We have started our Descent: Strikes and the Future of Public Sector Health Delivery

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.

The health sector ought to be the sector where compassion should be found. Photo Credit: Nigeria Health Watch
The health sector ought to be where the most compassion is found in a society. Photo Credit: Nigeria Health Watch

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.

Why Strikes continue to persist in the health sector. Infograph Credit:
Why Strikes continue to persist in the health sector. Infographic Credit:

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.

Junior Doctors in the UK went on strike for the first time in history in April 2016. Photo Credit:
Junior Doctors in the UK went on strike for the first time in its history in December 2015. Photo Source:

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

It's time to start a deeper conversation about the health sector.
It’s time to start a deeper conversation about the Nigerian 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:

Health workers performance evaluations should take into consideration their patient care approach. Photo Credit: Nigeria Health Watch
Health workers performance evaluations should take into consideration their patient care approach. Photo Credit: Nigeria Health Watch
  1. 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.

    Have appropriate numbers of health personnel for patients. Photo Credit: Nigeria Health Watch
    Have appropriate numbers of health personnel for patients. Photo Credit: Nigeria Health Watch
  1. 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.
  1. 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.

    Ensure transparency in reporting from tertiary hospitals.
    Ensure transparency in reporting from tertiary hospitals.
  1. 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.

    National Health Act Infographic 1

  1. 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.
When doctors and nurses go on strike, it is patients who are left stranded without care. Photo Credit: Nigeria Health Watch
When doctors and nurses go on strike, it is patients who are left stranded without care. Photo Credit: Nigeria Health Watch

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.


24 replies on “We have started our Descent: Strikes and the Future of Public Sector Health Delivery”

Absolutely true and honest with realities of the matter. I also agree with the recommendations. The question is, where is the political will to implement this and others…..?

Really good piece…
There needs to be a frank discussion about the rights and privileges of emergency services workers (which in my opinion includes doctors and nurses on duty), with the aim of ensuring that they are unable to down tools ‘willy-nilly’.
Nigeria needs to pass legislation that does not deny their right to strike action but establishes a process that ensures it the last resort following arbitration process that is overseen by an independent body whose ruling is binding on both the State and its employees (in this case, medical health workers)

I am of the view that strike at the expense of the helpless-sick must never be allowed no matter the degree of provocations and that other measures could be explored to address any misgiving that may arise in the healthcare industry.

Though reflective of the wider Nigerian Society, Corruption in the Health Sector is as embarrassing as it is shameful. That it predate this era is no justification. Unfortunately, as health workers. we have not demonstrated the prerequisite ethical standards in our professional conduct. This explains why nobody talks about quality of care, and how to guarantee that for our clients. We demand value for money in other sectors, but look the other way in our own sector that needs it most. Surely, having an accountability framework in place for the health sector is a sure way forward. It will detail what’s expected of every stakeholder. Unfortunately, the Federal Ministry of Health which is best suited to lead this cannot, because it is said that you cannot give what you don’t have. Let us all pull together and make this happen in a public -private synergy. This medium has already created a platform. I am in….Will you join, and stand to be counted??? Will you rather, as most people would, sit on the ubiquitous fence???? Let us seize the moment and momentum….

In addressing the ills in the healthcare system, the key players; the medical doctors, medical laboratory scientists, nurses, pharmacists, etc should demonstrate professionalism with their conducts. Collaboration among these caregiver should be the mandate for available, accessible, and affordable care with the challenge of grossly inadequate healthcare facilities. Policy matters on health issues should be jointly harmonized by all player- representatives with the minister/commissioner of health presiding at such a forum. And where/when there is a friction in function an arbitration panel comprising elders of the healthcare system and the state functionaries where applicable should sue for amicable resolution.

I am in total agreement with this initiative. Healthcare delivery in the public sector in Nigeria is an embarrassment. It is bedevilled with corruption, lack of resource and professional accountability. The tertiary facilities that should act as ‘factories’ for highly skilled workforce, centres for high quality clinical service and research have failed in these functions. Corruption and lack of accountability are the key reasons for the breakdown of relationship between physicians and other healthcare professionals. Professionals now spend more time being vibrant trade unionists rather than good doctors, nurses, etc to their patients. This discussion must start and must start now. Please count me in.

Thank you for bringing this issue up for discussion and your suggestions. The issues in the government health sector is a reflection of the entire public sector. There have been committees set up to look into some aspects of these in the past. I think their reports need to be revisited or analysed in a forum like this before going round another cycle

Thank you for once again drawing our attention to this rapid descent we have embarked upon. I agree with your analyses, and share your sentiments for an eventual collapse of the tertiary health care delivery system in Nigeria as is known today. We as doctors must be in the forefront of salvaging this profession because we are its custodians. No one can be more concerned with its decline than us. As we embark on these endless strikes, we erode public confidence on the profession, trivialize the profession and diminish our own individual self worth and value. Can you imagine a pilot walking out on you midway in a flight? But we walk out on patients in labour and those in ICU. I have appealed to the young ones that you cannot treat a profession with such disdain and expect it to provide the platform for you to pursue a career that will get you to the stars in 30/40 years time as it has done for a number of us. It will not happen. public opinion about you will be so bad that the public will consider you as a nobody. It will be payback time for the public.

This is an amazing piece, I completely subscribe to most of the points raised here. As a researcher, I see how these strikes cripple research activities within the so called teaching hospitals and research institutions. We simply have not quantified the enormous loss and damage done to our reputation as a country. These strikes make samples and materials often in projects from grant provided by tax payers money elsewhere go wasted, materials cant be sourced at the right time because grant admin is off duty, on and on the story goes. We simply need to overhaul the healthcare system in Nigeria. But first we need to show in quantifiable terms how much these strikes cost us as a nation. Thanks for the piece once again.

This article says it all in a language that most Nigerians particularly, the health workers may not appreciate but truth is truth and is a “constant” that will never change. This situation is rather unfortunate and embarrassing. Yes, there is so much rot in the system and what is being witness is an indication of systemic failure but must we as doctors further contribute to it by worsening the appalling health indices? What has all the previous increase in remuneration translate to? Poor quality of care and abysmal service delivery!
It is time to re-examine our conscience and work ethics otherwise we shall not only descend the hill with fractures and possible mortality but also would become extinct as documented in this article. While I agree with all the recommendations, I also want to suggest that the patients holds the key to the health workers being retained through patients’ evaluation and clients satisfaction processes.
Let me add that the older and senior doctors must be the vanguard to institute corrective measures into the profession otherwise, posterity will mark them as “failures”. I am therefore, appealing to all concern for a re-orientation and attitudinal change after-all, the people suffering are our people.
It is a collective responsibility on all medical professionals to arrest this monster before we are consumed.

This is a wonderful one, an answer to my prayers.
We can, it’s just that it looks like even the healthcare professionals have totally forgotten why they are there. Incessant quest for increase in salaries without considering, quality of care and job satisfaction. Unionisms has not also helped.
Employments are also done as if to alleviate poverty. Worsened by the fact that the health workforce are concentrated only in the urban arears.

This write up has indeed spelt out some of the factors that must be put in place to refurbish the Nigerian health sector. I really wish these recommendations will be read by those who need to lead and implement the policies. The level of degradation within the health sector is indecipherable and quick actions needs to be taken.

I rarely make comment on online articles, but this one strikes a resounding chord within me. As usual, it is well written in the style of Nigeria Health Watch! Kudos….so, on to the next step: “Belling of the cat”. Who is that entity to lead the five recommendations above? Is it the FMoH? NMA? JOHESU? Or a coalition of patients? There is an urgent need for a seismic shift to halt the way our Health System is being broken daily. Where do we start from?

Very nice article. There should be transparency in finances of the health sector. The health practitioners keep going on strike almost every now and then; and I begin to wonder what is the primary motive of being a health practitioner. Is it to save the lives of dying citizens who need medical attention or to enrich themselves? Have they forgotten about the hippocratic oath which was freely sworn by them? I believe this is a fight that has to be fought by both the citizens and the Government.

Very incisive write up.
However, the write up gives the impression that health care in Nigeria begins and ends with tertiary health care, which is not the case. Primary and secondary care are worse hit with appalling facilities and manpower situation with governments paying lip service to their improvements.
The nation needs functional primary and secondary health care services up and running so as to deliver adequate health services to her teeming population, pls.

I agree with the suggestions in the well-written article. In particular, there should be more accountability on the part of the hospital managers. However, we, as professionals in the health sector need to be accountable as well: is the taxpayer (who pays us through government) able to get value for money? What are the quality of care indicators which we use to check our service performance? Are there any process or outcome indicators for us to assess ourselves with?
Part of the conversation should include accountability on the part of the employer and the employees. But the millon naira question remains: who will lead the conversation on the required national scale? Who will bell the cat?

Nice one and very insightful!! Nigeria health system is crying for a reformation but the authorities concerned are not ready for that because they are benefiting from the old order. Change we know always have it’s opponents and proponents. The time is ripe for the proponents of a reformed health care system that is patients centered to push harder. I totally agree with you.

Well done summarizing some of the problems facing the Nigeria health sector and proffering suggestions for improvement. I am happy NHW is championing the use of statistics to monitor the impact of strikes.
The write-up reminds me of an observation I made a few weeks ago where an online recruitment drive for healthcare workers (medical and allied) by a teaching hospital did not have a single line of job description. It made me wonder how applicants determine if they matched a job or how an appropriate match is recruited, and when recruited, how does the new staff or old staff on promotion or reassignment know what is expected of him or her?
This is related to the ongoing inter-professional strife which is an underlying theme of industrial actions these days. A situation where all professionals want to be paid more and to have rights to management positions is incentivised by a context in which no particular outcome is expected. No one has been fired for performing below par or praised for exceeding expectations so it is a situation where anyone could muddle through the required tenure. This will be sorted if all public hospitals are required to demonstrate profitability.
I notice a few people have made comments here asking who would lead the discussion or the change. This looks like people trying to push the responsibility to someone else. May I suggest that the discussion and change could be led by anyone (regardless of age or professional affiliation) with clear vision of the health system that he or she wants everybody (regardless of class or wealth) in Nigeria to enjoy. The health sector is just one section of the general society and everybody in society is a stakeholder (no major or minor). This made me look for NHW’s usual Margaret Mead quote “never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has” but I saw it is no longer on this page. Maybe it is time to bring it back.

We had several conferences on the Nigerian Health System in the past with at least two major ones in the last 15 years but I will agree with Healthwatch that another Indaba is required , this time with sense of determination and timelines for implementation. It is, as a number of contributors observed, a problem of the entire health system. Primary, secondary and tertiary and involved all cadres of Healthcare personnel from Doctors, pharmacists, nurses, laboratory scientists , radiographers to the CHO, environmental officers CHEWS and JCHEWS.
The absence of goodwill and altruism among health workers is probably related to our training and also to kind of selfish and materialistic decadent society the young professionals find themselves in. The objective of each health worker in each cadre of health profession is to become a CMD or equivalent in order to control resources. This emphasizes the immediate need for strict accountability and blockage of leakages to make those few positions less attractive.
The intermediate intervention In this is the review of Healthcare curriculums at all level to emphasize healthcare as a call to duty and extensively work on etiquette and altruism as the main attraction to the field of healthcare . The long term is of course a reform of the society which may happen in many years to come – if indeed it is a goal for the country.
Medical care personnel will not go on strike on minor excuses if their employment is based on renewable contracts of one or 2 years duration as happen in other countries and they are re-employed at intervals in competition with other applicants. With the recent innovations in pension management and pension reforms ,the so called permanent and pensionable appointment is no longer the best form of security for pensioners.
There can not be unity among health professionals when their individual and collective focus is not on the patient. And there can never be unity among the professional groups when we have upto 36 regulating bodies attempting to regulate one health services system. You want to regulate health, you need one effective regulating body with the skills to respond to each professional sector.

Indeed a good writeup but the change needed in the health sector will not come if we the beneficiaries do not take up the fight. We have to spearhead the agitation for the change then the government will be forced to intervene. We’ve remained docile for too long a time.

This piece has really highlighted some of the major issues that are making the Nigerian health sector heading for the rocks. Many useful comments have been made and if these are looked into critically with the aim of turning things around for good, what we are experiencing today will one day be history. It takes two to tangle. For long, a good number of agreements reached between health workers through their union leaders and authorities who are the employers of labour are never implemented. No one is happy with the recent developments in the health sector at all levels for both the public and private health facilities. One thing we must agree is the fact that each one of us is a potential candidate for admission in a health facility either primary, secondary or tertiary in a public or private set up. It is high time we looked into issues leading to strikes in the health sector with a view to putting a halt. A good number of strikes are not just for remuneration but for provisions of conducive working environment and provision of needed tools to render effective and efficient services. A stitch in time saves nine.

I enjoyed the article on strikes in the public health sector. You are on point. I also agree with your recommendations for moving the country’s public health sector forward. It will however require the government with strong political will, the populace with genuine sincerity of purpose and focus to re-jigg the whole system.

We have operated on a faulty foundation in so many aspects of our national life for so long, not only in the health sector.
Well, let the conversation continue with round table discussions among stakeholders. Hopefully we will get it right someday.

I was going thru my Son’s health education note with him in preparation for their third term exam. In one of the questions,they were asked to list problems affecting the health sector and to my surprise one of the problems listed was nurses and doctors go on strike.
Talk of the effect of these repeated strike on posterity,these kids already are getting a negative impression of what health professionals stand for so for their sakes and the ones who put their life in our hands I say we forge ahead and whole heartedly support any “anti strike” move, afterall we started the trend and should take it upon ourselves to end it.

Well done Chikwe. This is a brilliant analysis. We have discussed this several times as critical issues in the Nigerian health space, and indeed, this reflects both the issues and the very creative solutions. There is the power factor with the professions. The ideas here are also likely to bring that to a positive and manageable level. Kudos and I hope this can get to as many as should read and act on it.

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