Rolling strikes are to blame for Nigerians losing faith in public health

NIGERIA
A woman looks down an empty corridor at the National Hospital Abuja, after staff members went on strike to demand for better employee welfare. REUTERS/Afolabi Sotunde

Health workers in Nigeria have been striking on and off for the last three years. There have been more than eight different strikes involving doctors, nurses and allied health care workers. Felix Obi explains to The Conversation Africa’s health & medicine editor Candice Bailey what lies behind the strikes, and their impact on the country’s health services.

Who is striking and how long have they been taking action?

The strikes have been taking place in Nigeria’s public sector hospitals. Private sector facilities have not been affected. The vast majority of Nigerians go to public hospitals to access and pay for health services because the user fees are far less than private clinics and hospitals, and are often better equipped and have more experienced health workers.

There are three main professional unions that are striking: the Nigeria Medical Association, the National Association of Resident Doctors and the Joint Health Sector Unions, which is an umbrella trade union that incorporates pharmacists, nurses, midwives, physiotherapists and other non-medics.

In December 2013 the Nigeria Medical Association embarked on a five day warning strike. This was followed by a two month strike in mid-2014.

After graduating all medical doctors register with the association. More than 35,000 doctors and dentists from 36 state branches and Abuja, the Federal Capital, fall under it. Strikes called by the association involve doctors in public hospitals owned by both the states and the federal government.

The National Association of Resident Doctors started a 24-day strike in October 2013 and have been striking intermittently for up to a month at a time. There are an estimated 16,000 resident doctors in Nigeria.

Strikes by resident doctors paralyse federal tertiary hospitals as well as state specialist and general hospitals. This is because doctors-in-training are in both the state and federal hospitals.

The Joint Health Sector Unions started striking in November 2014, initially embarking on a three-month strike. There are over 350 000 health workers in Nigeria.

The challenge is that sometimes the strikes overlap, other times they don’t. This means that there is continuous rolling disruption. Sometimes the strikes have been triggered in one union by deals struck between government and another one of the unions.

What’s driving the strike?

There are two reasons health workers are striking. The first is a dispute over the nonpayment of salaries as well as nonpayment of special allowances that the government had agreed to.

The second relates to working conditions and the state of Nigerian hospitals, including equipment and funding. At the heart of the problem is the fact that the Federal government made several deals with health workers but reneged on its undertakings. These agreements were reached through collective bargaining.

The National Industrial Court of Nigeria ruled in favour of the Joint Health Sector Unions based on the fact that it had reached agreement and secured undertakings from government through collective bargaining. These included:

  • introducing residency programmes for health professionals;

  • dealing with the lopsided management boards at federal health institutions which have a surplus of medical doctors represented but little representation from other health professional groups;

  • re-designating the heads of federal health institutions as chief executive officers to include other health workers who also have the experience, and expertise to run hospitals as opposed to only doctors; and

  • changing the design of the National Health Insurance Scheme to ensure that all members benefit.

What impact has the strike had on public health services?

The entire health system is disrupted as strikes are mostly nationwide except for the few that have been restricted to individual hospitals. This means that hospitals are closed down and entrances are locked. The wards stay open but the hospitals are forced to run with a skeletal staff. This means there aren’t any doctors to do ward rounds or prescribe drugs to patients and no new patients can be admitted. This has led to the deaths of patients who are in a critical condition or who require continued care.

The impact of these strikes are worse when they coincide with national health emergencies such as Ebola viral disease, Lassa fever or cholera outbreaks or even man-made emergencies like Boko Haram suicide bombings where there are mass casualties.

In one case in January 2015, people who were injured in a bomb explosion in Adamawa State in northeastern Nigeria were not given adequate medical care due to a strike.

In many instances people can’t afford to take their sick relatives to private hospitals and clinics.

The strikes have broader consequences too. They have resulted in the public losing faith and trust in the Nigerian health system. Many believe that their health needs will not be met. This has fuelled medical tourism to India, South Africa, Europe and the US for those who can afford it. Nigeria loses up to three billion Naira to medical tourism annually.

The incessant strikes have also resulted in a growing apathy towards doctors and health professionals. The federal government spends the largest chunk of its annual health budget on personnel costs at the federal tertiary hospitals. But this has not resulted in an improvement in health outcomes.

How can this vicious strike cycle be broken?

The strikes in the Nigerian health sector could end if two things were tackled: changing the way hospitals are managed and secondly, how health workers are paid.

To improve efficiency and quality of services delivered by public hospitals, the management and day-to-day running of hospitals should be done by professionals with expertise in health administration.

Health professionals protest working conditions. Reuters/Afolabi Sotund

To do this the government should consider privatising hospital management and handling it through public private partnerships. Garki General Hospital, which is owned by the Federal Capital Territory Abuja, has been managed in this way for nearly a decade. It has resulted in improvements in the quality of services the hospital delivers. Strikes have hardly affected the hospital.

Secondly, the government needs to change the way health workers are paid. Health workers are paid tiered monthly salaries and allowances.

This was not always the case. In the early 1980s all health workers had a unified salary scale. There was not a significant difference in the salaries of doctors and other health workers. But by the early 1990s doctors negotiated a separate salary scale. This resulted in huge salary disparities with other health workers. It meant that a young intern doctor might for instance earn far more than a matron, a senior physiotherapist or pharmacist who has been working for 10 years. This has created tension between doctors and other health workers.

If health professionals are paid based on their outputs similarly to the way the private sector works, it may make them more accountable and solve the scaled salary crisis.

Health workers also need to be reminded of their respective professional and ethical oaths which places the patients’ need before their own. This is important for the global move towards a more patient-centred approach to the delivery of health services.

The Conversation

Felix Abrahams Obi is affiliated with Health Sector Reform Coalition which advocates for improved funding and efficiency within the Nigerian health sector