A tale of two bills

There’s an age-old maxim that whether a cup is seen as half full or half empty depends on the worldview of the person making the judgment. And that worldview is informed obviously by the individual’s mindset: an optimistic mindset would see the cup in the progressive dimension of being half full, whereas a pessimistic mindset would view it in the regressive mould of being half empty. To be clear, it’s the same cup with the same volume of content, difference is only in the viewer’s perspective  When you consider efforts being plied to salvage Nigeria’s healthcare system from collapse, you can’t help seeing similar dynamics at work.

A bill was lately initiated in the House of Representatives to curb the emigration of medics from this country towards ensuring better healthcare for the average Nigerian. The bill seeks to bond graduates in medical and dental fields to practising in Nigeria for a minimum of five years before being granted full licence by the Medical and Dental Council of Nigeria (MDCN), which presumably would strengthen their hands to export their skills. The legislation passed for second reading in the Green chamber on 6th April. Sponsor of the Medical and Dental Practitioners Act (Amendment) Bill, 2022, Ganiyu Johnson (representing Oshodi-Isolo Federal Constituency 2, Lagos State), said it was aimed at making quality health services available to Nigerians considering the bourgeoning population of the country amidst high rate of emigration by medics. 

The lawmaker adduced compelling arguments for his proposition, including (i) the dismal doctor-to-patient ratio at one doctor to between 30,000 / 45,000 patients depending on the area of the country, as against World Health Organisation (WHO) recommended ratio of one doctor to 600 patients; (ii) alleged subsidy of medical education in Nigeria compared with the huge costs in other countries, among them countries to which Nigerian medics are emigrating; and (iii) the sheer dilapidation of healthcare services in Nigeria owing to acute understaffing that has resulted from personnel flight. Johnson said inter alia: “It has been observed that foreign embassies in Nigeria, particularly those of Britain, the United States and Saudi Arabia receive on a weekly basis 20 to 25 verification requests from Nigerian doctors wishing to migrate abroad. This translates to about 1,196 applications a year, while Nigerian people whose resources are being used to subsidise medical and dental education to train doctors and dentists suffer from poor health services due to the migration of our doctors and dentists. This is a clear (shortchange of) the Nigerian people. In view of the foregoing, this bill…will not only bring about necessary social justice to the Nigerian people but also improve health services available to Nigerians, because Nigerians will be able to enjoy the service of the medical doctors and dentists who were able to get trained through their resources, at least for the period of five years here proposed before migrating abroad.” 

As would be expected, the proposed legislation has avid supporters, but also livid opponents. Health Minister Osagie Ehanire lauded the idea of bonding medical and dental graduates, saying besides the good intention of curbing brain drain it also raised the question of morality and patriotism on the part of the graduates. “This is because the cost of training here is very small compared to school fees paid in foreign countries to become a doctor. I think this is the angle the representative was viewing the issue from,” the minister argued, explaining that it may not necessarily have to be by law but there should be moral understanding that if one receives quality education, he/she should give something back to the sponsor. Another boost for the bill, though unwittingly so, was the coincidence of a policy by the United Kingdom red-listing Nigeria among countries to be avoided in recruitment of medical workers. With 11,055 Nigerian-trained doctors in the U.K., Nigeria currently has the third-highest number of foreign doctors practising in that country after India and Pakistan. Now, the U.K. government says it is calling a halt to “active” recruitment of health and social care workers from Nigeria by its public and private healthcare bodies in light of WHO’s listing of the country along with 54 others as facing the most pressing health workforce challenges related to universal healthcare coverage.

“The Nigerian health sector is in crisis because those who should be concerned for its efficiency have alternatives abroad” 

The Reps bill, however, also elicited stiff opposition from major personnel centres of the health sector. The Medical and Dental Consultants’ Association of Nigeria (MDCAN) said concern for health of Nigerians that the bill sponsor cited as motivation for seeking to curb brain drain among medics was “misdirected, ill-informed, and poorly thought-through.” The Nigerian Medical Association (NMA) said the proposed bill would not stop emigration of medical personnel unless governments at all levels create “greener pasture” in the health sector as there is with political offices. On its part, the National Association of Resident Doctors (NARD) argued that the bill would compound the exodus of medical professionals because it constitutes “an affront to the Constitution of Nigeria and other enabling laws that guarantee freedom of movement, dignity of labour, and laws against enslavement and others.” Even in the Green chamber, there were voices raised against the bill. Among them, Uzoma Nkem-Abonta (Abia State) said it was “offensive” because what it seeks, namely bonding Nigerian-trained medics for five years before getting full licence, was not done in any other clime. Mark Gbillah (Benue State) argued that measures proposed by the bill would violate fundamental rights of Nigerian-trained doctors, adding: “Should we try to restrict these people and infringe on their fundamental human rights or allocate more resources to the medical profession?”

There is certainly a big crisis in the health sector. But that emigrating medics were not the core issue seemed to be the view of another bill earlier proposed in the same House of Representatives. The legislation initiated early in 2022 sought to prescribe seven years in jail or a fine of N500million, or both for public servants who spend taxpayers’ money on foreign medical treatment. Sponsored by Sergius Ogun (Edo State), the bill sought to amend the National Health Act, 2014 to make provision for sanctions against any public officer who violates the provisions of the Act, especially Section 46. The section to which amendment was sought reads: “Without prejudice to the right of any Nigerian to seek medical check-up, investigation or treatment anywhere within and outside Nigeria, no public officer of the Government of the Federation or any part thereof shall be sponsored for medical check-up, investigation or treatment abroad at public expense except in exceptional cases on the recommendation and referral by the medical board, and which recommendation and referral shall be duly approved by the Minister or Commissioner of Health of the state as the case may be.” Ogun had argued that while the Health Act prohibited unapproved spending of government funds on foreign medical services, it failed to prescribe punishment for disobeying the law and the point of his proposed amendment bill was to stipulate penalties.

Leading the debate on the amendment bill, the sponsor said it should discourage medical trips abroad to the detriment of local health institutions, and ensure revamping of the dilapidated sector because it would “spur public officers to pay more attention to our healthcare sector and take drastic steps to develop and improve on the sector.” This, according to him, would result in improved facilities, better remuneration for medical personnel and the possibility of attracting back Nigerian doctors abroad. He also argued that the proposed amendment would curtail capital flight on medical tourism by public officials and ensure that funds hitherto splashed on foreign medical trips are redirected into building an efficient and effective healthcare system in Nigeria as would in turn positively impact the lives and wellbeing of all citizens. Like the latest legislation, that amendment bill was passed for second reading but has since stalled in the legislative mill.

There is much to say, in my view, for this earlier legislation. The Nigerian health sector is in crisis because those who should be concerned for its efficiency have alternatives abroad. Make the system work and medics would stay back by default.