that, not only doctors, nurses. I have met many of them. They are also doing that.
So, you are not increasing the salary which is the bottom line, Minister?
Recently the President signed the minimum wage law. With that, there are implications, and there is a salary committee working on the compensation. You want me to just announce that? That is not what I’m going to do here. It’s not just about the economic remuneration, it’s an overall package. Things are really bad but this government is fixing it. We are building an infrastructure to re- industrialise the sector. You mentioned gloves, masks, syringes and pharmaceuticals, over time, we had not done it for many years. Some have to do it. Many years down the road, this will take off, and people may forget what this President has done, but it’s going to be done. But at this time, it’s about putting in place mechanisms, some monetary, some non -monetary, and other elements that will make it easier for those who choose to stay and for those who leave make it easier for them to re- enter. And there are many that are coming back to, so it’s not just about money.
Is the government giving commitment to increasing the take home of medical practitioners?
I will give you that commitment. Looking at the flood incident in Bauchi, I’m disturbed, because I’m from Bauchi state, that’s my home state, so my condolences to Bauchi state, but also to the people and all those affected by this terrible flood. And I hope God will make it easy for everyone involved. In terms of the compensation of health workers, I think there is an ongoing conversation. We’ve been having discussions with the NMA, with various professional groups. There are outstanding legacy issues, and we will continue to forge that through the Salaries, Incomes and Wages Commission, as well as the presidential salary Commission, which is looking at these matters in line with the upward reviews that has been occasioned by the minimum wage. So that is something that we are working on. But I cannot give you a figure, I cannot give you a time, but we are committed to making the welfare of health workforce in Nigeria better, in line with the overall mission of the President and his commitment to improve the work the welfare of all workers in our country. And mind you, he is the African Union champion for Health Human Resources as well. So this is something that is very much in his lane, and I’m confident that we can accommodate some of these demands that have been long overdue. In addition, beyond just pay, there are other non monetary incentives, which are as important for health, of course, which we would also drive to boost their capacity so that they function and have the meaning for which they were trained. Health workers are intrinsically motivated to serve others. They are called to serve, and that motivation is what keeps 70% of the health workers that we have in Nigeria here at home, regardless of what is at offer elsewhere. So we appreciate them. We will also continue to support them. And these policy measures are just one more step alongside other things that have been implemented over time; including retraining them, the infrastructure and all of that. You ask the question of, how can government prevent anyone from traveling? We are a free country, relatively speaking, and we are not envisioning to prevent those who want to leave from leaving. In fact, we anticipates that some will leave by increasing the training. If we train10 more, maybe two or three will leave, but seven will remain. We hope the three that are trained but left will, over time, will find their way home, and we will make it easier for them to come. So that’s why it’s a Managed Migration Policy. It’s not stopping people from migration.
So you are not literally tying anybody down?
No, The idea of managed migration is to accept that, look, the migration of people is here to stay. People will leave. Some will come back. Others will migrate to our country. How do we train more? Some would leave, but at least some will return. And there is experience. If you look at the Philippines, look at India, they tried that when they trained more, seven out of 10 remained. Three will leave, and they contribute to the economy of Philippines.
Some people would say, why not create a policy that if you finish from any of our tertiary public institution you cannot leave the country, except if you have practiced here after two years as a way of ploughing back into the country, the investment made on you, like some countries do, are you looking at that direction?
The educational system in Nigeria trains more than doctors. It trains lawyers, engineers, scientists all over and they have the freedom to leave. But how do you encourage them? How do we minimize the push factors that pushes them out, and how do you pull those ones that are out to come back. Our focus is a progressive, forward looking policy; that is saying- you’re free to leave, but we will make it conducive for you, that if you don’t have to leave, you don’t leave. And if you have left, how do you come back? And if we train more and we consider them even as experts, the Foreign Direct Investment, that is thr inflow into this country from Nigerians and diaspora, is multiple folds. We are concerned about several folds of Foreign Direct Investment that is coming to our country. So in that regard, the migration can be of value to the country. So by expanding the training, we’re making it easier for those who want to be trained to be trained here, to have good quality education, to leave if they want to leave, but for those who want to stay, also to stay and have meaningful considerations.
Some would say how can we train you here and you take the knowledge to somewhere else…
This is why I said this is progressive policy, it’s a different policy angle, to say, look, how do we solve this problem? The idea is not to keep people against their will to travel. Let it be so that we have enough, that some may choose to leave, and many will remain. And already, there are many that have remained and are still serving in this country. And for those who have left, encouraging; providing incentives for them. It’s a free country, and Nigerians are very vibrant, very entrepreneurial and very capable wherever they are. And if Nigerians hold back from the UK, for instance, I’m telling you, the NHS will struggle to provide the service that many Nigerians are going there to get. So we took this position that let’s expand the training. Let’s improve the circumstance of those who are here. Let’s have responsible recruitment, the kind of recruitment policies that make sense. I think it should be better considered and through the diplomatic channels, I’m sure that it will be contemplated. And therefore those who are going for graduate training, let them go, let them get the skills, the competencies and the networks. And we hope that they will come back, and we’ll make it easier for them to come back and serve and build in this country.
You talk about the push factor, in the immediate what are you doing or have done, how much of equipment are we getting and other benefits?
Cancer centres are being revamped, the infrastructure, the equipment.The President approved it through NSIA. There’s a lot of progress. It was approved in February and work is underway way, you will see us opening soon. This Friday, there will be 10 ground-breaking ceremonies simultaneously taking place, eight diagnostics, two oncology centres. These are very tangible. At the primary health care level, we are revitalizing thousands of primary health care through the state government. We’re retraining the frontline health workers so they’re very tangible things that are already happening to make it easier, to reduce the push, the circumstances that make people decide to pack their bags and go. In addition, I mentioned to you the mental well being of the physicians and healthcare workers themselves, their wellness checks, the working hours to be moderated so that no one works more than 12 hours continuously. If you are a pilot, there are certain number of hours that you cannot fly non stop. You need to take a break. We have been discussing with the Medical Dental Council of Nigeria for those kind of measures, and we’ve been speaking with them to try to put in place those mechanisms and also get the private providers, the state hospitals, to also follow suit, so we cherish this health workforce that we have, especially the younger generation of doctors, because they are the ones that will grow to be the leaders in this sector over time.
As the Coordinating Minister for Health and Social Services, what would you say is the most tangible thing that you have done that Nigerians can see?
Several things. And I’m so honoured, so privileged, that the President asked me to join his team to serve this country. If you look at our primary health care system, the expansion of the basic health care provision fund is already underway. More than 8800 facilities have received funds twice in the last six months, and those funds are being utilized to provide services. I have seen some of those facilities. I mentioned, more than 10,000 frontline health workers that have been retrained in the last seven months, and more than 2 million Nigerians have been included in the vulnerable groups fund so they can have affordable health care. I just mentioned to you the infrastructural development. There are cancer centres in six teaching hospitals in the country, there are also the many equipment, physical infrastructure. I just finished reviewing the University Teaching Hospitals’ completed massive infrastructural projects. Three weeks ago, I was at Nnewi, Anambra state, specifically at the Nnamdi Azikiwe University Teaching Hospital’s permanent site there are amazing, facilities there and also here at the University of Abuja teaching hospital. we are seeing tangible investment in infrastructure, in equipment, and the retraining of the health workforce, and the expansion of the quota that we have met for nurses schools and pharmacy schools, medical schools. I think that is the beginning, but it will take time for it to manifest. So there are many tangible things.
What about outstanding salaries and emoluments for health practitioners?
I think at the moment, I will say that for the federal government, much of that is up to date. There are outstanding arrears that are in the final stages of being released. There are outstanding salaries of 13 health agencies yet to be paid salaries from January 2024 to date
This is why we should thank the president. Before this administration came on board, a decision was made to de-fund all regulatory bodies. That was a policy decision that was taken. We came, and in and made the exceptional case for health regulatory bodies that they cannot be de-funded, because by de-funding them, we put everybody’s health at risk. And in his wisdom, the President approved that exceptional circumstances in January 2024. The process of finding the budget line, getting the necessary codes between the budget office and finance has taken place over the last several months. I told you that, that is at the very final stages for those regulatory bodies. But mind you, those regulatory bodies also receive revenues, whether it’s user fees or whatever contribution from the professionals that have been regulated by them. We just did not want them to be dependent on the profession they are regulating.
A lot of Nigerians go outside of the country to seek help medicaltreatment, they feel that some of the hospitals, public hospital have become death beds, what is the assurance are you giving that Nigeria about getting the best of healthcare in this country without having to go to India, to the United States, to Saudi Arabia or Dubai?
I will tell you, it’s a privileged few that travel abroad for medical care. There are others who travel back to Nigeria to get medical care, some from the UK, some from other African countries. The quality of care that we provide in this country is as good, if not better than many of other countries in the continent, and we are improving that. We want to make Nigeria a hub so that others, even from other countries can come and be served in Nigeria.
Our presidents and other top politicians travel outside the country for medications…
That is why we we are building and strengthening our health care system. And this President is committed to transforming Nigeria’s health sector, and we are on our way to doing that, and I assure you, over time we will get there but hard work has to be done, and that is why we need every health worker, every professional to be patriotic, to contribute to rebuilding our health system, because it benefits everyone.