Over the past ten years, no sector has been more affected by strikes in contemporary Nigerian history, than the health sector. Paradoxically, given the nature of its work, this is an area where one would assume that the most compassion in any society should be found. It does not add up. We need to reset our health and care services so they are fit for the 21st century.
Everyone in Nigeria used to respect doctors and nurses. And why not? These are jobs that are as demanding as they are vital. Healthcare workers were seen as arbiters of life and death, a duty that was held sacred. But the endless cycle of strikes seem to be eroding much of this. While doctors, nurses, and other healthcare workers often have a genuine dissatisfaction with the facilities where they work, accessibility to drugs, and general conditions of service, the core issue at the heart of these strikes has been remuneration and status.
Perhaps, it is time to expand this conversation beyond healthcare workers and government. Leaving it to healthcare workers and government in the past has only led to “collective bargaining agreements” (CBAs) for improved wages and conditions of service that have been unsustainable. Government accedes to these collective agreements in the heat of each strike, and it quickly becomes obvious that it cannot fund the agreements, especially when other professions start agitating as well, and then we are back to square one, and a new cycle begins.
At the moment, there appears to be only one inevitable trajectory to the situation with strikes; more strikes, which lead to more disruption, which leads to more risks to the professional reputations of doctors and nurses, leading to more loss of public patience, and ultimately, this will inevitably lead to the failure of the public sector healthcare delivery system. Without radical reforms, it is hard to see how the current management arrangement of tertiary hospitals in Nigeria will survive. Just like NEPA and NITEL, we have started our descent.
We do not realise the damage done by strikes in our context because no one bothers to count. When junior doctors working in the UK’s National Health Service (NHS) went on strike for two days recently, the first time this was happening in its history, it led to the cancellation of 125,000 operations and appointments. In Nigeria, strikes continue for months, with associated loss of life and income. If we counted the damage done by strikes in Nigeria, there would be widespread outrage.
The time has come to have a deeper conversation on the impact of strikes by health care workers on the lives of Nigerians. Nigerians can no longer afford to leave this to the professionals and the government to resolve. The Government is there to represent us, by allocating our common resources to pay health workers to provide care for us. It is time for us to raise our voices and assess how both our government and the healthcare workers employed on our behalf are fulfilling their responsibilities to us.
Getting out of the choke-hold of strikes in the health sector
In order to achieve success, and stop this alarming descent, we must urgently commence an Indaba, a conversation process, whose recommendations must lead to implementation, and not be shelved like the many previous ones. We must find some eminent and credible Nigerians to lead this conversation. It will have to be led by someone outside of the key medical professions because of the loss of trust among health sector professionals. During this Indaba, we must address some of the most fundamental issues facing the sector, which we have chosen to overlook over the years. There are five critical points that we think must be addressed:
- Introduce accountability into patient-care – There must be a relationship between salaries in public sector hospitals and outcomes. Outcomes have to include both process outcomes, such as numbers of patients seen, clinical outcomes, as well as patient satisfaction. As long as there is no form of accountability in the sector, the only source of motivation to work is healthcare workers’ altruism, which unfortunately is not sufficient in our context.
- Understand the appropriate doctor/nurse to patient ratio appropriate for each department in our tertiary hospitals – The situation at the moment where a single tertiary hospital has upwards of 20 consultants in a single department, and a handful in other departments, unrelated to activity, is simply unsustainable. Over the past few years, the government has continued hiring staff without any analysis of need or any understanding of workload. It is no surprise that they end up being unable to pay.
- De-centralise salaries – Every tertiary hospital in Nigeria currently arranges its own procurement of everything from paracetamol to equipment. There is absolutely no point anymore for a uniform salary structure from Port Harcourt to Potiskum, from Abeokuta to Damaturu, when the circumstances, cost of living, work load and almost every criteria to determine pay is radically different across Nigeria. Trying to sustain a uniform pay band across Nigeria might provide for equality but definitely not equity.
- Make every tertiary hospital in Nigeria publish its accounts – In tertiary hospitals, the “Chief Medical Directors” are Chief Executives with un-paralleled powers. Every decision begins and ends with them. Other than the annual publication of budgets, no one knows how much money they get from the Federal Government, from the National Health Insurance Scheme, from fee-paying patients or how much they are spending. Let Nigerians know how much of their money is going to salaries, medicines, equipment, etc.
- Implement that National Health Act – The new National Health Act provides for the establishment of a National Tertiary Health Institutions Standard Committee that would regulate tertiary health facilities, providing guidelines for the use of Tertiary Hospital Management Boards. If this is implemented, and hospitals held publicly accountable to its implementation, this will make the consequences of strikes much more immediate for each hospital.
We have always held the opinion at Nigeria Health Watch that strikes should be an extreme last option for healthcare workers. A strike means walking out on our patients, leaving them in the ICUs and emergency rooms. We recognise the challenges that many Nigerian healthcare workers face, trying to deliver care in a context where many of the basic functions of society are broken or non-existent; and the responsibility of the employer to the employed. But we also believe that a person choosing healthcare as a profession must examine their motivation and understand the choices that they make.
It is time for this conversation to happen, or else our descent will continue, and it may just reach the point… of no-return.