Foreign subsidies, local health policies

The health sector in Nigeria has been in the news lately, and sadly for the wrong reasons. Last Wednesday, the Punch newspaper reported that “No fewer than 10,296 Nigeria-trained doctors are currently practising in the United Kingdom”, citing the President of the Nigerian Medical Association (NMA), Dr Uche Ojinmah. A week before then, on Wednesday 19th October, Premium Times reported that over 5000 Nigerian doctors have moved to the UK in eight years and that Nigeria now has the third highest number of doctors in that country, after India and Pakistan.

Meanwhile, as a Daily Trust report says just this past weekend, despite claims of shortage of doctors in many hospitals owned by federal and state governments across the country, there is in fact, rising unemployment and underemployment among doctors in the country. The Daily Trust story is particularly galling as it goes beyond the numbers to show how the stakes in the medical labour market are overwhelmingly stacked against younger doctors, the very future of the medical profession and the health sector more generally in Nigeria.

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All of these give us just a bit of an idea about why the health sector in Nigeria is the way it is, where, as the Daily Trust story shows, Nigeria now has a ratio of one doctor to 30,000 Nigerians overall. This is higher still across the northern states, where the ratio jumps to one doctor for 45,000 people, and all in a country that exports doctors annually by the hundreds.

Now, as is our interest here today, what are the policy implications of all these statistical data and qualifying narratives? There are many such implications, but three above all. These stories and narratives illustrate the deep interconnects in the international labour market for certain professions, the strategic dimensions of international migration policy and how countries like Nigeria end up subsidising the health sectors of much richer countries like the U.S, UK, Saudi Arabia and others, simply because they don’t know any better, policy-wise. And all three issues, in fact, go together at once.

First, a doctor trained in Nigeria will acquire knowledge and skills that they can carry anywhere around the world once they deem that conditions for practice are unfavourable at home, or indeed, for any other reasons. Much the same applies to nurses, university professors, engineers, computing and information technology experts, and professionals in a few other sectors. Unfavourable working conditions like low salaries, punishing hours, under-appreciation by society, and a hostile environment for research and general career growth are some of the leading reasons doctors, nurses and other health professionals leave Nigeria, for other countries. Of course, the sheer personal gratification of living and working “abroad”, among many Nigerians including doctors is also a factor that cannot be discounted.  

At the same time, however, immigration policies in rich countries like the UK, U.S, Canada, EU countries, and oil-rich Arab countries, are strategically designed, through points-based visa systems to attract some of the best talents in key sectors from developing or poorer countries. And the reasons behind such strategic visas are entirely self-interested, rather than the much-touted “brain-gain” through the remittances that migrants in rich countries transfer to families and friends back home. In fact, the whole rhetoric of brain-gain, though often supported by quantitative figures in annual monetary transfers, is still a cover for the strategic elements of rich-country immigration policies.

But to understand that, one needs to look at the comparative cost of training doctors and nurses in countries like Nigeria and the UK. In Nigeria, as in all other countries, health policy begins with the training and education of all health professionals, particularly doctors and nurses, all the way down to the point where a patient receives quality care at a hospital or clinic by a doctor so trained. In this sense, then, Nigeria’s health policy is in direct competition with the health policies of other countries, whether we like it or not, and whether we are aware of it or not, since health is one sector where skills can easily move across borders.

Therefore, how and where doctors and nurses are trained, and at what cost, are all important matters for strategic decision-making for every country. more importantly, perhaps, how much doctors and nurses are renumerated, and what other benefits and career satisfaction opportunities are available for a doctor or a nurse here at home are also important matters for strategic and far-sighted policy-making. Otherwise, we risk robbing the local Peter, to pay the foreign Paul.

In Nigeria, tuition fee at all federal universities is free for all degree programs, including MBBS, the degree doctors take. Boarding, in the form of bed-space hostel accommodation, is also heavily subsidised and currently stands at no more than N50,000 per academic session, per bed-space, however over-crowded it maybe. Students cover their own living expenses on campus, and medical students, in particular, must also buy books.

In other words, with about N300,000 a year, a Nigerian medical student will be fine at any federal university. That makes for a total of just about N2million for the entire six years of medical education need to obtain an MBBS degree that can be useful anywhere in the world. And with the exception of a handful of states, especially in the south, this situation holds largely true even in state universities across the country.

But what if the same Nigerian medical student wants to obtain the same MBBS degree at a UK university, say the Norwich Medical School of the University of East Anglia, specifically?

They will be registered as an “international student” and will be liable to pay the “overseas fees”, which currently stands at £35,200 per year or a total of £176,000 over the five years of the MBBS degree programme. In addition, the student will need at least £1000 per month for living expenses, or £60,000 for five years. In short, our Nigerian medical students will need £236,000 or about N120 million to complete the same MBBS degree at the Norwich Medical School but which they would have completed with just around N2 million at Bayero University, Kano. The amount would be much higher in the U.S because the same student will first need to complete a four-year degree before undertaking the medical degree for a further five years, and must pay thousands of dollars in fees and living expenses each year throughout.

 In other words, if there are 10,000 Nigerian-trained doctors in the UK and US combined, then it means Nigeria is SUBSIDISING medical care in both countries to the tune of trillions of naira. In fact, it is precisely to attract these subsidies that governments such as those of the UK and U.S provide friendly visa regimes for doctors and nurses from countries like Nigeria. It is simply cheaper to attract doctors from countries like Nigeria if training them costs thousands of dollars and pounds in public money or student debts.

Now, how should the Nigerian government solve a policy problem like this? That would be a discussion for another day. But in this as in all cases, a problem properly understood is a problem half-solved.