The blind celebration of an increase in funds generated from the issuance of Nigerian passports by the Nigerian Immigration Service as a revenue-earning breakthrough is, to say the least, preposterously myopic.
Deep thinkers would rather view it as an ominous sign of impending break of more Nigerians, through our borders, from a country whose administrative architecture favors the scarcely inhabited center & its ruling appendages at the detriment of severely choked subnational inhabitants who constitute over 70% of the country’s population.
When obesity and lipids-induced arteries’ blockage occur as complications of perpetual and excessive food consumption, do you know that the blood supply by the tributaries of these blood vessels to the deep-seating body cells where organic growth & development actually take place would be impaired?
What suffers, you may ask? It’s the entire body, and not just the cells whose remote supplies of oxygen & nutrients via blood flow would have been truncated.
The dysfunctional system of government in our oil-rich Nigeria has similar deleterious effects on every part of our national life and I strongly posit that the mass departure of our health workers is one of such anomalies traceable to this glorified systemic malfunction.
Given that the entire national body called Nigeria is a caricature of the characteristic over-consumption and under-ingestion encompassing the national and sub-national governments respectively in Nigeria, it is important we conduct a dispassionate analysis of the root cause(s) of the conundrum of health workers’ emigration from Nigeria to be sure that it is not inextricably linked to this prolonged dysfunctional system of governance in Nigeria.
It thus appears that the over-centralization of powers sits chiefly, quietly and unsuspectingly as the culprit because if you over-feed the center and under-serve the periphery, you unwisely yet stifle the development and wellbeing of the entire body – pure and simple!
I last counted twenty-three Nigerian medical doctors and nurses, whom are well-known to me, who actually relocated to one of three countries – United Kingdom, Saudi Arabia or United States – in 2021 for health care jobs due to one of these five prompts of migration, in no particular order;
a. Poor health infrastructure
b. Poor remuneration of health workers
c. Low ratio of health workers to patients/Excessive workload
e. Poor quality of life of their families
Working alone, can the Federal Government (FG) redress these five causative factors? How does the current FG-dominated structure of governance therefore enhance the economic capability of subnational governments to rise to the occasion?
Although I couldn’t lay hold of any data showing the distribution of Nigerian doctors between the Federal and subnational governments, Ondo State’s scenario as at January 2022 with 500-600 medical doctors in the State civil service and about 200-250 physicians as Federal Civil Service employees (at the Federal Medical Center, Owo) is a reference point for this analysis.
The Federal-State ratio of physicians safely extrapolated for the entire country is therefore 1:3; meaning that for every medical practitioner at the Federal level of government, 3 doctors within the States’ purview require equivalent remuneration packages if the States were empowered.
Therefore, is Ondo State, with 23 secondary health care facilities (General Hospitals and Specialist hospitals), 1 Teaching hospital and 584 Primary Health Care (PHC) facilities not constitutionally repressed from exploiting its bitumen deposits, seaport-potentials and other areas of comparative advantage to strengthen her health care infrastructure; increase her number of health workers; scale up the remuneration of her human resources for health; and combat her -local security?
Who knows whether the States & LGAs are losing more medics to emigration than the Federal service?
Yet, according to the 1999 Constitution of the Federal Republic of Nigeria, health care is on the concurrent legislative list and the implication is that the Federal and State Governments have respective responsibilities as well as authorities over it.
Laughably, the same constitution avails the State of not-so-significant economic powers to effectively fund the ‘livewires’ – infrastructure, emoluments & training of human resource for health – of their individual health care sectors. What hypocrisy! Why won’t health workers consequently leave the country in droves?
Again, how many officials of the FG-owned National Food & Drug Administration & Control (NAFDAC) officials or national drug quality assessment gadgets are there in Ondo State to check the incidence of fake and adulterated drugs? Does the strangulating 1999 constitution sufficiently & economically empower Ondo State to effectively fund her newly established Drug & Health Commodities’ Management Agency in order to curb the menace of unsafe drugs within her geographical space? Does the Federal Civil Service have more health workers in its tens of Teaching Hospitals and Federal Medical Centers than the 36 States, Federal Capital Territory (FCT) and 774 Local Government Area (LGA) Councils collectively parade in their General Hospitals and Primary Health Care facilities? How many States have the financial muscle to pay equal or higher health workers’ wages than the Federal Government? Permit me not to dabble into the crescendo of insecurity and low quality of life of the average Nigerian due to poor access to pipe-borne water, stable electricity, good roads, affordable consumables (food, petrol, toiletries etc.) and all of which are non-health sector contributors to the emigration of health care professionals.
What then is an enduring strategy to resolve this problem? It is by deliberate devolution of powers. First, political leaders must accept the diagnosis of a dysfunctional structure of governance in Nigeria and its dire implications on every sphere of our national life including the moribund health care delivery system and demotivated health workforce. Secondly, a constitutional process of devolution of powers to the States and LGA Councils must be instituted as a catalyst for gigantic overall development of the health sector at subnational levels. Imagine that 36 States, the FCT administration and even 774 LGAs are awfully empowered to live up to their health care responsibilities enshrined in the toothless and mocking concurrent legislative list in the 1999 constitution of the Federal Republic of Nigeria (as amended). Won’t these subnational units be better positioned to significantly reduce the incessant migration of Nigerian doctors & nurses at least in their respective domains? Don’t we think that the devolution would further empower States and LGAs to combat insecurity and significantly contribute to improvement of the standard of living of Nigerians, thus deterring emigration?
Thirdly, devolution of powers to subnational units should be concurrent with encouraging them to work strategically with the private sector to develop the health care industry. In India, medical tourism employs more doctors than the government service as confirmed by a leading Indian news outlet, The Times of India, under a screaming headline in its December 25, 2018 edition – Healthcare for poor: Only 1 in 10 doctors join government hospitals. Excerpts from this very lucid piece reads; “A majority of India’s population may still be dependent on public healthcare, especially the poor, but only one in ten doctors in India serve at government hospitals or facilities. From lesser pay compared to the private sector to other facilities that doctors in the latter get, experts point to a host of reasons for 90% of the doctors opting for jobs in the private sector…” Unlike India, the overbearing ‘command and control’ center in Abuja continues to whittle down the tendency of States & LGAs to expand the top-notch private sector participation in the health care delivery systems of subnational sites other than say Lagos, Abuja and Port-Harcourt. How will hundreds of the likes of India-based Apollo groups of Hospitals evolve and thrive across Nigeria to provide alternative world-class employment bouquets to Nigerian health workers that can discourage a reasonable proportion of them from overseas job-seeking? Migratory health workers are perhaps ‘lucky’ that their skills are desperately needed by willing and highly functional nations.
Need I remind that the exodus of health care practitioners, especially nurses and medical doctors, to foreign stations occurs even in countries like India that have a relatively strong health care system, thriving medical tourism industry, larger number of trained health workers and a population (1.4 billion) about seven times ours. It is one of such problems that leadership has to confront in some parts of the world and “cannot be solved with a known algorithm”, especially overnight, and particularly because the causes vary across nations. Being a medical doctor previously trained and presently toiling in Nigeria, and notably as a health policy maker, I have examined this Keith Grint type of “wicked problem” as a passenger & crew member in the current ship of health care delivery in Nigeria. Albeit the causes seem multiple, a mindful brain and microscopic eyes are jointly required to decipher that the refusal of powers-that-be to decentralize authority in a populous Nigerian society is the underlying and ultimate source of the embarrassing and escalating trend.
Ultimately, if farmers, mechanics, hair stylists, security men etc. had high demands for their jobs abroad like doctors and nurses, are you still doubtful of their likely intention to take a break from this choking system of government? Maybe the mass exit of these non-health workers would be the new normal in Nigeria in years ahead so long as the epic docility of over 89 million impoverished Nigerians remain a perpetually fertile ground for the insatiable selfishness of the Nigerian political elite profiteering from this overcentralized governance structure.
Take it to the bank – the longer we prolonged the decentralization of the structure of governance in our 206 million-populated country, the higher the number of working (health & non-health) and unemployed Nigerians who would either legally disembark from this malfunctioning vessel or frantically jump ship.
Dr. Adetolu Ademujimi is a medical doctor and policy expert who wrote in from Akure in Nigeria via firstname.lastname@example.org