An interesting scenario played out in 2014. After a strike that lasted about two months, all resident doctors in Nigeria were sacked; the strike was then called off and the doctors were re-instated. This strike by doctors, across public sector hospitals in Nigeria continued for over two months despite the ongoing Ebola outbreak at the time, probably the most important health emergency faced by Nigeria in recent times. Doctors’ unions insisted on continuing the strike despite calls from across the country -from market women to the president-to call it off. After the issues were resolved and the doctors went back to work, it did not take a soothsayer, given the pattern of preceding years, to predict that a strike by non-medical colleagues in the health sector would follow. JOHESU, the main body representing non-medical staff in the health sector has been on strike since November 2014, leaving most public hospitals barely functional. Again appeals by many Nigerians have fallen on deaf ears. Many patients have suffered the consequences, including the late Prof Akang of UCH, the late Veronica Ezugwu from Enugu State and the victims of a recent terrorist attack in Adamawa. Despite the discontinuation of their salaries by government, the strike has continued. This pattern reinforces a continuing cat and mouse game relating to relative status and pay between doctors and other health sector workers in Nigeria. The interest of the patient never features in these discussions.
When Professor Chukwu was appointed Minister of Health in 2010, he stated as part of his “Action Push Agenda for Health” that one of his top priorities would be achieving “team work and industrial harmony”. As is the practice by this government, a committee was set up: The Presidential Committee on Industrial Harmony in the Health Sector. It had 42 members with Justice Bello Abdullahi of Zamfara State as chairman and produced a draft report which was not released. In 2013, another committee was set up; this time, it was termed the Presidential Committee of Experts on Inter-Professional Relationship in the Public Health Sector to end “unhealthy rivalries” among healthcare professionals. It was led by Yayale Ahmed, former Head of the Civil Service and its terms of reference included a review of the draft report of the Bello Committee to produce recommendations for implementation. The Ahmed committee submitted its report in December 2014 and some of the health sector unions have already began to reject some of the recommendations of the report. While the government can go on setting up further committees, at the end of the day – there are some tough decisions to be taken- which is what leaders are elected to do. Now is the time for the President to study this report and make firm decisions for the Nigerian health sector. Government cannot continue on the path of granting each union their requests, even if it is unreasonable, because it wants to prevent or end a strike. Some insights on how taking difficult decisions are critical in building nations can be found in Lee Kuan Yew’s epic description of the emergence of Singapore: From Third World to First.
For all these strikes, there is an inherent assumption that whenever they are called off, patients will return. This same assumption was made for many years by staff of NITEL and NEPA. Strikes by healthcare workers are slowly and irredeemably destroying Nigeria’s public healthcare system. With increasing access to India, no one that can afford it stays in Nigeria for serious ailments. At the same time, there is increasing interest and funds being devoted to raising the quality and lowering the cost of delivering healthcare in the private healthcare sector as exemplified by the Aliko Dangote backed Private Sector Health Alliance. What this means is that patients are getting used to seeking their healthcare outside the public sector, in the same way that we got used to making phone calls through private sector suppliers when NITEL failed. If patients do not attend public sector hospitals, then governments will have to consider alternative ways of delivering care. One option may be re-thinking the tax funded model of healthcare delivery completely.
Apart from the introduction of user fees, the principal structure of how we deliver healthcare through the public sector has not changed since independence. We have a tax-funded system, including user fees with very little regulation or quality assurance across the various tiers of government. Tax-funded models for the delivery of services in Nigeria have failed across all other sectors and there is no reason to expect that it will function in the health sector. The failure of successive governments to deliver services to the population, means that expecting a tax-funded social model of healthcare delivery to work in this country will not work. And no – we are not suggesting privatization! There are several other ways of using public funds to deliver health to the poor other than directly funding and managing hospitals and clinics.
In the absence of a strong government with a culture of accountability, health sector workers will continue to hold the government to ransom. As a colleague at a Nigerian teaching hospital put it to us simply – “As long as my salary comes from “Abuja”, there is really nothing the CMD (Chief Medical Director) can do to make me work. The only reason I go to work, is out of a sense of duty, many of my colleagues rarely do.” While we are not suggesting that this culture is representative of health sector workers across the country, at the moment there is almost no relationship between the healthcare services provided and pay; right now we have a system without accountability.
While the new National Health Act offers new accountability mechanisms, such as a standards regime for tertiary hospitals and the classification of health services as essential services; given the current scale of problems in the health sector, implementation will be challenging, as trust is broken.
Our view on Nigeria Health Watch has always been that there must be mechanisms for health sector workers to seek redress over issues other than strikes. Our fear is that it is almost too late: strikes have almost made the care provided in the public sector irrelevant to most Nigerians, as most patients now seek alternative sources of care.
Until we put the interests of the patient back at the centre of the care we provide, striking for our own benefits will only take healthcare workers down a path of no return: the “NITEL” path.