Support for the bill
In the following, this article presents the reactions of healthcare workers and the greater public, both pro and contra the Medical Brain Drain Bill. While fewer individuals expressed support for the bill compared to those who criticized it, the reasons for backing the legislation were multifaceted. Supporters cited moral considerations, emphasizing the greater medical needs in Nigeria than in Western nations, a sense of patriotism toward the nation, and the belief that medical education in Nigeria is government subsidized.
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Subsidized education
Osagie Ehinire, the immediate past Minister of Health (2019–2023), emerged as one of the most prominent voices endorsing the bill. Ehinire [24] argued that the legislation could effectively address the escalating medical brain drain in Nigeria by emphasizing the subsidized nature of medical education in public universities. Ehinire [24] highlighted that the medical workers’ education is……
subsidized with taxpayer money because if the government allows you to get training for about one-tenth or one-twentieth of the cost of the private university, then it means it is subsidized. Those in that category should also give back to the country, having received a classy education that is respected outside.
Ehinire [24] pointed out that medical students trained in public universities benefit from significantly lower fees compared to their counterparts in private institutions and developed countries. According to him, the burden of reciprocity lies with both the physicians and the country, and supporting the bill serves as a measure to encourage this commitment among medical professionals. The former Minister of Health believed that the education of physicians is highly subsidized, hence they should practice their profession on the ground of reciprocating the favor received. This argument aligns with the concept of “return service obligation” which refers to a contractual or policy-based agreement wherein individual recipients of subsidized education commit to serving in a particular location as a form of reciprocity. In the context of the Bill, Ehinire’s argument suggests a form of return service obligation, where physicians are expected to contribute back to the country that subsidized their medical education by practicing within its borders.
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Patriotic duty as moral obligation
Senator Danjuma Laah, member of the oppositional Peoples Democratic Party, whose tenure spanned from 2015 to 2023, reiterated the moral obligations physicians must remain in Nigeria based on patriotism toward the country. He emphasized that physicians should stay within the country to contribute to its development, driven by a sense of patriotism that should inspire them to overcome challenges and address the health needs of the nation. Laah [34] questioned the rationale behind a doctor, after graduating in Nigeria, choosing to leave the country and argued that a newly graduated physician is….
“supposed to be in the country to salvage his people, no matter the situation.”.
Laah’s argument emphasizes the notion of patriotic duty, suggesting that healthcare professionals should prioritize the well-being of their nation and contribute to its development. This argument aligns with a deontological ethical framework, since from a deontological perspective, the duty to prioritize the well-being of one’s nation and contribute to its development is considered absolute. But if one takes a consequentialist approach, which evaluates the morality of actions based on their outcomes, Laah’s statement might be evaluated differently: If staying in Nigeria does not contribute significantly to the country’s development, but only reinforces a negative situation, such as a lack of professional opportunities for doctors or hindering their personal fulfillment, Laah’s comments would raise moral concerns.
In conclusion, the endorsement of the bill by politicians rested on arguments related to subsidized education, patriotism, and the healthcare landscape amidst the challenges of brain drain. The viewpoint conveyed is that physicians, having benefited from a robust subsidized education, should feel a moral obligation rooted in patriotism to tackle the escalating health issues in the country, notwithstanding the obstacles they may face.
Criticisms against the bill
Although there were some public figures, specifically the above-mentioned three politicians, who voiced support for the bill, their stance was overshadowed by a much larger number of critics. Forty-three individuals and twenty-six medical organizations raised significant concerns about the bill. Criticisms against the bill encompass its impracticality due to inconsistencies, failure to tackle the root causes of brain drain, infringement upon doctors’ fundamental human rights, hypocrisy among the political elite, inconsistencies within the bill itself, worries about increased unemployment, and exacerbation of the brain drain issue.
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Not addressing root causes
Ejim Egba [23], President of the Nigerian Medical Students Association (NiMSA) asserted that the bill was not going to solve the problem of brain drain because it did not address the root causes:
The lack of infrastructure, inadequate and inappropriate remuneration, and poor working conditions are some of the major factors driving medical professionals away from Nigeria. These issues need to be addressed if we want to attract and retain our healthcare professionals and make our land green.
Egba [23] argued that in order to retain the brightest minds in the health sector, the government must address the fundamental challenges in the sector. A fresh doctor who is aware of what is obtainable in developed countries in terms of remuneration will likely migrate. In effect, the NMA president was demanding the government to offer a root cause analysis, that is, examining and addressing the underlying structural problems, rather than focusing on surface-level symptoms.
Other critics, too, highlighted that the proposed bill fails to tackle the root causes of medical brain drain, considering it merely a superficial intervention. Without addressing fundamental issues like inadequate infrastructure, insufficient funding, and poor working conditions – the actual push factor behind medical migration –, the bill is perceived as unlikely to curb the escalating emigration from the health sector. The absence of consultation with professionals during the bill’s formulation raises concerns about its efficacy. The Diaspora Medical Association (DMA), an organization that consist of Nigerian medical practitioners abroad, having been in the health systems of developed countries, issued a statement emphasizing that…
[t]he major causes of brain drain include a poor care delivery framework resulting from a failure to invest in healthcare to foster a conducive environment. Other major drivers include very poor welfare packages, a high level of insecurity, limited opportunities for employment, subspecialty training, and socio-political and economic instability [21].
Emphasizing the Nigerian healthcare system’s structural problems, these quotes demonstrate how representatives of the healthcare sector criticized the government for not looking at the root cause of migration in the health sector. Appealing to government action, these critics asserted that the government must take decisive measures to address the fundamental challenges within the healthcare sector.
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Violation of Doctor’s Fundamental Human Rights
Apart from the criticism of the bill’s alleged superficiality, the bill was widely condemned as a violation of the fundamental human rights of medical doctors, with critics arguing that it constitutes a breach of labor laws and equates to modern-day slavery. The Medical and Dental Consultants Association of Nigeria (MDCAN), boasting a membership of 2,000 and a commitment to maintaining standards and ethics in the medical profession, expressed strong disapproval, framing the bill as a form of modern slavery imposed on doctors:
Curiously, the bill violates the constitution of the federal republic of Nigeria, as Section 34 (1) b states that no person shall be held in slavery or servitude while Section 34 (1) c states that no one shall be required to perform forced or compulsory labor. This bill is, therefore, an excellent example of modern-day slavery [6].
Highlighting the alleged conflict between the bill and existing labor laws and emphasizing the need for adherence to established working conditions, the MDCAN made use of the strong and emotive expression “modern-day slavery” to characterize the bill’s perceived infringement on the rights and freedom of doctors. The use of this in the argument against the bill can be described as a form of rhetorical hyperbole, which involves the use of exaggerated language or statements to emphasize a point, evoke strong emotions, or make a particular issue seem more significant or severe than it might objectively be. By characterizing the bill as a modern-day slavery, the MDCAN strongly condemned and morally reproached the perceived violation of fundamental human rights. Other critics focusing on the perceived unconstitutionality of the bill, highlighted that a bill cannot discriminate doctors against other professions. Employing a rhetorical strategy that challenges the selectivity of the legislation and implies potential bias, Oladapo Ashiru [14], President of the Academy of Medicine Specialties emphasized that the Medical Drain Bill was lopsided against the doctors while let other professionals freely emigrate:
You cannot make a law that violates fundamental human rights. The law is illegal, and you cannot make a law to justify illegality. Nigeria cannot say that it is going to create a law to address just one group of workers; it cannot work.
In a similar fashion, the DMA in an open letter to Femi Gbajabiamila, Speaker of the House of Representatives, questioned why the bill was targeting doctors in particular, as there are other professionals in different sectors migrating out of Nigerien masse and the medical brain drain is just part of the larger picture. Instead of a selective focus on medical workers, the DMA [21] recommended that the government should be…
…taking a holistic approach to a sustainable solution will be ineffective. Young professionals leave the country in search of better opportunities. Many are frustrated by the consequences of governance failures that have progressively worsened over the past 30 years.
The mention of young professionals from various sectors leaving Nigeria implies a commonality of experience, seeking to create a sense of shared challenges among different professional groups. Dr. Enabulele [26], president of the World Medical Association reiterated the position of DMA and asserted that a significant wave of migration is affecting the workforce across all sectors of the economy. Like DMA, Adediran attributed this phenomenon to frustration arising from limited opportunities and the state of governance in the country.
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Inconsistencies in the legislative actions
In 2019, the legislators withdrew a bill aimed at stopping Nigerian political elites using public funds to get medical treatment abroad, citing fundamental human rights issues [50]. Some critics of the Medical Drain Bill juxtaposed this 2019 rejected bill proposal with the new bill introduced to stop doctors from emigration. LinkedIn user Yusuf Balogun [16] hinted at this connection:
What is even more surprising is that in 2019, the same House of Representatives rejected a bill to prevent public officials from seeking medical treatment abroad. Justifying their rejection, the lawmakers argue that the bill would discriminate against elected officials and encroach on their fundamental human rights. If such a bill would violate their rights, then the new bill seeking to tie Nigerian medical practitioners down for five years before they could leave the country is also a violation of the medical practitioners’ fundamental rights.
By juxtaposing the rejection of a bill preventing public officials from seeking medical treatment abroad with the introduction of a new bill targeting Nigerian medical practitioners, thus emphasizing the perceived contradiction or inconsistency in the actions of the House of Representatives, Balogun highlighted the apparent double standard in the legislature’s approach to issues of mobility and fundamental rights. Also calling out the alleged hypocrisy of the political elite, Twitter user (OJ_Banty) [17] argued that the legislators are the cause of the brain drain because they pass and implement “anti-people” bills and policies that will only favor their interests:
Who caused the brain drain in the first place? Keep passing anti-people bills. You kleptomaniacs caused the brain drain in the first place. They’ve come for doctors now, and a lot of you are quiet; it’s only a matter of time before they come for you too.
The latter perceptions are rooted in the belief that a lack of political determination to foster national development serves as a driving force behind the ongoing emigration trends among young professionals. This perspective suggests that political elites may overlook the challenges faced by the country as they are not directly impacted. Simultaneously, there is an expectation for doctors to demonstrate sacrifices and patriotism, as this article presented before.
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Inconsistencies in the bill
In addition to the moral, legal, and political concerns outlined earlier, critics also highlighted technical ambiguities and contradictions within the bill. These inconsistencies raise questions about certain key aspects, such as the commencement of the five-year period—whether partial licenses will be granted before this period begins, or if practitioners will be allowed to practice at all during this time. The bill lacks sufficient detail on these and other important matters. Former Chairman of the Senate Committee on Health, Ibrahim Oloriegbe [47], who transitioned from being a physician to a politician, posed five specific questions regarding the bill:
When does the 5-year period start, before or after housemanship? What sort of license will be awarded to a fully trained doctor instead of a full license to practice under the proposal? Is there going to be a limit to the doctor’s scope of practice, and to what extent are the limits during the five-year waiting period? And we need to establish why we are putting such limits in place—is it for lack of skills or political expediency?
By raising questions about the bill’s limitations and the rationale behind these limitations, Oloriegbe [47] emphasized the uncertainties in the proposed legislation. By drawing attention to potential flaws of the Medical Brain Drain Bill, the politician urged further examination and clarification. On the other hand, Femi Dokun-Babalola, President of the Guild of Medical Directors, expressed the view that mandating medical practitioners to stay without a prior agreement is impractical. According to Babalola (2023), if the intention is to enforce such a measure, providing scholarships with a condition to stay after graduation would be a more reasonable approach:
I don’t see how you can mandate somebody to practice when the person did not sign a bond. If you want to implement this law, you will have to give all medical students a scholarship and make them sign a bond to stay.
From a critical discourse analysis perspective, the arguments presented by both Oloriegbe and Babalola involve questioning and challenging the proposed legislation, revealing potential inconsistencies and suggesting alternative perspectives. Oloriegbe’s questions are a form of critical inquiry, highlighting the lack of clarity and potential drawbacks in the bill. On the other hand, Babalola’s argument is critical in nature, pointing out the impracticality of mandating medical practitioners without prior agreements and proposing an alternative solution involving scholarships and signed bonds. Both perspectives contribute to a critical examination of the bill, aiming to uncover its weaknesses and propose more viable alternatives.
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Challenges and potential for the economy
Another aspect that was raised by critics of the bill is that it would increase the unemployment rate for medical doctors. Some doctors are unemployed or underemployed, and many are not satisfied with their jobs. The bill assumes that the government could absorb all newly trained medical doctors, in addition to those currently employed, which is not always the case. As Uche Ojinma (2023), president of the NMA, observed, not all medical doctors are employed in Nigeria. Therefore, Ojinma (2023) suggested that before such a bill could pass, the government needed to create new jobs to absorb the new doctors:
Many qualified doctors remain unemployed in Nigeria, regardless of the brain drain in the health sector… Jobs and good remuneration should be given to the legion of doctors still seeking employment in the country… When you talk about rural areas, you may be talking about one to 9,000. When you talk of these areas where there is banditry and terrorism, it may be one in 20,000 or more.
Given the prevailing issues of unemployment and underemployment in the country, many individuals perceived the migration trend not as a brain drain but as a potential brain gain, offering both short- and long-term benefits. These voices argued that if lawmakers strategically manage migration, it could serve as a lucrative avenue. For example, according to the World Bank [58], Nigeria received $20.13 billion in remittances in 2022, displaying a consistent increase over the past three years.
One of these advocates for a positive view on emigration was Chima Christian (2023), a public affairs analyst, who contended that leveraging migration could lead to additional foreign currency earnings, considering the substantial global demand for Nigeria’s skilled workforce. According to Christian, this presents a significant opportunity for graduates, as there is a heightened demand for the skilled labor force from Nigeria. The analyst suggests that Nigeria could effectively export these skilled individuals, capitalizing on the demand and generating more foreign currency through remittances. In this perspective, human capital becomes an asset, akin to a new source of wealth, as emphasized by Christian’s assertion that “our new oil is human beings.”
In the same vein, Peter Obi, Labor Party presidential candidate in the 2023 Nigerian election, argued that the brain drain currently experienced would be to Nigeria’s advantage in the long term, especially when governance is taken seriously. The skills that Nigerians in diaspora have acquired will be needed to develop the country. Obi [40] stated that…
[o]ur brain drain today will be our brain gain tomorrow. Nigerians leaving the country may look like a loss today, but when we start doing the right things and taking the governance of our nation more seriously, the knowledge and resources from them will be critical in building the New Nigeria, as happened in China, India, Ireland, and other developing countries.
Challenging the conventional negative narrative associated with brain drain, Christian and Obi offer a positive reading of migration and argue that brain drain favors the economy both in short (remittances) and long term (skills for national development). Through positive framing and appealing to economic interests, they suggested that preventing skilled individuals, including medical professionals, from migrating may be counterproductive to the overall economic development of the country.
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The bill would aggravate brain drain
Finally, critics warned that the bill would not reduce brain drain but instead exacerbate the issue. The restriction on medical doctors is likely to create a sense of constraint, prompting them to explore alternative avenues to leave the Nigerian healthcare system. This might manifest in pursuits like seeking additional medical education abroad or resorting to other potentially unauthorized means. NMA president Ojinma (2023) warned the bill will intensify mass migration, as individuals tend to seek alternative paths when faced with limited options:
We will officially find a way to depart together. Everybody will go; it is like putting fuel on fire. That is what they will achieve.
Ojinma’s viewpoint was reiterated by Kayode Adesola, President of the Association of Nigerian Private Medical Practitioners. Adesola [7] asserted that the bill would worsen the brain drain “because medical doctors do not need Nigerian licenses to practice in other countries.” Other countries usually have their requirements and certifications that they may go for, such as the PLAB (Professional and Linguistic Assessment Board) test in the United Kingdom and the USMLE (United States Medical Licensing Examination) in the United States.
Furthermore, the Medical and Dental Consultants’ Association (MDCAN) anticipated that the bill would contribute to increased inequality. Parents with the means to send their children for medical education abroad might prefer that option, potentially leading to a scenario where doctors trained abroad may prefer to work in those countries rather than in Nigeria. This, in turn, raises concerns about the availability of healthcare professionals within the country:
Many parents who have the means to train their children abroad would gladly do that. Once these children are trained abroad, they will also want to work there. So, who will take over the doctors who are working here in Nigeria? [56]
In addition, the MDCAN statement evaluated the bill as ineffective in preventing medical students who have decided to emigrate. Rather than deterring them, these students might abandon their education in Nigeria to pursue new educational paths abroad. The bill is particularly criticized for potentially driving away bright and financially capable students, contributing to long-term competency challenges in the healthcare sector.
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