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Professionalization of
Physiotherapy in Nigeria:
Challenges, Threats and Opportunities
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A Presentation Delivered by Distinguished University
Professor Joseph Balogun* at the Scientific Session of the
55th Annual Conference of the Nigeria Society of
Physiotherapy (NSP) held at Lokoja, Kogi State, Nigeria
on October 28, 2015
________________
*Joseph A. Balogun is from the College of Health Sciences at
Chicago State University, 9501 South King Drive, BHS 607, and
Chicago, IL 60208.
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Abstract
Professionalism continues to be a subject of interest in physiotherapy. This is reflected
by the number of publications in physiotherapy journals and presentations made by
physiotherapists at professional and scientific conferences around the world. The origin
of physiotherapy profession in Nigeria from inception in 1945 up till 1975 was partially
chronicled by the doyen of our profession, Dr. Abayomi Oshin; but there has been no
corroborating evidence of his account in the extant literature. This presentation
provided an update on the history of physiotherapy profession in Nigeria; and critically
examined the factors and groups that facilitated and/or impeded the rapid pace of
development of physiotherapy. The lessons learned from the evaluation of the past
challenges, emerging threats and opportunities can be used to further accelerate the
professionalization of physiotherapy in Nigeria.
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Background
Mr. Chairman, please permit me to stand on the already established protocol. I am
deeply appreciative of the invitation extended to me to address this Scientific Session of
the 55th annual conference of the Nigeria Society of Physiotherapy (NSP) as a prelude
to the key note speech that I will deliver tomorrow morning in recognition of our
visionary leader, the late Chief Christopher A. Ajao. This lecture which is titled
“Professionalization of Physiotherapy in Nigeria” is indeed a relevant topic worthy of
discussion as our profession aspires to transition to the next level of excellence. We
cannot realistically discuss professionalization of physiotherapy in Nigeria in isolation; it
has to be examined globally, and within the context of the other professions in Nigeria.
Professionalism has over the years been a subject of interest to physiotherapists. This is
reflected by the number of publications in physiotherapy journals and presentations
made by physiotherapists at professional and scientific conferences around the world.
When the term “professionalism” was entered in the Cumulative Index of Nursing and
Allied Health Literature (CINAHL) data base, 6,171 “hits” emerged. When “physical
therapy” was added as a “key word” to the search engine, 210 “hits” was generated. On
the home turf, it was reported that a 2-day workshop on professionalism organized by
the NSP in 2011 engendered great enthusiasm and attracted “unprecedented turnout.” 1
Purpose of Presentation
The origin of physiotherapy profession in Nigeria from inception in 1945 up till 1975
was partially chronicled by the doyen of our profession, Dr. Abayomi Oshin; but there
has been no corroborating evidence of his account in our extant literature.2 Obviously, a
lot has happened in our profession that remains undocumented, particularly in the last
four decades. We have witnessed some achievements, intractable challenges, missed
opportunities and emerging threats which hitherto have not been reported in our
professional literature.
Two recent cross-sectional survey studies were conducted by Mbada and associates to
determine physiotherapists’ professional identity as perceived by the general public; and
to evaluate physiotherapists’ knowledge of the legislation guiding the practice of
physiotherapy in Nigeria. Mbada and associates found that only 51% of the
physiotherapists in Nigeria are aware of the reality that they are required by law to
obtain a referral from a physician before they can treat their patients.3a Furthermore,
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they found that only 16.8% of rural dwellers are aware of physiotherapy profession, and
the majority (60%) of the study participants associated physiotherapy with masseurs, and
30.8% with physicians. Physiotherapy ranked 6th and 7th in social standing (prestige)
and level of income when compared with eleven other professions.3bThe findings from
these studies are disconcerting and have seriously implications for our profession. The
findings underscore the need to create awareness about physiotherapy among the public
at large; and the need to educate the NSP membership on basic professional ethos and
identity.
The objectives of this presentation are to update the history of physiotherapy profession
in Nigeria; and to critically examine the factors and groups that facilitated and/or
impeded the rapid pace of development of physiotherapy. The lessons learned from the
evaluation of the past challenges, emerging threats and opportunities can be used to
further accelerate the professionalization of physiotherapy in Nigeria.
Hierarchy of Importance of Professions
The word “profession” was derived from the Latin word “profession” which means “a
public declaration with the force of promise.” In 1969, Etzioni4 classified occupations
into two broad categories: “Semi-Professions” and “Learned (or True) Professions”. I
would like to add a third category: “Vocational Careers.” The hierarchy of importance of
professions is presented in Figure 1.
Figure 1: The Hierarchy of Importance of
Professions
True Professions
Semi-Professions
Vocational Careers
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True-professions are at the top of the pyramid, semi-professions at the middle and
vocational careers at the bottom of the pyramid. Professions are generally rated by the
power and
prestige
they command within the society at large. True professions have
high esteem and political power. Semi-Professions have less autonomy in decision
making and generally lack wide societal acceptance. On the other hand, vocational
careers have technical skills, but they are associated with limited education and no
distinct body of knowledge.
What is Professionalism?
Without the knowledge of what professionalism is, a discussion of the topic for this
lecture (professionalization of physiotherapy in Nigeria) will be meaningless. Because
physiotherapy is a profession
and physiotherapists are professionals
,
it is important to
have a clear understanding of the term "professionalism".
Professionalism is a multi-dimensional construct with no simple and universally
accepted definition. It is easy to recognize professionalism but it is a difficult construct
to measure because it is kaleidoscopic in nature. Professionalism is often associated with
traits such as:
altruism, accountability, excellence,
duty
,
honor and integrity,
and
respect
for patients and their families, peers and stakeholders5 (Figure 2).
Figure 2: Traits Associated with Professionalism
Professionalism
Altruism
Excellence
Duty
Integrity
Respect for Patients,
Families,
Peers & stakeholders
Honor
Accountability
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Professionalism
is the internalized conceptualization of expected professional
obligations, attributes, interactions, attitudes, values, and role behaviors in relation to the
individual clients and society as a whole. Professionalism may be collective (practiced by
the profession as a whole) or individual.6, 7Individual professionalism refers to the
internalized beliefs of an individual member of a profession regarding professional
obligations, attributes, interactions, attitudes, values, and role behaviors. Individual
professionalism is also called “professional role concept (Figure 3).”
Figure 3: Individual Vs. Collective Professionalism
Professionalism
Collective
Professionalism
Individual
Professionalism
Internalized beliefs of an individual member of a
profession regarding professional obligations,
attributes, interactions, attitudes, values, and
role behaviors
Practiced by the profession as
a whole
Professionalization Defined
I consider professionalization as the social processes and evolutionary path through
which occupations attempting to obtain the status and power of a true profession
transcend (Figure 4). Of course, there is a plethora of other points-of-views about
professionalization. Forsyth and Danisiewicz posited that
“professionalization has to do
with the ability of an occupation to convince legislators and the public of the importance
of its work, rather than the intrinsic knowledge and value of that work
.” 8
Carr-Saunders defined professionalization
“as a process along a line of inevitable
progress, working towards the acquisition of a number of defining characteristics,
namely codes of ethics, professional associations, specialized skills and governance.”
9
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Wilensky emphasized the developmental aspect of professionalization, suggesting that
occupations transcend four sequential stages/functions during the professionalization
process: 1) creation of a full-time occupation, 2) the formation of training schools, 3)
creation of professional associations, and 4) the development and creation of code of
ethics. 10 Central to this perspective is the recognition that an occupation can enhance its
autonomy and professional status through social and political actions.8; 11-13The extent
to which professionalism is imbibed or internalized within an occupational group is a
valid barometer for judging the transition to true professional status. 14
Critics argue that the professionalization process for physiotherapy was pusillanimous
when compared to the other occupations that were imported into Nigeria during the
pre-and-post colonial era. The obvious questions to ask are: Are we satisfied with the
pace of our professionalization? Have we convinced enough legislators in the National
Assembly and the public-at-large about the importance of our work/trade? Do we have
enough people who can vouch that we are a true profession?
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To provide answer to the first question, my colleague and I designed a study to
investigate the pace of professionalization of physiotherapy and eleven other major
occupations imported into Nigeria by Europeans.15 The findings that emanated from this
study was presented this morning during the Scientific Session. We determined the
timeline when each occupation: 1) was imported into the country, 2) established a
professional association, and 3) obtained legislative mandate from the federal
government to establish a regulatory board (Figure 5).
The findings from our study revealed that physiotherapy ranked seventh out of the
twelve major occupations to be imported into Nigeria, and the second occupation to
quickly develop a professional association after importation into the country.
Unfortunately, it took physiotherapy longer time (33 years) to obtain a legislative
mandate to establish the Medical Rehabilitation Therapists’ Board (MRTB);
physiotherapy also ranked seventh among the twelve occupations to obtain approval
from the federal government to establish a regulatory body.15The factors responsible for
the slow pace of development of physiotherapy will be discussed later in this lecture.
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Contextualization of our History
The history of a profession in any country cannot be discussed in solitariness, because it
will potentially be influenced by events in the other parts of the world. It was during the
Middle Ages or Medieval period, which lasted from the 5th to the 15th century that
occupations evolved. During that era, only divinity, medicine, and law were recognized
as “learned” professions.16
In the USA, the discipline of surveying was the first to attain true professional status;
and it was followed by medicine, actuarial science, law, dentistry, civil
engineering, architecture and accounting. It is worthy to note that several American
Presidents such as George Washington, Thomas Jefferson, and Abraham Lincoln all
worked as land surveyors before they became politicians. With the advent of technology
and the enhanced advocacy for specialization in the 19th century, several disciplines
such as pharmacy, veterinary medicine, optometry and psychology have transitioned to
true professional status in the USA.16, 17
By using hydrotherapy, massage and manual therapy techniques to treat ailments as far
back as 460 BC, Hippocrates, the great Greek physician and philosopher, was the first
documented practitioner of physiotherapy. Globally, physiotherapy is relatively a young
profession when compared to occupations that evolved during the medieval period.
Physiotherapy became a bona fide occupation in 1894 when midwives and nurses in UK
took action to protect their practice of medical massage and formed the Chartered
Society of Physiotherapy. 18
In the USA, physiotherapy was initiated in 1921 with the formation of the American
Women’s Physical Therapeutic Association. The demand for physiotherapy services
increased during the 1940s and 1950s in response to the need to provide rehabilitation
services for soldiers of World War II and a nationwide poliomyelitis epidemic.19From
inception, physiotherapy was dominated by allopathic medicine and more recently also
controlled by state or federal governments.
Although UK was the first nation in 1894, followed by the USA in 1921, to form
professional associations in physiotherapy, the pace of professionalization of
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physiotherapy in UK was slow when compared to the USA which continues to provide
progressive reforms in physiotherapy education and clinical practice.19
The importation of occupations into Nigeria is relatively recent. Medicine was the first
occupation to be introduced into the region that later became Nigeria by Portuguese
allopathic physicians in 1472. Subsequently, Roman Catholic Mission opened a hospital
at St. Thomas Island off the Bight of Benin in 1504. During the later part of the 1800,
several other occupations were imported into Nigeria by Europeans (Danish, Dutch and
British). Law was introduced in 1862, followed by pharmacy in 1867, surveying in 1863,
and engineering in 1896. The 1900 witnessed the importation of veterinary medicine in
1932, physiotherapy in 1945, librarianship in 1948, and accountancy in 1950.15
Like all occupations imported into Nigeria, the professionalization milestones of
physiotherapy was influenced by several internal and external factors. Our journey as a
profession began in 1945 when physiotherapy was imported to Nigeria by two British
chartered physiotherapists; Miss Manfield and Mr. Williams. Their primary role was to
treat wounded and disabled Nigerians soldiers who returned home from Burma and
other countries during World War II.2, 20Our profession has made incremental gains
since 1945, but the pace of development has been a subject of concern to many NSP
members for some years now.
Generation Schism
At this seminal moment in our history, it is important to look back to identify the
individuals or groups that contributed to the development of our profession. During the
56 years history of the NSP, there are four generation of practitioners that have
contributed to the development of our profession. Each group has disparate educational
and career experiences with divergent social philosophies and interests.
Many of the first generation practitioners received their physiotherapy education from
the UK in the 1950s. After receiving the MCSP credential many of them returned to
Nigeria to contribute their quota towards national development. Another cohort of first
generation practitioners were homebred physiotherapist aides trained at Igbobi. After
several years of on-the-job experience, the physiotherapy aides were grandfathered into
the profession as physiotherapists. Prior to 1980, the preponderance of the NSP
membership was the first generation practitioners. They formed the NSP and developed
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degree and diploma programs in physiotherapy. In addition, they secured the initial
recognition of the NSP by the federal government, developed the NSP constitution and
produced the initial professional code of ethics for the profession.10 Today is a golden
opportunity to salute our founding fathers and mothers for their hard work and the
visionary leadership that they provided.
The second generation practitioners, obtained their BS degree or diploma in
physiotherapy from the Universities of Ibadan and Lagos, respectively. In the late 1970s
and early 1980s, many of the second generation practitioners proceeded to North
America to earn their Master’s and doctoral degrees. This generation of practitioners
brought pizzazz and zip that raised the profile of physiotherapy in the academy and
within the society at large. In 1988, they secured from the federal government the
legislation governing the practice of physiotherapy, and guided the subsequent
establishment of the MRTB in 1992.
The third generation practitioners are individuals who earned their physiotherapy
education (BS, Master’s and doctoral degrees) in the early 1990s from the Nigerian
Universities. A few third generation practitioners obtained their physiotherapy
education outside the country. They continue to build on the achievements of the
second generation practitioners.
The fourth generation practitioners are the Millennial or Generation Y members of the
NSP; they are primarily undergraduate physiotherapy students and recent graduates. It
is anticipated that the fourth generation practitioners will carry the mantle of our
profession in the years to come.
Ladies and gentlemen, there is no doubt that our profession has a virtuous history and
our forbearers laid a strong foundation for our development, but a lot of work remains
to be done before the house is fully built.
Early Years of Physiotherapy in Nigeria: Heroes, Foes and Allies
The framework that I used to examine the professionalization of physiotherapy in
Nigeria was anchored on the relationship between the
past, present and future.
The
relationship among the three phases of life was succinctly elucidated by William
Wordsworth, the British romantic poet who co-authored the Lyrical Ballads. He stated
that:
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“Life is divided into three terms: that which was, which is, and which will
be. Let us learn from the past to profit by the present, and from the
present, to live better in the future.”
21
Bob Marley, reggae maestro, also recognized the relationship between the past and the
future when he sang:
“In this bright future you can’t forget your past.”
22
Yes, we dire not forget our past. It was Patrick Henry, two terms post-colonial Governor
of Virginia who stated that he:
“
Know of no way of judging the future but by the past.”
23
The heroes, foes and allies of our profession in the early years deserve mentioning in
this presentation. The Polio Research Fund in England was a strong supporter of our
profession. This international organization in 1963 provided a £20,000 seed money to
establish a “School of Physiotherapy” at the University of Ibadan. The fund, according to
Dr. Oshin, was “earmarked for building and equipment.”24 Indeed, the physiotherapy
program at the University took off as planned in 1966, but the proposed building at the
University never materialized until today.
The Canadian International Development Agency was another ally of our profession.
The agency in 1972 provided a postgraduate scholarship award to the first graduate of
the University of Ibadan physiotherapy program (Mr. Godwin Eni now retired Professor
living in Canada) to study at the University of Manitoba in Canada.25The Canadian
University Services Organization (CUSO) deployed several physiotherapists to Oyo state
to serve within the community physiotherapy scheme that was launched by Chief Ajao.
In the early years, the World Health Organization (WHO) was a foe of our profession. In
the late 1970s, the WHO espoused policies that were incompatible with the mission and
vision of the NSP. The WHO was of the opinion that because of the great demand for
rehabilitation services, hospital-based, short duration cross-training of medical
rehabilitation personnel is the panacea for addressing the acute shortage of
rehabilitation workers in developing countries. The WHO aggressively promoted the
training of
“multi-purpose rehabilitation therapist”
instead of the training of
physiotherapist. Our forbearers must be commended for fighting both tooth and nail
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against the WHO’s proposal to develop
“multi-purpose rehabilitation therapist”
educational program in Nigeria.
Physiotherapy education in Nigeria started awkwardly, and was besieged with severe
teething problems for several decades. Due to time constraints, the early years of
physiotherapy education in Nigeria will not be discussed today. This issue will be
presented next year at the 9th annual conference of the Ife Physical Therapy Alumni
Association holding in Washington DC, USA.
I would, however, like to reminisce on the important role that students at the University
of Ibadan, in the mid-1970s, played in bolstering the image of our profession by
bringing physiotherapy to the consciousness of the Nigerian people. Physiotherapy
education at the degree level started rather timidly. The number of students admitted to
the physiotherapy educational programs at the Universities of Ibadan and Lagos is
usually 1 to 4 students per year. In 1974, this trend changed with the admission of 12
students at the University of Ibadan. The enrollment in 1975 increased to 20 students.
These cohorts of students at the University of Ibadan formed
The Association of
Undergraduate Physiotherapy Students
and used the platform as a vehicle to promote
physiotherapy profession in private homes, churches and market settings. In 1977, the
students organized the first
Physiotherapy Week
initiative which featured health
education activities, scientific symposia and a banquet. The events implemented were
well publicized by local and national radio/TV stations, and print media. The students
also established a publication called
PhysioMag;
the magazine was effectively used to
educate the general public on topical issues in medical rehabilitation.
One of the unsavory moments in the history of our profession was in 1975 when
physiotherapists were downgraded and placed on salary Grade 7; a level lower than what
university graduates with degrees in humanities, social and natural sciences were placed.
The salary disparities and inequities arose because of the wrong perception by federal
government bureaucrats that physiotherapy education was at certificate and diploma
levels.
The Association of Undergraduate Physiotherapy Students
from Ibadan
took this
issue head-on by advocating improvement in the conditions of service for
physiotherapists. The students found a way to appear before the Udoji Salary
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Regulation Panel created by the federal government in 1976 to harmonize salaries of
civil servants throughout the country.
The students brought to the attention of the arbitration panel, the best kept secret at the
time; the fact that physiotherapy education was being offered at the bachelor’s degree
level at the University of Ibadan. The effective presentation by the President of the
Association
of
Undergraduate Physiotherapy Students
(Mr. Bayo Sedenu, Now Dr.)
before the Udoji panel eventually led to improved condition of service for
physiotherapists nationwide.
The student heroes of that era who deserves special mention in the annals of our
profession were: Bayo Sedenu (President 1974-76), Ololade Aibana (Secretary 1974-76);
Late Dapo Adefihan (President, 1976/77), Muoyo Okome (Treasurer 1976/77; Chair,
Conference Organizing Committee), Chukuka Enwemeka (President 1978/79), Oyinkan
Sodipo (Treasurer 1978/79), Longinus Nwachukwu (PRO, 1978/79) and Victor Obajuluwa
(Editor-in-Chief,
PhysioMag
),
Globally, the medical profession is a domineering occupation that makes no pretense
about their modus operandi, and arrogated to their profession the designation of
“leader” of the health care team.26Paradoxically, the health care system is the only
pluralistic establishment that I know where a “leader” is assumed in perpetuity and not
democratically elected. But things are gradually changing as the functioning of the
health care system is becoming more interdisciplinary in practice. In a progressive
interdisciplinary practice setting, the “leader” of the team in charge of each patient
varies from time to time depending on the treatment plan. For example, a dentist may
be a “leader” of an interdisciplinary team managing a patient with temporomandibular
joint pain. In the same vein, a physiotherapist may be the “leader” of an interdisciplinary
team managing a patient with autism.
At the inception of our profession, physicians in Nigeria routinely “prescribe”
physiotherapy by specifying the type and dosage of treatment to be administered,
instead of the constructive consultation relationship that exists today between referring
physicians and physiotherapists. In the 1970s and beyond, it is common to receive from
a physiatrist or an orthopedic surgeon a referral that reads: “Diagnosis: OA right knee;
Treatment: Shortwave diathermy, wattage/pulse set at level 3 for 20 minutes; three
times a week; isometric and active exercise please.” Today, this level of specificity of
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treatment modalities and dosage from a physician will be considered ridiculous and an
insult on the acumen of the physiotherapist. Indeed, physiotherapy profession has come
a long way, but the battle is not yet won without professional autonomy.
In Nigeria, the medical profession exerts dominance and authority over the health care
delivery system. The medical profession has full professional autonomy, yet the
Nigerian Medical Association leadership worked very hard behind the scene to ensure
that physiotherapists do not have direct access to their patients. The medical profession
in Nigeria has not been a reliable ally of our profession. I will give three examples to
support my thesis.
Example #1: In the mid-1980s, it is herculean task for physiotherapist educators to be
appointed consultant in the university teaching hospitals. A physician is automatically
appointed a consultant following successful completion of their fellowship and on
joining the faculty at the rank of Lecturer I. During that era, a physiotherapist with a
Ph.D. must be a senior lecturer before being considered for appointment as a consultant;
and the appointment is not automatic. Furthermore, there was a wide inequity between
the stipend for a consultant physician and a consultant physiotherapist. The differences
in rank and pay for physicians and physiotherapists exist because employment decisions
were made by the university teaching hospital board; a cartel that is traditionally headed
and fully controlled by physicians.
Example #2: In 2001, the medical profession initially opposed a proposal that granted
call duty allowance to physiotherapists while at same time negotiating for their own
package. After the government granted physicians a 4% increase in their basic salary
(per unit) call duty allowance, the Nigerian Medical Association leadership worked
behind the scene with physician bureaucrats in the Federal Ministry of Health to ensure
that physiotherapists received only 1.7% increase in their basic salary. To add insult to
injury, other health professions (pharmacy and medical laboratory technologists)
subsequently received 2% increase.1
Example #3: Historically, the positions of dean and vice-dean in the Medical Schools in
Nigeria were considered the birthright of physician (“medics”) on the faculty. In 1990,
during a faculty meeting at an institution that I was employed, the dean of the College
of Health Sciences called for nomination for the vacant positions of dean and vice-dean.
He concluded his announcement with an off-the-cuff remark that “only medics need
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apply for dean and vice-dean positions.” I challenged the dogma held by many
physicians within the College, including the dean, that they are the only profession that
is qualified to assume leadership position in a College that educates different health
professions. After the meeting, I launched a campaign to context for the position of vice-
dean of the College. I won the election and served my tenure, with distinction, until
December 1991 when I departed Nigeria for the USA. The off-the-cuff remark made by
the dean revealed the arrogance and level of contempt that some physicians in position
of authority have for other health professionals. The dean who made this insensitive and
pompous remark passed away two years ago, and his name, in infamy, will remain
unmentioned today.
It is not my intention to imply that every physician in Nigeria was in opposition to
physiotherapy. There were several noble physicians who are respectful and supportive of
our profession. The late Professor T. Grillo at the University of Ife (now OAU) comes to
mind as a strong ally and supporter of our profession. He was a protégée to the late
physiotherapist icon, Professor Vincent Nwuga. In the mid-1970, Professor Grillo
recruited Vincent Nwuga (late emeritus professor) and Godwin Eni (the first University
of Ibadan physiotherapy graduate; now a retired professor of physiotherapy living in
Canada), to join the faculty of a new College of Health Sciences at the University of Ife.
Professor Grillo in his position as the pioneering dean of the College provided Mr.
Vincent Nwuga and Mr. Godwin Eni the opportunity to earn their postgraduate degrees
from North America at a time when none of the physiotherapist educators in Nigeria
has a Master’s degree. Professor Grillo later mentored Mr. Nwuga and supervised his
doctoral dissertation. Professor Grillo deserves our recognition as a hero in the forefront
of the struggle for equality for physiotherapist.
My point here is that as a group, physicians make no pretense about their interests; and
desire to dominate and control other health professions. The stated examples, and more
that I cannot discuss today due to time constraint, implies that physicians know how to
make rules to benefit their own profession. The medical profession does not mind to
leave their bride (any other profession) at the altar and walk away with grace.
As a profession, physiotherapy must never hamstring any other health profession, as the
medical profession overbore our profession in the early years. I cannot confirm if the
medical profession’s opposition to our profession is still ongoing, since I have not
resided in the country in the last three decades. However, I must caution the NSP
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leadership to keep their eyes widely open when they are in the room with the opposition.
Our leadership must always be professional in carrying out their duties and negotiate in
good faith but must meticulously verify the facts presented to them before signing the
dotted line or before committing to an agenda that may affect the future of our
profession.
Present Challenges and Opportunities
A critical issue that should keep all physiotherapists in Nigeria up at night is the lack of
autonomy to practice our profession. Physiotherapy profession was recognized by the
federal government in the early 1960s. Sadly, the long awaited legislation by the
physiotherapy communities in Nigeria and in Diaspora did not provide the autonomy
that our profession needed to transition to true professional status.27 The 2014 revised
MRTB legislation poignantly stated that:
“Physiotherapists
are
not allowed to see any patient, without a doctor’s
order, even if the patient were an excellent candidate for physiotherapy.”
28
It is important to note that the initial legislation on the creation of the MRTB occurred
during the tenure of the late Professor Olikoye Ransome Kuti, a pediatrician at the
University of Lagos, as the Honorable Minister of Health. It is a well known truism that
the medical profession had formidable administrative and strong network powers within
the federal government, at hospital level, and over the nation’s health service system.
Given this situation, it can easily be inferred that physicians at the corridor of power in
the Federal Ministry of Health, where the legislation that created the MRTB was
initiated, were not particularly helpful in ensuring that physiotherapy is accorded
professional autonomy.
Physiotherapy profession in Nigeria currently faces internal challenges that have the
potential to derail our aspiration to attain true professional status. We have within our
ranks, certain individuals who have spent valuable time and resources, taking
physiotherapy profession in the wrong direction by forming alliances with vocational
careers; and destroying the organization foundation and administrative structure
conceptualized by our forbearers. In the same vein, there are other physiotherapists who
have hijacked our profession for personal aggrandizement and career enhancement to
the detriment of our collective struggle towards professional emancipation. How we can
effectively reconcile and harness the disparate points of view of the four generations of
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practitioners within our profession is a conundrum that should be of concern to all and
sundry.
Despite our internal squabbles, I submit that this moment is an opportune time for all
physiotherapists in the country to begin the journey that will transform our profession
to a true professional status. The task ahead in achieving this goal is daunting and will
require the commitment of the entire NSP membership. In addition, our profession
desperately needs a core group of men and women of good will, blessed with Solomon’s
wisdom to shepherd our journey to the Promise Land.
As we embark on this journey, the NSP leadership must tap the energy and special
innovative talents of our students and the Millennial or Generation Y members. The
effectiveness of the marketing strategies employed by students at the University of
Ibadan in the 1970s convinced me that we collectively can move mountains if the
current NSP members and students in the seven universities currently offering
physiotherapy educational program are fully mobilized to be equal partners in our
struggle for professional emancipation.
Future Threats
The Nigerian health care system has over the years been underfunded. It is an
abomination to observe that successive Nigeria governments spends only 3.9% of the
nation’s gross domestic product on health services; compared to 17.1% in the USA, 9.1%
in UK, and 9.4% in Australia.29 Given the low priority apportioned to our health care
system for several decades now, it is not surprising that Nigeria has one of the worst
health indices in the world.30, 31
The Nigerian healthcare system is rapidly evolving with the introduction of the
National Primary Health Care Development Fund
program proposed in the
National
Health Bill
.32 The financing of the public health care scheme is fraught with disparities
due to: 1) severe budgetary constraints and uneven distribution of resources between the
urban and rural areas with the rural areas mostly affected by inequitable lower
budgetary allocation, and 2) shifting from government provided health care system to a
competitive market system that is based on the individual’s ability to pay for their care
out-of-pocket. The excessive reliance on the competitive market system has exacerbated
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the already inequitable access to quality care, and pushed the burden and risk of
obtaining health services to the poor. 32
With the dominance of the competitive market system, it is anticipated that the clinical
environment in the next decade will become more system and cost regulated and less
favorable to provision of quality physiotherapy services. In a managed care practice
environment, the job security of health care providers, including physiotherapists, will
become less predictable. Consequently, physiotherapists will need to be more adaptable
and strategic to survive the health care landscape of the future.
We physiotherapists need to identify our competitors in the market place; and critically
assess the level of their threat to the existence of our profession. As the adage goes,
nature abhors a vacuum. If we failed to meet the demands for physical therapy services
in Nigeria, other professions will evolve to fill the vacuum. Lessons from the other parts
of the world revealed that athletic trainers, developmental therapists, massage
therapists, and chiropractors are our potential competitors. Some of these professions are
not presently established in Nigeria, and those in existence in the country have few
practitioners. In all, our potential competitors do not presently pose significant threat to
our existence but the threat definitely deserves close monitoring in the years ahead.
Lessons Learned
A valid question to ponder over is when does a profession know it has attained true
professional status? Professions will know they have attained true professional status,
when they command esteem, power and influence in the larger society. Freidson
inferred that
“professionalization is perception; the public recognition of an identity
conferred from without. Essentially a vocational pursuit becomes a profession when
enough people agree that it is
.” For example, when the Nigerian Medical Association or
the Nigerian Bar Association sneezes, because of their large number and influence in
the society, the federal government shivers. These two professions wield great power in
our society and within the government, and they can claim true professional status.
At this juncture, I would like to contextualize the findings from the retrospective study
by Balogun and Aka15 that examined the pace of development of occupations that were
imported into Nigeria. The authors found, in sport analogy terms, that physiotherapy
21 | P a g e
profession got off the block faster than medicine, dentistry, law and pharmacy; but
progressively fizzled out in a contest that was meant to be a marathon race and not a
sprint. What happened to physiotherapy profession during the course of the marathon
race deserves in depth analyses. The slow pace of professionalization of physiotherapy
can be attributed to the following multidimensional factors (Figure 6):
Figure 6: Factors Associated With Our Slow Professionalization
Import of British PT
System of Education
Limited Public Awareness of our
professional identity
Entry-level Education;
Bs Vs. DPT
Medical Rehabilitation
Therapists’ Board:
Amalgamation of PTs with
other professions
Limited
number of
practitioners
Lack of Professional
Autonomy
Lack of physical presence;
mediocrity, poor image in
the academy;
Our PT Education
started in the Hospital
Setting to train PT Aides
Internal (conflicts) and
External (WHO, medical
Profession) Threats
1. The import of British system of physiotherapy education to Nigeria was
detrimental to the rapid development of our profession. The majority of the first
generation practitioners (T.A. Oshin, G.I. Ordia, Mr. and Mrs. Ajao, Mr. Okeke, Mr.
Kehinde, Mr. Obiri, Mrs. Aboderin, Mr. Bazuaye, Mr. Ayodeji, Vincent and Peju
Nwuga, Mrs. Mabogunje, Bitrus Gani-Ikilama, Mrs. Fawehinmi (late), Mr.
Onuoha etc) received their initial physiotherapy education in UK where the
training was hospital based and the highest education offered in physiotherapy
was a diploma (MCSP). Because there were no opportunities for postgraduate
education in the UK, many of our forbearers returned home with their MCSP
22 | P a g e
credential. Many of them were employed in the hospital setting as a
physiotherapist, and the others joined the Universities of Lagos and Ibadan as
assistant lecturer. Physiotherapy education in the UK did not transition to the
university setting until the 1980s compared to 1927 in the USA. The USA was the
first nation to develop Master’s and doctoral (Ph.D.) degree programs in physical
therapy; and the first nation to establish the t-DPT and entry-level DPT degree
programs. In my opinion, our professionalization process would have progressed
at a faster pace had physiotherapy been imported into Nigeria by the Americans
instead of the British.
2. Physiotherapy education in Nigeria, like in UK, also started on a wrong path. The
first physiotherapy training program in Nigeria also started in a hospital setting
at Igbobi where physiotherapy aides, instead of physiotherapists, were produced
for several years. The NSP was formed in 1959 and the first degree program in
physiotherapy at the University of Ibadan did not start until 1966; that was seven
years of dithering. Other reputable occupations imported into Nigeria
established their educational program in a university setting and professional
degrees were conferred; e.g., medicine, dentistry, veterinary medicine, law,
architecture.
3. As stated previously, in the early years, physiotherapy profession in Nigeria had
an image and credibility problem within the ivory tower because the MCSP
credential of our pioneer educators was dismal when compared to the terminal
academic degrees (medical Fellowships, Ph.D., Ed.D) earned by their colleagues
within the university. It took decades for our profession to overcome the
credential chasm.
4. At the inception of our profession, the scientific knowledge base of physiotherapy
was nonexistent. This is in contrast to the medical profession that has clear
defining paradigms of diagnosis, treatment, and prevention of disease.
Physiotherapy was generally perceived in the medical community as a vocational
career and not a true profession. Today, pathokinesiology which was proposed by
Dr. Helen Hislop in 1975 is universally accepted as the “science” of physiotherapy.
5. Physiotherapy profession in Nigeria from inception, and up till today, lacked
professional autonomy. During the early years, physiotherapy is often referenced
as a profession subservient or “allied” to medicine. In the UK, physiotherapy is
often described as a profession “supplementary” to medicine.
23 | P a g e
6. The adage that there is strength in number is still an illusion for our profession.
The number of physiotherapists in Nigeria is relatively small; and we are unable
to effectively exert political pressure to achieve our defining objectives. Of the
major health professions in Nigeria, physiotherapy has the lowest number of
practitioners. There are over 40,000 physicians, 4,000 dentists, and 3,000
optometrists practicing in Nigeria today.15a On the other hand, we have only
about 2,000 physiotherapists currently in the country. This represents one
physiotherapist to every 86,800 Nigerians; this ratio revealed that Nigeria has one
of the highest shortages of physiotherapy workforce in the world.15bDue to
limited human and physical infrastructures, the seven physiotherapy educational
programs in the country, are unable to produce enough physiotherapists to meet
the national demands.
7. In the early years, physiotherapy profession in Nigeria faced external threat from
the WHO. Our forbearers aggressively and successfully tackled the threats but it
cost them money, time and effort that could have been spent to develop the
profession.
8. The influence of physiotherapy within the Nigerian society-at-large was
diminished by the amalgamation of our profession with other health disciplines
during the establishment of the MRTB. No other major profession in Nigeria
today has a regulatory board that is composed of multiple professions. This issue
might not be a battle to take on right now, but it is worth revisiting it at the
appropriate time in the future.
9. The existing entry-level baccalaureate degree education in physiotherapy is
inconsistent with clinical doctorate that is awarded by medicine, dentistry, and
veterinary medicine. These professions command more power and influence than
other professions with entry-level education at the baccalaureate degree level
(physiotherapy, pharmacy, survey, engineering, and librarianship).
10. There is limited public awareness of our professional identity and our roles
within the health care system is unclear to many Nigerians; this situation is
antithetical to the professionalization process. We need to launch a mass
campaign to educate the public-at-large about our work and rebrand our image.
24 | P a g e
Moving Forward: Appeal for Unity
Physiotherapy, like other major occupations in Nigeria, has in the past experienced
internal rivalry and dissension within the leadership. We should take solace in the fact
that our experience pales in comparison to the strife and discord among other
professional associations such as the Nigerian Bar Association, Nigerian Medical
Association and the Pharmaceutical Society of Nigeria.33 We are all aware of the never
ending rift between the Institute of Chartered Accountants of Nigeria (ICAN) and the
Association of National Accountants of Nigeria (ANAN). In 2007, ICAN sued to have
the bill establishing ANAN declared void. 34
Thank God, we physiotherapists are more civil to each other than the other professionals
in Nigeria. Thus far, we physiotherapists have not involved the legal system in resolving
our cacophonies which have been relatively contained. Mind you, I do not take comfort
in the misfortunes of the other professional association, but physiotherapy can certainly
use the unfortunate experiences from the other professions as teachable lessons to guide
our future behaviors.
To this esteemed body, previous key note speakers, Dr. Muoyo Okome and Professor
Victor Obajuluwa, have expressed grave concern about the never ending conflicts within
our ranks arising from petty jealousy and acrimony even on fundamental issues.
Professor Obajuluwa alluded to the pervasive friction between the “academicians” and
the “clinicians” within our profession. He stated that “both factions fought themselves
like there would be no tomorrow, fighting with everything lethal and non-lethal such as
blackmail, character assassination, hatred and malice. 35
Adversity within any organization is always a clog in the wheel of progress. The lesson
learned from the conflicts within our profession is that the time and efforts spent on
feuding can better be used to enhance the rapid transformation of our professions. Our
tribulation, which I was told is behind us, is a thing of joy. But I remain concerned that it
may occur again in the future. Therefore, we need to be vigilant and all hands should
remain on deck.
Mr. Chairman, I will use this seminal moment to appeal for unity within our ranks.
Unity is important because a house divided cannot stand. For physiotherapy profession
25 | P a g e
to attain its full potential, we need to work together as a cohesive group, and be able
speak with one voice when we find solution to complex and vexing problems that will
confront our profession in the years to come.
Chief Ajao’s Unfinished Mission: Call for Political Discourse
It is high time our profession heeded the call made in 2011 by our late visionary leader,
Chief Christopher Ajao.33 In his address to the 41st annual conference of the NSP held
at Benin, Chief Ajao passionately pleaded that: “the time is now ripe for physiotherapists
to broaden the area of activities and engage activity in the field of political discourse.”
But who is Christopher Ajao, and why do we need to take his recommendation so
seriously? Chief Ajao needs no introduction to my generation of physiotherapists; but a
brief iteration of his illustrious life story is warranted here for the benefit of the
Millennial or Generation Y colleagues in the audience.
Chief Ajao was born on September 9, 1932 at Ogbomosho. He received his
physiotherapy education from Bradford School of Physiotherapy in the United Kingdom
(UK). 36 Chief Ajao, an unimposing statured, ebony skinned African with the traditional
Ogbomosho facial tribal marks, was one of the pioneers of physiotherapy profession in
Nigeria. I never had the privilege to know him close-up before he passed to the land
beyond our shores. I only met him twice as an undergraduate student at the University
of Ibadan. Both occasions were in 1976 and 1977 when he addressed the attendees of the
NSP conference. It was a thing of joy to witness the vocal power of this “larger than life”
physiotherapist as he intensely engaged his audience.
I heard great testimonies about Chief Ajao’s kindness and stupendous achievements
from my colleagues (Dr. Babatunde Adegoke and Mr. Yekini Akanni) who worked for
him in 1978 and beyond. Chief Ajao co-founded the NSP in 1959 with Dr. (Chief)
Thompson Abayomi Oshin. He was the pioneer secretary, and the first indigenous
President of the NSP. He served as President for three terms. Chief Ajao contributed to
the literature by documenting the history of the early years of the physiotherapy
profession in Nigeria.
Chief Ajao was the first Chief Physiotherapist in the old Oyo State and the first
physiotherapist to be appointed into a state-wide political office. He served in the early
26 | P a g e
1980s, during the military dispensation, as the Commissioner of Information and
Culture. Prior to his political appointment, in 1974, Chief Ajao introduced the concept of
community physiotherapy throughout the entire Oyo State by bringing services to the
door step of the disenfranchised and those with disabilities. This was an era in our
development when physiotherapy practice was confined to the four walls of the hospitals
and physiotherapists were never considered to have a stake in disease prevention. He
was such a gutsy leader; and decades ahead of his time. It is therefore so appropriate to
honor this patriot with an NSP memorial lecture to immortalize his legacy.36
I not only support Chief Ajao’s point of view on the need for political discourse; but in
fact would encourage more physiotherapists to seek elective office and use that platform
to elevate the image of our profession. Our noble profession desperately needs men and
women of Chief Ajao’s stature to provide steady and visionary leadership as we embark
on the last phase of the journey to true professional status. I will during the Third
Christopher Agboola Ajao’s memorial lecture tomorrow morning provide a 12 step
recommendation that I believe will transform our profession to one with esteem and
power in the years to come.
Conclusion
This presentation is my recollection of several events of historical significance to our
profession that spans over four decades. I am sure there are other points-of-views, and I
encourage my colleagues to contribute their quota in documenting our history. As a
profession, we are today embroiled in an attrition and retention quandary that requires
urgent attention. Although there are over 4,000 physiotherapists on the register of the
Medical Therapists’ Rehabilitation Board, only about 2,000 physiotherapists are
currently practicing in the country; the remaining 2,000 physiotherapists are practicing
in other countries around the world.37This is a major brain drain on our national
economy. To stem the tide of this conundrum, the condition of service of
physiotherapists must be significantly improved to incentivize our colleagues from
seeking greener pastures outside the country.
The aspiration to attain true professional status will only materialize if our vision is
shared among present and future physiotherapists. Given the importance of this vision
to our existence as a profession, I am of the strong opinion that professionalism contents
should be integrated into all physiotherapy curricula in Nigeria to better educate future
27 | P a g e
generation of practitioners. To actualize this recommendation, the NSP should ensure
that the proposed entry-level DPT curriculum under review by the National University
Commission includes the following contents on professionalism:
History of occupations around the world and in Nigeria
The developmental milestones of major occupations in Nigeria
Meanings of professionalism and professionalization
Classifications of professions
Characteristics of true professions
Fundamental attributes of professionalism
Path to Professionalism
Roles of the World Confederation for Physical therapy
Global perspectives on physiotherapy education
Pros and cons of direct access
To survive and prosper in the uncertain future of our educational and health care
systems, the NSP must develop strategies that will promote the professionalization of
physiotherapy. No doubt, we are at a pivotal phase in the transition of our profession to
greatness, and the path to our destiny will be fraught with challenges; but this is a
possible mission that we must create and bring to a successful conclusion. It is not in the
stars that we should hold our destiny but in our collective efforts. Only we
physiotherapists can control our destiny. I concur with Bob Marley who asserted that
“Every man gotta right to decide his own destiny.
” 22
Let each of us with solemn disposition and common purpose commit to answer this call
to duty with passion to carry forward the efforts of our progenitors. Let us finish what
our first generation practitioners started. As long as we are persistent in our pursuit of
our common goals, I am optimistic that we will reach our destiny. Moving forward, each
of us has to commit towards doing our best and extending ourselves just a little more
and the future will take care of itself.
I would like to conclude my presentation with excerpts from Hymn 703 of the Anglican
Hymnal Book: 38
Lead us, O Father, in the
paths
of peace,
without thy guiding hand we go astray,
and doubts appall, and rows still increase
28 | P a g e
lead us through Christ, the true and living Way
Lead us, O Father, in the
paths
of right,
blindly we stumble when we walk alone,
involved in shadows of a dark some night;
only with thee we
journey
safely on
Lead us, O Father, in the heavenly rest,
however rough and steep the
path
may be;
through joy or sorrow, as thou deemest best,
until our lives are perfected in thee.
I appreciate your listening to my review of our history, past challenges, emerging
threats and opportunities. I believe we can use the lessons learned from our past to
accelerate and transform our profession to the next level of excellence. I hope you will
join me tomorrow morning when I will engage in the discussion of the “next step” and
“way forward” for our profession. God bless the NSP, God bless the Federal Republic of
Nigeria and God bless the United States of America, my adopted country.
Acknowledgement
I would like to recognize key individuals in my personal and professional life. First and
foremost, I am indebted to my number one fans, my wife, Adetutu, and our four
children (Omotade, Omotayo, Omotola and Omotoluwafe) for their steadfast support;
and for providing me the time and space to put in my best effort as a faculty member
and a university administrator for over three decades of my professional career. My
gratitude also goes to Dr. Chidozie Mbada for sharing his two recent studies on
professional identity and professional autonomy; and for bringing to my attention some
of the references cited in this report. Furthermore, I am grateful for the assistance that
Dr. Muoyo Okome and Dr. Longinus Nwachukwu provided in validating my recollection
of events at the University of Ibadan in the 1970s.
29 | P a g e
References
1. Highlights of the NSP Workshop at Igbobi. Newsletter of the Nigeria Society of
Physiotherapy. National Physionews, 1 (3):16, pages 6; 28.
2. Oshin TA (1999): Physiotherapy: Yesteryears, Presently, and in the next
millennium, During the 40th Anniversary Celebration of the Nigeria Society of
Physiotherapy, Osun Presidential Hotel, Osogbo, Osun State, Nigeria. The Official
Newsletter of the Nigeria Society of Physiotherapy. National Physionews, 1 (3):16,
pages 5; 8-9.
3a. Mbada CE, Ojetola KD, Adedoyin RA, Okafor UAC, Johnson OE, Ogundele AO,
Awotidebe, Olumide TO, DadaO. (2015). Nigerian physiotherapists’ perception of
direct access and patients’ self-referral. Nigerian Journal of Medical
Rehabilitation 2015 Vol. 18, No 1, 1-20. Available at
http://www.njmr.org.ng/index.php/njmr/article/view/105
3b. Mbada CE, Ola-Ojo MJ, Johnson OE. (2015). Awareness, knowledge and
perception of professional identity of physiotherapy among residents of three
rural communities in Ife North local government, south west, Nigeria. Ghana
Journal of Physiotherapy, 6(1): 1-14
4. Etizioni A. The Semi-Professions and their Organizations: Teachers, Nurses and
Social Workers. New York: Free Press; 1969.
5. Williams, B., Brown, T., & Onsman, A. (2009). From stretcher-bearer to paramedic:
The Australian Paramedics’ move towards professionalization. Australian Journal
of Paramedicine, 7(4). Retrieved from http://ro.ecu.edu.au/jephc/vol7/iss4/8
6. Swick HM (2000). Toward a normative definition of medical professionalism.
Acad Med. 75(6):612-616.
7. Connelly JE (2003). The other side of professionalism: Doctor-to-doctor. Camb Q
Healthc Ethics. 12(2):178-183.
8. Forsyth BF, Danisiewicz TJ (1985). Toward a theory of professionalization. Work
Occupations; 12(1):59-76.
9. Carr-Saunders AM, Wilson PA. "Professions" Encyclopedia of the Social Sciences.
New York: MacMillan Company; 1944.
10. Wilensky H. The professionalization of everyone? American Journal of Sociology
1964;70(2):137-87.
11. Freidson E (1970). Profession of Medicine: A Study of the Sociology of Applied
Knowledge. New York: Harper & Row Publishers Inc; 1970
12. Vollmer HM, Mills DL (1966). Professionalization. New Jersey: Prentice-Hall Inc;
13. Ritzer G (1975). Professionalization, bureaucratization and rationalization: The
views of Max Weber. Social Forces 1975;53(4):627-634.
14. Mathur S (2011). Doctorate in Physical Therapy: Is It Time for a Conversation?
Physiother Can. 63(2): 140–142.
30 | P a g e
15. Balogun JA. (2015). A descriptive study of the professionalization milestones of
the twelve major occupations in Nigeria. A paper presented at the Scientific
Session of the 55th Annual Conference of the Nigeria Society of Physiotherapy
held at Lokoja, Kogi State, Nigeria.
15b. (http://www.who.int/disabilities/world_report/2011/chapter4.pdf).
16. https://en.wikipedia.org/wiki/Profession
17. National Initiative for Cyber Security Education. A historical Review of How
Occupations Become Professions.
http://csrc.nist.gov/nice/documents/a_historical_view_of_how_occupations_become_
professions_100312_draft_nice_branded.pdf
18. http://www.chrisreynoldspractice.co.uk/physiotherapy.asp.
19. http://www.apta.org/History/. Or
http://www2.paeaonline.org/index.php?ht=a/GetDocumentAction/i/69169SimilarY
ou
20. http://www.nigaps.org/physionghx.
21.http://www.brainyquote.com/quotes/quotes/w/williamwor140940.html#GdLJOl2lpkdT
B14A.99
22.http://www.brainyquote.com/quotes/topics/topic_future.html#01KbZoXbh3GEGPxQ.99
23. http://www.brainyquote.com/quotes/topics/topic_future.html#g5j5DJGHp0PF4BXy.99
24. Oshin TA (1986). History of Physiotherapy Training at the University of Ibadan
1966-1987. Published by Association of Physiotherapy students, University of
Ibadan.
25.http://www.nigeriaphysio.net/media/archive1/eulogy/Godwin_Eni_Tribute_to_Nwuga.p
df
26. Kenny DT, Adamson B. (1992). Medicine and the health professions: Issues of
dominance, autonomy and authority. Australian Health Review, (15):3, 319-334.
http://www.academia.edu/3485872/Medicine_and_the_health_professions_Issues_of
_dominance_autonomy_and_authority
27. https://www.mrtbnigeria.org.ng/en/about-mrtb/Welcome-to-the-MRTB.
28. Medical Rehabilitation Therapists Board (MRTB) (Registration, etc.) (2014). Act
subsidiary legislation. Enabling Law .Decree - #381. September 30th 1981.
https://www.mrtbnigeria.org.ng/en/about-mrtb/enabling-law. Accessed 02/09/2014
NAN (2014).
29. http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS
30. http://www.who.int/pmnch/activities/countries/nigeria/en/index1.html.
www.bioline.or
31. http://collections.infocollections.org/whocountry/en/d/Js7928e/8.html
32. http://www.ijhssnet.com/journals/Vol_2_No_15_August_2012/38.pdf.
31 | P a g e
33. Ajao C.A. (2001). Chairman’s Address to the 41st Annual Scientific
Conference/Workshop of the Nigeria Society of Physiotherapy. National
PhysioNews, 1 (3):16
34. https://en.wikipedia.org/wiki/Institute_of_Chartered_Accountants_of_Nigeria
35.http://www.nigeriaphysio.org/media/archive1/documents/UNITYASCOMPASSANDP
ATHFINDERTOPROFESSIONALGROWTHOFPHYSIOT.pdf
36. http://www.nigeriaphysio.net/?section=news&cmd=details&newsid=31.
37. Personal Communication with NSP President, October 2015
38. The Hymnal 1982 According to the Use of the Episcopal Church. Copyright 1985
by the Church Pension Fund, 445 5th Av., NY 10016.
