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The real costs and solutions for the migration of Nigerian doctors 05 Aug 2020

In July, the Nigeria Immigration Service (NIS) prevented 58 Nigerian doctors from travelling to the United Kingdom apparently to join the UK’s National Health Service (NHS). The reason the NIS gave for refusing to allow the doctors to depart on the chartered flight that came from London was that 56 of the doctors didn't have valid visas.
    
Public reactions to news reports on the development were divided. One group of people essentially defended the government’s action, stating that Nigerian doctors ‘owe’ their services to the country. They alluded to the subsidised medical education provided to doctors by the government. They also said it was ill-advised for doctors to leave the country during the COVID-19 pandemic. The second group argued that the government’s action was in violation of the doctors’ individual rights to emigrate and seek prosperity elsewhere at any time.   

Medical brain drain is an ongoing challenge in Nigeria. NOI Polls conducted a survey in 2017, showing that a staggering 88 per cent of doctors were actively considering work opportunities abroad. But Nigeria’s case is not isolated in Africa. Half of Egypt’s registered doctors have left the country. Over 10,000 doctors emigrated between 2016 and 2019, according to the country’s medical association.

But there are nuances to the debate about the emigration of doctors that were not provided in the public discourse that ensued following the NIS’s action. It’s not simply a binary issue of personal freedom and national interest. Doctors obviously have the right to legally migrate to wherever they like, within reason. And there should be no attempt to curtail their freedoms.

However, the decision to emigrate has huge consequences for a country already facing a dire crisis in its health system. With one of the lowest doctor-to-population ratios in the world at one doctor for every 5,000 people, losing more doctors to other countries would further worsen healthcare delivery in Nigeria.

According to a 2020 study in the British Medical Journal (BMJ), titled "The Impact of Physician Migration on Mortality in Low and Middle-Income Countries: An Economic Modelling Study," there is an estimated shortage of 2.8 million physicians worldwide. The report says developing countries suffer the greatest burden of medical brain drain.

As an example, the report says the excess mortality cost of Nigerian doctors’ emigration to rich countries is $3.1 billion annually. This is simply the cost associated with the loss of lives, including many mothers and children that could otherwise have been saved, had Nigeria-trained doctors not migrated to practice medicine elsewhere.   

Task-shifting primary care to non-physicians has its limitations; it is not a framework for replacing doctors. And at any rate, Nigerian nurses are migrating, too. Nigerian immigrants who are registered nurses in the United States are only outnumbered by Indian and Filipino nurses, according to a report by World Education News and Reviews (WENR).

Then, the argument that Nigerian doctors owe service to the country is also not cut and dried. Generally, doctors in Nigeria are poorly remunerated. Even their meagre salaries sometimes are unpaid for months. They lack adequate medical equipment. Residency training is often delayed due to limited slots. Expecting doctors to endure such conditions when better opportunities are beckoning is unrealistic. Furthermore, there are many Nigerian graduates in other academic fields who also receive subsidised education and scholarships to study in public universities. Few people have suggested they have a moral obligation to remain in the country.

To reconcile the two arguments on doctors’ freedom of movement and the question of moral obligation, a third position should be considered. Developed countries who hire doctors from emerging countries to address their shortage of doctors are unfairly extracting resources from the rest of the world. The UK, for instance, has 2.8 doctors per 1,000 people. While this itself is a low doctor-to-population ratio, compared with the average in other wealthy countries in Europe, it has continued to hire doctors from Nigeria, a country with an acute shortage of doctors.  

In effect, developed countries that fail to invest in training enough doctors locally are shifting the costs of training the human capital for their health systems to poor countries. This is akin to the capital flight, whereby the Global Financial Integrity says money and tax revenue from poor countries are diverted to rich countries, thereby depriving developing countries of much-needed resources. While part of the capital flight – and certainly the recruitment of doctors from developing countries – is completely legal; there are serious ethical concerns that can be raised. It is disingenuous to send development aid for health when your own health system thrives on recruiting scarce personnel from the same countries.

On this note, I recommend a better system that preserves the individual freedoms of Nigerian doctors, while accounting for the costs of subsidised medical education in the country. To retain Nigerian doctors and avoid subsidising healthcare for developed countries, multiple measures could be taken. For example, medical students could be offered a choice of state-subsidised training or market-rate education. Doctors who opt for subsidies would be required to work in Nigeria for a predefined period of time post-qualification or repay the subsidies. Requiring doctors to work locally for a couple of years is not unprecedented. The UK considered such a scheme in 2016.

However, one must concede that it would be unfair to single out doctors to repay education subsidies. Therefore, to make the compulsory work scheme more attractive, it can be combined with another option, which is to guarantee doctors employment and inflation-adjusted living salaries for a few years post-graduation on the condition that they stay in Nigeria. Apart from providing better remuneration, their work environment and career prospects should also be improved. Combining both measures may be even more effective. To quote the poet, Warsan Shire, “No one leaves home, unless home is the mouth of a shark.”

Nigeria should align with other countries that are facing high emigration of doctors to negotiate fair compensation with destination countries that persistently rely on foreign-trained doctors. In the UK, a conversation has already started about how poor countries are subsidising Britain’s healthcare system and should be compensated. About 19 per cent of doctors in the NHS are non-European Union nationals, according to the Office of National Statistics (ONS). The growing awareness by destination countries provides a context for discussing a compensation framework that can be both financial and technical assistance.

A 2011 study in the BMJ quantifies the financial cost of doctors emigrating from sub-Saharan Africa. The report estimates that the Nigerian government’s estimated loss of returns from investment for Nigerian doctors currently working abroad was $654 million. This amount does not include medical tuition – it is only the implicit subsidies that the government provides.

Nigeria has limited tools to retain more doctors and upgrade its health system. The federal government's healthcare budget for 2020 is just $69.6 million (N26.5 billion), a fraction of what it has lost to the migration of doctors to other climes. Nevertheless, imagine a future where Nigerian doctors benefit from more funds for training, salary, and technical exposure, as a result of strategic partnerships with countries that require foreign doctors. Emigration of doctors would not be so much of a concern, as long as the local system is well served.