The Nigerian health sector is strategic and significant to the nation on two critical grounds. On the one hand, it represents the pulse of the labour force in terms of how healthy an average worker could be, based on the medical and healthcare available to him or her. On the other hand, the health sector itself represents a section of the Nigerian work force notable for providing health and medical services to millions of the country’s populations. Being so entwined, it becomes possible to infer that the health of the health sector translates as the health of the labour force, while the strength of the workforce in the health sector invariably translates as health for the entire nation’s population, including its labour.
There is no misgiving that the arrival of colonial powers in Nigeria, as with many African countries, had translated into a superimposition of Eurocentric structures on the pre-existing ones which the native peoples and their ancestors had employed for eons. This also meant that ‘modern’ principles and practices would replace the primordial African healthcare philosophy and healthcare practitioners in the new colonial and post-colonial times would learn to imbibe not only the principles and ethics of medical practice, but also those of labour-employer relations mostly established by contract. For instance, every worker in the Nigeria labour market is expected to be familiar with the provisions of the Nigerian Labour Law, in addition to labour expectations and binding obligations in the particular sector of employment.
The Scimago Institution Ranking currently puts the ranking of the UCH at 78th in overall percentile of world hospitals in the ranking; 55th in the research percentile; 91st in the innovation percentile, and 74th
in the societal percentile. This is a grim picture for a medical institution that once ranked high and indeed among the first four best hospitals in the world, playing host to royals from countries in Europe and the Middle East. Since the 1990s, given the spate of economic and political crises owing to perceivable lack of direction by government, there have been slow and steady declines in the capacity of the Nigerian health sector to deliver on its professional and social expectations.
Surely, these sad trends in the Nigerian health services sector are symptoms of a national catastrophe. A public health crisis is often understood as a challenging condition or state of affairs which puts the health sector of any country in a difficult place, often with the potential to paralyse and cripple its efficiency. The World Health Organisation describes a ‘crisis’ as any ‘situation that is perceived as difficult. Its greatest value is that it implies the possibility of an insidious process that cannot be defined in time, and that even spatially can recognise different layers/levels of intensity. A crisis may not be evident, and it demands analysis to be recognised. Conceptually, it can cover both preparedness and response’. This may well be true for a patient in crisis as it is for a nation that has watched its healthcare services sink into troubled waters.
According to a 2017 study by Davies Adeloye and others, titled ‘Health Workforce and Governance: The Crisis in Nigeria’ by the Human Resource for Health, a biomedical platform, there is a close relationship between the health workforce and governance. As an institutional mechanism or an ‘administrative umbrella of the health system primarily concerned with policymaker- or government-led … rule-making functions targeted at achieving national health policy objectives for effective delivery of health services and attainment of universal health coverage,’ the health governance structure in Nigeria has remained detached from this function for some time. For instance, the report profiles the series of industrial actions by the Nigerian health workforce between 2006 and 2010.
Between 2010 and 2016, the National Association of Resident Doctors (NARD) had consistently staged protests and called strike actions to largely protest over the actions of chief medical directors (CMDs), namely irregular and non-payment of salaries for several months. The association also remonstrated against other conditions such as poor welfare which informed its demand for renovation of call rooms and better-quality call meals; the non-payment of teaching allowances and update courses and shortage of doctors in the hospitals, as interns and residents completing training were not replaced on time. Specifically, in 2011, 2013 and 2016, the association had downed tools to call for teaching allowance and skipping as well as an upgrade of doctors to the Integrated Payroll and Personnel Information System (IPPIS) platform; a full implementation of adjusted Consolidated Medical Salary Structure (CONMESS) across the board. The striking doctors also made request for residency training guidelines, appraisal and upgrading, while asking the Federal Government to address high-handedness of chief medical directors of some health institutions, and to implement the National Health Act.
In 2013, the Lagos Chapter of the Nigeria Medical Association had also called for a strike to press home its request for improved conditions of service, better welfare and improved medical facilities. In addition to this, the industrial action called by the Joint Health Sector Unions (JOHESU) in July 2014 was national in its coverage and was aimed at addressing the professional inequalities existing among the various specialisations within the JOHESU versus the Nigeria Medical Association. JOHESU wanted its members to be made consultants like medical doctors. It also demanded to establish directorates for nursing, pharmacy, physiotherapy, and other allied health sectors, while seeking an amendment bill to correct marginalisation of all health workers by doctors. Other demands included composition and appointment of the management boards of health institutions; extension of retirement age from 60 to 65 years; implementation of the National Health Insurance Scheme towards increased remuneration, and overall funding of health system.
Between July and August of the same year, the NMA itself also pressed for demands that included relativity and skipping in doctors’ salaries; the reversal of the consultant status and directorates of allied health professionals, and call for improved funding of health system. The call for a reversal of the consultant status and directorates of allied health professionals by the NMA clearly ran counter to JOHESU’s demand that there be directorates for allied workers in the nation’s health sector.
Ironically, the NARD’s demand bordering on the implementation of the National Health Act would turn out to be a major catalyst of crisis in the Health Ministry in later years. In 2019, the then serving Minister of Health, Isaac Adewole, had publicly admitted, during what appeared to be a clash of functions, that faulty structure of the establishment Act of the Nigeria’s Health Insurance Scheme (NHIS) had become a big monster haunting Nigeria’s Ministry of Health before and during his time. In a recent public appearance, the health minister had connected the failure of the NHIS to serve majority of the Nigerian people for whom it was created, to the existence of loose ends in the Act which made a national health insurance voluntary rather than compulsory. The minister had also argued that the vesting of excessive power in the Governing Board made it possible for successive Executive Secretaries of the scheme to perpetuate acts of corruption that compromised service delivery to subscribers of the National Health Insurance Scheme. To make matters worse, the serving minister at the time had pointed out that the NHIS establishing Act did not make provision for a ‘suspension’ clause which could make it possible to sack underhanded managers of the Scheme, such as executive secretaries. Hence, he made a call to the National Assembly to repeal the Act and make provision for a better version of it, which, among many other things, would give priority to Nigerians who subscribed to the scheme.
Sadly, while the health sector has become crisis-ridden owing to these series of industrial actions and counter-actions, the Nigerian people remain at the receiving ends of the negative consequences of many of these medical strikes. Patients in critical conditions – including strokes, HIV/AIDS, sickle-cell emergences, renal crises, and in most recent times, coronavirus patients – had often been left without any medical attention while strike actions lasted. The study by Davies Adeloye and co. establishes the direct links that exist between efficient health system governance and promising health workers outputs, which ultimately have positive effects on the health sector of any country. For Nigeria, some of the reasons for incessant strike actions are leadership and governance related, and often cover systemic issues in thematic areas such as personnel administration, policy, finance/ funding and remuneration, supremacy challenges, welfare and health workforce distribution.
The latest threat of strike action being issued by labour leadership is one in the series of recurring industrial actions in recent times. It is coming only more than a week after the National Association of Resident Doctors (NARD), a body of doctors in the employ of government, called off its strike over government’s failure to meet its demands of a payment of unsettled wages, a raise in their pay package, alongside their demand for life insurance coverage, the provision of adequate bed spaces and drugs in public hospitals. The strike action, which had been foreshadowed by a warning strike by the resident doctors in June, is also directed at the provision of adequate protective equipment for doctors in the frontline of the treatment of coronavirus patients in the country. The call-off of the strike is only based on an agreement to give the government some time since, the industrial action is according to the government, ‘ill-timed’. A similar situation had been recorded in 2004 when the NARD had threatened to embark on strike indefinitely if the government failed to meet the demands over its members’ wages.
As though lurking in the shadows of the NARD’s September strike, the Joint Health Sector Unions (JOHESU) had followed the trail of the NARD by going on a warning strike on the midnight of Sunday, September 13, 2020 to press home its demand for hazard and inducement allowance. While the Nigerian Minister of Health has been on his feet in the bid to make all needed interventions to the NARD and the JOHESU from the government’s end, the Labour Minister, through his ministry’s spokesperson, only issued statement to the effect that the striking Union was going on a head collision with the International Labour Organisation’s ‘Principles and Conventions on Strike’ as well as section 18 of the Trades Disputes Act, Cap T8, Laws of the Federation of Nigeria, 2004. The Labour minister, among other things, also greeted the unionists with the accusation that JOHESU was attempting to ‘arm-twist’ the Federal Government to meet its demands.
The Minister of Labour, Chris Ngige, had been seen calling out the striking unions as attempting to force the hands of government to meet their demands, while his counterpart in the Health Ministry, Prof. Osagie Ehanire, has been seen to be making frantic moves to reconcile the health workers and their issues with the government. The apparent contradictions in the discrete moves by the Minister of Labour and the Health Minister represent the often-counterproductive nature of government approaches to issues of public interests. As each government administration gives way to a succeeding one, there seems to be no creative and lasting solutions in sight. Different subsections of the health sector, especially the public health subsector, have continued to call government’s attention to its needs areas. Many of these are dictated by the gaps that now appear to be insatiable in the eye of the government.
With the perception of the state of things in the health services sector, the Nigerian government seems to have taken on more issues than it can adequately manage. Some of the solutions, going forward, will have to begin with the readiness of government to summon the political will to show sincerity towards mitigating all the existing conflict areas in the health sector. This must begin with a decisive and thorough engagement of the identified areas. Without adequate welfare coverage for the millions of medical workers across the nation, the chances remain continually slim that the country will ever make its health services robust enough to meet current demands on its personnel. Government must also review defective
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statutory provisions with the view to plug the various loopholes that make possible the seeming indiscriminate and unequal treatments of health workers in the allied health sectors. Inherent in these steps is a promising new order in which industrial actions are minimised; that is, if not completely suppressed. All of these expectations will find meaningful expression only through effective leadership, governance and personnel administration on the parts of government and the leadership of the discrete health unions.
Only when better conditions are restored in the health services sector can the Nigerian people and their government attain a new lease of life with far-reaching positive implications for the entire labour force and indeed for Nigerians of all ages and stations of life. Only then could the Nigerian state have come closer to the ideal world envisioned by Benjamin Disraeli the former British Prime Minster, when he wrote that ‘The health of the people is really the foundation upon which all their happiness and all their powers as a State depend.’
Abiodun Bello
