**4. Why the initial efforts were unsustainable?**

These initial efforts were not sustained owing to the following factors: poor funding and total neglect of health sector, brain drain syndrome, reliance on medical tourism, and competing double burden of diseases as well as corruption, nepotism. Other issues were poor social infrastructures such as public power and water supply, poor remuneration of health workers with incessant strike actions, and insecurity in the land and inter-professional conflicts [1].

#### **4.1 Poor funding and neglect of health sector**

Low government health spending over the last two decades has limited the expansion of highly cost-effective interventions, stunted health outcomes and exposing large shares of the population to catastrophic health expenditures. Nigeria spends less on health than nearly every country in the world. In 2016, government health spending was 0.6% as a share of GDP or just \$US11 per capita. As a result, Nigeria significantly underperforms on key health outcomes. Maternal mortality at 576 deaths per 100,000 live births is one of the highest in the world (2.6 times the global average); one in eight children dies before reaching their fifth birthday; and 25% of households spend more than 10% of their household consumption on health [13].

### **4.2 Brain drain syndrome**

The migration of health professionals from Nigeria to high-income countries medical brain drain, deserves critical attention due to its adverse effects on the healthcare system (HCS) for developing nations, which indirectly impacts population health outcomes and creates greater inequity among vulnerable populations. This international migration of medical doctors (MDs) has created a great challenge for public health systems; it worsens already weak healthcare systems, which widens the health inequalities gap worldwide. Globally, Nigeria ranks among the worst countries in regard to maternal health outcomes. Although it represents 2% of the global population, it disproportionately contributes to nearly 10% of global maternal deaths [14]. With the current new world order, where the world is a global village, it is very easy and fashionable for members of the team to migrate and work in other parts of the world. With the skill, training, exposure, vigor, endurance, and other qualities, the tested professional can easily leave the service and country and comfortably settle and earn hard currency. The attraction to brain drain is always there for members of this team, and this has adversely affected the growth of pediatric cardiac surgery and other programs in UNTH, in particular, and Nigeria in general. Unless something urgent is done, this trend will continue, and Nigeria will be the loser.
