Over the past twenty years, 35,000 medical doctors have left Nigeria to seek job opportunities in foreign countries especially the United Kingdom, United States of America, Canada and Australia. As years have gone by and increasing global development, we might have expected those numbers to decline. In fact, they are growing rapidly.

In 2017, the National Association of Resident Doctors (NARD) estimated that about 2500 doctors were actively planning to leave Nigeria and seek employment and training opportunities abroad – more than three times the medical resource migration figures from 2015. Every day more physicians are dedicatedly exploring ways to join them, including our most experienced medics. Not too long ago, the majority of doctors emigrating were junior doctors in early phases of training, but now it is not unusual to hear of senior level physicians and surgeons, consultant specialists packing up and leaving in alarming numbers. The queues of health professionals that recently responded to Saudi Arabia’s call for over one thousand doctors adds yet another disastrous example to the list. Of course, this worrying trend is not peculiar to Nigeria and is being seen across sub-Saharan Africa. However, Nigeria with its vast population of qualified professionals, makes up the biggest national cohort of African migrant health workers anywhere in the world.

This loss of doctors is costing us dearly – in health and in cash. We are wasting our most precious resource – our people – by failing to keep them at home. At the same time, wealthier countries such as Australia, Canada, the United States of America and the United Kingdom are benefiting hugely. Nigeria has invested greatly in the education and training of its health professionals, and this relentless emigration translates to a loss of considerable resources with the direct benefits accruing to the recipient states who did not bear the cost of educating them. Research from the University of Ottawa estimates financial benefits amounting to USD 2.7 billion to the United Kingdom, USD 846 million to the United States, USD 621 million to Australia and USD 384 million to Canada.

According to a 2018 report released by the Mo Ibrahim Foundation, sub-Saharan African countries such as Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia and Zimbabwe spent upwards of USD 4.6 billion on training doctors at an individual cost of between USD 21,000 and USD 59,000 each. When they leave to work in the United Kingdom, United States and Canada, these African countries sustain losses of upwards of USD 2 billion. The United Kingdom’s register of doctors updated in July 2017 shows Nigeria as the fourth country of qualification out of over a quarter of a million medical practitioners in the country, almost five thousand of whom earned their medical degrees in Nigeria with numbers that have increased by the hundreds since that report. In a study conducted by Ihekweazu, Anya and Anosike back in 2005, graduates from three consecutive years (1995-1997) from the College of Medicine of the University of Nigeria (UNN) were traced with very startling results showing that 40% were living abroad, predominantly in the United States and United Kingdom, and this research holds true for my UNN medical school class of 2001, with almost 50% of the class practising outside the shores of Nigeria. Doctors who were trained in tropical medicine, with the expectation of treating patients in the tropics have had to make their way to the West to survive and thrive.

I doubt it is Nigeria’s intention to train doctors for the developed world, yet that is what we are doing – to our cost. These doctors are sorely needed at home. The World Health Organization’s standard for physician to patient ratio is one medical doctor to 600 patients. In the United States, that ratio is approximately 1 to 300, whereas one Nigerian doctor is available to about 5000 patients. Nigeria would therefore need more than 250,000 medical doctors for its estimated population of over 195 million. By the WHO standards, Nigeria qualifies and registers only a quarter of the doctors it needs, and despite this has only about 10 percent of the physicians its population size requires practising within the country.

The fact is that doctors in Nigeria are notoriously underpaid and overworked; yet despite this, the dedication of majority to their profession and their patients is no less than doctors elsewhere. One of the most essential resources in a country’s health system is the human capital that constitutes it. These highly qualified health professionals, who include doctors, nurses and allied health professionals are subject to numerous regulatory measures to ensure the quality, equity and sustainability of health care delivery. Unfortunately, Nigeria is amongst the countries leading in the export of qualified medical professionals globally. As this constant flow of emigration occurs, our country is being depleted of the doctors and skilled health professionals our population needs.

Why do they go? Well, it is not just about higher salaries elsewhere.

Research highlights key factors which are referred to as the ‘push and pull’ factors affecting physician migration. The environment in which doctors work over the duration of their careers has to be understood more deeply. Investment in human capacity development and human resource for health does not end the instant medical and allied health students graduate from early training. Investments in an enabling environment for practice and healthcare delivery should also be recognised as critical to developing the sector, in addition to attracting and retaining necessary talent.

Push factors driving our doctors away include unfavourable government policies and decisions, frustrations with postgraduate training, insufficient technology for patient care and research, minimal opportunities for career advancement, low wages, poor overall economic conditions and a desire for improved prospects for one’s children. Others are social conditions such as labour strikes, political corruption, poor infrastructure, and poor work conditions, especially in rural areas, which have been cited as factors pushing Nigerian physicians to migrate.

Pull factors, on the other hand, are those factors in the receiving country which attract doctors. Widespread physician shortages, ageing populations, attractive graduate medical education and visa policies favourable to migrant doctors enhance the pull of physicians away from Nigeria. The ease of integration into the country, and the presence of family, friends and ethnic organisations in the receiving country are very important pull factors as well. As undergraduate medicine is taught in English, there is no language barrier to practice for Nigerian doctors. Family members and Nigerian organisations also provide avenues for physician migrants to locate jobs, accommodation and valuable information about the workings of the destination country’s society and systems.

The Nigerian government’s declaration of a ‘state of emergency’ on medical migration is not before time. I would argue that the situation has long been Code Red – a disaster for our country’s health and future. We must improve our investments in health and address this crisis if we are going to have any chance of building a successful, healthy country.

This is an Africa-wide problem and demands an Africa-wide solution. The continent bears 24% of the global burden of disease, has only 2% of the global supply of doctors, and spends less than 1% of global health expenditure. However, Nigeria is at the bottom of the class. According to the World Health Organization, Nigeria’s spending on health as a share of its gross domestic product is less than that of Rwanda, Kenya, Malawi, Uganda and Sudan. This health expenditure gap is not only felt in salaries but directly translates along the entire value chain of health care provision in health promotion, disease prevention, maternal and child health, primary and rural health care, infection control, universal health coverage, emergency care and health systems strengthening. The weakness of our current health system basically encourages the exodus of qualified medical personnel who do not feel encouraged or motivated to remain in-country to practise medicine. Opportunities abound in the global North and even South Africa, and therefore doctors naturally migrate to take those opportunities.

Nigeria also records more deaths from communicable diseases than the average in Africa, in addition to a current double burden in rising levels of non-communicable diseases. Given this high mortality from both communicable and non-communicable diseases, and the very low physician-to population ratio in Nigeria, it is obvious that the exploding numbers of physicians leaving the country will produce even more dire health statistics in the years ahead if unchecked.

In seeking solutions or reasons for this crisis, it is not enough to point to higher salaries and better working conditions and opportunities overseas and say, ‘what can we do?’

If we intend to put brakes on the growing number of recruiters and facilitators luring our doctors and health professionals overseas, certain steps must be taken. Our government needs to engage urgently with counterparts in destination countries – Australia, the United Kingdom, Canada and the United States to slow their recruitment of African medics – while also asking them to help us build stronger health systems that will keep our professionals at home where they are needed. Development partners must support this process as a more impactful and sustainable form of assistance. It is not acceptable that wealthy nations can trumpet their aid to deficient systems in Africa while benefiting to a significant degree from employing African health workers trained at a fraction of the cost of UK or American-trained medical staff.

Until different levels of government and authorities in Nigeria and across Africa acknowledge and respond to these ‘push and pull’ factors which facilitate and actively encourage the migration of health professionals, it is safe to assume that the trend will continue with dismal consequences for Nigerians and Africans.

Our government can and must also do more to increase health sector funding through higher and more accountable budget allocations, innovative financing mechanisms, as well as enhanced deployment of technology for training, research and service delivery. It also has to look at the bigger picture so that staying in Nigeria is attractive for health professionals and their families. That means focusing on economic strengthening, more and better investments in basic infrastructure such as power, water and sanitation, as well as urgent matters of security and quality education. This will not only minimize the push of physicians to foreign countries but could also attract medical tourism to a stronger healthcare system with more expert and motivated personnel.

Nigerian physicians in the diaspora have long been recognised for their competence in their practise of the art and science of medicine and appear to have built a niche position in the global biomedical landscape as providers of a unique and distinctive way of practising medicine that distinguishes and sets them apart. Given that the majority of these Nigerian physicians practising in the diaspora were trained in Nigeria with its myriad challenges, one can safely conclude that the difference lies in the practice environment. Efforts must therefore be made to strengthen the health system in the country and put Nigeria on the map for quality healthcare delivery from within Nigeria.

Herein lies the challenge to stakeholders at every level in determining the direction of healthcare and economic strengthening in Nigeria. We have to work from within or prepare to face a time when even fewer physicians remain and the country’s health system grinds to an inevitable halt with hardly any doctors available to provide even the most basic health care to our population of almost 200 million men, women and children.

Adaeze Oreh, a family physician and public health expert, is a 2019 Aspen New Voices Fellow.