Navigating brain drain: understanding public discourse on legislation to retain medical professionals in Nigeria

Abstract

Nigeria is witnessing a mass emigration of its active labor force to more advanced economies, just like other developing countries. Approximately half of licensed medical doctors in Nigeria have emigrated, contributing to a widening doctors-to-patients ratio. In response to this concerning trend, in 2023, a legislator introduced a bill to restrain doctors from leaving Nigeria upon completing their studies by withholding their full license for five years. The public, including health professionals, criticized the bill. This study investigates the public discourse on the bill by extracting and analyzing responses published in newspaper articles, blogs, tweets, and LinkedIn posts. The analysis revealed that, while a few politicians supported the bill, the general populace opposed it due to perceived inconsistencies, a lack of focus on the core causes of migration, allegations of political elite’s hypocrisy, concerns about human rights violations and unemployment. By conducting this research, this article sheds light on the complexities of public opinion surrounding the proposed legislation, providing valuable insights into the multifaceted challenges associated with addressing the medical brain drain in Nigeria. The article contributes to the ongoing debate on the migratory trends of highly skilled workers from developing countries to advanced economies.

Introduction: challenges of healthcare workers in Nigeria

Health disparities and physician migration have always existed. However, the current migration pattern of doctors moving from lower-income to higher-income nations is increasing rapidly [32]. More than 70% of African medical providers have migrated, although they constitute up to one-fifth of physicians in developed countries [22]. In 2016, the World Health Organization (WHO) estimated that there was an international shortfall of 4.3 million medical workers. Sub-Saharan Africa (SSA), which has 24% of the world’s disease population but only 3% of its health workers, suffers the most from this shortage [15]. Although, the brain drain affects all African nations in varying degrees [35], countries in SSA are worst hit, for instance, as of 2017, the doctor-to-patient ratio was about two doctors per 10,000 people [19]. In contrast, the analysis of the World Bank open-source data shows that higher-income countries have 3.3 physicians per 1000 people. Thus, the statistics indicate that low-income countries in SSA have shortfalls of health professional, and the prevailing brain drain will worsen the doctor-patient ratio.

Nigeria serves as a notable example of the challenges faced by many SSA nations. The growing population of Nigeria and its implications for healthcare have already been explored from different vantage points. For example, Omoleke & Taleat [48] examine how recent challenges in the Nigerian health industry have increased the death rate or made the health sector inefficient and unaffordable for many Nigerians [5, 9]. Omoleke and Taleat [48] identified five problems in the Nigerian healthcare system: underpayment, obsolete infrastructure, inadequate medical facilities, and low fund allocation. As a matter of fact, the medical sector receives too little funding to make a difference,Nigeria's healthcare allocation is merely 4% of the annual budget [1]. All these studies highlight the lack of medical professionals: In a country with a population of more than 200 million and 35,000 doctors, Nigeria's doctor-to-population ratio stands at 1:5000, lower than doctor-to-patient ratio of 1:600 recommended by the WHO [4]. In 2023, when Nigeria’s population hit 218 million, there were only 24,000 licensed doctors [49]. A significant contributing factor to this low ratio in the most populous African nation is the widespread migration of healthcare professionals.

Numerous push factors compel Nigerian medical workers to emigrate, including salary delays, non-payment of insurance benefits, unsafe working conditions [10], and systemic issues like poor healthcare delivery, inadequate health programs, and inefficient resource utilization [8]. Further driving migration are low salaries, substandard living conditions, limited career opportunities, poor-quality institutions, dissatisfaction with the political environment, dilapidated infrastructure, corruption, and nepotism [25, 29]. Studies also highlight the pivotal role of health policy formulations which, despite being crafted since 1960, suffer from poor management and implementation, leading to persistent challenges in affordability, fund allocation, facility modernization, and doctor welfare [2, 37, 57]. Moreover, long queues, equipment shortages, and inefficient drug and vaccine management exacerbate these issues [9]. Omoleke and Taleat [48] emphasize that inadequate remuneration diminishes worker motivation, impacting infrastructure maintenance and logistical support [3]. Despite sufficient financial resources, rampant corruption prevents effective healthcare funding, undermining system efficiency and public trust. This dysfunction prompts politicians and wealthier citizens to seek medical care abroad, reinforcing the healthcare disparities between Nigeria and wealthier nations [5, 9]. These systemic limitations led to poor performance across the health industry and were highlighted by 17 fruitless industrial strikes between April 2016 and April 2017, which failed to address issues like poor remuneration and job insecurity [46, 49].

These push factors drive many Nigerian doctors to seek better compensation abroad [49]. The pull factors for migration of Nigerian medical professionals include higher salaries, more supportive work environments, opportunities for professional development, advanced healthcare infrastructure, access to research, and well-established professional networks, which not only promote career growth but also enhance social recognition [18, 27, 30]. As a result of these pull and push factors, as of November 2021, over 8,000 licensed Nigerian doctors had relocated to the United Kingdom, and by mid-2022, an additional 700 had left to practice internationally [38]. From 2016 to 2018 alone, nearly 9,000 Nigerian medical professionals moved to the UK, US, and Canada, with the demand for healthcare staff in these industrialized nations further amplified by the COVID-19 pandemic [28]. Licensing in these countries is a relatively straightforward processes: In the UK, a preferred destination due to its established Nigerian communities, competitive salaries, and robust healthcare system, Nigerian doctors must meet English language proficiency standards, pass UK Nursing and Midwifery Council qualification verifications, succeed in a computer-based examination, and cover registration costs. The US and Canada have similar requirements involving transcript reviews and licensing exams. [18, 28].

The drain of expertise in Nigeria’s healthcare sector leads to further challenges, such as shortages in rural healthcare, burnout, and lower presenteeism [39]. Anetoh & Onwudinjo [12] and Okafor & Chimereze [44] observed that migration results in more people needing health care, healthcare disparities, a lack of expertise and resources, negative effects on the economy, and public health concerns. Although, doctor migration may affect home and destination economies [43, 51], losing qualified physicians in the home country may limit healthcare services, increase the workload for remaining healthcare professionals, and raise healthcare costs as governments may need to hire more costly temporary employees or recruits [37]. However, in the destination countries, talented physicians may address holes in the healthcare system and enhance treatment at the expense of their home nations [31]. Thus, the migration of Nigerian doctors to industrialized nations deprives the country of crucial healthcare expertise that could mentor future medical professionals and influence healthcare policies [42]. The COVID-19 pandemic caused a severe public health crisis that endangered human lives and heightened the inability of the government to invest in healthcare. During the pandemic, the national health systems could not handle effectively the increased demand of vulnerable people and patients who require admission into critical care unit to treat COVID-19 [52]. For example, the existing facilities were burdened with common health conditions such as diabetes, cancer, high blood pressure, meningitis, stroke, tuberculosis, and cardiovascular ailments [53]. Moreover, essential health services such as routine immunization, family planning, perinatal care, tuberculosis, HIV/AIDS, and malaria were disrupted [45]. Amid the surge of the COVID-19 pandemic, the Nigerian government cut down budgetary allocations straining the already struggling system leading to insufficient personal protective equipment (PPE), lack of essential medicine, shortage of health workers due to illness, disruption of health services, and low motivation of health work force [41, 45], Thus, the setback caused by the pandemic on the Nigeria’s health sector, due to the lack of preparedness for the pandemic and low investment [41], caused many healthcare professionals to seek greener pastures in western countries [54]. The COVID-19 pandemic further exacerbated the dire situation of the healthcare system, ultimately leading to the 2023 Anti-Brain Drain Bill.

The Anti-Brain Drain Bill

In 2023, House of Representatives Member Ganiyu Abiodun Johnson, belonging to the ruling All Progressives Congress party, introduced a law called the "Medical and Dental Practitioners Act Amendment Bill" in response to the worrisome trend of brain drain in the health sector. This bill mandates graduates in the medical and dental fields to serve in Nigeria for five years post-graduation before obtaining a license. The bill in its essence compels health workers to contribute to their home country's healthcare system before considering emigration [13]. The bill successfully passed the second reading in the House of Representatives, marking it as an interim measure to address the escalating migration trend. Sule [55] asserted that the House of Representatives proposed the Medical Brain Drain Bill as a quick fix for this trend.

The bill has generated varying comments from government officials, health experts, and the public. While fielding questions from journalists, Minister of Labor Chris Ngige argued that the bill is unworkable due to the human rights infringement on the doctors, despite its good intentions [13]. Members of the Opposition in Parliament criticized that the bill infringes on medical doctors’ rights, but the Speaker of the House, Femi Gbajabiamila pointed to Sect. 45 of the 1999 constitution which allows the Federal Government of Nigeria (FGN) to suspend certain rights due under specific conditions [36]. The bill sparked significant controversy and backlash among healthcare professionals and the public. Innocent Orji, the president of the Nigerian Association of Resident Doctors, expressed disapproval of the bill. Orji [49] highlighted the government's failure to address critical issues such as poor compensation, job insecurity, stagnant wages, and currency exchange rates, which, he argued, justified medical workers' reluctance to remain and practice in Nigeria. Healthcare professionals abroad strongly opposed the bill, viewing it as a violation of their rights, particularly considering the government's track record of not fulfilling promises regarding the welfare of Nigerians [11].

Exploring the criticisms and suggested solutions is crucial to the sustenance of the health sector in Nigeria. The present study identifies the public’s mixed reactions to the medical brain drain bill and doctors’ emigration from Nigeria. These reactions are evaluative mechanisms about the doctors’ frequent emigration and the government’s reaction to the trend. Investigating these discourses is crucial for gaining insights into the underlying sentiments, concerns, and evaluations expressed by citizens and healthcare professionals, shedding light on the complexities of the medical brain drain issue and providing valuable perspectives for informed policymaking and public discourse. Understanding the diverse perspectives, concerns, and arguments presented by various stakeholders allows policymakers to consider a broad range of factors before implementing or amending legislation. Public discourse analysis also helps identify gaps, inconsistencies, and concerns within the proposed bill. By examining the arguments made by different groups, policymakers can pinpoint areas that require further clarification or revision. This contributes to the development of more robust and effective policies.

Methods

This study employed a grounded theory approach to analyze data extracted from X (formerly known as Twitter), newspaper articles, and blogs related to the medical brain drain bill. The dataset primarily consists of secondary, publicly available data, including observable and reported information. National newspaper websites such as Vanguard Nigeria, Punch Nigeria, The Guardian Nigeria News, Business Day Nigeria, Business Post Nigeria, Daily Post Nigeria, This Day Live, Leadership Newspaper, Premium Times, and The Cable Nigeria, along with news websites like Per Second News, Ripples Nigeria, Business Post, Deutsche Welle, LinkedIn posts, and tweets on X. X searches were conducted using the keywords "health brain drain Nigeria,'' "medical brain drain," "brain drain bill," and "anti-brain drain bill" to locate tweets discussing reactions to the Bill. We conducted searches on X and Newspapers between July 5 to July 7, 2023.

The gathered tweets, newspaper articles, blog posts, and LinkedIn posts were compiled and edited. Notes from the compilation were then subjected to Thornberg and Chamaz's (2014) grounded theory approach by analyzing actions and processes through the use of gerunds for the initial codes, creating descriptions and narratives, and developing inductive categories in the focused coding. The initial coding technique involved sentence-by-sentence reading. Using the initial codes that emerged from the first process, we developed focused codes developed to discover the most frequent and significant initial codes. The focused codes are “not addressing the root of medical brain drain”, “aggravating the brain drain”, “concerns about unemployment”, “subsidized education”, “hypocrisy of the political elites”, “moral obligation”, “inconsistencies in the bill”, “infringement of fundamental human rights”, “enabling environment”, improved working conditions of the doctors”, “improved funding of the health sector”, “infrastructure and amenities”, “subsidized education versus market rates”, and going to court against the bill”. These focused codes were subsequently categorized into three overarching themes: support for the bill, criticism of the bill, and suggested solutions. For the sake of brevity, the current study used the first two themes – support and criticisms of the bill. We tested our focused codes with the concepts in the Push and Pull theory such as unemployment, low wages, lack of economic opportunities, lack of access to education, political instability, among others. We did not de-identify the names of public figures, leaders of healthcare professional associations, and names published on newspaper channels, and social media posts (LinkedIn and Twitter not restricted because these data were in the public domain.

The grounded theory approach of Thornberg was used to guide this study because it allows for a systematic yet flexible methodology for investigating complex social phenomena. Grounded theory is useful in this context because it does not start with a preconceived theory; rather, it allows theories to emerge through the process of data collection and analysis. This is essential when examining contemporary social issues like the medical brain drain, where the factors involved, and their interrelationships can be complex and multifaceted. Moreover, Thornberg and Charmaz's version of grounded theory emphasizes constructivist elements, recognizing that the findings are co-constructed by the researcher and participants. This perspective acknowledges the subjectivity inherent in the interpretation of social data, which is critical when analyzing discourses on contentious topics such as healthcare migration policies. By situating the analysis within the specific contexts of the data sources—such as social media platforms and newspapers—this approach provides a rich, nuanced understanding of how different stakeholders perceive and articulate their positions on the brain drain bill. Although, the goal of grounded theory is to create a theory, we used the elements of the approach to create the analytical categories for the understanding of medical brain drain in Nigeria, and the public’s responses to the anti-migration bill.

Results

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.

• a 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.

• b 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.

• a 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.

• b 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.

• iii. 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.

• iv. 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.

• e 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.

• f 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.

Conclusion

As this article has shown, the 2023 Medical Brain Drain Bill in Nigeria has triggered extensive public discussions, revealing divergent viewpoints on its potential impact on the healthcare system. Supporters argued that restricting the migration of medical professionals could positively affect healthcare standards and accessibility within Nigeria. Supporters argued that by retaining more medical professionals within Nigeria, the country can strengthen its healthcare infrastructure tackle the healthcare provider scarcity, and challenge wait times, lower-quality care, and limited access to specialized services, especially in rural areas.

Conversely, critics emphasize the importance of granting healthcare professionals' greater freedom for personal and career development. They argue that restricting their mobility might impede career advancement, potentially leading to frustration and disengagement within the local healthcare sector. Critics highlight root causes such as poor working conditions, low wages, limited career opportunities, oppression, and inadequate safety measures and resources as key drivers pushing medical professionals to seek opportunities abroad.

The discussions surrounding the Medical Drain Bill reflect broader socioeconomic and political issues in Nigeria, such as corruption, inadequate public healthcare funding, and skepticism regarding the government's capacity to effectively manage the sector. Further exploration and engagement with various stakeholders, including healthcare professionals, policymakers, and civil society organizations, are necessary to identify potential solutions that strike a balance between the healthcare system's needs and the interests of medical practitioners. With the diverse responses to the bill, it is crucial to weigh different perspectives and engage in comprehensive discussions and research to formulate effective policy decisions and address the Nigerian healthcare system's challenges.

The migration of healthcare personnel in Africa is an enduring problem with evasive solutions [33], while some previous solutions focused on underdevelopment and shortage of manpower, others focused on the neglect and hopelessness faced by skilled workers in Africa [20]. This article presented a nuanced understanding of the complexities involved, laying a foundation for evidence-based interventions and further efforts to strengthen healthcare systems in SSA, and Nigeria in particular. Hopefully, this analysis can contribute to a better understanding of the challenges facing the Nigerian healthcare system.

The challenges facing the healthcare sector in Nigeria are a product of widespread social dissatisfaction among the citizenry, and specifically among the professionals. Thus, the study recommends the creation of an enabling society with better welfare packages, improved working conditions with advanced technologies and infrastructures, increased funding to the health sector, equity in salary payment, increased living standards with better housing, quality education, and improved security. Also, we recommend that any retentive policies and laws in the health sector must be entered into voluntarily, with profound consultation with the stakeholders, and guided by the principles of fundamental human rights. With better funding, investment in healthcare, and patronization of the political elites, the Nigerian healthcare sector will become attractive to both the health professionals in Nigeria and those in the Diaspora. Despite the novel approach of the study, it has some limitations. First, we only captured the conversations on social media and the newspaper posts, which may bias the conclusion of the study. Future studies could examine empirically, the migration trend among healthcare professionals in tertiary, secondary, and primary healthcare facilities in Nigeria. Also, other studies could examine medical tourism among the political elites of SSA countries using secondary data.