RAPE OF THE BLACK GOLD – NMA Strike and the Crisis in Nigeria’s Health Sector Part 2 By Agwaza Maxwell Dagba

On 04/Jul/2014 / In Articles

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.
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.
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!
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.
By Agwaza Maxwell Dagba


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