Dr Usman Abdulrahman is the Medical Director, Ajaokuta Steel Company Medical Centre (ASCMC). A Consultant physician and public health expert, he sets an agenda for the new government as he talks on various health issues including brain drain, one on one replacement, medical tourism and gaps in the health sector in this interview with REGINA OTOKPA. Excerpts:

What are some of the challenges confronting healthcare delivery in Nigeria?

One of the major issues in health unfortunately, is the access and affordability of healthcare services of which money is the key factor. About 70 percent of health financing in the country is still mostly out of pocket of individuals seeking health services. Definitely it will hinder or reduce access to healthcare, especially in the present depressed economy where people are struggling to eat, have shelter. Infrastructure is a big challenge especially when it comes to bringing health to the rural areas. There is need to strengthen our primary health care system if we must enhance access to healthcare services especially to the rural populace.

This will help reduce the burden on the tertiary system which is supposed to be a referral system. The absence of a strong primary healthcare service system is the reason our secondary and tertiary healthcare systems are being overloaded. A strong primary healthcare system requires manpower; we need to encourage healthcare workers with incentives to stay in the rural areas so that they can deliver healthcare to the people that need it. Unfortunately, Nigeria is facing what we call Japa syndrome where many health workers not just doctors, but others especially nurses, are leaving the country on a daily basis. Presently, most hospitals are virtually empty, it’s just the structures that are there. Chief Executive Officers of almost all health facilities in the country are all crying because what you see on a daily basis are resignation letters on your table of people leaving the country for greener pastures. Government needs to look at that area.

We need to motivate our health workers, we need to give them enough incentives that will make them stay put in Nigeria. We need to ensure health facilities are not just every where, but they are well equipped; at least one in every local government of Nigeria should be well equipped with equipment and tools because it’s one thing to have manpower it’s another to have what to work with. If we really want to get it right in healthcare service delivery system in the country, we shouldn’t leave any area unattended to.

With hospitals empty of its workforce due to “Japa Syndrome,” how does this affect health services?

It’s a serious issue but Nigeria is not the only country experiencing Japa syndrome; people are leaving other African countries to Europe and other countries. The implications are in two folds; delivery of healthcare services and healthcare givers. First, it will reduce the quality of healthcare services in hospitals, it’s going to prolong or elongate the waiting time to see a doctor, and it’s going to make some services not readily available. On effects on the healthcare givers, it leads to burnout syndrome due to reduced number of people; one person is doing the work of five people so the healthcare person will be exhausted, tired and probably depressed. Of course you don’t expect 100% perfection from somebody that is already exhausted, depressed or tired.

We have seen few cases where a doctor collapsed and died and nobody knows what happened. Maybe it was due to burnt out syndrome because we are seeing situations where a doctor is on call for 72 hours, there are reduced number of off days because there are just few people to continue the work and so the health of the person is not too good, it can result in stress and from stress other things can come up. In summary, there will be poor quality of services to patients at the end of the day because one person is doing the work of 10 people.

With this burnt out syndrome, government is yet to implement the one on one replacement of doctors. What does this portend for the country?

Every organisation has been talking about it, the NMA has been at the front burner in this campaign,the NARD had even gone on strike because of this and the government promised that they’re going to issue a circular for immediate replacement but up till now that has not been done. Hospitals are still left empty because people are still leaving on a daily bases yet we have not seen an effective or efficient replacement I am using this opportunity to call on the government to look into what is obstructing the immediate replacement of all these workers. We have some doctors, nurses who are still looking for jobs despite that many of them are going out of the country. The chief executive cannot replace immediately but the truth is we need to immediately replace those who are leaving for effective healthcare service delivery in all hospitals in the country.

Besides the search for greener pastures, are there other factors responsible for the mass exodus of health workers from Nigeria?

It’s not just the search for greener pasture, for some people it’s not love for money. There is a problem with our healthcare system; people are not satisfied with the facilities available for them to practice. If government is able to equip especially some of these tertiary hospitals with state of the art equipment, probably people might if they are very satisfied and happy with the environment, stay put to work in Nigeria. Nigerians are intelligent, they are handling most of the cases in hospitals outside the country so we need to look into why they are leaving. It’s not just incentive that is the issue;for most of them it’s because the tools and equipment are not just there and they don’t want to stay back idle without practising what they have learnt.

We have people that are more intelligent than the people they are going to meet. Most of the leading hospitals abroad are being managed by Nigerians. Some of them were even trained here in Nigeria, some even had their secondary training here in Nigeria before going abroad but when they go there because of the facilities they are exposed to, they perform better so we need to have political will but unfortunately, the people that are supposed to be committed politically are the ones enjoying the medical tourism.

Should the slight increase in the 2024 health budget call for commendation or do we reprimand government for failing to still adopt the Abuja Declaration of 15%?

If you want 100 and you get 60 when maybe what you were getting before is 40, of course there should be slight jubilation that we’re not yet there but there’s a progress, there is hope that we will finally get the 15% we are asking for probably in the next two budgets instead of being stagnant. It means somebody is now listening to the cries and discussions in the health system.

Do you align with the call on lawmakers to mandate treatment of certain ailments in the country to curb medical tourism?

The issue of medical tourism has been there and will continue to be there no matter what you put up in Nigeria. People take it as luxury, however, most of our people going out for treatment are now being treated by Nigerian doctors. Imagine someone traveling to Dubai just to check their blood sugar, it doesn’t make sense so there should be a policy on what ailments should take you out of the country. That will also reduce medical tourism because medical tourism is more like money making to the other countries people are going to.

Personal practice by most doctors is having a downturn on poor Nigerians. How can this be addressed as this out of pocket expenditure is very high?

The law is already there that doctors should not engage in personal practice while in government service and if you must have, you must not be found not to be there where you are supposed to be in the government hospital that is paying your bill and so, let the law apply. Once government make one or two people a scapegoat, others will comply. Some CEO’s don’t encourage it at all, some have been disciplined and sacked as a result.

Do you agree that medical students must serve five years in Nigeria before they can receive their certificates?

I vehemently condemn that and I have published some articles in news- papers on that. It is not practised anywhere because you will be infringing on the right of the person and how do you even do that? If you decide to apply it on those who studied medicine in government schools in Nigeria what happens to those who studied in private universities or abroad and decided to come back. It will not have universal applicability, so why start it. That is not the way out.

What then is the way out?

We need to look at the pull and the push factors and mitigate them. Let’s look at the pull factor of why people are leaving Nigeria which are incentives, lack of facility and equipment, insecurity and poor economy. Some people don’t even leave because of their own benefits but their children and future generation because they believe their children’s future, especially people that are already in their 50s, are more secure abroad. Once we identify the issues we look for mitigation strategies and one of them is to ensure that the economy is favourable, insecurity is tackled because many doctors are being killed in the rural areas especially in the North.

There is need to look at the welfare of health sector practitioners and motivate them not only in increasing their salary but government can mortgage houses, cars for them, that is what they do abroad. There is a way you can make somebody more comfortable that they won’t feel like going out. One more reason why people are leaving is because the exchange rate of the dollar to naira is very high. when they convert their salaries which is in dollar the difference is huge, so we need to stabilise the economy, if our naira is stable people won’t be ‘japaing’ anyhow. We really need to think outside the box, if the economy is very good it will discourage them from moving out.

How has it been managing the hospital attached to the non functional ASCL?

So far so good we thank God. Things have not been easy but we have been able to improve the quality of service delivery to the community of the Ajaokuta people and environs. The hospital is situated in a very key location; it’s situated on the main route that links the South South and South East to the South West so people going from the North to South East, most times have to pass there. The hospital has played a major role especially in attending to minor accidents and we have been able to do our best to ensure the victims survive. We have also improved the quality of healthcare services delivery by trying to ensure some of the obsolete equipment in the hospital are replaced and few more doctors, nurses and other health workers are employed.

Are they certain gaps begging for attention?

There are a lot of gaps but let me just say equipment purchased 10 years ago are obsolete now, so there is need to upgrade the facility with state of the art equipment. We also need government to review the policy mandating hospitals or health centres attached to a company to self sustain, so that they can take back most of these hospitals’ funding. It’s a key issue.

It’s the beginning of a New Year, and first year of a new administration. What are your expectations from the government?

The government of the day is trying but we still have a long way to go in so many areas. The Universal Health Coverage is a very good policy we must focus on because it will definitely reduce out of pocket spending. There is need to inject more funds to the health system because the idea is there; most CEOs know what’s to be done it’s just lack of funds or inadequate funds to do them. I know government also has its issues but I encourage them to see how they can fund more hospitals and provide state of the art equipment. All of these will reduce the issues of japa syndrome, not having access to hospital and hospital not being affordable to poor people because all we need is equity, an effective and efficient healthcare delivery system in Nigeria.