Nigeria considers law that would prevent doctors from leaving for five years after training
BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p1234 (Published 30 May 2023) Cite this as: BMJ 2023;381:p1234
Doctors’ groups in Nigeria have condemned a bill before Congress that would deny newly qualified doctors a full Nigerian medical licence until they have worked for five years in the country.
The country’s health system is under pressure from an accelerating brain drain that saw nearly 4% of its registered doctors depart last year—almost half of them to the UK.
Educated Nigerians have historically emigrated in large numbers, but the country’s recent economic troubles and growing insecurity have given new impetus to the trend now commonly known as “japa,” a Yoruba word for fleeing or moving to greener pastures. The proportion of Nigerians willing to relocate abroad rose from 32% in 2019 to 73% in 2021, according to one survey.1 In 2022, the number of Nigerians granted work visas in the UK doubled to 34 133 people, of whom 932 were doctors. The General Medical Council is aware of 7875 Nigerian doctors currently practising in the UK.
Last October, the Nigerian Medical Association (NMA) said that 50 doctors a week were moving overseas. The National Association of Regional Doctors said that 60% of its polled members planned to do the same.
Local population “cheated”
The number of doctors serving Nigeria’s population of 215 million is the subject of heated political debate, but most estimates range between 24 000 and 53 000. The lower figure was cited by Ganiyu Johnson, a lawmaker from the ruling All Progressives Congress party, in introducing his bill that would require the Medical and Dental Council of Nigeria to delay granting full licences until medical graduates had worked five years in the country. Some rural regions had one doctor per 45 000 people, he told Congress.
Nigeria is effectively subsidising the healthcare of richer countries, Johnson argued. “This is a clear cheat of the Nigerian people,” he said. Citing medical tuition costs of up to £100 000 in Western countries, Johnson said that “in Nigeria, the cost of studying medicine in public institutions ranges from 40,000 to 150,000 naira (£70-£250). Medical and dental education in Nigeria is seriously subsidised.”
He added, “With the latest mass relocation of trained doctors in Nigeria to the UK the doctor-patient ratio might become worse, leading to an overstretch. This could push even more doctors to join their colleagues in a more favourable working environment, resulting in further losses to Nigeria.”
The bill passed its second reading last month, but its passage this year is no certainty. The legislative calendar is tight, and the government of President Bola Ahmed Tinubu, sworn in for a second term this week, is likely to prioritise other business.
Medical brain drain
The proposed law faces fierce opposition from doctors’ groups. Uche Rowland Ojinmah, NMA president, told Nigeria’s Sun newspaper that the government had finally awoken to the problem of medical brain drain, but the proposed law “cannot solve the problem. The question is why the doctors are leaving, why are they going for greener pastures? They should make the pastures at home green.”
The president of the Nigerian Association of Resident Doctors, Emeka Innocent Orji, told Nigeria’s Guardian newspaper that the government’s concern was understandable but the bill was “laughable” and based on faulty information. “We need to improve remuneration, the working environment, security, and incentives,” he said. “If you give a doctor a mortgage, you have tied him or her down. If you give him a car loan, you have tied him or her down.”
The Nigerian president of the World Medical Association, Osahon Enabulele, also weighed in on the bill, calling it “retrogressive” and “likely to generate a worse ailment and crisis.”
The World Health Organization counts Nigeria among 53 mostly African countries that are on its “red list” for medical brain drain, and the UK government returned Nigeria to its own red list last month. But while this prevents active recruitment campaigns by foreigners in the listed countries, it does nothing to prevent doctors leaving of their own accord.
Rwanda requires doctors who receive a public scholarship to sign “retention contracts” with the health ministry, in which GPs commit to two years’ service in the public health system, and specialists to five. The proportion of doctors to population in Rwanda has climbed since the policy was implemented, according to official figures. But the proposed Nigerian law, Ojinmah says, fails to distinguish graduates of public universities from those who paid their own way at private institutions.
While the UK is by far the leading recruiter of Nigerian medical workers, Nigeria is not the leading source of foreign medical workers in the UK. Nigerians accounted for 12% of medical work visas given by the UK last year, while Zimbabweans accounted for 18% and Indians for 33%.