Dr. Robert SandaSunday, July 26, 2009
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Alberta, Canada



he Daily Independent newspaper carried a story on its friday, July 24, 2009 edition titled “Brain Drain: Borno woos medical doctors – indigenes lament poor healthcare delivery”. Sources close to the hospital management board of the state were quoted as stating that in its bid to curtail the outward drift of doctors from the services of the ministry of health of the state to other states or to federal institutions the government is awarding car loans amounting to about 160 million naira to doctors in a bid to retain them. The story went further: “...virtually all hospitals in the state have insufficient or no medical doctors and other health personnel...(in spite of the fact that) the state government had sank billions of naira in the health sector in the last six years especially in the construction and repair of new hospitals and clinics...” The story made the now-familiar theme that governments around the country often deny. “This measure, according to sources, appears not to be yielding the desired results”.

In a society and culture that delights in trading blames career politicians and public servants with conscience who are charged with running an economy and expected to produce positive results must be pitied. Graciously enough someone was keeping records because we are reminded that in six years billions of Naira was invested in the health sector of the state. This is to the credit of managers of the affairs of the state and this is the result of policy and administrative continuity. Imagine the result if someone can come up with a financial statement of the amount invested on health in the state over the past 20 years? For those administrators who want to bury their failures it would be a convenience but for those who genuinely want to move the state forward, such retrospection will be invaluable in learning from past mistakes and charting a viable and feasible path forward.

Nigeria's history in my generation will have to be written with the peculiarities and vagaries of fortune and mismanagement, of hope and uncertainty. The years of military rule have left their marks. Both the rulers and the ruled have certain hang-ups about the responsibilities of leadership. We only spend flitting moments considering the roles of elected officials as managers of profitable conglomerates while all the time we regard and accept our leaders as the ambivalent omnipotents that they are not. They are not the precolonial leaders of centuries past who can sell their citizens into slavery without compunction and without having to answer to anyone for it. In a democracy leaders no longer enjoy despotic powers and therein lies the power of the people to hold them to accountability. The separation of powers of the different arms of government is an idea that many executives and their parties want to keep blurred from the prying eyes of the electorate in order to exercise more powers than is allowed in a democracy. Law-makers are not tools to be used by state or federal executives so when these two tend to get along well, it is likely that the people have been betrayed by their parliamentarians who have allowed themselves to be bought.

The difficulties being encountered by the Borno state government in meeting its responsibilities to provide basic healthcare to its people is not peculiar to it but is a microcosm of a widespread social ineffectiveness that are faced in most parts of the world. The problems are enormous and multi-faceted and no one approach can solve it but rather a concerted, prioritized and step-wise strategy is called for to implement the processes that would lead to achieving the desired goals. The lessons learned from one part of the world can be extrapolated to another like Borno state. Without the attention and dedicated patronage of the chief executive of the state any plans to turn around the situation in the health sector is doomed to failure. Similarly without a guarantee of sustaining policies across administrations, the efforts of the present administration will wilt away soon afterwards.

A crucial first step in attempts to reverse negative indices and trends in the health sector is to accept that health is a commodity. The providers of healthcare must see themselves as engaged in a business. The life of any business is tied to its profitability. The era of the welfarist Nigeria died with the military regime of Olusegun Obasanjo at the end of the 1970s. Any leader who now promises free healthcare during electioneering campaigns must be prepared to back-pedal on assuming office or be faced with the prospects of breech of promises or a dysfunctional health system that the present generation of Nigerians know all too well. The bottom-line is Nigeria, and indeed Borno state, does not have the means to provide free healthcare for its citizens.

Apart from a few oil rich countries in the Middle east with considerably small populations the rest of the world attains its healthcare objectives through shared responsibilities. Rich countries like the United States, Germany and Japan have reached their goals by spreading to the cost of health as a commodity between the government, the individual and third parties. In these countries health care is expensive but to be sure that the burden is equally shared by the tripod of its supporting pillars (government, individual and third party) the government ensures the proportion of the workforce that is on social benefits is kept to a minimum by creating jobs and supporting the self-employed like farmers with incentives to boost their capacity. That way everyone is doing his best to support the system. Even Canada whose healthcare is often criticized as being too welfarist, the government does not idly watch unemployment figures, industrial output and inflation run out of control. If that happens, the government is quick to intervene with measures like adjusting interest rates at the apex bank, adjusting tax, etc., to maintain economic balance. In other words, the health of a society is intricately tied to the health of its economy. Therefore, for health policies to be effective, sound economic policies must be the bedrock on which a health system is built.

The constitution of Nigeria does not tie the hands of state governments from pursuing policies that could lead them to achieve their own set goals. When the government of Zamfara state voiced plans to impose tuition fees for children of parents who are not indigenes of the state a few years ago the uproar that this plan provoked soon died down in the face of the realities of constitutional provisions. While I will not advocate a discriminatory payment for healthcare provision in Borno state, it is prudent for the Borno State government to realize that it is under no obligation to provide free medical service to any or all residents or indigenes of the states. Be that as unpopular as it may seem on introduction if properly executed any policies to distribute the cost of healthcare delivery in the state among the stakeholders the population will be better off for it in the intermediate and longer terms. However, this will require a political boldness and will that is not a frequent attribute of the nigerian political office holder.

The newspaper article made a point that the problem is not limited to a shortage of doctors but also involves other professionals in the health system. Doctors don't run hospitals alone. They depend on a host of other professionals and skilled workers like nurses, pharmacists, medical laboratory technicians, radiologists, administrators, medical records clerks, security men, cooks, cleaners, gardeners, launderers, drivers, as well as a host of other artisans who must be relied upon to work harmoniously in tandem with doctors to provide adequate care for patients. Without the goodwill of these other workers the doctors cannot run a hospital effectively by themselves. The bane of health administrators and planners is that they do not frequently look back to notice the futility of isolated solutions to solving industrial actions in the healthcare system. Meeting the demands of striking doctors is often the trigger to send nurses and other workers to strikes of their own. Year in year out no amount of salary increases has bought governments respite from the problem of strikes because a comprehensive service remuneration has never been seriously addressed. As a result it shouldn't surprise anyone if after providing incentives like the ones the government of Borno State is offering to retain doctors in its service that nurses and other workers who have been contented with what they are paid now make fresh demands for car loans or threaten to down tools. The problem will never be solved this way because today's solution will be the catalyst for tomorrow's problems.

About 25 years ago, I recall the military administrator of Borno State, Major-General Abubakar Waziri (1984-1985) lamented the shortage of doctors in Borno state. The ratio of doctor-patients in the state was then 1:65,000. With the current 70 doctors in the payroll of the Borno state ministry of health (assuming of course all 70 are not on studies elsewhere but actively in service and assuming that the commissioner for health and other doctors serving as directors in the ministry of health spend considerable amount of time doing clinical work) and an estimated population of 4,151,193 in 2006 the current ratio is approximately 1:59,000 which is a marginally (but statistically insignificant) improvement over the situation a quarter of a century ago. This comparison must be made in the backdrop of the relative economic boom of 1984 compared with 2009 and the increase in the number of medical schools across the country and the increased intake capacity of the existing ones. The question that the present governor of Borno State, Alhaji Ali Modu Sheriff must address is what was the impact of the billions of naira that his and previous administrations have invested in capital projects in the state over the years?

The accounting officer of the state is the executive governor but down the line are people who are charged with the tasks of strategic planning and auditing and whose duty it is to inform and advise successive administrations of policies and projects. The governor does not require an education in health policies to supervise a viable healthcare regime in his state but he is expected to ask for results and if he is not satisfied to remove or even prosecute managers who failed or mismanaged resources allocated to health. That is a task that the governor cannot remove himself from. In this regard, the failure of the healthcare system will be seen as the failure of the governor of the day and those that succeed him. The billions invested in capital projects in the state over the past six years that did not result in measurable improvement of the expectation of the ordinary people of the state must be seen as a wastage that the governor oversaw. So standing on the premise of Borno State as an industry or company, the reputations and legacies of the various administrations in the state will stand or rise with a comparison of their performance and the expectation of the people. Here, the words of a US business academic and writer is pertinent: “A strategy is only as good as the vision that guides it”, wrote Burt Nanus.

Strategies and tactics are tools of competitive campaigns and they are true for the game of chess as they are true for wars or for running a company providing services. “A corporation without a strategy is like an airplane weaving through stormy skies, hurled up and down, slammed by the wind, lost in the thunderheads. If lightning or crushing winds don't destroy it, it will simply run out of gas”, wrote Alvin Toffler. While commending the latest efforts the government aimed at retaining doctors to provide services to remote areas of the state by offering them car loans to cushion their hardships in those areas, let me add that this is an old tactic that has been tried in other states in the past and it did not work as expected. The offer does not go far enough to entice most of these young doctors with ambitions in their focus. To be an effective allurement the government of Borno State must do more than that because tactics don't win wars, strategies do. In the words of the late british writer and broadcaster, the late Frank Muir, “Strategy is buying a bottle of fine wine when you take a lady out for dinner. Tactics is getting her to drink it”. In spite of the lightheartedness of this humour this is a somber maxim. If you do not have the wine, don't even think about asking the woman to drink it.

The government is said to have allocated about 160 million naira for car loans. To be meaningful, this figure should be accompanied by other figures that is unfortunately were missing. This much money for each doctor? (Why not, what is US$1,072,026 in 70 places, or US$75 million for a state like Borno!) Not many Hollywood actors or sports stars drive cars that cost over a million US dollars. Although not stated, what is on offer is much more likely to be the realistic N2,285,714 or US$15,314 each assuming the amount is to be shared out among the 70 doctors in the state. This again poses a new question and a new problem. What if 70 new doctors took the offer? Would the N160 million now be shared by 140 doctors and thereby cut the amount they are led to believe they stood to get by half? Or would the government double the money to accommodate the new doctors? All this will be well done if nurses and other healthcare workers would accept the notion that they are lesser beings in the task of providing healthcare and resign to fate. My instincts tell me that not long after the first such cars hit the streets with its happy owner cruising around town than other workers would down tools in demand for car loans as well. The government would have disturbed the honest nest.

Another spinoff the government should be prepared to handle is the loan itself. It is clear from the article that the government is offering that money as a loan. We are not told over how many years the money will be repaid so let me assume that the loan is payable over five years and a deduction of 20% of the gross salary of the doctor will go towards repaying the loan. Therefore, a doctor needs to earn N190,476 (US$1,276) monthly to repay the loan. Is the state government prepared to raise the salary of doctors that much? If it does, how about other workers in the state? Will anyone even contemplate confronting all the various unions across the state on behalf of the government in attempts to persuade them to return to work without car loans of their own? Once again, the government's offer will open an entire can of worms it cannot handle without resorting to undemocratic powers like violently suppressing strikes and arbitrarily terminating dissenters. I believe that the advisers of the government are counting on 70 doctors to do the impossible to improve the healthcare delivery in the state all by themselves. This is absurd.

Alright, the young doctor is given the money to buy a new car. The posh cars that the government is dangling before the doctors are probably not designed for the bumpy and dusty roads of Borno State. How long would the local mechanic in Kukawa or Monguno has to wait before “Doctor's” new car is towed in for repairs? Would the mechanic know anything about the latest engine designs? Would he have the appropriate parts to replace the damaged one or would he convince “Doctor” that since Nissan and Toyota are both Japanese cars their parts are inter-changeable? In short, how long will a new car remain on the kind of roads I have in mind? You see, a doctor that will accept to remain in Borno State after NYSC just to drive a new car must have come from a state with less social amenities than my dear state. How many such states exist today? Any wonder, then, that doubts are being expressed all too soon about the effectiveness of the scheme?

Yes, the administration of Alhaji Ali Modu Sheriff has poured billions of naira into capital projects in the health sector over the years and he should be commended on his dedication and the sacrifice of the people of Borno State who had to do with less money for other contingencies. Unless the government sits back and reviews its investments the black hole of bureaucracy is waiting to swallow more money and give back nothing to the people who are waiting for campaign promises to be fulfilled. Buildings and equipments do not cure patients, medical professionals do. Conversely, professionals are ineffective middlemen when basic infrastructures are lacking. Building a new, fully-equipped hospital in a remote locality in the absence of an adequate number and quality of medical professionals will not result in the provision of healthcare. The reverse is the falacy that career politicians thrive on and this is what is at the core of the outward migration of doctors.

Doctors and other healthcare professionals work in a highly stressful environment and by their social standing they are expected to dress better, eat better and have extra to give to others less fortunate than themselves and after all is said and done they want to enjoy comfort in their homes. New cars is a step in the right direction but not an end in itself.

Like I pointed out earlier, these young doctors are still dreaming of a better life than just being doctors. Many of them have plans to do postgraduate trainings to elevate themselves in their careers not just for satisfy an inner urge for self-actualization (remember that youngsters that choose to study medicine are, by and large, highly ambitious individuals) and the need to enhance their earning capacity as senior doctors or consultants. So unless the government's offer includes plans to enable them to enhance their careers it will do little to retain them in the austere localities of rural Borno State. For this reason, a car loan that will tie them to the state for another five years or more will be seen as restrictive and runs counter to their plans. The best strategy will be for the government to make plans to keep them on the short-term. Offer them the incentives of working in Maiduguri after their NYSC and a prospect for postgraduate training after a number of years of service and in return for a proportionate number of years of further service to the state. For example, a doctor who served for a year in a place like Damasak during his NYSC year is more likely to be retained if he is transferred to Maiduguri Specialist Hospital rather than facing the option of remaining in Damasak. After another two years of service with the Borno State Health Management Board such a doctor, based on his potential and the recommendation of his seniors can enter into a bond with the government to be sponsored by the Borno State government to do a year training to obtain a postgraduate diploma in anaesthesia, dermatology or a masters degree in public health in return for two years service for the state. Doctors who want to further their education and career might be more likely to be tempted by this offer rather than the offer of a car loan. Based on merits some of these doctors that are not indigenes of the state may be offered equal civil service career opportunities as indigenous doctors. This may be more effective in retaining them.

So far this has looked at the doctors' side.

That the era of free medical service in Nigeria has ended is known to all but the politicians (and ignorant people who vote for them) who feel that promises based on fantasy is a guaranteed way to win elections. That perception is not about to change any time soon so I will not even get into that but it is reasonable to expect an elected governor to be factual with his constituency after he has been elected into office. The government cannot and should not lower its financial commitment to the health of its citizens but the people must be told that the government cannot do it all alone. It is not being done by any government anywhere and the government of Borno State is not any different. In Saudi Arabia I know several hospitals where equipments were purchased by the community and donated to the hospital. I have personally seen and verified that hemodialysis machines, mechanical ventilators, laparoscopic surgical sets were bought by communities to supplement government efforts in that country. Here in Canada I overheard administrators of my hospital the other day discussing the need to inform the community that I live in to raise money to buy new sets of laparoscopic and colonoscopic sets because the ones they bought many years ago have reached their service life-spans and need to be replaced. This is the same Canada where the government is being criticized as being too welfarist in terms of healthcare provisions. The same communities that are lacking medical doctors in Borno State must rise to the challenge and contribute money to buy equipments for their hospitals to supplement government efforts.

Due to its nature government procurements take too long to be implemented. If it will take considerable time to get regular supply of petrol for the standby hospital generator or to obtain medical gases for use in the operating rooms, or to replace tires on hospital ambulances, the community can tax its members according to their means to raise money to fix these problems rather wait for the approval and purchase and instalment of such necessities from the government. Such things are painfully slow in any government network but communities can shorten the waiting period. Sometimes hospitals are cut off from other communities because of floods and other natural phenomena and do such communities rise up through communal efforts to fix the roads? Most will wait for government agencies to work out the details of opening the road which we all know takes time.

The national health insurance scheme is a welcome and overdue but even the program cannot suddenly reverse the negative performance indices in the health sector without other backup measures. The earning capacity of the work force in the state must be enhanced to enable them to afford food and shelter which directly impacts on their health. In doing so the government indirectly enhances the individuals to assert themselves financially in relations to affordable healthcare. There is nothing that says that the national health insurance scheme cannot be supplemented by other health insurance coverage that a state like Borno can implement for its citizens.

In conclusion I will summarize the key points raised. Health is an expensive commodity and the healthcare industry is susceptible to the same economic forces that govern commercial enterprises. Globalization of the economy has not left governments anywhere in the world with much options to pursue a purely socialist agenda. Community participation is a paramount consideration in the provision of optimal healthcare that even the wealthy countries are subject to. The government, the private sector and individuals have roles to play in order to achieve optimal healthcare coverage in any society. An economy that has long been welfarist has an uphill task in meeting ever-changing goals of healthcare in a growing population with dwindling resources such as in Borno state. Investing in capital projects is good but it is not enough to assure adequate healthcare. For doctors to give their best the other professionals in the health sector have to be encouraged with similar incentives as those being offered to doctors otherwise dysfunctional hospitals will be the consequence. To meet any reasonable healthcare goals the government of Borno State must do more than introduce tactics that may work for a brief period and then be replaced with strife. This article calls for the government and people of Borno State to have the courage to do a serious reality check and come up with viable options through strategic thinking for the long term interest of the state in a country that is daily edging towards disintegration and anarchy and with it the bulk of revenue to provide social services like healthcare in the state.