NMA, NARD AND THE HEALTH SECTOR CRISIS

As Nigerian doctors poised for a sow down with the federal government over their remuneration and condition of service, Dr. Niran Okeowle, the General Secretary of National Association of Resident Doctors (NARD) in this feature article traces the genesis of issues at stake and proffers the way forward.

The highly engaging blog, Nigeria Health Watch, has lately been doing a good job of chronicling the fortunes of health care in Nigeria. The host, Ike Anya, addresses issues such as tobacco smoking, the National Hospital, measles outbreaks, primary health care centres, polio, HIV/AIDS, the Pfizer Trovan controversy, Vamed project, and more. He reminds us of our alarming health indices, such as maternal mortality which has been reported as high as 800 per 100,000 births, twice the world average. Other indices such as infant mortality and life expectancy are just as bleak.

The myriad problems encountered in the health sector have their impact on the political economy. Among the productive forces, labour or human capital plays a major role especially in a developing country like Nigeria. Taking each worker as a unit of productivity, the effective man-hours and consequently the quality and quantity of output are a function of the mental and physical fitness of the worker. The health of the work force is a major variable in determining the wealth of nations. Nigeria’s health sector has over the years been bedevilled by several ills of poor infrastrusture, equipment that is either obsolete or simply unavailable, inadequate funding, scarcity of affordable drugs and other requirements as a result of which the nation’s best hospitals were once described by a former military ruler as mere consulting clinics.

Arguably the biggest challenge facing the health sector is the shortage of trained medical personnel in the country. Despite the fact that our teaching hospitals produce doctors yearly, the best of these are easily lured away to greener pastures due to the harsh realities on ground: poor remuneration, lack of facilities and structures to practice at the highest level. The doctor-patient ratio is alarming. For instance, in a field like psychiatry, there are barely 100 psychiatrists practicing in the entire country, a figure less than in some European and American cities. That gives a doctor-patient ratio of 1 to 1.4million. This is replicated in other specialties, and in general practice. Meanwhile, by some estimates, there may be as many as 40,000 Nigerian doctors practicing in North America, 10,000 in Europe, not counting the Middle East, Asia, Australia and indeed other African countries. Those who remain are often demoralized in the face of the daunting challenges. The lacuna is filled by quacks, charlatans and opportunists. The domino effect of this is seen in the entire national landscape.

The Nigerian Medical Association has over the years set itself the task of trying to address this alarming brain drain and its consequences. As far back as 1988, the NMA submitted two memoranda to the Presidential Committee on Brain Drain headed by Justice Atanda Fatayi Williams. The two memoranda were on Review of Remuneration for Doctors in Government Employment and a Review of Undergraduate and Postgraduate Medical Training, establishment of a Health Service Commission and improvement of working conditions. These documents traced the exodus of doctors to the high-handedness of the military regime of the mid-1980s, compounded by the economic consequences of the structural adjustment programme, currency devaluation, runaway inflation, poor income, poor incentives and working conditions. The WHO recommendation of at least 5% of the total annual budget of each developing nation to be allocated to the health sector was not met. In addition, overseas clinical attachment and clinical supplementation were not given priority. The status of doctors was compromised due to a lack of constitutional privilege, exclusion from order of precedence, and abolition of differential structure of emoluments payable to doctors. All this, the NMA predicted, would lead to a band wagon exodus, deterioration in the standard of health care, worsening doctor-patient ratio and a sharp rise in morbidity and mortality with adverse effects on the work force. Twenty years down the road, these forecasts have proven painfully accurate.

As a way of stemming this tide, the NMA suggested short-term measures such as a tax-free graded allowance, suitable entry point for newly qualified doctors and adoption of a new salary structure, distinct from the civil service structure, for medical personnel to be known as the Medical Services Scale. It also proposed medium term measures such as provision of decent lodgings within or close to the hospital premises, rent subsidies, car loans, consolidated votes for sustained supply of medical consumables ( such as drugs, dressing and diagnostic reagents) and proper maintenance of facilities and infrastructure. Long-term measures such as funding for equipment, teaching and research were also proposed, as well as an appropriate national health policy, health insurance, health legislation and funding, and the creation of a Health Service Commission.

These recommendations were reiterated in 1990 by the then Minister of Health, Professor Olikoye Ransome-Kuti, in a memorandum to the National Council of Ministers on the introduction of new salary scales for health services personnel. Subsequently, the Medical System Scale was effected in 1991 but its death knell was soon sounded when a review of salaries in the public sector in 1992 excluded doctors. This, and subsequent reviews, whittled away the relativity which had existed between doctors’ remuneration and the general public service on the one hand and the rest of the health sector on the other. The former had been in existence even before independence, and the basis for the latter had been well argued out in a comparative analysis of posts in the health service as compiled by the Nigerian Health Services Panel which recognized various aspects of the doctors vocation as physician, manager, community leader and mobiliser, teacher, researcher, ethical professional and friend of the court. Job characteristics such as education/training, responsibility for contact and communication, supervision and coordination of other staff, decision making and organizing ability, physical environment, work hazards and working period were also factored in. In 1996, the NMA reached an agreement with the Federal Government that the principle of relativity will always be observed. This however proved not to be with the introduction of the Harmonized Public Service Salary (HAPSS) and the Harmonized Tertiary Institutions Salary Scale (HATISS) and the subsequent award of 22% increase in basic pay.

When the idea of the Consolidated Tertiary Institutions Salary Scale (CONTISS) was birthed, the NMA in January 2006 forwarded a memorandum to the Committee on the Consolidation of Salaries and Allowances in the Public Sector on the appropriate salaries and allowances of doctors in public service. In this document, the NMA outlined the various inequities that had occurred with respect to doctors remuneration over the years. It was fervently hoped that these would be addressed by the CONTISS. It was however with utmost dismay that the NMA received the contents and overall framework of the CONTISS circular and the approved allowances. Grievances as expressed by the NMA included:

1. The CONTISS circular and allowances completely distorted the principle of relativity in health sector wage structure as practiced world wide.

2. There was a reduction in the take home pay of all doctors with the CONTISS/allowances circular. This negated all known labour conventions/laws which forbade any loss of income for any worker following any salary review exercise.

3. All allowances previously paid to clinicians for the clinical services they offered had been consolidated and now applied to persons who rendered no clinical services.

4.The call duty allowance, hitherto a percentage of basic salary per unit call, had been made a lump sum and the actual amount reduced. In fact, a category of doctors no longer earned call duty allowance.

5. Clinical supplementation hitherto paid to honorary consultants who are primarily university staff has been eroded. Honorary consultants have therefore suffered a substantial loss of income for the extra work they do in the hospitals, in addition to their primary teaching duties.

6. The CONTISS and allowances circular failed to take cognizance of the submission of the NMA to the Shonekan panel requesting a reinstitution of the MSS/MSSS salary structure for doctors in Nigeria.

The demands of the NMA were as follows: immediate withdrawal of the CONTISS circular and approved allowances as it affected medical/dental practitioners; approval and reinstitution of the MSS/MSSS salary structure as updated as the basis for remuneration for Medical and Dental practitioners; creation of a Medical Service Commission for conceptualization and implementation of medical services in Nigeria; creation of the position of Surgeon General/Minister of Health; payment of the arrears of monetization to all doctors. All doctors in the federation including state and local government doctors must also be beneficiaries.

The NMA subsequently embarked on industrial action which was SUSPENDED after some token adjustments in the CONTISS circular and a promise by the federal government to look closely at the other demands. However, a year down the road, not much had changed. This became very glaring with the eventual implementation of the CONTISS scheme late last year, leaving the NMA no choice but to issue a deadline.

As an affiliate of the NMA, the National Executive Committee of the National Association of Resident Doctors therefore resolved that a Committee for Actualization of MSS/MSSS be constituted by NARD. Also, a series of one-day solidarity strikes with the NMA were to be observed by all the branches of NARD. The first of these held on Friday 1st February 2008. The rest were suspended after promising deliberations with the government.

These, in a nutshell, are the immediate and remote origins of the current clamour of NMA and NARD. The expectation is that government will follow through on its renewed commitment to finding a resolution, so that other problems mitigating against the health sector budget and policy, personnel training/funding for research, health infrastructure, among others etc. can equally be placed on the front burner. That is the only hope of the common man who cannot travel overseas to access basic health care.

But history has thought us lesson that people in government have no interest and stake in public health care. This is why they travel abroad for treatment for a common headache that could be treated locally as they have over the time staved the health sector, just like other vital sectors the required resources to make it functional at optimal capacity. It is very doubtful that the present crops of political class can salvage the health sector from its present degenerate state. Only a pro-poor people government with the interest of masses at heart can inject the required resources to the sector to make it functional. Labour and poor working people should therefore wake up to their historical responsibilities to bring about this government that will bring quality health care to the door step of the poor who could not afford the cost of traveling abroad for medical attention.