Medical Tourism and the Challenge of Healthcare Delivery in Nigeria

By Olusegun Adeniyi

After a morning walk, six medical doctors were at a neighbourhood restaurant enjoying their cups of tea, when they saw a man limping across the road towards their direction. Out of idle curiousity, a conversation ensued on the nature of what might be ailing the man. The first doctor to comment said from the way the man was walking, he must be suffering from Left Knee Arthritis. The second doctor disagreed, saying he suspected Plantar Facitis. The third doctor said from what he could discern from distance; the man may have just suffered an Ankle Sprain. ‘Look at the way he is walking’, said the fourth doctor, ‘It’s obvious that man cannot lift his knee, he looks like he has Lower Motor Neuron lesion’. At this point the fifth doctor cut in: ‘To me he seems to have Hemiplegia Scissors Gait’.

Before the sixth and last doctor in the group could offer his own diagnosis, the man entered the restaurant and asked one of the attendants, “Is there any cobbler around this place who can help repair the pair of sandals I am wearing?”

Mr Chairman, distinguished ladies and gentlemen, I am delighted to be here today for the 36th Annual General Meeting and Scientific Conference of the Association of Resident Doctors, University of Ilorin Teaching Hospital. While I thank you for considering me worthy to speak here today, I must also salute all the medical doctors that are here. I know what it takes for you to remain in the profession and in the country despite all the frustrations and lack of appreciation for your efforts and sacrifices. Let me also thank Dr Wuraola who came to receive me at the airport yesterday and Dr Tijani who visited me last night with another doctor. I appreciate all the kind gestures.

Meanwhile, there are several lessons we can take away from the story of the doctors who were diagnosing a patient from afar. But if we will be honest, that in a way speaks to the state of healthcare delivery in Nigeria today. When medical personnel do not have the requisite tools to do their job, as it is the case in our country, they will be reduced to mere guess work. Yet, misdiagnoses can only result in incorrect treatment that could then worsen the condition of patients or even lead to death. Many of such fatalities have been recorded in our country in recent years with all the blame put at the doorsteps of medical doctors.

When I was asked to speak on “The interminable trend in medical tourism; a corollary or ancillary of collapse in the Nigerian health sector?”, I wondered whether I should not decline the invitation. The conclusion I could draw, especially after I was asked to send my slides and power points, was that some people just wanted to set me up for humiliation by seeking an academic paper in the field of medicine from a quack. It took the insistence of both Dr Wuraola and Dr Tijani with whom I have been exchanging communications in the past few months for me to agree to be here this morning. But I will not pretend to be what I am not. I will use the few minutes I have not to sound like an expert but rather to provoke a conversation around the issue of medical tourism, especially as it affects the health sector in Nigeria today.

Even though I am not a doctor of any kind, I have in recent years had the privilege of several interactions with respected professionals in the health sector in our country. In November 2017, I was among the 26 Nigerians appointed by the then Minister of Health, Prof Isaac Adewole, into a group called National Advocates for Health (NAH) with a mandate to “help change the narrative on health at different levels in the country.” With Professor Oladapo Ladipo as our chairman, other members included Dr Ibrahim Wada, a foremost gynaecologist, Prof Joy Ezeilo, a former United Nations Rapporteur on Human Trafficking and Mrs Moji Makanjuola, a popular broadcast journalist with bias for health reporting. To aid our assignment, we formed a WhatsApp chat group and as a result, I have been able to learn more on the challenges of healthcare delivery in Nigeria from these distinguished professionals.
This is also an issue on which I have done some interventions. I recall a series I did more than a decade ago on ‘Who Wants to be a Doctor?’, which dwelt on the frustrations that go with the practice of medicine in Nigeria. And in March this year, I wrote a column titled, ‘The Exodus of Nigerian Doctors’. Following the publication, I received a deluge of mails from several practitioners. Let me share one from a doctor who works in the psychiatry department of one of the leading University Teaching Hospitals in Nigeria today:

‘Dear Segun, I read your publication with deep enthusiasm and bitterness at the same time. Practicing medicine in Nigeria is of all things, depressive! Five years after graduating from medical school, I am still wondering if I made the right choice rooting for medicine instead of following my father’s footsteps in enlisting into the Nigerian Army. There are times I wake up and wished I was presented with a rewind of 11 years; chances are that I would have been more fulfilled than I am now. I can confirm to you that almost half of my classmates are outside the borders of Nigeria, practicing medicine. This is serious! I have hoped that tomorrow I will be somewhere, anywhere, just anywhere other than Nigeria. I have considered Togo, Gambia, Seychelles in the past. With each break of the day, my hopes are culminating into palpable results. Nigeria is not ready! Nigeria does not care about itself!’
I am sure many people in this room can relate to that message. It is the sort of lamentations you hear from medical doctors in Nigeria, almost on a daily basis. Lack of a conducive working environment, poor remunerations, weak governance framework, as well as lack of adequate and consistent government policies are some of the issues we must deal with to revamp the health sector. Because if we don’t, there is no way we can even begin to address other challenges.

Before I go to the substance of my presentation, it is important to highlight one clear danger that stares us in the face as a nation. Although the World Health Organisation (WHO) recommends one doctor to 600 patients, the ratio in Nigeria now, according to most estimates, is about one to 7,000 patients and it can only get worse, with medical doctors fleeing the country in droves. According to figures from the Organization for Economic Co-operation and Development (OECD), Nigeria is one of the three African sources of foreign-born physicians who practice abroad. As at February 2018, according to figures released by the British government, no fewer than 5,405 Nigerian-trained doctors and nurses were working with their National Health Service (NHS). At regular interval, the British Council plays host to several of our medical doctors who sit for the Professional Linguistic Assessments Board (PLAB) exams. Canada, Australia, Saudi Arabia, United Arab Emirates are some other destinations for our medical professionals.
It is therefore no surprise that the WHO recently ranked Nigeria 187 out of 191 countries in the world’s health systems with our country placed just above Democratic Republic of the Congo, Central African Republic and Myanmar. Neighbouring countries like Ghana, Togo, Niger, Mali, and Chad were ranked better than Nigeria.

The pertinent questions to ask are: Why is it that the average life expectancy in Nigeria is 54 years as against 75-85 years in both Europe and America? Why is Nigeria still ranked very poorly on the incidence of tuberculosis (128 out of 138 countries) and the prevalence of HIV (123 out of 138 countries)? Why is it that on under-five child mortality, there are 89 deaths per 1,000 live births in our country, which is way above the target of 64 deaths per 1,000 live births set in the United Nations Sustainable Development Goals (SDGs)? Why is there high reliance on out-of-pocket (OOP) payments as a means of financing health system in Nigeria with 98 percent of population living without health insurance? What has happened to all the various national health plans and other policies that have been enacted in recent years?

The most obvious answer to these questions is finance but it goes beyond money. In 2001, Nigeria hosted Heads of State of member countries of the African Union (AU) where the leaders pledged to commit at least 15 percent of their annual budgets to improving their health sector. Since that commitment was made, Nigeria has not made any progress towards achieving the benchmark. The highest ever reached was in 2012 when 5.95% of the budget was allotted to health care services. In 2018, the budget for health represented only 3.9%. And given the foregoing situation, do we then understand why our doctors are fleeing the country with the attendant consequences on our health sector?

Unfortunately, the Minister of Labour and Employment, Dr Chris Ngige, who incidentally happens to be a medical professional, cannot appreciate the enormity of the challenge confronting our nation. According to Ngige, there was nothing wrong with doctors leaving the country in large numbers. “I am not worried (about doctors leaving the country). We have surplus. If you have surplus, you export. It happened some years ago here. I was taught chemistry and biology by Indian teachers in my secondary school days. There are surplus in their country and we also have surplus in the medical profession in our country. We have more than enough (doctors). You can quote me. There is nothing wrong in them travelling out. When they go abroad, they earn money and send them back home here. Yes, we have foreign exchange earnings from them and not just oil,” Ngige said early this year. But the minister is wrong.

In 2017, the NOI-Polls, in collaboration with Nigeria Health Watch, conducted a very revealing survey on the reasons many of our medical personnel were voting with their feet. Titled, “Emigration of Nigerian Doctors Survey Report,” the NOI-Polls CEO, Dr Bell Ihua, described the situation as “a ticking time bomb which needs to be nipped at the bud by engaging in critical reforms of our health systems, structure and policy.”

In September this year, just about three months ago, PUNCH Newspaper did a detailed nationwide report on this same issue. In the report, the Kaduna state chairman of the Nigerian Medical Association (NMA), Dr Stephen Kache made a startling revelation which speaks to the gravity of the situation. He said: “In 2018, we did a survey in some hospitals within the state and in one of the hospitals as of January, there were 21 doctors and by August of the same year, there were eight doctors remaining. We went round other hospitals and the picture was similar. Recently, the state government tried to replace those that had left and 33 doctors were employed. I am aware that out of the 33 that were employed, only eight of them have reported.”

I am sure the situation is not different in majority of the other states. Even without this exodus, we don’t have enough medical personnel to take care of our ever growing population. Nigeria has just about 72,000 medical doctors registered with the Medical and Dental Council of Nigeria (MDCN), with only approximately 35,000 practicing in the country. When these figures are compared with the World Health Organization (WHO) recommended doctor to population ratio of 1:600, we can easily deduce how poorly Nigeria is performing against this benchmark. Going by the current projections, Nigeria will need more than 300,000 medical doctors to meet the demand, and no fewer than 11,000 new doctors annually to join the medical workforce at a period majority of our young medical professionals are already seeking greener pastures abroad. Only at this level can we expect good quality patient care that is not compromised by errors occasioned by overworked medical doctors.

Therefore, it is no surprise that Nigeria has become a major exporter of patients to various countries of the world from where they seek medical solutions to what ails them. And that brings me to the issue of medical tourism and the Nigerian health sector. While the most common destination is India, essentially because that is where majority of the middle class patients go, Germany, United Kingdom, United Arab Emirates, South Africa, Saudi Arabia and even Ghana are also prime destinations for our medical tourists. Many factors influence this decision. Some people travel for care because treatment is considered cheaper in those countries. Still others travel to receive a procedure or therapy that may not be readily available in Nigeria. But some Nigerians also travel because it has become a status symbol to say ‘I just came back from London where I went to do my medical’. At least that sounds sexier than to say ‘I had my medical at Idi Araba’. It is not a coincidence that in all the states where outgoing governors have enacted legislations to award themselves and their deputies pension for life, the prescription is for foreign medicals. The sad reality is that a society where you have such elite mentality cannot aspire to any great thing.

Every month, almost 6,000 people leave the country for various forms of treatment, including some that can be carried out in Nigeria. And with that, medical tourism is costing the nation huge sums of money, estimated to be over $1.3 billion, according to the Price Waterhouse Coopers (2016) report. Of this amount, about 60 percent is expended on four key specialties, namely: oncology, orthopaedics, nephrology and cardiology. This is a significant percentage of the total government spending on public health and if we are serious, these should be areas of priority to our health authorities.

However, medical tourism has become a major global business such that it is growing exponentially compared to regular tourism. Some Nigerians have also keyed into this business. Just yesterday, I came across one of these companies which advertised itself as “a Nigeria based medical tourism agency that connects Nigerian patients with quality and affordable medical facilities abroad” with assurance of “a rewarding and positive outcome to our clients through our personalized service and partnership with some of the world’s leading medical facilities in India, UAE, Germany, the United Kingdom and Israel.”

The company offers consultation to hospital selection and specialists medical diagnosis, visa processing, travel planning and hotel booking. I am sure there are many others but what they may not be telling their customers is that medical tourism also comes with huge risks. The specific risks depend on destination countries and the procedures being performed, but some general issues have also been identified. For instance, communication may be a problem. Receiving care at any facility where you do not speak the language fluently might increase chances of misunderstanding about the treatment you actually need with dire consequences. There is also the issue of medication which could be counterfeit or of poor quality. I knew about this when the late Professor Dora Akunyili was at NAFDAC. Some of these countries where patients from our country troop to today were notorious for peddling counterfeit drugs at the time. May be they still do. So, what is the guarantee that many of these outbound patients are not simply jumping from frying pan to fire?

Besides, the management of tropical diseases may be better in our own country. I am aware of instances when patients who travelled abroad for medical treatment returned with complications/infections. The challenge is that many of these hospitals being accessed abroad have no oversight regulation or medical personnel supervision and they exploit vulnerable patients. So, invariably, many of our people travel abroad without necessarily understanding that if anything goes wrong, they may not be able to seek any redress.

From the foregoing, it is very clear that medical tourism has several downsides. But it is largely caused largely by our weak health system. People who have money want to get the value they believe they cannot get here not necessarily because our medical personnel are not competent but rather because they lack the necessary tools to do their job in a system where the reward system is already skewed against them. Besides, modern diagnostic and treatment facilities especially for major procedures are unavailable or grossly inadequate.

If we must be honest with ourselves, there is also a challenge with the attitude of many of our health professionals in the country. This much was confirmed in 2014 by no less a personality than the then Permanent Secretary in the federal ministry of health, Mr Clement Uwaifo. “With relatively good number and mix of health workers in the country, these workers are mostly idle in public facilities as absenteeism is recorded at 29% on the average, with average patient load of three per day”, Uwaifo lamented.

Mr chairman, distinguished ladies and gentlemen, I have an answer to the question I have been asked by the organisers of this conference and I will keep it simple: Medical tourism is both an effect and cause of our weak health systems. But when nations face challenges such as Nigeria faces today in the health sector, they go ahead to design solutions that would help them overcome. There is nothing we can do to stop medical tourism since people travel to cities or countries where they will receive better or cheaper care or where the environment will help them with healing. Because it has become a big business, so many countries have developed policies to attract international patients. Some of these include global marketing campaigns, fast track visa processing, logistics and airport services, hotel and concierge services, language interpreters etc. (a whole value chain).

Along this direction, Nigerian government and the healthcare stakeholders can also begin to plan to leverage on the opportunity to market our country as a destination of choice, especially for our West African neighbours. In addition, the federal and states governments must look into developing and implementing people-friendly policies, fund medical research and create an enabling environment for our citizens to trust and have faith in the healthcare sector. The government must be ready to support individuals and groups in the technology space to come up with forward-thinking ideas to make the healthcare system more effective and efficient.

There are still some very good hospitals in Nigeria but our laws discourage health facilities from advertising their services. Meanwhile, foreign hospitals advertise online and our people go there. So, why do we prevent our hospitals from advertising their services, especially in a society where quacks actually advertise? These are people who claim they can cure any and every ailment, from HIV/Aids to cancer. These charlatans are promoted every day, especially in the social media while we downplay the pockets of heroic acts by our professionals in the health sector.

To reduce outbound medical tourism from Nigeria, we must ensure that our healthcare sector is adequately funded, improve the healthcare facilities and upgrade medical equipment across all public hospitals in the country. The working conditions in Nigeria’s health sector will also require the intervention of all critical stakeholders.

What we are now seeing today is that, many of these countries that Nigerians are visiting for medical reasons and where we spend hundreds of billions of Naira yearly have started introducing new visa regimes for medical workers to further allow free-pass into their country due to the demand of healthcare services. But it would seem that the Nigerian authorities are not paying attention. Through this new visa regime, the UK now invites many more overseas doctors and nurses to come and work in their National Health Service (NHS). According to the UK’s Home Secretary, Ms Priti Patel, this move is to address the shortage in the UK’s healthcare services sector. We know the implication of this for our country.

While brain drain is not a new phenomenon in Nigeria, the main concern is that doctors are now leaving much earlier in their careers. We have to address this challenge. To do so, we have to fix what is broken, which is the entire healthcare system. The goal will be to focus more on health financing and beyond that, there must be policy consistency to meet the realities in the sector and provide solid groundwork for development of infrastructure. We must begin to implement some of the various policies that are already in place, which include the National Health Act of 2014 and the one that prescribes for 1% of the Consolidated Revenue of the Federation to be invested in Healthcare. Additionally, health insurance should be made compulsory for all citizens and residents of Nigeria.

To fix our healthcare delivery system, we also need to create both the facilities and specialization for most of the ailments that necessitate many Nigerians going abroad to seek medical solution. The private sector should be encouraged to do more but that will mean reducing import duty on hospital equipment; or giving concession to hire purchase of equipment. We must also create the enabling environment for our Diaspora experts to operate at home. Finally, all critical stakeholders like the federal and state ministries of health, professional groups, the civil societies and the media must collaborate for massive reforms in Nigeria that will guarantee quality, accessible and affordable healthcare for all citizens and residents of Nigeria.

Distinguished ladies and gentlemen, as I take my seat, let me advocate that as a nation, we must begin to prioritise the health sector as they do in most other countries, implement workable policies, provide the requisite infrastructure and pay our medical doctors living wages. Put simply, we must begin to imbibe the truism in the popular saying that when health is absent, wealth is useless.

Thank you very much for listening and good morning.

•  Paper delivered by Olusegun Adeniyi, Chairman of THISDAY Editorial Board at the 36th Annual General Meeting and Scientific Conference of the Association of Resident Doctors, University of Ilorin Teaching Hospital, in Ilorin, Kwara State on 4th December, 2019