Mike Ogirima, a professor of Orthopaedic and Trauma Surgery, is the President of the Nigerian Medical Association, NMA, and President of Nigeria Orthopaedic Association. In this interview he speaks on critical issues in Nigeria’s health sector and doctors’ perspective of the way forward.
A major problem facing the medical sector in Nigeria is brain drain where most of the doctors after completion of study leave the country for greener pastures abroad. What is NMA doing to curtail this, as most hospitals complain of shortage of medical personnel?
The number one reason why doctors and other health workers run away from the country is the working environment. When you are trained as a specialist in your field and you are left empty handed, there will be frustration. No equipment to work with. There are lots of doctors now roaming the street and there is general embargo on employment of health workers. This is a country that cannot boast of enough number of health workers to manage our system.
For example, the doctors on register in Nigeria are about 35,000. That is doctors registered under the Medical and Dental Council of Nigeria. In total it is 87,000, but practically maybe out of this figure, 5,000 are in the UK, another 10,000 in Saudi Arabia or United States. Then in the Far East, we see Nigerian doctors.
We don’t have enough doctors to patients ratio. It is not enough, yet the ones we are training are not being employed as at when due.
Even when they are employed, they don’t have up to date facilities to work. We all know the situation of our public hospitals.
These are the salient reasons why you have doctors looking for greener pastures.
Apart from that, though the government tried to favour doctors’ entry into the salary scheme. In those days, a graduate will enter at Grade Level 8, while a doctor will enter at grade level 10 or 12, because there was no 11. In as much as there is a structure like that on ground, it is not enough package to turn back the tide of brain drain.
The only thing one as an association can do is to plead with the government to rehabilitate our hospitals. Make the working environment of a doctor conducive. If you enter any doctor’s office in any of these hospitals, you will be shocked by what you see. You will enter some public hospitals where you don’t even have wash hand basin. It could be as bad as that, where a doctor has to share toilet facilities with so many other people, they have to leave the office for conveniences. That’s how the working environment is.
In places where you have cases of surgery, there is a waiting time. You have to wait until it gets to your turn. You pray it’s not an ailment that will kill the person, but that is the reality on ground.
Government should try and train more, make sure our training institutions are up to date in terms of facilities to train. Make sure the ones you train are engaged and reabsorbed back into the system.
Yes, some fraction will still find a way of looking for greener pastures but if you keep on training, going by global standard I think the brain drain will be there but we will have enough to take care of the population.
What is the NMA doing on the issue of quackery How many have been arrested and what has been done with them?
NMA is not a law enforcement agency but just a professional body that advocates and would cry foul if we find quacks.
But as an association, anytime we have a case, we report to the law enforcement agents. And we also advise the law enforcement agents that when they catch a quack, they should not label that quack a doctor until they have gone to MDCN to establish whether that person has a licence from MDCN.
We have numbers, I know my file number with MDCN. That is why NMA has a strategic plan which is going to bring a lot of innovations to checkmate a lot of excesses. Every doctor will have his own stamp just like the engineer.
We are doing a lot, in as much that there is internal discipline among ourselves, we are going to go out fully. I am sure that in the last three months you heard that NMA came heavily on some members. As long as you register with MDCN as a doctor in this country, you are automatically a member of NMA and if you are not obeying our constitution, we will discipline you.
So we will start with house cleaning, then we will extend it outside. Slowly we will get there, quacks will be identified and prosecuted.
It has been noted that consultants refer patients from government hospitals to their own private hospitals.
It is an abuse of the system. The MDCN allows a consultant to own a clinic. What we mean by clinic is a small place where you can see a patient and recommend treatment plan.
MDCN code of ethics states that if you are working in a public hospital, you cannot manage in-patients in your facility. So you cannot run a hospital.
But the mentality of Nigerians, the people are not knowledgeable to know the difference between a clinic and a hospital. I will support a situation where the government will come out clearly and make directive that those employed under the public hospitals (government services) are not allowed to have a clinic. Then we will work by the rules to curtail excesses.
But I know that there is a law in this country that any civil servant cannot practice outside the working hours except if you have a farm. How many people are obeying that law? You have surveyors, pharmacists, lawyers in the government that have external practices. The government should come out clearly to bring out a law that will ban extra-curricular practice or private practice in all the professions.
Why is there an embargo on employment when the number of doctors in the country is a far cry to what is needed, especially in terms of doctors patients ratio? Ogun State for example lamented having only 150 doctors in the public hospitals.
Ask the government. I am not the government, NMA is not the government. But we have also observed and we have been shouting. In my state, I met a doctor in my village of about 200,000 people and he is alone in that general hospital.
I asked him how he has time for his family and when is his weekend, he said he has no weekend. So it’s not only in Ogun State, it is all over the country. The worst hit is the northern part of the country.
There are so many general hospitals without doctors. That is the point we are making; that how can we be in the midst of plenty and we are suffering? There are doctors looking for jobs. Maybe it is the recession. I pray this recession will end fast so that the government should employ more doctors, more nurses, because you go to the hospital in a 40 bedded ward, only one nurse is on duty for shift.
Our doctors are dying, health workers are dying because of fatigue. They are collapsing. The last time we had two episodes in Zaria, a nurse collapsed, a doctor collapsed, they died because of the pressure of work.
So we are using this opportunity to call on government that they must employ health workers to fill up the existing vacancies. A lot of vacancies exist in the hospitals.
Resident doctors have always gone on and off strikes. What is your opinion on this? And what is the association doing about cases of doctors who have passed their primary and have no placement for residency programme until it lapses?
Ogirima – Agreements were reached between the government and the residents, between the government and professional bodies. In 2014, doctors went on strike for 52 days. The reasons they went on strike then are the same reasons they still go on strike. The last time they went on warning strike and they are back to their duty post. What is happening in their January salary is that there is a shortfall of about 30 to 50 per cent. We are asking the government again, why? And I am seizing this opportunity to ask the government, particularly the Minister of Finance to release that shortfall within one week. Other hospital workers have collected their salary full, 100 per cent. But only doctors, resident doctors particularly have been subjected to only 50 per cent or 70 per cent of their salary.
Is it a punishment because they went on warning strike? I am being forced to believe it is a deliberate attempt. Those are the reasons why a doctor would abandon his patients. If a doctor is hungry and nobody to feed the doctor. I am sure if a doctor and any other professional go to the market to buy any item, for the fact that you introduce yourself as a doctor they will give those products at a very high price.’
In those days, the populace fight for the doctors’ right and that is why we are telling everybody the reasons now. What crime have they committed? They have done their job 100 per cent but they were not paid 100 per cent.
But if they abscond from duty, there will be no work, no pay in the same system. That is injustice. So while I will appeal to my colleagues not to go on strike, they should tell the public the reasons why they go on strike and let the public judge and be the advocate of their plight.
I as an individual, I don’t like going on strike and at my stage, I will never encourage strike from any health worker. With the National Health Act, it is illegal for any health worker to go on strike. As a consultant, I can never go on strike because the law states that as a consultant before you go on strike, look for another consultant to handover the patients to and it is not possible.
For those who can’t get in for residency, it is still the embargo. The residency programme is a temporary stage in the doctor’s career. As you finish, another set of residents are employed. But here we have an embargo. In fact, in most teaching hospitals now, the top cadre of residents of residency programme is congested. People who are already waiting to exit, they don’t have the junior residents as back up to replace the ones that are been trained.
I think it is the embargo or recession, but we are begging the government to please make sure that the specialist cadre in the health sector is not depleted. They must sustain the residency training programme because if you don’t have primaries you cannot be engaged in the residency programme. A lot of doctors are having primaries, yet they are looking for placement.
As an orthopaedic surgeon, you deal with images most of the time. But looking at Nigeria where we have few hospitals with imaging equipment and the private ones either expensive for patients or not functional, how have you been coping?
As an orthopaedic surgeon, I started without a tray and I wasn’t frustrated because that was my call. I have a passion for orthopaedics. But I had POP (Plaster of Paris) to apply. So we started from non-operative treatment and gradually with my personal efforts I got a tray and I was using it. (Surgeons tray contains all the gadgets they use for surgery).
The medical imaging is a dynamic and revolving field. Whatever x-ray you use today, in the next two years it is obsolete. You need to keep updating. Yes, a lot of private hospitals are giving the government competition now in that respect. If you look around, private hospitals are coming up, doctors are forming partnership, group practice.
Why are the government hospitals not measuring up with these gadgets? The reason is simple. Governments talk about subsidy in medical care, government will buy an X-ray equipment of, let’s say $100,000, the same X-ray equipment will be bought by a private hospital for $900,000. But the private hospital will have a pricing system that will make the private hospital factor in the price of changing the machine in some few years and also make profit. There is usually sustainable costing of service in the private hospitals.
This is quite the opposite in government hospitals where tests are usually subsidised and done at cheaper rate. They tend to overwork the machine and when it breaks down, they will be going to the Ministry of Health or Ministry of Finance to ask for money to repair or buy a new machine. That is a bad system.
Another reason people would go abroad for medical care is because you have a building called teaching hospital with non- functional machines because they have broken down and they keep telling people to come back in weeks.
If government has instituted maintenance culture according to our services, that would not be happening. So that you will have a plan maintaining the machine, have enough money to buy a backup. Most MRI (Magnetic Resonance Image) machines we have are just single unit in all teaching hospitals. If they break down, it takes another one year to start budgeting and get a spare part. This is not how to run the medical business.
Yes, some have subsidiary, but is the government providing the deficit in the charge to the operating hospital to maintain the machine? Yet hospital management cannot exceed certain limit in the costing of services to maintain the hospital.
Can you say how much Nigeria has lost to medical tourism?
There is no study that will harness all the losses we are having for medical tourism abroad. But there was an estimate about three years ago, on a conservative estimate, Nigeria spends about $2 billion looking for health care outside the country.
India takes about 80 per cent of that fund. That is a conservative estimate. The good thing about the economic recession is that there is no money again for those patronising the hospitals outside so they are forced to look inward and patronise the good hospitals around us.
What is your view on the 2017 proposed health budget?
I am not comfortable with that figure. The money budgeted is a far cry from the15 per cent agreed for health sector by African countries. I don’t think it will solve a lot of problems, but I am hoping and trusting that the National Assembly will pass a budget that will provide extra funds for the health sector, maybe through the operationalisation of that National Health Act.
At least one per cent of the Consolidated Revenue should be set aside for the health sector. If they do that, there will be more funds in the health sector.