Nigeria: Brain Drain - Beyond Minimum Wage, Give Doctors Welfare Package - Lagos NMA

21 January 2020

As Nigeria battles with brain drain in the health sector with a ratio of one doctor to 6,000 patients, medical doctors have urged the government to look beyond the minimum wage and come up with a proper welfare package to end migration of health professionals abroad.

Speaking at the Good Health Weekly on Vanguard Live the experts maintained that while minimum wage is good, it is not the ultimate now that an estimated eight out of every 10 doctors are contemplating leaving the country for greener pasture and about four leave every month.

The medical doctors, Dr. Saliu Oseni, Lagos State Chairman, Nigerian Medical Association, NMA, a General Surgeon at the Ikorodu General Hospital, Lagos, and Dr. Moruf Abdulsalam, Publicity Secretary, Lagos NMA and a Paediatric Surgeon, at the Lagos State University Teaching Hospital, LASUTH, agreed that with proper welfare package, Nigerian doctors will remain in the country. Excerpts:

We have the internal grading and the external grading. The internal one is so that we have medical personnel moving from the State institutions to more comfortable Federal institutions while the external is when you have either of them leaving the country for greener pasture. The causes are quite enormous.

The main cause is actually around remuneration. Remuneration of the health providers is quite poor compared to their contemporaries all over the world. The condition of service is poor, the environment of service is poor, facilities available to run the services is also poor.

The recent attack on health workers is demoralising and very subsuming for the health practitioner and indeed we have situations where even those that are here are actually encouraging more to leave and the real fear is such that the succession period, the gap between the young ones coming in and the older ones that have been in the system is going to have a very grievous effect, such that by the time the younger ones are coming into service, the older ones are actually putting the younger ones through what they are supposed to know and they are going to have a wide gap and that is why we have been advocating that government should learn to do exit replacement on time. The eventual problem will be that we may end up not having good health delivery because of lack of qualified personnel.

Conditions of service

Government is responsible for the conditions of service and remuneration, but the other truth is that we as citizens have not actually been monitoring our leaders.

The health providers are actually working in a very inconducive environment but because we are trained to care for our people, doctors have taken oath to save lives not to take blame because when you have a dying patient coming in, all you want to do is to see what you can do to save the patient, but by the time you are being accused of murder then it is demoralising.

So the public needs to understand what rights and privileges are. Yes, it is your right to good health but the truth of the matter is the doctor has no absolute control over providing that good health.

Protection of doctors' welfare

We had a health summit where we tried to analyse the causes of the problems we have in health and we have the summary of the findings and we try to work on how to ensure that those things are under control. But the truth of the matter is that, all effort to get the government to do the needful are fruitless. For instance, you have a setting where you have 200 doctors working at mid year it becomes 100 doctors and yet when a year is down the line there is no replacement. The exit replacement has become a problem affecting welfare of our colleagues.

When something goes wrong everybody's head is at stake. So, it makes health providers insecure in their supposed comfort zone. When you are not secure in your comfort zone, it is a problem. Current review of what has been happening shows to us that we have an average of one to two doctors leaving their facilities for greener pasture within six months. We have 27 hospitals in Lagos State, so if one or two doctors leave monthly, we have between 30 and 60 people leaving within six months, and this is real.

More reasons for brain drain

The increasing level of violence is part of it. People are venting anger, and frustration on health workers. With poor facilities on ground in those places,doctors know so much but can only do little because we don't have the tools to work.

The industry we are in is such an emotional one. When people lose their dear ones they tend to be emotional and being emotional, a state of denial you want to vent that anger on someone and the rightly available person that you can vent that anger on are health providers - the doctor or the nurse. But we cannot condone that.

In the National Health Act it is already written that the health care provider may refuse to attend to any individual, who physically or verbally abuses the health provider. So, it is a matter of law. If a patient physically or verbally abuses a doctor, then the doctor will have no choice than to protect himself by telling the person to withdraw.

Doctors are stressed

We have witnessed cases of health care issues developing among doctors, we know that being hypertensive or diabetic is age-related or if you have a family history. Doctors and other health care workers that are affected have not found time because of the schedule of the work to take care of themselves.

We now have increasing mental illnesses among doctors, in fact doctors are now sneaking to go see their psychiatrists because of the stress of work. Doctors who are female can't even do exclusive breastfeeding because of the pressure of work that has caused conflicts in their various homes.

Of recent in LASUTH, because of the shortage of resident doctors, government had to convert services of medical officers to resident doctors without issuing them any letter to start residency. The resident's life is more stressful than that of a medical officer.

Solution and recommendation

The condition of service can only be improved when we have enough manpower because if one doctor does the work of three doctors then you are not likely to give your best. The issue of exit replacement is something that the government must develop realistic policy. If you give me 10 doctors and two leave this month, you should give me one month notice, if they are going to retire they should have informed three months earlier. So I should ask for standby replacement for those people once they leave. The essence of notification is for the system to prepare replacement but what we find is that even when staff tender resignation there is no replacement for two, three months.

So the reality is that when doctors are suspended or sacked, it is their contemporaries that are punished because they suspend the doctor for instance you will only not pay him for the work he has not done but you will not bring a replacement to do his job, so his contemporaries around there will have to make-up for the deficit and that will put a weakness in the system.

If government finds it so easy to terminate and sack a doctor they should be also be quick to replace the appointment. We have a lot of doctors in the country, that are jobless, and are seeking employment. There is no room for the government to give an excuse that they do not have replacement. The truth of the matter is that people make the issue of replacement so difficult, if you are budgeted for 100 doctors and in the middle of the year it is 50 doctors, are you going to return the remaining 50 doctors salary? What we see is when government is trying to save the cost by not replacing then when something goes wrong.

Currently, what we have is a lot of senior officers in service are being made to do the work of a junior officer. Of course that will not bring satisfaction. So, exit replacement system has to be improved, condition of service need to be improved, renumeration has to be look into compared to best practices all over the world.

Government needs to empower the private sector. Most of this developed countries that we talk about, more of the health care is being serviced by private institution where as the reverse is the case here.

In South Africa for instance you won't just go to a public hospital when you have not been to the private hospital. So government should make available such loans for the private individual, so that they also can help improve the condition of service and can help grow the infrastructure. Government can look at the issue of tax relief for doctors.

Effect of minimum wage

We as a medical body are yet to really get a clear picture of what Lagos state government has done as its minimum wage. I will tell you that my salary dropped below what I had even before the minimum wage came on board and Indeed the government declared the bonus at December. But the December salary was below what I had even before minimum wage. So, the first thing is for everyone to be clear about what they call the minimum wage. It is not just enough to come and say you've commenced minimum wage when the effect of minimum wage is not there.

The other part of it is that beyond minimum wage we need welfare package. If I had a good school that my son or children can go to and I don't have to waste money on school and I have a good accommodation that is well catered for, I have a good car that is probably replaced maybe every three, four years and the loan is a soft loan that government is taking care of such loan and all this, why will I want to travel out. So what we've been advocating to government is that they should provide avenue for welfare packages.

The minimum wage is good but I can tell you that if minimum wage is established fully now within six months inflation will catch up, so it is not just about the financial value. The reality is that financial wise, the civil servant salary is dropping irrespective of the fact that we are having managing value increment.

If I am given opportunity for soft loans and government is taking care of such loans, why will I want to travel out? What is greener about pasture? What we have been advocating to government is to provide avenue for welfare package.

Minimum wage is good but I can tell you that if minimum wage is established fully within six months, inflation will catch up with it. It is not just about financial value, in reality, financial wise, civil servants salary is dropping irrespective of the fact that we are having monetary value increment.

So we need a proper welfare package. For instance if the government gives a loan to a staff that will run over 10 years, and he knows and he knows that he already has a house while in service, he will not want to leave, because if he leaves, government government will take back the house.

These are the things you will use to tie them down not that you will insist that they should sign a bond. Sign bond for what?"

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