New Frontiers for Improved and Sustainable Health Care in Nigeria: Leveraging on Diaspora Professionals and Investors

Shared by Peter Toyinbo

Keynote address, December 1, 2021

By Dr. Oluwole Odutolu, Senior Health Specialist, World Bank/Global Financing Facility

To the Faculty of Clinical Sciences 2021 Week, College of Health Sciences, Obafemi Awolowo University, Ile-Ife Nigeria.

Protocols

The Vice-Chancellor Prof. Eyitope Ogunmodede – a highly dynamic and quintessential Public Servant, – I want to congratulate you for enviably holding the mantle of your predecessors, who were great leaders, and for admirably fitting into their shoes. Thank you for keeping the flag of our great institution flying high and for your services to our country.

The College Provost – Prof. Kolawole and the immediate past Provost Prof. Kayode Ijadunola – Kayode and I are from the same city – so small that we are all cousins and so big that it has a Polytechnic. We are both from Iree in Osun State. (And of course, his amiable wife).

Our indefatigable dean of the Faculty of Clinical Sciences Prof. Dayo Sowande and other Deans and HODS in the house.

I crave your indulgence to recognize my friends and colleagues /classmates for 7 years who are current members of the faculty – Prof. Norah Olubunmi Akinola (Bamigbaiye), Prof. Benjamin Olusola Fasuba, Prof. Anthony Olubunmi Akintomide, and Prof. Olufemiwa Niyi Makinde. I thank them for their services to the College, for giving back and raising the next generation of professionals.

I want to salute other faculty members, students in the faculty at post and undergraduate levels, friends of the faculty, ladies, and gentlemen of the press.  Great Ife.

I. Pre-Introduction

Thanks for inviting me to give the keynote address for this year’s Faculty of Clinical Sciences’ week and Scientific Conference, which is auspicious as we are also celebrating 60 years of the existence of Obafemi Awolowo University, Ile Ife. This landmark celebration lauds the vision of our leaders and fathers, who in the performance of outstanding and unparalleled public service in Nigeria established OAU and nurtured it to an enviable center of learning and culture. We should also recognize the selfless service of the academic giants who strode the lands of this great university and made it an enviable institution of which we are all proud. Similarly, we should recognize our alumni – home and abroad – who are also doing us proud in all forays of life from medicine to politics, business, technology, and as astute managers of men and other resources. We should be proud of our collective achievements and grateful for what this institution has become and the future that we see.

As we enjoy the celebration, we should also pause and reflect – have a full introspection or evaluation of the past 60 years and ponder on the future – how are we going to sustain and improve on this legacy? Two generations have passed since OAU was established; the next generation has an arduous task in the face of critical national challenges including (i) worsening economic reality (ii) insecurity and (iii) for the health sector – the reality of confronting the COVID 19 pandemic and its effects on the already fragile and poorly performing health system. It is in short, triple jeopardy.

But the Faculty of Clinical Sciences in setting the agenda for the future is challenging us on how we manage our assets, our tens of thousands of professionals that are produced annually but have not directly impacted our health system because we lose them to the much-advanced economies who free-ride on our production lines of doctors, nurses/midwives, and pharmacists, etc. The faculty has also rightly chosen the solution approach with the topic ‘Panacea for Brain-Drain’.  We should in our collective find workable solutions, forge alliances, explore innovations in service delivery including digital health, crowding resources from within and outside the country, etc. I also think it is the right time if we really want to solve the intractable problems of healthcare in Nigeria. The COVID 19 lockdown taught the rich Nigerians a great lesson of their lives as no one can quickly jet out to other countries to obtain health service as they were wont to do. This is the time when all and sundry should invest to build a resilient healthcare system and not lose the auspicious momentum.

II. Introduction

The United Nations defined the now well-established concept “brain drain” as a one-way movement of highly skilled people from developing countries to developed countries that exclusively benefit the industrialized (host) world. It is tantamount to depletion or loss of intellectual and technical human capacity from the source country. It is a phenomenon of ‘free riding’ for the host countries that would have not borne the cost of training of these highly qualified individuals, especially medical graduates, who migrate to seek employment outside their countries of origin. (Oberoi et al 2006). According to the International Office of Migration (IOM 2020), which painted a near balanced view: ‘migration gives an optimistic livelihood strategy for migrant workers and their families, contributes to the economic growth of the destination state/country, while the origin state/country benefits from the remittances and the skills acquired during their migration’.

Migration is an age-old phenomenon but worsening economic conditions in many developing countries and the allure of the developed economies made it more irresistible, the push and pull factors of migration are well documented in the literature. The push factors are unfavorable home country conditions of remuneration, conflict, and working environment.  The pull factors are the real or perceived ‘greener grass’ in host countries. To put this in perspective, the migration of Nigerian healthcare professionals in the last four decades has been alarming both in terms of stock and flow. However, this is not a Nigerian phenomenon alone but more of a developing country issue.

Policymakers and some economists argue that physician emigration hurts the continent in three respects (Hagopian et al 2005):

First, migrant physicians leave behind distressed health sectors that cannot care for a young and growing population because there is a loss of experience when highly qualified and competent professionals leave the system. The impact is that the low ratio of healthcare workers to patients is significant in accounting for maternal, infant, and under-five mortalities (Anand and Bärninghausen 2004).

Second, their migration disrupts and undermines the functional ability of the health sector to organize and expand, with poor planning and incoherent policies ultimately leading to the contraction of health institutions.

Third, Hagopiana et al (2005) also noted that physician migration also has financial ramifications for African countries. African governments highly subsidize medical education. For example, medical education annually costs between $2,000 and $10,000 per student in West Africa, excluding personal costs incurred by the student. It costs a government an amount equivalent to approximately US$100,000 or more to train a medical student. It has been estimated that the total annual monetary loss by developing countries due to losing the healthcare workers they have trained is approximately US$500 million. Similarly, Mills et al (2011) argue that “medical education is typically highly subsidized by the public sector in African countries, and they estimate that for every Nigerian doctor that moves to the UK, Nigeria loses $71,757 in investment.

From the 1980s, there has been an avalanche of brain drain of healthcare professionals from Nigeria to the Middle East, especially Saudi Arabia and Qatar; to Europe especially the United Kingdom; and America especially the United States. In the beginning, it was highly qualified doctors with subspecialist qualifications from the universities but subsequently, younger doctors who went abroad for residency or post-graduate studies were lost to the system. These doctors can be found in medical institutions and in health service delivery outlets in their countries of abode. Several Nigerian nurses, midwives, and pharmacists have equally emigrated to many countries.  The unrelenting and continuous flow has been of major concern not only in terms of loss to the economy but also the consequence of the capital flight on the quality of care in the country.

 It is not all gloom and doom as the Diaspora has constituted itself into a powerful economic force making significant contributions to the gross domestic product (GDP) of Nigeria. In the professions, they are technically skilled and making the country proud in their different pursuits and many have already been building bridges with colleagues in Nigeria. Through such collaborations, they are establishing specialist clinics, and hospitals introducing new technology to support diagnosis and treatment, and infusing finances to the sector. On the other hand, there are other non-health professionals in Information Technology, Finance, and Management, who have a lot to give back to the Nigerian health sector.

I will frame this discourse on how to leverage the diaspora momentum to better improve the health outcome of Nigerians. I will review the literature to analyze the challenges of capital flight, assess the magnitude of the problem, and explore opportunities based on learning from the experiences of other countries and contemporary occurrences in Nigeria to mitigate the problems.

III. What is the Magnitude of the Problem?

In a South Africa study, the major push factors frequently noted were poor remuneration and wages, lack of job satisfaction, lack of prospects (further education and career development), poor working conditions, HIV/AIDS, lack of quality of life, high levels of crime and violence, civil conflict and political instability, and a decline in the quality of the school education system. Financial factors were indicated as a reason for leaving by 86.2% of the respondents, better job opportunities by 79.3% (Bezuidenhout et al 2009). In both Ghana and Nigeria, regular labor strikes, lack of political will, poor infrastructure, and the generally low standard of living make life difficult. It is also the product of a long history of medical migration. Students learn from their professors, family members, and others about the benefits, both tangible and intangible, of the migration experience. (Hagopiana et al 2005)

The Nigerian story of the brain drain of physicians is more complex and the push factors are unbelievably enormous. These factors are conflicting institutional mandates and responsibilities for human resources for healthcare in a federal system; lack of willingness to frontally address the issues of brain drain or address structural impediments for retention; locational overproduction of doctors especially in the south; maldistribution of the healthcare workforce, inadequate opportunities for residency program (further education and career development); unemployment of some junior doctors and insecurity. Lastly, there is the threat of the collapse of primary and secondary levels of care and preferential movement of personnel to teaching hospitals and Federal Medical Centers. The development portends a dangerous threat to the retention of physicians in the country. Trite assumptions that those who leave do so because of a lack of patriotism tend to substitute emotion and political rhetoric for logic.

In conclusion, nobody knows the actual number of Nigerian physicians, nurse/midwives, and pharmacists abroad; our national institutions have no such statistics, or they are not sharing them. But from back-end data gathering from the major host countries, we have an idea that the problem is humongous. According to the General Medical Council UK, there were over eight thousand (8246) Nigerian doctors in the UK (10% of all doctors registered in the UK) as of May 2021. Of these, 1,217 were specialists; General Practitioners were 1,370, and 4,132 were staff grade and subspecialist doctors. In October 2020, there were a total of 4,300 physicians in the American Medical Association (AMA) database of United States physicians with birthplace Nigeria or medical school graduation from Nigeria in about 120 specialties. The top migrant healthcare professionals in the US are the Indians, and Filipinos, followed by Nigerians that clearly demonstrates the magnitude of migration of professionals from Nigeria.  About 80,000 doctors and dental surgeons were registered with the Nigeria Medical Council as of 2018, If I can hazard a guess 30-40% of Nigeria-born and/or graduates of Nigeria medical schools are working abroad.  It should be noted that in some countries, of which the Philippines is a prime example, there is a deliberate state policy to produce and encourage the export of health workers, with expectations of economic benefit from the foreign currency remittances from those workers back to their home country. (DeParle, J. 2019)

 IV. How has Brain Drain Affected the Nigeria Healthcare System?

There is no empirical data directly linking brain drain to the parlous state of Nigeria’s health system, but Nigeria is grossly underperforming with regards to most health outcome indicators especially maternal mortality, infant and under-five mortality, and quality of care. Even if the specific impact on patient outcomes is difficult to quantify, it could be argued that healthcare worker migration adversely impacts overall health systems.

Nigeria’s poor human capital outcomes reflect the low levels of public expenditure and weaknesses in service delivery. In terms of the Human Capital Index (HCI), Nigeria was the 7^th lowest in the world—168^th out of 174 countries — with one of the highest maternal mortality, under-five mortality, and stunting rates in the region in 2020.

• 714,000 Nigerian children under five die every year, the country is responsible for 26% of all under-five deaths in sub-Saharan Africa and 13% globally (Nigeria accounts for 2.5% of the world’s and 18% of Africa’s population).
• Nigeria will soon overtake India as the country with the highest absolute number of under-five deaths in the world despite India’s population being 7 times larger.
• Nigeria is already the largest contributor to maternal deaths in the world, with India second.
• Nigeria also has one of the highest levels of inequality in health outcomes and service utilization. The under-five mortality rate (U5MR) in the poorest wealth quintile Nigerian households is highest in West Africa. Poorest Nigerian children are about 3.3 times more likely to die before age five than children from wealthy households.

Health Financing: Nigerian government investment in healthcare is one of the lowest in the world. In 2017, government healthcare spending of US$10 per capita or 0.5 % of GDP, was among the lowest in the world. Against comparators and from World Bank (2018), Nigeria’s 2018 domestic general government healthcare expenditure of $12.45 per capita or 0.58 % of GDP is lower than the Sub-Saharan African average of $30.25 or 1.87 %, respectively, and lower than its regional peers Ghana ($30.3 or 1.38 %) and Kenya ($37.24 or 2.18 %).

Despite the poor outcome highlighted above, Nigeria still grapples with the burden of communicable diseases (including the ongoing pandemic), high fertility rate, and increasingly emerging non-communicable diseases (NCDs). There are also challenges of inadequate human resources for healthcare; inadequate budgetary allocations to healthcare (plus inherent allocative and technical inefficiencies and inequity); and poor leadership and management.

The overall situation is neither good for the retention of healthcare professionals nor attractive for those in the diaspora to return to Nigeria. Even in the face of all the challenges there is growing spatial unemployment of young doctors and nurses, lack of capacity for further training, poor conditions of service for those who are employed, and lack of a retention plan. A genuine retention program would have to include better conditions of service for the healthcare professionals, better opportunity for further training to specialist positions, considerable investment from the private sector, or low-interest rates for loans for expansion of medical services. Economics is critical to decision-making on migration.

V. Taking Advantage of the Growing Diaspora Momentum

The concern about brain drain is germane. There is the need for a change of perspective and proper channeling of the newfound Diaspora momentum into transforming policies and practices in Nigerian emigrants. It is counter-intuitive (wishful thinking) to expect to stop or reverse brain drain. The choice of homecoming is personal and where it ever happened there had been two scenarios (i) to return home with one leg in the host country to test the waters – which mostly results in retracing their steps or (ii) return home at old age when they would have little or no direct benefit to the system. In this wise, the question might be how to leverage the diaspora momentum of experienced medical experts and other professionals in management, banking, and financing to enhance the quality-of-service delivery and boost efficient management of resources to bridge the human capital gap. But before I venture into proffering solutions, it will be expedient to examine the role of state, regional or national government in harnessing the diaspora momentum.

Nigeria should acknowledge and be deliberate in addressing the problem of brain drain and actively manage it.  There are two example countries that have put structure into supporting migratory workers to learn from – India and the Philippines. India has the largest diaspora (18 million) with the number of migrant workers in the Gulf countries alone accounting for 8.4 million (Ministry of External Affairs, 2021). There are 10 million Filipinos living abroad and more than one (1) leaves the country each year to work abroad.  India is also amongst the largest recipient of remittances at USD 78.6 billion in 2019(International Organization for Migration, 2020). Remittances to the Phillippines from around the world continue to grow and it is about $25 billion in 2020 with $11.7 billion from the US alone. While the absolute number of Nigerian migrant workers is unknown remittances in the last couple of years have been about $20 billion per annum except for 2020 when it was $16 billion. For 2019, it was $23.6 billion and the highest amount in sub-Saharan Africa in absolute amount and it constitutes 6.7% of Nigeria’s GDP> Nigeria should therefore be in the league of Indi and the Philippines that have identified labor migrations as the national thrust for economic growth and, actively have laws and policies for managing and regulating migration.

For example, the Ministry of External Affairs (MEA) set up the India Centre for Migration (ICM) to) serve as a research think-tank to MEA on all matters relating to international migration and mobility. The ICM conducts empirical, analytical, and policy research and undertakes pilot projects to document good practices. The Philippines is a global model for regulating migration. Nigeria should empower and enable the Diaspora Commission to perform similar functions. The collection, analysis, and data usage of diaspora healthcare professionals should be a priority. On an immediate basis, I propose the following:

   1. Reverting Medical Tourism Through Increased Participation of Professionals in Diaspora

 Before COVID 19 pandemic, Nigeria annually was spending over $1 billion annually on medical tourism to India, South Africa, Europe, and the US. There is a growing population of middle-class with increased demand for quality healthcare. Nigerians agree on the need to revert medical tourism both for economic and health reasons. But there has been little traction in this regard. The structural challenge is that most healthcare institutions are public, and they cannot respond that quickly and efficiently to the opportunity staring us in the face. This creates a niche for the private sector in the healthcare delivery industry and financing.  This is an area where we can leverage on the diaspora professionals who will be able to work better with the private sector. Here are examples of such collaborations that have birthed:

• The Nigerian American Medical Foundation with the vision to re-enthrone excellence not only for medical care but also medical school education and research. The main strategy is to use year-round rotations of visiting physicians at the Foundation’s Hospital in about 100 sub-specialties. They have started operation in Lekki Lagos using as many would want to give back in skills and are in the process of building and enlarging their facility and operations.
• Centre for Advanced Specialty Surgery (CASS) was established with a vision of bringing America to Nigeria and delivering to Nigerians surgical care equivalent to what is obtained in abroad. It was registered in 2013, started seeing patients in 2014, initially commenced as a small outpatient clinic, and later in 2016 expanded to a boutique hospital in Lagos, Nigeria. A second facility was subsequently established in Owerri, Nigeria.
• The Duchess International Hospital, Lagos, Nigeria is an impressive facility delivering advanced primary, secondary and tertiary healthcare services across specialist areas in Medicine, Surgery, Obstetrics & Gynecology, Pediatrics, Family Medicine, and Dentistry. The Duchess International Hospital has 100 beds and out-patient facilities that are distributed across 7 floors for high-quality clinical and hospitality-focused service.

There are many more such collaborations with professionals in the Diaspora especially in Lagos and the rest of the South West Zone of Nigeria. There are also collaborations with the teaching hospitals in the zone especially the three of the five Nigeria medical schools that are known to have produced the largest number of migrant doctors to the US and the UK – Lagos University Teaching Hospital, University College Hospital Ibadan, and Obafemi Awolowo University Teaching Hospital Ile -Ife. Nigeria can make the zone the hub for reverting Medical Tourism and creating a medical Mecca. (Perhaps the most important first step towards reversing medical tourism is to ban the use of public funds for medical care outside Nigeria. That will force political actors to spend more money to improve the quality of care in our hospitals.)

     2. Targeting High Net Worth Diaspora Investors (Companies and Individuals, Hedge funds, etc.) to Finance Modern Health Infrastructure

Nigeria grossly underinvests in healthcare infrastructure. Upgrading the health centers and hospitals to global standards will require a substantial injection of funds for modern infrastructure in buildings and equipment. It is estimated that Nigeria requires an extra 386,000 hospital beds at an estimated cost of $82 billion to bring the country up to the global average of 2.7 beds per 1,000 people (Whitetaker 2021). Such funds can be raised through Foreign Direct Investment including funds from Diaspora investors (not necessarily healthcare workers alone). A successful example is the 165-bed multi-specialty tertiary care hospital in Lekki developed by Evercare Group, and financed by a $1bn fund managed by TPG Growth. Investors in the fund include development banks such as CDC and Proparco, healthcare operators Philips and Medtronic, and the Bill & Melinda Gates Foundation. The lesson from the COVID pandemic when even the rich cannot travel for overseas treatment is that Nigerians need to invest in healthcare infrastructure at home; thus, they need to explore more foreign direct investment. This will require aggressive marketing and the creation of enabling environment by the government.

     3. Establishment of Diaspora Health Equity Fund

Another area where Diaspora investment can improve the health of Nigerians is through the establishment of the Diaspora Health Equity Fund. The Federal Government currently supports and makes annual appropriation towards Basic Health Care Provision Fund (BHCPF) to finance primary health care in the country by allocating 1% of consolidated revenue fund (CRF)to the fund as enshrined in the National Health Act. The Act makes provision for development partners and other investors to contribute to the fund. Diaspora Health Equity fund can directly target poor Nigerians or pay the health insurance premium of their relatives through the NHIS funded by part of the BHCPF to improve access to healthcare for the poor and strengthen the healthcare system towards financial protection in the ambit of universal health coverage (UHC).

    4. Using Diaspora Experts to Increase the Use of Digital Health

Telemedicine has advanced a lot in the last decade and its use was accentuated during the heat of the COVID 19 pandemic. The increasing internet and mobile phone penetrations, instant messaging, and advances in the use of video conferencing (Zoom, Microsoft teams, etc.) mean that we can take advantage of the ‘virtual world’. Doctor’s consultation is mostly remote now, especially for NCDs. Surgical back-up has also been done through video conferencing while a lead surgeon guides an operation remotely. But it requires setting up the infrastructure and building up a collaboration with diaspora institutions. Local and diaspora IT experts can support the transition from report-based information to user-centered systems including a national scale Electronic Medical Record (EMR); strengthen eHealth capacity, system security; and interoperability of digital platforms to meet demand and support innovation; and support in developing the National Digital Health Strategy.  Also plausible is telementoring to improve the quality of care in remote and underserved populations.

     5.  Innovations in Management and Service Delivery

The management of our healthcare system is a lot outdated; it needs revamping to bring it to the international and business-oriented standard. There are thousands of health management specialists who are Nigerians in the diaspora either as individuals or who are running big corporate entities on health especially in the United States. Nigeria will need a complete overhaul of the management system for the healthcare of the future and could use the expertise out there.

On the service delivery side: Twenty years after the landmark publication of World Development Report (1993)– Investing in Health, the Lancet Commissions on Future of Health (2014) report points to the possibility of achieving dramatic gains in global health by 2035 through a grand convergence around infectious, child, and maternal mortality; major reductions in the incidence and consequences of NCDs and injuries; and the promise of universal health coverage. The Commission endorses two pro-poor pathways to achieving UHC within a generation. The first being publicly financed insurance would cover essential healthcare interventions that would directly benefit the poor because they are disproportionately affected by these problems and the second with larger benefits package, funded through a range of financing mechanisms, with poor people exempted from payments. .  In stressing public financing for health insurance, I note that in a country with large populations of poor people, the government must pay the insurance premium for the poor.  For health insurance to be effective, there is a need to expand the base for service provision through public-private partnership (Bhattacharryya et al 2010) between the government and the private for-profit and private not-for-profit entities (social entrepreneurs) with the strategies below:

• Adopting a new marketing strategy of social marketing, performance contracting of NGOs, and franchising.
• Using Financial strategies for lower operating costs, high volume and low unit costs, cross-subsidization including government subsidy for the extreme poor, generating revenue and capital fund for the franchise.
• Concession of public facilities for social enterprises to run or the Saudi Arabia model of building tertiary health institutions and contracting the management to private HMOs may need exploring. Government can build a specialty-focused center of excellence in each geopolitical zone and contract the maintenance to diaspora HMOs (renewable based on performance)
• Optimizing human resources and increasing outreaches.

VI. Conclusion

The thrust of this keynote address is to get us thinking on how to benefit from our healthcare professionals and investors in the diaspora instead of daydreaming about bringing them back – the incentives are not there.  The following are my concluding remarks:

• Nobody knows the actual number of Nigerian physicians, nurse/midwives, and pharmacists abroad; our national institutions have no such statistics, or they are not sharing them. But from back-end data gathering from the major host countries, we have an idea that the number is humongous.
• There is no empirical data directly linking brain drain to the parlous state of Nigeria’s health system, but Nigeria is grossly underperforming with regards to most health outcome indicators especially maternal mortality, infant and under-five mortality, and quality of care.
• The overall health situation is neither good for the retention of healthcare professionals nor attractive for those in the diaspora to return. Even in the face of all the challenges there is growing spatial unemployment of young doctors and nurses, lack of capacity for further training, poor conditions of service for those who are employed, and a lack of retention plan
• Nigeria should acknowledge and be deliberate in addressing the problem of brain drain and actively manage it. Nigeria should empower and enable the Diaspora Commission to perform similar functions as found in India and the Philippines. The collection, analysis, and data usage of diaspora healthcare professionals should be a priority.
• Annually, Nigeria spends over $1 billion on medical tourism to India, South Africa, Europe, and the US and there is a growing population of middle-class with increased demand for quality health care which means that the marker is there. Nigeria could revert Medical Tourism through increased participation of professionals in the Diaspora. To start with, make the South West zone the medical Mecca of Nigeria.
• Nigeria grossly under-invest in healthcare infrastructure; to upgrade the health centers and hospitals to global standard Nigeria requires an extra 386,000 hospital beds at an estimated investment cost of $82 billion the country up to the global average of 2.7 beds per 1,000 people. Such funds can be raised through Foreign Direct Investment including funds from Diaspora investors
• One of the lessons from the COVID pandemic when even the rich Nigerians cannot travel for overseas treatment is that Nigerians need to invest in healthcare infrastructure; we should explore more foreign direct investment. This will require aggressive marketing and an enabling environment by the government.
• Telemedicine has advanced a lot in the last decade and its use was accentuated during the heat of the COVID 19 pandemic. Nigeria can increase the use of digital health with the use of Diaspora experts.
• Nigeria will need a complete overhaul of the management system for the health of the future and could use the expertise out there.
• The current public-led healthcare system has failed; Nigeria needs to adopt new marketing strategies such as social marketing, performance contracting of social enterprises, and franchising and use the following financial strategies – lower operating cost, high volume, and low unit costs, cross-subsidization including government subsidy for the extreme poor, generating revenue and capital fund for the franchise. Nigerians in the diaspora work within a similar framework and could support the strategic move.

The time is now.

Thanks for listening and thank you for having me.

Acknowledgment

I am grateful to Prof. Oladipo Otolorin, Dr. Olusoji Adeyi, and Dr. Adebisi Adegbile for being the sounding board that birthed and shaped the discussion in this keynote address. Professor Otolorin and Dr. Adeyi also read the first draft and made useful comments. I also want to thank my cousin Remi Kajogbola for providing enormous insight into the US health system particularly the management of hospitals. I am grateful to Drs. Adeyinka Shoroye and Aham Onyike are both activists within the Association of Nigerian Physicians in America (ANPA) who provided useful documents and insights on Diaspora participation in the delivery of healthcare in Nigeria. Special thanks to my cousin Prof. Layi Adeola for editing and making excellent comments and to Joy Gebre Medhin for editing and formatting the final draft.

 VII. References

1. Anand S, Bärnighausen T. Human resources and health outcomes: cross-country econometric study. Lancet, 2004, 364(9445):1603–1609
2. Benetar SR. An Examination of Ethical Aspects of Migration and Recruiting Health Care Professionals from Developing Countries. Clinical Ethics 2007;2(1):2–7.
3. Bezuidenhout MM, Joubert G,  Hiemstra LA,  Struwig Reasons for doctor migration from South Africa SA Fam Pract 2009 212 Vol 51 No 3
4. Centre for Advanced Specialist Surgery (2020) https://cassurgery.com/services/ cited on November 29, 2021
5. DeParle J (2020) A Good Provider is One Who Leaves – One Family and Migration in the 21^st Penguin Books
6. Edward J. Mills, Steve Kanters, Amy Hagopian, Nick Bansback, Jean Nachega, Mark Alberton, Christopher G Au-Yeung, Andy Mtambo, Ivy L. Bourgeault, Samuel Luboga, Robert S. Hogg, and Nathan Ford. 2011. “The financial cost of doctors emigrating from Sub-Saharan Africa: human capital analysis.” BMJ https://doi.org/10.1136/bmj.d7031
7. Labonté R, Packer C, Klassen N. Managing Health Professional Migration from Sub-Saharan Africa to Canada: A Stakeholder Inquiry into Policy Options. Human Resources for Health 2006; 4:22–36.
8. Hagopiana A, Ofosu B, Fatusi A, Biritwumd R, Essele A, Harta GL, Watts C(2005) The flight of physicians from West Africa: Views of African physicians and implications for policy Social Science & Medicine 61 (2005) 1750–1760
9. International Organisation for Migration (2020). World Migration Report 2020. UN Migration. Retrieved from https://publications.iom.int/system/files/pdf/wmr_2020.pdf.
10. Khan, A., Arokkiaraj, H. Challenges of reverse migration in India: a comparative study of internal and international migrant workers in the post-COVID economy. CMS9, 49 (2021). https://doi.org/10.1186/s40878-021-00260-2
11. Mutume G. Reversing Africa’s “Brain Drain”: ttp://www.un.org/ecosecdev/geninfo/afrec/vol17no2/172brain.htm (Accessed 10/04/2008).
12. NAMFI Clinic Foundation-Nigeria’s first Referrals-only Superspecialty Hospital, Lekki-Epe Atlantic Coast Medical staff Attending Physicians in 100 sub-specialties. NAMFI (100 sub-specialties, One Mission) Official Newsletter Summer 2020.
13. National Bureau of Statistics (NBS) and United Nations Children’s Fund (UNICEF). 2017 Multiple Indicator Cluster Survey 2016-17, Survey Findings Report. Abuja, Nigeria. Available at: https://www.unicef.org/nigeria/sites/unicef.org.nigeria/files/2018-09/Nigeria-MICS-2016-17.pdf
14. Oberoi SS, Lin V. Brain Drain of Doctors from Southern Africa: Brain Gain for Australia. Austr Health Rev 2006;30(1):25–33.
15. Oleribe OO, Momoh J, Uzochukwu BSC, Mbofana B, Adebiyi A,  Barbera T, Williams T, and Taylor-Robinson SD (2019) Identifying Key Challenges Facing Healthcare Systems In Africa And Potential Solutions, Int J Gen Med.2019; 12: 395–403; Published online 2019 Nov 6. doi: 2147/IJGM.S223882
16. Whiteaker J (2021) Can FDI fix Nigeria’s broken healthcare infrastructure?https://www.investmentmonitor.ai/business-activities/real-estate/can-fdi-fix-nigerias-broken-healthcare-infrastructure cited on November 15 2021
17. World Bank. “World Health Organization Global Health Expenditure database.“ Available at: https://data. worldbank.org/indicator/SH.XPD.GHED.GD.ZS?locations=ZG-NG&most_recent_value_desc=true
18. World Bank. 2018. “Investing in Human Capital for Nigeria’s Future.” Nigeria Biannual Economic Update Fall 2018. Washington, DC: World Bank. http://documents1.worldbank.org/curated/en/346771542864299850/pdf/132316-21-11-2018-17-31-9-NigeriaBEUAMF.pdf
19. World Health Organization (WHO) “WHA57.19 International migration of health personnel: a challenge for health systems in developing countries.” Resolutions and Decisions of the 57th World Health Assembly. https://apps.who.int/gb/ebwha/pdf_files/WHA57/A57_R19-en.pdf
20. WHO Global Health Workforce Alliance: Nigeria (2021) https://www.who.int/workforcealliance/countries/nga/en/