Decamping From Clinical Medicine to Public Health: Nigeria's Intra-health sector Japa

 

The verb “decamp” is almost confined to political parlance among Nigerians, as it frequently adorns the headlines of media houses when they raise the alarm over the defection of politicians from one political party to another. It turns out, however, that major news outlets haven’t been led to investigate and create a sense of urgency on the need to control the cross-carpeting of a critical group of workers in one of the most essential non-political sectors of Nigeria’s landscape. Therefore, this article aims to shed light on a similar drift within Nigeria’s health sector, as well as the carrots being dangled by the receiving end (public health) that leave the donor entity (frontline clinical health) at the short end of the stick.

I often hear colleagues in Nigeria tell me of their desire to exit clinical practice in search of “WHO-like jobs” (World Health Organization-type careers) that can take them around the world, attract them to conferences in beautiful hotels, earn forex-denominated monies that include salaries, per diems & estacodes, and guarantee other perks that frontline clinical practice rarely offers. Of course, every professional wants high returns – rightfully so – on their investment in acquiring knowledge, skills, expertise, and certifications. However, if the political and bureaucratic administrators could read between the lines, they ought to sense the greater disaster in the quiet but mass defection of medical doctors to public health.

Nigeria’s public health system has mainly remained funded by external donors and offers relatively higher salaries & allowances to physicians who are fortunate to secure employment slots within this space. Amid the general shortage of doctors in Nigeria, the public health sector receives a larger percentage of these few medical hands. In that case, it is likely due to doctors migrating from economically challenging clinical settings to more financially stable public health settings. Our country’s healthcare development partners have not necessarily attracted genuinely interested public health practitioners who are driven by a natural passion for non-clinical practice beyond the hospital setting. It is the incentives, calculated by converting dollar equivalents of budgeted earnings to naira, that continually lure male and female Nigerian medical doctors out of traditional hospitals where they directly interface with patients. Again, such cravings signify a legitimate want of better working conditions than the conventional in-hospital jobs typically offer the Nigerian doctor, pharmacist, medical laboratory scientist, nurse, midwife, and so forth.

Please note again that my concern does not stem from any assertion that other medical doctors lack the right to pursue better career opportunities, but from the shortage of clinicians in the traditional hospital environment. After all, I am a public health practitioner too, one who began his medical career in a hospital but opted for the public health field primarily out of my knack for coordination, management, administration, leadership, planning, implementation, and monitoring of the larger healthcare system (and not merely a hospital). However, I often offer voluntary clinical services after my 9-5, as I have a moderate interest in clinical consultations, minor surgical interventions, and sundry in-hospital practices.  As a Health System Strengthening expert, I am understandably pained that those who should know and act are oblivious to the fact that an unpalatable hybrid of the Japa syndrome (a sobriquet for the international migration of Nigerians) may already be in our hands and lives if a larger proportion of medical school graduates choose public health over frontline clinical practice.

A Yoruba idiom, “Ase’yi s’oun ma ba’bi kan je (tend to all parts equitably without destroying any part), is a reminder of the unacceptably lukewarm disposition of Nigeria’s political office holders and healthcare administrators to the gradual dearth of one section to the benefit of another. The fact that Nigeria has only 30,000 medical doctors registered by the Medical & Dental Council of Nigeria (MDCN) for its estimated 220 million population is a sad reality in itself. To assume that this inadequate number of caregivers provides frontline healthcare services within hospitals is a tragic reminder of our penchant in this part of the world for the pretentious use of data for critical policy interventions. At first glance, this “intra-sector” but “inter-workspace” migration may appear harmless to the entire health sector, as public health is a critical field of medicine that cannot be ignored in healthcare policy formulation, community medicine, disease surveillance, emergency preparedness & outbreak response, healthcare financing, and so forth. However, a thorough examination of the consequences of the defection (Japa) of many hitherto hospital-based Nigerian medical doctors to the public health space, abandoning critical in-hospital services such as medical consultations, surgical interventions, accident & emergency response, and birth deliveries, may unveil the fire we are stoking. Shall we all drift to public health at the expense of clinical practice? Are there suggestive remedial steps? Yes.

First, let’s follow the data; I recommend that the Federal Ministry of Health conduct a survey among Nigerian medics to determine how many have abandoned poorly remunerated clinical services for better-paying public health jobs, and that the study be objectively tailored to elicit the rate of defection, determinants (monetary and non-monetary), and other essential information. I noted non-monetary because, for instance, someone once mentioned to me that the repetition of poor infrastructural state of doctors’ call rooms, lying-in wards, hospital toilets, and so forth across the three General hospitals (secondary care facilities) where he had worked was his push to a public health career where he now sits in an air-conditioned office alongside other comfortable working conditions. Furthermore on strategic information use, it may be helpful that an analysis is conducted on the enrolment pattern for medical postgraduate training over the past ten years to determine the proportion of medical doctors in training who flood the public health & community medicine field compared to those who opt for other specialist fields (such as internal medicine, surgery, radiology, paediatrics, Obstetrics & Gynaecology).

Secondly, I recommend that the MDCN desist from bulk-labelling the number of medical doctors in the country during its routine data-sharing sessions, as such practices obscure reality and create a false impression of the depth of the emigration crisis among doctors. This write-up notes that the emigration of Nigerian physicians is not only international (from Nigeria to other countries) but also inter-practice (from clinic care to public health). Therefore, MDCN will do justice to creating a sense of urgency by disaggregating to the hearing of the Federal, State & Local government authorities, the number of doctors who work within the hospitals and those who are preoccupied with varied out-of-hospital works of epidemiology, healthcare administration & regulation, policy implementation, emergency response, health economics, strategic information, etc.

Thirdly, I recommend that the federal, state, and local government authorities make concerted efforts to significantly improve the emoluments of frontline medical doctors (those working in hospital settings to offer direct patient care) to be at par with the average donor-funded “living” wages accruable to their public health counterparts (those who work outside hospital settings). This will significantly curtail the trend of seeking to quit the perceived impoverishing hospital work for a rewarding public health career, all for the pay.

In summary, this written prompt aims to prevent a potential future scenario in which a significant proportion of the few medical school graduates who have no Japa plans will, from the outset, transition to public health, leaving a substantial number of our hospitals uncrewed by the frontline medical doctors needed in clinical settings. Let those with ears hear.

Dr. Adetolu Ademujimi is a Medical Doctor, Health Finance Specialist, Author, Reformer, Coach, Public Policy expert, and social entrepreneur who can be reached in Abuja via adetoluademujimi@gmail.com 

 

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