The President, Medical and Dental Consultants Association of Nigeria, Dr Victor Makanjuola, shares with TUNDE AJAJA his thoughts on the brain drain of consultants, the solutions and the issues of mental health in the country
Many Nigerians are familiar with the mass exodus of doctors from Nigeria but not much was heard about consultants leaving the country until you mentioned it recently, how serious is it?
It’s pretty bad. We conducted a survey in our 82 chapters in March, and out of the 37 that responded, 253 consultants from different specialties have left the country for greener pastures in the last two years. The remaining chapters have not sent in their response for some reasons. We are estimating that if 90 to 100 per cent of all the chapters respond, over 500 consultants might have left the country in two years. That’s our rough estimate and that is a major disaster for the country. However, there may be consultants working in the private sector and are not members of our association. Our members are those working in government health institutions, both state and federal. Judging from the length of time it takes to train a consultant – six years in medical school, one year for housemanship and one year for the National Youth Service Corps programme – that makes eight years. Then, the minimum number of years for residency training is six years. For some specialties, it takes longer and could be up to 10 years. That’s an average of about 14 years of training lost to other countries. So, it’s a big loss to Nigeria, and it’s even more so because consultants lead most of the health services. It may result in closing down or scaling down of some services in those places the consultants left from. It’s a scary and unpleasant picture.
The gradual depletion of personnel presents the picture of a looming crisis in the health sector if nothing is done about it, has your association informed the government of this costly trend?
Our first survey was conducted in January and when we sounded the alarm, we reached out to the Office of the Head of the Civil Service of the Federation, and the Permanent Secretary was directed to meet with us. The Ministry of Health was then directed to set up an inter-ministerial committee but that line of discussion went cold for months. Eventually, the committee was inaugurated last week Wednesday (September 14). It seems the government has really woken up to the import of the information we gave them at that time. The committee has been asked to produce a report within four weeks.
Nigeria has an estimated population of 200 million, what is the current shortage of consultants like?
We have about 5,000 consultants currently. We have honorary and hospital consultants; the honorary consultants are about 3,000 and the hospital consultants are about 2,000. But even at 5,000 to 200 million people, it’s still a far cry from the ideal. When it comes to the ratio of doctors to the population, the desirable figure is about one to 600, according to the World Health Organisation. But Nigeria has about one doctor per 5,000 persons. For specialists, a 200 million population to 5,000 consultants is around one consultant to about 40,000 people. It is grossly inadequate.
Could you share with us the sufficiency of consultants per specialisation?
I don’t have that figure here. However, being a psychiatrist, I can tell you that we have about 200 psychiatrists practising in the country. If you juxtapose that with 200 million people, that gives a ratio of one consultant to one million people. We sometimes joke among ourselves that we are so special that we are one in a million. We produce many psychiatrists but most of them are now outside the country. Some other specialties have more consultants; paediatricians are more than 200 and internal medicine physicians are more, but there are some that are possibly fewer than us, like anaesthesiologists. Neurosurgeons are also very few.
There was a report a few weeks ago that millions of Nigerians have mental health issues, could the shortage of consultant psychiatrists have worsened that prevalence and what are the other enablers?
Inadequate professionals in the mental health field can worsen the figure, but there are other factors. Lack of education about mental health is a major enabler; people don’t know what constitutes mental health issues and they assume that only the person who has stripped themselves naked or shouting and destroying things is the one with mental health challenges. There are several mental health conditions that do not include being destructive, hearing voices or the drama that people tend to portray as a mental health issue. We call that one psychosis and they occur in just about one per cent of the population. But there are some other mental issues that are commoner that people are not aware of.
Can you explain that?
We have issues like depression, anxiety disorder, social anxiety and generalised anxiety. Many of these anxiety disorders are quite common. They may occur in up to 30 per cent of the population. So, the lack of mental health education is a major enabler of issues escalating to become the drama that we see outside. Addiction is also a major mental health issue; like drug and alcohol addiction. So, there are so many other conditions other than the dramatic ones. Also, a country that does not provide social safety net risks having high mental health issues among its people. People can become hungry or homeless when they become unemployed and the stress can be too much for them. There could be mental health consequences for that, but if there is a social safety net, such that when you lose your job, you earn some unemployment benefits until you are able to get another job, that loss of job will not be as catastrophic as it would have been. Poor housing conditions are also a factor. Also, the lack of housing is a major enabler of mental health challenges. When all these factors come together, the number of persons with mental health challenges will definitely go up. Therefore, not having enough professionals would mean that a lot of people will not receive treatment even though their illness is obvious to people around them. They can end up with quacks or traditional healers or all sorts of people.
Many people believe that when a mental health issue becomes dramatic, it has some spiritual dimensions, is that level of mental health issue fully scientific or some are truly spiritual?
As far as we are concerned, there is a basis in science for every form of psychosis that people develop. We don’t believe the cause is spiritual. Of course, when people experience what they cannot explain, by default they ascribe it to God or the devil. That’s why our people tend to think it is spiritual. When you also don’t have access to treatment, it’s easier to assume that it’s spiritual. So, they take the person to a church or a traditional healer, who will offer some care. That is why that notion is being perpetuated. The moment we have the adequate number of specialists and treatment facilities, the notion that it is spiritual will begin to reduce. It’s not unique to us as Nigerians or Africans. In the dark ages in Europe, they also ascribed all mental illnesses to spiritual forces. But the moment science started coming up and the medications became common, the notion that it was spiritual was no more in Europe and America. The biological basis of the illness is what they talk about now.
Nigerians are a religious people, do you think a time will come when they will see mental health issues as a medical condition and not a form of affliction?
We will get there when we also have enough facilities and access. In fact, access to treatment is the most important thing, but we are grossly understaffed now. Less than 10 per cent of the people with psychosis or any form of psychiatric illness get to see a specialist, partly because they do not have the money. Also, they may not have the knowledge that this could be taken care of in a hospital. That was why I said lack of education is a major factor. But if right from the primary school people were taught about depression and anxiety the same way we teach them about HIV/AIDS and tuberculosis, they know that if it happens, doctors can take care of it and they will go to the hospital if they see the symptoms. If we can provide more access and people don’t have to spend out of pocket, that will help a lot of people.
Does it mean there is no level of psychosis, which people call madness, that cannot be treated by science?
There is no type of psychosis that cannot be treated medically. However, not every medical condition that doctors treat gets solved. That is the nature of orthodox medicine, because not everybody responds the same way to treatment. Also, the severity differs.
What then do you make of people seeking miracles in worship centres?
Sometimes, people seek miracles out of not having options. It is not that when you go for these miracles, some psychosis cannot get better. They will, because some of those conditions are actually self-limiting. Even without any treatment, some of them will improve. That is why you may see a man on the street for about six months and the seventh month you may not see him again. The person may suddenly become aware of himself, move away from the street and try to start a new life somewhere else. So, when you take someone to a prayer house for one year, that is enough time for most psychosis to get better. The tendency is to believe that it was the prayers that made the person better, but it was not. It is because you have provided some care, you were feeding the person and there was some occupational therapy by engaging them in some work. The illness tends to go down by itself after some time. One cannot underestimate the service rendered by the people taking care of mentally ill persons. There are actually more mentally ill persons seeking care from those places than from hospitals.
Two, even if you do a large sensitisation now, the hospitals cannot take everybody. Even for the ones who go to the hospital, there is not enough bed space for them. Sometimes, people wait for weeks before their relatives can get a space. So, those people would still be relevant when it comes to care, but they just need to get the right orientation about the illness, not thinking that excessive prayer and fasting will make the person better. No. You can pray for the person, which is good as it can be helpful, at least it’s not harmful, but what is harmful is when they chain them and beat them. Some say it’s a way of trying to beat the illness out of them. That is one of the harmful, unwholesome practices that we frown at. We don’t condemn the fact that people go to spiritual houses; it’s what is available that people go for. But, we don’t believe it’s an affliction or a curse. No, it’s an illness that occurs everywhere in the world, but some other parts of the world have good healthcare systems that can take care of anyone with mental health challenges.
One of your colleagues, who is the President of the Association of Psychiatrists in Nigeria, Prof Taiwo Obindo, said a few weeks ago that about 60 million Nigerians suffer from mental illnesses. That’s a huge figure, is that the true reflection of things?
When we use such a figure, we are not talking about the person stripping themselves naked alone. That is just about one per cent of any population. But when you put all mental disorders together and you look at the global estimate that at least one out of four individuals will develop a mental health challenge in the course of their lifetime, you see that the 60 million is not outrageous. That’s about 25 per cent (of the country’s population). If you multiply that by four, it gives you about 240 million people. Nigeria’s population varies, so he was talking about 25 per cent of the estimated population. When you are doing an hypothesis, you look at the upper limit of the figure, not the lower limit. So, I agree with that figure, and this explanation is the rationale behind it.
With the varieties of challenges in the country, how can people manage their mental health without sliding into mental illness?
It is important for people to cut their coats according to their clothes. They should also set realistic goals. Unmet goals can lead to mental health consequences. But if your goals are realistic and you give reasonable timelines, you won’t have any problem. People should also have a realistic expectation of things not going according to plans sometimes. We have this magical way of thinking that we will achieve everything in a certain year, but the reasonable thing is that you may achieve some and not achieve others. If you set realistic expectations, which include expectations that unfortunate things may happen, when those things happen, they won’t break you. Some Nigerians say, ‘It’s not my portion’, and what they say it is not their portion is a randomly occurring event, like losing a loved one, family friend or a friend. Nobody prays that it happens to them, but you should have a reasonable expectation that it may happen. If it does, you won’t have a sense of catastrophe that it is over. That is important because our prayer point is that all things will be perfect for us. It’s good to pray that way, but at the back of your mind, know that life is not perfect; some things you don’t like may happen.
However, you should be optimistic, not thinking about the worst of every situation. Some people wake up and say, ‘Ha! Nigeria is messed up, everything will collapse’. But Nigeria has never collapsed even though people have always said it. Nigeria is still standing, and if you even look at things more rationally, Nigeria is still developing. There are things that are present now that were not there 20 years ago. So, despite the problems, we are moving ahead, but someone who is pessimistic will see only gloom and doom, and such persons are more prone to develop mental health issues. A positive mindset about your environment, yourself and chances of getting on in life is very important for mental health in this difficult time. You also need to do exercise; it helps to build resilience, not only for the body but also for the mind, because some helpful chemicals are released during exercise.
You advocated that the retirement age of consultants should be increased from 60 to 70 years. Some people would see it as a way for consultants to perpetuate themselves in the system but you said it’s for the benefit of the system. Can you expatiate on that?
It will be a good system if we adjust our retirement age according to needs. The retirement age in the United Kingdom is not fixed. In fact, it’s as if they review it almost every year or every two years. Sometime ago, it was 62 but now it’s about 67. There are so many things to factor in to determine the retirement age. The major problem we have now is that many people are going out and most of them are the young ones. In fact, a survey we conducted in the MDCAN showed that 89 per cent of the people who were going out were people who had spent less than five years as consultants. They qualified recently but they don’t want to stay. So, the people who are older are less likely to travel out and we need them to train more doctors. When these young ones leave, there is a huge gap. If you allow people to retire immediately they clock 60, there will be no one to train the new intakes in the residency programme. It’s on a needs basis that we are making this advocacy, not just on a whim. Ideally, it won’t be a blanket adjustment. There will be a caveat that you have to remain productive and fit. These are existing conditions already. Even if you are less than 60 and you are not physically or medically fit, such persons are retired on medical basis. So, when we say people should stay up to 70, it’s for those who are still productive and medically fit to continue rendering service. We understand that there are concerns that if these people stay on, there will be no space for new people to come, but now those new people are not even staying in the country.
How do you plan to push this through because it has to do with the constitution?
Yes, there are many obstacles to its actualisation because the retirement age in Nigeria is a constitutional matter and a matter for the National Council on Establishment. It has to go through that process. For something that is urgent, you can’t take that decision as quickly as possible. However, we are engaging with the Heads of Service at the national and state levels, who are the ones who constitute the National Council on Establishment. We have visited many of them and explained the logic behind our request to them and quite a number of them seem to understand why we are making that request now. It is our hope that when the matter goes back to the council, it will be given a favourable look and approval to take us through this period. If the system has a responsive retirement age, there will be no problem at all; you will simply just increase the retirement age. If in three to four years the need is no longer there, you can always revert to what is necessary. Now, we just have a blanket rule that everybody should retire at this age, which is not a scientific way of determining the retirement age.
The National Postgraduate Medical College of Nigeria in its guidelines provides for four resident doctors to be under one consultant. Doctors used to have difficulty with placement because the accredited health institutions don’t always take their full quota. What’s the situation now?
The National Association of Resident Doctors estimated that about 2,000 of its members have left the country in the last two years. So, you notice that they were not even taking up to four residents per consultant before. Now, when health institutions advertise for doctors for residency, they don’t even get enough applications for those positions anymore because of brain drain. Even when they try to bring in everybody that is qualified and they ask the applicants to pick up their employment letters, some refuse to pick up those letters. That is because between the interview and the time to pick up the employment letters, some would have left the country. So, we have employment letters waiting for pick-up. So, that ratio of four to one, which is good, is not being met, even when adverts come up for employment because of brain drain.
You recently spoke about medical entrepreneurship as a goldmine that has yet to be substantially tapped by stakeholders, but there are people who believe it can create conflict of interest. Can you speak more on this?
There are two parts to it; I visited a medical entrepreneur on Wednesday and I saw that model play out. Employment can be provided for many of the doctors leaving the country. The hospital I visited has about 19 or more consultants, so we are encouraging entrepreneurship in that sense; that you can provide even more employment for doctors, medical officers, residents and consultants within the private sector if we do things right. Secondly, anyone who thinks the remaining consultants and residents will stay in this country and do 8am to 4pm government work and go back home and not do any private practice to earn a salary that has been devalued by about 300 per cent because of the exchange rate is living in a fool’s paradise. Decades ago when there was the first wave of brain drain in Nigeria, one of the ways General Ibrahim Babangida was able to retain the few people who stayed back to train us was to put a caveat that doctors and professionals in general could moonlight – do private practice after their official government hours. Mainly, that caveat was for doctors, but of course when you say professionals, it meant lawyers, accountants and other professionals can finish their work and do some private practice. What we are advocating is that our members, who choose to stay, can augment their income outside their official working hours by engaging in what the government allows, and that in our own statute is that you can run a clinic and do procedures in a private hospital, but you cannot own a hospital where you will admit patients. That is because when you admit patients, you can be called anytime and sometimes it can be when you are in the government hospital. There is also telemedicine now, which is video consultation, which you can do in your spare time to augment your income. Those are the two parts of entrepreneurship we are promoting. If some of the consultants I saw at the private hospital I visited on Wednesday were not at that facility, they could have migrated to another country. That is also because government hospitals are not employing as fast as they should.
How bad is the vacancy that we have now?
We have so many vacancies now, but there is a bureaucracy of employment, which can take about one year or two years. That is a problem. So, what we propose is not something that will conflict with their contract with any government hospital. We advocate that any chief medical director that has a staff member that is violating his terms of engagement in the hospital should be dealt with appropriately.
Your association seems to be opposed to the Teaching Hospital Act Amendment Bill, but some other professionals in the sector like the Nigerian Union of Allied Health Professionals and Association of Hospital and Administrative Pharmacists of Nigeria support it. What do you have against the amendment?
There were some crises in the past and the amendment being proposed now is like asking us to go back to that period of crisis. When the teaching hospitals started, they were under the universities and in running the hospitals, they were under what was called house governors, who were supposed to be retired military men. So, plainly they were initially under administrators, not doctors. Of course, there could be the head of clinical service, who would be a doctor, but decision-making was completely by the administrator. Over time, the conflict arising from the administrator’s decision-making became obvious when resources became scarce. When the hospitals started, resources were there and it was only the University College Hospital, Ibadan, in the whole of West Africa, so the health budget was between it and some smaller health posts. The resources were there when the administrators were running it, but at some point in the 1980s, the resources dwindled and it was still the administrators in charge. When it came to prioritising when you have small resources, the administrator would prioritise things that would make the hospital run at a profit, rather than things that would make it meet its mandate of training, research and service. The doctors in the system had to be fighting for basic things and so there was a major crisis in the teaching hospitals. It was General Olusegun Obasanjo, who said because of the persistent agitation by doctors and the fact that the administrators were not able to solve the problem of the teaching hospitals, whoever was the dean or provost of the college of medicine in the university should also be the head of the hospital. That was done for a few years with good results. And that was what led to the enactment of the 1985 Act by General Muhammadu Buhari’s regime that there was too much responsibility for one person to be the dean or provost as well as the head of the hospital.
What solution worked?
They decided to create another position – somebody with an equal qualification with the dean/provost of the college of medicine to be in charge of the hospital. They felt the person must also be in a capacity to train medical students, which was what teaching hospitals were set up for. That was how the Teaching Hospital Act came up and those clauses were there, that the person must be a medically qualified person and must have specialist training, among other provisions. It was also to make sure that the CMD was not inferior to the provost of the college of medicine. It also maintained that doctors are the head of the hospitals to balance that issue of training, service delivery and research, which is their core competence, compared to that of the administrator, who just wanted the hospitals to run and make profits, whether patients were satisfied or not.
What provision in the amendment are you opposed to?
What these people are asking for is for us to go back to that era that a non-doctor should head the hospital. Now, they will have a lot more confusion. During that era, the only non-doctor that was heading the hospital was the administrator. Now, nurses, pharmacists, laboratory scientists and others are there. Even drivers feel they can also head the hospitals. If we return to that era, it’s not only administrators that will be fighting for that role, it will be all of them. At the end of the day, it will create a huge problem, and in four years they may be able to decide who will head the hospital. That is why we are strongly against it, so we can maintain the consistency and quality of training that make our products appealing to people outside the country. Knowing that that Act corrected an anomaly and in terms of performance, what people try to compare now is the CMDs who have no substantial vote from the government these days to the administrators of those days who had thousands of pounds to spend on the UCH alone. They keep saying the UCH, but at that time, if any patient walked into the UCH, it was completely free of charge. Some of our female colleagues gave birth at the UCH; if you were going home, the hospital would give your parents a gift. That was how good the country was at that time. It’s not like that for those managing the system now. Many of our senior colleagues, who managed the hospital in the 80s, said the resources they were given was more than the resources the current managers were being given by the government. So, you wonder why any doctor wants to head the hospital under this chaos, but most of those CMDs are doing fairly well, pulling resources from everywhere to get the system going. The people who are agitating to come in now are seeing the paraphernalia around those offices but they don’t know the headache that whoever is heading those hospitals get every night over the delivery of those services.
Members of the MDCAN are threatening to go on strike. What are your demands?
For the past one year, we have been negotiating with the government over a particular allowance that needs to be upgraded and we both agreed. But at the point of implementation now, everything has gone cold and we think that is very unfair to a group that refused to go on strike for a very long time. It’s beginning to look like if you don’t go on strike, you cannot get anything from the government. That we think is very unfortunate but we have been pushed to that point. We have delivered our communiqué from that NEC meeting to the Minister of Labour and of course given him a week or two to resolve the issue, after which a strike notice may go out. We have yet to send the strike notice, but depending on our engagements with him in the next one week or two, a strike notice may go out from us. In this case, we are talking about consultants going on strike, which means the hospitals will be completely grounded, because residents don’t work unless we are on the ground. We supervise them. So, your supervisor cannot be on strike and you will be working. It will be a complete shutdown of the system except the emergency services, which our colleagues run. That is the only one we leave open when any strike is on.
What other solutions do you propose to address the brain drain problem?
We have proposed a number of things, and it’s for the government to choose anyone it feels comfortable with. We have proposed increased remuneration, improved condition of service, incentives like housing and car loans, and we have proposed that those who leave should be replaced immediately. That way, the people around who are still contemplating leaving, because they are not gainfully employed, may be persuaded to stay. They will fill the vacant slots available, but it seems the government is looking at that option. We are working with them to facilitate that option, including the several other options that we listed, like the elongation of the retirement age.