Misplaced Rivalry (V), by Dr. Ibrahim Toli

  • Other causes of health sector dispute

This article, which is the fifth in the series, continues to examine the major causes of disharmony in the health sector of Nigeria. The previous article identified and discussed a major cause; cravings for leadership.

Other causes include; One, lack of use of jobs description and organogram make the sector rudderless and chaotic making various segments dabbling way out of their jurisdictional competence. Nobody seems to know where his job begins and where it stops based on his intellectual and statutory ability. There is unnecessary confusion as to who heads a medical team among the key players; Nigerians with leadership craze. Doctors lead medical teams not because they have differential genetic superiority over others, but for competitive knowledge advantage.

Two, inherent rivalry within the sector more especially among the top players; Doctors, pharmacists, nurses and now physiotherapists, psychologists, dietitians, radiographers, optometrists and lab scientists. Doctors are being seen as dominating the scene with born to rule and know it all mentality. That is what is being peddled on the surface. In reality this rivalry actually begins right from school where the minds of innocent students are being poisoned against a gigantic Grendel-like monster in the form of a Doctor whose influence needs a Beowulf for neutralisation. They therefore graduated with that convoluted mindset and self-imposed inferiority complex. Cultural and religious organizations even at the undergraduate level are segregated along such lines. The environment also contributed a lot where it recognizes and epitomizes only the almighty Doctor relegating others to the background. To an average man, every white-coat wearing hospital staff is a Doctor. Thus the other party reflexively adopts defensive mechanism manifesting as bizarre prefixes all over the place, curriculum redesign, academic calendar extension, demand to be consultants, relentlessly and desperately seeking for recognition. It is not uncommon to see other groups, including the lowest cadre, prescribing drugs other than over the counter ones or attempting to do surgical procedures as highlighted earlier. Communication between these groups is so poor and now is mostly through treatment sheets and consult forms, God bless you as a Doctor you don’t check drug chart daily else your patient might go days without his medications. That is how bad it is. In the 2012 military Sci-Fi Battleship, Lieutenant Alex Hopper assumed command and re-enlisted retired veterans, old enough to be his grandparents who had fought battles when he was in diaper, unto the decommissioned USS Missouri to face alien invasion. They all followed his command simply because of his unique combat training without the slightest feeling of inferiority.

Three, there are grudges about discrepancies involving monthly wages among the various groups. All the other health workers consider it unfair the disproportionate remuneration to Doctors in the public hospitals. This also brings about the deliberate mystification between calls and shifts. Now, all hospital staffs are civil servants, however because of the nature of disease temporal unpredictability, they are required to be on ground 24/7. Since they are not cybernetics, issue of calls and shift arises which the employer compensate to cater for their lost leisure hours. It is only Doctors that take peculiar call hours others have more humane calls or shifts. A Doctor comes to work at 8:00am and closes 4:00pm just like any other civil servants. When he is on call which in most tertiary institutions averages 4-week day call per month and one-week end call per month, however many units like Neurosurgery, Urology, Orthopaedic, Pediatric surgery, Special Care Baby Unit etc take daily call. What this means is that Resident comes to work 8:00am-4:00pm on a weekday and by that same day at 4:00pm call will start and continues up till the following morning 8:00am where he continues with work till 4:00pm when he finally closes and go home. Weekend call starts 8:00am Saturday until 8:00am Monday where again he continues until 4:00pm when he closes. This is mainly for the residents as the house officers or medical interns spend an average of 16 hours per day throughout their mandatory one-year stay. By calculation, a resident spends minimum of 112 call hours plus 160 regular hours per month and a house officer at least 480 hours during the same period. The House Officers although being the most junior doctor in a hospital setting, are pivotal for effective management of patients. They carry out all given instructions regarding optimal patient care. It is a pity that these senior staffs are continuously being relegated to do the work of porters for the sake of patients’ care. At GL 10 they are denied teaching allowance and yet a very junior, including non-professional, hospital staff at GL 8 receives same. Doctors working in states or local governments work far more than this where you may have maximum of two Doctors per LGA or even one per 2 LGA. Down there one Doctor covers the whole 4 clinical departments. For house officers doing internship in states hospitals where you may have maximum of 4 interns per department, it is only left to be imagined. This is on the average and over simplification as Doctors don’t actually have closing time until their patients are stable or lab procedures are completed. Ironically, the federal government pays for 40 units of call hours per month to all Doctors. A shift on the other hand requires 8-12 hour staff change. In the case of the nurses, they do 3 unequal shifts per day 8:00am-2:00pm, 2:00pm-9:00pm and 9:00pm-8:00am as morning, evening and night shifts on weekly rotating basis respectively. What this means is that if a nurse does morning shift this week, she receives 1-2 day work free off, then in the second week she will do evening shift where she will receive 5 days off and the third week will be her night shift routine after which she receives 9 days off. Nurses equally get a day off for any public holiday they work in. This is the same in all the level of hospitals no matter how small; they don’t get posted to any centre that can’t afford this, even if they do they only take one shift. On the average, therefore a nurse works for 168 hours per month as against a Doctor’s ≥272 hours (160 regular hours + ≥112 call hours) while the other health workers spent 170-180 hours per month. All others do calls or shifts similar to or slightly different from the nurses in addition to reduced regular work hours. I deliberately left out consultants and seniors nursing staff. Senior nursing staffs work only morning shifts. As mentioned earlier consultants direct the units during ward rounds, clinics, surgery, procedures and calls in addition to teaching and research. These are what the hospital and the university employed them to do. Consultants that are lecturers receive their basic salary and teaching allowance from the affiliated university, because they teach medical students who are under Federal Ministry of Education, while the teaching hospitals pay them clinical allowances. They are called honourary residents and consultants respectively. It is this dichotomy for ease of administrative work, some people want to exploit. They don’t want research productive honourary consultants, but rather prefer academic redundant hospital consultants just like the way they currently are. Let’s remind ourselves of the pillars of a tertiary hospital; they are research, advance training, clinical services and community service. Are the Doctors being favoured in wages? Let us look in to two identical salary circulars that emanated from the FG (National Salaries, Incomes and Wages commission) for CONMESS (Doctors) and CONHESS (others) dated 29th September and 8th December 2009 with reference numbers SWC/S/04/S.410/220 and SWC/S/04/S.410/Vol.II/349 respectively to base our analysis of relativity among health workers. The new salary structure eroded the relativity between Doctors, pharmacists and nurses from 4:2:1.7 to now 1:1:1 as we shall see subsequently. A fresh, i.e. entry point, BNSc Nurse and generalist/Registered nurse are permanently employed at CONHESS 07/02 (GL 08/02, the RN is initially employed at CONHESS 06/02 before promotion 6-12 months later to catch up with BNSc nurse) while Pharmacists, lab scientists and other degree holders are employed at CONHESS 08/02 (GL 09/02, but recently the first two are now employed at CONHESS 09/02 [GL 10/02]). A fresh Junior Resident (irrespective of years of working experience) or fresh Medical officer in Federal Institution is on CONMESS 02/02 (GL 12/02) while a Senior Resident is on CONMESS 03/03 (GL13/03). The Medical officer is a Doctor that opted to practice after MBBS degree without residency fellowship. He progressed like any other civil servant or may choose to add academic degrees and thus rises like any academician. He receives no specialist allowance even though he can attain CONMESS 07 (GL 17) and by statuary law cannot head the tertiary health institution no matter his academic credentials other than being a registered specialist. A fresh Consultant is employed at CONMESS 05/04 (GL 15/04). At the moment the government pays flat amount to all specialists irrespective of field of specialization, a peculiar package. The cadre that receives specialist allowance among the other health workers starts from the level CONHESS 13/01 (GL 15/01). This shows that other health workers at CONHESS 13, the equivalent grade of a Consultant, are not only given specialist allowance but that both the basic salary and specialist allowance at that level are strangely figure by figure identical to that of a Consultant/Specialist! Paradoxically, both the Senior Residents and Medical Officers (from Senior Medical Officers up to Chief Medical Officers) receive no specialist allowance. These still seem fair to JOHESU elements that see it as normal, more so they even know that boy who came yesterday only now to start collecting this fat salary, so they reasoned. So the annual basic salary ratio between fresh Resident/MO vs fresh degree-holding health worker on one hand and the fresh generalist nurse on the other hand is 1.62:1.37:1 relativity; i.e. entry point Doctor:degree holder:Nurse. Do you notice that? The salary ratio of a GL 12 Doctor to that of GL 10 and GL 08 health worker is 1:0.85:0.62 putting it another way. In case it is still fuzzy, it means a GL 12 Doctor earns 15% and 38% more than a health worker at GL 10 and 8 respectively. In reality however it is far from it as the equivalent of CONMESS 02/02 is CONHESS 10/02 with identical wage values and the ratio is 1:1:1. This unremitting injustice is what JOHESU sees as fair play. The relativity of a Senior Resident with an equivalent rank among the other health workers is appalling and even drop further. CONMESS 03/03 is the same as CONHESS 11/03 and the relativity is 1:1! You don’t need a calculator for similar ratio between consultants and the other health staffs at CONHESS 13; 1:1. No need for an eagle eye to see the relativity between Doctors and other health workers with equivalent rank is diminishing at the time intellectual prowess is increasing. This same ratio is about to plummet further when the demand for skipping CONHESS 10 is implemented. Looking at the same 2009 circular, CONHESS 10 is equivalent to GL 12 i.e. GL 11 has already been skipped just like it is done for any other civil servant. Doctors endured such erosion of relativity atrocity for many years because there was no time for close perusal and the emphasis is on patient care. On the 3rd January 2014, the FG, from same Commission, released a compromised circular with a reference number SWC/S/04/S.176/VOL.II/464 in an attempt to correct the anomaly aiming at relativity of 1.2:1 at GL 13, 1.3:1 at GL 14 and 15, 1.4:1 at GL 16 and 1.5:1 at GL 17 i.e. it is from GL 13 upwards that Doctors will begin to earn between 20-50% more than their counterparts on an equivalent grade level. This now brings the unimplemented relativity to 1:1, 1.2:1, 1.3:1, 1.4:1 and 1.5:1 for Doctors GL 12 and below, those on GL 13, those on GL 14 and 15, those on GL 16 and those on GL 17 respectively against their equivalents among the other health workers. This is what JOHESU went to town screaming blue murder demanding raise in salary of its members from GL 8 upwards for what it mischievously termed increase salary for all Doctors, but in reality it was correction of an earlier omission and it affects only those from GL 13 (senior residents) upwards. If you observe I have been using only two ratios in the latter part of the discussion, because the FG in its weird wisdom put all the remaining health workers, professionals and non professionals, under the same salary scale! I didn’t bother to mention the hazard allowance of ridiculous value of ₦5,000 per month flat to every Doctor. This amazing amount is provided to compensate the many occupational hazards he/she may get expose to. Let me buttress my point; to treat hepatitis B viral infection with potent oral medication like Entecavir requires a minimum of ₦600,000 while treatment of hepatitis B or C viral infections with Injectable Interferon will gulp at least ₦1.5-2M. Imagine contracting HIV or any of the dreaded viral hemorrhagic fevers. Thank God Tuberculosis treatment with genuine drugs is free for now and there is hepatitis B viral vaccine available. Do the Doctors really earn too much or being favoured? The facts are there, you figure it out for yourself. Consultant attains that level only after success in two exams and dissertation whereas others need no more than basic certificate and natural passage of time to attain such. That is not even the bone of contention; I think people earn wages based on the quality of their cerebral input to an event. It is difficult to analyze States wages for health workers since each pays according to its financial capability, but generally speaking the ratios are similar.

After scientific job evaluation of public servants in Ghana by Price Water Coopers, it came out with Single Spine Salary Structure (SSSS). Frank Kumi of the Pharmaceutical Society of Ghana has this to say; “As clear as it was, the exit point of the nursing profession on the SSSS, a Principal Nurse, even scored 597-only 28 points higher than the entry point of the pharmacist. The Pharmacist scored 569 while the Medical Officer (entry grade of doctors on the SSSS) obtained 791”. In Ghana the entry point of a Pharmacist is 18H while that of the Doctor is 21L and the exit point of a Nurse is 20H http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel.php?ID=271855. Here in Nigeria where anything goes, the entry point of a Medical Officer is GL 12 while the entry point for others are GL 8 and 10 and exit point for not only health professionals, but any one working in the hospital is GL 17 (CONHESS 15) except perhaps those with secondary school certificate. Nigeria is probably the only country in the world where specialist doctor has identical salary scale with other hospital staffs.

In recent time Nigeria too have attempted to identify and resolved this seemingly unending imbroglio although to no avail. On the 9th of August 2010, Goodluck Jonathan directed the inauguration of Presidential Committee on a Harmonious Work Relationship Amongst Health Workers and Amongst Professional Groups in the Health Sector. After what it called extensive discussion and analysis of memoranda, the committee summarized the 22 causes of disharmony in the health sector as “the struggle to be accepted as “most important” profession in health care; struggle for leadership posts in the health care system, and parity in remuneration” http://xa.yimg.com/kq/groups/21149353/1523988562/name/OBNOXIOUS.pdf. Looking at the whole report, however, one is appalled at the conspicuous total lack of even a single reference (not even from a dictionary) in this internet age! What is more amazing the committee was chaired by a Hon. Justice Bello A. Gusau and the secretary is a strategist a Dalhatu Sule, mni. One wondered was it lack of time that mitigated against the production of a quality report in this very important task or was the committee compromised even before it started? I should have expected a committee of that calibre would have done extensive research and visited sampled countries to fully understand the workings of their health sector before contemplating conclusion. This would have saved it the embarrassment of the inability to define basic words like Consultant, medically qualified and non-medically qualified or the absurdity of restriction to Residency training. Who will even dream of putting restraints to postgraduate training as a warp solution against labour dispute! Again on the 13th of September 2013 FG still constituted Presidential Committee of Experts on Inter-Professional Relationship in the Public (Health) Sector with Yayale Ahmed as the chairman among other committee members. The committee was given just merely eight weeks within which to examine and proffer solutions to this hydra headed mutated monster. Amazingly, nearly seven weeks after inauguration (inaugurated on 18th September 2013), the committee was without needed funds for smooth operation that necessitated the chairman’s resignation at the time http://www.premiumtimesng.com/news/144874-jonathan-inaugurates-committee-solve-frequent-health-workers-face-offs.html, http://www.punchng.com/news/ex-sgf-yayale-resigns-from-presidential-committee-in-protest/. Although Yayale has been cajoled back, it is now more than sixty-four weeks since inauguration i.e. more than fifty-six weeks behind schedule. Why this obvious emasculation? I guess someone somewhere doesn’t want the committee to succeed for whatever reason. Obviously local committee may not able to tackle this convoluted problem due to selfishness and clash of interests.

Four, residency sponsorship is also generating grudge among the various cadre. As it is with Nigeria, there is no comprehensive national policy on residency training in terms of funding. The program is currently poorly funded and partly under FMOH. Residents aspire to be specialists in their chosen fields, and therefore require availability of medical equipments, books and other learning aids and sponsorship. A resident requires at least ₦1,000,000 during junior residency for collegial revision courses and exams while senior residency needs ₦1-2M for similar events with additional project cost. These excludes funds for house rents, utilities, books and other learning materials as at present there is no standard library in the country, yet residents must read current stuffs to be at par with their peers in the first worlds. At present the training centers pay one-time fee for revision courses and exams only while residents bear the cost of books, project and subsequent events. Because residents are paid this financial assistance, this does not go down well with others who see it as favouritism. The amazing thing is that when other hospital staffs go on study leave, they don’t only go with their full wage package but most don’t even study in their primary working place.

Five, which I see as the most ridiculous, is perceived arrogance of Doctors as claimed by the other group. To start with, most Doctors are melancholic in temperament and only the training brings out confidence in many of them. Meeting a young well drilled military officer out of Nigeria Defense Academy or a lawyer out of Law School oozing self confidence, one can easily mistake him to be arrogant. If Doctors are accused of being emotionally cold is understandable, for they are calm during emergencies. Imagine a Doctor crying in front of patients or their relatives. Doctors are ethically trained to show empathy and not sympathy.

Ibrahim Toli
Resident Physician,
Department of Internal Medicine,
Ahmadu Bello University Teaching Hospital Zaria, Kaduna State, Nigeria.
[email protected]