MISPLACED RIVALRY (VI): Solutions to Nigeria’s Health Sector Dispute

by Ibrahim Toli

This is the sixth and final part in the series where we will attempt to proffer solutions to this imbroglio and finally conclude in the hope that the policy makers will do the needful and save the health sector from collapse.

The policy makers must address the following concerns.
1. Which categories of people are supposed to work in properly constituted tertiary hospitals and by extension the secondary and primary health centres?
2. What is the minimum educational qualification needed to interact with patients in tertiary hospitals and by extension the secondary and primary health centres?
3. What is the justification of maintaining the existing bizarre doctors’ call duty schedule?
4. Why are the resident doctors temporary staffs?
5. What is the academic weight of residency programme for both Part I and II respectively?
6. What does it take to distribute job description manuals at the time of employment?
7. When will health care services be properly organise?
8. What is the rationale of putting administrative and account staffs under CONHESS?
9. Where do optometrists belong to and why do they draw their salary from CONHESS and call allowance from CONMESS; can their ever be medical emergency in ophthalmic refractive errors?

To solve this recurring problem, there is need to completely redesign the health sector. One, the FG shall hands off tertiary health institutions and takes over PHCs from the LGAs. This arrangement can be achieved whereby tertiary health institutions are manage through Public Private Partnerships. The government shall provide the existing buildings, effective supervisory role and efficient wide coverage health insurance scheme while private investors shall provide equipments, management including employments, wages (differential even among doctors), job description, repairs/replacements etc. There are many advantages to this kind of arrangements like provisions of quality health services, minimize labour dispute, raising clinical standard, ensure quality assurance, reducing health tourism, improve clinical governance, encourage capital investments and perhaps most importantly reduced the burden of preventable infectious and non infectious diseases at the primary level. Significant percentage of medical cases seen in the tertiary health institutions are actually cases of PHCs and GHs that bypassed existing protocols due to lack of confidence in those centres. Therefore, if the FG can takeover PHCs from LGAs and employ a team per PHC comprising of minimum of a Doctor, a Registered Nurse, a pharmacy technician, a medical laboratory technician and a physiotherapist with a good remuneration package, I am certain we will begin to see reduction in the incidence and prevalence of many preventable diseases. Good package will encourage people to leave the cosy cities and head to municipal areas. I don’t have a problem if such doctors earn more than me in remuneration.

This may not be feasible due to paucity of doctors in the employ of States and local government areas. To mitigate against this potential health disaster, the FG need to employ all medical doctors in the country through a single Federal agency like it is done in many countries. After that, the agency can post any doctor to any of the PHCs for a specified period of time e.g. to serve there for two years immediately after internship before contemplating postgraduate degrees. After serving the specified period in the PHC, the doctor can now based on his/her choice begin to pursue further studies while still being in the employ of the government. By this method, the FG can fill in the wide medical service gaps that exist at that level. In my opinion there is no need for the youth service participation for MBBS holders, it’s just a waste of precious time and misplacement of priority. In addition employing all health workers in the country, not only doctors, through a single agency will not only make regulation easier, but will equally improves quality of service. There will be uniformity of the single most important factor in the recurring dispute; money. By this, a health worker working in the village will have the same basic salary as the one in the city. The difference will now be on allowances based on qualification, expertise, cost of living, hazard, patient load etc. In this arrangement the States can continue to provide funding for GHs in their domains. All the States need to do is to provide counterpart funding to this desirable agency based on its population since health workers will be equitably distributed across the country. I am not oblivious about the current distrust and tribal conflicts among the various groups in the country. I am basing my suggestions based on the premise that we are not going to continue to kill ourselves just because of tribal or religious differences.

In the event of yet existing gap after implementation of the above, I think this is where nurse practitioner programme with clear cut job description and good referral system will help bridge the gap at the PHCs level. The nurse practitioner’s prescription and other management plan must be under a doctor’s supervision. The supervision need not be physical, but can also be achieve through teleconference or other communication means in this internet age. There will be fears that with progression in time, the nurse practitioner will eventually usurp the doctor’s job description as it is currently happening. What is happening now happens because there is no system of medical audit and statutory bodies that are charge with maintaining order in the sector abdicate their duties. Such bodies are now notoriously prominent only during payments of annual dues or issuing threats of discipline. In my opinion a well trained nurse practitioner is certainly better and safer in the PHCs than the existing arrangement where patients at that level are being mismanaged. It is at PHCs one sees malaria being treated with very strong antibiotics, meningitis being treated with oral antibiotics, renal disease patients are being given nephrotoxic drugs, transient ischaemic attacks or even hypertensive urgencies are being effectively converted to strokes, results of hepatitis B serology positivity only are being blindly treated with Lamivudine, any dyspeptic symptoms is being regarded as peptic ulcer disease, etc.

There certainly will be fears among the citizens concerning cost of tertiary health services that may go beyond the affordability of average Nigerian. This fear is genuine considering the high level of government policy distrust and insincerity. To mitigate that, such major policy change shouldn’t be subjected to hasty implementation, but rather gradually sustain over 1-2 decades. When the people are well informed about the advantages of such policies including a robust health insurance scheme for all and for all ailments, they will certainly welcome such change.

Two, on the alternative the FG can maintain the status quo. In this case it can invite international job evaluators like PricewaterhouseCoopers (produced SSSS in Ghana), Agenda for Change (produced NHS in UK) etc to scientifically evaluate all health and non health workers and accordingly categorise them based on measurable indices. This will place every worker in his/her own niche and prevent unnecessary distractive industrial disputes. Using locally constituted committees will never achieve an objective outcome since it is practically impossible to remove bias and clash of interest.

Three, FG shall reduce the financial enticements attached to the office of CMDs/MDs and then make it open to all eligible and qualified staff of the hospital based on intellectual capacity, research works and managerial skills. My suggestion is anybody selected as the chief executive shall go with his total monthly pay and then a maximum of preferably not more than 50% of his/her basic salary flat amount to be added to this, not a penny more not a penny less and no privileges whatsoever. This will encourage only the ones with genuine desire to serve humanity seek for the office.

At the moment even the tertiary health centres are more or less glorified general hospitals in terms of equipments. Many health services cannot be optimally rendered due to lack of such needed equipments even though expertise may exist. The governments at all levels must provide the needed modern tools to aid proper diagnosis and optimal therapy of the many ailments afflicting the populace.

There is need to improve the quality of every component of the health system from the PHCs through the GHs to the tertiary health centres. After ensuring availability of personnel at every level, the next is to equip the hospitals. This is going to be very tasking and capital intensive considering we will have to start from the scratch. It can however be achieved albeit in phases. The first thing to do is to identify the most common ailments afflicting the populace and to categorise them according to specialties. The next is to setup centres of excellence to cater for such ailments in the six geopolitical zones in equitable distribution. Concurrently, reference laboratories must also be setup in the regions with specific expertise. Finally, means of prompt transportation of patients and samples must be put in place to transport each category between such hospitals i.e. air and road ambulances. After setting up regional centres of excellence then gradually every other primary, secondary and tertiary hospital will be upgraded to actualise its mandate. Without prejudice to other specialties, most ailments fall under Internal Medicine, Paediatrics, Surgery and Obstetrics and Gynaecology and thus the government must begin to prioritise them accordingly. Even among the four specialties, it will be the most prevalent diseases that will be tackle first. That does not mean other specialties will be relegated to oblivion or other diseases will be ignored. It just happens that some diseases have reach epidemic proportions with very high morbidity and mortality burden and need urgent intervention. Again other specialties in other hospitals and even in the ones designated centres of excellence are not to be neglected. Below is my attempt to categorise the initial step to take to manage this health system emergency intervention and rescue. It is just an arbitrary suggestion and need not follow the way I allocate the various centres. My main objective is for the centres to be equitably distributed among the six geopolitical zones.

Table 1: Proposed regional health centres of excellence in Nigeria
Serial Number Region Centre of Excellence
1 Northwest Cardiology + Cardiothoracic surgery
2 Northeast Gastrointestinal + GIT/Hepatobiliary surgery
3 Northcentral Endocrinology + Breast and endocrine surgery
4 Southwest Neurology + Neurosurgery
5 Southeast Respiratory + Cardiothoracic surgery
6 Southsouth Nephrology + Urology
7 FCT Haematology + Oncology, Paediatric surgery, Infectious Disease, Rheumatology + Orthopaedic/Spine surgery

These centres shall be established with the view to achieve the peak of service delivery superiority including organ transplant. The many centres I allocated to Abuja need not be sited in any single hospital. In general, each tertiary hospital in the country must have state of the art radio-diagnostic and laboratory units. In addition there has to be reference laboratories in each of the geopolitical zones and Abuja as mentioned earlier. There is need to improve and encourage the establishment of pharmaceutical industries to produce quality drugs so as to discourage the current substandard drug importation frenzy.

Four, Provide job description manuals to every staff to acquaint and restrict himself to his/her specific professional duties before resumption of duty.

Five, provide adequate funding for the residency programme in order to improve the quality of health service delivery. With good funding and equipment upgrade, there will be no need for overseas medical training. There is also need to regularise employment of Residents to permanent one while pursuing their postgraduate clinical degrees, then allow their promotion based on existing civil service rules irrespective of specialist exam outcome. However, they will not receive specialist allowances until and when due. At the end of the programme if the consultant have no place in the training institution, then it is transfer of service that he shall seek and not starting afresh. Meanwhile include senior residents to receive not more than 50-75% of specialist allowance. Statutorily senior residents can act in place of their consultants and their clinical decisions are binding on patients’ management. Yet this cadre of medical subspecialists in training receives no allowance for any of its specialist input. The temporary nature of residency prevents Residents, who can attain GL 14, from many privileges like obtaining loans, mortgages, credit cards, enrolment in to pension schemes etc. The question is how can any employee be employed for six or more non renewable contract years on temporary basis? The university lecturers pursuing postgraduate degrees are equally under training and yet they are permanently employed. Nobody ever calls them student lecturers.

Six, there has to be policy reconciliation concerning academic evaluation and weight of residency programme so as to properly placed it where it belongs. We mentioned the difference between traditional postgraduate degrees and residency earlier. To have Master and PhD requires no more than average of 50 and 100 credit units respectively. These are equivalent to 50 and 100 academic hours only through the entire 12-24 months and 36 months respectively. Fellowship is a non classified postgraduate degree and thus not based on credit unit system. Notwithstanding, if Part I and II will be graded for the sake of argument, I am sure neither will be less than 500 credit units. Therefore, the National University Commission and the National Postgraduate Medical College of Nigeria must come together and harmonise this academic dispute even if it means amending the law establishing them.

Seven, payment of additional supplement for working hours and call hours beyond the 40 hours per week and 40 hours per month respectively to all doctors which shall be at least 1.5-2 times the existing rate i.e. 50-100% compensation. The current trend of static payment is not tenable anywhere in the world. It is a misnomer paying other workers overtime while ignoring others. Most doctors, if not all, work far more than the 40 hours government is paying for call or regular hours especially those working in general hospitals. As I mentioned in the previous series, doctors spend minimum of continuous 32 hours and 56 hours in the hospital during weekday calls and week end calls respectively. These exclude units that take calls daily because of certain peculiarities. In my opinion doctors shall start taking shifts per day even if it means absence of work free off every month. It is a waste of energy and human resources, especially in the tertiary centres, to see 8-12 doctors in any single department on ground during calls apart from emergency team doctors. Again there has to be a maximum number of patients one doctor can see per day beyond which compensation shall be paid accordingly.

Eight, FG must regularise prescription in the country to avoid catastrophic consequences. This can be done by adopting the best practice where prescription sheets are customise to each doctor with his identity and registered license number. This will not only curb the menace of negligent prescription, but also serve as a medical audit platform. It will certainly weeds out prescription from non qualified personnel.

Nine, establishment and sustenance of medical audit unit in every hospital to minimise medical negligence and errors. At the same time, there must be comprehensive insurance coverage to all doctors to cater for litigation cases shall they arise.
Ten, ensure wage relativity among all health workers based on clinical intellectual input. There is nowhere in the whole world where wages of doctors is the same as other health workers, none! In my opinion, even the adjusted CONMESS approved by the government is not adequate. Difference of only 20-50% is certainly a cheat if not robbery. What then is the use of spending this so much time in acquiring a superior knowledge only to be disenfranchised?

Eleven, ensure paid annual comprehensive medical check up to all health workers (and their families) and pay appropriate compensation in the event of risk exposure. At present all health workers pay the same rate for hospital services like anyone else; what then is the benefit of working in the setting? In other climes, hospital bills incurred by employees are fully paid by the employer.

Twelve, avoid politicising the health sector for political gains; I see no reason why government officials will encourage impunity in our health industry while conforming to the norm when they go overseas. Many top government officials needlessly attend hospitals abroad or even die there and thus cannot claim ignorance of what is obtainable as best practice over there.

Thirteen, educate the populace to improve their health seeking behavior and knowledge on the health sector. I realise very few people, including principal officers of the affiliated university, understand the workings of a hospital, residency programs, staff specific duties etc.

As a Doctor do I consider myself more important than the other health workers or indispensable in the sector? Certainly no. Do I have problem with salaries of other health workers, honestly I don’t even know how much they earn before this piece. What worries me, however, is less privilege people living in the village (or even towns) being manage for acute or chronic ill health by less qualified people simply because the country is rudderless or due to self seeking recognition. Ironically, those fighting or blackmailing the Doctors take themselves or their family members not to their professional colleagues, but to the same castigated and arrogant Doctors meanwhile they insist to negligently treat the hapless and unsuspecting populace, funny. Division of labour and specialization is the back bone of every successful corporate organisation. I don’t give a damn, apologies to Goodluck Ebele Jonathan, who becomes a chief executive, what is important is quality service to humanity with the highest degree of efficiency, effectiveness and good governance in general.

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