After trying hard to avoid putting pen to paper to express the bottled up emotions inside me, a news item on a national TV station has finally pushed me over the edge to try to explain to whosoever cares to listen, the reasons why the NMA is on strike, and why there should be public agitation in favour of it. In the said news item, members of the public are yet to understand the reason for the strike. For the avoidance of doubt, I am a medical doctor and I write from a possibly biased point of view. As you go through this article, you may discover areas where I agree or disagree with the issues raised by my mother association. But while I do that, I will try to be as reasonable and dispassionate as possible.
I do not believe that strikes should be the handle by which the Nigerian government turns, such that it is impossible to press home the demand of a labour union or group in this country without grabbing it. The feverish efforts used to approach an industrial action towards its end can be applied at the moment when there is a NOTICE of action. If this were the habit of those in government, perhaps the current NMA action and many others strikes by other bodies of workers before it would have been averted. My aversion to the use of strikes is even more amplified when it involves the truncation of flow of an essential service – be it power, health, transportation, security or other. The oath which I and my noble colleagues took reads in part, “I will practice my profession with conscience and dignity; the health of my patient will be my first consideration”. In all fairness, I want to say that inspite of the dearth of modern day equipment, dilapidated infrastructure and terrible working conditions, we are still struggling to live true to our promise.
Most doctors I know today work extra hours unpaid, donate to help patients obtain medications or pay bills, or go out of their way to perform “non-doctor” work just to make the patients well. The following two examples are true at least in the Jos University Teaching Hospital. Doctors run around the wards to pick up instruments and case notes (files) of patients, when many times the nurse is idle in the ward. Carrying files and getting all instuments required by a doctor on ward rounds should be a nurse’s responsibility, or at least she should direct her orderlies and substaff on what to do. In addition, she should make contributions, report relevant events which occured in the doctor’s absence, and take her own notes during the ward round. That is what our teachers tell us used to happen in the past. But alas, that is not the case. She sizes up the doctor first, to see his rank. If he or she is a house officer (the lowest cadre), he may just as well proceed without her. Afterall, she has a daughter at home that is older than this “small boy”. African megalomania at its worst. If the doctor is a Consultant(topmost grade), she may then gauge whether this doctor is the “friendly type” or the “difficult type”. Because for the difficult people, the rules have to be obeyed or else there will be trouble. This category of doctors is thus spared the pain of others. My second example, though recently corrected by a circular from management, is that doctors sometimes become porters, carrying blood samples and results to and from the laboratories. In the course of seeking for results in the laboratory, a doctor was recently slapped in the face by a laboratory staff, leading to the management response. While that malady lasted, excuses for the staff who were employed for that purpose ranged from “too few hands” to “engaged with something else” to “its not our job”! for want of space, I will leave other examples alone.
I hope this leaves no one in doubt that we do our jobs (and sometimes the jobs of others – just to make the system work)
Now to the issues.
WHO SHOULD HEAD A HOSPITAL?
Who should head a hospital? Of course, this kind of absurd question would not arise in a private hospital. As we know it, the law in Nigeria requires registration with the Medical and Dental Council of Nigeria (MDCN) and up-to-date payment of Annual Practicing fees for an individual to set up a private hospital. I carefully choose the word “hospital” because Nigeria has an endless number of appelations for both health facilities and slaughter houses. And the nigerian public is so misled that there is now no distinction between hospital, pharmacy, clinic, dispensary, nursing home, patent medicine seller, and a community health officer’s spare bedroom. All manner of attrocities are committed – there are consulting rooms in pharmacies, theatres in nursing homes, abortion facilities in dispensaries, and operating rooms on people’s dining tables. The mess is so mad that everybody who has ever witnessed the administration of an intravenous drug or watched an appendectomy is now fully “medically qualified”. So the criminals who do these things, due to the ineptitude of law enforcement, now see themselves as equal to all others who have licences to practice professionally. And a handsome majority of perpetrators of these acts are the other health professionals and allied health professions.
The problem as I have stated, cannot arise in proper Private hospitals. It is in the public institutions, where salaries do not depend on how much work is done, but on how much the institution receives from the “national cake”. Not on how much training we have received, but on how many years we have been sleeping at the office. Not on our individual skills and interests, but on how many pieces of possibly fraudulent paper are found in our credential file. For if these attributes were to be sought by our employer, we would never have arguments for how much we should receive. Or who should be in charge. Regrettably, however, our employer is an object that neither has a head or a brain. It cannot reason and thus cannot make any reasonable judgment. Our employer is the black gold that runs beneath the land and waters of the Niger Delta and other parts of southern Nigeria. Our employer is crude oil – our birthright and ticket to laziness, our excuse for brazen corruption, and our foundation for mediocrity and lack of desire for development. And to tell the truth, I secretly pray sometimes that the oil would just dry up, if only to induce sanity into our country. For if this employer were reasonable, it would ask why there should be a difference between the private hospital (which performs its duties and makes a profit) and a government institution which is just a black hole into which money is sunk, neither getting profit nor benefitting the masses for which it was built.
The law setting up teaching hospitals specifies that to become the CMD, a person has to have a basic medical degree (here meaning Bachelor of Medicine, Bachelor of Surgery) and have become a consultant, owning a fellowship of one of the Postgraduate medical Colleges, as well as a few other requirements. This is one of the cardinal disputes of today.
Let me introduce the Joint Health Sector Unions (JOHESU), an amalgam of Labour Unions formed a few years ago and basically including all other staff except Medical Doctors. Even to a blind and deaf person, this is an association of strange bedfellows. Pharmacists, Nurses and laboratory Scientists alone would have made some sense. But add Administrative staff, accountants, medical records staff and it starts to get confusing. When you finally integrate cleaners, porters and other junior staff into the mix, it tells what the only object of such a hydra-headed conspiracy could be – the extermination of the disciples of Hippocrates.
JOHESU seeks for appointment of CMDs to be “made open to all competent and qualified health professionals”. The arguments for them are that this is done in some parts of the world, that their members also have medical knowledge, and that it would promote equity and fairness. On face value, these seem to be reasonable and genuine demands. And central to our response has been one issue – training. Apart from medical doctors, other health professionals attend university courses based on the semester system in Nigeria (let us leave out those who have sub-degree programmes for now – they know themselves). Apart from the Pharmacists, who do 10 semesters, most other professionals spend 8 semesters. Two of these semesters however are spent doing basic science, which is essentially same across board. So in effect, pharmacists spend eight semesters and other six, preparing for working life. Now doctors also do the same basic science, with higher credit unit loads than most others. After the first year, however, the difference in training time is incredible. The semester system for the doctor is over. The remaining five years of training are basically without holidays. When there are breaks, they last between 2 and 3 weeks, usually after exams – and in the University of Jos, for example, there are just three major examinations beside continuous assessments, which are regular. So on the generous side, a medical student has perhaps nine to twelve weeks of official breaks out of five years. That is an incredible four-and-a-half years of training. Compare that with six semesters of four months each, totalling 24 months or 2 years. Or for the Pharmacist, eight semesters of four months, which would be two years and eight months. The amount of knowledge difference is surely massive.
Asides that, the doctor is schooled in EVERY aspect of HUMAN medicine – and in appreciable depth. What the other professionals are schooled in, as far as it pertains directly to human medicine, we also learn. So what then is the doctor’s advantage as a chief executive? A doctor has a wider scope of training and is equipped to understand the entire workings of a hospital as it relates to patient care. Thus if a lab scientist, pharmacist, nurse or other health professional for example, speaks to a doctor CEO about the needs of his department or problems they are having, the doctor would fully comprehend. If a pharmacist were giving the same information to a lab scientist, however, the situation would be different. This wide scope of training and central role also has a bearing on decision making for the best possible allocation of resources and manpower, enabling the hospital to run smoothly for the good of the patients. That is why a career engineer would most likely be the head of a construction firm and not a welder or bricklayer, even if they all had PhDs. A lawyer would be the head in the courtroom, whether the clerk has a thorough knowledge of court procedure, court rulings and how to decide cases or not. Its simple logic.
Where people start to argue about whether doctors are trained in management, my answer is that other health professionals are generally no different in that respect. Seeking for “fairness” and “equity” and trying to avoid things being “skewed” has absolutely no bearing in an industry whose objective is to preserve human life. This is not sports or entertainment or tourism, where ignorance and mistakes can be condoned. Any managerial mistake in a hospital can lead to loss of life, which is irreplaceable. And for the records, recent studies in the UK have shown that doctors head very few hospitals in that country, but most of the top 100 performing hospitals are among those headed by doctors. That kind of evidence based argument in a sane society can have no reply. The document regulating the tertiary hospitals in Nigeria has said the doctor should be the head. Since the status quo has not been deemed a failure by the government, it should remain. It is pertinent to add here that the clamour for the interpretation of the phrase “medically qualified” by JOHESU is part of the ploy to co-opt their members into the league of persons entitled to apply for CMD in the tertiary institutions in the country. To be mild, this loophole seeking is simply childish. For if medically qualified were to be a general term for any diploma (certificate) related to medicine, the makers of the law would not have added a postgraduate fellowship, which is peculiar to doctors, to the list of requirements.
APPOINTMENT OF DIRECTORS AND THE POST OF DEPUTY CHAIRMAN, MEDICAL ADVISORY COMMITTEE (DCMAC)
Like I mentioned earlier, we live in a ludicrous society. There is little respect for order, and people appear to be more at home with anarchy than sanity. Let’s go back to the structure of a teaching hospital. There are three directors in a teaching hospital – Director of Administration (DA), Head of Clinical Services (HOCS, also known as Chairman, Medical Advisory Committe – CMAC), and the Chief Medical Director, who is the Chief Executive. The DA handles purely administrative matters, while the CMAC handles issues related to patient care. The CMD, of course, is their superior and serves as the CEO. This ensures that patient care is not sacrificed on the altar of administrative issues and vice versa. There are assistant directors in areas such as nursing, finance, works, and so on. This creates a visible chain if command within the hospital. The yearning of JOHESU is that their members be promoted to Director Cadre within the hospital setting. Knowing the Nigeria we live in, no director will be answerable to another within the same ministry or agency. A director, as far as I know, is only answerable to a permanent secretary. Now unless the titles of the CMD, DA and CMAC are changed, what will become of the hospitals when we have, say, 100 other “Directors” walking the corridors of the teaching hospital? And if you make all the CMDs in Nigeria permanent secretaries today, what will become of the Ministry of Health? For surely, such permanent secretaries will only report to the Minister! And how many ministers can we have at once?
This whole debacle is directly related to the quest for salary increase, if u ask me. How many other government institutions have a hundred Directors within them as will be the case if this request is granted? Now the irony of it is that if this policy is approved, many doctors would also proceed to become directors. But our question is this – what benefit does it add to the system? None! And what does it take away? First, increased wage bills for the government. Secondly, increased anarchy in a system that is already bastardised by unprofessionalism. Thirdly, many “directors” will abscond from their duty posts since they would now be too big to sit in a clinic, laboratory, pharmacy or hospital ward. And who would bear the brunt of it all? Our dear old black oil. Raped, plundered and wasted, but still faithful. Nothing can be more senseless. If people wish to pursue an increasein pay, they are free to do so. But for Pete’s sake, let there be order in the hospital!
On the appointment of DCMACs, JOHESU would simply not hear of it. Their argument is that it is unlawful; possibly because it is not written out in the document that created teaching/tertiary hospitals in the country. But they forget to add that there are circulars from the government that support the creation of the office. Also, the law gives the boards of the teaching hospitals powers to take measures that ensure the smooth running of the hospitals, and these appointments are made by the boards! The job of the CMAC is indeed a tasking one and like every other Director in the civil service, he/she should have deputies to help with functions. I think that is simple enough.
SKIPPING OF GRADE LEVEL 12
The Ministry of Health has issued a circular stating that contrary to what was hitherto obtained, where all other staff of the Ministry skipped a grade level at some point in their careers except doctors, we should also be included. Though the Ministry is still in court over the legality or otherwise of skipping, it is only fair that all members of the family enjoy what our father, the Federal Government, has brought home from his hunting adventures. Abi the oil money don finish? Na on top our head una wan talk say the money no go reach again? Lai lai!. I don’t believe this should be a matter of contention. What is good for the geese is also good for the gander.
THE TITLE OF CONSULTANT AND THE QUEST FOR SPECIALIST ALLOWANCE AND TEACHING ALLOWANCE
Every person and profession has the right to determine how the career progression goes. To that extent, I do not have any grouse whatsoever with people attaining Consultant status in their field. But as the saying goes, things are not always what they seem. This point will require a little of history. Before the nineties, the health system in Nigeria was a lot more organised. There were clearly defined roles for each group of health personnell, and the salary scales truly represented relativity, which is the difference in take-home pay that should exist due to differences in training, skills and input to patient care. Gradually, the unions agitated for more and more increases, more allowances, and so on. But there was a problem lurking. For while the other unions (now grouped as JOHESU) fought and battled the Military governments for pay rise after pay rise, the doctors “kept their cool” and “were more concerned with the good of the patients”. Of course in Nigeria, the loudest person gets heard first. So gradually, the gap between the salary of the doctor and the other professionals closed up. At a point, there was barely any difference. In 2008, after many years of struggle, the government approved a new salary scale for doctors which, though flawed, was meant to correct the relativity between professions. As part of that document, there was an allowance for medical and dental consultants tagged “specialist allowance”. That is the source of the problem. In a quest to get more allowances, the term “Consultant” has suddenly crept into the vocabulary of the other professions, notably Nursing and Pharmacy, of which I will make examples. They perhaps have heard that there are “Nurse Consultants” and Consultant Pharmacists” in other climes. The question is, WHAT ARE THE ROLES OF THESE CONSULTANTS IN THOSE COUNTRIES, AND WHAT ARE THE QUALIFICATIONS REQUIRED TO ATTAIN SUCH STATUS?
According to the UK’s National Health Service website, a Nurse consultant “is a specialist in a particular field of healthcare… and spends at least half of her time working directly with patients, and in addition develops personal practice, is involved in research, and contributes to the education, training and development of other nurses”. To become a nurse consultant, a basic nursing degree is required, as well as a master’s degree in nursing, health services or administration, or public health, with working experience. Some even add that one requires a PhD or at least should be working towards getting one. There are other nurse consultants who may not work with patients but give advice to law firms on medical cases (e.g. malpractice cases) they have in court. The latter type of nurse consultant surely does not fit into our teaching hospitals, but the former may.
Most definitions of a Consultant Pharmacist describe him/her as one involved in the care of the elderly or people in nursing homes, where he reviews their medications. Infact, the history of Consultant Pharmacy actually began in homes for the elderly. Other sources describe the job as having to do with “advanced roles in patient care, research and education”. Even in these countries where the title is mentioned, it appears to be a new and evolving role rather than an established position that has relevance to patient care. Requirements include a Pharm D degree, interest and experience. Some articles I came across also require a Master’s degree in pharmacy. In the absence of proper guidelines and laid down procedure for such appointments, as well as regulatory or accrediting agencies, my view is that caution be exercised in adopting this relatively new terminologies into a developing country’s health system.
The issue of Consultant status is where I may differ slightly from the NMA’s position. Let anybody become a consultant of whatever profession he wants to, as long as there are stipulated procedures for doing so. The caveat is that as far as patient care is concerned, the Medical/Dental Consultant acting directly or through his lieutenant, is the only person to give directives about the patient’s care. To cut it short, being a consultant in any other field of healthcare should not give a person the right to change, obstruct or delay the implementation of a doctor’s management plan. The roles of such specialists should be merely advisory.
On the part of the Government, they can go on and appoint as many consultants as they want –, Nurse Consultant, Consultant Pharmacist, Consultant Physiotherapist, Consultant Optometrist, Consultant Radiographer, Consultant Cleaner, Consultant Porter, Consultant Gateman, Consultant Accountant and Consultant Administrator. Kai, even start having Consultant visitors. Afterall, the Niger delta oil is a whore, and her patrons are endless. Just one more defilement won’t do much harm. Then the next, and the next.
Let me conclude this section with a comment on the issue of teaching and specialist allowances. With the difference in knowledge between a house officer and nurse, the house officer surely does teach them a few things… if the person involved is humble enough. The point is that these guys also teach medical students, nurses and other personnell. Finally, everyone in the Health sector now wants to receive a specialist allowance and teaching allowance. Infact, some optometrists on the CONHESS salary structure now receive specialist allowances from the CONMESS salary structure. Only in Nigeria can such brazen effrontery be seen. One person, being paid on two contrasting salary scales. Well I will leave that to the public to judge, but if without additional training a lab scientist, pharmacist, optometrist or nurse wants to be called a specialist and receive allowances, the gander are also ready. The spree has only begun.
RELATIVITY IN THE HEALTH SECTOR
Now many that are outside the health sector may be confused about this. But to put it simply, the healthcare system revolves around a TEAM. In every team all players are important and perhaps indispensible, but there is always a captain or a leader. Usually the coach will choose a captain either based on current form, or based on age, or based on experience, or based on number of years spent in the team. In medical circles this leadership role, albeit traditional, was foisted on the doctor because of qualities including being central to patient care, perfect understanding of both normal and abnormal body function, understanding of the development of diseease and different options for curing or relieving it, and a general scope of the different areas of human medicine. As is seen in every normal salary structure, the more the training, the higher the pay. That is why a secondary school leaver and a university graduate are not put on the same grade level when they are employed. Even among graduates, those of engineering, law and pharmacy are paid higher than others. Doctors (medical and veterinary) are paid still higher. This is the concept of relativity, put simply.
However in the Nigerian health sector, this rule has been and is being continually thrown to the winds. Some nurses without university degrees earn higher than pharmacists and doctors. From being started out on step 4 of the grade level as used to be the case, House officers are now started on step 2. Reasons? None! Like stated earlier, this is the result of the failure of doctors to use strikes to press home their demands, choosing negotiations instead. The only time when we got heard was during the strikes that introduced the Consolodated Medical Salary Scale (CONMESS) in 2008/2009. And in that document, there were fundamental flaws. For as you moved higher up the scale, your salary seemed to be stagnant. The creators of that document cleverly made the calculations such that a promotion added almost nothing to your total emoluments. This led to a call by the NMA for a new salary structure that makes the effect of promotion better, and government is “still looking into it”. Realising its “mistake”, government issued a circular on the 3rd of January 2014, correcting the anomalies in CONMESS. Take note that this was not NMA’s demand, but even the implementation of the government’s own response to the problem has taken six months. Not a single kobo has been released to that effect. But since we are a breed that has a genetic aberration which has foisted limitless patience on us, JOHESU will have the public believe that we are unreasonable.
One funny tweet I read this morning from @bilquees_01 under the #nmastrike read, “a duke mutum a hana shi kuka”. It is in hausa and means “to beat up someone and prevent him from crying”. This perfectly describes NMA’s situation in Nigeria. We are squeezed in on every side, pressured, ambushed and bashed, but the rule is “Thou shalt not complain”. Each time there is an industrial action, you see sudden movement from the house of representatives, senate, presidency, and the so called “well meaning nigerians”. As soon as we retreat to work to observe the situation, all agreements become unbearable burdens for the government. JOHESU rushes off to introduce another variable to unbalance the equation. But thou, o physician, shalt not talk. For it is you alone that has moral obligation to the sick of the world. Arrant rubbish!
HAZARD ALLOWANCE, RURAL POSTING AND OTHER ALLOWANCES
Let me start with the hazard allowance. I will simply ask a question here to any member of the public. Is five thousand naira (about 28 USD or 18 GBP) enough compensation for any of the following risks to your life (and by extension, the life of your immediate family) every single day? People coughing into your face; blood splashing onto your clothes, skin, eyes and mouth; handling human faeces, urine, flesh and other fluids; working with razors, knives and needles around patients with highly infective conditions (HIV, Hepatitis B, Hepatitis C, Lassa Fever, Tuberculosis and others)?
If anyone would say yes to the question, or argue that they are more exposed to these dangers than the Doctor or Nurse, let them come out. I will stop at that.
When an official of the Federal Ministry of Health (FMOH) travels from Abuja to Portharcourt and spends the night, he gets paid for the inconvenience. But a doctor POSTED to a rural setting away from family and civilisation needs to go on strike to get a circular saying that he should be paid his due. For if that is not done, he may get his money, or a quarter of it. Or nothing.
There is God o!
The current crisis in the Nigerian Health sector is essentially borne out of Government’s non-affirmativeness in handling issues related to clear definition of roles, lack of a global salary structure that takes into account training, skills and competencies, and the toleration of disrespect for laws and circulars of government. This is further worsened by its lack of implementation of agreements and slow response to threats of industrial action across the country.
Doctors, as part of the solutions to this quagmire, have advocated for the signing into law of the National Health Bill as passed by the Senate of the Federal Republic of Nigeria. This will resolve SOME of the problems.
Secondly, a global structure for salaries and wages in the health sector, based on the points stated in paragraph 1 of this conclusion, is key to putting a stop to the impending collapse of the health sector. That action should be based on practices in advanced nations of the world who we aspire to be like. Copying some things related to relativity from the UK’s NHS would be a good start. After that, any further pay rise for staff in the health sector should be done en masse to maintain the relativity across board. This alone will bring lasting peace.
A permanent resolution of these crises thus still lies at the feet of Mr President and his advisers and committees.
I will bow out with a comment on the oath we took, which I quoted earlier. That oath, called the Hippocratic oath and disputably assumed to have originated from Hippocrates, never envisioned that a time would come when a physician (here referring also to a surgeon) would be an employee of the state or work in conditions so terrible that he/she would consider withdrawing services to enforce his rights and those of his patients. Hippocrates never thought that the family atmosphere that existed in all the homes he visited to see patients would condense into vampiric institutions where lieutenents would challenge his leadership and seek to take his place at the head of the team. If he had, he would perhaps have added an escape clause.
For there is no longer any dignity in this practice; and our patients suffer everyday on account of all this back and forth over the same issues. Definitely, some of these problems I have dicussed are at the very heart of the matter, and others are thrown into the fray as a response to the frustration that engulfs us in the moment. But for our conscience to remain and our patients to enjoy the benefits of the doctor’s indepth knowledge and training, the atmosphere has to be right. That is what NMA is standing for today.
Having gone through some of the hard facts in this article, and perhaps having been inspired by my emotive tone, I hope that more members of the public will come to agree that the current strike, apart from seeking to correct some anomalies in the health sector, will ultimately lead to greater good for the primary object of existence of the medical profession – the patient.
Agwaza Maxwell Dagba writes from Jos, Nigeria