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The Problems In Nigeria's Health Sector (Part 1)

By DR PAUL JOHN
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Why is it that the workers in our health sector cannot work as a team?Why is it that our tertiary hospitals have recorded,if not the highest,at least one of the highest number of industrial actions in the country?

Initially it was between the nurses and doctors but when the former discovered that it was almost impossible to fight the doctors alone,they had to surreptitiously involve other health workers in the name of JOHESU (JOINT HEALTH SECTOR UNION) and since JOHESU came into existence,Neither the health sector nor the government has known any peace. JOHESU is an umbrella body comprising every worker in the tertiary hospitals except the medical doctors.

When JOHESU goes on strike the hospital is almost paralysed not because they are the key players in the health sector but because they are made up of other 'non-medical' staff such as cleaners,security men,accountants,porters etc.

I think this is the time for this cold war that has been in existence between doctors and other health professionals to be solved permanently. Why are doctors not part of the JOHESU,if the ulterior motive of forming JOHESU was not primarily to fight doctors?Why must all members of the health sector ,including non-medical staff ,be part of JOHESU except medical doctors or are doctors not part of the health sector again?Surprisingly,in the private hospitals,one will see the type of cordial relationships that exist between health workers and doctors,the question then is: why must it be in the government owned hospitals that there will be problems and leadership tussle between other health workers and doctors?

The answer is simple,in the private hospitals,other health workers know their duties and their limits. They are aware that if somebody decides to come to the hospital,the person is coming to see the doctor and the onus lies on the doctor to know if the patient can further benefit from the services of a medical laboratory scientist,radiographer etc. Even when such further services are requested by the doctor, it is still the doctor that will give interpretative meaning to the investigative results.

The doctor by virtue of his training knows what the nurse,radiographer,physiotherapist,optometrist and medical laboratory scientist are doing and can as well do what these professionals can do individually. The doctor knows when to reject and request that a test be re-run if the result is not in line with his clinical observation. There is no gainsaying the fact that the doctor occupies a central position in the health sector.

Meanwhile,other health professionals do not struggle with doctors over leadership positions in the private hospitals since they know that if a patient decides to raise any litigation against the hospital,it is the doctor that is targeted but coming to the government health institutions,the opposite is the case. Everybody wants to head any department with or without the requisite qualifications.

Meanwhile, many doctors after their first degree(MBBS) still continue to acquire additional qualifications-through residency programme or msc/phd-whereas some doctors may still decide to remain as medical officers without the pursuit of additional qualifications. Those that want to remain as medical officers know that it will be extremely difficult for them to become Chief medical directors in tertiary health institutions. In fact,the maximum level they can reach is Chief medical officer in general hospitals. Also the medical officers find it somewhat difficult in becoming the leaders of our modern NIGERIA MEDICAL ASSOCIATION(NMA).

The reason is simple,the world has grown to the point that one's qualifications speak faster than one's personality. Now,if such relationship exists among doctors,how will it be possible then for a JOHESU member who has first degree certificate as the only educational qualification to come and head the departments or hospitals where there are medical consultants? Even in the law court,the evidence tendered by a professional with higher qualification supersedes that of another professional with lower qualification. Nigeria is a country where one day,a blind man will sue minister of sports, NFF/NFA and Super Eagle coach for disqualifying him as a super eagle goalkeeper since section 42 of our constitution abhors discrimination in its entirety.

Time has come for us to tell ourselves the truth. There is no way a doctor and a johesu member are equal in terms of training hence the salary package should not be the same. The higher the risk one takes in life,the higher the profit. There is no way a trader who buys his commodity from the next village will have the same profit as he who travelled abroad to buy same goods in a larger quantity. Six-year courses will not have the same salary packages as those of the five-year courses etc. I know that many professionals will like to increase the number of years they spend in school just like the optometrists have done in order to meet up with higher salary package.

The point we should note again is the volume of work in that six-year curriculum,if it is abused(which is not unexpected) by stretching a course that should otherwise have lasted for four years or by introducing time-buying courses,such a six-year programme should be reverted to four or five-year programme. This reminds me when I just finished my second MBBS examination,I was travelling home in a commuter bus,the passenger sitting next to me was an Anatomy graduate from another university,we introduced ourselves and thereafter an argument ensued,he told me that the anatomy we did was periphery and we could not challenge them in anyway.

In order to end the argument,I challenged him to ask me ten questions while I would ask him ten questions and that if he got three of mine and I got less than seven of his own,he would be the winner .That was a bait and he fell prey to that trap. The summary is that I won him in that encounter even when I was not among the first ten brilliant students in my class.

This simple illustration shows how a doctor is trained to be versatile. Remember that I won somebody that read the course for five years even when we studied the course for only eighteen months along with other professional courses like Medical biochemistry and Physiology. A doctor is trained to play a central role in the field of medicine and that is why a radiologist can perform and interpret the work of a radiographer;the haematologist and chemical pathologist can perform and interpret the work of a medical laboratory scientist.

The truth is that the central role and the ubiquitous nature of doctors in the health sector will render any industrial action by any single professional union in the health sector not only ineffective but also nugatory hence the need to form JOHESU in order to have a mass effect.

The first thing government should do, if they intend solving the problems in the health sector,is to disband JOHESU immediately or let doctors be one of the members of JOHESU because once JOHESU is in existence,doctors will be their primary target and peace cannot return to the health sector. There is no way everybody in the tertiary hospitals will gather under an umbrella called JOHESU against doctors and you think peace will return to the health sector.

They included non-medical workers like the clerical staff,cleaners,porters,security men,mortuary-attendants etc in JOHESU so that when they go on strike the hospitals will be paralysed. The founding members of JOHESU are smart because they know that Act Cap M8 LFN 2004 empowers the doctor to specialise in all fields of medicine hence: if the Radiographers go on strike alone,doctors called radiologists will take over;if the nurses go on strike alone,the doctors called house officers will take over the nursing care of patients along with the patients' relatives;if medical laboratory scientists go on strike alone,doctors called pathologists(comprising haematologists,chemical pathologists,medical microbiologists,immunologists,histopathologists) and 'side-labs' manned by doctors will take over.

Also,the work of physiotherapists is what any doctor with MBBS certificate can perfectly do. Meanwhile,the doctors called ophthalmologists are already there waiting for the optometrists to misbehave whereas the dental surgeons are there in case the dental technicians want to assume air of importance. This was exactly what all these professional bodies saw and ensured that JOHESU was formed in order to attack doctors from all angles. One of our consultants once told us his experience when he was a house officer,the nurses went on strike,the doctors through house officers in conjunction with patients' relatives took over the nursing care of the patients.

The hospitals ran as if nobody went on any strike and expectedly the government did not attach any importance to their demands. Thereafter,they had to go and beg for them to resume their duties. I wish the government could increase the salary packages of doctors and allow JOHESU to proceed on an indefinite strike while the governing boards of the hospitals engage the services of private firms in areas of security,clerical work,cleaning services and other non-medical services needed in the hospitals. The achievements that will be recorded will not only be daunting but will show that doctors are really the pillars of the health sector and have been the ones accommodating their sister professions for peaceful co-existence in the health sector.

Meanwhile,With the residency programme of doctors covering all fields of medicine,doctors can work effectively once clerical and other non-medical services are made available during any of the JOHESU industrial actions. Many of these our multinational companies,just like many of the institutions in developed countries,are running hitch-free businesses because they run contract employments.

Imagine PHCN workers who could not solve the problems of our power sector for many years started protesting when president Goodluck Jonathan drew a roadmap in the sector in line with his transformational agenda in order improve on our power supply?That is Nigeria for you. Is it not madness for somebody who has first degree or RN certificate to aspire to be a Chief medical director or a head of the department in the tertiary hospitals where medical consultants work,even when it is practically impossible for fellow doctors who are medical officers to contest with the distinguished medical consultants for the same post?

I think very soon in this country,the members of :the Nigeria police force, the National security and civil defence corps,the man-o-war, the Boys' scout, the Nigeria customs service etc will go on strike because they want one of them to become the Chief-of-defence staff since they are part of the security agents. Also, very soon the reverend sisters and reverend brothers in the catholic church will start disturbing that they want to be celebrating masses in the church since they are also in the same vineyard as ordained reverend fathers.

Now tell me, why if the aim of establishing JOHESU was not to fight doctors, why did they attack the appointment of the Surgeon-general of the federation?Why did they not fight for their own JOHESU-general of the federation or better still break it into their component units such as Nurse-general of the federation,Radiographer-general of the federation,Cleaner-general of the federation,mortician-generation of the federation etc?

The painful aspect of these 'freedom fighters' is that many of them wanted to study medicine but somehow the vicissitude of life either in the medical college or by JAMB forced them into paramedical courses,now the principle of; if-you cannot-join-them,kill-them is being applied. Many of them hate doctors but are ready to see to it that their children study medicine in the higher institutions at all costs and worst still ,many people address them as medical doctors since an average Nigerian believes that anybody that wears lab/ward coat is a doctor.

Now,a laboratory scientist answers a laboratory doctor,a radiographer prefers to be addressed as a radiation/imaging doctor etc.They are what Aye Kwe Amah called chidodo birds in his novel,The beautiful ones are not yet born.The chidodo birds hate faeces but feed on maggots that feed on the faeces.Why introduce yourself as a doctor when you are not a doctor and at same time exude loathsome hatred for the real doctors?

Many of these JOHESU members will tell you that doctors have mismanaged the tertiary hospitals hence the need for JOHESU members to take over. The truth is that we cannot because our presidents have failed us as a country,we will now invite a foreigner to be the president of Nigeria. Also,the clerical and other staff in the law courts or in the ministry of justice will not because of 'mismanagement' of funds or mal-administration by the past leaders in the judiciary now present themselves as candidates for the posts of Chief judge or the Attorney-general respectively.

At times we seem to waste our time arguing over specious arguments. How can a member of the bench,now want to become a senior advocate of Nigeria(SAN) or a member of the bar,now wants to become the chief justice of the federation without first joining the bench?Wonders,they say, shall never end and this is exactly why many of our tertiary hospitals are shut down incessantly. I think this issue has to be tackled now or never.

Also,many of the nurses will tell you that in Europe,America and other developed climes,nurses are paid higher than doctors. Well,as the psychologists will always say that :it becomes more difficult to accept the truth when the lies told to you were exactly what you wanted to hear,there is no way a nurse will be paid higher than a doctor who is the man at the centre of the management of the patient even if the nurse works in an elderly people's home where the nurse takes care of packing the faeces due to faecal incontinent nature of the elderly patients there.

These JOHESU members have equally argued that the post of a secretary of health(an equivalent to our own Minister of health) in other climes is not an exclusive preserve of medical doctors.There is no gainsaying about that but they have also failed to appreciate that those secretaries of state who were not medical doctors,did not get there with their first degree certificates,they went further to acquire additional certificates. How many JOHESU members can boast of additional certificates today?

Regrettably,many of them in the tertiary hospitals believe that the only criterion used in determining whether one heads a department or the hospital itself is the number of years one has worked hence many of them will not deem it necessary to acquire additional qualifications. Instead,they prefer attending all these one-day,two-day etc seminars/workshops forgetting that thousands of those certificates are not equal to a master's degree.

It will be against the principles of natural justice if JOHESU members with first degree certificates come to head departments or hospitals where there are medical consultants. It will be likened to the regime of our former Igp Abubarkar Ringim,who was appointed from a lower rank of Assistant-Inspector-General of police when there were higher officers at the rank of Deputy-Inspector-General of police. We all saw how his tenure started and ended despite the man's efforts.

I am happy that our president learns from history unlike our past presidents hence when President Goodluck Jonathan appointed the current Inspector-General of police,he retired all senior police officers. It then follows that to allow any JOHESU member with first degree or RN certificate to head any department or the hospital,the president should then retire all medical doctors from the rank of house officers to medical consultants. I do not need to emphasize how our hospitals will look like then. As I have already noted before, among doctors,medical officers(those that refuse to specialise) hardly enter into contest with medical consultants.

Why is it that we Nigerians like short-cuts? Somebody who could not gain admission to study medicine and surgery now wants to not only be like medical doctors but to also lead the doctors. I got admission to study one of the paramedical courses but when I saw the central role of a medical doctor in the management of patients and I was not ready to play a second fiddle to anybody,I spent good four years of my productive years in the paramedical course before changing over to medicine.

There are stories here and there of how people finished their first degrees,served out their NYSC years and applied through direct entry to study medicine. In fact in my class,my best friend, who had a first degree in medical laboratory science,painfully failed out in our second MBBS examination. He was not deterred,he collected his transcript and moved on to another school.

The paradox there was that he became a doctor before many of our classmates,those were the vagaries of life. Also,my own roommate,popularly called master,who is now a resident doctor at Federal Teaching Hospital,Abakaliki,finished his first degree,served out his NYSC years,worked for few years and later returned to school to run a master's programme. He was a demonstrator in one of our first year practical courses. While still in the programme,he applied to study medicine through direct entry and when he got the admission,he consulted many people,even his own supervisor advised him to suspend his master's programme to pursue the medicine.

My roommate passed through the pains of being in the same class with 'little kids' that he taught barely one year and who saw him as demi-god then. The funny thing there was that he was not doing better in terms of academic performance than the 'little kids' he once taught. In fact,he was not among the first hundred brilliant students in the class but he persevered and today he has fulfilled his life ambition.

No wonder,one of the former ministers of education during Chief Olusegun Obasanjo regime once proposed that medicine and surgery should be studied as a second degree course in Nigeria,though the proposal was later abandoned,just like any other Nigerian projects/policies, by the successive administration.

Many people are calling for peace to return to the health sector while the underlying problems are not first nipped in the bud. It is like requesting to make a peace with a man while at the same time asking the same man to prepare a timetable for how you will be sharing his wife with him. As psychologists will always say that-peace is not the absence of war but the presence of justice-there is no way you can sit on my nose and get balanced. In the actual sense of it,the doctors are the ones that have been at the receiving end.

In the private hospitals, if a doctor makes a mistake and sends a patient out to a medical laboratory scientist to run a test and come back,that is a farewell to that patient as the medical laboratory scientist after the test will interpret the result and will still go further to prescribe drugs to the patient-thanks to broad spectrum drugs.

Drug interactions along with other pharmacodynamic and pharnacokinetic properties of drugs are not taken care of hence the emergence of drug resistance and the high rate of kidney failures among patients(I do not want to talk about all these herbal mixtures with NAFDAC registration numbers-may be that should be covered in my subsequent write-ups). In some areas,some pharmacy shops are in symbiotic relationship with some medical laboratory firms. When a patient comes to a pharmacy shop,whoever is there refers the patient to the laboratory firm and after the test,the patient is sent back to the pharmacist for prescription and vice versa.

I don't need to call names but if at all we have functional regulatory agencies,they can verify my claims as pharmacy shops are now giving intravenous drugs and still go on to manage diarrhoeal diseases of children with anti-motility drugs ,just to mention but a few. Traditional-birth- attendants and midwives are now 'medical' directors in their 'registered' maternity homes,they only refer out their patients when the whole situation gets complicated,most of which the patients will die on the road before reaching the nearest hospital. Was it not my auntie that was advised by a consultant gynaecologist last year that her pregnancy would end with caesarean section(cs) since the first was by cs?

Thereafter, my auntie was convinced by her pastor that she would deliver normally if she delivered in one of their members' maternity,who knows if the pastor gets any commission for each referral.The summary is that,that my auntie is no longer in the land of the living today courtesy of the trial of labour in a pregnant woman who became pregnant less than one year of the previous delivery by cs and who presented with the same conditions that led to the first Cs. I decided not to go into any litigation because I warned both my auntie and the husband but they attached more importance to the prophetic declaration by their pastor.

Why is it that the regulatory agency that accredits a pharmacy shop will not approve a pharmacy shop if it is discovered that the said shop is owned by a medical doctor or that it is in the same compound with a hospital even if the shop has satisfied all the requirements including employing pharmacists?Anybody who is not happy with the central role of doctors in the health sector should simply pick up JAMB forms-either UTME or direct entry-to come and see what we saw,may be after passing through the difficulties of the course, the person will now advocate that doctors should be pushed to the corner while the JOHESU members who study their courses semester by semester with no difficulty will then become the leaders of the health sector .Nelson Mandela did a similar thing by picking a law form and studied law while in the prison in order to further his fight against the apartheid regime in his country.

In view of the above,I think if the government can neither disband JOHESU nor make doctors integral part of it,and cannot allow JOHESU to proceed on their proposed indefinite industrial action while salary packages and well fare of doctors are improved,then the only option left is to establish parallel JOHESU hospitals and possibly create another federal ministry just like ministry of Niger delta. The name may be federal ministry of JOHESU.I am very sure that such an establishment will not survive more than a year and it is then that people will understand that JOHESU is an amorphous body like a keg of gunpowder waiting to explode.

The the non-medical staff in JOHESU will realise that all these years,medical staff part of JOHESU have just used them in achieving their ulterior motive which is primarily to fight doctors. The porters,the cleaners,ward-maids,mortuary-attendants etc will realise that they have been used by their more educated JOHESU members and that they have more differences than similarities for them to have existed together as a group.

It is akin to what happened in one of George Owen's novels,the Animal farm,where Napoleon after leading other animals to overthrow the owner of the manor farm,later turned out to be the worst ruler ever known . If they care to learn from history,they will know what radiographers passed through in 2012 over the change of name of their regulatory body. It was then that the Bsc holders saw the HND holders as junior and inferior colleagues. A word, they say,is enough for the wise.

DR PAUL JOHN
[email protected]
08083658038

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