50 YEARS OF POSTGRADUATE MEDICAL EDUCATION IN NIGERIA:
ACHIEVEMENTS, CHALLENGES AND PROSPECTS.
Keynote Address
by
Nimi Briggs, OON, DFMC, FAS.
PROFESSOR Emeritus, University of Port Harcourt.
at the
50th Anniversary celebrations
of the
National Postgraduate Medical College of Nigeria
Wednesday, September 18, 2019
email: nimi@profbriggs.net
website: nimibriggs.org
DEDICATION
This lecture is dedicated to the memories of late Professors Emmanuel Adeyemo Elebute, DFMC and Michael Akintayo Bankole, who, at their tenures as President and Registrar respectively of the National Postgraduate Medical College of Nigeria, worked assiduously to advance the fortunes of the institution.
ACKNOWLEDGEMENTS
I thank the authorities of the National Postgraduate Medical College, especially the College Registrar, Professor Owoidoho Udofia and the College Hon. Treasurer, Professor Stanley Anyanwu for supplying some of the information which enabled me to prepare this keynote address. I also thank my colleagues, Professor Alice Nte, Professor of Paediatrics and Child Health, University of Port Harcourt and Professor Isaac Adewole, immediate past Hon. Minister of Health of the Federal Republic of Nigeria who read through the script and made valuable suggestions.
In the past 50 years or thereabout, two Colleges, the National Postgraduate Medical College of Nigeria (NPMCN) and the West African Postgraduate Medical College (WAPMC) have been saddled with the responsibility of promoting formal postgraduate medical education in Nigeria, especially the training of competent clinical specialists. Like all things of enduring value, the establishment of these two Colleges was not without its challenges as there were cynics who were of the view that the time was not opportune for the country and the sub region to embark on such a measure. Thank God the visionaries that were sedulously dogged in their pursuit of the noble venture at the time steered the course, giving rise to the success story of today. For, not only have these Colleges fulfilled their mandates to a large extent, they have also proved to be some of the greatest assets of not just our dear country, Nigeria, but also of the West African sub region.
I therefore feel privileged and honoured to be invited to deliver the golden jubilee anniversary lecture of one of them, the NPMCN. My appreciation heightens when I recollect that it was only last year, precisely on 20th September 2018 that the College conferred on me the status of Distinguished Fellow of the Medical College (DFMC) at its 36th convocation ceremony. Accordingly, I wish to commence this golden jubilee anniversary lecture by expressing my profound indebtedness to the President, Professor Opubo daLilly-Tariah and the other authorities of the NPMCN for their kind invitation.
Formal medical education at the Bachelor’s degree level commenced in Nigeria with the establishment of the University of Ibadan, first as a College of the University of London in 1948 and then, as a full-fledged and autonomous university in 1962 when Nigeria’s federal parliament passed a Bill for the establishment of the University of Ibadan. Along with this development came the founding of the University College Hospital (UCH) Ibadan in 1957 as an apical health institution for training health personnel especially medical students, caring for the sick and carrying out health related research. Not only was the Ibadan university/teaching hospital complex an instant success, other medical schools and faculties of medicine with corresponding teaching hospitals in Lagos, Enugu, Zaria, Benin and Ile Ife followed on the heels of Ibadan and in similar mould thereby sufficiently preparing the grounds for medical education to be taken beyond the Bachelor’s degree level in the country. So, when under the general supervision of the Nigeria Medical Council (NMC), the regulatory body in Nigeria for the practice of Medicine and Dentistry at the time, structured formal postgraduate teaching in Medicine began in the late 1960s, there were sufficient well-trained staff to take on such a technical assignment, albeit, still amidst jeers and doubts from pessimists for the prospects of such a venture. However, the point must be made that even before this formal commencement, some doctors who trained abroad for their Bachelor’s degrees, especially in the United Kingdom (UK) occasionally came to hospitals in Nigeria like the Adeoyo State Hospital, Ibadan, Aba General Hospital, Aba, Braithwaite Memorial Hospital, Port Harcourt with a good compliment of foreign doctors, to gain wider experience in clinical practice in informal ways before returning to the UK to complete their postgraduate work in one or the other of the Royal Colleges in Medicine.
Thus, the Residency Training Programme in Nigeria formally commenced under the auspices of the NMC, which is now known as the Medical and Dental Council of Nigeria (MDCN), following the amendment, in a new section 7A of the Medical and Dental Practitioners’ Act of 1963, by Decree 44 of 1969, the date on which this year’s golden jubilee celebrations are predicated. Pursuant to that amendment, the NMC set up Joint Boards in Medicine, Surgery, Obstetrics and Gynaecology, Paediatrics, Public Health and Dentistry. In 1970, the Nigerian Medical Council (Postgraduate Examinations) Regulations (including the syllabi) were published. The first examinations by the NMC were conducted in 1972 and the first set of trainees completed the programme in 1976. Before this initiative, all postgraduate specialist medical trainings, in the whole of West Africa, were done abroad.
After the commencement of training by the NMC, the National Medical College Act, Decree 67, of 24th September 1979 now Cap N 59 Laws of the Federation 2004 transferred the responsibility for postgraduate medical education from the Medical and Dental Council of Nigeria (MDCN) to a designated College – the National Postgraduate Medical College of Nigeria (NPMCN) which was set up as a body corporate with perpetual succession and a common seal.1 The College is charged majorly with the responsibility of producing specialists in all branches of Medicine and Dentistry through the production of curricula, accreditation of training institutions, conduct of professional postgraduate examinations and the certification of candidates.
At about the same time, the West African Health Community (WAHC) established the Commonwealth West African Regional Health Secretariat in May 1972. This was done by the Governments of The Gambia, Ghana, Nigeria and Sierra Leone in co-operation with the Commonwealth Secretariat in London. The Assembly of Health Ministers of these countries together with that of Liberia signed the Treaty in October 1978 establishing the West African Health Community to undertake such activities as would contribute towards the attainment of the highest possible standards and protection of health of its people through co-operation among the Member States. In January 1975, the West African Postgraduate Medical College (WAPMC) a specialised agency of the West African Health Community (WAHC) was established to serve as an umbrella College for the West African College of Physicians (WACP) and the West African College of Surgeons (WACS). The structure of Faculties, Curricula and Regulations for training and examinations leading to the award of the Fellowships in the Colleges of the WAPMC emerged and the first examinations took place in October 1979. Consequently, the Residency Training Programme leading towards the production of clinical specialists as an important component of postgraduate medical education in Nigeria has become firmly established through the activities of these Colleges – NPMCN, WACS and WACP. Furthermore, the success of the training programmes in Nigeria which commenced in 1969 with the Nigerian College has spurred other countries in the sub region, especially the anglophones to establish similar programmes in their respective countries. For instance the Ghana College of Physicians and Surgeons was established as a National Postgraduate Medical College for training specialist doctors in Medicine, Surgery and related disciplines by an Act of parliament in 2003, while those in Liberia and Sierra Leone were established in 2013 and 2018 respectively. This was without prejudice to the training programmes by the WACS and the WACP which are also run in most countries in the sub region.
Done with the historical background, I will subsequently focus more on the NPMCN in addressing the issues raised by the theme of the anniversary celebrations, which is also the title of today’s lecture. In the first place, it is the NPMCN’s golden jubilee anniversary that is being celebrated. Secondly, it was only last year (2018), on the 27th February, that I had the privilege of delivering the 20th in the series of the Big Lecture – the Sir Samuel Manuwa Memorial Lecture of the WACS at Banjul, the capital city of The Gambia. In that lecture, titled In Pursuit of Justice and Equity: Rooting For The Health Of The Poor2, I made some remarks on the achievements, challenges and prospects of the WACS which, to my mind, should serve today’s purpose.
I will examine the issues that are involved in the title of today’s keynote address – the achievements, challenges and prospects of the College, seriatim.
Certification and recognition as specialists by the NPMCN is through its fellowship. Thus specialists of the College are known as Fellows of the College.
4.1 Fellows by Examination.
In accordance with its mandate, the NPMCN has produced many specialists in several branches of Medicine and Dentistry who are designated Fellows of the College in their areas of specialisation.
Fellowship by Examination is currently the highest of the College’s earned qualifications and is open only to medical graduates of approved universities who have been fully registered by the MDCN. Thus far (2018), the NPMCN has produced 6,052 of such Fellows as specialists in 15 fields of Medicine and Dentistry (Table1). Since this is the major remit of the College, it can be argued that the College is achieving the purpose for which it was established.
To obtain this qualification, candidates have to undergo a Residency Training Programme, an amalgam of what obtains in several different countries, of not less than four years in a health facility approved for the purpose by the Senate of the College, after the candidate would have passed the primary examination of the College or those of other institutions recognised for the purpose, to determine trainability in his or her area of choice. In addition, the candidate is expected to pass the Parts I and II Examinations of the relevant faculty during the period of the residency training, having met the requirements for sitting for the examinations.
In order to arrive at its current training, examination and certification models, the College produced curricula for programmes in various faculties, identified courses to be taught, from the basic sciences through to the clinical disciplines, accredited various hospitals in the length and breadth of the country to house the Residency Programmes and also accredited qualified teachers to supervise the training of the candidates. The fact that the College has been largely successful in putting this package together, is attested to by the quality of the Fellows by Examination who are generally regarded as competently trained specialists. The College deserves commendation for evolving such a complex system of training in higher education.
The impact of this achievement on higher education especially medical education as well as health care in Nigeria has been tremendous. For one thing the trainee-fellows all rendered services while in training – services that would have been lost to the health care delivery system had they trained outside the country. Furthermore, many of the academic staff currently serving in the medical schools of various universities in Nigeria are Fellows by Examination or Foundation Fellows of the NPMCN and/or one of the West African Postgraduate Medical Colleges. There they have risen through the ranks to the very pinnacle of the university system as Vice-Chancellors, Presidents of Postgraduate Colleges, Chief Medical Directors of University Teaching Hospitals, Professors, Honourable State Commissioners and Federal Ministers. They also serve as consultants to their various affiliated teaching hospitals, undertake care of critically ill patients and carry out research. Furthermore, a good number of them have established high quality private medical care facilities in the country. The story of the late Dr. Stella Ameyo Adadevoh is compelling just as those of the many other Fellows who have rendered exceptional services to the country.
Fig. I. Stella Ameyo Adadevoh (27 Oct.1956 – 19 Aug. 2014)
Dr. Stella Ameyo Adadevoh, not having previously seen one, accurately diagnosed an index case of Ebola virus infection in Nigeria which reported in July 2014 to a private hospital in Lagos where she served as a consultant physician. She applied the principles of Public Health and quarantined the patient even against threats and so saved Nigeria from the heavy burden of the epidemic that was ravaging parts of West Africa at the time. In the process, she contracted the infection and died. She was a graduate of the University of Lagos and also had her postgraduate medical education at the Lagos University Teaching Hospital (LUTH).
.
In all, it is difficult to imagine what the state of medical education and specialised health care would have been in Nigeria without the input of the Fellows of the Postgraduate Medical Colleges in the country. Of the 104 specialists serving as lecturers/consultants in the four clinical Departments of Obstetrics and Gynaecology, Surgery, Internal Medicine and Paediatrics at the University of Port Harcourt Teaching Hospital, 102 (98%) are holders of the Fellowships of one of the West African Postgraduate Medical Colleges or the NPMCN or both.3 Not surprising therefore, a number of Fellows by Examination of the College have received recognition by reputable foreign postgraduate medical colleges confirming that the training they had in Nigeria is as good as they would have had in other good centres of the world. The award of the Fellow ad eundem (FRCOG) to Professors Friday Okonofua (2008), Isaac Adewole (2016), Akinyinka Omigbodun (2017) and Oladosu Ojengbede (2017), all Fellows by Examination of the NPMCN, and also Professor Bisallah Ekele (2015), Fellow of the WACS by the Royal College of Obstetricians and Gynaecologists, London, as well as similar recognitions to Fellows in other disciplines, support this position.
So also is the fact that several recruiting agencies from different parts of the world come to Nigeria to recruit Nigerian trained doctors and specialists for job opportunities in other countries.
Okonofua Adewole Omigbodun Ojengbede
Ekele
Fig. II. Nigerian trained Fellows awarded Fellow ad eundem (FRCOG) by the Royal College of Obstetricians and Gynaecologists, London (2008-2017).
Furthermore, only recently, in March this year (2019), Theresa May, then Prime Minister of the United Kingdom had cause to congratulate Nigerian professionals in the British National Health System (NHS) at the Nigerian HealthCare Professionals UK Celebrations and Awards Night, marking the NHS @ 704 at which the then Nigeria’s Hon. Minister of Health, Professor Isaac Adewole was the Guest of Honour. Said she at that event, “Your contribution has had an important influence on our vital health care system helping to shape the NHS and the diversity of its workforce.” It transpired that a good number of the doctors who were honoured at that event, had their postgraduate training in the Residency Training programmes in Nigeria and passed one or both of the postgraduate medical college’s examinations in the country before migrating to the UK to commence a new career. There, some have become professors in acclaimed universities, serve as consultants to various Hospital Trusts, while others are excelling in private medical practice.
4.2 Fellows by Election and Awards
The College also admits Fellows by Election and awards Fellowships to eminent personalities in society (Hon. Fellows of the Medical College -HFMC) or Fellows of the College who have distinguished themselves in the service of the institution – Distinguished Fellow of the Medical College (DFMC). So far, there are 900 Fellows by Election, 20 Honorary Fellows and 51 Distinguished Fellows in addition to the Foundation Fellows of the College. Being highly placed individuals with a track record of noticeable achievements, these Fellows advocate for the College as its ambassadors, raising its profile and visibility. The current list of Fellows outside those by examinations includes former presidents/heads of state, former presidents of the College, academics of global repute, revered natural rulers, state governors and highly successful businessmen. The College deserves commendation for extending recognition to such persons as they advance the course of the institution.
4.3. Diplomates
In an effort to ameliorate critical shortages in some dedicated areas of clinical care, the College approves the award of Diplomas as middle level, sub-fellowship certifications with sufficient clinical component to enable recipients operate with safety in the designated areas. These areas include Anaesthesia, Family Medicine, Ultrasonography in Radiology, Audiology in Otorhinolaryngology and Forensic Pathology in Pathology. Some of the areas have produced Diplomates – Anaesthesia (26), Family Medicine (717), others are still in the process of training.
4.4 Medical Residency Training Act, 2018
Only recently, residency training of medical doctors and dentists in Nigeria was given a boost by the signing into law of the Medical Residency Training Act, 2018 by President Muhammadu Buhari on 26th June 2018. The Act directs the NPMCN to be the regulatory body in charge of the implementation of its content and requests it to establish a National Curriculum and Scheme of Work in consultation with the West African College of Surgeons and the West African College of Physicians for a junior and senior residency programme. This is another important landmark for the College as its residency programme is now recognised by law. The Act provides additional platform to improve funding of residency training programme by creating budget line items within the budget of the training institutions as well as timelines for training and exit from the programme.
4.5 Administrative Setup
The Act establishing the College made provision for a College President to serve as chief executive and accounting officer. This post has been occupied by persons who are not employees of the College and so do not carry out the day to day management of its affairs. Additionally, there were issues bordering on the status of the faculties in relation to one another, chairmanship of the governing board and senate of the College. At its inception, getting round all this proved difficult for the juvenile college and led to friction and altercations among organs of the College. However, that period proved to be a learning curve as the College seems to have established a mastery over the system and now runs its activities in a seamless manner. This is a great achievement as such disagreements hardly arise now in the administration of the College. Furthermore, during the period of the learning curve, the College was still able to carry out its statutory functions of postgraduate training and certification without major disruptions.
4.6 Permanent Site and Physical Development
It is an important achievement for the College to have secured a large parcel of land at Ijanikin, Kilometre 26 Lagos – Badagry Expressway in the suburb of Lagos for its permanent location and development of college infrastructure, considering the difficulty associated with land acquisition in the crowded city of Lagos and its environs. The College prior to that acquisition relied on the benevolence of other institutions for office space, moving from one location to the other – the premises of the NMC in Lagos, an office at LUTH and the premises of the Ikejiani Hospital on Apapa Road, Lagos. Although infrastructural development is always work in progress, the College has constructed access roads, senate building, administration hall and other structures needed for its effective function. The development of the permanent site gives prominence and credence to the existence of the College which now has a permanent address and location.
4.7 Continuing Medical Education
The College has established a number of continuing medical education activities designed to enlighten its fellows and the general public. These consist of public lectures, seminars and public debates that are delivered in various ways including on-line services. It also runs research methodology and health resource management courses twice a year for candidates preparing for the Part II fellowship examinations. In addition, the College has founded a peer reviewed journal of international standard – The Nigeria Postgraduate Medical Journal which is published quarterly and allows free on- line access (open access). The journal serves as an outlet for disseminating scientific information by Fellows and trainees of the College as well as the general public. It is registered with a number of abstracting partners and is indexed with MEDLINE, Index Medicus and SCOPUS among others. Furthermore, the Federal Government of Nigeria recognises the NPMC as a resource institution from which it seeks advice and expert opinion on issues pertaining to health and health care delivery.
4.8 Local Impact
A public institution of the calibre and status of the NMPCN is expected to positively impact the environment within which it is located. Indeed, the College does. Ijanikin, the suburb of Lagos where the College is situated, has experienced phenomenal influx of population and increase in business activities, at least in part, due to the presence of the College in Ijanikin town. Furthermore, a good number of the sons and daughters of Ijanikin have secured employment in the College and are doing well. The College also owns a Guest House in Ijanikin which is open to the public.
5.1 Annual Output of (Trainees) Fellows by Examination.
Most Fellows by Examination prefer to pursue careers in universities and their affiliate teaching hospitals or with huge corporate organisations or establish private practice in one of the big cities in the country where social amenities, especially electricity and schools are better. This leaves very few to serve in health institutions established in distant areas mostly by state and local governments. Criticisms have therefore arisen that the College is not producing enough specialists to service the health care delivery system of the country. A review of Table 1 shows that even the faculties with the highest trainee outputs – pathology, internal medicine and obstetrics and gynaecology produced 764 (12,6% of total output), 764 (12.6% of total output) and 749 (24.9% of total output) respectively in the 50 years of training which are being celebrated. This gives an average of 15,15 and 14 specialists per annum even for the most productive faculties! While accepting that the numbers are few, the College is of the view that the turnover is related to several factors – availability of places for residency training, availability of qualified supervisors for the programme and the time taken by the trainees to acquire the relevant skills and proficiency needed to pass the various examinations and practise as competent specialists. The College argues that it will not compromise the quality of its training and that one way of solving the problem is to improve the standards of public health institutions where training of residents is carried out so that more doctors can take on the training. Furthermore, the general unwillingness or inability of state governments to implement the proper renumeration scales for physicians, let alone the poor working environment of many state health institutions makes a career with state ministries of health unattractive to many doctors. This is borne out by the concentration of consultants in federal teaching hospitals compared with their presence in state ministries of health in the states in which they are located: UCH Ibadan 325, Oyo State Government 25; University of Maiduguri Teaching Hospital 101, Borno State Government 10; University of Port Harcourt Teaching Hospital 195, Rivers State Government 58; Usmanu Danfodiyo Teaching Hospital 112, Sokoto State Government 21; Nnamdi Azikiwe Teaching Hospital 150, Anambra State Government 50 of which 40 are in the state teaching hospital; and University of Ilorin Teaching Hospital 155, Kwara State Government 18.
Another approach would be for the College to consider awarding a certification, say a membership at the successful completion of the Part 1 Examination. Such candidates can then go on to become clinical specialists and can work as such in any part of the country while the Part II Fellowship candidates can opt to pursue careers with more academic requirements as those in universities. The WACS is currently applying this measure to solve the problem of shortage of specialists.
Furthermore, the College can also establish a hospital in Abuja, the nation’s capital, through a Trust or Foundation which will not only serve as a teaching institute for the training of postgraduate doctors but also as a Quaternary Medical Centre in the pattern of the Great Ormond Street Hospital, Hammersmith Hospital, London or the New York Presbyterian Hospital, all with postgraduate institutions where very advanced medical care, not easily accessed by the general public will be made available. In conjunction with the NPMCN, such a complex will not only give the College presence in the nation’s capital but will also form the basis for the National Referral Hospital and Postgraduate Medical School – a concept that received strong government attention in recent times. Among others, this will permit an expansion of the existing faculties to allow for sub specialisation and an increase in the overall capacity for training. It can also serve as an attraction to the many highly trained Nigerian specialists in the diaspora who are keen on returning periodically to offer various forms of specialised care. The institute could offer them adjunct appointments in order to make the relationship formal. It was this model of interchange that was described as brain circulation as opposed to brain drain at the 36th Convocation Lecture of the college last year.5 As is currently the case, the brain drain phenomenon among doctors, which sadly is strongest among the newly qualified, has now reached crisis proportion in the county.
In this regard, the celebrations of the College’s golden jubilee in the nation’s capital city of Abuja seems to be an opportune time for the College to meet federal government authorities for an appropriate parcel of land in the city to situate the proposed expansion of the College.
5.2 The “one year abroad” programme
Spending a period of at least six months in an overseas hospital as part of the training before sitting for the Part II Examinations was initially approved by the Council for the Faculties of Ophthalmology and Obstetrics and Gynaecology. The aim was to expose the trainees to aspects of clinical care in those disciplines which had not been sufficiently developed at the time in the country. Thus, it was meant to be temporary and to be phased out as facilities improved in the training institutions in the country. But the programme suffered some difficulties. First, all faculties came on board with their trainees. So, the number on the programme ballooned and became a burden first to the training institutions which paid the bill initially and then to the Federal Ministry of Health which came to the rescue of the training institutions later, at a time when the nation’s currency, the naira, had suffered massive devaluation. Furthermore, there were abuses. In some cases, overzealous college officials sought very expensive institutions abroad for their cronies and there were also cases of trainees who took advantage of the opportunity and abandoned the Nigerian programme and did not return to the country after completing their period abroad. Accordingly, the programme ultimately atrophied and died. So, current trainees no longer have the opportunity. But there is a strong clamour for the programme to be resuscitated since the current condition of many of the training institutions is worse than was the case when the programme was in operation.
To my mind, resuscitating the programme in its original form will be a tall order given the parlous state of the nation’s economy. A better alternative would be to upgrade the institutions here to the required standards, including the establishment of a Quaternary Hospital. This was what the Federal Government of Nigeria/VAMED Engineering Teaching Hospitals Rehabilitation Project of 2002 and those before it and after are supposed to have done but the initiative was not sustained after some initial successes.
5.3 Career of Fellows
Doctors at all levels are not immune to the effects of living in the harsh environment which Nigeria has become – sporadic killings, incessant kidnappings for ransom, unbridled chaos, massive unemployment, lack of job satisfaction and environmental rot have become daily issues to deal with. This is fuelling a strong urge of people to leave the country in search of safety and greener pastures, especially, the youths and the middle-aged. Doctors appear to be leading this vanguard. Realities dawn usually following graduation at the Bachelor’s level when even obtaining placement for internship becomes a problem.6 According to the MDCN, of the 29, 406 doctors who were registered to practise in Nigeria in 2018, 1,551 requested for and obtained Letters of Good Standing from Council to enable them to emigrate from the country. About 90% of such persons, obtained placements outside the country. As for the Fellows of the postgraduate colleges, theirs is hinged on finding good places in which to pursue decent careers – a situation that pushes most of them to flock to universities in search of lecturer/consultant positions.
5.5. Relationship with other members of the Health Team
There is currently some animosity between some members of the health team and doctors in Nigeria to the effect that doctors should no longer be considered as leaders of the health team. The laboratory scientists seem to hold more strongly to this view than any other and have even gone on to obstruct some pathologists – especially microbiologists, haematologists and chemical pathologists from sharing laboratories with them. This has led to unhealthy rivalry in some places. While it is absurd for anyone not to recognise the centrality of the doctor in the health delivery team, it is equally important for doctors to reflect on those issues that bring them into conflict with other members of the health team. Experience shows that this happens more in environments where doctors have not satisfactorily lived up to expectation as leaders. Doctors and especially specialists in the health sector must earn and regain the respect and deference that have traditionally been extended to them by all strata of society from time immemorial.
5.6 PhD. for Fellows
The announcement by the NUC in 2008 that the PhD. had become the minimum mandatory qualification for persons who wish to pursue academic careers in all disciplines in universities sparked off some controversy, especially by groups, such as the doctors who had used qualifications other than the PhDs, like the Fellowships of various professional bodies to pursue very successful professional and academic careers. The doctors took issues with the announcement on the ground that the Fellowships have enough research elements to cater for the requirements of a PhD. Although the NPMCN took a strong stand against the proposal ab initio, the jury is still out on the matter as the College, on further reflection and in line with the findings of a commission it set up on the matter is now engaged in discussions with the NUC. A solution is anticipated from these deliberations.
My personal view is that the issue can be easily resolved as there are several avenues for obtaining a PhD or an MD while undergoing the residency programme of the various colleges, i.e., before applying for the lecturer 1 position in universities. Furthermore, the law establishing the NPMCN even as it currently stands, allows the College to award various degrees like the Masters’, PhDs and MDs, a position which the College can exploit to resolve the matter. To my mind, obtaining an additional PhD or MD, neither denudes nor reduces the importance or value of the Fellowship which is an absolute requirement for highly skilful and specialist clinical practice. Rather, such a combination will produce proficient clinicians with equally strong academic standing and among other things, obviate the need to request senates and councils of universities to accept as special cases, the Fellowships as being equivalent to PhDs. Happily, a good number of clinical teachers in various universities at the levels of lecturer 1 and beyond are already registering for and pursuing PhDs/ MDs in universities, just as some before them had done.
It is partly this dichotomy, with all its problems, between professional postgraduate medical training, conducted by academic staff of universities that leads to the Fellowships which is hospital-based and under a Ministry of Health on one hand, and pursuing the purely academic qualifications that are based in universities and again run by academics but under a Ministry of Education that lead to the Masters’, PhDs, MDs and DScs, on the other hand, that is giving traction to the current push toward establishing medical universities. So far, there are five such universities in the country – one owned by the federal government, two privately owned and two owned by state governments of which the recently established Bayelsa Medical University (BMU), owned by the Bayelsa State Government is one. At that university (BMU) the plan is that all staff of the teaching hospital will be staff of the university and under the Ministry of Education. The hospital will be run by a chief medical director of the rank of a deputy vice-chancellor under the supervision of a board which would ultimately report to the council of the university through the vice-chancellor of the institution. The medical students’ curriculum will place emphasis on integration and collaboration and several related subjects like biomedical engineering, ICT, anthropology and medical sociology will be taught. This will enable doctors not only to understand the complexities of human behaviour but also appreciate how the vast array of commodities they use in medical practice are produced – lint, swabs, medical fluids, needle holders, needles, stiches, catheters, naso-gastric tubes, urine bags and many others. At the postgraduate level, candidates will be trained throughout within the umbrella of a university of which a teaching hospital is an integral part, both operating under a single ministry: education. The expectation is that such doctors, at undergraduate and postgraduate levels, will serve society better, have a wider spectrum of activities and more fulfilling career prospects and also go into fields, other than clinical practice that help to support the health care industry.
5.7 Funding
A review of Table 2 reveals that, as is common with most government funded agencies, there was a deficit between what was budgeted for capital projects and what was released to the College for each of the years depicted. The size of the deficit at 37%, 70%, 64%, 50% and 36% serially for each of the years, varied from year to year.
This deficit as well as other huge expenditure on examinations, accreditation visitations, power generation and additional housekeeping expenses are met from the money trainees pay as examination fees. It is this poor funding that has resulted in the less than impressive physical development of the permanent site which the College should seek other ways of addressing. The services of an Advancement Office in the College would be invaluable as recommended in the later part of this lecture.
5.8 Impact on National Development
The mandate of the College to train and certify specialists in all branches of medicine is not an end by itself. Outside other expectations that impact on national development, the purpose is for the specialists so trained to contribute to a rapid and sustained improvement of the health of Nigerians, positively advance their health seeking behaviour and enhance the efficiency of the country’s health care delivery system through specialised care, advocacy and innovations following research outcomes.
While it is true that some progress has been made in improving the health of Nigerians with increasing graduation of health personnel from various training institutions in the country, including specialists from the NPMCN, the gains made have not been impressive. Nigeria failed to meet the targets in all but MDG5 – Improve Maternal Health of the health related components of the recently concluded MDGs (2000-2015).7 Even on this, whereas the National End Point Report indicated a drop of maternal mortality ratio to 243 per 100,000, available evidence suggests that actual ratios are much higher.1 Nor are the other health indices faring better even with the on-going SDGs. Deaths and disability from vaccine preventable diseases, childhood illnesses, metabolic disorders, infections, cancers and many others have all not shown appreciable declines. Meningitis and Lassa fever take their toll from time to time; thank God the country was spared the catastrophic devastation of the Ebola virus disease. Cases of infection by the Human Immunodeficiency Virus (HIV) and its related Acquired Immunodeficiency Syndrome (AIDS) and their bedfellow tuberculosis, are still areas of concern even though recent National HIV/AIDS Indicator and Impact Survey (NAIIS) showed a drop of HIV prevalence to 1.4%. The health care delivery system has remained in the doldrums, bugged down by several challenges.8,9
No one expects that physicians alone would solve the health problems of Nigeria, seeing the protean and vast nature of the determinants of health – environment, waste disposal, portable water, nutrition, safety of life and property, conflict, housing and many more. In fact it is held that people oriented decisions taken in a parliament by politicians are more likely to improve the health of a country’s citizens than the actions of all its doctors in hospitals. But by the nature of their calling and the leadership role they occupy, doctors should feel more concerned about the health of the people and seek to do something about it more than any other group. This should be especially so if they are Fellows of this great college.
The prospects of the College in the years ahead are probably the most important aspect of today’s lecture and so perhaps, require some preamble. Notwithstanding the challenges the College has had in the past 50 years the issue now is for the College to exploit the totality of its experiences to produce Fellows for the future and enhance its relevance in the scheme of things in the country and abroad within the context of rapidly changing local and global environments. It is on its ability to properly tackle and address these tasks that the prospects of the College will depend.
Some of the issues involved in this obligation are existential, affecting the very fabric of the College and have been addressed, if in parts, in the earlier sections of this lecture. They include:
Outside these, there are a number of other issues ranging from changes in the local and global communities to those of requirements of the future specialists, down to matters that would better assure the success of the College that still need to be addressed. I will briefly discuss them in this section.
6.1 Expected changes in Nigeria and abroad and their possible impacts
Of the many changes expected to occur in Nigeria in the near future, one that would most certainly impact her enormously is that of population growth. With a population estimated at independence in 1960 as 45.2 million, estimates galloped to 166.2 million in 2012, 178.5 million in 2016 and 200.96 in 2019. At this current estimate of over 200 million persons, the country ranks 7th in the world and growing at about 3% per year, it is estimated that there would be 402 million people in the country by 2050, ranking it 3rd in the world.10 The expected positive and negative effects of this massive increase will impinge on all aspects of human activities. With the possibility of such huge population, the prayer is that the country would have found the economic wizards and effective leaders to convert such a change into an advantage for the benefit of all. The corollary is also true: such huge population could negatively affect all facets of life in the country. Pressure on the economy may get worse; unemployment and environmental degradation may rise, and food supply may become insecure. The health of the people may be affected directly and indirectly through collateral effects from other components. Thus, the chances of disease occurrence, especially epidemics and new diseases could be enhanced and the capacity to deal with them, reduced.
At the global stage, there is the current drive towards populist governments by far right groups, open rejection and taunting of people of colour, surge in bellicosity of white supremacy campaigners across Europe, America and Australia. The outcome of the Brexit saga in the UK remains uncertain, even with the emergence of a new prime minister. In parts of Africa, xenophobic attacks, particularly targeted at Nigerians are on the rise. These fears and hostile actions will make emigration from Nigeria to Europe and America as well as transborder travel more difficult.
Medicine and medical practice within and outside the country will also change. Not only are the possibilities of the emergence of new diseases high, technology will play increasingly important role in the practice of medicine. Moreover, with improved internet penetration in the country as internet for everyone is already on the cards, patients’ knowledge of their disease conditions will be enhanced, enabling them to demand more from attending physicians. They may even have robots that compete with doctors. The College should respond to these uncertainties in the training of the specialists for the future as these factors will determine, to a large extent, the level of proficiency, relevance and career prospects of its future graduates. For the balance of the time remaining for today’s lecture, I will briefly address a few of them.
6.2. Training the Fellow for the future: Number, Quality and Type
The NPMCN will need to produce Fellows at a faster rate for the future. With the country’s population escalating beyond 400 million in the next 30 years or thereabout, with a doctor/patient ratio of 1 to 4,148, far below the WHO recommendation of 1 to 600 and with the health care system still dysfunctional, more qualified health personnel, including doctors would be required in Nigeria. Not only will specialists from the NPMCN be needed to serve in an expanded health delivery system, they would also be needed to train younger colleagues in the additional institutions that would spring up for the profession. Teaching methods will increasing become important for Fellows.
What rate of production will be needed to fill current void and provide for future requirements will be difficult to calculate. Such estimates would have been easier when Nigeria had development plan periods with expected outcomes which current governments do not have. The point must be made that failure of proper planning of graduate output directed towards coordinated national development is partly responsible for what appears to be a glut of graduates in Nigeria. Graduates of higher education institutions such as the NPMCN are arrowheads for local, regional and national development. Their production should be tied to well-articulated national development plans so that they can be appropriately absorbed with fitting renumeration packages at all levels.6
Concern about the quality of products of the programme has been expressed in some quarters in recent times and with the anticipated increase in production, the College should ensure that standards are not compromised.11 This is important because it is by assuring the quality and proficiency of its Fellows that the College will build its reputation and cultivate favourable public perception. Thus, quality assurance is not only a desideratum for the College but an imperative for its sustainability.12, 13 The College should establish a Quality Assurance Department to track the quality and placement of its Fellows by examination. Areas to be kept on constant surveillance should include the quality of the institutions accredited for training, knowledge capacity and professional competence of trainers, the integrity of the qualifying examinations and the level of efficiency of the administration of the College. The surveillance should include reports from organisations that employ College graduates and periodic feedbacks from the Fellows themselves indicating how well the training they had equipped them for the jobs they are performing. The College should seek to invite internationally acclaimed accreditation bodies to accredit its operations including the qualifications it awards. This will place it in good stead to have the qualifications recognised by other countries.
As for the type of Fellows, the difference will be in the dominant role technology will play in the training and practice of future Fellows. To be the specialists of the future, trainees have to be skilful in the use of modern technology in all aspects of patient care including history taking, clinical examination, diagnosis, investigation, management, record keeping, follow up, prescription and much more. Furthermore, Fellows of the future must be ready to work in a world led by the 4th Industrial Revolution (4IR) brought about by globalisation and digitalisation in which robotics, automation, artificial intelligence, organ printing, 5G and mixed reality technologies, internet of things and other forms of technology driven activities will drastically alter the way people live and relate with one another. Indeed, as they say, a future that inspires and terrifies. So, even the patients that future fellows will encounter, will be different in their knowledge content, lifestyle and much more. Some may even have microchips in their brains!
However, since it is unlikely that ignorance, poverty, illiteracy, environmental rot, lack of opportunities and other major issues facing Nigeria will disappear overnight, Fellows in the future will have to contend with these even as they face up to the global realities of a digital world. Such rigorous preparation for the future by the College will serve many purposes. Not least, it will help assuage the vexing issue of medical tourism by which the rich, mighty and powerful leave the country for treatment abroad, even for ailments as minor as lancing an abcess with the attendant huge capital flight that it constantly entails.
6.3 Research and Innovation
How well the College is able to encourage, stimulate, direct and possibly supervise the conversion of research carried out under its auspices to policies, technologies, goods and services through innovation for the benefit of all is another area that will determine its prospects and relevance in the future. Key Performance Indicators (KPIs) of research and innovation are intellectual property rights secured through patents, publications, products that generate royalties and start-ups that contribute to economic development of society. By current count, the College has graduated over 6,000 Fellows by examination, who all produced dissertations based on various research projects they carried out. In addition to fulfilling a requirement for qualification for the Part II Fellowship Examination, research undertaken by trainees is meant to give rise to tangible contributions that could provide things of value and or address common problems in society. So far, it would appear that this has not been the case with dissertations at the College as there is neglect of harvesting intellectual property.
Happily, the College is taking the initial steps in getting at least some findings of the research published by digitalising all accepted projects as prelude to further development into start-ups, creative works, policies, advocacies, goods and services. This remains one of the cardinal expectations of society from such tertiary training institutions like the NPMCN. For, among others, none of the SDGs to which Nigeria is a signatory can be achieved without such contributions from higher education training institutions in the area of research and the other areas of expertise.14
6.4 Strategic Plan and Advancement Office.
A new well-articulated strategic plan will need to be in place to face a future as complex as the one envisaged. Such an instrument should be well-reasoned, realistic and expertly done. It should clearly delineate where the College currently is, where it intends to be and how it could get there. A retreat for this purpose to which experts are invited to contribute to extensive debate prior to developing the plan will be appropriate. Preferably, the plan should be a long term one to ensure institutional stability in an uncertain world led by the 4IR. The current strategic plan (2018-2022) by the College may not be sufficiently robust to address the complex issues of the future and since it is going to terminate soon, I suggest that arrangements should commence towards planning for the new one.
Furthermore, an Advancement Office, not a public relations office, appropriately staffed, is now an absolute necessity for the College. Such an office will cultivate symbiotic and synergistic relationships between the College and its many audiences, like the various governments of the federation, trainees, training institutions, the Ijanikin community, media, corporations, industries friends and alumni. So that as the College works to improve the welfare of society, it in turn receives support and goodwill from society by way of philanthropy, advocacy, grants and gifts. Additionally, an advancement office will keep a database of Fellows and publish Newsletters that will inform and encourage alumni to be involved in the affairs of the College in order to promote its welfare. On its part the College has to make quality the essence of its operations because it is institutions with proclivity for scholarship, integrity and accountability that are able to earn the respect and reputation on which successful advancement activities are grounded.15
6.5 Hitting the Bull’s-Eye: A Word for the Convoking Fellows.
Let me now congratulate all the convoking Fellows by Examination during this 50th Anniversary Celebrations. By being the ones on the spotlight today, at this golden jubilee celebrations of the College, you have hit the bull’s-eye. Enough attention has been drawn to the fact that the circumstances into which you would be graduating from tomorrow will be different from those of previous Fellows by Examination. But as was amplified at the 36th Convocation Lecture of this College last year, Do Not Be Afraid5 because fresh opportunities will also present themselves. Take for instance the opportunities offered by the new African Continental Free Trade Area (AfCFTA) agreement between African Union member states which Nigeria recently signed. Seen as one of the largest free trade areas ever created, AfCFTA is expected to yield significant benefits for higher education and professional labour mobility on the continent.16 Explore how you can take advantage of it.
Practise your specialised disciplines with diligence. Remember that you are primarily doctors before you became specialists, and so, show interest in the wider concept of the health of all Nigerians by seeking to focus some attention beyond hospitals and clinics on people in their homes and communities.8 In this regard, let me then leave you with a plea to show interest in three areas of concern that could greatly impact the wellbeing of Nigerians – education, especially female education, family planning and universal health coverage. They are important enablers of the Basic Minimum Package of Health Services of our country.9
Be a strong advocate for compulsory, sound foundational education for all children born in Nigeria to prevent the growing army of out-of-school street children who become easy prey as vehicles for violence by religious extremists and unscrupulous politicians.17 Show interest in secondary education to ensure our children do not study under trees and dilapidated classrooms without roofs. As for our universities, stringent measures are being put in place through the courtesy of the National Universities Commission, Tertiary Education Trust Fund and the Joint Admission and Matriculation Board to improve quality.12 I enjoin you to render services there if you are so inclined.
Nigeria’s population growth without matching infrastructure and an economy that is sufficiently robust to provide job opportunities is another area of concern. Among the many remedies here is to give families the opportunity to plan so as to have the number of children they can conveniently cater for. Help the country to achieve the goal of “Family Planning 2020”.18 It is an important contributor to Women’s Reproductive Health. Lastly, support Primary Health Care services. It is through them that Universal Health Coverage can be achieved.19
I wish you all well.
7.0 Conclusion
At the commencement of this lecture, I indicated that the NPMCN was born out of a matrix of hope and cynicism. Hope for the prospects of a breakthrough and a quantum leap; cynicism from a mindset of incompetence and ineptitude. That we are gathered here at 50 is a manifest indication that belief triumphed over doubt and tenacity over fickleness. So, the College has every cause to crow. I salute all those who have directed the course of affairs of the College over these many years especially its current principal officers.
The success of the College so far should embolden it as it strides beyond the present into an uncertain and complex future with fortitude and determination realising those areas where it did not quite make the mark. In all this drive quality should be given pride of place as on it depends the prospects of the College
I finally end with some words of exhortation for the College. Think big; Plan big because the NPMCN is the jewel in the crown of the nation as far as medical education is concerned.
I thank you all for your presence.
TABLE 1
NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA
FELLOWS BY EXAMINATION
(1969-2018)
FACULTY PERIOD
| FACULTY | 69-78 | 79-88 | 89-98 | 99-08 | 2009-2018 | total | % |
| KANAESTHESIA | 20 | 19 | 24 | 36 | 113 | 212 | 3.5 |
| DENTAL SURGERY | 9 | 35 | 30 | 67 | 86 | 227 | 3.8 |
| FAMILY DENTISTRY | 7 | 3 | 10 | 8 | 42 | 70 | 1.2 |
| OBSTETRICS & GYNAECOLOGY | 84 | 123 | 53 | 149 | 340 | 749 | 12.4 |
| OPHTHALMOLOGY | 14 | 44 | 52 | 83 | 239 | 432 | 7.1 |
| RADIOLOGY | 13 | 35 | 44 | 79 | 148 | 319 | 5.3 |
| SURGERY | 73 | 118 | 83 | 68 | 27 | 369 | 6.1 |
| ORL | 0 | 22 | 20 | 34 | 34 | 110 | 1.8 |
| ORTHOPEADICS | 8 | 7 | 28 | 48 | 85 | 176 | 2.9 |
| FAMILY MEDICINE | 46 | 118 | 59 | 48 | 236 | 507 | 8.4 |
| PAEDIATRICS | 27 | 77 | 66 | 106 | 304 | 580 | 9.6 |
| PATHOLOGY | 40 | 72 | 77 | 161 | 414 | 764 | 12.6 |
| INTERNAL MEDICINE | 79 | 117 | 78 | 174 | 316 | 764 | 12.6 |
| PSYCHIATRY | 19 | 38 | 24 | 52 | 150 | 283 | 4.7 |
| PUBLIC HEALTH & COMMUNITY MEDICINE | 62 | 48 | 58 | 131 | 191 | 490 | 8.1 |
| Total | 501 | 876 | 706 | 1244 | 2725 | 6052 | 100.0 |
SOURCE: Registrar NPMCN.
TABLE 2
NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA
FINANCIAL RECEIPTS FROM FEDERAL GOVERNMENT, 2012-2016.*
| YEAR | CAP. BUDGET* | CAP. RELEASED* | PERSONNEL* | OVERHEAD* | TOTAL* |
| 2012 | 116,606,619 | 73,436,218 | 174,469,664 | 37.976.804 | 285.822.686 |
| 2013 | 191,901,785 | 58,153,363 | 171,703,183 | 32,630459 | 262,487,004 |
| 2014 | 148,033,037 | 52,929415 | 167,423,937 | 20.309.178 | 240,662,530 |
| 2015 | 20,000,000 | 10,000,000 | 201.737.263 | 13,101,671 | 224,838, 934 |
| 2016 | 20,000,000 | 12,822,900 | 223.317,682 | 11,773,043 | 257,973.625 |
| TOTAL | 496,541,441 | 207,401,896 | 948,651,729 | 115.791,155 | 1,271,844,779 |
*Naira
SOURCE: Strategic Plan Document of NPMCN (2018-2022)
REFERENCES
Pro-Chancellor and Chairman of Council, Federal University, Lokoja, Nigeria. February 2016
Member, Court of Governors, College of Medicine, University of Lagos, October 2015 for four years.
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