Nigerian Hospitals Better Managed By Seasoned Administrators Than Medical Doctors – Josiah, JOHESU President

In this interview with GBENRO ADEOYE and AFEEZ HANAFI, the President, Medical and Health Workers Union of Nigeria and National Chairman of Joint Health Sector Unions, Mr Bio Josiah, speaks on some contemporary challenges in the health sector and why health workers are threatening another strike action

Nigerians are asking why the Joint Health Sector Unions is embarking on yet another strike, especially at this crucial period. Why is it that JOHESU is almost always going on strike or threatening it?

You are aware that we have had pseudo peace in the health sector in the last seven months or thereabouts. Our members have tried to be very civil and law-abiding even in the face of extreme provocation from government quarters, especially the Federal Ministry of Health. When we called off our last strike on May 31, 2018 after interventions by prominent Nigerians, including the Senate President, Dr Bukola Saraki, we pursued matters at the Alternate Dispute Resolution Centre of the National Industrial Court of Nigeria, Abuja. Ordinarily, resolution should take 21 days at the ADR, but we were there from June till December 2018 because of the several unorthodox hurdles associated with the mediation efforts. Unfortunately, in those six months, we could not take action or even brief our members because the rules of ADR prohibited such. Even now I cannot begin to disclose what happened at the ADR publicly. Do however recollect that one of the major issues that took us to ADR was the desire to get government committed to the terms of agreement reached with JOHESU, which compelled government to adjust the Consolidated Health Salary Structure which is the preferred methodology of payment for JOHESU members. Significantly, after another six months of being law-abiding and exercising physiological calmness, negotiations in this regard were stalled. In other words, we need to protect the destiny of JOHESU members through other methodologies in tandem with due process and this is the reality we contend with at the moment.

Apart from the issues surrounding salary, the rivalry with doctors seems to be one of the issues in contention. What is really at the root of these strike actions?

At the root of these avoidable strike actions is the desire for benefit packages and privileges for all concerned. These clamours from all sides of the divide appear to have been grossly mismanaged by government at all levels over the years. Contrary to the superiority mentality created in some quarters, some of our members and doctors got into the public service on the same grade level up till 1991. In Nigeria, pharmacists started on GL 08 step 2, while doctors entered on GL 08 step 3 because of the one year difference in the duration of training. After the mandatory one year youth service, pharmacists proceeded to GL 09 step 2 and doctor GL 09 step 3. This was the pattern till the Prof Olikoye Ransome-Kuti leadership in the Federal Ministry of Health got the military administration of the then General Ibrahim Babangida to approve the Medical Salary Scale, a discriminatory salary wage in favour of medical doctors in public service. The MSS obviously disrupted the equilibrium of public sector wages as it became the basis for other sectoral players’ request for exclusive wages in the health sector. After the MSS was introduced, the Health Salary Scale was introduced for health workers apart from doctors. In 2009, the government of the late President Umaru Yar’Adua adopted the Federal Ministry of Health’s new salary scales for the health sector. A CONMESS scale was approved for medical doctors, while CONHESS was the scale of choice for health workers, including the rank and file of all health professionals. The fundamental spirit of the adoption of CONMESS and CONHESS scale in 2009 was to ensure relativity in the two scales at all times.

Does it then mean that the rift over the disparity in the salary of doctors and other health workers would always be a cause for concern?

It is extremely important we put on record at this juncture that after tinkering with the existing public sector wage structure in 1991, the salaries of health workers and doctors were distorted significantly, such that doctors began to enjoy an extremely significant difference in wages with at least one full grade level difference without any change in the duration of training which remains five years for health professionals and six years for doctors. From an initial difference of N7.00 monthly or N84.00 per annum prior to 1991, the difference in entry point for these cadre of personnel now runs into about N1.2m per annum. Despite this scenario, health workers on the CONHESS scale took things easy until more provocative incremental adjustments were awarded for doctors first in January 2014 and then in September 2017. On both occasions, the enabling circulars to legitimise the increases for doctors took only 14 days. Other health personnel have been agitating for adjustment in the spirit of relativity on both scales which was entrenched in the spirit of the 2009 MoU with the Federal Ministry of Health. This led to a strike by health workers in 2014 and 2017. In 2017, under the aegis of JOHESU/Assembly of Healthcare Professionals Association, the Federal Government signed a five-term settlement agreement on September 30, 2017 to resolve the September 2017 strike of health workers. The agreement was to be actualised within five weeks with circulars effective September 30, 2017. It is sad to inform you that almost 17 months after the agreement with the Federal Government; nothing has come from legitimate agreements with government at the highest level. In fact, five years have passed since January 2, 2014 when we clamoured for this adjustment without government doing the needful.

At that time, perhaps, government at some point found the incessant strikes frustrating and then moved to stop the salary of those on strike.

(Cuts in…) You see, while all these were playing out, Federal Ministry of Health came up with two circulars in April and June to pave the way for seizure of the April and May salaries of our members who were on strike. This amounted to a violation of the September 30, 2017 terms of agreement where all parties declared that there would be no sanctions on those who participated in the strike action. There were also specific court declarations at the National Industrial Court of Nigeria which urged that all parties, in an action brought against JOHESU and others by a non-governmental organisation, must maintain peace and refrain from provoking one other. As we speak now, our members have yet to receive their April and May salaries for embarking on legitimate actions to boost their welfare. These are the major reasons why our restive membership can no longer be persuaded not to embark on another strike action if government fails to meet our ultimatum which expired by January ending.

It was gathered that the Federal Executive Council approved the no work, no pay principle, leaving the Federal Ministry of Health with no choice but to implement it. Isn’t that understandable?

It was a smokescreen to disguise hatred laced with antiquity and the obvious strategy of the Federal Ministry of Health hierarchy and its cohorts to destabilise the JOHESU leadership. The ministry recognises that the extremely wretched pay regime to our members makes them very vulnerable when it comes to sustaining struggles.

It had always boasted that all it needed to discredit the JOHESU high command was to invoke this strategy maximally. In the unfolding scenario, the ministry will however discover the futility of this ill-conceived implementation plan against our members. Let me point out that, fundamentally, as of the time we proceeded on strike on April 17, 2018, there was no FEC resolution, so you cannot begin to retroactively apply non-existent rules pre-April 17, 2018.

The other leg is that there is a clear violation of the terms of agreement by the Federal Government, which impugns the character and integrity of the prime movers of this unwholesome development. In unambiguous terms, if a subsisting court declaration forbids any provocative action from parties in a suit and you proceed to circulate directives that are punitive, then you have a major distortion capable of truncating judicial outputs. If you learn to call a spade a spade, it amounts to geriatric rascality and outright recklessness for people in exalted positions to insist on dealing decisively with the downtrodden.

Even when I try not to make these things personal, it is worthy of note that the honourable minister of health, who was a medical activist in the days of yore has never failed to signpost this bias and vengeance against other constituents in the health sector apart from his medical colleagues. A perfect example that tells you that the action of the minister is vindictive against health workers is the scenario you see in other sectors. Members of the Academic Staff Union of Universities have been on strike for weeks but the Minister of Education has not invoked the ‘no work, no pay’ rule because he wants genuine peace in that sector.

The Federal Government said in 2018 that it had met 14 out of JOHESU’s 15-point demand, which led to its strike. Is that true?

This has proved to be mere propaganda of the Honourable Minister of Health, Prof (Isaac) Adewole, when he made that claim in 2018. The issue at stake is that the Federal Ministry of Health cannot be trusted. At a point, the ministry said there was no agreement between it and JOHESU until we showed the world through paid adverts that government indeed signed agreements with us. If government entered into 17 terms of agreement freely on September 30, 2017, then the implementation should be holistic. No more, no less.

On the disparity in the salaries of doctors and other health workers, why are you bent on having parity in the salaries?

For the umpteenth time, I am telling the world that parity is not the watchword but relativity as entrenched in the 2009 MOU signed between the ministry and health workers. This is a deliberate blackmail of the Honourable Minister of Health and his followers. At a time, he said JOHESU members wanted equality in emoluments with doctors and we have never failed to state our case that what we clamour for is equity and not equality.

What do you think has to be done to stop internal crisis among workers in the health sector?

Let us go back to basics by engendering genuine reforms in our health system. The take-off point is through appropriate appointments of seasoned administrators and managers with cognate experience as ministers and commissioners at federal and state levels. With good appointments of neutral players and conciliators, we can organise the first Nigerian Health Summit of all workers in that sector to put building blocks in place.

You have repeatedly accused the leadership of the Ministry of Health of planning to privatise federal health institutions. Some people would describe it as a good thing that would improve efficiency of the institutions. What do you think are the consequences of that?

The conspiracy theory of the incumbent leadership crew from inception was to paint health workers as unproductive and fruitless. From the very beginning, an infamous group of medical elders were mobilised to visit President Muhammadu Buhari to advise that the only way to sustain health services in our country was to privatise all the Federal Health Institutions. It took wisdom on the part of the President to resist the poisonous proposal from those yesterday’s men who have institutionalised a damaging hegemony in the health system of a country that ordinarily is destined to be Africa’s leading light.

It is a sad story in some of Federal Health Institutions where these aberrations are entrenched. Please conduct independent studies on the situation at Garki Hospital, Abuja, which is operating under a concession today. Find out the persons who were all set to procure the Trauma Centre at the Teaching Hospital in Gwagwalada in FCT, Abuja. You need to visit Lagos University Teaching Hospital, Idi-Araba, where a lot of health services have been commercialised. Of course, there are so many other centres where these inglorious models of outsourcing care services are deeply entrenched.

Could you expatiate more on that?

In Abuja, the Federal Staff Clinic has become extremely notorious for anti-labour practices, including complete reliance on the use of only locum staff to cover services in pharmacy, laboratory, nursing and even to a large extent medical services. Chief Medical Directors and Managing Directors have in many instances become unrepentant tyrants who hound and persecute the generality of staff in their facilities.

Every productive health team hinges its outcome on the well-being of the patient who is at the centre of a pool of professionally-inclined services. In Nigeria, where poverty is endemic, how are these patients who are kings in other climes ever going to afford services and cost of drugs offered in commercialised or privatised facilities, on the one hand?

How do we sustain or consolidate a culture of producing an array of good quality health care professionals in Federal Health Institutions that are commercialised? This is logical because research and training will no longer be areas of interest to a commercialised health facility. Government therefore has salient responsibility to stop persons who indulge in nocturnal circles of political secrecy geared towards disrupting rendition of health care services as a social welfare inclined agenda to the generality of the people. The media has a huge role to play in terms of advocacy in the days ahead to stop the dangerous manoeuvres of the Federal Ministry of Health and other private profiteers who champion this agenda.

Why are you bothered by the alleged moves by the government to engage contract and locum health workers?

It is anti-labour and anti-people. The only reason it is attractive to managements in our facilities is the multiplier effects of pecuniary gains that accrue to people in high places. This cadre of personnel do not have normal or formalised employment protocol so they are at the whimsical and capricious propensities of management who use them to settle scores. In terms of professionalism, core values and ethics, these cannot be vouched for because their loyalty to the facilities where they work remains suspect and this affects productivity. Let me also ask you pointedly that if you have a malpractice or unethical misconduct that is threatening a client’s life, who do you hold responsible? Is it the locum staff members who have no stake, because they are not bound by Public Service Rules, or in the event of corporate bodies, is it a profiteer who conveniently circumvents Corporate Affairs Commission’s regulations with minimal or no sanctions oftentimes?

I can authoritatively confirm that privatisation is no longer an option because global surveys confirmed its failure in all the climes it was applied. In Nigeria, what happened to the private participation in pharmacy projects in Federal Health institutions like University College Hospital, Ibadan and the over six Lagos State Government hospitals where such was applied in 2002? Let us be good students of history for once by building sustainable initiatives which will be driven by competence.

What is your recommendation in this regard?

A worthy beginning is to ensure the appointment of fit and proper persons in charge of the Federal Ministry of Health and our Federal Health Institutions. Like they say, you cannot continue to do the same thing the same way and expect new results. As we therefore prepare for the 2019 general elections, our presidential and governorship aspirants must note that health care management transcends the borders of professional expertise. It is an endeavour for seasoned administrators and managers with cognate experience.

At the December 2018 public hearing on the Federal Medical Centre bill in the House of Representatives, the approach of JOHESU focused on total reforms. Can you give a comprehensive insight into what these reforms should cover?

JOHESU sent far-reaching recommendations for holistic and very robust health reforms in the country. Contrary to what is provided for in this bill, this opportunity of Federal Medical Centre Bill affords us a major ground for health reforms. The paradigm shift in this agenda is that major stakeholders in health care have an opportunity with the representation listed in this paper to be involved in the day-to-day decisions and policies in health care management.

We also highlighted the need for government to provide facilities for the training of students in all the health professions. Government has the responsibility to ensure total and unhindered access to training for all component members of the health team. This promotes a collaborative spirit and the often-emphasised team approach in health care.

We also noted that in recent years, Nigeria has had to contend with negative indices in the health sector. This is directly traceable to leadership deficiency inherent in the training and the subsequent output of medical doctors, who have been imposed as heads of health facilities in Nigeria since the advent of Teaching Hospital Act. Cap U15 LFN 2004. JOHESU puts it on record again that health care is a global practice which derives its norms from international best practices.

This best practice does not dictate that medical doctors should be appointed as head of medical facilities. At the World Health Organisation, which is the number one health platform globally, the Director-General, who is the world’s number one health worker, is not a medical doctor.

We must redress a structure which places our health system as 187 out of 191 rated health system by the WHO. Nigeria needs to go back to the era when seasoned administrators were in charge of the various hospitals. UCH Ibadan was one of the top five facilities in the whole of the Commonwealth of Nations in that dispensation and was led by administrators who were designated as House Governors.

The above submission is in tune with the spirit of Section 42a and b of the 1999 Constitution, which prohibits discrimination against any citizen of Nigeria on the basis of gender, social-cultural, religious, political and professional affiliations.

It is believed that the dearth of quality health care facilities and manpower is largely responsible for the reason why many politicians and wealthy individuals travel abroad for health care. What is JOHESU doing to address the situation?

This is why I continue to harp on the appointment of fit and proper persons in charge of health care endeavours. Have you ever wondered what we were doing right when UCH Ibadan was rated as one of the top five facilities in the Commonwealth of Nations? This facility and others like it were led as well as managed by hospital administrators, which is the trend if we are thinking globally. The advantage is that health professionals are compelled to apply themselves in their areas of due competence which enhances therapeutic outcomes to patients and establishes a functional structural output that works maximally in the health system. Therefore, government must be bold at the level of the legislature to approve the FMC Bill before the House of Representatives. The Executive must be ready to alter the cycle of the delinquent status quo, which this misfiring health sector presently symbolises. The personnel remain world class but we must channel their outputs methodically to bridge health tourism.

The way the politicians and the rich travel abroad for simple ailments would almost make one wonder whether the medical personnel in the country lack the requisite competence to treat Nigerians. Are you bothered?

I reiterate with all sense of responsibility that our personnel are of finest quality. Give them the necessary equipment, financial resources and other levels of motivation and you will see them at the apex level.

Wrong diagnosis is another major issue in the health sector. What do you think is responsible for it?

A lot of the time, modern gadgetry is now employed to aid perfect diagnosis. We still lack a lot of these 21st century equipment, hence failed diagnosis remains occasional possibility. Let us put professional managers in charge of health care and you will discover we shall have improved output and outcomes.

To what extent does excess workload for health workers influence wrong diagnosis?

I would say maybe a slight chance of impact. It is certainly not a predominant challenge.

Treatment of terminal diseases is very costly and is barely available in public hospitals in Nigeria. What can JOHESU do to help in solving the problem?

This is why we cannot continue the trend of sustaining health care with out-of-pocket expenditures. A major source of health care funding remains Social Health Insurance or Managed Healthcare. Unfortunately, however, those who encourage a massive usurpation of the authoritative exclusivity of health workers apart from doctors have continued to ruin globally acceptable norms in health insurance at both federal and state levels. Look at even the recent Managed Health Scheme launched with fanfare by the Lagos State Government with its imagined sophistry; it looks to me to be dead on arrival because other health care professionals apart from doctors have not been programmed to embrace it from inception.

Many patients with gunshot wounds have died because they were requested to present police reports at hospitals before they could be treated. Why do hospitals still deny them treatment?

Simply put, the police harass health workers who genuinely wanted to save lives in such situations in the past. I know that an Act of Parliament has been in place since 2017 to redress this. We must make sure the spirit of the Act sees the light of day in terms of enforcement in facilities to halt that negative development.

Despite the police’s directive that hospitals must not reject patients with gunshot wounds, some health facilities still fail to comply. What sanctions do you think should be taken against such health care facilities?

In fairness to all concerned, this is not about meting out sanctions to hospitals. The police must come up with polished rules of engagement with health care staff to assure them they will not be unduly harassed.

Insufficient oxygen is a major issue alleged to have claimed lives, over time, in some public hospitals. Who is to blame?

Don’t let us make it a blame game. The supply chain of medicines and equipment needs to be tinkered with to facilitate seamless distribution of essential medicines, equipment and specifically life-saving agents like oxygen.

Many patients usually complain of having nasty experiences with medical officials, especially nurses. What do you think is responsible for such poor attitude, like hostility?

Today’s health care personnel are better trained in interpersonal and communication skills. This makes room for the finest tenets of human relationship management. One of the reasons we insist government must improve on welfare conditions is to boost the morale of all cadres of personnel. A poorly motivated staff in any sector will naturally not give their possible best.

What is JOHESU doing about the upsurge in drug abuse in Nigeria?

JOHESU was one of the organisations that drew the attention of the general public to the huge volume of cough syrup being abused in the North, leading to advocacy visits to Senate President, Speaker of the House of Representatives, traditional rulers, governors of affected states and the Director-General of National Agency for Food and Drug Administration and Control. We strongly condemn unethical practices and consistently educate, retrain, certify and advocate for ethical practice by stakeholders.

We shall work with regulatory agencies like Pharmacists Council of Nigeria, NAFDAC and National Drug Law Enforcement Agency to improve regulation by ensuring laws are updated to reflect current realities, motivate easy compliance, promote integrity of the medicines supply chain and provide sufficient penalties to wrong doers.

We call on all members of the public to speak up and ask their representatives to mandate the Federal Government to implement the NDDG as agreed with stakeholders.