Early this month the Minister of Labour, Dr. Chris Ngige, revived a controversy he had spurred in April 2009, to wit: that there are not just adequacy in the number of doctors in Nigeria but that there is a surplus of them. For illustration, in 2019, he asserted that just about 20 percent of applicants for specialist training (residency) in Nigeria’s tertiary hospitals could be admitted. He added approvingly that the others “try their luck elsewhere” (see “Doctors brain drain”. The Vanguard, 26 April 2019). Because the country has a surplus, according to him, he was not worried about our doctors trying their luck elsewhere. In his own words, “if we have a surplus, we export” (see FACT CHECK: Does Nigeria Truly Have A Surplus Of Doctors, As Claimed by Ngige”, the Sahara Reporters, 25 April 2019). The Nigerian Medical Association disagreed with him. The Association held that the number of doctors was inadequate and warned that the brain drain of doctors “might lead to the collapse of the Nigerian health system” (see “Despite official data stating otherwise, Ngige claims Nigeria has ‘surplus doctors”, the Premium Times 24 April 2019). Several newspapers, like the one cited immediately above, did facts checks and asserted that the country has a shortage, rather than a surplus, of doctors. Many of those that disagreed with Ngige lambasted him in the media and on social media platforms. “It was a national embarrassment, considering the office he occupies”; “What he said is completely false and I expect him to have apologized to Nigerians by now”; “For Ngige to have made such an unguarded statement shows that there is something wrong with those at the helm of affairs in this nation”; “So full of himself and so removed from reality”; “Our politicians can identify white as black and defend it”: these are some of the things said about Ngige in newspapers and social media platforms.
Ngige probably based his assertions on what I assume many of us in Nigeria have seen, heard or read: graduate doctors finding it difficult to get places for internship; large numbers of unemployed doctors; rejection of numerous applications by general practitioners seeking to become resident doctors; and fewness of patients in most public health centres, general hospitals and private hospitals. On the other hand, the Minister’s critics and traducers base their view on the things I also assume many of us have also noticed: the scarcity of doctors in most rural areas; the fewness of doctors in many, especially northern, states; the lack of doctors in most government health centres; the overcrowding and delays in seeing doctors in some general hospitals, teaching hospitals and federal medical centres; and seeking of treatment abroad by many Nigerians. In the view of the critics and traducers of the Labour Minister, it does not make sense to say there is a surplus of doctors when there are no doctors in many places and facilities that need doctors, when patients in need of major surgeries have to wait for months before the surgeons will find time to perform them.
Clearly, the eyes and ears of the Minister and his critics are not deceiving them: the things they see or hear are real. There are large numbers of unemployed as well as underemployed doctors in Nigeria. At the same time, there are persons and places that need the services of doctors and cannot find them or have difficulty in finding them. The challenge here is to find an explanation for what seems to be a paradox. I am convinced that a valid explanation will lead to the appropriate combination of measures needed to improve healthcare delivery in Nigeria. It would also make the country refrain from taking wrongheaded measures in response to popular demand or widespread outrage.
It seems to me that this controversy about the numerical adequacy of doctors in Nigeria derives from the use of different principles to determine the existence of a surplus. To the Minister’s critics, the principle is that of need. To the Minister, it appears the principle is what in this essay I call absorptive capacity. Let us discuss the principle of need first. Apart from the needs they see and hear about, the Minister’s critics rely on the recommendation of the World Health Organization (WHO) to its member countries to achieve a doctor-to-population ratio of 1:600. In 2020, the federal government disclosed that the ratio of doctors to population in Nigeria was 1:2753 (see “Ratio of Nigerian doctors to population is 1: 2753—FG”, Business Day, 4 March 2020). The estimated population that was used to calculate this ratio was not stated in the report. So it is not used here for analysis. A newspaper report of April 2021 states that the doctor-to-population ratio of Nigeria was 1:5000 (see “Bridging doctor-patient ratio gap to boost access to healthcare delivery in Nigeria”, The Guardian, 4 February 2021). The report indicated that this ratio was based on an estimated population of 200 million. Using this population as a basis, and assuming that the ratio of 1:5000 is correct, Nigeria has only about 40,000 doctors when it needs about 333,333 to meet the WHO recommendation. Thus, using the principle of need, there is a shortage of 293,333 doctors in Nigeria.
It is my view that the principle of need is the wrong standard to use for the purpose of determining the existence of a surplus or a shortage. The principle does not resolve the contradiction between the joblessness of doctors and the need for doctors. So let us consider the principle of absorptive capacity. Applied to the numerical adequacy of doctors, the principle holds that, if the number of doctors in any country is lower than the number of doctors that can be employed as medical practitioners and who have enough incentive to remain in the country, there is a shortage of doctors in that country. By the same token, if the number of doctors is higher than the number that can be employed and who are comfortable working in the country, there is a surplus of doctors in the country. In other words, what determines surplus is not the overall number of doctors in relation to the number of potentially sick people in a country, but the effective demand (ability and willingness to pay) for the services provided by doctors in the country. Thus, when a country cannot effectively demand the services of all the doctors it produces, even when it needs the services of even more than the doctors it produces, it has a surplus of doctors. Using this principle, therefore, the Minister’s assertion that there is a surplus of doctors in Nigeria is correct.
Let us mention some of the determinants of low absorptive capacity, especially in Nigeria. One of them, of course, is that government investment in health is poor. Another one, mainly but not exclusively a product of bad government, is that the country is fiscally poor and the generality of its people are poor. Thus, government cannot employ all qualified doctors, and low patronage by poor people cannot sustain most of the doctors in self employment. Absorptive capacity is partly determined by security. Assume, for instance, that the medical needs of the residents of Bama (Borno State) can be met by three doctors as well as ten nurses. If, because of insecurity, all of them relocate to Victoria Island where many doctors and nurses are unemployed or underemployed, these internally displaced medical personnel would become surplus to the country’s absorptive capacity. Another determinant of low absorptive capacity is the reluctance of many doctors to live and work in rural areas. Even with decent accommodation and other incentives, as the Chibuike Amaechi government provided in Rivers State, many insist on living in cities. Some resign rather than accept postings to rural areas. This means that such doctors, especially those that are not optimally engaged as doctors in the city, are surplus to the country’s absorptive capacity. Yet another determinant of low absorptive capacity is that large numbers of Nigerians in all parts of the country prefer to use traditional recipes for the treatment of diseases. For instance, most Fulbe pastoralists do not use so-called Western medicine. If doctors sent to mobile hospitals meant for the pastoralists do not see any patients and thus return to places where they cannot find work, those doctors become surplus to the country’s absorptive capacity.
It is needful to make the trite point that to deal with the challenge of poor absorptive capacity would entail dealing with its determinants. It would require, from a right-of-centre perspective, measures that we all seem to know but find difficult to adopt—measures that would increase the wealth of the country such that government can invest more in health and more persons can afford to pay for the services of doctors. Increasing the absorptive capacity would also require some left-of-centre measures, notably expanding health insurance coverage.
The other controversial point made by Dr. Ngige is that it is a good thing that our doctors are going abroad to find work. As we have seen, he was widely condemned for this view. The condemnation was based on the principle of need. The thinking is that it cannot be good to export what you need and which is insufficient in your country. The principle of absorptive capacity suggests a different conclusion. While it is bad that we lack the capacity to employ enough doctors to meet our needs, it is worse if those doctors remain unemployed or underemployed in the country. By way of analogy, if because of low purchasing capacity, food that is needed to feed the hungry in a country cannot be purchased, the food will rot if there is no export market for it. Therefore, it makes sense to export food that cannot be purchased. Money earned from export would help to raise the purchasing power for food in the country. As it is for food, so it is for doctors. Surplus in a time of need is bad. But having a market for the surplus is good, even if it is a surplus of skilled manpower. Indeed, to have a vent for surplus is good for the economy of any country. Unfeeling as it sounds, annoying that an appointee of a government that is deservedly despised is saying this, it is good that many of our doctors “try their luck elsewhere”.
Okechukwu Edward Okeke is a professor of History at Federal University Otuoke, Nigeria. He can be reached via okekeoe@fuotuoke.edu.ng or okeyedwardokeke@yahoo.com
