Health Professions in Nigeria: An Interdisciplinary Analysis 981163310X, 9789811633102

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Health Professions in Nigeria: An Interdisciplinary Analysis

Joseph Abiodun Balogun

Health Professions in Nigeria

Joseph Abiodun Balogun

Health Professions in Nigeria An Interdisciplinary Analysis

Joseph Abiodun Balogun College of Health Sciences Chicago State University Chicago, IL, USA

ISBN 978-981-16-3310-2    ISBN 978-981-16-3311-9 (eBook) https://doi.org/10.1007/978-981-16-3311-9 © The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover pattern © Melisa Hasan This Palgrave Macmillan imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

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This book is dedicated to my students, research collaborators, and colleagues who have challenged me intellectually to search for new knowledge.

Foreword

Professor Joseph Abiodun Balogun has written a book that will, for a long time to come, influence the way scholars, policymakers, and the general public look at healthcare professionals in Nigeria. Balogun is a veteran scholar and administrator of commanding influence in the field that spans Nigeria’s borders and the United States. He brings much of that influence to bear in this publication, which follows his seminal books Healthcare Education in Nigeria: Evolutions and Emerging Paradigms (Routledge, 2020) and Nigerian Healthcare System: Pathway to Universal and High-Quality Healthcare (Springer, 2021). The two-common trait of this book with the previous publications is Professor Balogun’s unstinted commitment to interdisciplinary research—away from the current insularity in curricula and the lack of interprofessional teamwork that characterize Nigeria’s health and education systems. Balogun is an apostle of interdisciplinary work, and his scholarship collaboration and student mentoring cut across different fields. This book will appeal to audiences seeking information on the training, roles, and responsibilities of healthcare professionals in Nigeria. In actuality, it does more. In the word of the author, it “promote[s] the culture of the interdisciplinary team[ship],” “improve[s] communication,” in a bid to “engender respect and cooperation in patient care” and “modulate[s] the incessant interprofessional conflicts” among healthcare professionals. The book’s heart is Chapter 5, which appraises the current ix

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status of interdisciplinary teamwork or lack thereof in Nigeria. Professor Balogun is dismayed by the insularity in the different health professions curricula, together with the lack of interprofessional kindred spirit. In this publication, he provides solutions straight from the heart, with the verve and authority of a griot engrossed in a contemporaneous chronicle of the story he is narrating. Finally, the elephant in the room this book calls attention to is Nigeria’s broken healthcare system, rendered more embattled since 2020 by the pandemic challenges of COVID-19. Professor Balogun’s suboptimal scenarios relating to healthcare professionals and healthcare education are all symptoms of Nigeria’s dysfunctional healthcare system. His scholarship is reflected in the Igbo saying that “the traveler drenched by rain will not dry from the wetness that afflicts him unless he can recall the point at which the rain started beating him.” This book’s significance points the reader to that turning point—without which no healing takes place. This stately and contemporary book is recommended highly to students, researchers, policymakers, and lay readers interested in the professions within the Nigerian health system. March, 2021 Philip C. Aka

Preface

The catalyst for writing this book emerged from my experience as a faculty member at Obafemi Awolowo University (OAU), Ile-Ife, Nigeria, from 1986 to 1991. At the time, the Faculty of Health Sciences at the University consisted of several health disciplines such as Medicine, Dentistry, Physiotherapy, Environmental Health, and Nursing. Despite the diverse academic programs offered in the Faculty, to my surprise, many of my colleagues had no firm knowledge of the roles and responsibilities of the other health professions outside their specialties. This knowledge deficit was because the different healthcare professions’ curriculum was insular and lacked contents on interprofessional education. The sad story is that 35 years later, the situation remains mostly unchanged. In the last two decades, protracted industrial strikes, even during the COVID-19 pandemic and conflicts among healthcare professionals and professional organizations have become the norm in the Nigerian healthcare landscape. These concerning developments have caused the death of many innocent people and prevented optimal healthcare delivery. Several respected scholars have advocated reforming the healthcare education curricula to include content in interprofessional education, team dynamics, and other health disciplines’ roles and expertise. The knowledge deficit created the impetus and urgency to write this book to educate healthcare professionals in Nigeria. The primary aim is to promote an xi

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interdisciplinary team’s culture, improve communication, engender respect and cooperation during patient care, and modulate the ongoing interprofessional conflicts. In this publication, the term healthcare profession includes the health disciplines offered in Nigerian universities to underscore this author’s interdisciplinary philosophy. The health disciplines are human medicine, dentistry, veterinary medicine, nursing, pharmacy, optometry, physical-­ and-­occupational therapy, prosthetics and orthotics, clinical psychology, medical laboratory science, radiography, nutrition/dietitian, biomedical engineering/technology, and public/community health. Chapter 1 of this book discusses the fundamentals of health professions to contextualize the issues presented in the book properly. Specifically, the chapter presents the hierarchy of occupations, professionalization, and the evolutionary path and socialization milestones that occupations attempting to attain true professions’ status and power transcend. It also analyses the differences between professional autonomy, direct access, and independent practice. Chapter 2 identifies Nigeria’s primary healthcare professions and discusses their central roles, including the specialty within each discipline. Chapter 3 identifies the healthcare occupations—vocational careers— within the Nigerian healthcare system and discusses their central roles. Chapter 4 chronicles the biography of 35 notable pioneer Nigerian healthcare professionals—fifteen physicians, two dentists, eight pharmacists, eight physiotherapists, and two nurses—during the nineteenth and early twentieth centuries. Chapter 5 analyses the causes and adverse impacts of industrial action within the Nigerian healthcare system and proposes using the interdisciplinary team concept as a panacea to curtail the prevalent interprofessional conflict and industrial action in Nigeria. This publication should be of interest to health system policymakers, technocrats, and students in search of information on the roles and responsibilities of healthcare professionals and vocational career workers in Nigeria and other developing countries with fledgling health systems. The publication is ideal for adoption as a reference textbook in the Introduction to Health Professions, Healthcare Dynamics, Interdisciplinary Healthcare Delivery, Special Topics in Allied Health, and Health Systems courses offered in Nigerian universities.

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 elow Are a Few Comments B from the Reviewers of This Book “The book fills historical gaps in the evolution of Nigeria’s health professions, the most populous country in Africa. And also serves as a guide for many developing countries that wish to improve other health professions in their countries.” “The book provides a broad and deep perspective on the health professions in Nigeria and will be of interest to many educators in developed countries interested in including international experiences in their academic programs.” “The book will make significant contributions to the field, especially for educators and students in developed countries interested in the history of Nigeria’s health professions. The book will engage health administrators’ attention in developing countries, exploring best practices in health care and the role of the different health professions in their countries.”

Chicago, IL, USA

Joseph Abiodun Balogun

Acknowledgments

My work experience at OAU between 1986 and 1991 and several visits to Nigeria between 2015 and 2019 informed the opinions expressed in this book. I owe many people some gratitude that I would like to acknowledge in this space responsively. I am grateful to all my colleagues at the University of Medical Sciences (UNIMED), Ondo City; Center of Excellence in Reproductive Health Innovation, at the University of Benin; and Women’s Health and Action Research Center Benin City, where I spent part of my sabbatical leave in 2019. I am indebted to my iconic academic friend, Professor Friday Okonofua, pioneer Vice-­ Chancellor of UNIMED and the hardest working academic I have met, for inviting me to present the Second Distinguished Guest lecture in June 2017. A significant part of the materials in this book came from the speech. I genuinely appreciate my esteemed colleague and research collaborator, Professor Philip Aka, for finding time out of his exceedingly busy academic and university administrative work schedule to meticulously read through the initial draft of this work and provide extensive feedback. Also, I want to express my appreciation to my mentor Professor Eyitayo Lambo, former Nigerian Minister of Health, for meticulously reading the first draft and providing many useful references and comments used to improve the depth and clarity of this publication. I am indebted to my brothers-in-law, Admiral Bamidele Daji and Admiral Olumuyiwa Olotu, and sister-in-law, Dr. Feyisayo Daji, for xv

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providing transportation and security protection during my many visits to Nigeria. I also acknowledge the support of the UNIMED Public Relations Officer, Mr. Temitope Oluwatayo, and Colonel (retired) Dr. Paschal Mogbo for providing the pictures in this book. No doubt, these photographs have added value to the information presented. I wholeheartedly thank my colleagues, Professor Adetoyeje Oyeyemi, Professor Dele Amosun, and Dr. Idowu Bello, for providing the salary information presented in Chapter 5. Finally, I owe sincere gratitude to all the authors whose work I cited. I want to thank Joshua Pitt at Palgrave Macmillan for the encouragement and opportunity to publish this work and Sarulatha Krishnamurthy (Mrs), Project Manager, and other staff at Palgrave Macmillan for working with me to meet the production deadline. Tinley Park, IL, USA March, 2021

Joseph Abiodun Balogun

Contents

1 The Fundamentals of Health Professions  1 Introduction   2 Professional Hierarchy   4 What Is Professionalization?   6 Autonomy and Independent Practice   10 Regulatory Boards/Councils  14 Professional Association/Society  16 Conclusion  18 References  19 2 The Healthcare Professionals in Nigeria 23 Introduction  24 The Healthcare Professions in Nigeria   24 Physician  26 Dentist  27 Physiotherapist  29 Occupational Therapist  31 Pharmacist  31 Optometrist and Dispensing Optician   32 Medical Laboratory Scientist   33 Radiographer  35 Nutritionist  36 xvii

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Dietitian  37 Prosthetist and Orthotist   37 Biomedical Engineer/Technologist  38 Public Analyst  39 Audiologist  39 Speech Therapist (Speech-Language Pathologist)   40 Veterinarian  41 Clinical Psychologist  42 Social Worker  44 The Professionalization Milestones of Major Health Disciplines  45 Capacity of the Healthcare Professionals Workforce   47 Distribution of the Healthcare Professions’ Workforce   51 Gender Inequity Among Healthcare Professionals   52 Conclusion  54 References  56 3 Health Occupations (Vocational Careers) in Nigeria 61 Introduction  62 Nurses  64 Midwives  66 Pharmacy Technicians  67 Physiotherapy Aides/Technicians  68 Medical Laboratory Technicians/Assistants  70 Occupational Therapist Assistants   70 Medical Record Officers   71 Community Health Workers  72 Dental Therapists  73 Dental Technologists/Therapists  74 Environmental and Public Health Workers   74 Complementary and Alternative Medical (CAM) Practitioners  75 Training of the Health Occupation (Vocational Career) Workforce  76 Training of Occupational Therapist Assistants, Medical Laboratory Technicians/Assistants, Dental Technologists/

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Technicians, Complementary and Alternative Medicine Practitioners  76 Training of Nurses and Midwives   76 Training of Pharmacy Technicians   77 Training of Medical/Health Records Personnel   77 Training of Community Healthcare Practitioners   77 Training of Dental Technologists and Therapists   78 Training of Environmental Health Officers   78 Training of Complementary and Alternative Medical Practitioners  79 Distribution of Health Occupation Workers   79 Conclusion  80 Appendices  80 Appendix 1  82 Appendix 2  82 Appendix 3  82 Appendix 4  83 Appendix 5  83 Appendix 6  83 References  83 4 Notable Pioneer Nigerian Health Care Professionals 87 Introduction  88 Methodology  88 Results  89 Physicians  89 Dentists 108 Pharmacists 109 Physiotherapists 113 Nurses 120 Discussion 123 Conclusion 127 References 127

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5 Interdisciplinary Healthcare Team: A Panacea to Curtail Interprofessional Conflict and Industrial Action in Nigeria133 Introduction 134 Operational Definitions  135 Causes and Adverse Impacts of the Industrial Action Crises  136 Conflicts Among Healthcare Professionals  138 Causes and Dimensions of the Crisis  138 Management of Interprofessional Conflict  140 Types of Healthcare Teams  142 Benefits of the Interdisciplinary Team Approach in the Delivery of Healthcare  143 Characteristics of a Successful Interdisciplinary Health Team  144 Leadership Controversy  146 Current State of Interdisciplinary Collaboration Within the Nigerian Healthcare System  148 Recommendations on Fostering Interdisciplinary Collaboration 153 Adoption of the Interdisciplinary Teaching Method in Healthcare Education Programs  153 Training of Healthcare Leaders Who Will Manage the Health System  156 Primary Healthcare and African Traditional Medicine Curricula Reform  157 Teaching and Modeling of Professionalism and Ethics  159 Engage Health Professional Students in Community Service-Learning 160 Improvement of Work Condition  161 Conclusion 162 References 167 Index175

About the Author

Joseph  Abiodun  Balogun FAS, is a distinguished professor in the College of Health Sciences at Chicago State University (CSU), USA; Emeritus Professor of Physiotherapy at UNIMED, Ondo State, and visiting professor/ program consultant at the Centre of Excellence in Reproductive Health Innovation at the University of Benin, Nigeria. He is the founder and President/CEO of Joseph Rehabilitation Center, a social service organization at Tinley Park, Illinois, USA, which provides community-­integrated living arrangement services for adults with disabilities.Professor Balogun obtained the Bachelor of Science (Honors) degree in Physiotherapy in 1977 from the University of Ibadan, Nigeria. He earned his master’s degree in Orthopedic and Sports Physical Therapy (1981) and Ph.D. in Exercise Physiology (Cardiac Rehabilitation) with a Minor in Research Methodology from the University of Pittsburgh (1985). He has held full-time and visiting faculty and administrative positions at various universities around the world—Russell Sage College, Troy, New  York, Obafemi Awolowo University (OAU), Ile-Ife, Nigeria; University of Florida, Gainesville; Texas Woman’s University, Houston; the State University of New York Health Science Center at Brooklyn (SUNY-HSCB); Barry University, Florida; and King Saud University, Saudi Arabia. He served for 13 years xxi

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About the Author

(1999–2013) at CSU as Dean of the College of Health Sciences. He established seven academic programs and the HIV/AIDS Research and Policy Institute to address the disproportionate incidence and complex burdens of HIV/AIDS in minority populations. He also served for six years as Chairman of the Physical Therapy Program (1993–1999) and Associate Dean for Student Academic Affairs (1994–1999) at SUNYHSCB, and Consultant Physiotherapist (1988–1991) and Vice-Dean in the Faculty of Health Sciences at OAU (1990–1991). Professor Balogun has contributed to Physical Therapy, Cardiovascular Epidemiology, Ergonomics, and HIV Behavioral Research. He has authored six books; 30 book chapters, monographs, technical compendia; over 200 full articles; and 24 peer-reviewed conference abstracts and proceedings. In 2015, he delivered the third Christopher Ajao’s keynote speech at the 55th Annual Conference of the Nigeria Society of Physiotherapy. In 2017, he gave the second Distinguished University Guest Lecture at the UNIMED, Nigeria and in 2021 delivered the keynote speech at the inaugural conference of the International Association of Nigerian Physical Therapists. Professor Balogun is the Deputy Editor of the African Journal of Reproductive Health and serves on the Editorial Board of half-dozen other journals around the world. He has received over a dozen service and an academic fellowship award from the Academy of Medicine Specialties (FAcadMedS), Royal Society for Public Health (FRSPH), Institute of Management Consultants (FIMC), Academy of Science (FAS), Nigeria Society of Physiotherapy (FNSP), and the American College of Sports Medicine (FACSM). In 2003, he was awarded the J.  Warren Perry Distinguished Author’s Award by the Journal of Allied Health and in 2018 was conferred with the Distinguished Decorated Affiliate of the American Health Council. Professor Balogun’s most recent books include Healthcare Education in Nigeria: Evolutions and Emerging Paradigms (Routledge, 2020), Contemporary Obstetrics and Gynecology for Developing Countries (Co-edited - Springer Nature, 2021), and The Nigerian Healthcare System: Pathway to Universal and High-Quality Health Care (Springer Nature, 2021).

List of Figures

Fig. 1.1 Fig. 1.2 Fig. 1.3 Fig. 2.1 Fig. 2.2 Fig. 2.3 Fig. 2.4 Fig. 2.5 Fig. 2.6 Fig. 3.1 Fig. 3.2 Fig. 3.3 Fig. 3.4 Fig. 3.5 Fig. 5.1

The hierarchy of importance of occupations 4 Professionalization processes and pathways 7 Professionalization milestones 8 Recognized healthcare professions in Nigeria 25 A physician explaining the condition of a patient to relatives 27 A dentist attending to a child here 28 A physiotherapist treating a patient with shortwave diathermy 30 A medical laboratory scientist prepares to draw blood from a patient34 A radiographer preparing to take an x-ray of a child 36 Recognized healthcare occupations in Nigeria 64 A nurse at work in a pediatric ward 65 A midwife at work 66 A pharmacy technicians educating patients on their medications 67 A dental therapist at work 71 A group picture with attendees of a national workshop on Best Practices in Academic/Clinical Department Administration and Scholarship of Discovery presented by the author at UNIMED, Ondo City, Nigeria on July 9 and 10, 2018 158

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List of Tables

Table 1.1 Characteristics of occupations, semi-professions, and true professions5 Table 1.2 The major health occupations, semi-professions, and true professions in the United States 11 Table 2.1 Profile of Nigerian health workforce (per 1000 people) 50 Table 2.2 Physiotherapists (PT) per resident ratio in selected countries around the world 51 Table 2.3 Distribution of the health professional workforce by region 52 Table 2.4 Gender distribution of the health professional workforce as of 2008 (Labiran et al., 2008) 53 Table 2.5 Percentage of females in healthcare occupations in the United States for 2016a53 Table 5.1 Entry-level salary for the primary healthcare professions in Nigeria, Ghana, and South Africa 163

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1 The Fundamentals of Health Professions

Abstract  This chapter discusses fundamental concepts in health professions to contextualize the issues presented in this book properly. It apprises the hierarchy of occupations and reviews the divergent views on professionalization and the evolutionary path and socialization milestones that vocational careers attempting to attain true professional status transcend. The chapter also analyzes differences between professional autonomy, direct access, and independent practice. Keywords  Health professions • Professionalization • Occupations • Vocational career • Semi-professions • True professions • Autonomy • Independent practice Learning Objectives After reading this chapter, the learner should be able to: . Describe the hierarchy of the importance of professions. 1 2. Discuss the primary milestones that an occupation must undergo before it attains true professional status. 3. List the health professional associations and their regulatory boards in Nigeria.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 J. Abiodun Balogun, Health Professions in Nigeria, https://doi.org/10.1007/978-981-16-3311-9_1

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Introduction Before the Middle Ages, mathematics, physics, astronomy, chemistry, and biology emerged as the earliest occupations in Europe. Subsequently, from about the fifth to the sixteenth century, United Kingdom recognized divinity, medicine, and law as “learned” professions (Carr-­Saunders and Wilson, 1944, Perks, 1993). Surveying garnered professional status first in the United States, followed by medicine, actuarial science, law, dentistry, civil engineering, architecture, and accounting. Several American Presidents, such as George Washington, Thomas Jefferson, and Abraham Lincoln, all worked as land surveyors before becoming politicians. During the early nineteenth century, the medical profession in England was overcrowded by several unqualified physicians. This situation created competition between the “skilled” and the “unskilled” physicians and led to denying those who were truly qualified to practice. As a result, “skilled” physicians complained of “bodily harm” done to patients. These problems led to physicians’ widespread demands to establish a registration system and minimum training requirements to be admitted into the profession. A lengthy campaign of claims by “skilled” physicians led to the Medical Act of 1858 in the United Kingdom. This development laid the foundation for the creation of the General Medical Council. The Council consisted primarily of physicians, charged with regulating the medical profession on behalf of the state government, oversee medical training, and maintain a register of qualified practitioners. The movement to ensure only qualified practitioners enter the medical field spread to the United States, where physicians founded the American Medical Association in 1847. The Association’s primary goals were to advance the profession’s knowledge base, improve medical training standards, establish a code of medical ethics, and improve public health. Nursing came into existence as early as human existence and one of the first caring professions. It has evolved over the years to develop its own culture, language, norms, arts, and sciences from the patients’ physical,

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psychosocial, and spiritual needs. Nursing history is universally traced to Miss Florence Nightingale (1820–1910) during and after the Crimean War (1854–1856). Nursing was the first occupation to form an international organization, the International Council of Nurses, founded in 1899. Subsequently, in 1916, the Royal College of Nursing was established, while in 1919, the General Nursing Council for England and Wales was founded. With the advent of technology and the enhanced advocacy for specialization in the nineteenth century, several health disciplines, such as pharmacy, veterinary medicine, optometry, and psychology transitioned to true professional status in the United States (Buckley & Buckley, 1974). The origin of nursing, physiotherapy, occupational therapy, and estate management is of recent vintage traced to the nineteenth century. In the twentieth century, other disciplines, such as computer science, bioengineering, molecular biology, medical laboratory science, radiography, audiology, speech therapy, optometry, nutrition/dietetics, prosthetics, and orthotics, also evolved. In today’s world, with different fields competing for relevance in the eyes of the public and patients, image and prestige have taken center stage as an essential measure in judging true professions. Occupations attain specific developmental milestones at different timelines and display similar patterns in their journey from the entrance into a country to recognition by the legislative and governmental authorities. There are always observable differences in the pace of growth and popularity of occupations, by the number of schools offering academic programs and their practitioners’ size. These differences resemble many countries’ developmental journeys, including the United Kingdom that created and colonized modern-­day Nigeria and the United States, whose presidential system of government Nigeria adopted since its Second Republic in 1979. The evolutionary developments of healthcare education and the Western-style health system in Nigeria from 1472 to the contemporary era, including why universal healthcare has been elusive for over 60 years, are discussed comprehensively in two previous books published by the author (Balogun, 2020, 2021).

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Professional Hierarchy Often, the words occupation (vocational careers) and profession are used interchangeably, but there are differences. Vocational jobs do not require extensive education, and such work does not require in-depth knowledge and skills. Besides, vocational workers usually need supervision and are marked by low societal recognition and no ethical code of practice. They are not paid for their expertise but only for what they produce. Occupations aspire to become true professions by attaining significant milestones during their professionalization journey. Healthcare professionals (HCPs) are a group of people with unique knowledge and skills derived from research and education and prepared to apply the specialized knowledge and expertise in the public’s interest. They are trained to provide preventive, curative, or rehabilitative services to clients, families, or communities. The hierarchy of health disciplines is classified into three broad domains: true (learned) professions, semi-professions, and occupations (vocational careers) (Fig. 1.1). Professions are rated by the power and prestige they command within the society at large. True professions are at the top of the pyramid, semi-­ professions at the middle, and occupations (vocational careers) at the bottom of the pyramid. True professions have high esteem and political

True Professions

Semi-Professions

Vocational careers

Fig. 1.1  The hierarchy of importance of occupations

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power. Semi-professions have less autonomy in decision-making and, generally, do not enjoy high societal recognition. Conversely, occupations have technical skills, but they have limited education and no distinct body of knowledge. The distinguishing traits of occupations, semi-­ professions, and true professions are presented in Table 1.1, respectively. Table 1.1  Characteristics of occupations, semi-professions, and true professions S/N Occupations 1 2 3 4 5 6

Primarily acquire technical skills following training Limited education, certificate, diploma, or associate degree Shorter training period—usually less than three years Less prestige Low-paying job Work is supervised by a professional Examples: Nursing, pharmacy assistant, phlebotomist, X-ray technician, medical sonography technician

S/N Semi-professions 1 2 3 4 5 6 7 8 9

Entry-level education at BS or MS level Lower in occupational status and prestige No distinct body of knowledge Lacks wide societal recognition Majority of the members are women Practitioners often lack the degree of control over their work—work supervised by another professional Licensure process required Less autonomy in decision-making Lacks independence in practice Examples: Medical laboratory scientists, social work, orthotics, and prosthetists, radiographers

S/N True professions 1 2 3 4 5 6 7 8 9

Entry-level education is at the doctoral level Distinct body of knowledge possessed only by those representing that profession. No other profession can do the job Commitment to research that improves the quality of life Accountability and advocacy Positive public image Public service Collaboration with other health professions, Prestige and high financial rewards Often supervise other occupations (continued)

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Table 1.1 (continued) S/N True professions 10 11 12 13 14 15 16 17 18 19

Level of expertise in a specific area Exerts authority in a specialized area Interaction with patients is characterized by “affective neutrality” that entails adherence to a code of ethics that directs behavior Professional stature is predicated on the individual’s performance concerning standards determined by his or her colleague group Professional decisions are not based on self-interest or personal gain, but on the altruistic goal of helping others Formation of a professional organization that requires self-control of their professional behavior Legal recognition by the government including approval of a regulatory board that governs training, and practice Licensure process required Professional autonomy Direct access and independent practice Examples: Medicine, dentistry

All over the world, the prestige that occupations hold is influenced by the rigor and training length (Shortell, 1974). Professionals need extensive education, and specialized knowledge brings the power of independent practice, higher social status, and prestige. They are rewarded for their unique talents and in-depth knowledge of their occupation. Ethical codes guide their work, and government statute regulates their practice. Globally, true professions enjoy high social status and esteem within society. High regard arises primarily from the valuable selfless and social roles of the professional’s work. Financial rewards and remuneration substantially influence the power that a profession commands vis-à-vis the image and desirability of that profession.

What Is Professionalization? Professionalization is the evolutionary path and socialization milestones that an occupation attempting to obtain a true profession’s status and power goes through. There are a plethora of other views about professionalization. Ritzer (1975) defined “professionalization” as the “social processes or developmental stages through which occupations move to

1  The Fundamentals of Health Professions 

General Public

Legislators

Government

Developmental Milestones Inception of Occupation

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True Professional Status

Power, Influence and Esteem

Fig. 1.2  Professionalization processes and pathways

attain the power and status that professions have traditionally held in society.” Forsyth and Danisiewicz (1985) averred that “professionalization has to do with the ability of occupation to convince legislators and the public of the importance of its work, rather than the intrinsic knowledge and value of that work.” Some scholars contend that the transformation of occupation into the true profession is a systematic process that involves changes similar to humans’ evolution. The developmental journey’s pace and success are modulated and influenced by the general public, legislators, and the national government (Fig. 1.2). While it takes some discipline less than three decades to navigate the journey from occupation to true professional status, it may take another field over a century. The professionalization process is marked by milestones, an index or indicator of achievement that an occupational field attains in its quest to reach and maintain professional power and esteem. For an occupation to transition to a true profession, they must seek political and legal recognition for that stature. The change requires hard work and advocacy on the part of the members to attain the essential professionalization milestones. Carr-Saunders (1944) viewed professionalization along “a line of inevitable progress, working toward the acquisition of some defining characteristics, namely codes of ethics, professional associations, specialized skills, and governance.” Wilensky (1965) emphasized the developmental aspect of professionalization, suggesting that occupations must achieve

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General Public

Importaon of Occupaon

Legislators

Formaon of Professional Associaon

Government

Approval of Regulatory Board

True Professional Status

Fig. 1.3  Professionalization milestones

the following four sequential stages/functions: (1) creating a full-time occupation, (2) establishing training schools, (3) developing a professional association, and (4) producing a code of ethics (Fig. 1.3). The achievement of these four developmental milestones does not mean that the occupation will attain the haven of a true profession. Central to this perspective is the recognition that occupation can enhance its autonomy and professional status through social and political actions. Around the world, an essential trait associated with health professions that have attained true professional status is entry-level doctoral education. Respectable HCPs have specialization within the highly skilled work called “professional expertise.” The expectation of specialization requires regular updating of clinical skills through post-professional education and continuing education life-long learning practices. Another trait that is a desideratum for true professions is developing a unique and esoteric knowledge base that sets it apart from other disciplines. For example, the body of knowledge of medicine is based on germ theory. On the other hand, the body of knowledge and science of physiotherapy is based on pathokinesiology theory. For a profession to garner esteem from the general public, it must engage in research that addresses health problems and improves the society’s quality of life. Moreover, professional autonomy and independent practice are attributes that are a sine qua non to attain true professional status.

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One of the barriers against the transitioning of semi-professions to true professional status is the perception that women dominate semiprofessions, and therefore, they engage primarily in “women’s work.” This sexist perception elevates the prejudices against semi-­professions regardless of the amount of skill involved in the profession. In several countries worldwide, the physiotherapy profession is female-­dominated with concomitant sexist bias, an added burden to overcome in attaining true professional status (Balogun, 2015a, 2015b). The literature reveals that the licensure process is considered one of the traits of true professions. Licensure is a quality assurance procedure that occurs following the education process that reassures the public that the occupation is trusted and respected. Codes of ethics and standards are also required attributes of reputable professions. True professions willingly collaborate with the other members of the healthcare team. Another core trait of a respectable health discipline is accountability to the individual patient, society, and the professional association. True professions are held accountable for fulfilling the implied agreement governing the patient and practitioner role and abiding by the job’s ethical codes of practice. Advocacy is the act of supporting a social issue or policy. True professions have a moral duty to advocate for at least one social cause, develop a positive image in society, engage in charitable projects, and members work hard to protect the image of the association. A semi-­ profession is not a true profession until all the requirements and criteria listed in Table 2.3 are met. This chapter will use the emerging developments in physical therapy to illustrate the characteristics and relationships among occupations, semi-­ professions, and true professions in the United States. In the healthcare industry, allied health providers work collaboratively in health teams with well-known traditional HCPs—physicians, nurses, dentists, and pharmacists—to provide service for the patients. Allied health consists of more than 80 different health disciplines and represents approximately 60% of all healthcare providers. There are five million allied healthcare workers in the United States. The healthcare jobs grew from 15.6 million to 19.8 million between 2010 and 2020, with an increasing number of jobs requiring bachelor and graduate degrees (Liaison International, 2020). Over the decade, jobs in the healthcare industry grew more than

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20%, while employment in the remainder of the economy only increased by 3%. Healthcare jobs will grow at three times the rest of the economy during the next decade (Salsberg & Martiniano, 2018). Some allied healthcare providers work collaboratively with physicians, nurses, dentists, and pharmacists and play critical roles in evaluating patients’ needs, keeping the physician and others informed of the patient’s progress, and caring for them. Other allied healthcare providers work independently as specialists in nutrition, exercise, speech, audiology, health education, and daily function. Allied health providers fall into two broad categories: technicians/assistants (occupations—vocational careers) and therapists/technologists (semi-and-true professionals). Technicians’ education lasts less than two years, and they are trained to perform procedures under the supervision of technologists or therapists. Examples of occupations in this category are cardiovascular technicians, ophthalmic medical technicians, and medical assistants. Therapists or technologists’ education is more intensive and includes acquiring procedural skills and learning to evaluate patients, diagnose conditions, develop treatment plans, and understand the rationale and side effects behind the various treatments that they apply. Audiologists, physical therapists, speech-­ language pathologists, neurodiagnostic technologists, and occupational therapists are examples of semi or true professionals in allied health (Liaison International, 2020). The primary healthcare occupations, semi-professions, and true professions in the United States and their average entry-level salary are presented in Table 1.2. A majority of the professions with entry-level doctoral education, except for physiotherapy, have direct access and independent practice rights, and their compensation is substantially higher than that of semi-professions and occupations.

Autonomy and Independent Practice Autonomy and independent practice are the last and most difficult traits to attain in the evolutionary journey of occupation to true professional status. Autonomy in making professional decisions is one of the “litmus tests” of true professions. Autonomy is usually a negotiated social

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Table 1.2  The major health occupations, semi-professions, and true professions in the United States

Health discipline in S/N alphabetical order

Entry-level education

1

Athletic trainers

BS

2

Audiologists

3

Chiropractors

4

Clinical laboratory technologists and technicians Dental hygienists Dentists

5 6

Associate DDS

47,510 75,920 71,410 52,330

Occupation True profession Occupation

74,820 156,240

Semi-­ profession Semi-­ profession Semi-­ profession Occupation

60,370

Occupation Semi-­ profession Doctoral (OD) True profession Master’s Semi-­ profession Doctoral True (PharmD.) profession Doctoral Semi-­ (DPT) profession Master’s Semi-­ profession

71,730 84,270

8

Associate Cardiovascular technologists and technicians Dietitians and nutritionists BS

9

Exercise physiologists

BS

10

Genetic counselors

Master’s

11

Associate

12 13

Nuclear medicine technologists Nurse (RN) Occupational therapists

14

Optometrists

15

Orthotics and prosthetists

16

Pharmacists

17

Physical therapists

18

Physician assistants

7

Classification

Semi-­ profession Doctoral (Au. True D) profession Doctoral (DC) True profession BS Occupation

Average entry-level salary per year ($)

Associate Master’s

67,080

49,270 80,370 76,820

111,790 69,120 126,120 87,930 108,610 (continued)

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Table 1.2 (continued) Average entry-level salary per year ($)

Health discipline in S/N alphabetical order

Entry-level education

Classification

19

Doctoral (MD)

True profession

208,000

True profession Semi-­ profession Occupation Semi-­ profession Semi-­ profession Occupation

129,550

True profession

93,830

20

Physicians (family physicians post-residency) Podiatrists

21

Radiation therapists

Doctoral (DPM) Associate

22 23

Radiologic technologists Respiratory therapists

Associate BS

24

Speech-language Master’s pathologists Vascular technologists and Associate diagnostic medical sonographers Veterinarians DVM

25

26

82,330 61,240 60,280 77,510 67,080

contract between occupation and policymakers based on public trust to act in society’s best interests. What is it that the public expects? The public expects HCPs to have specialized knowledge, use it altruistically to serve humanity, regulate themselves, and maintain integrity and standards to assure high-quality care. Professional autonomy is the extent to which an occupation perceives freedom and independence in its clinical role. Autonomy includes release from those outside the occupation and the organization that employs the professional. A core purpose of professional autonomy is to preserve the individual independence of people. Swisher and Page (2005) opined that occupations with high autonomy in decision-making with high degrees of control over their work are true professions and occupations whose members enjoyed less autonomy in decision-making, and less control over their work are vocational careers, or semi-professions, or paraprofessions, or non-professions. Professional autonomy and independent practice are not the same. In self-determination theory, autonomy means that the occupation has free will and can stand behind their actions and values. No external board can

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force an occupation to do something they disagree with. Independent practice means the occupation does not need or accept help, resources, or care from other occupations—they can function without others. Attainment of autonomy does not automatically confer independent practice status. An occupation can be autonomous but dependent on another discipline for help and support. In the United States, physical therapy attained professional autonomy in education when the Secretary of Education, Ernest Boyer, in June 1977 recognized the American Physical Therapy Association (APTA) as the sole accrediting body for physical therapy education programs. The American Medical Association’s Council on Medical Education has undertaken this function since 1959 as the exclusive accrediting agency. The APTA constituted the Commission on Accreditation in Physical Therapy in 1978 and was recognized by the Department of Education and the Council for Higher Education Accreditation as the sole authority in charge of accrediting entry-level education programs for physical therapists and physical therapist assistants (APTA, 1978). The American Medical Association strongly opposed the APTA’s power and continued until today to oppose legislation that allows patients direct access to physical therapy services. Although physical therapy entry-level education in the United States is at the doctoral level since 2015, it has not attained true professional status because many physical therapists are employed in physician-owned physical therapy (POPT) clinics. Direct access and independent practice are yet to be attained. The APTA opposes POPT because they feel it limits a patient’s freedom to choose the physical therapist provider of their choice. Although physical therapists have the autonomy to see patients without a physician’s referral, working directly for a physician implied that physical therapists are dependent upon a physician’s referral to provide treatment (MyPTsolutions, 2020). In many states, the practice law continues to impose arbitrary restrictions on patients seeking physiotherapy evaluation and therapy directly. The law only grants access to physiotherapy for a limited period and under certain circumstances. Such barriers do not recognize the physiotherapists’ professional training and expertise. Additionally, the practice law causes an unnecessary delay of treatment, higher costs, frustration, and decreased patients’ functional outcomes. Elimination of the arbitrary restrictions will lead to timely and more effective care. The

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physiotherapy profession in the United States is still tied to the apron of medical work. As of 2020, all 50 states, including the District of Columbia and the US Virgin Islands, have direct access to physiotherapist services, but provisions and limitations vary among jurisdictions. For example, in Alabama, Missouri, and Mississippi, patients have limited access to evaluation, fitness, and wellness. Treatment is provided only to specific patient populations or under certain circumstances, such as patients with a known medical diagnosis or a prior physician referral. On the other hand, in 20 states, patients have unrestricted access to physiotherapy services: Alaska, Arizona, Colorado, Hawaii, Idaho, Iowa, Kentucky, Maryland, Massachusetts, Montana, Nebraska, Nevada, North Carolina, North Dakota, Oregon South, Dakota, Utah, Vermont, West Virginia, and Wyoming (APTA, 2020). And in states—Arkansas, California, Connecticut, Delaware, Florida, Georgia, Indiana, Illinois, Kansas, Louisiana, Maine, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Virginia, Washington, Texas, and Wisconsin, including the US Virgin Islands territory and Washington DC,—patients have access to evaluation and treatment with some restrictions, including time or visit limitations or referral requirements for a specific intervention such as needle EMG diagnosis or spinal manipulation. The relevant question is, when do occupations know when they have attained true professional status? The highest level is achieved when the discipline commands esteem, power, and influence in the larger society, among legislators, and within government (Balogun, 2015b). Freidson, in 1986, adroitly described the situation best by stating among other things that, “professionalization is perception,” elaborating that practically an occupation “becomes a profession when enough people agree that it is.”

Regulatory Boards/Councils Having a regulatory board/council is an affirmation of a profession’s legitimacy by the government and a necessary developmental milestone in the journey toward true professional status (Wilensky, 1965). The boards’

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primary purpose is to protect the public by assuring that all HCPs are competent and public safety is not put at risk by quacks. The regulatory board provides an avenue to discipline HCPs when necessary. Regulatory boards may suffer embarrassment or even censure if problems arise from any scandal and maladministration. Suffice it to say, regulatory boards must be well managed, and their credentialing process maintained according to best practices and standards. The following 14 health professional regulatory boards are recognized by the Nigerian government (Federal Ministry of Health – FMH-, 2018): 1. Medical and Dental Council of Nigeria (MDCN) 2. Nursing and Midwifery Council of Nigeria (NMCN) 3. Medical Rehabilitation Therapist Board (MRTB) 4. Radiographers Registration Board of Nigeria (RRBN) 5. Optometry and Dispensing, Optician Registration Board of Nigeria (ODORBN) 6. Dental Therapist Registration Board of Nigeria (DTRBN) 7. Institute of Public Analyst of Nigeria (IPAN) 8. Health Record Registration Board of Nigeria (HRRBN) 9. Community Health Practitioner Registration Board of Nigeria (CHPRBN) 10. Pharmacists Council of Nigeria (PCN) 11. Institute of Chartered Chemist of Nigeria (ICCON) 12. Medical Laboratory Science Council of Nigeria (MLSCN) 13. National Institute of Pharmaceutical Research and Develop ment (NIPRD) 14. National Primary Healthcare Development Agency (NPHCDA) One of the regulatory board’s statutory functions is to periodically update the code of conduct and make it desirable for its practice. The code of practice guides the actions and behaviors of all registered HCPs toward patients and families. Any registered practitioners who, after given the opportunity to defend self is found to have abridged the rules shall be guilty of professional misconduct, and the board may impose penalties for the infringement by admonishment, suspension for a stated period, or deleting the name of the practitioner from the register.

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The regulatory councils periodically review the academic standards to conform with global best practice and oversee examinations in the discipline(s) by awarding certificates to candidates who complete clinical specialist or fellowship training. It also accredits academic programs and clinical sites where students have their preceptorship and internship training. The board eliminates quackery through meticulous screening of new members’ credentials and maintains an up-to-date register of all licensed members. Regulatory boards also ensure members are life-long learners by mandating continuing professional development education to enhance the knowledge and clinical skills of HCPs and partner with other health professions to strengthen the healthcare system.

Professional Association/Society Another critical developmental milestone in the journey toward true profession is forming a professional organization, also called the professional body, or professional organization/society—usually a non-profit body (Wilensky, 1965). In Nigeria, the following 16 professional associations are recognized by the FMH: 1. Nigerian Medical Association (NMA) 2. Nigerian Dental Association (NDA) 3. Nigeria Society of Physiotherapy (NSP) 4. Occupational Therapists Association of Nigeria (OTAN) 5. Pharmaceutical Society of Nigeria (PSN) 6. Nigerian Optometric Association (NOA) 7. Nigerian Psychological Association (NPA) 8. National Association of Nigeria Nurses and Midwives (NANNM) 9. Association of Medical Laboratory Scientists of Nigeria (AMLSN)/ Association of Science Laboratory Technologists of Nigeria (ASLTN) 10. Association of Radiographers of Nigeria (ARN) 11. Nutrition Society of Nigeria (NSN) 12. Nigerian Dietetic Association (NDA)/Dietitians Association of Nigeria (DAN)

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13. Nigerian Prosthetic, Orthotic, and Orthopedic Technology Society (NPOOTS) 14. Association of Biomedical Engineers and Technologists of Nigeria (ABETN) 15. National Association of Community Health Practitioners of Nigeria (NACHPN) 16. Nigerian Veterinary Medical Association (NVMA). Professional associations are dedicated to safeguarding the interests of the public and members of that profession, advancing the science and practice of the discipline, and promote leadership, innovation, foster collegiality, inclusiveness, trust, and integrity. They also set standards to improve healthcare and clinical practice quality and operate with transparency in their work and strive for the highest standard possible. Professional associations have a national Executive Council that governs their operations, and they have full authority to act on behalf of the General Assembly and make policy decisions. The National Executive Council meets at least twice annually to deliberate on critical issues and make substantive decisions on behalf of the organization. The Chief Executive Officers (CEOs) of the Council usually consist of the President, Vice-President, Secretary, Treasurer, and the Editor of the journal. The CEOs, assisted by the secretariat personnel, oversee the daily operations of the organization. The General Assembly, which comprises all professional association members, is the apex decision-making organ of the profession. The Assembly is typically convened once a year during the annual conference. The Assembly members vote for the CEOs and vote to amend or repeal bylaws and standing rules. The Assembly can also adopt ethical principles and standards to govern members’ conduct and modify or reverse the decision of the CEOs or the Council. Besides the General Assembly meeting, several statutory committees make recommendations on topical issues for consideration by the Council. Many organizations have State chapters and coordinators to enhance the association’s administrative effectiveness. Professional associations typically have several roles that include the following:

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Advocacy: Advocacy is the willingness to voice opinions and participate in both a formal network of institutions and an informal network that enhances the association’s image and develops partnerships where active communication is needed. Research and scientific conference: Professional associations typically hold annual and scientific meetings. Information on best practices, cutting-­ edge research, and innovative ideas and discoveries in all the specialties are also disseminated during these conferences. Capacity building: Professional associations always invested in strengthening the capacity of their members through active collaboration with key stakeholders, CEOs, and staff. The capacity building also extends to supporting the training of auxiliary HCPs to improve their proficiency and skills. Setting standards of practice: Professional associations play a vital role in ensuring that there is an evidence-based standard of clinical practice that is disseminated widely during general conferences, workshops, and through other channels of information dissemination. This process can influence the quality of service delivered by the members of the association over time. These practices are usually in clinical guidelines and protocols shaped by expert opinions in the specialties. Fellowship examinations: National associations usually collaborate with the professional regulatory body to provide training and conduct fellowship examinations in the clinical specialties. Global collaboration: The national associations typically join and network with members from the international professional association.

Conclusion The evolutionary path and socialization milestones that each occupation transcends are modulated and influenced by the public, legislators, and the national government. While it takes some disciplines less than three decades to navigate the journey from occupation to trueprofessional status, it may take another field over a century.

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Case Study Using the information presented in Tables 1.1 and 1.2, indicate in the table below the occupational status of the primary healthcare disciplines in Nigeria and justify your selection. Health discipline in alphabetical order

Justification Entry-­level Classification for your degree of occupation classification

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Medicine Dentistry Pharmacy Physiotherapy Occupational therapy Clinical psychology Optometry Radiography Medical laboratory science Nutrition/dietetics Public environmental health Community health Biomedical engineering Prosthetics and orthotics Nursing and midwifery Medical records/information management 17 Dental therapy 18 Public analyst

References APTA. (1978). APTA brings academic accreditation “in house.” [online]. Available at: https://centennial.apta.org/timeline/apta-­brings-­academic-­accreditation-­ in-­house/. Accessed 10 Feb 2020. APTA. (2020) Direct access advocacy. Improving direct access at the state level. Levels of patient access to physical therapists services in the U.S. [online]. Available at: https://www.apta.org/advocacy/issues/direct-­access-­advocacy; https://www.apta.org/advocacy/issues/direct-­a ccess-­a dvocacy/improve-­ direct-­access-­state-­level; https://www.apta.org/advocacy/issues/direct-­access-­ advocacy/direct-­access-­by-­state. Accessed 10 Feb 2020.

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Balogun, J. A. (2015a). The path to our destiny: The transitioning of physiotherapy from a semi-profession to a true-profession. https://doi.org/10.13140/ RG.2.1.2003.4008. [online]. Available at: https://www.researchgate.net/ publication/284300009_THE_PATH_TO_OUR_DESTINY_The_ Transitioning_of_Physiotherapy_from_a_Semi-­Profession_to_a_True-­ Profession. Accessed 10 Oct 2020. Balogun, JA. (2015b) Professionalization of physiotherapy in Nigeria: Challenges, threats and opportunities. [online]. Available at: https://www. researchgate.net/publication/321792036_Professionalization_of_physiotherapy_in_Nigeria_Challenges_threats_and_opportunities. Accessed 10 Oct 2020. Balogun, JA. (2020). Healthcare education in Nigeria: Evolutions and emerging paradigms (1st ed.). Routledge Publications. [online]. Available at: https:// www.routledge.com/9780367482091 Balogun, J. A. (2021). Chapter 3: Evolutionary Developments, Threats and Opportunities within the Nigerian Healthcare System. In Nigerian Healthcare System: Pathway to Universal and High-Quality Healthcare. Springer Nature. Buckley, J. W., & Buckley, M. H. (1974). The Accounting Profession (p. 4). Quoted by Perks. Carr-Saunders, A. M., & Wilson, P. A. (1944). “Professions” Encyclopedia of the Social Sciences. University of Chicago Press. Federal Ministry of Health (FMH). (2018). [online]. Available at: http://www. health.gov.ng/index.php/department/hospital-­services. Accessed 10 Oct 2020. Forsyth, B. F., & Danisiewicz, T. J. (1985). Toward a theory of professionalization. Work and Occupations: An International Sociological Journal, 12(1), 59–57. [online] Available at: https://eric.ed.gov/?id=EJ311099. Accessed 3 Febr 2020. Freidson, E. (1986). Professional powers: A study of the institutionalization of formal knowledge. University of Chicago Press. [online]. Available at: https:// www.press.uchicago.edu/ucp/books/book/chicago/P/bo5958556.html. Accessed 3 Feb 2020. Liaison International. (2020). Allied health professions: Overview. Explorehealthcareers. [online]. Available at: https://explorehealthcareers.org/ field/allied-­health-­professions/. Accessed 10 Oct 2020. myPTsolutions. (2020). Working in a physician-owned physical therapy clinic: Arguments for and against. [online]. Available at: https://myptsolutions.com/ working-­physician-­owned-­physical-­therapy-­clinic-­arguments/. Accessed 10 Feb 2020.

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Perks, R.W. (1993). Accounting and society. Chapman & Hall (London). Premium Times Nigeria: Nigerian universities to get new p ­ harmacy curriculum. September 30, 2017 Agency Report. Ritzer, G. (1975). Professionalization, bureaucratization and rationalization: The views of Max Weber. [online]. Available at: https://www.jstor.org/ stable/2576478?seq=1#page_scan_tab_contents. Accessed 3 Feb 2020. Salsberg, E, Martiniano, R. (2018) Healthcare jobs projected to continue to grow far faster than jobs in the general economy. [online]. Available at: https://www.healthaffairs.org/do/10.1377/hblog20180502.984593/full/. Accessed 10 Feb 2020. Shortell, S. M. (1974). Occupational prestige differences within the medical and allied health professions. Social Science and Medicine, 8(1), 1–9. [online]. Available at: http://www.sciencedirect.com/science/article/pii/0037785674 900031. Accessed 3 Feb 2020. Swisher, L. L., & Page, C. J. (2005). Chapter 1 – Introduction: The physical therapist as professional. In Professionalism in physical therapy: History, practice, and development (pp. 1–21). [online]. Available at: https://www. sciencedirect.com/science/article/pii/B9781416003144500057. Accessed 10 Feb 2020. Wilensky, H. (1965). The professionalization of everyone? American Journal of Sociology, 71(1), 84–86. [online]. Available at: https://www.jstor.org/stable/ 2774776?seq=1. Accessed 3 Feb 2020.

2 The Healthcare Professionals in Nigeria

Abstract  This chapter identifies the primary healthcare professions in Nigeria and apprises the readers of their central roles and clinical specialties. The chapter also analyzes the professionalization milestones of the major health disciplines, the capacity, and distribution of the healthcare workforce, including gender inequity and working conditions. Keywords  Healthcare professionals • Roles/responsibilities • Clinical specialties • Nigeria Learning Objectives After reading this chapter, the learner should be able to: 1. Identify the primary health professions, including specialties, and articulate their primary roles and responsibilities. 2. Discern the differences between health professional associations and regulatory boards. 3. Analyze the professionalization milestones of the major health disciplines in Nigeria. 4. Contrast the capacity and distribution of the healthcare workforce in Nigeria with that of the United States.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 J. Abiodun Balogun, Health Professions in Nigeria, https://doi.org/10.1007/978-981-16-3311-9_2

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Introduction The origin of western medicine occupations in Nigeria is of a more recent vintage. After the amalgamation of the Northern and Southern “Protectorates,” along with the Colony of Lagos in 1914, Nigeria became a colony of Britain, and occupations imported into the country evolved to meet society and communities’ needs. The birth of medicine occurred after 1914, and medicine and dentistry were the first health disciplines to be introduced into Nigeria by the Portuguese allopathic physicians. Pharmacy, physical-­and-­occupational therapy, veterinary medicine, clinical psychology, public and environmental health, and dental therapy were also imported into the country by foreigners. On the other hand, speech therapy and audiology, radiography, medical laboratory science, optometry, medical records, nutrition, dietetics, biomedical engineering, prosthesis and orthotics, public and environmental health, chartered chemist, public analysis, and social work were pioneered in the country by Nigerians who studied abroad. As of 2018, Nigeria had about 2500 hospitals, an average of 7920 Nigerians to one hospital, and an average ratio of physician 1:3000, and an average nurse ratio of 1:2000. More depressing, the hospitals are poorly funded and understaffed, and the government officers and politicians are merely paying lip service to the healthcare needs of the country (Ojewale et al., 2018).

The Healthcare Professions in Nigeria Globally, health disciplines fall into two broad categories: professionals and occupational (vocational) careers. Occupations like X-ray technicians and occupational therapy assistants are trained to perform procedures under the radiographers’ and occupational therapists’ supervision. Their entry-level education is outside the university setting or is hospital based and usually lasts less than four years. On the contrary, professionals’ training occurs in an accredited university and is more intensive and lasts from four to seven years after secondary school. HCPs have unique skills to assess patients, diagnose conditions, develop treatment plans,

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and administer treatment. The following 17 professions are recognized by the Nigerian government—medicine, dentistry, pharmacy, physiotherapy, occupational therapy, clinical psychology, optometry, radiography, medical laboratory science, chemist, nutrition, dietetics, public environmental health, community health, biomedical engineering, prosthetics, and orthotics (Fig. 2.1). In a recent publication, Balogun (2020) analyzed the significant developments in the training of HCPs in Nigeria. Significant changes include the upgrade in admission requirements into medical and dental

Medicine

Optometry

Pharmacy

Medical Laboratory Science

Physiotherapy

Radiography

Social Work

Major healthcare professions

Prosthecs and Orthoc

Denstry

Public and Environmental Health

Occupaonal therapy

Nutrion/ Diecian

Public Analysis Biomedical Engineering Technology

Clinical Psychology Veterinary medicine

S Speech therapy and Audiology

Fig. 2.1  Recognized healthcare professions in Nigeria

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J. Abiodun Balogun

programs; transition of the entry-level training in pharmacy, optometry, and physiotherapy to the doctoral level; the establishment of specialized health sciences universities; and development of fellowship programs in several disciplines. Next is the description of the HCPs, including their roles and responsibilities in delivering services and clinical specialties.

Physician Physicians are vital members of the healthcare team tasked with multiple roles and responsibilities. They are trained to coordinate the patient’s overall healthcare plan. During a consultation, physicians take their patient’s medical histories, examine them, perform and interpret tests to make a diagnosis, prescribe medications, treat injuries or illnesses, and make referrals to other members of the healthcare team. Besides, they counsel patients and family members on the diet, hygiene, and preventive healthcare practices (Fig. 2.1). Following graduation from medical school, the medical and dental students in Nigeria are inducted into the profession and become members of the Nigerian Medical Association (NMA) and the Nigerian Dental Association (NDA). Before they can practice, they are required to undergo a one-year internship before registering with the Medical and Dental Council of Nigeria. Physicians and dentists specialize during the residency training in any of the 15 specialties offered by the Faculty of the National Postgraduate Medical College of Nigeria (NPMCN) or that of the West African College of Physicians and the West African College of Surgeons. After completing the required fellowship examination, they are appointed as consultants in secondary and tertiary hospitals and have automatic membership of the Medical and Dental Consultants Association of Nigeria (MDCAN). The NPMCN is at the apex of medical education in Nigeria and offers specializations in anesthesia, dental surgery, family medicine, family dentistry, internal medicine, obstetrics and gynecology, ophthalmology, orthopedics, otorhinolaryngology, pediatrics, pathology, psychiatry, public health, radiology, and surgery (Fig. 2.2). The West African College of Physicians prepares medical specialists in the following six disciplines: community health; family

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Fig. 2.2  A physician explaining the condition of a patient to relatives

medicine; internal medicine; laboratory medicine; and its major subspecialties of anatomical pathology, chemical pathology, hematology, and medical microbiology; pediatrics; and psychiatry. Similarly, the West African College of Surgeons offers fellowships in seven specialties: anesthesia, dental surgery, obstetrics and gynecology, ophthalmology, otorhinolaryngology, radiology, and general surgery (Omigbodun, 2012).

Dentist Dentists specialize in the diagnosis and treatment of oral diseases, promotion of oral health, and disease prevention. They operate on the teeth, bone, and soft tissues of the oral cavity and monitor the teeth and jaws’ growth. During a comprehensive exam, dentists examine the teeth and gums and look for any abnormality in the form of lumps, swellings, discolorations, and ulcerations (Fig. 2.3). When indicated, dentists perform procedures, such as diagnostic tests for chronic or infectious diseases,

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Fig. 2.3  A dentist attending to a child here

salivary gland function, screening tests, and biopsies for oral cancer. Also, dentists can spot early warning signs in the mouth that may indicate disease elsewhere in the body. The level of education and clinical training for dentists are at par with those of physicians. Specialization in dentistry, offered through approved tertiary hospitals, requires successful completion of the final examination of the Faculty of Dental Surgery of the NPMCN or the West African College of Surgeons. In Nigeria, the recognized specialties in dentistry are (1) Dental Public Health (prevention of dental disease through organized community efforts); (2) Endodontics (diagnosis, prevention, and treatment of diseases, as well as treatment of injuries to the dental pulp and surrounding tissues, and root canals); (3) Oral and Maxillofacial Pathology (diagnosis of the conditions of the mouth, teeth, and surrounding regions); and (4) Oral and Maxillofacial Radiology (diagnosis and management of oral diseases and disorders using X-rays and other forms of imaging). Other available specialties include (1) Oral and Maxillofacial Surgery (diagnosis and surgical treatment of illness and

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injuries of the mouth and maxillofacial region); (2) Orthodontics and Dentofacial Orthopedics (diagnosis and correction of dental and facial irregularities); (3) Pediatric Dentistry (diagnosis and treatment of the oral healthcare needs of infants and children through adolescence); (4) Periodontics (diagnosis and treatment of diseases of the gum tissue and bones supporting teeth); and (5) Prosthodontics (replacement of missing teeth or oral structures with artificial devices, such as dentures and restoration of the natural teeth).

Physiotherapist Physiotherapists remediate impairments, restore function, optimize the quality of life, and enhance their patients/clients’ health and well-being through examination, diagnosis, prognosis, and physical intervention. In treating their patients, physiotherapists utilize a spectrum of modalities that include manual therapy (such as massage, traction, and mobilization), therapeutic exercise, electrotherapy (such as ultrasound, diathermies, laser bio-stimulation, and iontophoresis), cryotherapy, and infra-red radiation (Fig. 2.4). Although a large number of physiotherapists in Nigeria seek employment in the general and tertiary hospital settings, a significant number is in private practice, sports facilities, physical fitness centers, and universities offering academic physiotherapy programs (Nigeria Society of Physiotherapy, 2017). The first-generation physiotherapy programs in the country are all located in the southwest region. The northern states did not have a physiotherapy program until 1990 when Bayero University was established. Much later, in 2003, the north established the second physiotherapy program at the University of Maiduguri (Balogun, 2016b). A five-year entry-­ level professional Bachelor of Physiotherapy (BPT) degree is offered in 13 out of the 174 existing universities in Nigeria (Bolaji, 2020). Master’s and Ph.D. degrees are offered at seven of the universities with a physiotherapy program. Physiotherapists seeking to pursue academic careers by completing master’s and Ph.D. degrees can do so at the federal universities located at Ibadan, Lagos, Ile-Ife, Nsukka, Kano, Maiduguri, and Nnamdi Azikiwe University, Akwa (Balogun et al., 2016a, 2016b). Like the medical and

Fig. 2.4  A physiotherapist treating a patient with shortwave diathermy

dental professions, physiotherapy professions now award a Fellowship credential by the National Postgraduate Physiotherapy College of Nigeria after completing a culminating examination and published article in a peer-reviewed journal at the end of an intensive residency program. The eight clinical specialties offered are in orthopedics and sports, cardiopulmonary, neurology and mental health, pediatrics, geriatrics, women’s health, and community physiotherapy. In 2020, the College of Medicine at Kaduna State University initiated the first entry-level Doctor of Physiotherapy (DPT) degree program in the country (Balogun, 2020). A degree in physiotherapy or medical rehabilitation, followed by a one-year internship in an approved hospital, is required to register with the Medical Rehabilitation Therapist Registration Board of Nigeria (MRTB)—a parastatal under the Federal Ministry of Health established by Decree 38 of 1988 (Acts M9 LFN, 2004) to regulate the education and practice of seven professions in the health sector (physiotherapy, occupational therapy, chiropractic, osteopathic medicine, speech therapy, audiology and prosthetics, and orthotics).

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Occupational Therapist Occupation therapists are an essential member of the medical rehabilitation team. Occupation therapists are primarily concerned with re-­ integrating people after an injury or disease back to their healthy lives. Occupational therapists care for patients of any age with physical, sensory, or cognitive disabilities and help them become independent and return to their occupation and live a healthy and productive life. Occupational therapists focus on important personal issues concerning managing activities of daily living, such as washing, dressing, getting around indoors and outdoors, bathing, preparing, eating meals, or participating in work, school, or leisure activities. In addition to dealing with the patient’s physical well-being, occupational therapists focus on the social, environmental, and psychological factors that can affect functioning differently. Occupational therapy is one of Nigeria’s most challenging health professions regarding inadequate human capacity (Nurudeen, 2015). Occupational therapists in Nigeria are employed primarily in the hospital and academic settings. Upon graduation from an accredited occupational therapy program, a one-year internship in an approved hospital is required before an occupational therapist in Nigeria is qualified to be fully registered and licensed by the MRTB to practice.

Pharmacist Pharmacists are professionals with a primary role in drug regulation and control, formulation and quality control of pharmaceutical products, inspection and assessment of drug manufacturing facilities, assurance of product quality throughout the distribution chain, drug procurement agencies who also serve on national and institutional formulary committees. Pharmacists’ in-depth knowledge of the management and properties of medicines brings them closer to the prescribing physicians/dentists as a source of independent information about the therapeutic options and the positive and negative consequences of all medications. Their expertise

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also brings them closer to patients in the community as readily available dispensers of medicines and health-related information (Yakasai, 2016). In Nigeria, pharmacists are employed in regulatory control and drug management, community pharmacy, hospital pharmacy, the pharmaceutical industry, and the academic setting. The pharmacy profession in Nigeria has transitioned its entry-level education from the bachelor’s (B. Pharm) degree program to a Doctor of Pharmacy (PharmD.) level. The change in entry-level education from baccalaureate to doctoral level will position pharmacists to help patients attain more efficient and effective drug therapy outcomes. The pharmacy profession offers career opportunities in the hospital, community, wholesale, industrial, veterinary, administrative/organizational, journalism, and education/academia (Pharmapproach, 2019). The B. Pharm degree takes five years of university education and a one-year internship before registration with the Pharmaceutical Society of Nigeria. The implementation of the six years duration doctoral (PharmD) curriculum is anticipated to increase the knowledge base and skills of pharmacists, particularly in public health, entrepreneurship, administration, and drug therapy, which has become one of the cornerstones of contemporary healthcare delivery.

Optometrist and Dispensing Optician Optometrists diagnose and treat diseases of the eye with topical and therapeutic drugs. A dispensing optician is a technician who designs, fits, and dispenses corrective lenses for the correction of a person’s vision following prescriptions from an optometrist (Daniel, 2014). Optometry is the comprehensive examination of the eye, treatment of simple ocular diseases, correction of refraction errors using glasses and contact lenses, and orthotics to treat vision imbalance between the two eyes, contact lens practice, and general eye care. In Nigeria, optometry practice is mainly at the secondary and tertiary healthcare centers in some states. The Optometrists and Dispensing Opticians Registration Board of Nigeria regulate the profession. The qualification for registration with the Board of Nigeria is the following:

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diploma in optometry obtained before 1976 and BSc. in optometry and equivalent qualification from a recognized institution. The accepted qualification for registration as a dispensing optics with the Board is the following: Certificate of the National Institute; Diploma in Dispensing Optics; and any equivalent qualification from a recognized institution (Optometrists and Dispensing Opticians Registration Act, 2017). Upon graduation from an accredited optometry program, the students are inducted into the Nigeria Optometric Association. They proceed for the one-year internship in an approved hospital or eye clinic, then another one-year mandatory National Youth Service Corps (NYSC) before they can practice. The recognized specialties in Nigeria are primary care, public health, and rehabilitation. Primary care optometry entails knowledge and clinical skill over complete vision care and areas of eye-related healthcare. Public health optometry evaluates and organizes comprehensive eye examination and management of the eye health and well-being of the public. Rehabilitative optometry and low vision care make use of whatever vision is left to live an independent life. With low vision aids/devices, persons with low vision could attempt to live a healthy life (Emurotu, 2016).

Medical Laboratory Scientist Medical laboratory scientists perform chemical, hematological, immunologic, histopathological, cytopathological, microscopic, and bacteriological diagnostic analyses on body fluids, such as blood (Fig. 2.5), urine, to enable physicians/dentists to make a diagnosis; as well as in monitoring treatment outcomes or prevention (maintenance of health). Medical laboratory scientists use state-of-the-art biomedical instrumentation, computers, and methods requiring manual dexterity. Medical laboratory scientists are employed in teaching and specialist hospitals, primary health centers, research, private health centers, private clinics, quality control or reference, public health, and forensic and law enforcement laboratories. They can own diagnostic/research laboratories. The specialties in medical laboratory science are medical microbiology and parasitology, virology and mycology, public health and epidemiology,

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Fig. 2.5  A medical laboratory scientist prepares to draw blood from a patient

histopathology and cytopathology, chemical pathology or clinical chemistry, hematology, and blood group, serology, and immunology. The pioneer medical laboratory scientists in Nigeria were trained in the United Kingdom as medical laboratory assistants, technicians, and technologists (Uchejeso et al., 2021). Today, a degree in medical laboratory science is offered in the College of Medicine or the Faculty of Health Sciences of many accredited universities in the country. Medical laboratory assistants and technicians are trained in the College of Health Technology distributed across the country. The duration of training for medical laboratory scientists is five years in the university setting, leading to a Bachelor of Medical Laboratory Science degree, plus a one-year internship program followed by the one-­year NYSC. Medical laboratory science courses include medical biochemistry, human anatomy, human physiology, hematology, pharmacology, forensic analysis, embalming techniques, clinical pathology, biostatistics, virology, medical microbiology, parasitology public health, and epidemiology. The duration of training for medical laboratory assistants and technicians

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(sub-medical professionals) in the polytechnic is only two years leading to the Ordinary National Diploma (OND) and an additional two years for a Higher National Diploma (HND). Science laboratory technology is offered in the Faculty of Biological or Natural Science in Nigerian universities and under the School of Science in the polytechnics. The duration of training for science laboratory technology offered in the university is four years, leading to the Bachelor of Technology (B. Tech) degree and one-year NYSC, making a total of five years. Graduates of the science laboratory technology from the polytechnic are technicians while their universities’ counterparts are laboratory technologists. Science laboratory technologists are not medical health professionals. They are employed in environmental health institutions where they are involved in food analysis to protect public health or in public water work department where they perform water analysis. They also work in secondary schools and tertiary institutions as science teachers or in biology or chemistry laboratories as technologists. They can also own and operate private research laboratories for food and water analysis for public health protection. Science laboratory technology has the following specialties: applied biology and microbiology; applied chemistry and biochemistry; physics and electronics. The course offered by students of science laboratory technology is pure and applied chemistry, microbiology, physics, electronics, photography, plants, and animal taxonomy, among others (Tam, 2015).

Radiographer Radiographers are health professionals who use X-rays, computed tomography scans, ultrasounds, and magnetic resonance images to produce images of patients to help physicians/dentists diagnose the patient’s medical condition (Fig. 2.6). Once pictures are taken, the radiographers are responsible for developing the film or processing the digital images and storing them correctly. Radiographers work in concert with radiologists to perform special examinations such as hysterosalpingography, intravenous urography, angiography, and mammography. The radiographer’s role involves planning and applying appropriate doses to obtain optimum outcomes. Radiographers also participate in radiation protection

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Fig. 2.6  A radiographer preparing to take an x-ray of a child

checks in hospitals. Specialty practice in the profession includes therapy radiography, nuclear medicine scans, and sonography. Radiographers are employed primarily in hospitals and clinics, private practice, accident and emergency units, operating theaters, and wards, working with patients of all ages. Besides clinical work, they are also employed as lecturers in universities to educate more radiographers (Health Times, 2015; Imaging in Developing Countries Special Interest Group, 2017).

Nutritionist Nutritionists are experts in food science and public health trained to educate people to attain optimal health through sound advice about healthy food choices. In Nigeria, nutritionists do not have clinical internship experience and are not registered with any government-approved professional organization. They are employed as researchers, consultants, advisors,

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public health and health promotion officers, community development officers, quality and nutrition coordinators, food technologists, or media spokespersons. Nutritionists are trained to design, coordinate, implement and evaluate health interventions that will improve the well-being of individuals, communities, and the population at large, through better food and nutrition choices (Nutrition Australia, 2017).

Dietitian Dietitians (also spelled “dieticians”) are professionals trained in human nutrition and the regulation of diet. Dietitians are employed in hospitals, medical clinics, corrections, food and nutrition services, food industry (manufacturers/producers), catering/hospitality industry, the pharmaceutical industry, universities and colleges, media consultant/ private practice (Dietitians Association of Nigeria, 2017). Dietitians assess, diagnose, and treat patients with nutritional problems. Following the evaluation of the patient’s diet, they alter the patient’s food based on their medical condition and individual needs. In Nigeria, dietitians are not presently licensed as in developed countries. The profession is awaiting approval from the federal government to establish a regulatory body to control its training and practice.

Prosthetist and Orthotist Prosthetics is the science of fabricating artificial devices or appliances to replace a missing body part, such as upper or lower extremities, for example, trans-tibia and trans-femoral prosthesis for the lower body extremity and trans-radial and trans-humeral prosthesis for the upper body extremity. Orthotics is the science of fabricating artificial appliances to substitute for a missing body function due to disease. An orthosis is built for the spine in the form of a corset to correct deformity around the back and the lower and upper extremities. Prosthetists and orthotics are integral members of the rehabilitation team trained to design, fabricate, and fit custom-made artificial limbs, or

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“prostheses,” and provide related patient care services. Orthotists design, make, fit customized orthopedic braces, or “orthoses,” as well as pre-­ fabricated devices, and provide related patient care services. They evaluate patients, formulate treatment plans, and provide follow-up care to promote the patients’ overall well-being. Their unique expertise in patient assessment, design, and materials offers patients increased mobility and independence. Prosthetists and Orthotists work in hospitals and rehabilitation facilities. In Nigeria, lower limbs are more often involved in amputation and require prosthetics. Nigeria currently has only 100 prosthetics and orthotics working in tertiary and general hospitals, private practice, and the three National Orthopedic Hospitals located in Kano, Lagos, and Enugu (NPOOTS, 2017; Sasona, 2014).

Biomedical Engineer/Technologist Biomedical engineering, also known as bioengineering, is applying engineering principles to the fields of biology and healthcare. Biomedical engineers collaborate with physicians/dentists, and therapists to design equipment and devices, such as artificial internal organs, replacements for body parts, and machines for diagnosing medical problems. They install, adjust, maintain, repair, or provide technical support for biomedical equipment. Biomedical engineers are employed in industries, hospitals, research facilities, medical institutions, universities, and government regulatory agencies. In the industry, biomedical engineers are involved in testing the performance of new or proposed products. In government positions, biomedical engineers work in testing new products for safety and establishing safety standards for devices. In the hospital setting, biomedical engineers counsel their clients on how to use their medical equipment and supervise performance testing and maintenance of the equipment. They also build customized devices for specialized healthcare or research needs. In research institutions, biomedical engineers oversee laboratories, equipment, and direct research activities in collaboration with other researchers in medicine, physiology, and nursing. Biomedical engineers often serve as technical advisors for the marketing departments of companies, while some are in

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management positions. Biomedical engineers have training in other areas of medicine combined with an advanced understanding of the technology needed for direct patient care or clinical research (Catholic University of America, 2017). The available specialties in the discipline are bioinstrumentation, nanotechnology, clinical deformity, and rehabilitation engineering, as well as computational biomechanics (Usman, 2017).

Public Analyst Public analysts are professionals registered to analyze and determine the composition of food, drugs, cosmetics, and medical devices. They study food to determine their moisture content, crude fiber, pH, protein content, carbohydrates, fats, and oils. They also define the physicochemical and microbiological materials of water-soluble vitamins, such as Assay and test for total quality. Public analysts perform antibiotic and analgesic assays to test for purity, pH, solubility test, specific gravity. They also provide services in metrology by measuring instruments that are calibrated and conduct training on the best use of precision instruments and laboratory techniques. Furthermore, they perform advanced hands-on laboratory training on products (The Institute of Public Analysts of Nigeria, 2004).

Audiologist Audiologists are professionals who diagnose and treat individuals with hearing and balance disorders from birth through the lifespan. Although hearing testing centers exist in urban areas, there is a shortage of qualified audiologists in Nigeria. There is a need for audiology services in hospitals and individual schools for the hearing-impaired. Furthermore, audiologists are needed to develop, conduct, or supervise hearing conservation programs at local government health centers and school and industry settings. There is currently a limited training program for audiologists in Nigeria, and there is presently only one audiologist to one million Nigerians (Oyiborhoro, 1988).

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In the metropolis of Lagos, there are only four audiological centers: Bsa Hearing and Speech Centre, Decibel Hearing Consultants, Phonics Hearing Centre, and the International Hearing Center. The four centers provide audiological consultation, screening, diagnostic hearing tests, hearing health counseling, hearing aids assessment, fitting and management, provision of swim plugs, and ear protectors for noise-exposed workers.

Speech Therapist (Speech-Language Pathologist) Speech-language pathologists (also known as speech therapists) evaluate, diagnose, and treat patients of all ages to enhance communication and prevent swallowing disorders. There are less than 300 speech pathologists and audiologists employed in Nigeria because there is a limited training program in speech therapy and audiology. In general, Nigerians do not take seriously speech disorders that require the attention of speech pathologists and audiologists. The disorders include stuttering, delayed speech in children, incoherent pronunciation (misarticulation), and speech problems relating to hearing loss. The high level of noise in the urban centers, which often exceeds the recommended standards, has a cumulative effect that may gradually cause hearing loss after 50 years of age (Ademokoya, n.d.). The Speech Pathologists and Audiologist Association in Nigeria is responsible for accrediting training programs and ensuring ethical standards in the practice of speech pathology and audiology in the country. Membership is open to academics and clinicians in Ear, Nose, and Throat departments in private or governmental institutions. The Association is the Nigerian equivalent of the Worldwide Association of Professionals in Speech and Hearing Rehabilitation. The Association is registered under the Nigerian Corporate Affairs Commission and recognized by the Federal Ministry of Health (FMH) and the MRTB. The qualification required for full membership is a master’s degree or equivalent with specialization in speech pathology and or audiology and must have completed the one-year internship in an approved hospital/clinic and pass the

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requisite clinical competence examination. Associate members have a bachelor’s degree in other allied professions with related practice experience in speech/language and hearing, such as psychology, otolaryngology, counselors, social workers (Speech Pathologists and Audiologist Association in Nigeria, 2020). Although the MRTB legally recognizes both speech pathology and audiology, there is currently limited open-­ access information on speech and aural rehabilitation, audiological and hearing clinical practice in the country (Oyiborhoro, 1988).

Veterinarian Some readers might find it a bit odd why veterinary medicine is included among the professions discussed in this book. The decision is intentional because animals and humans are both mammals and biologically share organs (heart, lungs, liver, kidneys) that work in the same way. Around a third of medicines used by veterinarians are also used in the treatment of humans. Moreover, monkeys have been used to advance deep brain stimulation treatment for Parkinson’s disease and perfect new surgical techniques before being performed on humans. Furthermore, research with mice helps develop new cancer treatments; rabbits and cattle are used for cancer vaccines and goats in developing blood clotting agents from milk. The veterinarian assesses the well-being of animals to make a diagnosis and prescribes medication or performs surgeries on them as surgeons would for humans. Veterinarian ensures that pets, livestock, and wildlife are healthy and free of bugs. They are educated to prevent and treat diseases, disorders, and injuries in all animal species, both domesticated and wild. A veterinarian also plays an essential role in environmental protection, food safety, animal welfare, public health, disease prevention, research in developing medicine, and perfection of surgical techniques applied in humans. Veterinarians work in various settings in developed countries, such as private practice, government, academy, research institutes, or livestock industries. They also work in zoos, farms, wildlife reserves and collaborate with other health workers, such as veterinary nurses, physiotherapists,

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and dentists who specialize in working with different animal species and farriers. This level of cooperation with other health workers is presently not a common practice in Nigeria. In general, Nigerians do not keep pets and usually kill sick animals. Consequently, veterinarians are not in high demand. Veterinary medicine is among the least known academic disciplines in Nigeria, and employment is not readily available for recent graduates. The academy and civil service are the two sectors where jobs are readily available in the country for veterinarians (Ifedigbo, n.d.). Veterinary services are delivered and monitored by the federal, state, and local governments by providing laws and regulations. Regulations relating to veterinary medicine exist in clinical service, herd health management, quarantine services, laboratory diagnostic services, abattoir management, disease surveillance, research and development, and drug administration. Some of the existing laws and regulations are vague and conflicting. For effective veterinary care delivery, there is a need for harmonization of veterinary policies to avoid the multiplication of laws by different government agencies to, among other things, keep them up to date with the socio-economic development in the country (Garba 2004). A career in veterinary medicine requires six years of university education to obtain the Doctor of Veterinary Medicine (DVM) degree. The duration and rigor of training for veterinarians are comparable to those of physicians and dentists (Ifedigbo, n.d.).

Clinical Psychologist Psychologists assess and treat complex human problems, including mental, emotional, and behavioral disorders, and promote change. They also promote resilience and help people discover their strengths. The field of psychology is divided into three sub-disciplines: clinical, counseling, and research psychology. Clinical and counseling psychology are similar in that both involve diagnostic and therapeutic interaction between the psychologist and the client. On the other hand, clinical psychologists focus on diagnosing and treating mental, emotional, and behavioral disorders, such as learning disabilities, substance abuse, depression, anxiety, and

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eating disorders. Counseling psychologists help their clients adjust to changes in career and family situations. Research psychologists study the relationship between mind and behavior. There is a great need for qualified clinical psychologists in the educational sector to handle the increasing psychological disorders that afflict Nigerian children, teenagers, adults, and the elderly (Obot, 2007). In the United States, a master’s degree is the minimum qualification for licensure as a clinical psychologist, and practitioners with a master’s degree often go on to earn a Ph.D. or Psy.D terminal degree. Most school psychologists have a master’s degree or specialist (Ed.S.) degree. Clinical and counseling graduate students are usually required to undertake a one-year internship at the end of their doctoral program. A Ph.D. in psychology is considered a research degree and requires an original dissertation. A Doctor of Psychology (Psy.D) is a clinical degree that requires practical research and a written and oral examination. There is currently no law regulating the education and practice of clinical psychology in Nigeria, even though graduate programs at master’s and Ph.D. degrees in psychology are now offered in many universities. The psychology curriculum in the country remains decidedly Western-­ oriented at the expense of a local approach to the discipline. Unfortunately, the emerging trends in clinical psychology are the limited interactions among academic psychologists across the country. The Nigerian Psychological Association conferences and the traditional use of external examiners in the universities tend to be regionalized. This occurrence makes the objective evaluation of the standard of clinical psychology nationally tricky. Furthermore, the regionalization of clinical psychology membership negatively affects the financial standing of the Nigerian Psychological Association due to the reduced payment of annual dues by members, thereby hampering the association’s effort to pursue its core objective to get the National Assembly to enact a law to regulate psychology in the country (Obot, 2007). The absence of a regulatory board has a deleterious impact on the psychology professoriate. The number of journals published has increased dramatically, but unfortunately, many of these journals withered away soon after being launched. The proliferation of individually owned journals (actually glorified blogs) associated with the “cash and publish”

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practice has contributed to the lowering of the rigor associated with the peer-review process and, eventually, the quality of published “articles.” Despite these suboptimal practices, the individually owned journals still enjoy extensive patronage among psychologists (Obot, 2007). While the growth in the number of psychology departments in the country is remarkable, the prevailing conditions make the future of the profession uncertain. Many of the existing programs do not have the human and material resources for a world-class psychology program. Most of the psychology departments in Nigeria do not have research laboratories and those that have one lack the state-of-the-art instruments needed for any meaningful investigation. Another problematic effect of the absence of a regulatory board is the hijack of the profession by quacks and charlatans who engage in dubious practices. Some of them claim to be experts in the field. However, often they act as factories for the mass production of graduate degrees for conniving aspiring psychologists. Unfortunately, many of the recipients of the bogus degrees find their way into the community to practice clinical psychology or gain employment in the universities to teach. One upside to all this is that many of the available psychology textbooks used in Nigeria are produced locally.

Social Worker In Nigeria, social work is a practice-based profession that promotes social cohesion, change, development, empowerment, and liberation. Central to its core values are the principles of social justice, human rights, collective responsibility, and respect for diversities. The profession’s underpinnings are the theories of social work, social sciences, humanities, indigenous knowledge, and the means through which social work engages people and structures to address life challenges and enhance well-being. Social workers focus on early intervention and offer treatment for individuals, groups, and the public through education, advocacy, and improving access to services, resources, and information.

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The remaining section of this chapter apprises the evolutionary development of the primary healthcare professions, including the workforce capacity, distribution, and gender inequities.

 he Professionalization Milestones of Major T Health Disciplines In Nigeria, the medical and dental professions are well known and respected. Conversely, other health disciplines are recognized less in society. Following the importation of the different fields into the country, they progressed at varying paces in establishing educational programs and their quest for true professional status and prestige. The pace of professionalization for several occupations imported into Nigeria during the pre-and post-colonial era was pusillanimous. The obvious questions to ask are as follows: what are the factors responsible for the slow pace of progress, for several health disciplines, toward achieving true professional status? Are the members of the different occupations satisfied with the speed of their professionalization? Have members of the various occupations convinced enough legislators in the National Assembly and the public-at-large about the importance of their work/trade? Do the different occupations have enough people who can vouch for the importance and relevance of their business? In 2018, Balogun and Aka investigated the professionalization journey of the principal occupations (presently with a doctoral degree as entry-­ level education)—medicine, dentistry, optometry, pharmacy, physiotherapy, and veterinary medicine—imported into Nigeria. The three pertinent questions concerning each occupational field asked were: When did the occupation make its entrance into Nigeria? At what point did it become established as a profession? And at what period did it receive a legislative imprimatur from the federal government to create a regulatory board/ council? The findings in the study revealed answers as disparate as the occupational fields themselves. They uncovered a considerable entrance gap, running into several centuries, between the first health occupation, medicine, introduced into the country by the Portuguese in 1472, and

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physiotherapy, whose date of entrance, 1945, occurred just fifteen years shy of the country’s independence in 1960. Though nothing resembling the difference in the entry between medicine and physiotherapy, a similar gap is also observable regarding the legislative mandate to establish a regulatory board. Medicine and dentistry were the first occupations imported into the country in 1504—517 years ago. Physiotherapy was the last profession to gain entrance into Nigeria in 1945. The pharmacy was the first health discipline to form a professional association, followed by medicine, physiotherapy, veterinary medicine, dentistry, and optometry. It took physiotherapy the shortest duration of 14 years to develop a professional association following their entrances into the country compared to medicine and dentistry, which took an eternal 479 and 495 years, respectively. Medicine is especially notable, being the first health discipline to make its way into the country in the latter part of the fifteenth century (Balogun and Aka, 2018). Professional associations’ duration to achieve legislative imprimatur for the regulatory board varied widely among six different health occupations imported into Nigeria—medicine, dentistry, optometry, pharmacy, physiotherapy, and veterinary medicine. It took dentistry and medicine only 4 and 11 years, respectively, to receive legislative approval from the federal government. The timeline bears no comparison with pharmacy and physiotherapy, whose numbers are 65 and 33 years, respectively. Physiotherapy ranked fifth among the six health occupations in the years it took to receive government approval to form a regulatory body following formation as a professional association. After importing the different occupations into the country, they progressed at varying paces in their quest for professional status and glory (Balogun and Aka, 2018). On a similar trajectory, a cross-national study in 2018 compared the developmental journeys of physiotherapy education in Nigeria with the milestones of Australia, the United Kingdom (UK), and the United States. The study found that the United States attained major educational milestones faster than Australia, the United Kingdom, and Nigeria. It took Australia 4 years, the United States 6 years, Nigeria 21 years, and the United Kingdom 62 years to transition physiotherapy education from the hospital milieu to the university setting. The United States was the first country to develop BSc and MS degree programs in physiotherapy, followed by Australia, the United Kingdom, and Nigeria. Similarly, the

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United States was the first to establish Ph.D. programs in physiotherapy, followed by Australia and Nigeria. It took Nigeria 39 years after launching the first BSc degree program in physiotherapy to offer the first Ph.D. program in the discipline. It took the United Kingdom 109 years, the United States 55 years, and Australia 92 years to attain the same feat. The United States was also the first to develop the entry-level DPT and the post-professional DPT program, followed by Australia, to offer the first Ph.D. program in physiotherapy (Balogun et al., 2018).

Capacity of the Healthcare Professionals Workforce Among the six key determinants of a robust health system is a well-­ functioning, competent, sufficient, and evenly distributed workforce that is responsive, fair, and efficient in achieving the best health outcomes within the limit of available resources (World Health Organization— WHO, 2000; Ubochi et al., 2019). The status of healthcare education and training of HCPs in Nigerian universities is well documented in a recent book published by the author (Balogun, 2020). As of June 2020, 170 universities are accredited by the National Universities Commission. The federal government owns 43 of the universities, 48 are state-funded, and 79 are private (Bolaji, 2020). Of the 170 universities, only 44 (26%) offer healthcare education programs—17 (39%) of the healthcare education programs are funded by the federal government, 19 (43%) are state-­ funded, and the remaining eight (18%) are private universities. The HCP students in Nigeria receive their clinical experience primarily within the UTHs, Federal Medical Centers, Specialist Hospitals, and community-­ based clinics located across the country. At 0.389 physicians per 1000 people, Nigeria is far from meeting the low benchmark of the 2.5 physicians, nurses, and midwives per 1000 people set by the WHO (SwankPharm, 2015). The WHO recommended one physician to every 600-person benchmark to have an efficient health system. To meet the WHO’s physician-to-patient standard, Nigeria would need over 237,000 physicians (Ighobor, 2017; Ogunsola, 2015). However,

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annually, only 3000–3500 physicians are produced by all the medical schools in the country (NOIPolls, 2017) compared to the average of 16,000 physicians produced in the United States (Association of American Medical Colleges, 2021). By the WHO standards, Nigeria is not on track to meet the very low benchmark of 2.5 physicians, nurses, and midwives per 1000 people. The WHO recommends one pharmacist per 2000 population, but there is approximately one pharmacist per 12,000 people in Nigeria. The WHO benchmark for nursing is one nurse per 700 population, but Nigeria has one nurse per 1066 people. In 2014, Nigeria had 150,000 registered nurses for its estimated 160 million people (Ogundipe et al., 2015). The current pace of the emigration of physicians abroad is worrisome and an existential threat to the survival of the healthcare system (Abang, 2019; NOIPolls, 2017). By 2017, Nigeria had 240,000 nurses and midwives but will need 471,353 nurses and midwives and 149,852 physicians by 2030. At the current production pace, 333,494 nurses and midwives and 99,120 physicians will be available by 2030—a gap of 50,120 (33.5%) physicians and 137,859 (29.3%) nurses. The demand and supply shortfall makes the health system vulnerable if the production of HCPs is not substantially scaled up (Healthfacts.ng, 2017). Using the census population growth rate and WHO’s health workforce growth rate, Adebayo et al. (2016) estimated the future medical and nursing needs in Nigeria by 2030. They projected that the population would increase to 272.5 million, and the estimated range of physicians and nurses/midwives combined that will be required will be between 422,018 and 621,205 (Mean = 515,668). The estimated required physicians will range between 101,803 and 149,862 (Mean = 124,394) and nurses/midwives will range from 320,216 to 471,353 (Mean = 91,274). If no effort is made to surge the present workforce supply, the range of deficit for physicians and nurses/midwives will be 31–34% (Mean = 32%.) and 26–30% (Mean = 28%), respectively. Based on these findings, there is a need for a drastic increase in admission and training of HCPs to tackle the supply deficit and solve the heavy disease burden and improve the country’s dismal health outcomes positively. It is pertinent to put the HCPs shortage in the global context. Nigeria has one of the largest HCPs among the 57 African countries, but they are not available in adequate numbers to meet the fast-growing population’s

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demand. Nigeria is ranked seventh among countries worldwide with a shortage of HCPs. With a shortage of 144,000 HCPs, Nigeria ranked second in Africa, behind Ethiopia with 152,000 HCPs. Nigeria has one physician for every 2660 people, compared to one physician for every 354 people in the United Kingdom. The latest WHO data reveals that Nigeria’s physician-­to-patient ratio is four physicians per 10,000 patients, the United States ratio is 26 physicians per 10,000 people, and 28 in the United Kingdom (Adegoke, 2019). Cuba, a small island in the Caribbean with 11.4 million people in 2015, produces three times the number of physicians in the United States. Vis-à-­vis other countries in the world, Cuba has some of the best health outcomes and health indicators. In 2005, Cuba had 70,594 physicians (Souers, 2012) and had one of the lowest patients to doctor ratio, 155:1, while the U.S. trails way behind at 396:1. With its surplus of physicians, Cuba has medical missions in over 75 different countries, led by nearly 40,000 HCPs, almost half of whom are physicians. Unlike Cuba, the United States and United Kingdom import HCPs from lowincome nations, thereby contributing to the shortage in the underdeveloped countries, including Nigeria. One of the significant abnormalities is the overall shortage of HCPs (per 1000 people) in Nigeria compared to the rest of the world. The data revealed that Nigeria has one of the worst HCPs-population ratios in the world (Table 2.1). In addition to the scarcity of physicians/dentists and nurses, other HCPs are also in short supply. For instance, the physiotherapist per population ratio (density) in 2015 stands at 63,349, and it is one of the highest (i.e., worst) in the world (Table 2.2). The number of physiotherapists per population ratio was 63,349 in 2015, but the country needs over 40,000 physiotherapists to meet the growing demands in rural and urban centers. Nigerian universities have produced 4748 bachelor’s degree prepared physiotherapists since the University of Ibadan in 1976 first established a degree program (Balogun et al., 2016a). Sadly, only 1000 of them are currently gainfully employed in the country (Okoghenun, 2015). The remaining 3748 physiotherapists have migrated to other countries due to unsatisfactory service conditions at home and because the federal and state governments do not create positions annually. In a 750-bed hospital where 70

Physicians/dentists Nurses/midwives Pharmacists Community health officers Community health extension workers (CHEW) 6 Junior CHEW 7 Radiographers 8 Medical laboratory technologists 9 Physiotherapists 10 Occupational therapists 11 Prosthetics and orthotics

1 2 3 4 5

Professions 0.389 0.148 0.010 0.0035 0.0253 0.0168 0.00076 0.0113 0.0017 0.0001 0.0005

28,458 1286 19,225 2818 20 100

Nigeria

65,759 249,566 16,979 5986 42,938

Number of practitioners

Table 2.1  Profile of Nigerian health workforce (per 1000 people)

2.7

USA 3.2

2.8 8.4 0.84

France UK

2.1

Canada

2.5

South Korea

0.8

7.5 8.0 0.3 0.1

Cuba

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Table 2.2  Physiotherapists (PT) per resident ratio in selected countries around the world

1

Country Nigeria

Population 178,516,904

Number of PT 2,818

PT Density; 1PT per resident 63,349

2 3

India

1,252,000,000

30,000

41,733

Egypt

83,386,739

3,000

27,796

4

South Africa

53,491,333

6,686

8,000

5

Germany

81,198,000

31,000

2,608

6

Australia

23,932,593

11,000

2,176

7

Canada

35,749,600

17,312

2,065

8

USA

320,090,000

184,000

1,740

9

UK

63,843,856

51,383

1,243

10

France

64,982,894

75,164

865

11

Sweden

9,600,000

13,000

738

physiotherapists are needed, only six are employed (Okoghenun, 2015). Here again, Nigerian universities are training physiotherapists for export to other countries when they are acutely needed at home. The poor are suffering these deficits because the elites and politicians can afford to travel abroad for their medical rehabilitation.

Distribution of the Healthcare Professions’ Workforce There are disparities in the distribution of HCPs across the country (Labiran et al., 2008). The majority of the HCPs are concentrated in the southwestern region, with an acute shortage in the Northern states, particularly in Niger, Jigawa, Zamfara, and Taraba. In the south-south area, there was an acute shortage in Bayelsa state. The uneven distribution is more prevalent among physicians, radiographers, pharmacists, and physiotherapists than the other HCPs. For instance, over 40% of the physicians, radiographers, pharmacists, and 62% of the physiotherapists were employed in the southwestern region (Table 2.3).

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Table 2.3  Distribution of the health professional workforce by region South North North South North South West West East Central East % % % % % %

Serial Health # profession

N

1 2 3 4 5

52,408 9.7 840 14.3 13,199 19.9 1473 10.8 12,703 6.8

Physicians Radiographers Pharmacists Physiotherapists Medical laboratory scientists

4.1 3.7 3.8 2.7 1.7

8.4 6.0 7.8 8.3 3.6

19.6 15.0 11.7 8.6 35.3

14.4 18.3 12.4 7.9 23.9

43.9 43.0 44.0 62.0 29.0

More than 50% of specialist physicians in Nigeria are employed in the southwestern region. The disparities in the distribution of HCPs are due to the educational and socio-economic attainment differences among the states. In addition to the well-known educational inequality between the six geopolitical regions, some Northern states hire HCPs who are non-­ indigenes on a contractual basis rather than give them pensionable appointments. Thus, making the job offer unattractive for non-indigenes to seek employment in the northern region. Additionally, the geographical distribution of HCPs between rural and urban centers is uneven. HCPs are more concentrated in the urban centers, tertiary (teaching and specialist) hospitals, and Southern states. To address the uneven distribution of HCPs, newly qualified physicians/dentists, pharmacists, nurses, and physiotherapists are deployed usually to the rural areas during the one-year mandatory NYSC service.

 ender Inequity Among G Healthcare Professionals In addition to the uneven regional distribution of the HCP’s workforce, there is also gender inequity among the HCPs (Table 2.4). Medicine, dentistry, pharmacy, radiography, and physiotherapy professions have predominantly men. On the contrary, speech therapy and

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Table 2.4  Gender distribution of the health professional workforce as of 2008 (Labiran et al., 2008) Serial #

Occupation

N

% Female

1 2 3 4 5 6 7 8 9 10

Physicians (Nigerians) Physicians (non-Nigerians) Dentists (Nigerians) Dentists (non-Nigerians) Pharmacists Physiotherapists Occupational therapists Speech therapists Radiographers Optometrists

52,408 2968 2356 215 13,199 1473 29 29 840 1415

22.0 28.7 40.8 42.3 30.5 40.7 44.8 65.4 32.3 53.0

Table 2.5  Percentage of females in healthcare occupations in the United States for 2016a Serial #

Occupation

% of women

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Dietitians and nutritionists Pharmacists Physician assistants Occupational therapists Physical therapists Respiratory therapists Speech-language pathologists Veterinarians Licensed practical/licensed vocational nurses Registered nurses Nurse practitioners Diagnostic related technologists and technicians Medical records and health information technicians Opticians, dispensing

89 60 70 89 69 74 98 63 90 90 94 73 92 70

a

https://www.ultrasoundschoolsinfo.com/breaking-­glass-­ceiling-­healthcare/

optometry are women-dominated. Only 22% of the physicians are women, while 65% of speech therapists and 53% optometrists are women (Labiran et al., 2008). The gender distribution of the healthcare workforce in Nigeria is vastly different from the United States, where most healthcare occupations, as of 2016, are women-dominated (Table 2.5).

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Conclusion Medicine and dentistry were the first occupations imported into Nigeria in 1504, about 517 years ago. It took dentistry and medicine only four and 11 years, respectively, to receive legislative approval from the federal government. The statutory approval timeline for pharmacy and physiotherapy was 65 and 33 years, respectively. It took physiotherapy the shortest duration of 14 years to form a professional association following its entry into the country compared to medicine and dentistry, which took an eternal 479 and 495 years, respectively. Following the importation of different disciplines into the country, each progressed at varying paces in their quest for professional status and glory. Nigeria has diverse HCPs that are consistent with practice in developed countries. Unfortunately, interdisciplinary teamwork is still a new concept in the Nigerian health system, where clinical practice is still primarily a solo (single discipline) effort. The health professions are divided and embroiled in territorial turf wars, and in many clinical settings, there is limited communication or interaction among the HCPs. This issue is discussed further in Chap. 5.

Interdisciplinary Team Case Study 1 The following assignments are meant to promote understanding of other health professions. Exploration of Different Health Professions The students will select and conduct an in-depth literature search of five different health professions and write a paper to address the following issues: 1. Name of the professional career. Present an overview of the profession, include duties, responsibilities, work environment/hours, and places of employment. 2. Educational requirements: add types of certificates, diplomas, degrees, and other credentials, such as licensure, certification, and registration. Is this a true profession or occupation? Justify your position. What are the occupations within the profession and their level of education? 3. Name the specialties within the profession, and occupations within the profession, including career/professional growth or development opportunities.

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4. Current average salary and related benefits, include salary ranges and types of employee benefits (such as life and health insurance, tuition reimbursement) 5. Present the job outlook for the future, include current numbers and projected numbers, with percentage increase or decrease. Discuss the reasons for the expected increase or decrease. 6. Provide three names of schools in the surrounding areas that offer the health professional program. 7. In conclusion, summarize the overall experience.

Interdisciplinary Team Case Study 2 Interview of a Health Professional Student will select a profession other than their discipline and conduct an interview using the following questions as a guideline:   1. What is your full job title? Where do you work?   2. How long have you worked there?   3. Have you worked at any other facility?   4. If so, which ones and for how long at each?  5. What are the primary duties and responsibilities of your job? Please describe it adequately.  6. How and why did you select this profession? Did you consider other professions? If so, which ones?   7. What is your educational background (including majors and/or degrees obtained)? Where did you go to school (include location)? What are your credentials (license, certification, registration)?   8. What are the opportunities for advancement at your current place of employment? What are your career goals?   9. What do you like and dislike about your job? What, if anything, would you change about your working conditions? 10. What are your working hours and days? Is there some choice or control of your work schedule? Please describe. 11. Do you believe that you have job longevity in your current position? Why or why not? Do you think your profession is in high demand? Why or why not? 12. Are you satisfied with your current salary and benefits? Why or why not? 13. What is the salary range at your place of employment and some of the employee benefits? (continued)

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(continued) 14. Do you feel respected by others, such as co-workers, other health professionals, and patients? Why or why not? What can you do to change the situation? 15. Are you a member of any health professional organizations? Why or why not? If so, which ones? Describe the benefits of membership, if any? 16. What advice would you give to someone considering your profession?

References Abang, M. (2019). Nigeria’s medical brain drain: Healthcare woes as doctors flee. Al Jazeera News. [online]. Available at: https://www.aljazeera.com/ indepth/features/nigeria-­m edical-­b rain-­d rain-­h ealthcare-­w oes-­d octors-­ flee-­190407210251424.html. Accessed 10 Feb 2020. Acts M9 LFN. (2004). Medical Rehabilitation Therapists (Registration) Board of Nigeria. [online]. Available at: https://www.mrtb.gov.ng/media/archive1/docs/ ethics/code-­of-­ethics.pdf#:~:text=established%20by%20Decree%2038%20 of%201988%2C%20now%20Medical,the%20regulation%20and%20control%20of%20training%20and%20practice. Accessed 23 Sept 2020. Adebayo, O., Labiran, A., Emerenini, C. F., & Omoruyi, L. (2016). Health workforce for 2016–2030: Will Nigeria have enough? International Journal of Innovative Healthcare Research, 4(1), 9–16. [online]. Available at: https://seahipaj.org/journals-­c i/mar-­2 016/IJIHCR/full/IJIHCR-­M -­2 -­2 016.pdf. Accessed 10 Feb 2021. Adegoke, Y. (2019, April 25). Does Nigeria have too many doctors to worry about a ‘brain drain’? BBC Africa, Lagos. [online]. Available at: https://www. bbc.com/news/world-­africa-­45473036. Accessed 10 Feb 2021. Ademokoya, A. (n.d.). Nigeria has only 300 speech pathologists, audiologists. [online]. Available at: http://logbaby.com/news/nigeria-­has-­only-­300-­speech-­pathologis t s % 2 D % 2 D a u d i o l o g i s t s % 2 D % 2 D -­a d e m o k oy a _ 1 7 5 7 7 . h t m l # . W4nrfehKg2x. Accessed 23 Sept 2020. Association of American Medical Colleges (AAMC). (2021) Medical education – 2020 Facts: Enrollment, graduates, and MD-PhD data. [online]. Available at: https://www.aamc.org/media/9631/download. Accessed 10 Feb 2021. Balogun, J. A. (2020). Healthcare education in Nigeria: Evolutions and emerging paradigms (1st ed.). Routledge Publications. [online]. Available at: https:// www.routledge.com/9780367482091

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Balogun, J. A., Aka, P. C., Balogun, A. O., Mbada, C., & Okafor, U. (2018). Evolution of physical therapy education in Australia, United Kingdom, United States of America, and Nigeria: A comparative analysis. International Medical Journal, 25(2), 103–107. [online]. Available at: https://www. researchgate.net/publication/323945677_Evolution_of_physical_therapy_ education_in_Australia_United_Kingdom_United_States_of_America_ and_Nigeria_A_comparative_analysis. Accessed 3 Feb 2020. Balogun, J. A., & Aka, P. C. (2018). Professionalization milestones of medicine and eleven other professional disciplines in Nigeria. International Medical Journal, 25(1), 2–8. [online]. Available at: https://www.researchgate.net/publication/322628378_Professionalization_Milestones_of_Medicine_and_ Eleven_Other_Professional_Disciplines_in_Nigeria. Accessed 3 Feb 2020. Balogun, J. A., Mbada, C. E., Balogun, A. O., & Okafor, U. A. C. (2016a). Profile of physiotherapist educators from anglophone West African countries: A cross-sectional study. International Journal of Medical and Health Sciences, 3(9), 99–109. [online]. Available at: https://www.researchgate.net/publication/311209577_Profile_of_Physiotherapist_Educators_in_Anglophone_ West_African_Countries_A_Cross-­Sectional_Study. Accessed 23 Sept 2020 Balogun, J. A., Mbada, C. E., Balogun, A. O., & Okafor, U. A. C. (2016b). The spectrum of student enrollment-related outcomes in physiotherapy education programs in West Africa. International Journal of Physiotherapy, 3(6), 603–612. [online]. Available at: https://www.researchgate.net/publication/311477857_The_Spectrum_of_Student_Enrollment-­R elated_ Outcomesin_Physiotherapy_Education_Programs_in_Westafrica. Accessed 23 Sept 2020 Bolaji, F. (2020). List of all universities in Nigeria approved by NUC – 2020 latest list. [online]. Available at: https://campusbiz.com.ng/list-­of-­universities-­in-­ nigeria/. Accessed 10 Feb 2020. Daniel, S. (2014, May 3). Nigeeria ahead in optometry practice in Africa. Vanguard. [online]. Available at: https://www.vanguardngr.com/2014/05/ nigeria-­ahead-­optometry-­practice-­africa-­dr-­udom/. Accessed 23 Sept 2020. Dietitians Association of Nigeria. (2017) [online]. Available at: http://dietitians. org.ng/?page_id=1358. Accessed 23 Sept 2020. Emurotu, D. (2016, March 19). Optometry in contemporary Nigeria. The Guardian. [online]. Available at: https://guardian.ng/opinion/optometry-­in-­ contemporary-­nigeria/. Accessed 23 Sept 2020. Garba, S. (2004). Environmental health in Nigeria, yesterday, today, and tomorrow. Environmental and Public Health Watch. [online]. Available at: https:// tsaftarmuhalli.blogspot.com/2011/04/environmental-health-in-nigeria. html. Accessed 23 Sep 2020.

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Healthfacts.ng. (2017, May 11). Nigeria ranked 7th among countries facing shortage of health workers. [online]. Available at: https://www.physicianleaders. org/news/how-­many-­patients-­can-­primary-­care-­physician-­treat. Accessed 10 Feb 2021. Health Times. (2015, November 6). What is a radiographer? [online]. Available at: https://healthtimes.com.au/hub/medical-­imaging/10/guidance/nc1/what-­is-­a-­ radiographer/590/. Accessed 23 Sept 2020. Ifedigbo, SN. (n.d.). The dilemma of being a vet in Nigeria. [online]. Available at: http://www.gamji.com/article8000/NEWS8651.htm. Accessed 23 Sept 2020. Ighobor, K. (2017) Diagnosing Africa’s medical brain drain: Higher wages and modern facilities are magnets for Africa’s health workers. Africa Renewal. [online]. Available at: https://www.un.org/africarenewal/magazine/december-­ 2016-­march-­2017/diagnosing-­africa%E2%80%99s-­medical-­brain-­drain. Accessed 10 Feb 2020. Imaging in Developing Countries Special Interest Group. (2017) The role of radiographers in Nigeria. [online]. Available at: http://idcsig.org/page30.html. Accessed 23 Sept 2020. Labiran, A., Mafe, M., Onajole, B., & Lambo, E. (2008). Health workforce country profile for Nigeria. Africa Health Workforce Observatory, 8. Accessed 10 Feb 2021. Nigeria Society of Physiotherapy. (2017). Who is a physiotherapist? [online]. Available at: https://www.nsphysio.org/. Accessed 23 Sept 2020. NPOOTS – Nigerian Prosthetic, Orthotic and Orthopaedic Technology Society. (2017) Brief history of NIPOTS. [online]. Available at: http://www.nipots. yolasite.com/. Accessed 23 Sept 2020. Nurudeen, NA. (2015, September 8). Nigeria needs occupational therapists. DailyTrust. [online]. Available at: https://allafrica.com/stories/201509080258. html. Accessed 23 Sept 2020. Nutrition Australia. (2017). Nutritionist or dietitian – Which is for me. [online]. Available at: https://www.nutritionaustralia.org/national/resource/nutritionist-­ or-­dietitian. Accessed 23 Sept 2020. NOIPolls. (2017). Emigration of Nigerian medical doctors: Survey report. [online]. Available at: https://noi-­polls.com/2018/wp-­content/uploads/2019/06/ Emigration-­o f-­D octors-­Press-­R elease-­July-­2 018-­Survey-­R eport.pdf. Accessed 10 Oct 2020. Obot, I. S. (2007). Psychologists in the Nigerian health care system: A brief report. Journal Psychology & Health, 12(1), 39–42.[online]. Available at: 10.1080/08870449608406919. Accessed 23 Sept 2020.

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Okoghenun, J. (2015, August 10). Nigeria has only 1,000 physiotherapists, say experts. Guardian Newspaper. Ogundipe, S., Obinna, C., & Olawale, G. (2015January 27). Shortage of medical personnel: Tougher times ahead for Nigerians. Vanguard. [online]. Available at: https://www.vanguardngr.com/2015/01/shortage-­medical-­personnel-­tougher-­ times-­ahead-­nigerians-­1/. Accessed 16 Oct 2020. Ogunsola, F. (2015). Nigeria needs 237,000 medical doctors but has only 35,000. Premium Times. [online] Available at: https://www.premiumtimesng. com/news/top-­news/192536-­nigeria-­needs-­237000-­medical-­doctors-­but-­ has-­only-­35000.html. Accessed 16 Oct 2020. Ojewale, C., Obokoh, A., Ani, M., & Ikwuetoghu, C. (2018). The numbers that tell how bad Nigeria health care system is. BusinessDay. [online]. Available at: www.businessdayonline.com. Accessed 16 Oct 2020. Omigbodun, A. O. (2012). The membership certification of the West African College of Surgeons and its relevance to the needs of the west African sub-­ region. Journal of West African College of Surgeon, 2(3), 83–87. [online]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4240233/. Accessed 23 Sept 2020 Oyiborhoro, M. A. (1988). Audiology training in Nigeria—I: A training model. Social Science & Medicine, 26(10), 1035–1042. [online]. Available at: 10.1016/0277-9536(88)90221-3. Accessed 23 Sept 2020. Pharmapproach. (2019). History of pharmacy, pharmacy education, career and ethics in Nigeria. [online]. Available at: https://www.pharmapproach.com/ history-­of-­pharmacy-­in-­nigeria-­2/. Accessed 23 Sept 2020. Sasona, A. (2014, September 23). I’m in Nigeria to change the lives of amputees. Vanguard. [online]. Available at: https://www.vanguardngr.com/2014/09/im-­ nigeria-­change-­lives-­amputees/. Accessed 23 Sept 2020. Speech Pathologists and Audiologist Association in Nigeria. (2020). [online]. Available at: http://www.spaan.org.ng/. Accessed 23 Sept 2020. Souers, JM. (2012, July 30). Cuba leads the world in lowest patient per doctor ratio: How do they do it? [online]. Available at: http://www.socialmedicine. org/2012/07/30/about/cuba-­leads-­the-­world-­in-­lowest-­patient-­per-­doctor-­ ratio-­how-­do-­they-­do-­it/. Accessed 3 Feb 2020. SwankPharm. (2015) Shortage of medical personnel – Tougher times ahead for Nigerians. [online]. Available at: https://swankpharm.com/blog/2015/01/ 27/3026/. Accessed 10 Feb 2021. Tam, A. (2015, August 30). Difference between medical laboratory science (mls) and science laboratory technology (slt). Medical Word Nigeria.

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The Institute of Public Analysts of Nigeria. (2004). Who is a public analyst? [online]. Available at: https://www.ipan.gov.ng/publicanalyst.php#:~:text=The%20 Institute%20of%20Public%20Analysts,Analysts%20established%20by%20 Decree%20No.&text=16%20LFN%202004%20to%20train,Analysts%20 and%20regulate%20their%20practice. Accessed 23 Sept 2020. Ubochi, N. E., Ehwarieme, T. A., Anarado, A. N., & Oyibocha, E. O. (2019). Building a strong and sustainable health care system in Nigeria: The role of the nurse. International Journal of Nursing and Midwifery, 11(7), 61–67. [online]. Available at: https://doi.org/10.5897/IJNM2019.0374. Accessed 16 Feb 2020. Uchejeso, M., Etukudoh, N. S., Chongs, M. E., & Ime, D. M. (2021). Challenges of inter-professional teamwork in Nigerian healthcare Book Chapter. IntechOpen. [online]. Available at: https://www.researchgate.net/ publication/349607538In. Accessed 15 Mar 2021. Usman, S. I. (2017). Biomedical engineering in Nigeria. [online]. Available at: http://nigerianbme.org/. Accessed 23 Sept 2020. WHO. (2000) The world health organization’s ranking of the world’s health systems, by rank. [online]. Available at: https://photius.com/rankings/ healthranks.html. Accessed 10 Oct 2020. Yakasai, A. (2016). Nigeria: Redefinition of pharmacists’ role to boost healthcare services. Macmillan Company.

3 Health Occupations (Vocational Careers) in Nigeria

Abstract  This chapter discusses the roles and responsibilities of the vocational health workers presently trained in Nigeria—pharmacy technicians, physiotherapy assistants/technicians, medical laboratory technicians/assistants, occupational therapist assistants, dental laboratory technicians, and community health officers. Keywords  Health occupations • Vocational careers • Auxiliary health workers • Roles/responsibilities • Nigeria Learning Objectives After reading this chapter, the learner should be able to: 1. Identify the primary health vocational careers within the Nigerian healthcare system 2. Articulate the primary roles and responsibilities of the health vocational workers in Nigeria 3. Discuss why certain professional association and regulatory boards in Nigeria are against the training of auxiliary healthcare workers

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 J. Abiodun Balogun, Health Professions in Nigeria, https://doi.org/10.1007/978-981-16-3311-9_3

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Introduction The universities in Nigeria do not currently produce adequate healthcare professionals (HCPs) to meet the national need (Balogun, 2020). Hence, health occupation workers are critically needed to supplement the shortage of HCPs. Health occupation workers do not require a university degree or extensive education; their training duration is relatively short, leading to a certificate or diploma credentials. Within the health system, they serve in supportive roles, usually under the supervision of the HCPs regulating the discipline. They play an integral role within the healthcare system and often serve as stepping-stones to advanced education or training opportunities in a lengthy and costly health profession. Health occupation (vocational) workers have technical skills, and their jobs require limited education and enable them to enter the workforce quickly. There are pros and cons to the use of health occupation workers in healthcare. Critics avow that given their limited education, serious medical conditions and complications may be left undetected when the HCPs do not supervise their work well. Antagonists argue that because of the “Nigerian factor,” health occupation workers present themselves as HCPs. Such a situation is problematic as the public may be confused in discerning between the HCPs and auxiliary workers. Proponents assert that health occupation workers’ supportive services allow the HCPs adequate time to concentrate on more complex and advanced treatments. Thus, their contribution reduces healthcare costs and prevents burnout of HCPs. Nigeria has some vocational health workers, but they are limited in scope compared to developed countries. For example, the United States has several vocational workers that are presently not trained within the Nigerian health system despite the acute shortage of HCPs. They include nursing assistants, cytogenetic technologists, nuclear medicine technologists, physician assistants, emergency medical personnel (paramedics), medical assistants, phlebotomists, and surgical technologists. In high-income countries such as Australia, Canada, United Kingdom, and the United States, physician assistants (PAs) play an integral part

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within their health system, but not in Nigeria. The situation is due to bad politics because both the Nigerian Medical Association (NMA) and the Medical and Dental Council of Nigeria (MDCN) are against the training of PAs for fears of losing authority and control over their practice and job protection (Obembe et al., 2008). The opposition to the training of PAs is absurd given that Nigeria, in 2009, has only 38 physicians per 100,000 people and two dentists per 100,000 people. A decade later, in 2010, the number of physicians in the country plummeted to 18 physicians per 100,000 people. In contrast, globally, there were 146 physicians per 100,000 people in 2009. In the same year, developed countries have an average of 283 physicians per 100,000 people (The World Bank, 2020). The experience in the United States suggests that the training of PAs in Nigeria will increase access to medical care, particularly in rural areas. The first PA educational program in the United States was established in 1965 because of physicians’ shortage and uneven distribution. The curriculum was modeled after the “fast-track” approach to training physicians adopted during World War II. Today, PAs provide medical care to rural and other medically underserved populations under the supervision of physicians (Yale School of Medicine, 2019). In many regions, physicians do not need to be on-site; consultation occurs via electronic means or telemedicine medium, depending on state laws. The scope of practice accorded PAs varies by jurisdiction and healthcare setting. Since 2010, the number of certified PAs in the United States has grown by 54%. In 2018, there were 123,089 certified PAs and 235 accredited entry-level programs with the potential for additional 32 new entry-level training programs by 2020 (Morton-Rias, 2017). The recognized health vocational workers in Nigeria are pharmacy technicians, dental technicians, medical laboratory technicians, medical laboratory assistants, environmental and public health workers, occupational therapy assistants, medical record officers, physiotherapy aides, and community health officers (Fig. 3.1). Their roles and responsibilities within the health system are discussed below.

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Medical laboratory technicians /assistants Community health officers

Pharmacy technicianss

Dental technologists/ therapists

Nurses and midwives

Healthcare occupations

Medical record officers

therapy aassistants EEnvironmental Physiotherapy Phy and public aides/ health workers te technicians

Fig. 3.1  Recognized healthcare occupations in Nigeria

Nurses Nurses provide healthcare services for patients of all ages with physical, mental, and terminal illness, and disability; monitor the sick; and advise pregnant women, their families, and communities on maintaining optimal health. Their roles also entail the prevention of disease and health promotion in urban and rural settings. They are trained to assess, plan, and implement care in collaboration with the other members of the healthcare team. Nurses work to enhance the quality of life of their patients, regardless of disease or disability. They provide a wide range of

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Fig. 3.2  A nurse at work in a pediatric ward

technical support from basic triage to emergency surgery and practice in the primary healthcare setting, private clinics, general and tertiary hospitals (Fig. 3.2). The nurses’ and midwives’ critical role within the health system cannot be overemphasized. They are the largest healthcare worker group in Nigeria, and their education, expertise, and numerical strength make them the first point of contact with most patients. They are well-­ positioned to champion health care transformation (Ubochi et al., 2019). The nurses with a Bachelor of Science in Nursing (BSN) degree, like all other graduates, participate in the mandatory one-year National Youth Service Corps (NYSC) program. University graduate nurses and registered nurses, and midwives can now enhance their clinical skills by enrolling in the post-basic training in nursing or midwifery or the community midwifery program. Besides, they can specialize in psychiatric nursing, post-basic peri-operative nursing, post-basic ophthalmic nursing, post-­basic aesthetics nursing, post-basic burns and plastic nursing, postbasic cardiothoracic nursing, post-basic orthopedic nursing, post-basic

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orthopedic nursing, and post-basic pediatric nursing. A professional nurse with a BSN degree can also enhance their career by seeking master’s and Ph.D. nursing degrees at approved universities in Nigeria.

Midwives The word midwife means “with a woman.” Midwives take care of women with a healthy pregnancy and monitor them and their baby throughout a phase of antenatal care, during labor and delivery, and follow them up to a month after delivery (Fig. 3.3). Hospital midwives work in hospital obstetric or consultant units, birth centers, or midwife-led units, and they staff the antenatal clinic, labor, and postnatal wards. Community midwives work in teams to provide continuity of care either at home or at a clinic. During delivery, they are available for a home birth, or in a few places, they may come into the labor ward in the hospital to be with their patients and make home visits when the baby is born for up to ten days

Fig. 3.3  A midwife at work

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afterward. Community midwives also provide postnatal care for women looked after during labor by hospital midwives.

Pharmacy Technicians The Pharmacists Council of Nigeria (PCN) is empowered by the PCN Decree 91 of 1992 to regulate and control the practice of pharmacy technicians. The professional organization for pharmacy technicians is the National Association of Pharmaceutical Technologists and Pharmacy Technicians of Nigeria. Registered pharmacists supervise pharmacy technicians and pharmacy assistants who are expected to have taken the conversion course to pharmacy technicians by 2007. Pharmacy technicians supply prescribed medicines to patients, provide relevant drug-related information to patients and other HCPs, and manage the areas of drug supply such as dispensaries (Fig. 3.4).

Fig. 3.4  A pharmacy technicians educating patients on their medications

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Unlike the NMA, NSP, and MRTB, the Pharmacists Council of Nigeria (PCN) is in full support of the training of pharmacy technicians. The PCN, in 2016, approved the training of pharmacy technicians by private Colleges/Schools of Health Technology in the country. The move increased the number of accredited Colleges/Schools of Health Technology from 18 in 2009 to 26. The approval also led to a 67% increase in admission into pharmacy technician programs and the number of pharmacy technicians produced annually in the country (Ogundipe, 2016). On the other hand, the Pharmaceutical Society of Nigeria (PSN), the NMA, the Public Health Professionals Association of Nigeria, the Quality Assurance Advocacy in Nigeria, several civil society organizations, the Federal Ministry of Health (FMH), the Office of the Attorney General of the Federation and the Nigeria Law Reform Commission were against the bill for the creation of the Pharmaceutical Technologists and Pharmacy Technicians Regulatory Board. The PCN maintained that the vexatious bill would create a leadership tussle between pharmacists and the pharmacy sub-cadre group and would likely ignite another dilemma in the health sector. The PCN’s spokesperson observed that “a parallel department for this sub-cadre would have to be added to the existing pharmacy department in all health facilities nationwide, including in the armed forces, the police, and various paramilitary bodies and even at the National Assembly” (Moshood, 2019). The approved pharmacy technician institutions are presented in Appendix 2.

Physiotherapy Aides/Technicians Physiotherapist assistants in Nigeria provide basic treatment procedures in the physiotherapy departments under the direct supervision of the physiotherapists. They do similar jobs to physiotherapist aides, but they have higher responsibilities and additional tasks like fabricating simple splints and fitting orthotic appliances. At the entrance of the physiotherapy profession into Nigeria, the School of Physiotherapy at Igbobi produced physiotherapy assistants, but the diploma program was dismantled after the University of Ibadan bachelor’s degree program commenced.

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Over the years, many unsuccessful attempts were made to reintroduce physiotherapy assistants on a large scale into the Nigerian healthcare system. However, the need to create a supportive staff cadre for physiotherapists remains controversial and not approved by the Nigeria Society of Physiotherapy (NSP) and the Medical Rehabilitation Therapist Board (MRTB). Despite the opposition from the NSP and MRTB, physiotherapist assistants are presently trained at the military (army and naval) hospitals in Lagos to meet the military’s needs. The School of Health Technology at Offa trains physiotherapist assistants to meet the need in Kwara State. The duration of training is two years following secondary school education. The firm position of the NSP to produce only physiotherapists with a university degree education has led to an acute shortage of physiotherapists. A growing number of calls from outside the profession drew the NSP and MRTB to the acute shortage of physiotherapists and the need for more Nigerians to have access to rehabilitation services. At the occasion marking the 50th anniversary of physiotherapy education at the University of Ibadan on March 29, 2016, Professor Eyitayo Lambo, former Federal Minister for Health, criticized the training of only physiotherapists with DPT, Ph.D., and clinical specialists’ credentials. He declared that the situation “may be very constraining to achieving some national and global health policy goals in Nigeria.” He, therefore, challenged the NSP and MRTB to proffer an innovative career ladder pathway within the profession to make physiotherapy services readily accessible, particularly in the rural areas where most Nigerians live. The current position of the MRTB and NSP against the introduction of physiotherapy assistants in the healthcare system is due to the experience of the pharmacy profession. For economical and cost-saving reasons, most private hospitals and clinics in Nigeria prefer to hire pharmacy technicians instead of licensed pharmacists. Unfortunately, the laws that defined the scope of practice for pharmacy technicians are often disregarded. Consequently, several employers take advantage of this vacuum and require pharmacy technicians to carry out advanced clinical tasks that they are competent to perform after years of work experience. The unfortunate lesson from the pharmacy profession is what the physiotherapists are careful not to repeat.

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In the United States, physiotherapy assistants require three years of training that culminates in an associate degree and licensure. They discharge their duties by working under the direct supervision of licensed physiotherapists. Physiotherapy assistants are knowledgeable and skilled health workers trained to administer a treatment that will improve physical disabilities, movement dysfunction and reduce pain resulting from injury, disease, and disability. They document the progress made in achieving the treatment plans prescribed by the physiotherapist. Physiotherapist aides in Nigeria receive on-the-job training at physiotherapy departments across the country. A minimum of secondary school education is required to be a physiotherapist aide. Their primary roles are to clean equipment and the treatment area and assist physiotherapists with the transfer and ambulation of patients, as well as assist with relocating equipment and instrument accessories needed for treatment.

Medical Laboratory Technicians/Assistants In Nigeria, medical laboratory technicians/assistants work under medical laboratory scientists’ supervision to conduct laboratory tests ordered by physicians/dentists on human bodily fluids and tissue samples (Fig. 3.5). Medical laboratory technicians pursue specialty training in immunology, microbiology, and clinical chemistry. Medical laboratory technicians’ training is of two-year duration leading to the award of a diploma credential. The medical laboratory assistants receive on-the-job training for their career.

Occupational Therapist Assistants The federal government in 2003 established the first occupational therapy assistant program in West Africa at the Federal Neuro-Psychiatric Hospital, Lagos, and named the institution the Federal School of Occupational Therapy. The first cohort of students admitted into the three-year diploma program graduated in December 2005. On average, the school produces 40–50 occupational therapist assistants annually. The Medical Rehabilitation Therapy Board of Nigeria (MRTBN) licenses the graduates.

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Fig. 3.5  A dental therapist at work

The University of Benin Teaching Hospital admitted the pioneering students into its three-year diploma program in occupational therapy during the 2018/2019 academic session. Admission to the program required a minimum of five credit passes in not more than two sittings in the WASCE/NECO/GCE ordinary level subjects, which must include English language, mathematics, chemistry, physics, and biology. Occupational therapy assistants are supervised directly by occupational therapists while providing treatment to patients.

Medical Record Officers The terms medical record, health record, or health information are used interchangeably to denote the systematic documentation of a single patient’s medical history and care across time within one particular healthcare provider’s jurisdiction. The Medical Record Officers (also known as Health Information Officers) are responsible for reviewing

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patients’ records for promptness, completeness, accuracy, and relevance, organizing and maintaining the data for clinical databases and registries. Additionally, they are responsible for monitoring patients’ outcomes for quality assessment, electronically record data for collection, storage, analysis, retrieval, and reporting; using billing software to assign clinical codes for reimbursement and data analysis; and maintaining the confidentiality of the patient records. The increasing use of computers for electronic health records will continue to change medical record officers’ job responsibilities and prestige. Medical record officers can specialize as medical coders, sometimes called coding specialists, or as cancer registrars. Medical record officers are employed primarily in tertiary, state, local, and private hospitals and offices of physicians/dentists. The approved medical records and health information management schools are presented in Appendix 3.

Community Health Workers Community health workers (CHWs) are frontline auxiliary workers with shorter training and an in-depth understanding of the community’s culture and language. They have intimate knowledge and a trusting relationship with their community and provide culturally competent health services (Olaniran et al., 2019). CHWs build capacity by increasing patients and community health knowledge and self-sufficiency through outreach, community education, informal counseling, social support, and advocacy. Their roles vary with the locale and cultural setting, but they work most often in underprivileged and marginalized communities with limited resources and lack access to quality health care. Community HCWs are expected to speak the local language and be adept at building local capacity while delivering culturally competent services. With their deep understanding of the local cultural norms, they often gain their patients’ trust and develop one-on-one relationships with consumers/clients, and providers. By contributing to primary and preventive care delivery, they facilitate improvements in health status and quality of life in rural communities. These impacts can be substantially enhanced when fully integrated with physicians/dentists, nurses, and

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other healthcare workers. Community HCWs have certain advantages over other healthcare workers. They can communicate more effectively in the local language and develop culturally relevant and highly accessible health information materials. They can reform the healthcare system to suit their population’s needs better and create cost-effective extensions of the healthcare system (Valuemedic, 2016). Typically, CHWs have deep roots or shared life experiences, values, ethnic background, socio-economic status, and the same language as the people they serve. They serve as liaisons between the community and the health care, government, and social service systems. The CHWs provide counseling services, health screenings, referrals, and human capacity to address health issues (Kaur, 2020; The Rural Health Information Hub, 2020; Brieger et al., 1995; WHO, 2007; Olaniran et al., 2019). The approved CHW schools are presented in Appendix 4.

Dental Therapists Dental therapists are a vital member of the dental team who provide preventative and restorative dental care at the three levels (primary, secondary, and tertiary) of the healthcare system. Dentists supervise the work of dental therapists to perform the oral examination in both adults and children, scaling/polishing, taking impressions of teeth, and applying materials to teeth such as fluoride and fissure sealants. They provide routine restorations from class 1-V in permanent and deciduous teeth, pulp treatment of deciduous teeth, placement of metal crowns on deciduous teeth, extract deciduous teeth under local analgesia, and emergency placement of crowns and fillings, if removed during the procedure (Fig. 3.5). Besides, they treat patients under conscious sedation if the dentist remains in the vicinity during the treatment. Dental therapists perform oral assessment, do subgingival debridement, take dental radiographs, and provide dental health education on a one-on-one basis or in a group situation. They also offer treatment for those that are mentally, physically, and medically compromised. Dental therapists are employed in public and private hospitals, clinics, and dental health training institutions. Areas of specialty in dental

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therapy are advances in non-surgical periodontal treatment, specialization in antiom and orthodontics care, care of implant, forensic procedures, and dental health education.

Dental Technologists/Therapists Dental laboratory technicians in Nigeria work under the supervision of dentists to plan, design, and fabricate dental prostheses for individual patients. Dentists are responsible for providing the dental laboratory technicians with a prescription detailing the final treatment choice and restoration or corrective device in the patient’s mouth. The dental technicians assist the dentists in selecting the material and case design and are responsible for fabricating the final prostheses or corrective devices. Dental laboratory technologists’ specialties include crown and bridge, ceramics, dentures, partial dentures, implants, orthodontics. The approved dental laboratory technician/therapist institutions are presented in Appendix 5.

Environmental and Public Health Workers Environmental health is a critical aspect of public health which deals with disease prevention, detection, and control of environmental hazards and sustenance of ecological integrity. The primary functions of environmental health as specified by the World Health Organization (WHO) are waste management, food control, hygiene, pest and vector control, environmental health control of housing and sanitation, epidemiological investigation and control, and air quality management, and occupational health and safety. Besides, environmental health contributes to water resources management and sanitation, noise control, protection of the recreational environment, radiation control and health, control of frontiers, air and seaports and border crossing, pollution control and abatement, educational activities (health promotion and education), promotion and enforcement of environmental health quality standards, collaborative efforts to study the effects of environmental hazards (research), and environmental health impact assessment (Environmental Health Officers Registration Council of Nigeria—EHORECON, 2015).

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In Nigeria, the environmental health officer (EHO) is regarded as the general practitioner of public health since they are in daily contact with the source of ill health in the community. The profession also has sub-­ professional groups (environmental health technicians and environmental health assistants) that work under the supervision of the EHOs (EHORECON, 2015). The EHOs monitor and enforce health and hygiene legislation and investigate pollution and noise problems, toxic contamination, pest infestation, or an outbreak of food poisoning. They spend time in the communities inspecting the environment, collecting specimen evidence from incidents, and providing advice. They also compile reports, conduct training, investigate complaints, serving legal notices, provide evidence in court, and liaise with community organizations (GTI Media Ltd., 2020). The origin of environmental health in Nigeria dates back to the eighteenth century when the colonial government introduced the sanitary inspectors to the colony of Lagos to control the breeding of mosquitoes, which was a major killer of colonial settlers. Environmental health remained unregulated until 2002, when the federal government recognized it with the enactment of the environmental health officers (Registration, etc.) Act 11 of 2002. The law established a Council charged with responsibility for regulating the standards of knowledge and skill of members and providing certificate or diploma education in environmental health. The professionalization of environmental health is delayed because of the medical profession’s dominant and superior influence, which annexed the occupation as part of clinical practice, even though the WHO recognized environmental health as a distinct prevention-­oriented discipline.

 omplementary and Alternative Medical C (CAM) Practitioners Besides African traditional medicine, other occupations are emerging within the Nigerian healthcare system. They include three complementary medical systems—acupuncture, chiropractic, and osteopathy—and seven alternative medical systems such as traditional Chinese medicine, Ayurveda, naturopathy, homeopathy, aromatherapy, spirituality, and traditional African medicine (Balogun, 2021).

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 raining of the Health Occupation (Vocational T Career) Workforce  raining of Occupational Therapist Assistants, Medical T Laboratory Technicians/Assistants, Dental Technologists/Technicians, Complementary and Alternative Medicine Practitioners The federal government established six non-degree awarding institutions where senior, medium, and junior-level ancillary healthcare workers are trained. The institutions are the: 1 . Federal School of Occupational Therapy, Yaba, Lagos State 2. Federal School of Medical Laboratory Technology, Jos, Plateau State 3. Federal School of Dental Technology and Therapy, Enugu 4. Federal College of Complementary and Alternative Medicine, Lagos 5. Federal College of Complementary and Alternative Medicine, Abuja 6. Federal College of Orthopedic Technology, Igbobi, Lagos State

Training of Nurses and Midwives Entry-level education in nursing has been a subject of controversy for decades. There are different entry-level levels to become a nurse in different parts of the world—a two- or three-year diploma program, a two-year associate degree in nursing (ADN), or a four-year Bachelor’s (BSN) degree leading to a registered nurse (RN) designation. Those with BSN can pursue a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) or a Ph.D. degree to enhance their career in clinical or administrative high-paying and high-demand nursing jobs (Balogun, 2020). There are two routes to becoming an RN in Nigeria. After completing secondary school education, a three-year basic general nursing certificate program, and a five-year generic BSN degree program (Chiedu, 2016). The overwhelming majority of nurses and midwives in Nigeria enter the profession through the nursing certificate program. They are trained at

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institutions accredited by the Nursing and Midwifery Council of Nigeria. Nationwide, there are 90 certified Schools of Nursing, 47 School of Basic Midwifery, 37 School of Post Basic Midwifery, 52 School of Post Basic Nursing, 28 Department of Nursing (BSN), and eight Community Midwifery Programs distributed unevenly across the country (Appendix 1). Admission to the Schools of Nursing and Midwifery is limited to 50 students per cohort to maintain a high-quality standard (Nursing and Midwifery Council of Nigeria, 2019; Labiran et al., 2008). The Federal Ministry of Education in 2007 approved the recommendations of the expert assessors’ committee to accord official recognition to rate holders of the general nursing and basic midwifery qualifications as equivalent to a Higher National Diploma (HND) at salary grade level 08 (step 1) in the public service (Nigeria Nursing World, 2007).

Training of Pharmacy Technicians There are 21 accredited Schools/Colleges of Health Technology where the pharmacy technicians are trained and certified by the PCN (Appendix 2). Pharmacy technicians receive a diploma following training at an approved institution or on-the-job training (PCN, 2020).

Training of Medical/Health Records Personnel The Health Records Officers Registration Board certifies the educational program of the two categories of medical/health records personnel training at ordinary and higher national diplomas (Health Records Officers Regulation Board of Nigeria, 2020). Nationwide, there are 19 accredited Schools of Health Information Management Programs and 87 Schools of Health Technology (Appendix 3).

Training of Community Healthcare Practitioners Community healthcare practitioners (CHCP) were introduced in 1978 by the minister of health, Professor Ransome Kuti, with the

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primary purpose of meeting the healthcare needs in rural areas. CHCP comprises community health officers, community health supervisors (training stopped in 1990), community health assistants (renamed community health extension workers), and community health aides (renamed junior community health extension workers). CHCP remained the core occupation in the Nigerian primary healthcare system (Ibama & Dennis, 2016). The Community Health Practitioners Registration Board of Nigeria was established on November 24, 1992, by President Ibrahim Babangida and formally constituted in December 2000. The Board regulates the training and practice of CHCP as specified by the FMH parastatal decree 61 of 1992 (LFN CAP C19 DF 2004). There are 14 institutions accredited for training community health officers and 43 for community health extension workers (Appendix 4). Since the inception of the training program, over 200,000 CHCP have been produced. Healthcare delivery by CHCP is Nigeria’s unique and impactful contribution to the global healthcare system (Ibama & Dennis, 2016; Uzondu et al., 2015).

Training of Dental Technologists and Therapists The Dental Therapists Registration Board of Nigeria regulates the dental technologists’ and therapists’ training (Dental Therapists Registration Board of Nigeria, 2020; Olabanji, 2020). There are three accredited dental technology and 21 dental therapy training institutions (Appendix 5).

Training of Environmental Health Officers The duration of training as an environmental health officer is four years in a School of Health Technology or School of Hygiene (Appendix 6). At the end of the training, the student is qualified to take the professional examination conducted previously by the Royal Society of Health,

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London, or the HND awarded by the West Africa Health Examination Board, a body approved by the National Board for Technical Education (Garba, 2004; EHORECON, 2015). The EHORECON and the Federal Ministry of Environment, in collaboration with UNICEF, developed a degree program in environmental health (BSc/BTech). The degree program is offered at the Federal University of Technology Owerri and the University of Ilorin (Mohammed, 2011). A one-year compulsory practical internship is required for registration with the EHORECON (2015).

 raining of Complementary and Alternative T Medical Practitioners Seventeen institutions exist for training CAM practitioners in Nigeria—3 are public, while the remaining 14 are private institutions. The ordinary national diploma and certificate are the entrylevel education for CAM practitioners. A two-year higher national certification is also offered for those desirous of advanced specialty training (Balogun, 2021).

Distribution of Health Occupation Workers The number of nurses in Nigeria is five times more than physicians (Scott-Emuakpor, 2010). There is an uneven distribution of health occupation workers within the healthcare system. The majority of them are employed in the southern region. For instance, over 30% of the environmental and public health workers, dental technologists and therapists, and pharmacy technicians are from the southwest region of the country (Balogun, 2020). The nursing workforce is concentrated primarily in the urban centers and the southern areas of the country. Many rural health centers, particularly in the northern states, are run by nurses (Scott-­ Emuakpor, 2010). In addressing the apparent disparities in the

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distribution of the auxiliary healthcare workers between rural and urban areas, President Olusegun’s administration mandated nurses and midwives without a degree to participate in national service. This requirement emanated from the recommendation of a Committee constituted by the federal government to investigate how to reduce the maternal mortality rate in the country. This program has been discontinued due to a lack of cooperation from several state governments. There is gender inequity within the health occupation workforce (Balogun, 2020). The health occupation workforce in dental technology, medical records, environmental health, chartered chemistry, and public analysis are predominately males. On the other hand, nursing, midwifery, and community health are female-dominated. Women make up 95% of nurses, 100% of midwives, and 59% of community health officers (Labiran et al. 2008).

Conclusion Australia, Canada, the United Kingdom, and the United States train healthcare workers categorized as “occupations” to supplement the shortage of HCPs within their health system. In Nigeria, vocational workers’ utilization is controversial because the professional regulatory boards do not support their training. Given the shortage of HCPs in the country, the professional associations must reconsider their protectionist position and embrace vocational workers’ training to meet the nation’s workforce needs.

Appendices The approved institutions for training the different occupations can be accessed at the following websites:

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Interdisciplinary Team Case Study Role-Playing Project The students should complete the following assignment to develop in-­ depth knowledge of other health professions. Group Activity Role-Playing Project The students will participate in a small group activity project that involves a role-playing scenario whereby multiple healthcare disciplines are working together. The students will be assigned a role representing a specific health professional/role in a broader situation. Also, one student will serve as the narrator for each group to begin the presentation by providing an overview of the scenario and keep the group on track during the performance. The narrator will also give a summary/conclusion of the performance. He or she will also play a role in the presentation. Students must accurately demonstrate the duties and responsibilities of their assigned health professional/role for their particular scenario, dress, and act in the profession assigned with appropriate instruments. The entire group must address scenario #1 narrated below, but each group must have a different injury (not disease) with the emergency care aspect included in the scenario (not condition). Example of Small Activity Group Project Scenario # 1 There was a major road traffic accident involving a truck and a Toyota sedan car near a township hospital. The driver of the passenger car was severely injured. Come up with one significant injury that you think the driver sustained and describe the roles and responsibilities of the different healthcare professionals from where the emergency number was called to report the accident till one year after the accident. The meeting members are the ER physician, ER nurse, director of radiology imaging, clinical lab director, health information director, director of rehabilitation services, and pharmacy director. Scenario # 2 The local hospital has a meeting to plan for a disaster drill in such an emergency. The disaster is a train wreck located near the hospital. Each member helps define his or her primary role in the accident using the Hospital Incident Command System. The meeting members are the ER physician, ER nurse, director of radiology imaging, clinical lab director, health information director, director of rehabilitation services, and pharmacy director. . ER Physician ____________________________________________________ 1 2. ER Nurse _______________________________________________________ 3. Director of Radiology Imaging ______________________________________ (continued)

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(continued) . Clinical Lab Director ______________________________________________ 4 5. Health Information Director _________________________________________ 6. Director of Rehabilitation Services ___________________________________ 7. Narrator/Pharmacy Director: ________________________________________ https://www.dhs.wisconsin.gov/wicpro/training/conflict/conflict-­ resolution-­training-­casestudy.pdf

Appendix 1 Nursing https://www.abnews247.com/2017/06/list-­a pproved-­s chools-­ nursing-­nigeria-­2017/

Appendix 2 Pharmacy Technician https://medicalworldnigeria.com/post/pharmacists-­c ouncil-­ of-­nigeria-­pnc-­list-­of-­approved-­colleges-­schools-­of-­health-­technology-­ training-­pharmacy-­technicians-­in-­nigeria?pid=38462

Appendix 3 Medical/Health Records http://www.hrorbn.org.ng/list-­of-­accredited-­schools

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Appendix 4 Community Health Practitioners https://schoolnews.com.ng/chprbn-­accredited-­institutions/

Appendix 5 Dental Technologists and Dental Therapists https://www.medianigeria.com/list-­o f-­s chools-­t hat-­o ffer-­d ental­technology-­in-­nigeria/ https://doctorsquarters.com/list-­o f-­a pproved-­a nd-­a ccredited-­ school-­by-­dental-­therapists-­registration-­board-­of-­nigeria/

Appendix 6 Environmental Health and Community Health Officers https://servantboy.com/environmental-­health-­community-­health/

References Balogun, J. A. (2020). Healthcare education in Nigeria: Evolutions and emerging paradigms. Routledge Publication. [online]. Available at: https://www.routledge.com/9780367482091. Accessed 23 Dec 2020 Balogun, J. A. (2021). Nigerian healthcare system: Pathway to Universal and High-Quality Healthcare. Springer Nature. Brieger, W. R., Oshiname, F. O., & Oke, G. A. (1995). The role of community health workers in the management of essential drugs. International Quarterly of Community Health Education. [online]. Available at https://journals.sagepub.com/doi/abs/10.2190/4QM8-­9E40-­TJVQ-­Y42M?journalCode=qcha. Accessed 23 Sept 2020

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Chiedu, J. (2016). Must read: Before you buy that School of Nursing admission form. Nursing World Nigeria. [online]. Available at: http://www.nursingworldnigeria.com/2016/03/must-read-before-you-buy-that-school-of-nursing-admission-form-by-jude-chiedu. Accessed 25 Jan 2020. Dental Therapists Registration Board of Nigeria. (2020). Dental therapists registration act. [online]. Available at: https://www.lawyard.ng/wp-­content/ uploads/2020/04/DENTAL-­T HERAPISTS-­R EGISTRATION-­E TC.-­ ACT.pdf. Accessed 10 Feb 2020. Environmental Health Officers Registration Council of Nigeria. (2015). History of environmental health. [online]. Available at: http://www.ehorecon.gov.ng/ welcome; https://www.ehorecon.gov.ng/Environmental-­Health-­Officers-­ Registration-­Council-­of-­Nigeria. Accessed 23 Sept 2020. Garba, S. (2004). Environmental health in Nigeria, yesterday, today, and tomorrow. Environmental and Public Health Watch. [online]. Available at: https:// tsaftarmuhalli.blogspot.com/2011/04/environmental-­health-­in-­nigeria. html. Accessed 23 Sept 2020. GTI Media Ltd. (2020). Environmental health officer: Job description. [online]. Available at: https://targetjobs.co.uk/careers-­advice/job-­ d e s c r i p t i o n s / 2 7 9 4 5 7 -­e n v i r o n m e n t a l -­h e a l t h -­o f f i c e r -­j o b -­ description#:~:text=Environmental%20health%20officers%20are% 20responsible,an%20outbreak%20of%20food%20poisoning. Accessed 23 Sept 2020. Health Records Officers Regulation Board of Nigeria. (2020). [online]. Available at: http://www.hrorbn.org.ng/list-­of-­approved-­schools. Accessed 10 Feb 2020. Ibama, A. S., & Dennis, P. (2016). Role of community health practitioners in national development: The Nigeria situation. International Journal of Clinical Medicine, 7, 511–518. [online]. Available at: https://www.researchgate.net/ publication/305642915_Role_of_Community_Health_Practitioners_in_ National_Development_The_Nigeria_Situation. Accessed 10 Feb 2020. Kaur, M. (2020) Community health worker. Liaison International. [online]. Available at: https://explorehealthcareers.org/career/allied-­ health-­professions/community-­health-­worker/. Accessed 23 Sept 2020. Labiran, A., Mafe, M., Onajole, B., & Lambo, E. (2008). Health workforce country profile for Nigeria. Africa Health Workforce Observatory, 8. Available at: http://www.hrh-observatory.afro.who.int/images/Document_Centre/ nigeria_country_profile.pdf LFN CAP C19 DF. (2004). Community Health Practitioners (Registration, etc.) Act. [online]. Available at: https://laws.lawnigeria.com/2018/04/20/lfncommunity-health-practitioners-registration-etc-act/. Accessed 20 Sep 2021.

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Mohammed, S. G. (2011). Environmental and public health watch. Training and functions of environmental health practitioners/environmental health officers. [online]. Available at: https://tsaftarmuhalli.blogspot.com/2011/07/ training-­and-­functions-­of-­environmental_26.html. Accessed: 23 Sept 2020. Morton-Rias, D. (2017). Statistical profile of certified physician assistants annual report of the national commission on certification of physician assistants. [online]. Available at: https://prodcmsstoragesa.blob.core.windows.net/uploads/file s/2017StatisticalProfileofCertifiedPhysicianAssistants%206.27.pdf. Accessed 23 Sept 2020. Moshood Y. (2019). Why PCN opposed pharmaceutical technologists and pharmacy technicians’ bill – Mohammed. [online]. Available at: https:// www.pharmanewsonline.com/why-­p cn-­o pposed-­p harmaceutical-­ technologists-­and-­pharmacy-­technicians-­bill-­mohammed/. Accessed 23 Sept 2020. Nigeria Nursing World. (2007). RN Equivalent to RN – Federal Ministry of Education. [online]. Available at: http://www.nursingworldnigeria. com/2012/06/rn-­equivalent-­to-­hnd-­federal-­ministry-­of-­education. Accessed 10 Feb 2020. Nursing and Midwifery Council of Nigeria. (2019). Approved schools. [online]. Available at: http://www.nmcn.gov.ng/apschool.html. Accessed 10 Feb 2020. Obembe, O. A., Onigbinde, A. T., Adedoyin, R. A., & Adetlinbi, O. G. (2008). Opinion of a section of Nigerian physiotherapists on training and utilization of middle-level workers. Journal of the Nigeria Society of Physiotherapy, 16(1), 23–30. Ogundipe, S. (2016) PCN approves training of pharmacy technicians in private institutions. [online]. Available at: https://www.vanguardngr.com/2016/11/ pcn-­approves-­training-­pharmacy-­technicians-­private-­institutions/. Accessed 23 Sept 2020. Olabanji, I. (2020). What you need to know about Dental Therapy Board of Nigeria. [online]. Available at: https://www.healthsoothe.com/what-­you-­ need-­to-­know-­about-­dental-­therapy-­board-­of-­nigeria/. Accessed 10 Feb 2020. Olaniran, A., Madaj, B., Bar-Zev, S., & van den Broek. (2019). The roles of community health workers who provide maternal and newborn health services: Case studies from Africa and Asia. BMJ Global Health, 4(4). [online]. Available at: https://gh.bmj.com/content/4/4/e001388. Accessed 23 Sept 2020 PCN. (2020) Accredited Schools of Health Technology. [online]. Available at: http:// www.pcn.gov.ng/webpages.php?cmd=N&pages=30&mt=Pharmacy%

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20Technician%20Training&smt=Accredited%20Schools%20of%20 Health%20Technology. Accessed 10 Feb 2020. Scott-Emuakpor, A. (2010). The evolution of healthcare systems in Nigeria: Which way forward in the twenty-first century. Nigerian Medical Journal. [cited 2017 Jun 30]; 51:53–65. [online]. Available at: http://www.nigeriamedj.com/text.asp?2010/51/2/53/70997. Accessed 10 Feb 2020. The Rural Health Information Hub. (2020). [online]. Available at: https://www. ruralhealthinfo.org/toolkits/community-­health-­workers/1/roles. Accessed 23 Sept 2020. The World Bank. (2020). Physicians. [online]. Available at: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=NG. Accessed 23 Sept 2020. Ubochi, N. E., Ehwarieme, T. A., Anarado, A. N., & Oyibocha, E. O. (2019). Building a strong and sustainable health care system in Nigeria: The role of the nurse. International Journal of Nursing and Midwifery, 11(7), 61–67. [online]. Available at: https://doi.org/10.5897/IJNM2019.0374. Accessed 16 Feb 2020. Uzondu, C. A., Doctor, H. V., Findle, S. E., Afenyadu, G., & Ager, A. (2015). Female health workers at the doorstep: A pilot of community-based maternal, newborn, and child health service delivery in northern Nigeria. Global Health Science Practice, 3(1), 97–108. [online]. Available at: https://www. ncbi.nlm.nih.gov/pmc/articles/PMC4356278/. Accessed 10 Feb 2020. Valuemedic. (2016). Roles of community health workers in healthcare delivery – Health. [online]. Available at: https://www.nairaland.com/3391197/roles-­ community-­health-­workers-­healthcare. Accessed 23 Sept 2020. WHO. (2007). Community health workers: What do we know about them? [online]. Available at: https://www.who.int/hrh/documents/community_ health_workers.pdf. Accessed 23 Sept 2020. Yale School of Medicine. (2019). History of the PA profession. [online]. Available at: https://medicine.yale.edu/pa/profession/history_profession/. Accessed 23 Sept 2020.

4 Notable Pioneer Nigerian Health Care Professionals

Abstract  This chapter chronicles the biography of 35 notable pioneer Nigerian healthcare professionals—15 physicians, two dentists, eight pharmacists, eight physiotherapists, and two nurses. Their career trajectory exemplified the evolutionary phases of healthcare practice in West Africa during the nineteenth and early twentieth centuries. Keywords  Pioneer • Nigerian • Healthcare Professionals • Biography • Scholarship productivity • Service contributions

Learning Objectives After reading this chapter, the learner should be able to: . Describe the history of major healthcare professions in Nigeria. 1 2. Identify and enunciate the academic and service contributions of the pioneer Nigerian physicians, dentists, pharmacists, physiotherapists, and nurses.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 J. Abiodun Balogun, Health Professions in Nigeria, https://doi.org/10.1007/978-981-16-3311-9_4

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Introduction Traditional medicine was the healthcare delivery system in Nigeria before 1472, when western-style allopathic medicine was first imported into the country, courtesy of the Portuguese. The establishment of the Roman Catholic Mission Hospital at St. Thomas Island off the Bight of Benin in 1504 marked the formal introduction of orthodox healthcare service. Subsequently, the Roman Catholic Mission opened the Sacred Heart Hospital at Abeokuta in 1865, followed in 1898 by St. Margaret’s Hospital in Calabar. The Medical Examining Board’s record in 1789 contained only the names of Europeans, mainly Dutch, Danish, and British nationals (Medical and Dental Council of Nigeria, 2020). The high mortality among Europeans who came to West Africa in the middle of the nineteenth century made the British Army train West Africans as physicians and deployed them to serve in their native countries. Unfortunately, the details regarding their contributions have remained in obscurity. This chapter sets out to identify the pioneer Nigerian healthcare professionals during the nineteenth and early twentieth centuries and examined their scholarship productivity and contributions to healthcare delivery in Nigeria.

Methodology This investigation was conducted through the PubMed, CINAHL, and PsychInfo databases using the keywords: Nigeria, healthcare professionals, health fields, research productivity, and service contribution. Subsequently, an exhaustive search of several Nigerian affairs-leaning websites produced 35 pioneer Nigerian health professionals—15 physicians, 2 dentists, 8 pharmacists, 8 physiotherapists, and 2 nurses. Relevant information about their academic productivity and service contributions is presented below:

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Results Physicians Dr. Williams Broughton Davies  (1833–1906) was born on October 25, 1833, to Yoruba parents in Wellington, Sierra Leone. He attended the Fourah Bay Institute of Freetown in 1850 and trained as a catechist in preparation for a career in the ministry. When the Church Missionary Society (CMS) wanted three West African youths to train in England as physicians for services in the British Army, Williams Davies, James Horton, and Samuel Campbell were selected. On arrival in the United Kingdom, Samuel developed severe bronchitis and was returned to his native country Sierra Leone where he died shortly. After completion of their medical education in the United Kingdom, Drs. Davies and Horton were appointed Staff Assistant Surgeons in the Army medical services, and they arrived at Cape Coast in October 1859.  Unlike the versatile and prolific Horton, Davies is less scholastically inclined and only wrote the necessary official letters. A stately gentleman with the Victorian age’s courtly gentility, Davies was reserved during his 22 years in the Army and afterward. He died in Sierra Leone on January 12, 1906 (Adeloye, 1974). Dr. James Beale Africanus Horton  (1835–1883) was born on June 1, 1835, in Gloucester, Sierra Leone, to Ibo parents and was the only survivor of eight children. He attended the Fourah Bay Institute, spent two years training for the ministry, and in 1855 was sponsored by the British government to train for the medical position in the Army. James graduated from King’s College in 1858 after an eminently distinguished undergraduate medical career. He received the academic prize award for surgery and five certificates of distinction in different specialties of medicine.  On graduation, James was elected to the college’s Associateship, a position that implies proficiency in studies and an unimpeachable academic character. On October 19, 1858, James enrolled at Edinburgh University, and in March 1859, he submitted an MD thesis titled “The medical topography of the West Coast of Africa, with sketches of its botany.” On the title

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page of his MD thesis, James christened himself “Africanus,” the “native of West Africa.” Several scholars of African ancestry hailed this new name change as evidence of his political awakening. Many speculated that the erudite James imitated the practice of eminent scholars such as Jacques Dubois, the French anatomist, who Latinized his name to Jacobus Sylvius, and Andrew Wesel of Brussels, who became Andreas Vesalius Bruxellensis. After completing the MD degree in 1859, both Drs Davies and Horton enlisted in the British Army as Staff Assistant Surgeons and were deployed for services in West Africa. Dr. Horton served in the Gold Coast (now Ghana) until 1880, when he retired from the British Army as a Surgeon-­ Major. After that, Dr. Horton took up banking and in December 1882 established the Commercial Bank of West Africa. His first publication was the MD thesis on tropical diseases submitted to Edinburgh University faculty. The research analyzed the medical craft and climatic conditions of West African countries from the archipelago of the Spanish Canaries to the Island of Fernando Po. He detailed the practice of circumcision among the Gallinas and the plausible link between the sanguinary gnat and malaria fever. He also discussed the botany of West African plants used for therapeutic purposes. The plants include the bark of the mangrove tree as a febrifuge in the Gambia, the leaves of the castor oil plant (Ricinus Africanus) as a sialogogue among the women of Cape de Verde Islands. He also described using the antiemetic Citrus medicae and the unripe pawpaw (Carica papaya) as a vermifuge in Sierra Leone. He sent his thesis to the London headquarters of the CMS in 1861 but remained unpublished. In 1867, Dr. Horton published a book based on the meteorological and geographical peculiarities of West Africa based on his six years of experience as an army surgeon in the region. The book was a great success, which launched him to stardom and gained the confidence of the colonial government. When he passionately pleaded for improvement in sanitation in Freetown, the government, for the first time in the history of Sierra Leone, immediately instituted a Board of Health (Njoh, 2000). A year later, in 1868, Dr. Horton published a monograph on guinea worm infestation and the regional distribution of the disease, based on

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his experience with the disease in Ghana and used his in-depth knowledge of geology to explain the distribution. He made his unique contribution to medical science in describing the treatment of guinea worm. He meticulously discussed the extraction of the worm by rolling it around a piece of stick (or a crow-quill) and the application of tincture of asafoetida (an oleo-gum resin made from the roots and rhizome of Ferula assafoetida). He stated, when taken orally, the herb “will rapidly destroy the parasite and produce pain relief.” Dr. Horton’s most well-known work was the publication on the diseases of tropical climates and their treatment, which he published in 1874. The book consists of three parts—Part one covers fevers, part two describes the disorders of the gastrointestinal tract and its related viscera, and part three discusses generalized affections, anemia, nutritional deficiencies, chronic rheumatism, and parasitic infestations. The second edition of the book, published in 1879, was extended by a 27-page Appendix on Materia medica. He is acclaimed for his superb skill and artistry as a writer who provides relevant historical background and details of tropical diseases. The significant advances in medical science at the end of the nineteenth century rendered Horton’s work obsolete. Unfortunately, his early death deprived him of witnessing the new changes and including the latest developments in his book. His contribution to the advancement of modem medicine in West Africa would be incomplete without mentioning his advocacy for healthcare education in West Africa. His efforts led to the establishment in 1876 of Fourah Bay College in Sierra Leone, which was affiliated with the University of Durham, UK. Dr. Horton died in October 1883 in Sierra Leon from a severe attack of erysipelas (Adeloye, 1974). Dr. Nathaniel King (1847–1884) was born on July 14, 1847, in Hastings, Sierra Leone, to Yoruba parents. His father, Rev. Thomas King, and Ajayi Crowther translated several catechisms and portions of the Bible into Nigerian languages. The transfer of his father from Sierra Leone to the Yoruba mission in Nigeria in 1850 allowed Nathaniel to come to his country of origin. He showed exceptional intellectual brilliance and caught the attention of Dr. A. A. Harrison, MD (Cantab), the

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missionary physician who, under Rev. Henry Venn’s direction in 1861, oversaw the CMS Theological Institute at Abeokuta. He started a “medical school,” and Nathaniel was one of the four students trained by Dr. Harrison. They used the four copies of Hooper’s Physician’s vade mecum, provided by the CMS at Salisbury Square, London. Dr. Harrison taught chemistry, botany, Materia medica, surveying, anatomy, physiology, the snippet of Euclid, and “only got as far as the fifth proposition.”  Unfortunately, the “medical school” established at Abeokuta was short-lived, as one student was dismissed, and two deployed to Lagos Schools to teach. Nathaniel was the only survivor and became a personal assistant to Dr. Harrison. The premature death of Dr. Harrison in 1864 brought to an abrupt end the first medical institution in Nigeria. In 1934, Yaba Higher College was established, and in 1948 the College relocated to the University College, Ibadan, as a College of Medicine (Adeniyi et al., 1998). By 2020, the number of medical institutions had surged to 43 (Balogun, 2020). In 1866, the CMS sent Nathaniel to Sierra Leone to prepare for a medical career like Horton and Davies before he got enlisted in the Army medical service. In 1871, he enrolled at King’s College, London, and graduated in 1874 with a BS degree and in 1876 obtained the MBBS and MD degrees three years later from Edinburgh. After his medical education, Dr. King returned to Lagos in 1878 and was employed at the CMS for a meager salary of “fifty pounds per annum” until January 1882, when the employer increased it to seventy-five pounds. As a highly talented and popular man, he broke the color barrier and discrimination and became a consulting physician to most European companies in Lagos. Dr. King died prematurely on June 12, 1884, leaving behind a promising career and a well-deserved legacy for improving sanitation in old Lagos. His academic literary and scientific knowledge, comparable to that of Dr. Horton, was acknowledged by his peers (Adeloye, 1974). Dr. Obadiah Johnson  (1849–1920) was born on June 29, 1849, at Hastings, Sierra Leone, and was the fourth child in a family of seven. He was enrolled in 1855 at the Day School in Hastings by a family known

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for ecclesiastical, linguistic, and literary excellence. As a result of his father’s transfer to Ibadan in 1858, he continued his primary education at Kudeti, Ibadan, and Faji Day School, Lagos, in 1864, where his brother, Nathaniel, was a schoolteacher. Obadiah left Faji in 1868 for Lagos to learn carpentry. After two years, he returned to Sierra Leone to resume his education in Freetown and was admitted to Fourah Bay College in 1877. Luckily, in 1876, two scholarships were created when Fourah Bay became affiliated with Durham University. Obadiah completed his BA degree in 1879 and received a scholarship to study medicine. Like Drs. Davies, Horton, and King, he enrolled at King’s College, London, won all the science awards, and completed his medical degree in April 1884. Like Dr. Horton, Obadiah was elected to King’s College’s Associateship by the Council and spent two years in Edinburgh before returning to Lagos in 1886.  Dr. Johnson spent a year in private practice in Lagos and, in 1887, was employed as a medical officer of health in Sherbo, Sierra Leone. At the invitation of Governor Moloney, he returned to Lagos to serve in the colonial medical service. Dr. Johnson, in 1889, was appointed an Assistant Colonial Surgeon in Lagos and the same year submitted a thesis on “West African therapeutics” to Edinburgh University for the MD degree. The research was based on his first-hand experience at Sierra Leone and its environs that included Lagos. He described the traditional medicine practiced by the Yoruba “botanists” medicine men—despite their lack of scientific education. The medicine men knew what herbs to use for particular disorders. Johnson claimed the selection of herbs by medicine men is based on its resemblance to the diseased part or “from the association of ideas in the name of the plant.” For instance, the velvet leaf (Cissampelos pareira) is used to manage excessive vomiting during pregnancy and excessive fetal movement. The Yoruba plant is known as “Jokoje,” which means “let remain quiet, or keep quiet.” In his monograph on the origin and customs of the Yoruba people, Johnson discussed the use of incantations by the Yoruba medicine men in what he referred to as “speaking the cure.” He reported on the frequent occurrence of multiple births in the village of Igbo-Ora, where a twinning rate of 45 in 1000 deliveries is the highest rate in the world

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compared to 11–12 per 1000 for women in England and Wales. He also reported that Nigerian women in certain regions claimed to make an antenatal diagnosis of multiple pregnancies. The practical implication of this ability among the Calabar in Southern Nigeria will potentially be advantageous since, before the arrival of Mary Slessor, twins in that region were killed. The original manuscript of his brother, Samuel Johnson, submitted to an English publisher was lost. After Samuel died in 1901, Obadiah Johnson resuscitated his brother’s voluminous documents. In 1916, he sent the new manuscript to England but arrived two years later in 1918 due to the capture of the ship carrying the manuscript during the First World War. The post-war scarcity of paper in England further delayed the publication of the monograph until August 1921—a year after Obadiah’s death. In July 1897, Dr. Johnson stepped down as the Assistant Colonial Surgeon and served 13 years in the Legislative Council following his appointment in 1901 by Sir William Macgregor. He made great strides in sanitation and environmental health in Lagos during his tenure. He died in September 1920, in London, where he was buried (Adeloye, 1974). Dr. John Randle (1855–1928) was born on February 1, 1855, in Regent, in Sierra Leone, to Thomas Randle, a liberated slave from a village in Oyo in Western Nigeria. After his primary school education in Regent, he went to the Grammar School in Freetown. In 1874, he was admitted to the Colonial Hospital, Freetown, to train as a dispenser and graduated in 1877. He immediately departed for the Gold Coast (Ghana), where he participated in public health programs, including extensive smallpox vaccination. He saved almost every penny he earned to finance his medical education at Edinburgh University. He enrolled in 1884 and graduated as a physician in 1888, and won the gold medal in Materia medica.  Dr. Randle returned to Lagos in December 1888 as a locum Assistant Colonial Surgeon at the Lagos Colonial Hospital and obtained a substantive position as an Assistant Colonial Surgeon shortly after the appointment of Dr. Obadiah Johnson. In November 1890, he married Victoria Matilda Davies, eldest daughter of the famously rich James

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Labulo Davies. His mother was Sarah Forbes Bonetta Davies, the Yoruba slave girl who was adopted and educated at the personal expense of Queen Victoria. Maltida’s wedding gown was provided by the queen, who selected the material before sowing and sent a charming message. At work, Dr. Randle encountered a discriminatory salary differential based on race, which he forcefully denounced. He received half the salary paid to his European colleagues despite the distinguished credentials he acquired from Edinburgh. In 1893, he refused to continue to do tours of duty at Ijebu-Ode, where Governor Gilbert Carter stationed some British troops and was dismissed for dereliction of duty. Governor Carter magnanimously acknowledged his expertise in the management of yellow fever. Using his royal connection, Dr. Randle established an extensive private practice in Lagos among the indigenous elites and the agents of several European companies. Although Dr. Randle did not obtain a postgraduate MD degree, he still contributed to medical science within the limitations of his education. He produced two articles; one on the “Treatment of guinea worm,” in 1894, and the other on the incidence of “Cancer among the African Creoles.” In sharp contrast to the strong recommendation by Horton, Dr. Randle actively discouraged the use of assafoetida in the treatment of guinea worm but prescribed it for psychiatric disorders. For guinea worm, he advocated a combination of poultices, constant daily traction, and incision of any accompanying abscesses “using a Paget’s knife.” Although effective medication is today available to treat guinea worm, Professor Adeloye, in 1974, opined that the principles of treatment espoused by Randle are still valid. In 1899, Governor Sir William Macgregor appointed Dr. Randle into the Legislative Council as a “provisional member.” With his enormous energy and stamina, in 1908, he launched the first political party in Nigeria, the Peoples Union Party, which he led until his demise on February 27, 1928. Dr. Orisadipe Obasa took over the leadership of the party. Many analysts considered Dr. Randle one of the most remarkable physicians in West Africa. He was a man from humble origins but overcame his disadvantages to become one of his era’s most financially successful physicians.

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This enigmatic physician is often embroiled in controversies in his private life, professional actions with patients, and political activities. He is recognized and celebrated for his frugality and extremes of harsh discipline—he never owned a vehicle but rode a bicycle even at seventy. Surprisingly, he was a great philanthropist and a man of many contradictions. For instance, he passionately encouraged many students to pursue higher degrees, yet some of his children accused him of neglecting their primary education. He is a fierce believer in African culture and adored his African attire but ordered his food from London. He passionately cared about his patients, and when they disobeyed his dietary instructions, he invoked police action to enforce his medical prescriptions. Dr. Randle died in 1928. In 1940, his remains were moved from the rear of Ikoyi Cemetery to the front yard in recognition of his legacy and achievements. Dr. Oguntola Odunbaku Sapara  (1861–1935) (born with the name Alexander Johnson Williams), without a doubt, is the most articulate of the eight Nigerian pioneers of modern medicine. He was born in Freetown, Sierra Leone, on June 9, 1861 to a liberated slave father from Ilesha in Western Nigeria, and his mother, Nancy, was from Egba land. His sister, Mrs. Clementina Foresythe, died in labor in 1877, and the disaster influenced him to study medicine. His brother, Christopher, trained as a lawyer and became a jurist, legislator, and bar leader in Lagos. Oguntola attended the Buxton Memorial Day School and the Wesleyan Boys’ High School in Freetown.  When his family returned to Lagos in 1876, he attended the Lagos CMS Grammar School until 1878 and opted in 1879 to learn a trade as a printer. Oguntola abandoned this career path and entered the Colonial Hospital in Lagos as a volunteer assistant dispenser under Dr. J. W. Rowland. In 1888, he enrolled at St. Thomas’s Hospital Medical School, London, and won honors in midwifery. Oguntola subsequently went to Scotland, where, in 1895, he completed the medical training and was elected a Fellow of the Royal Institute of Health. He returned to Lagos and was appointed an Assistant Colonial Surgeon in the medical department and

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served in other capacities until his retirement in January 1928. He died in June 1935. Dr. Sapara made impactful contributions to social and preventive medicine in Southern Nigeria. For instance, in 1900, he started the fight against the “filth and jungle” of Ebute Metta and, in 1901, organized the construction of the first public dispensary at Saki. His most impactful scholarship contribution was the paper he presented in 1918 with Dr. J. M. Dalziel at a conference convened in response to the alarming surge in the incidence of tuberculosis in Lagos. Their article implicated overcrowding, poor ventilation, and mass ignorance as to the vector for tuberculosis. They recommended improved environmental sanitation to control the disease. As the Health Week Committee Chairman, Dr. Sapara effectively fought against the bubonic plague, which struck Lagos in 1924. His outstanding role in eradicating smallpox in Epe in 1897 is one for which he is most remembered. It was alleged that a cult of smallpox worshippers was responsible for spreading the disease during the scourge. He joined the cult to understand better their modus operandi. In 1909, he summoned the priests to a meeting and threatened them with prosecution for spreading the disease, and used perchloride of mercury solutions to treat the ailment. The cult leaders left Epe in disgust, and the epidemic was controlled. Subsequently, a “Witchcraft and Juju Ordinance,” which made the worship of smallpox punishable by imprisonment, became law. As a result of the law, an immediate and substantial decrease in the incidence of smallpox outbreaks occurred, and this was a personal achievement for Sapara. Unexpectedly, Dr. Sapara was bestowed with many honors. In June 1923, he received the Imperial Service Order award for his smallpox activities by King George V. His Highness, the Alake of Abeokuta, awarded him the Honorary Consulting Physician to the Egba Native Administration, three months later. Early in 1924, the Owa of Ijeshaland, the paramount ruler of his homeland, conferred him with a chieftaincy title symbol of Bashemi, unique recognition of his contributions to medicine. The ceremony was the most auspicious occasion of his career. Dr. Sapara, for years, yearned to return to his homeland, and his long-­ cherished dream was achieved in death.

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Before passing, he successfully convinced the government to convert the dispensary in Lagos into Massey Street Hospital in 1926. The street behind the hospital was named Sapara Avenue, and a plaque was erected within the hospital in his honor. Before his death, Dr. Sapara was at the forefront of the campaign to reduce infant mortality in Lagos. He established an organization with the primary mission to train midwives and organize lectures to educate midwifery girls. He sponsored his daughter to qualify as a midwife in the United Kingdom and encouraged several Nigerian girls to study nursing. During his professional life, Dr. Sapara took a particular interest in traditional medicine and spent time, money, and efforts on the scientific investigation of herbal medicine. He popularized the decoction of Rauwolfia vomica leave as a febrifuge and an anticonvulsant. His medicinal preparations were patented, and reputable pharmaceutical outlets in Nigeria still market them. Unfortunately, only scanty and sometimes misleading records of his herbal pharmacopeia are available following his death in 1935 (Adeloye, 1974). Dr. Orisadipe Obasa  (1863–1940) (born with the name George Stone Smith) was born in Freetown, Sierra Leone, in January 1863 to the Elekole of Ikole-Ekiti. His mother was from the royal family of Akija of Ikija in Abeokuta. He came to Lagos in 1878 and was admitted to the newly established Wesleyan Boys High School, Lagos, as a Senior Foundation Scholar. In 1879, he was first among the 16 prize-winners and, in 1883, was sponsored by his parents to study medicine in the United Kingdom. He graduated from St. Thomas’s Hospital Medical School, London, in 1891 and returned to Lagos in 1892 to begin private practice. He was the last of the eight Nigerians who qualified in medicine in the nineteenth century.  In 1900, Dr. Obasa was employed as Assistant Colonial Surgeon in the medical services and took a leading role in public health campaigns in the Lagos colony and other districts within the Southern region. His most notable contribution was in 1903 in connection with Governor Macgregor’s smallpox vaccination scheme in Ekiti, the community of his origin. His medical reports indicated that he found “yaws peculiar to the Ijebus, ankylostomiasis the commonest parasitic

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infestation in Southern region, and in Ikorodu and Shagamu.” He noticed that inguinal hernias generally occurred on the right, “left inguinal hernia is an exception.” In 1902, Dr. Obasa married Charlotte Olajumoke, the daughter of Richard Blaize, a wealthy merchant of old Lagos. He resigned his appointment as a colonial surgeon in 1904 and returned to private medical practice, and launched himself into politics to form the first political party in Nigeria, the People’s Union Party, with Dr. Randle as President and him as Secretary. In 1916, the People’s Union fell out of favor with the electorate; even a change of party name to Reform Club did not revive the unpopular People’s Union when the virile Nigerian Democratic Party, led by Herbert Macaulay, was launched. On his merit, in 1921, Dr. Obasa became a member of the Nigerian Legislative Council and served creditably on several committees. In September 1923, he was defeated when the first parliamentary elections to the Legislative Council were held. He became the bonafide leader of the People’s Union when Dr. Randle died in 1928. Two years earlier, Dr. Obasa was diagnosed with Parkinson’s disease with progressively declined function and gave up the ghost on April 15, 1940 (Adeloye, 1974). Dr. Isaac Ladipo Oluwole  (1892–1953) was born in 1892 to Anglican bishop Isaac Oluwole, principal of CMS Grammar School, Lagos, and Mrs. Abigal Johnson, a music teacher. He started his secondary school education at CMS Grammar School. He transferred to King’s College, where he and James Churchill Omosanya Vaughan were among the pioneer students, when it opened in September 1909. Ladipo was the first senior prefect of the prestigious school. Later, Ladipo and Omosanya went to the University of Glasgow medical school in 1913. As African, they stood out in the crowd and were both subjected to racial prejudice. Ladipo was called “Darkness visible” after the phrase from Milton’s Paradise Lost. In 1918, both Ladipo and Omosanya returned to Nigeria after graduating from the University of Glasgow medical school. Dr. Oluwole went into private practice in Abeokuta, where he consulted with patients in his office or visited them in their residence and involved in a

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few community activities. He established a boy scout group in 1923; The latter boy scout group received the Prince of Wales when he visited Abeokuta. Dr. Oluwole returned to Glasgow to obtain his DPH degree after a few years in private practice. In 1917, Lagos passed the public health ordinance, a series of health regulations to improve sanitation in the city. However, the implementation of the law was a challenge due to the limited number of trained medical personnel. In 1922, the Lagos Town Council, dominated by Europeans, suddenly opened the doors for more opportunities to the newly elected African members. The new members advocated for an African medical officer in the Lagos Municipal Board of Health. By 1924, the Lagos Town Council decided to hire an African who could speak the local language. Dr. Oluwole was offered the job and sent for further training in public health administration before assuming duty. In 1925, Dr. Oluwole started work and became the first African Assistant Medical Officer of Health in Lagos. He established the first School of Hygiene in Nigeria, at Yaba, Lagos. The school provided training to sanitary inspectors from all parts of the country. On graduation, the students obtained the Diploma of the Royal Institute of Public Health, London. He re-organized sanitary inspection procedures in the port of Lagos to control the spread of the bubonic plague and set up the West African Board of the Royal Society of Health. The Board developed the first standards of practice for public health in Nigeria. The bubonic plague in Lagos between 1924 and 1930 in unsanitary shanty towns caused many deaths. The government demolished many of the slums, thereby forcing their inhabitants to resettle into the unregulated suburban areas of Lagos. Dr. Oluwole reclaimed swampy islands to control malaria, worked to improve food hygiene, and also built a new abattoir. In 1925, he started the first school health services in Lagos and introduced regular sanitary inspections and vaccination for children. During his tenure, the Lagos Town Council established the Massey dispensary in 1926, and a department of antenatal and child welfare services created to form part of the new dispensary. The reorganization gave birth to the first distinct maternity and child services program within the Lagos Public Health

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department. The primary objective of the new antenatal clinic was to reduce child and maternal mortality rates in Lagos. Between 1926 and 1930, the Massey dispensary developed an infant welfare clinic, and a children’s ward opened. The success of the Massey clinic led to the establishment of another clinic for the Lagos mainland residents in Ebute Metta. The clinic treated health visitors and ensured midwives advised patients during clinic hours. The health visitors promoted good health practices by visiting discharged patients to check on their welfare. Dr. Oluwole also focused his attention on school-age children ensuring that Lagos schools include hygiene in their curriculum, but the teaching was primarily theoretical and lacked practical demonstrations. In 1927, he visited 57 schools to inspect their sanitary conditions, and a year later, he made another visit. During the inspections, he observed several shortcomings in the hygienic conditions of the schools and proposed some remedies. In 1930, as a result of his recommendations, regulations were enacted that made it mandatory for regular inspections of schools and students every three years. The principal objective was to uncover children’s ailments, provide medical treatment to alleviate the conditions, and educate teachers about better practices in hygiene and sanitation. In recognition of his leadership, in 1936, Dr. Oluwole became the Medical Officer of Health in Lagos, and in 1940 he was awarded the Order of the British Empire (OBE). When he died in 1953, he was acclaimed as the father of public health in Nigeria. Dr. Richard Akinwande Savage  (1874–1935) was born in 1874 to a successful Lagos merchant who descended from Egba land and Sierra Leone Creole descent. He became a prominent physician, journalist, and politician in Lagos during the colonial era. Richard studied medicine at the University of Edinburgh and served as an officer in the Afro-West Indian Society. From 1899 to 1900, Dr. Richard Savage edited Edinburgh’s Student HandBook and served as the sub-editor of The Student. In July 1900, he attended the Pan-African conference in London. Richard was the last African appointed as an Assistant Colonial Surgeon in the colonial medical service before the declaration by Joseph Chamberlain in 1902 that the service was restricted to Europeans. For several years, he

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worked in the Gold Coast (Ghana) as a government physician and private practitioner. Dr. Savage was one of the leading members of the Peoples Union Party, founded in 1908 by Dr. John K. Randle (1855–1928). Other active members of the party were Dr. Orisadipe Obasa (1863–1940), Kitoye Ajasa (1866–1937) and Adeyemo Alakija (1884–1952). Although men with conservative views controlled the People’s Union, some progressive professionals, including Ernest Ikoli (1893–1960), a prominent journalist and founder of the Nigerian Youth Movement, also joined the party. The party favored the gradual introduction of reforms and opposed the more radical and nationalist views of the Nigerian National Democratic Party, founded in 1922 by Herbert Macaulay. Around 1914, Dr. Savage was among those who found the National Council of British West Africa, which consisted of elites from across West Africa. The Council, in 1919, emerged as a broad-based party and held its first congress in Ghana in 1920. Among the party’s demands were establishing a university, greater African participation in the Legislative Councils of the British West African colonies, and appointment of Africans to senior civil service positions. He returned to Lagos around 1915, where he began to practice medicine privately and continued to contribute to local newspapers such as the Gold Coast Leader. He later established the Nigerian Spectator (1923–1930) and the Akibooni Press and set up the National Council of British West Africa’s Lagos Committee. After the party failed to nominate an Egba land representative on the Legislative Council, he broke up the National Council of British West Africa Lagos Committee. He was one of the founding members and secretary of the Egba Society, formed around 1920. He died in 1935. He was married to Maggie Bowie in 1899, a Scottish woman with whom he had two children—Major Richard Gabriel Akinwande Savage and Dr. Agnes Yewande Savage. Both of them trained as physicians and followed in their father’s footsteps. Dr. James Churchill Omosanya Vaughan  (1893–1937) was born in Lagos on May 30, 1893, to James Wilson Vaughan, a wealthy Yoruba

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merchant who descended from the nineteenth-century American artisan Scipio Vaughan through whom he also had Cherokee ancestry. He was one of the students admitted at the prestigious King’s College, Lagos, founded in 1909. After King’s College, he and Isaac Ladipo Oluwole were the two Nigerian students first enrolled at the University of Glasgow medical school in 1913, and they both graduated in 1918. They experienced racial prejudice during their education. During the final dinner, the school gave him an epithet of Robert Burns’s “The Twa Dogs”—a foreign-born dog, “whalpit someplace far abroad.” He returned to Nigeria in the early 1920s and set up a private medical practice and provided free medical services for the needy.  Dr. Vaughan and Dr. Kofo Abayomi, and other leading political activists, including Hezekiah Oladipo Davies, Ernest Sissei Ikoli, and Samuel Akinsanya, were outspoken critics of the British colonial administration. In 1934, Dr. Vaughan was elected the first President of the Youth Movement that initially had higher education as its primary mission. Within four years, he had become the most influential nationalist organization in the country. It was renamed the Nigerian Youth Movement in 1936 to emphasize its pan-Nigerian objectives. One of the movements’ first incursion was to revise the curriculum of the medical program at the Yaba Higher College. Dr. Kofoworola “Kofo” Adekunle Abayomi  (1896–1979) was born on July 10, 1896, in Lagos to Yoruba parents. Between 1904 and 1909, he attended UNA School, Lagos, and later attended Wesleyan College (now Methodist Boys High School) Lagos. He subsequently attended Eko Boys High School from 1912 until 1914 and left to join the African Hospital, Lagos, as a dispenser. He worked voluntarily as a dresser at the base hospital in Cameroun’s during World War I. He enrolled at the Yaba Higher College to study pharmacy. He subsequently attended the University of Edinburgh medical school, and graduated in 1928, worked briefly as a demonstrator.  Dr. Abayomi returned to Nigeria and worked briefly for Dr. Oguntola Sapara, but in 1930, he returned to the United Kingdom to study tropical medicine and hygiene. In 1939, he enrolled in the postgraduate program in ophthalmic surgery and medicine. As an African with British medical training, he had to join the British Colonial Medical Service and cope with British peers who felt that Africans were

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inferior to Caucasians. He returned to Nigeria as an ophthalmologist and later became a politician. In 1934, Dr. Abayomi was one of the nationalist Lagos Youth Movement founders and had a distinguished public service career. The Movement was formed by the Lagos intelligentsia, who protested against the establishment of the Yaba College because it would provide inferior education to Africans. The organization was initially called the Lagos Youth Movement but was renamed in 1936 to reflect its broader scope. He became President of the Movement in 1937 following Dr. James Churchill Vaughan’s death, and a year later, in 1938, he was elected a member of the Legislative Council. Dr. Abayomi resigned from both positions and returned to the United Kingdom for further studies. His departure precipitated a political crisis. The rival candidates, Ernest Ikoli, an Ijo man, and Samuel Akisanya, an Ijebu, were supported by Nnamdi Azikiwe. However, the party executive selected Ikoli as their candidate; both Akisanya and Azikiwe left the party with most of their followers. In 1941, Dr. Abayomi returned to Nigeria to continue his successful family practice and became the first private practitioner elected as the Nigerian Medical Association president. A branch of the Egbe Omo Oduduwa, a Yoruba social welfare organization formed in London in 1945, was inaugurated in June 1948 in Ile-Ife. Sir Adeyemo Alakija was elected President, and Dr. Abayomi elected treasurer. Between 1949 and 1951, he was a member of the Governor’s Executive Council, and in 1950 the Alaafin of Oyo, Adeyemi II, awarded him the chieftaincy title of One-Isokun of Oyo. Two years later, Oba Adele II of Lagos also awarded him the title of Baba Isale in April 1952. Dr. Abayomi was one of the founding members of the Action Group when the party’s Lagos branch was inaugurated on May 5, 1951. Coincidentally, there were several tax-related riots in the northern Oyo towns during the first half of 1954. And several Yoruba chieftains sent him to the Alaafin of Oyo in August of that year to withdraw his support for the nationalist National Council of Nigeria and the Cameroons. In 1948, the Nigerian Legislature on the Governing Council appointed Dr. Abayomi to serve on the Board of the University College Hospital (UCH) from its foundation. He became Deputy Chairman of the Board

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of Management in 1951 when it was inaugurated and served on the Board until 1961. In 1958, he also became the Chairman of the Lagos Executive Development Board. At the time, the Development Board had the authority to demolish unsanitary buildings and undertake town planning schemes. The Board authorized the freehold housing and estate development in Surulere, the reclamation projects of the northeast, and southwest Ikoyi. The Board reclaimed up to 1000 acres of land in Victoria Island. In 1958, Dr. Abayomi became the first Nigerian Chairman of the UCH Board and held the position until 1965. A year later, in 1959, he served as Chairman of the Lagos University Teaching Hospital Board of Management. Toward the end of his career, he served as a Board member and as the Chairman of several companies. On January 1, 1979, Dr. Abayomi died peacefully at home at the age of 82, leaving behind a widow, Oyinkan, who was herself a prominent figure in the political history of Nigeria. Dr. Samuel Layinka Ayodeji Manuwa  (1903–1976) was born in 1903 to Reverend Benjamin Manuwa, a minister who was himself the son of Oba Kuheyin, the king of Itebu—Manuwa, and Mrs. Matilda Aderinsola Manuwa, who hailed from the Thomas family of Ondo town. He attended the CMS, Lagos, for his primary education and King’s College for his secondary education, which he completed in 1921. He immediately enrolled at the University of Edinburgh and completed a bachelor’s degree in chemistry and a medical degree in 1926. At the undergraduate level, he won the Robert Wilson Memorial Prize in chemistry and every prize given in the medical school, including the Welcome Prize in medicine. He later completed the tropical medicine program offered at the University of Liverpool.  Dr. Manuwa returned to Nigeria in 1927 and joined the colonial medical services as a medical officer and rose rapidly through the ranks and became a specialist surgeon and senior specialist in the service and regarded as a skilled surgeon. Early in his career, he received various administrative job offers but turned them down and continued his clinical work for more than 18 years. He invented an excision knife to treat tropical ulcers. He obtained the postgraduate MD

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degree from Edinburgh in 1934, after submitting the thesis titled “Chronic splenomegaly in West Africa, with special reference to Nigeria: An inquiry into the observation on the common signs of this disease among West African negroes.” Dr. Manuwa was the first Nigerian elected Fellow of the Royal College of Surgeons of Edinburgh in 1938, the first Nigerian elected to the Royal College of Physicians of Edinburgh in 1960. He served in different administrative positions as Deputy Director of Medical Services (1948), the first Nigerian Director of Medical Services (1951), Inspector General of Medical Services, Chief Medical Adviser to the federal government (1954), Member of the Privy Council of the Federation of Nigeria, President of the West African Association of Surgeons and Physicians. Dr. Manuwa was the first Nigerian Commissioner of the Federal Public Service Commission and served as a Nigerian aristocrat. As the Inspector General of Medical Services, he worked assiduously to improve essential health services in the rural areas and established, in 1948, the first University Teaching Hospital in Nigeria—UCH, Ibadan—the citadel of the first medical school in Nigeria. In 1966, he was elected the President of the World Federation for Mental Health. He also served as the Pro-Chancellor and Chairman of the Governing Council at the University of Ibadan (UI). Throughout his career, he worked to improve essential health services in the rural areas of Nigeria. He received various chieftaincy titles from the Yoruba land, including the Obadugba of Ondo land, the Olowa Luwagboye of Ijebu land, and the Iyasere of Itebu–Manuwa. He had six children from his two marriages; his children are accomplished professionals in medicine, law, nursing, education, and public service. Dr. Richard Gabriel Akinwande Savage (1903–1993) was born in 1903 in Edinburgh, Scotland, of mixed ancestry to the prominent Nigerian physician Richard Akinwande Savage of Sierra Leone Creole descent, who married a Scottish woman, Maggie Bowie. Gabriel was a physician, soldier, and the first West African commissioned into the British Army. His sister, Agnes Yewande Savage, was also the first West

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African and Nigerian woman to qualify as a physician. Gabriel enrolled as a medical student at the University of Edinburgh, graduated in 1926, and completed housemanship in 1927. On September 23, 1940, he was commissioned as a Second Lieutenant in the British Army, making him the first West African appointed as an officer. Ghanaian Seth Anthony is usually erroneously referenced as the first West African commissioned in the British Army (SEAL67, 2015).  Dr. Richard Gabriel Savage was promoted to the rank of Captain in September 1941 and served with distinction as a physician in the Asian Theater during the World War in Burma, where he cared for wounded British soldiers. Among the soldiers who Major Richard Gabriel Savage treated in Burma was Isaac Fadoyebo, a wounded Nigerian soldier in the Royal West African Frontier Force. The latter recounted the high quality of care provided to him and other West African soldiers by Major Richard Gabriel Savage. Like his father, he married a Scottish woman and retired to Scotland until he died in 1993. Dr. Agnes Yewande Savage  (1906–1964) was born on February 21, 1906, in Edinburgh, Scotland, to Dr. Richard Akinwande Savage Sr, and Maggie S. Bowie, a Scottish woman. Her brother Richard Gabriel Akinwande Savage was also a physician. Agnes, in 1919 at the age of 19, gained admission into the Royal College of Music and received a scholarship to study at George Watson’s Ladies College, where she passed General Proficiency in Class Work and the Scottish Higher Education Leaving Certificate. In her fourth year, Agnes obtained first-class honors in all subjects. She won the dermatology prize award and a medal in forensic medicine—the first woman in the history of Edinburgh to achieve such a feat. Also, she was awarded the Dorothy Gilfillan Memorial prize as the best woman graduate in 1929 (Anonymous, n.d). Agnes Savage was the first Nigerian and West African woman to earn a university degree when she graduated from medical school in 1929 at the age of 23. She subsequently trained to qualify in orthodox medicine (University of Edinburgh, 2018).  At Edinburgh, she faced racial and gender institutional barriers. After graduation, Agnes joined the colonial service in the Gold Coast (now Ghana) as a junior medical officer. She received fewer accolades and

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benefits than her male peers, even though she was better qualified than most of them. In 1931, the headmaster of Achimota College recruited her and at the urging of the headmaster, Alec Garden Fraser, the colonial government gave her a better contract. Dr. Agnes Savage worked at Achimota College for four years as a medical officer and a teacher (Dee, 2019) and returned to the colonial medical service after being offered a better concession. She was assigned to the Korle-Bu Hospital in Accra and put in charge of the infant welfare clinics. She supervised the establishment of the Korle-Bu Nurses Training College. She retired relatively early in 1947, exhausted from fighting institutional sexism and racism (Ososanya, n.d.). She spent the golden years of her life in Scotland, raising her niece and nephew until 1964, when she died of a stroke.

Dentists Dr. Sydney Obafemi Philips,  the first Nigerian dentist, was born on November 29, 1894, into the Lagos socialite family of Philips. He had his early education at CMS Grammar School and King’s College, Lagos, and obtained his dental degree in 1926 from the University of Glasgow. He returned to Nigeria and established a thriving dental practice in Lagos (Michael, 2016).  Dr. Simisola Olayemi Onibuwe Johnson  (1929–2000) was born in Lagos to Alfred Latunde and Harriet Susan Johnson (née Crowther Nichol) as the last born of her parents. His father was a lawyer and the pioneer director of the National Bank of Nigeria in 1933. Ajayi Crowther was her maternal great-great-grandfather, and her great-grand-­ uncle was Herbert Macaulay. Dr. Johnson received her early education at CMS Grammar School and attended Sunderland Technical College and Durham University from 1954 to 1957, with Grace Guobadia. Both qualified as dentists in 1957 and became the first female Nigerian dentists. Dr. Johnson trained as an orthodontist at the Royal College of Surgeons, Glasgow, and returned to Nigeria as the first female orthodontist.  Johnson was employed as a dental surgeon at the General Hospital, Lagos, on July 14, 1958, and rose to become the chief consultant dentist

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in the Federal Ministry of Health (FMH). She was a pioneer member of the Nigerian Dental Association in 1962 and later became a Fellow of the National Postgraduate Medical College of Nigeria (NPMCN). Dr. Johnson was an associate lecturer in dentistry at the University of Lagos and was subsequently appointed the Federal School of Dental Hygiene and Technology Principal. In 1983, Dr. Johnson served as the Minister of Social Development and Culture during the Shagari administration. She was the head of Nigeria’s delegation to the Third World Conference on Women, held in Nairobi, Kenya, in 1985. The conference recommended that member nations eliminate discrimination against women and adopt policies that promote the socio-economic development of women. As the head of the women’s advisory committee during the Babangida’s administration, Dr. Johnson fought to create the Ministry for Women’s Affairs, established in 1989. Before her death in 2000, she served as the chairman of Lagos State branch of the Allied Bank and the National Council of Women Societies.

Pharmacists The first known pharmacy outlet in the world was established in Baghdad, Iraq, at the then Babylon, Asia Minor, in 754—in the eighth century. The first pharmacy in Europe dated back to the eleventh century (Association of Community Pharmacists of Nigeria, 2020). The genesis of pharmacy practice in Nigeria is traced back to 1887, but the profession did not start as a distinct healthcare discipline. Training of pharmacists in the country began in response to the need to assist expatriate physicians (Pharmapproach, 2019). The biography of the pioneer Nigerian pharmacists is presented below. Dr. Richard Zachaeus Bailey (1829–1911), a European popularly known as the “doctor,” opened a pharmacy outlet along Balogun Street in Lagos in 1887, which catered primarily to Europeans. Richard Zaccheus Bailey trained several dispensers, including Alfred Philip, Julius Apena, Nelson Cole, S. R. Macauley, Moses Da-Roche, and John Caulcrick—all

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the dispensers subsequently trained as physicians (Erah, 2003). Before training as a physician, Kofoworola “Kofo” Adekunle Abayomi (1896–1979) worked voluntarily as a dresser at the base hospital in Cameroun during World War I. He enrolled at the Yaba Higher College to study pharmacy and attended the University of Edinburgh medical school, and graduated in 1928.  Emmanuel Caulcrick  was the first Nigerian registered as a pharmacist on September 1, 1902, and later established a drug store in Lagos. He was followed by Mrs. Ore Green (foreigner), who registered in 1919 as the first female pharmacist. The Timi of Ede, who trained as a dispenser, later became a physician in 1914, and Chief Hunponu-Wusu also received his dispenser qualification in 1922. Other notable pharmacists include Mr. Azariah Olusegun Ransome-Kuti, Mr. Robert Olatunji Adebowale, Mr. Afolabi, I. Kinoshi, Mr. Peter Etim Archibong, Mr. D. A. Pratt, Dr. Gordon Taylor, Mr. J. P Marquis, and Chief (Mrs.) Ekanem Bassey Ikpeme, the (first Nigerian female pharmacist) (Pharmapproach, 2019).  Thomas King Ekundayo Phillips  (1884–1969) was born in 1884 to Bishop and Mrs. Charles Phillips. He was admitted to the Government Training School for dispensers and trained as a chemist and druggist. He opened a drug outlet—Philips Medicine Store—in Tinubu Square in Lagos and was the first President of the Pharmaceutical Society of Nigeria (PSN). He served from 1947 to 1951 and later trained as an optician (Erah, 2003). Mr. Phillips was an organist, conductor, composer, teacher, and the “father of Nigerian church music.”  Dr. Ahmed Tijjani Mora  was born in Zaria on May 13, 1956, to the late Dr. Abdurrahman Mora. He attended Barewa College and graduated in 1974. He obtained both bachelor’s and master’s degrees in pharmacy from Ahmadu Bello University (ABU) in 1978 and 1985. He later earned a doctorate in management from Usmanu Danfodiyo University and was inducted as a Fellow of the West African Postgraduate College of Pharmacists (FPC Pharm) in 2002. 

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Dr. Mora joined ABU in 1986 as lecturer II and was promoted in 2001 to the status of a senior lecturer. In October 2003, he was elected as the Registrar of the Pharmacists Council of Nigeria (PCN) and served nine years in that capacity. He was appointed the founding dean of the Faculty of Pharmaceutical Science at Kaduna State University (KSU) in 2012. He served as dean until June 2016 and returned to ABU. On September 27, 2013, in recognition of his vital contributions to health in Kaduna state, the Emir of Zazzau and Chairman of the Kaduna State Council of Chiefs Alhaji Shehu Idris bestowed him with the Chieftaincy title of Wakilin Maganin Zazzau of the Zazzau emirate. Professor Gabriel Ediale Osuide  was born on March 15, 1935, and attended the University of London. He studied pharmacology and graduated with a BSc First Class (Honors) in July 1963 and later with a Ph.D. degree. The late Mallam Adamu Dikko, Mallam Peter Omar Ishaku (Pa Ishaku), and Prof. Gabriel Osuide established pharmacy education in Northern Nigeria. As teachers, the triad nurtured pharmacists’ training at different educational levels—the dispenser’s certificate, chemist and druggists’ diploma, pharmaceutical chemist diploma, BS (Pharmacy) degree, and the bachelor of pharmacy (B. Pharm). Both Dikko and Ishaku died—in 1979 and 1981, respectively. Professor Osuide began his academic career at ABU in 1968 as a lecturer, rose through the academic rank, and became the founding dean of the faculty of pharmaceutical sciences (1970), head of the drug manufacturing unit (1970–1987), dean of the postgraduate school (1982–1987), deputy Vice-Chancellor (VC; 1977–1979) and acting VC (1986). After 19 years at ABU, he relocated to the University of Benin (UNIBEN) in 1987. He served from June to December 1992 as the first director of the Food and Drugs Administration and Control (FDAC) in the FMH. He was re-­ assigned in 1992 as the pioneer director-general (DG) and CEO of the National Agency for Food and Drugs Administration and Control (NAFDAC) and served for eight years until 2000. During his illustrious career, he was an external examiner in medical and pharmacy education at the UI (1978 and 1979), Nsukka (1977), Enugu Campus (1981), Benin (1976), Lagos (1980, 1987, 1990, and 1991), Jos (1989, 1990 and 1991), Ghana (1975 and 1976), and Uganda (1978).

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Professor Osuide is a founding Fellow of the Nigeria Academy of Science, Fellow of the PSN, Nigerian Society of Neurological Science, Association of Psychiatrists in Nigeria, Council of the World Federation of Biological Psychiatry, American Society of Biological Psychiatry, Association of Neurophysiologists of Nigeria, and West African Society of Pharmacology. He served as the Acting Editor of the West African Journal of Pharmacology and Drug Research. In 2011, he received the National Universities Commission (NUC) distinguished professor of pharmacy award (Folorunsho-Francis, 2015). Deacon Adebowale Robert Tade  is a reputable pharmacist with vast marketing, administration, and human resource management experience. He registered with the PCN in 1972 and later inducted fellow PSN and the West African College of Pharmacists. He was a marketing and divisional manager of the Pfizer Products Plc, Lagos (1977–1981 and 1982–1984), Pharmaceutical Division Director, Pfizer Products Plc, Lagos (1984–1985), Deputy Managing Director, General Manager in charge of Manufacturing, Marketing/Sales, Finance, Medical and HR, Pfizer Products Plc, Lagos, (1986–1991), Executive Chairman, Livestock Feeds Plc, Lagos (1991–1998), Executive Chairman, Pfizer Anglophone West Africa (Nigeria, Ghana, Liberia, Sierra Leone, Gambia; 1998–2005), Non-Executive Chairman, Livestock Feeds Plc, Lagos (1998–2013) and Chairman, Mastoofy Ltd., Lagos (2005 to date) (Folorunsho-Francis, 2018; Trinity University, 2019). HRH. Oba John Adetoyese Laoye  (1899–1975) was born in 1899 and trained as a dispenser through a hospital apprenticeship that he competed in 1917. He worked as a dispenser in Kano, Kaduna, Jos, Ibadan, Akure, Sapele, Maiduguri, Benin, Warri, and Forcados. He was the founding father of the Nigerian Western House of Chiefs (1952), a king and world-renowned drummer. In 1956, he put the Yoruba “talking drum” on the high pedestal with his famous signature tune of the then Nigeria Broadcasting Service, the precursor of today’s Radio Nigeria – “B’olu badan ba’ku ta ni o joye (who is the next king, if Olubadan passes on) …….Ojogede dudu inu ntakun (he eats an unripe plantain and suffers stomach discomfort)…Ko so ni gbese ni bi lo si le keji (there is no debtor here, go to the next house)” (Sonemic, Inc., 2000). He enlisted in the army as a sergeant dispenser during the First

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World War and worked under some European pharmacists and physicians (Pharmapproach, 2019). Alhaji Adamu B. Dikko (1911–1979) was born in Makarfi, Zaria in 1911. He enrolled in elementary school in 1922 at Makarfi and transferred to Zaria Provincial School in 1924. He subsequently attended Katsina Higher College in 1927 and was among the foundation students at Zaria Pharmacy School in 1930. He qualified as a dispenser in 1934 and taught at Zaria Pharmacy School for two years and later transferred to Yaba School of Pharmacy, where he worked for 15 years—from 1936 to 1951. Mr. Dikko rose through the academic ranks and became the Principal of the Yaba School of Pharmacy, and later joined the Zaria Native Authority as a part-time counselor. He received the Member of the Order of the Federal Republic award in 1964.  As the first northern pharmacist, he was the father of modern-day pharmacy in the region. After the state’s creation in 1968, he served as the permanent secretary in the North Central State Commission. He also served as the first executive chairman of the Kaduna Capital Development Board between 1970 and 1975 and the Kaduna State Scholarship Board executive chairman from 1975 to 1979. Mr. Dikko died on April 26, 1979 (Pharmapproach, 2019).

Physiotherapists Dr. Theophilus Abayomi Oshin  (1926–), the doyen of physiotherapy in Nigeria, was born in Mobalufon, Ijebu-Ode, on July 30, 1926. He attended the Holy Trinity School, Kano, for elementary school education (1932–1940) and the Baptist Academy, Lagos (1941–1946). He was employed from 1947 until 1950 as a draftsman at Lands and Survey Department, Lagos, and later traveled to the United Kingdom and enrolled at the School of Physiotherapy at St. Nicholas Hospital, London. (Anonymous, 2013; Osso, 2017).  As the first African chartered physiotherapist, he was invited on October 24, 1954, by the British Broadcasting Corporation to broadcast to West Africa on “The Value of Physiotherapy.” He married Miss Victoria Adepeju Olufunmilayo Ogunwo on September 25, 1954, at Christ Church, Highbury, London. His wife was a trained and qualified nurse, midwife, and orthopedic nurse. Between 1963 and

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1965, Mr. Oshin was a lecturer at the School of Physiotherapy, King’s College Hospital, and the University of London (University of Manitoba, 2004). Mr. Oshin returned to Nigeria in December 1954 and took up an appointment as a physiotherapist at the UCH, Ibadan, on January 10, 1955. Through hard work, he rose quickly through the ranks to become the Physiotherapy Department Head ( 1966). In the same year, the UI also appointed him as an Associate Lecturer to develop the BSc degree program in physiotherapy. In 1969, he earned his Bachelor of Physical Therapy degree from the University of Manitoba, Winnipeg, Canada. In the same year, he was appointed Lecturer I and Consultant Physiotherapist at UI and promoted to senior lecturer in 1977. He received both his Master of Philosophy (1982) and Ph.D. (1986) degrees from the UI. Dr. Oshin is a member of several national and international professional associations and societies and obtained the covetous Scout Wood Badge at Gilwell Park, London, in 1954. He was the co-founder of the NSP in 1959 and served as the President from 1970 to 1972. He also served as the Secretary-General of the Africa Physiotherapy Organization (1980), and Secretary, Nigerian chapter, International Society for the Welfare of the Cripples. Furthermore, he served as an Honorary Consultant Physiotherapist to the NEPA Hospital, Kanji (1975–1978). He was appointed Justice of the Peace (JP) by the Oyo State Government (1983) and the State Scout Commissioner in Oyo State for decades. Chief Christopher Ajao  (1932–2011), an unimposing stature, ebony-­ skinned Nigerian with the traditional facial tribal marks, was born on September 9, 1932, at Ogbomosho. He received his physiotherapy education from Bradford School of Physiotherapy in the United Kingdom and co-founded the NSP in 1959 with Mr. Oshin. He was the pioneer Secretary and the first indigenous President of the NSP and served as President for three terms. He was the first Chief Physiotherapist in the old Oyo State and the first in the profession to be appointed into a statewide political office. He served in the early 1980s, during the military dispensation, as the Commissioner of Information and Culture. Before his political appointment in 1974, he introduced the concept of itinerant

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and community physiotherapy programs throughout the entire Oyo state by bringing services to the doorstep of the disenfranchised and those with disabilities. During this era, rehabilitation services were confined to the four walls of the hospitals, and physiotherapists were not considered to have a stake in disease prevention.  As a trailblazer, Chief Ajao conceived the idea and implemented community-based physiotherapy by bringing rehabilitation services to the rural areas before WHO proposed community-based rehabilitation in 1978. He collaborated with the Canadian University Services Organization through the Canadian Embassy in Lagos to recruit Canadian-trained physiotherapists and deployed them to work in rural communities. This decision was a departure from the practice of having physiotherapists work at Adeoyo Hospital, Ibadan. In addition to working in their primary domicile community, Chief Ajao ensured that physiotherapists in the state drove government vehicles from their domicile station to the other rural areas to provide rehabilitation services to the populace and return to their base at the end of the workday. Chief Ajao was a courageous leader and decades ahead of his time. The itinerant and community physiotherapy programs that he conceptualized are now standard practice globally. His ingenuity exemplified Nigeria’s contribution to innovative thinking in healthcare delivery to the world. He died on November 10, 2011, at the age of 79 years. During his illustrious career, he received several awards and honors, the Silver Jubilee Merit Award of the NSP (1985) and an honorary fellow of the NSP (2001). He was married for 52 years to Chief (Mrs.) Ajao, former chief physiotherapist at UCH (Nigeria Physiotherapy Network, 2011a). Professor Gabriel Ikhidero Odia  (1934–2015) was born on April 30, 1934, and attended St. Peters Primary School, Benin City (1941–1945), and Igbobi College (1946–1951). He received his physiotherapy education in the United Kingdom and earned a BSc degree from the University of Manitoba, Winnipeg, Canada. And started his academic career in physiotherapy as an Assistant Lecturer at the UI and transferred to the College of Medicine, University of Lagos (CMUL) in 1971. He established the CMUL’s three-­year diploma program in physiotherapy and upgraded it to a degree program in 1977. He rose through the academic

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ranks from Associate Lecturer to Associate Professor when he voluntarily retired in April 1992 after 35 years of exemplary service. He died on Monday, December 7, 2015.  During his academic career, Professor Odia served on various committees at CMUL and the national level. He served as a Consultant Physiotherapist at CMUL, President of the NSP for two terms, and a member of the Board of Trustees for the Spinal Cord Injuries Association of Nigeria. He was one of the founding members of the Nigerian Association of Science and Sports Medicine. He served as the pioneer Chairman of the Medical Rehabilitation Therapists Board of Nigeria (MRTB) from 1992 to 2003 and Board Member from 2004 to 2007. He also served as the team physiotherapist for the Nigeria contingent to the third All African Games held in Algiers, Moscow Olympics, Fourth All African Games held in Nairobi, and the Seoul Olympics. He also served as the Secretary of the Medical Sub-Committee of the 1980 Africa Cup of Nations soccer team. He was a member of the Canadian Physiotherapy Association, Chartered Society of Physiotherapy (Great Britain), Society for the Rehabilitation of the Disabled, and International Society of Prosthetics and Orthotics (John, 2015). Professor Hyacinth Nnagbogu Okeke  (1938–2015) was born on July 2, 1938, at Okpueze Umumba Ndi-Uno in Enugu and had his physiotherapy training at the West Middlesex Teaching Hospital, London. He started his career at the Hilling Don General Hospital, Uxbridge Middlesex, and returned to Nigeria to start the Physiotherapy Department at the University of Nigeria Teaching Hospital, Enugu. He became the Chief Physiotherapist and Head of the Department (HOD) from 1981 to 1994. He proceeded to the University of Manitoba, School of Medical Rehabilitation, Winnipeg, Canada, for his BSc degree and worked as a physiotherapist at Powell River Hospital, British Colombia, Canada. He received his MS in pathophysiology from New York University and Ph.D. from Hawaii Pacific University, USA. He worked professionally at Long Island Developmental Center Melville, New York (1988–1990), King Khaled Specialist Hospital, Tabuk, Kuwait Ministry of Health (1995 and 2001).  Professor Okeke taught physiotherapists, nursing students, and medical students at the University of Nigeria, Enugu. He also lectured at Khaled University Teaching Hospital, Saudi Arabia, Kuwait

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University, and Madonna University. He served as the President of the NSP from 1985 to 1988 and was honored with a fellowship of the NSP. He was deeply involved in his community serving as Assistant Secretary, Secretary of Enugu Rotary Club, and State coordinator of the Polio-Plus Mass Immunization Program developed by Nigeria Rotary International. He was an embodiment of peace, unity, and philanthropy, with a good sense of humor (NSP, 2015). He was married to Lady Constance Akuegbonwu Okeke (Nee Onyeagba), and the union was blessed with four children and grandchildren. Bitrus Gani-Ikilama  (1944–2011) was born on February 25, 1944, at Donga, in Taraba State. He became blind at the age of five after contracting measles. As the first blind child in Nigeria to be enrolled in primary school at the School for Blind Children, Gindiri, Plateau State, in 1955, and the first blind teenager to attend the Boys’ Secondary School Gindiri, he encountered several life challenges. Growing up as a child who is blind and working as a physiotherapist, he faced several obstacles because of his disability, but he defied all the odds. From 1963 to 1967, he attended the School of Physiotherapy at the Royal National Institute for the Blind in the United Kingdom.  Mr. Gani-Ikilama returned to Nigeria after completing his studies and registered as a Member of the Chartered Society of Physiotherapy. Potential employers were skeptical a blind man could work as a physiotherapist. Still, ABUTH employed him in 1967, and he rose through the ranks and became the Chief Physiotherapist and Head of the Department. In 1976, he was instrumental in producing the first tape recording services for the blind in Nigeria. The project was so successful, more people requested services, and the organization expanded, in 1979, to provide Braille production, guidance and counseling, consultancy, and vocational training. With the expansion of the facility, the name changed to Hope for the Blind Foundation. His accomplishments were impressive, even as a blind man. He won numerous awards, including an Officer of the Order of the Niger, Fellow of the NSP, and the Nigerian Government Icon of Hope. He had over ten publications to his credit before he died on February 20, 2011, at the age of 67 (Nigeria Physiotherapy Network, 2011b).

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Chief Joshua O. Obiri  was one of the founding fathers of the physiotherapy profession in Nigeria who served as the President of the NSP from 1968 to 1969. As a master clinician and associate lecturer at the UI, he mentored many students and practitioners. He established the Plaster of Paris unit for splinting and correction of foot deformities at the UCH.  Mr. Obiri received advanced training in the management of neurological disorders from Canada. On return to Nigeria, he popularized wound dressing and offered several workshops on stroke rehabilitation and demystified the specialty of neuro-physiotherapy. One of his mentees described him as “an all-rounder who never gave up on any clinical condition; he instead went back to the drawing board where he had anatomy, physiology, and principles of physics well laid out!” Another mentee referred to him as “a dogged fighter for justice, a humane mentor, a worthy role model, an effective teacher of teachers.” He was very generous, kind, firm, but fair. He was a neurologic physiotherapist par excellence, a humane mentor, a worthy role model, an effective teacher of teachers who transitioned to glory at the ripe age of 85 (Nigeria Physiotherapy Network, 2012). Professor Godwin O. Eni  (1938–) was born in 1938 in Anambra State. He was the only student admitted in 1966 to study physiotherapy at UI’s newly developed degree program. He graduated in 1969 with a second-­ class upper honor’s degree. He obtained a certificate in proprioceptive neuromuscular facilitation techniques from the University of Saskatchewan in 1971. In 1972, he returned to Nigeria and joined the faculty at Obafemi Awolowo University (OAU), as an assistant lecturer, with his close friend, Vincent Nwuga. Both of them joined the faculty at OAU at the invitation of Professor Adesanya Grillo, who left UI to establish the Faculty of Health Sciences at Ile-Ife. After a brief stay at OAU, Professor Eni applied for a leave of absence for postgraduate studies in Canada. He was employed as a clinical instructor in physiotherapy at the University of Western Ontario from 1973 to 1979 (Eni, 2015). Professor Eni earned his MSc degree in health services planning and administration (1981) and a Ph.D. in medical sociology from the University of British Columbia (1987). Between 1983 and 1986, he was appointed director of the Department of Rehabilitation Services at the University

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Hospital, Vancouver, BC, clinical assistant professor at the University of British Columbia, director of the graduate program in health services planning and administration at the University of British Columbia (1987–1995), and the chair of the division of health policy and management at the University of British Columbia, visiting adjunct Professor and Executive Graduate Program in Health Administration at the University of Colorado, Denver (1991 and 1995). He worked as director of the Rehabilitation Services at Injury Management Solutions, Surrey, BC (2001), chaired both the Commission on Accreditation of the Council on Chiropractic Education of Canada, and the West-Side Community Health Committee of the Vancouver Regional Health Board (2002–2005), visiting professor in the Department of Medical Rehabilitation at the University of Nigeria, Enugu (2007–2008), and LEAD scholar at the NUC (2007–2008) (Nigeria Physiotherapy Network, 2020a). Professor Eni consulted with several NGOs and multi-national organizations on health system reform and women’s health in 19 African countries, South-East Asia, Australia, the Caribbean, and Eastern Europe. Before retirement, he was the President of the Vancouver Multicultural Society, Vice-President of the Affiliation of Multicultural Societies and Service Agencies of British Columbia, and a Vancouver School Board member. He founded the Black Educators’ Association of BC and the Nigeria-Canada Development Association of BC (Blacks in Canada, 2016). Professor Arinola Olasumbo Sanya (1953–) was born in Lagos on April 25, 1953, to Pa Daniel Oladejo and Madam Felicia Adeoti Akinpelu of Ibadan. She attended Salvation Army School, Lagos, in 1966, and Queen’s College, Lagos, where she obtained the Higher School Certificate (1973) and was the Head Girl of the esteemed Girls’ College. She earned her BSc in physiotherapy (1973–1976), MSc (1981), and Ph.D. (1986) degrees in exercise physiology from the UI. In April 1978, she joined the UI faculty as a graduate assistant and was promoted to full professor in 2000. The promotion made her the first female professor of physiotherapy in Africa and the second professor of physiotherapy in a Nigerian

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university—after Professor Vincent C.B. Nwuga.  During her productive academic career, Professor Sanya worked as an assistant professor of physiotherapy at King Saud University (1990–1992), a locum clinical teacher at the Hamad Medical Corporation, Qatar (1997), and visiting professor at the CMUL (2004). She also served as an external examiner at several universities in Nigeria and the University of Ghana and as the Commissioner of Health in Oyo State in 2005 (UI, 2020). She supervised more than 75 undergraduate capstone projects and master’s theses, including six Ph.D. dissertations. She served as the coordinator, and HOD of Physiotherapy and served for one year as the deputy VC (Administration) at UI (2012). At the national level, Professor Sanya was a member of the NUC’s panels to accredit undergraduate degree programs in different health disciplines. She was the chair of the NUC panels to draw the Revised Minimum Academic Standard for Physiotherapy, SIWES for Physiotherapy, Merger Document for Minimum Academic Standard, and Benchmark Statement. She also served on the MRTB (1993–2007), Board of the UCH (2005), Vice-Chairman of the Oyo State Action Committee of HIV/AIDS (2005). She is married to Sir (Dr.) Adeyemi Sanya and the matrimony is blessed with four children and one grandchild (Nigeria Physiotherapy Network, 2020b).

Nurses Kofoworola Abeni Pratt  (1915–1992) was born in 1915 to Augustus Alfred Scott and Elizabeth Omowumi (née Johnson), a prominent family in Lagos. He attended St. John’s Secondary School and CMS Girls’ Grammar School, Lagos. Like Florence Nightingale, she grew up with the ambition to be a nurse, but her parents did not consider nursing a prestigious career. She trained as a schoolteacher and worked at the United Missionary College in Ibadan from 1936 to 1940. Kofoworola married Olu Pratt, a Nigerian pharmacist who subsequently studied medicine at St. Bartholomew’s Hospital, London.  In 1946, Kofoworola studied nursing at the Nightingale School at St. Thomas’s Hospital and

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qualified as a registered nurse in 1950 and was employed by the National Health Service (NHS) as the first registered black nurse. During that era, it was unusual for married women to be a nurse. She was an active member of the West African Students’ Union that in 1942 called for Britain’s West African colonies’ independence. She experienced racial discrimination at St. Thomas’s Hospital when a patient refused to be treated by a black nurse. After four years at the NHS, she returned to Nigeria in 1954 and rose to become the first black matron at UCH, Ibadan, following independence in 1960. She was appointed in 1965 as the chief nursing officer at the FMH. She served as the Vice-President of the International Council of Nurses and Commissioner of Health for Lagos. She established a nursing school in 1965 at the UI and founded the Nigerian Professional Association of Trained Nurses. She served as the Co-Editor of the journal Nigerian Nurse and President of the National Council of Women’s Societies (1971). In 1973, she was awarded the Florence Nightingale medal (the highest international distinction a nurse can achieve)—the award was presented to her on December 21, 1973, by Sir Adetokunbo Ademola, the President of the Nigerian Red Cross Society. In 1975, she was honored with the Iya Ile Agbo of Isheri and inducted as a fellow of the Royal College of Nursing (1979). She died on June 18, 1992 (King’s College London, n.d). Dr. Justus Akinsanya  (1936–2005) was born on December 31, 1936, at Okun-Owa, Ijebu. He left the country in the late 1950s with the ambition to studyeconomics but changed his mind and enrolled at Abergele Sanatorium in North Wales to study nursing. He qualified in 1960 and worked as a general nurse with a specialty in tuberculosis cases at Crumpsall Hospital, Manchester. In 1967, he took several continuing education courses in orthopedic, dermatology, and psychiatric nursing and simultaneously studied for the GCE Advanced Level. He later obtained a BS (Hons) degree in human biology and a Ph.D. from the University of London. He was employed as a tutor at King’s College Hospital, London.  Dr. Akinsanya returned to Nigeria in 1975 to work for the Nigerian Nursing Council and two years later was promoted as

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the acting registrar. Subsequently, he was seconded to the FMH but did not desire a career as an administrator. He returned to the United Kingdom to begin an academic career. During that era, the British nurses were in danger of modeling the American nurses by following the social science track in the 1940s and 1950s. He emphasized the importance of biological sciences and propounded, in 1985, the bio-nursing concept based on his doctoral work. He published the results of a major national study on nurses’ attitudes and their teachers to AIDS. Between 1976 and 1977, he held different positions as an administrator, researcher, and lecturer at the Institute of Management and Technology in Enugu. From 1985 until 1989, he was employed at Dorset Institute, now Bournemouth University, where he was promoted reader and professor and head of the health care research unit. In 1988, Dr. Akinsanya was inducted as a fellow of the Royal College of Nursing (FRCN) and appointed the dean of the newly established Faculty of Health and Social Work at Anglia Polytechnic University. He served in that capacity from 1989 until 1996, but kidney failure led to his early retirement and was appointed as an emeritus professor. He carried out his dialysis and eventually had a transplant. He devoted his time to charitable activities on behalf of the Disability Croydon, Nurses Fund for Nurses, and the Nigerian Council of Elders. He served as a local education authority administrator for two schools in Croydon. As a researcher for the Commission on Racial Equality, Dr. Akinsanya experienced racism within the NHS. He was the first black nurse to be elected to the English National Board for Nursing, Midwifery, and Health Visiting, serving from 1988 to 1993. He was a persuasive communicator who enthusiastically attended conferences all over the world. He was married in 1967 to Cynthia Marcelle, and the union was blessed with three sons and one daughter. He died in London on August 11, 2005. at the age of 68 after contracting an infection at the International Council of Nurses conference in Taiwan some months earlier (Dopson, 2005).

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Discussion This chapter identified 35 pioneer Nigerian healthcare professionals—15 physicians, two dentists, eight pharmacists, eight physiotherapists, and two nurses—during the nineteenth and early twentieth centuries and analyzed their scholarship and service contributions. The impact of the pioneer went beyond their era; some of their ideals and optimism still linger on today. After their education, the Nigerians returned to West Africa between 1858 and 1895. They encountered the traditional medicine men who had practiced their healing craft for generations treating fevers, dropsy, and mental illness. The traditional medicine men had no hospitals to practice, but their pharmacopeia was an amalgam of herbs, amulets, and other ingredients, too many and too esoteric to recount. Their concept of disease etiology differed radically from the conventional western allopathic medicine. Many of the pioneer Nigerian physicians—Horton, Johnson, and Randle—supported their life-long interest in medicine through philanthropic gifts to medical science. Dr. Randle donated his medical and scientific books and journals to Fourah Bay College, Sierra Leone, and some Nigerian physicians benefitted from his undergraduate medical scholarships. Unfortunately, unforeseen monetary depreciation created difficulties for the implementation of some of these donations. Shortly after Horton’s death, his dreams of a medical college disappeared with the collapse of his financial investments. At Fourah Bay College (now the University of Sierra Leone), the authorities did not fill the “chair of science” endowed by Obadiah Johnson. The two Randle professorships were also not filled as of 1974. The annual salary of three hundred pounds sterling provided by John Randle for his endowed professorship did not generate enough interest to fund the academic chair. The pioneer physicians expected financial gains from herbal medicine, but their dreams never materialized. They believed African traditional herbal medicine could contribute to therapeutics and encouraged African governments to promote organized research in African traditional medicine. In the early 1970s, the Faculty of Pharmacy at the University of Ife was the nucleus of the vision. The research activities at Ife, followed by the Department of Surgery at the UI, produced encouraging results in developing an

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anti-­tumor agent from local plant extracts used by herbalists to treat cancer (Adeloye, 1974). In a book titled, Healthcare Education in Nigeria: Evolutions and Emerging Paradigms, this author showcased the scholarship and service contributions of 19 pioneer Nigerian healthcare academicians in the twentieth century (Balogun, 2020). The scholars featured include 14 physicians: Professor Oritsejolomi Thomas (1917–1979), pioneer maxillofacial reconstructive and plastic surgeon; John Oluyemi Mabayoje (1920–), the first Nigerian professor of medicine at CMUL and first President of the West African College of Physicians; Professor Chukwuedu Nathaniel II Nwokolo (1921–2014), second Nigerian to obtain the MRCP qualification, advisor to the WHO; Theophilus Oladipo Ogunlesi (1923–), the first Nigerian professor of medicine; Thomas Adeoye Lambo (1923–2004), the first Nigerian professor of psychiatry and former Deputy Director-General of the WHO; Emmanuel Olatunde Odeku (1927–1974), the first professor of neurosurgery in West Africa; Thomas Adesanya Ige Grillo (1927–1998), the first professor of anatomy in Nigeria; Olikoye Ransome-Kuti (1927–2003), the first Nigerian professor of pediatrics and former WHO Deputy Director-General and Minister of Health. Other pioneer Nigerian physician academics in the twentieth century include Adetokunbo Oluwole Lucas (1931–2021), Harvard professor and world-renowned global health expert; Professor Oladipo Olujimi Akinkugbe (1933–2020), former principal and foundation VC of the University of Ilorin and VC of ABU; Professor Benjamin Oluwakayode Osuntokun (1935–1995), pioneer neuro-epidemiologist in Africa and the doyen of neurology in Nigeria; Professor Adelola Adeloye (Rufus Bandele Adelola Adeloye) (1935–), Nigerian foremost physician and surgeon; Professor Babatunde Osotimehin (1949–2017), former Minister of Health, Executive Director of the United Nations population fund, and Under-Secretary-General of the United Nations; Professor Fabian Anene Ositadimma Udekwu (1928–2006), pioneer cardiothoracic surgeon in Nigeria. The book also featured prominently non-physician academics of the twentieth century: Elfrida O. Adebo (1928–), the first Nigerian professor of Nursing; Professor Paul Ogbuehi (1936–2016), father of optometry in Nigeria; Vincent Chukumeka Babatunde Nwuga

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(1939–2015), the first Nigerian professor of physiotherapy; Cletus Nzebunwa Aguwa, the first professor of clinical pharmacy in Africa, and Dennis Chima Ugwuegbu (1942–), the first Nigerian professor of psychology. Nigeria has a thriving and well-established academic and clinical dental practice. The genesis of modern dentistry in the country was in 1903 when Dr. Ewart Gladstone Maclean, a Baptist missionary, debuted a clinic in Lagos and later practiced at Saki, Ogbomoso, and Iwo (Ogunbodede, 2015). Other notable early dentists in private practice with the first Nigerian dentist, Dr. Sidney Philips, include Dr. Demetius Voudzourakis, Dr. E.O. Otun, and Dr. Iyeowuna Dublin Green (Michael, 2016). The physiotherapy profession was imported to the country in 1945 by two British chartered physiotherapists—Miss Manfield and Mr. Williams (Oshin, 1999; Oyeyemi, 2009; Eni, 2011; Balogun et al., 2017; 2018). There are now four generations of physiotherapists, each with varying educational backgrounds and divergent social philosophies and interests. The first-generation received their training from the United Kingdom in the 1950s and 1960s. The second-generation obtained their BSc degree or diploma in physiotherapy from the U.I. and CMUL, respectively. The third and fourth-generation practitioners are the Millennial or Generation Y members, who primarily consist of students and recent graduates (Balogun, 2015). The foundation physiotherapists left many indelible footmarks in the sands of time as tenacious fighters on behalf of the profession. The profession has adequate homegrown human resources and a deep bench of experts in the diaspora who can contribute to human capacity building and provide the expertise needed to launch the entry-­ level doctor of physiotherapy program approved by the NUC since 2017, but has hitherto remained in limbo—only KSU has started the implementation. Today, the physiotherapy profession has an army of highly competent intellectuals employed in the Nigerian universities: Professor Isaac O. Owoeye—HOD, CMUL, Professor Matthew O. Olaogun—pioneer Dean, Faculty of Basic Medical Sciences, Bowen University; Professor Adetoyeje Oyeyemi, pioneer Dean, Faculty of Allied Health, University of Maiduguri; Professor T. Kolapo Hamzat at U.I., Professor Babatunde

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Adegoke, former Dean, Faculty of Allied Health, UNIMED, Ondo City; Professor Sunday R.A. Akinbo, former Deputy Provost, CMUL; Professor Aderonke Akinpelu and Professor Ade Adeniyi, Deputy Provost at U.I.; Professor Ganiyu Sokunbi, Bayero University; Professor Soji Adedoyin, Dean, Faculty of Basic Medical Sciences, OAU; Professor Christopher Akosile and Professor Joseph Nwankwo, Nnamdi Azikiwe University, Awka, Nnewi (Nigeria Physiotherapy Network, 2020). Furthermore, the profession has several Nigerian intellectuals in the diaspora—Professor Godwin Eni, Canada; Professor Chukuka Enwemeka, former Provost and Senior-Vice-President at San Diego State University; Professor Akinniran Oladehin, former HOD, Physical Therapy, Missouri State University, Springfield; Professor Felix Adah, Department of Physical Therapy, University of Mississippi Medical Center; Professor Victor Obajuluwa, Ivy Tech Community College, Indiana; Professor Abiodun Akinwuntan, Dean, School of Health Professions, University of Kansas Medical Center; Dr. Emmanuel John, Chair, Department of Physical Therapy, Chapman University; Distinguished University Professor Joseph Balogun, Chicago State University; Professor Francis Adelaja Fatoye, Co-Director for Health, Psychology and Communities Research Center, Manchester Metropolitan University, UK and Professor Dele Amosun, Deputy Head of the Division of Physiotherapy, University of Cape Town. The history of nursing in Nigeria is tied to the establishment of St. Margret Hospital, Calabar, in 1894. Miss. Margret Graham, a European, served as the first nursing sister. Miss. Graham was joined by Miss Jane Mac Cofter, who later established the famous Abeokuta Infant Welfare Centre to train midwives and specialized in domiciliary services. The formal training of nurses and midwives in Nigeria started in 1930, mostly in mission hospitals and a few government hospitals (Ajibade, 2013). Many notable pioneer Nigerian nursing academics in the twentieth century include Professor F. O. Okedeji, UI; Professor (Mrs.) E.O. Adebo, HOD of Nursing, U.I.; Miss. O.O. Kujore, HOD of Nursing, OAU; Professor Adelani Tijani, first Nigerian Professor of Nursing from the North; Professor Musa Kolawole Jinadu, former HOD of Nursing, OAU, and founding Dean of Nursing, Niger Delta University, Wilberforce Island, Bayelsa State; Mrs. O.O. Alade, Principal, School of Nursing, UCH, Ibadan; Alhaji D.A. Adamu, Principal Nursing Officer, Ministry of

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Health, Kano; Mr. P.O. Odeh, Chief Nursing Officer, General Hospital, Makurdi, Benue State; N.N.I. Nwangwu, University Teaching Hospital, Enugu; Mr. J.A. Akinsanya, Deputy Secretary/Registrar (Education), Nursing Council of Nigeria; Mrs. R. O. Sosanya, Principal, School of Midwifery, Ijebu-Ode; Mrs. S. O. Savage, Deputy Chief Nursing Officer, FMH (Ajibade, 2013).

Conclusion This chapter chronicles the biography of 35 notable pioneer Nigerian healthcare professionals—15 physicians, 2 dentists, 8 pharmacists, 8 physiotherapists, and 2 nurses. The analysis revealed all the professionals received their education in the United Kingdom or the United States, and they contributed substantially to healthcare delivery and healthcare education in Nigeria and beyond. Their career trajectory exemplified the evolutionary phases of healthcare practice in West Africa during the nineteenth and early twentieth centuries. The inception of the other healthcare professions—audiology, occupational and speech therapy, nutrition, dietetics, medical laboratory science, radiography, orthotics and prosthetics, and social work—in Nigeria was in the late twentieth century. Case Study Identify a mentor or role model in your profession. Discuss why he/she is your hero. Research and write about his/her upbringing, education, and professional accomplishments.

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Ososanya, T. (n.d.). The life and times of Yewande Savage, West Africa’s first female doctor. [online]. Available at: https://www.legit.ng/1170449-­the-­life-­times-­ yewande-­savage-­west-­africas-­female-­doctor.html. Accessed 10 Feb 2020. Osso, N. (2017). Oshin, Dr. Thompson Abayomi. Blerf ’s who is who in Nigeria. [online]. Available at: https://blerf.org/index.php/biography/oshin-­dr-­ thompson-­abayomi/. Accessed 10 Feb 2020. Oyeyemi, A. (2009). Fifty years of physiotherapy in Nigeria: Trends, perspectives, and future direction. Journal of Nigeria Society of Physiotherapy, 17, 30–35. Pharmapproach. (2019) History of pharmacy, pharmacy education, career, and ethics in Nigeria. [online]. Available at: https://www.pharmapproach.com/ history-­of-­pharmacy-­in-­nigeria-­2/. Accessed10 Feb 2020. SEAL67. (2015). Captain Richard Gabriel Akinwande Savage, the REAL first African Army Officer. [online]. Available at: http://subliminalcodesintext. blogspot.com/2015/01/captain-­richard-­gabriel-­akinwande.html. Accessed 10 Feb 2020. Sonemic, Inc. (2000). Oba Adetoyese Laoye. [online]. Available at: https://rateyourmusic.com/artist/oba-­adetoyese-­laoye. Accessed 10 Feb 2020. Trinity University. (2019). Adebowale Robert Tade. [online]. Available at: https:// www.trinityuniversity.edu.ng/member_detail.php?id=13 University of Edinburgh. (2018). Agnes Yewande Savage (1906–1964): Influential Scottish-Nigerian doctor, and the first woman of West African heritage to train and qualify in orthodox medicine. Alumni Services. [online]. Available at: https://www.ed.ac.uk/alumni/services/notable-­alumni/alumni-­ in-­history/agnes-­yewande-­savage. Accessed 10 Feb 2020. University of Manitoba. (2004) Alumni Newsletter. [online]. Available at: https://news.umanitoba.ca/wp-­content/uploads/2015/05/OnMB_Dec04. pdf. Accessed 10 Feb 2020.

5 Interdisciplinary Healthcare Team: A Panacea to Curtail Interprofessional Conflict and Industrial Action in Nigeria

Abstract  This chapter apprises the readers of the causes and adverse impacts of the ongoing interprofessional conflict and industrial action within the Nigerian healthcare system. The chapter proposes using the interdisciplinary team concept as a panacea to curtail interprofessional scuffle and industrial action activities in Nigeria. The chapter also discusses other synergistic effects that the implementation of the team strategy would have within the healthcare system. The likely impacts include improved communication among HCPs, reduced medical errors and mortality rates, improved patient outcomes, and healthcare quality. Keywords  Multidisciplinary • Interdisciplinary • Intradisciplinary • Collaborative team • Interprofessional conflict

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 J. Abiodun Balogun, Health Professions in Nigeria, https://doi.org/10.1007/978-981-16-3311-9_5

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Learning Objectives 1. Apprise the readers about the causes, dimensions, and impacts of interprofessional conflicts in Nigeria. 2. Differentiate between the different types of healthcare teams. 3. Describe the characteristics of a successful interdisciplinary health care team. 4. Discuss the benefits of an interdisciplinary health team. 5. Analyze the status of the interdisciplinary health team in Nigeria. 6. Discuss the controversies surrounding the leadership of the healthcare team and health institutions in Nigeria. 7. Provide recommendations on how to foster interdisciplinary team collaboration within the Nigerian health system. 8. Compare the conditions of service of the healthcare professionals in Nigeria with their counterparts in Ghana and South Africa.

Introduction Nigeria’s health system in 2000 ranked 187 out of 190 member states of the World Health Organization (WHO). The “Giant of Africa” only managed to outpace war-torn Liberia. Surprisingly, Malawi’s health system ranked above Nigeria on the quality of care delivered. Nigeria is further besieged with considerable attrition of its healthcare professionals (HCPs) to the western world and other African countries, like Ghana, Mozambique, Namibia, and South Africa. The “brain drain” leaves the Nigerian hospitals with an acute shortage of HCPs. The other unresolved developmental challenges within the Nigerian health system are daunting. They include climate change, poverty, food security, infectious diseases, maternal and child health, endemic non-communicable diseases, gender inequality, and energy insufficiency (Balogun, 2021). Instead of confronting these multifaceted challenges, the HCPs in Nigeria are notoriously known for frequent industrial strikes, unfortunately, to the detriment of the patients that they serve. Besides the constant labor strikes, the HCPs are divided and embroiled in territorial professional turf wars (Oleribe et al., 2016, 2017). More

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concerning, the different professions are continually feuding and suspicious of one another. Each discipline perceives the other as the enemy and threat seeking to usurp the rights of the other. The hatred and antagonism are inimical to effective health outcomes and genuine collaboration in inpatient care, a symptom that is a cog in the wheel of an efficient healthcare system. All over the world, healthcare practice is a collaborative team effort directed to ensuring optimum treatment outcomes and patient safety. Over the last half-century, clinical practice has evolved from the “lone-­ ranger, I know it all” system to an interdisciplinary healthcare team (IHT) approach. The IHT strategy has taken firm root in the developed nations and the reasons for their efficient health system that is devoid of constant interprofessional acrimony and industrial strike. It is worrisome that the IHT concept is still not fully embraced in the Nigerian healthcare system.

Operational Definitions To fully understand the issues discussed in this chapter, it is pertinent to operationalize the following basic terms: • A discipline is the academic domain of knowledge such as medicine, dentistry, pharmacy, physiotherapy, occupational therapy, clinical psychology, and optometry. In Nigeria, the entry-level education for HCPs is at the university, and the training typically lasts four to seven years, depending on the field. • A leader refers to the point-person on an IHT or the Chief Executive Officer (CEO) of the hospital or health minister. The leader inspires, motivates, and directs the followers to achieve the teams, organizations, or systems’ defined goals. • The follower is a member of healthcare teams, a group of employees, or subordinates in organizations or systems who reports to a leader.

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 auses and Adverse Impacts of the Industrial C Action Crises Unions and professional associations play a significant role as an advocate for change in the health sector. The Nigerian Medical Association, Nigerian Dental Association, and the Medical and Dental Consultants Association of Nigeria (MDCAN) are the most influential and powerful professional associations and unions in the health sector. The incessant industrial strike by the HCPs is the bane of quality healthcare in Nigerian hospitals (Oleribe et al., 2016, 2017). Many infamously notable labor actions have occurred in the last decade. They include the 108-day shutdown by the Association of Resident Doctors in the University College Hospital, (UCH) Ibadan; a five-month-long strike at Ladoke Akintola University of Technology Oshogbo; the two-month strike at the Psychiatric Hospital in Yaba; and the three-month-long strike at Federal Medical Centre in Owerri (Ihekweazu, 2015). Some public-sector hospitals also experienced desertions during the Ebola outbreak in 2014 and the COVID-19 pandemic in 2020, resulting in many unwarranted deaths. The Joint Health Sector Unions (JOHESU) in 2018 embarked on a protest that lasted for over a month to draw attention to their many grievances and the action paralyzed healthcare delivery services nationwide (Oleribe et al., 2016; Adeloye et al., 2017). JOHESU is an amalgam of five registered associations—Senior Staff Association of Universities, University Teaching Hospitals (UTHs), Research Institutes, and Associated Institutes, Nigerian Association of Nigerian Nurses and Midwives, the Non-Academic Staff Union, Medical and Health Workers Union, and the National Union of Allied Health Professions—and at the forefront of leading industrial actions. The members include pharmacists, medical record officers, physiotherapists, occupational therapists, nurses and midwives, medical laboratory scientists, and optometrists (Ugah et al., 2018). The cause of the industrial action within the Nigerian health system are due to a multitude of factors—ineffective leadership, docile administration/governance, dysfunctional policies, inadequate funding, supremacy

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challenge, uneven distribution of the HCPs workforce, poor working condition/remuneration (Adeloye et al., 2017). An area of tension in the health sector is the agitation for better conditions of service, massive discrepancies in the remuneration of HCPs on the same grade levels across the federal, state, and local governments (Ihekweazu, 2015; NOIPolls, 2017). Poor service conditions, including low salaries and benefits and long work hours, are the primary source of conflict between management and the professional unions, often leading to industrial strikes (Oleribe et al., 2016, 2017; Adeloye et al., 2017). Several analysts posit that the dominance of the leadership position in the health sector by physicians and dentists is responsible, in part, for the mistrust among the HCPs and industrial actions (Oleribe et al., 2016, 2017; Adeloye et al., 2017; Uchejeso et al., 2021). Ethically, the lockout embarked upon by HCPs is reprehensible because it is against the “first, do no harm” tenet of the Hippocratic Oath and the regulatory laws of the health professions to which they solemnly pledged (Greek Medicine, 2012; Lambo, 2019). The constant labor strikes produce untold hardship, suffering, irreversible organ damage, and countless fatalities. This situation contributes to the high morbidity and mortality rates, particularly among women and the poor who cannot afford private healthcare services. Furthermore, the pervasive industrial actions promote inequality in quality healthcare services and force some patients to seek care at private hospitals and clinics at prohibitive cost. Many who cannot afford the cost of care at private hospitals resort to traditional medicine with uncertain medical outcomes. The multiple and often protracted industrial strikes have prevented optimal healthcare delivery in the country (Ogoh & Hunduh, 2016). The federal government has previously constituted several commissions to address the intractable industrial actions in the health sector, but they were unsuccessful in resolving the disputes among the warring factions (Alubo & Hunduh, 2017). Decreasing the incidence of industrial strikes is imperative for the Nigerian health system to function effectively.

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Conflicts Among Healthcare Professionals Causes and Dimensions of the Crisis Conflict among HCPs is a recognized problem known to hinder quality healthcare service delivery (Olajide et al., 2005; Uchejeso et al., 2021). In the hospital setting, authority does not usually come from a single person, nor is it exercised in a single chain of command, as in most large organizations. Physicians exercise substantial authority within the hospital structure and enjoy high autonomy. The independence within the medical and allied professions often incites conflicts within the hospital settings (Obembe et al., 2018). The interprofessional conflicts cause dissatisfaction and suboptimal contributions of the feuding professional groups to patient care and encourage outbound medical tourism by affluent Nigerians who can afford it. It also contributes to patient dissatisfaction, increases job-associated stress and staff turnover, and further weakens the health system. Several empirical-based studies have examined the causes of conflict and rivalry among HCPs in Nigeria. The findings from these studies are presented below. In a cross-sectional mixed design study, Olajide and associates (2005) determined the causes and modes of expression of conflicts between physicians and nurses in two tertiary hospitals in Ekiti state. The findings revealed that physician-nurse conflict is associated with a combination of socio-economic and interpersonal-intergroup factors such as limited opportunities for staff interaction and desire for more influence and autonomy by nurses. Ogbonnaya et al. (2007) examined the perception of six HCPs on the factors responsible for the conflict in a tertiary hospital in southeast Nigeria. The study participants believe the causes of disagreement include differential salary between physicians and the other HCPs, physician intimidation and discrimination against other HCPs, “inordinate ambition” of the other professions to lead the health team, and envy of the physicians by the other HCPs. Both parties perceive mutual respect for competence, adequate remuneration, clear delineation of roles and responsibilities, and appreciation of the salary differential as critical

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factors to resolving the ongoing conflict. While they all accepted mutual respect and fair pay as valid, the perception of the other HCPs differed significantly from physicians on the salary differential in resolving the conflict. Iorngurum and Godowoli (2008) investigated the nature of competition and conflicts among HCPs. Nurses, pharmacists, and physicians, 15 from each profession, were randomly selected from four tertiary hospitals—UCH, Ibadan, Jos University Teaching Hospital, and University of Maiduguri Teaching Hospital. The three professional groups—nurses (100%), pharmacists (100%), and physicians (80%)— all agree on competition and conflicts among them. They also all agree— nurses (80%), pharmacists (87%), physicians (67%)—that the extent of competition and conflicts called for serious government and policymakers’ intervention. Nurses (73%), pharmacists (93%), and physicians (87%) perceive the competition to be unhealthy and counterproductive. Okhakhu et al. (2014) explored the lived experiences of nurses and physicians (n = 100) on how cultural socialization impacts conflict resolution and its impact on patient care. The findings revealed that cultural socialization weighs heavily on strategies for handling conflicts, and it is negatively affecting healthcare delivery—physicians’ perceived dominance and superiority over nurses harm nursing. The findings underscore the value of collegiality in inpatient care and point to a new direction in understanding collaboration. Omisore and associates (2017) assessed the interprofessional rivalry (IPR) between physicians (n = 24) and other HCPs (n = 96) and their understanding of its apparent adverse effects at a state specialist hospital. Among the HCPs, 70% perceive IPR to be the leading cause of conflicts. Physicians and other HCPs had significantly divergent opinions on the leadership of the health team, patient management, establishment positions, monetary issues, and the effects of IPR, with more physicians recognizing its hazards. Nearly 50% of the study participants believe that strikes are justifiable, and the most recommended method is for the government to meet the group’s needs. Obembe and associates (2018) investigated how the relationship of authority and influence between physicians and nurses generated conflicts and evaluated the effectiveness of managerial strategies utilized to

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resolve the dispute in selected hospitals. HCPs (n = 323) from a secondary and a tertiary hospital completed a questionnaire followed by three focus group discussions (FGDs) with physicians and nurses. The study revealed that physician–nurse conflict is caused by several organizational factors such as reporting structure, management ability to resolve disputes, partisan approach to conflict resolution, and lackadaisical approach in tackling conflicts by the hospital administration. Olaopa et al. (2020) examined the causes, consequences, perpetrators, and victims of conflict among 14 early-career physicians from seven tertiary hospitals across the country. The physicians believe conflict is inescapable in clinical settings and occurred at different levels, and the perpetrators are the other HCPs. The causes are primarily task-related, although there are relational disputes with the government on labor issues that are also prevalent. Confusion on job description and roles, including power struggle, was highlighted as the driver of conflicts between physicians and other HCPs.

Management of Interprofessional Conflict The federal government has previously constituted several commissions to address the crisis in the health sector, but they were unsuccessful in resolving the disputes among the warring factions (Alubo & Hunduh, 2017). Decreasing the incidence of industrial strikes and developing a harmonious health team is imperative for the health system to function effectively. Based on the findings from the existing studies conducted on the interprofessional conflict in Nigeria, recommendations on effectively managing the crisis are appropriate. The hospital management must understand the interplay among the HCPs and institute appropriate managerial policies to tackle the problem appropriately before it rots. Second, the federal government must create a mechanism to ensure adequate involvement of all health professions in decision-making concerning patient care and make collective bargaining more transparent and ensure respect for legitimate collective bargaining agreements and timely honoring such contracts. The collective

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bargaining agreements should be realistic. The HCPs should not make unrealistic wage demands, which could bankrupt the nation and hamper other equally critical social services to the public. The leadership of the FMH, state Ministries of Health should establish open communication channels with professional organizations for information sharing and review existing legislation concerning tertiary hospitals consistent with global best practices. Furthermore, the federal government and hospital management must understand the dynamics of the socio-economic and interpersonal-­ intergroup factors undergirding conflicts and recognize its critical role in managing the disputes in a fair and timely manner. All HCPs must understand team building and group dynamics through continuing education training (Olajide et al., 2005). Until both MDCAN and JOHESU grievances are settled, the health system will continue to experience disruption of services, and the Nigerian people will continue to suffer from the crisis emanating from interprofessional conflicts. Given the wide salary disparities among the HCPs, the struggle to be accepted as the “most important” profession in healthcare, and the battle for leadership (Ogbonnaya et al., 2007; Iorngurum & Godowoli, 2008), the federal government must adopt measures based on equity, and transparency, and provide “bright and full opportunities” for all HCPs. Furthermore, the government must recalibrate the pay between physicians and other HCPs to ensure social justice and fair play. An ethical approach from all stakeholders and recognition by HCPs that they all have an equal moral obligation to serve society’s best interest is paramount (Osakede & Ijimakinwa, 2014). The ongoing interprofessional conflict partly explains why the service delivery in the hospitals is fragmented and why the Nigerian health system is one of the most inefficient in the world (WHO, 2000). The IHT practice, which is now a sine qua non in developed nations, is universally recommended to promote genuine collaboration among HCPs (Venzin, 2018; The HRH Global Resource Center, n.d.; Nancarrow et al., 2013). Unfortunately, the practice is still new in Nigeria, and healthcare is primarily a solo (single discipline) practice with limited communication or interaction among the HCPs.

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Types of Healthcare Teams A healthcare team consists of professionals with different clinical expertise working in concert to provide service to patients. Examples of healthcare teams are a cancer team, hospice team, or poliomyelitis team. The composition of an IHT varies depending on the diagnosis, but the patient is always a team member. The traditional members are physicians, nurses, pharmacists, physiotherapists, occupational therapists, and social workers. The more the members work together, the better they can provide the best quality care possible. Each professional in an IHT serves a unique role, perspective, and expertise. Some team members diagnose disease, and others are experts who treat illness or care for individuals with physical disabilities or emotional needs. The following are the primary types of health and organization teams: 1. The multidisciplinary team or transdisciplinary team consists of HCPs from various health disciplines who provide service to the patient, but their care does not overlap. Each professional serving the patient has separate treatment plans and rarely communicates or interacts with one another. Consequently, multidisciplinary/transdisciplinary team practices are fragmented and unable to provide efficient and high-­ quality healthcare. 2. The intradisciplinary team consists of HCPs from the same discipline, such as three physicians from different specialties collaborating in managing a patient. 3. The interdisciplinary team consists of HCPs from diverse fields who collaborate to provide service to solve a patient’s problem or gather clinical information. Each professional is involved in establishing a joint treatment plan designed to achieve optimum outcomes. The IHT enhances communication among the HCPs in setting, prioritizing, and achieving optimum treatment goals. 4. Cross-Organizational Teams: An example of a transdisciplinary team in the workplace designed to break down divisional, functional, or departmental lines and cause collaboration in an important project is a cross-organizational team.

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 enefits of the Interdisciplinary Team B Approach in the Delivery of Healthcare The multidisciplinary team approach, where interaction between HCPs is informal, is the standard of care in the Nigerian health system. The clinical practice is fraught with delayed treatment and medication errors due to communication breakdowns. The delay causes deterioration in inpatient health, increased disability, decreased work capability, worsened patients’ quality of life, and many unnecessary fatalities (Kunkel, 2020). Furthermore, delayed treatment drastically increases patients’ anxiety and negatively impacts mental health, often leading to overestimated symptoms—making it difficult for HCPs to monitor conditions accurately (OrthoBethesda, 2021). The deterioration in patients’ mental and overall health increases the patient’s financial burden and healthcare cost borne by the taxpayers. These factors combined explain the high mortality rates and poor health outcomes in Nigeria (WHO, 2000). Interdisciplinary collaboration is an essential means of facilitating communication between HCPs (Manias, 2018). The collective intelligence of the HCPs makes the IHT approach ideal and integral to improving patient outcomes by reducing medical errors and increasing care quality (Whitaker and Shrader, 2019). The benefits of IHT have been widely reported in many studies, resulting in the widespread adoption of team-based healthcare models worldwide. Following a comprehensive and critical review of the literature, Derrick (2018) reported that the IHT decreased hospital stay length by between 0.3 and 6.6 days. Surgeons and anesthesiologists reported improved communication with the medical training team while nurses’ perception was unchanged. Adverse drug events (ADEs) improved significantly when a pharmacist is on the care team, and preventable ADEs decreased by 78%. However, the findings on hospital readmission and staff satisfaction are mixed; one study found that the hospital readmission rate decreased by 44%, but several other studies found no change. Staff satisfaction remained the same but communication improved from 88% to 91% using structured interdisciplinary rounds (SIDR) for physicians and 44% to 74% among nurses.

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A Triad for Optimal Patient Safety (TOPS) project improved patients’ perceptions of being respected by physicians and nurses and understanding their needs. Still, there is a disparity between how physicians perceive communication within teams. Physicians’ perceptions are more favorable during nurses’ lag. This schism was attributed to the traditional hierarchical structure in healthcare. Derrick (2018) concluded that “interdisciplinary care has many benefits to both the healthcare organization and patients and should continue to be studied and implemented.”

 haracteristics of a Successful Interdisciplinary C Health Team A systematic review by Nancarrow and associates (2013) identified ten attributes that are paramount for effective interdisciplinary teamwork. Organizational behavior studies published by the United States Institute of Medicine (2004) and other researchers (Mayo & Woolley, 2016; Whitaker & Shrader, 2019) also support the following ten traits described by Nancarrow and associates (2013): 1. Leadership – The success of an IHT depends, in part, on the administrative and communication skills of the leader and the cooperation of all the HCPs. The appointed team leader must give clear direction and share power with others. The leader encourages and supports team members and promotes morale and motivation within the group. Leaders utilizing appropriate listening skills, reflective practice, and understanding members’ strengths and weaknesses can recognize and respect the unique features of the team. 2. Communication – Each team member must develop appropriate communication skills, and communication within the team must be adequately stated. Organization theorists opined that healthcare teams are more productive when members communicate respectfully and compassionately with one another and support the leader appointed to coordinate the services (Venzin, 2018).

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3. Ongoing Training – Team members should have access to career development and training opportunities on the functioning and dynamics of interdisciplinary teams. 4. Procedures and Organizational Support – The team should have regularly scheduled team meetings, working with organizational support. 5. Appropriate Skill Mix – Team members should have a wide array of skills and personalities and utilize each member’s knowledge and skills to their fullest ability. To keep an appropriate skill mix in the team and identify a replacement for each leadership position. Organization theorists contend that the functioning of the IHT will be cohesive and effective when each member of the group understands their expertise about the clinical goals and treatment outcomes for each patient, including the roles of the other team members (The HRH Global Resource Center, n.d). 6. Organization Culture and Climate – An organization environment that is trusting and empowering influences the success of the interdisciplinary team. 7. Respect for Individual Characteristics – Respect for individual characteristics makes the team strong. 8. Clarity of Team Mission and Vision Statements – A team must have a clear mission and vision statements and values to drive the team’s purpose and expectations to which team members are held. 9. Quality and Outcomes of Care – The team’s primary goal is to provide exceptional care to the patient, and all care decisions should be patient-centered. The group should encourage feedback, capture and record evidence of adequate care, and then use it to provide feedback that will improve the team’s performance. 10. Knowledge of Individual Expertise and Roles – A team should share power, work collaboratively, and leadership must regularly shift. This issue is discussed further below.

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Leadership Controversy The qualifications and required skill set for the position of the health minister have been an ongoing controversy in Nigeria (Alalade, 2015). Before 1985, the leadership of healthcare institutions in Nigeria was not “zoned” to a particular profession but based on qualification and experience. When Decree 10 was promulgated in 1985 it mandated that the leadership of the UTH—Chief Medical Director (CMD) —must be a physician. The implementation of the decree extended without any legal backing to all health institutions in the country and removed the need for competency and experience in administration, but made leadership positions the exclusive “right” of physicians. Hence, only physicians are appointed as ministers in the Federal Ministry of Health (FMH), including the headship of health agencies, tertiary hospitals, and commissioner of health at the state level (Uchejeso et al., 2021). The other HCPs attribute the industrial strike in the country to these fundamental inequities and alleged that the federal government favors physicians and dentists not only in leadership appointments, but also in conditions of service, including salary and promotion opportunities. These widely held perceptions led to the formation of JOHESU—with the stated purpose to resist and fight the injustice in the health sector and counter the significant influence wielded by the MDCAN (Uchejeso et al., 2021). JOHESU enthusiasts point to the fact that in Nigeria 48% of the ministers of health who served from 1952 to 2020 were physicians and that in other countries physicians are rarely appointed as secretaries of health. For example, in the United States, only 25% of health secretaries, between 1980 and 2021, were physicians while 42% were lawyers. The incumbent and previous secretaries of health have been lawyers. On the contrary, MDCAN argues that 46% of the ministers of health in the WHO’s member nations are physicians—consistent with the 48% in Nigeria (Balogun, 2021). There is a growing sentiment, especially among the public and the other HCPs, that most physicians and dentists in the reins of power are unskilled administrators. Critics opined that the medical and dental curricula in Nigeria lack content in management and team dynamics. These

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curriculum deficiencies limit physicians and dentists’ ability to work effectively in teams and cannot lead large healthcare organizations and systems effectively (Ojo & Akinwumi, 2015; Oleribe et al., 2016, 2017). It is now recognized more widely in developed countries that what makes a physician a great clinician may not necessarily make him/her a great leader. Today, most hospitals in the United Kingdom and the United States have CEOs who are non-physicians. Of the 6500 hospitals in the United States, only 235 (3.6%) have a physician as their CEO. An unscientific survey from the United States reported that physicians disproportionately led the “Best Hospitals” in the annual “News and World Reports” (Lambo, 2019). Many people often extrapolate from this survey that having physicians as CEOs will improve hospital performance and patient care. Unfortunately, no empirical study has investigated the hypothesis that physician-led hospitals perform better. The lack of research evidence is because establishing a clear relationship between leadership and organizational outcomes is challenging. Many of the conditions regarded for casual analysis cannot be met. A longitudinal design study is warranted to investigate the hypothesis as to whether physician-led hospitals have better performance outcomes than those led by non-physicians. Dr. Atul Gawande, a physician in the United States, stated it best when he opined that “healthcare is moving towards teams, but that collides with the image of the all-knowing, heroic healer. We’ve celebrated cowboys, but what we need is more pit crews. There’s still a lot of silo mentality in healthcare.” The same point of view was echoed by Dr. Thomas Lee, also from the United States, who affirmed that the problem with healthcare is that “people like me – doctors (mostly men) in our fifties and beyond, who learned medicine when it was more art and less finance…. is to adopt high personal standards and then meet them. Now at many healthcare institutions and practices, we are in charge. Also, that’s a problem because healthcare today needs a fundamentally different approach – and a new breed of leaders” (Dodson, 2017). The leadership ruckus in the health sector is a complex issue with legal, ethical, and professional ramifications. The prevailing struggle among the HCPs creates a recipe for mistrust and conflict and must be addressed to ensure peace and stability in the Nigerian health system. There is a need to consider the fundamental concept of shared team decision-making to

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effectuate interdisciplinary work of any kind. In the global healthcare landscape, the team leader (headship/CEO) is selected based on competency and experience. In the clinical arena, the team leader naturally emerges during the different phases of the hospitalization and rehabilitation services provided to the individuals. Typically, the HCPs with the unique beneficial clinical skill, interest, or knowledge in a particular case will take on the leadership role. For example, during admission and the inpatient (hospitalization) phases, the physician will assume the leadership role to make a medical diagnosis. The leadership may change as the treatment plan progresses to the rehabilitation phase. Similarly, a dentist may lead an IHT managing a patient with temporomandibular joint pain. In the same vein, during the rehabilitation phase, a physiotherapist may lead a team caring for individuals with autism or poliomyelitis.

 urrent State of Interdisciplinary Collaboration C Within the Nigerian Healthcare System There is currently limited evidence-based information on the development and effectiveness of IHT in Nigeria. As of February 2021, only 11 studies were identified that investigated the topic, and the studies’ findings are summarized below. In 2009, Akinmoladun and Obimakinde assessed oro-facial cleft care in Nigeria among practitioners using the IHT approach. Sixty-three specialists (mean age = 43.5 years) who attended the Pan African Congress on cleft lip and palate completed a survey in 2007. Most of the respondents are oral and maxillofacial surgeons (38%) and plastic surgeons (22%). Only 48% of the specialists belonged to cleft teams. Most oral and maxillofacial surgeons (70%) and plastic surgeons (63%) belonged to cleft teams, while speech pathologists (20%) and orthodontists (37%) were less represented in IHTs. The authors concluded that IHT care for the cleft patient is not yet fully embraced in Nigeria. They attributed their findings to several factors, including the non-availability of the requisite specialists, the relatively young age of cleft care practice, and the poor state of infrastructure.

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There is limited specialized health services for the elderly in Nigeria. The University of Benin Teaching Hospital (UBTH), established in 1973, took four decades to develop a geriatric unit. In this article, Akoria (2016) described the development of specialized “interdisciplinary” health services for older adults, including the training and professional development opportunities in geriatrics provided for physicians. The hospital adopted the acute care for elders (ACE) model, and the physicians worked in tandem with the “ABCs” of implementing ACE units. Medical residents and house officers in internal medicine participated in four and 12-weekly rotations, respectively. The experience includes a robust academic program that provides for once-weekly geriatric pharmacotherapy seminars, once-weekly interdisciplinary seminars, and two-weekly journal club meetings alternating with geriatric assessment tools. The authors, with great optimism, concluded that it is possible to establish geriatric services and achieve best practices in resource-limited settings by investing in human resources and infrastructure. Regrettably, this worthwhile project did not include other HCPs—physical, occupational, and speech therapies—that play unique roles in caring for the elderly. Consequently, the project implemented is an intradisciplinary team and not an interdisciplinary team, as stated by the authors. A cross-sectional study by Okoronkwo and associates (2013) investigated the factors that enhance and hinder IHT among physicians (n = 110) and nurses (n = 95) at the Nnamdi Azikiwe Teaching Hospital, Nnewi. Both groups had a positive perception of IHT, and years of experience significantly influenced their perception. Clear individual roles and good working relationships enhance IHT while prioritizing professional status rather than expertise were seen as the main hindrance to IHT. Oguntade and associates in 2014 reviewed the literature on the challenges facing HCPs working with patients living with cancer in Nigeria. They observed that IHTs are virtually non-existent and are long overdue in the country. The lack of required infrastructure, the absence of an organized MDT structure, and the scarcity of trained staff were the primary challenges of setting up regular IHT meetings. The federal government can overcome these challenges by enacting legislation mandating MDTs as a cancer management policy and providing adequate

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infrastructure, broad-based MDTs and regional teams, and the employment of needed well-trained staff. Iyoke and associates (2015) assessed the knowledge and attitude toward an IHT among obstetricians and gynecologists employed in two teaching hospitals in the South East. About 74% of the study respondents (n = 116) were aware of the IHT concept, but only 15% of respondents who were aware of the IHT concept had “very good” knowledge of it, 52% had “good” knowledge, and 33% had “poor” knowledge. Only 29% of “knowledgeable” respondents reported ever receiving formal teaching/training on IHT working in their professional development. About 78% of those aware of teamwork believed that IHT would be beneficial in obstetrics and gynecology practice, with 89% reporting that it would be “very useful.” About 77% of those aware of IHT would support establishing and implementing the strategy at their centers. The authors concluded that the positive attitude of the obstetricians and gynecologists might not impede the implementation of an IHT approach. An analytical paper by Arulogun and associates in 2016 describes their unique experience of utilizing an IHT to facilitate the multipronged behavioral intervention needed to enhance stroke outcomes in Nigeria. The authors identified limited medical system resources and inadequate patient health literacy as barriers to implementing a coordinated IHT. They observed that previous investigators primarily executed intervention studies to improve healthcare among physicians and nurses with minimal participation by other HCPs and limited contributions from patients, caregivers, and the community. In a retrospective study, Ekenze and associates (2017) investigated the health outcomes from neonatal surgery performed before and after implementing a focused IHT project at two referral hospitals in Enugu metropolis, between 2011 and 2015. The authors compared the cases (N = 91) managed before 2013 (group A, n = 47) with those after 2013 (group B, n = 44). The two groups had similar birth weight, age at presentation, and associated complications. Postoperative complications occurred in 47% cases (55% in group A and 39% in group B, p > 0.05), and the overall mortality was 35% (49% in group A, and 23% in group B; p