4th April, 2023
Asiwaju Bola Ahmed Tinubu,
The President Elect,
Federal Republic of Nigeria,
Your Excellency Sir,
LETTER OF CONGRATULATIONS AND CHARTER OF DEMAND
The Joint Health Sector Unions (JOHESU) and Assembly of Healthcare Professional Associations (AHPA) heartily congratulate Your Excellency on your recent electoral victory at the 25th February, 2023 presidential election to become the next President and Commander-in-Chief of the Armed Forces, Federal Republic of Nigeria.
JOHESU/AHPA is the umbrella Union/Association of all health professionals and workers in Nigeria apart from Medical Practitioners. We collectively represent over 95% of all health work force in Nigeria. We are particularly gladdened by the uninterrupted democratic transition since 1999 return to civil rule in Nigeria. Democracy is still the best form of government that must be jealously nurtured, guided and defended at all times. May your Administration witness overall transformation, peace and stability in our dear country-Nigeria.
In the current dispensation, the realities in our country is that we need far and wide reaching reforms to generate new building blocks for sustainable development in all frontiers of our collapsing social fabrics.
Our Health Sector has been progressively destroyed in the last three dispensations of leadership with special regards to ministerial appointments at the Federal Ministry of Health since 2011 to date when we have had to contend with unprecedented destructive proclivities in team spirit of the health workforce orchestrated by the trio of Prof. Christian Chukwu, Prof. Isaac Adewole and Dr. Osagie Ehanire who are all physicians.
Today the Health System in Nigeria which is rated 187th out of 191 Health Systems by the World Health Organisation (WHO) through the machinations of the leadership of Physicians stands no chance of redemption except if the President-elect comes up with a unique model of reforms which places a premium on Change-Agents who are not necessarily health workers to redress the pestiferous propensities in the heavily infested Health System of our country as presently nurtured by Physicians at the Ministerial, Parastatals and other Agencies of the Federal Ministry of Health.
In a larger bid to redress the gargantuan ills in the Health Sector, the JOHESU/AHPA wishes to facilitate the reform agenda of the President-elect by proposing the reflected Charter of Demand to the in-coming administration.
1. Appointment of the Minister of Health
2. Deficiencies of the University Teaching Hospital Act Cap 436, Laws of the Federation of Nigeria, 2004
3. Discriminatory salaries and wages in the Health Sector
4. Imbalances in the directorate structure of the Federal Ministry of Health
5. Poor implementation of the National Health Insurance Scheme now National Health Insurance Authority
6. Non-adherence to the norms of the Drugs Revolving Funds
7. Poor implementation of interventionist health agencies
1. Appointment of the Minister of Health
At the height of ministerial nomination and screenings in the country, Nigerian Physicians have always taken parochial and insulting positions that one of its own must be appointed at the helm of the Federal Ministry of Health because according to it, this was a global practice. The Nigeria Medical Association (NMA) in a particular dispensation under the Jonathan’s Administration threatened the then Acting President that it would ground the Health Sector if its position was not adhered to. This arrogant stance has perennially polarized the health sector with dire consequences.
Section 147 (1) and (2) of the Constitution of the Federal Republic of Nigeria1999 as amended are very clear as to how Ministers are appointed. Section 42 (1) (a) and (b) also compels a right to freedom from discrimination on the basis of Ethnic Group, Place of Origin, Sex, Religion, Political Opinion, e t c as it prohibits all of these in all its entirety. A Minister of the Federal Republic of Nigeria is a political appointee whose duty is purely administrative.
It has been established that, the tenure of many non-physicians at the helm of the Federal Ministry of Health witnessed stability and harmony as epitomise by the leadership of Late Aminu Kano, Admiral Patrick Koshoni, Admiral Jubril Ayinla, Prince (Pharm.) Julius Adelusi-Adeluyi, Professor A.B.C, Nwosu and lately Professor Eyitayo Lambo. Perhaps it is appropriate to also remind all that, Physicians have, at different times, led other Ministries that are not related to Health.
Professor Jubril Aminu was at different times Education and Petroleum Minister. Also, Dr. Olusegun Mimiko, former Governor of Ondo State; a Physician was Minister of Housing and Urban Development under the Obasanjo’s Administration. In these capacities, these eminent Physicians enjoyed the support of other core professionals in these different Non-Health Ministries. It is worthy of note that Physicians were the only group of health workers that protested the appointment of Prince Julius Adelusi-Adeluyi, a distinguished Pharmacist as Secretary of Health in the Interim Administration of Chief Ernest Shonekan.
Under the Jonathan’s Administration, the two Ministers in-charge of the Federal Ministry of Health were Physicians in a multidisciplinary set up such as Health, the first in the history of this nation, yet there was no threat to their appointments from other stakeholders in the Health Sector.
President Buhari consolidated the Jonathan aberration by appointing two Physicians again as Ministers in-charge of Health and went ahead again to initially appoint another Physician as Permanent Secretary in Federal Ministry of Health. This was unprecedented, and various ugly events occurred before the Permanent Secretary was removed that validated our position that it was an error of judgement.
The general perception on why physicians want to continue to be Minister of Health is to maintain the hegemony of an unjust entry-level in the civil service, discriminatory salary scales and continue to intimidate the Nigerian Public with their frequent and selfish strike action.
While Physicians perpetrate these less than noble acts, their privileged position in high places in the Federal Ministry of Health makes it possible for them to truncate the career growth and development of other health workers in Nigeria.
2. Deficiencies of the University Teaching Hospital Act Cap 436, Laws of the Federation of Nigeria, 2004
i. Lopsided Composition of the Boards of Management of Teaching/Specialist Hospitals: The Composition of the boards of Management of Teaching/Specialist Hospitals is unjustly titled in favour of Physicians. Whereas only one person represents more than fifteen other health professions, the medical profession is represented on every board (Section 2.1.d). In addition to the Provost of College of Medicine, the Chief Medical Director, the Chairman, Medical Advisory Committee, the representation of the State Ministry of Health and the Vice Chancellors are also usually Physicians.
In the immediate past dispensation when the fifty-six (56) Boards of Teaching, specialist and Federal Medical Centres were inaugurated, Physicians had at least, over 324 membership representation on these Boards, all the other healthcare professions consisting Pharmacists, Radiographers, Physiotherapists, Medical Laboratory Scientists and others had less than 20 representatives on the fifty-six (56) Boards.
Professor C.O. Chukwu in the old order between 2011 and 2015 insisted no professional other than Physicians will be appointed on core teaching hospital boards contrary to the enabling Teaching Hospital Law. The Pharmaceutical Society of Nigeria (PSN) challenged this position at the Federal High Court, Abuja, before the Presidency intervened and directed the Federal Ministry of Health to appoint other Health Professionals on the Boards of Federal Health Institutions. This does not allow an equitable and fair input by other stakeholders in the process of policy formation in the system. The result has been an obvious Nigerian style of healthcare delivery anchored on input from only one discipline in a multi-disciplinary sector.
ii. Non-implementation of the Scheme of Service of other Healthcare Professions: The limitation to only two directorates; Clinical and Administrative directorate in Federal Tertiary Health Institutions stifles the growth potentials of care providers other than Medical Doctors/Physicians. This prevents them from legitimately reaching the peak level of Grade Level 17 or equivalent in the hospital service against Federal Civil Service Structures which allow all professionals to attain Grade Level 17 when they deserved it. This situation is in conflict with the scheme of service of other healthcare professionals. It is on record that at the State Level, Health Professionals easily attain Grade Level 17 status in the hospital system, while this is jeopardized in the federal Health Institutions (FHIs). JOHESU/AHPA agitation of 2013-2015 reversed the unfavourable status-quo albert officially but in reality most FHIs are still not complying with Circulars of the Federal Ministry of Health without consequences.
iii. Residency and Specialist Programmes in Healthcare: One of the tragedies entrenched in today’s Cap 436 Laws of the Federal Republic of Nigeria, 2004 is that unlike salient provisions of law which specifically facilitate the training of medical students and resident Physicians for clinical programmes, other healthcare providers do not enjoy same benefits. Physicians, therefore, continue to frustrate efforts/attempts to bring in health professionals into hospital wards for training. In 2010 at the inauguration of the Presidential Committee on Harmony for Health Workers, the Federal Ministry of Health celebrated part of the recurrent problems in healthcare when it inaugurated a Committee to take care of overseas training of resident Physicians but was nonchalant about other cadres in the health sector, when the right attitude should have been a budget for local and foreign training for all deserving healthcare providers. Residency training should be extended to other healthcare providers to build a respectable health sector that is sustainable.
iv. Monopolisation of the Headship of Federal Teaching and Specialist Hospitals by Physicians: The position of Chief Executive of Federal Teaching and Specialist Hospitals have been monopolized by Physicians to the detriment of all other professions by unilaterally interpreting the term “medically qualified” clause contain in Decree 10 of 1985 to epitomise a package for only Physicians. Their leadership style is very unfair, unjust and selfish. This has led to disenchantment and frustration by other professionals leading to distrust and conflicts. Experience had shown clearly that our hospitals and indeed, the entire healthcare delivery system fared much better when professional health service Administrators were the Chief Executive Officers (CEOs) of hospitals in Nigeria. The University College Ibadan (UCH) was rated as one of the top five (5) hospital facilities in the Commonwealth under a Hospital Governor (Administrator), but we all know what Physicians leadership has reduced UCH to. Since the 1980s, when Physicians hijacked the position, our healthcare service has been the worst for it.
In the United Kingdom, the United States of America, Germany, India, Russia, and Botswana (with the best health indices in Africa), to mention a few, hospitals are not permanently headed by Physicians. This is usually anchored by core hospital Administrators versatile in the co-ordination of hospital activities.
v. The Skewed Composition of the Top Management Committees of Federal Teaching and Specialist Hospitals: Modern healthcare delivery is a multi-professional and multi-disciplinary service involving many health professionals and workers. It has grown beyond the training and competence of any single profession. All the professionals involved have an equal right to organisational leadership position in the industry; provided anyone aspiring to such position has the right leadership skills, training and integrity. Organisational leadership is entirely different from clinical or medical jobs. The attitude of medical practitioners in Nigeria in populating the top management positions of hospitals with Physicians/Medical Doctors is the root of the collapse of our healthcare delivery system. This is because the input of only one group of professionals is used in managing the hospitals. Organisational leadership deals with the ability to plan for growth, productivity, profitability, financial efficiency and innovative business strategy.
3. Discriminatory Salaries and Wages in the Health Sector
Only on two different occasions in the past; first in 1985 when Late Professor Olikoye-Ransom-Kuti was the Minister of Health and most recently, under Professor Babatunde Osotimehin, discriminatory salaries and wages were designed for Physicians to consign other health workers to houseboy status perpetually. It is a fact that in these two dispensations of Physicians –Health Ministers, the most junior Physicians (House Officer) with only one year experience earned more than other health professionals who would have put in over thirty (30) years of work experience.
Before the appointment of Late Professor Babatunde Oshotimehin as Minister of Health during the Late President Umaru Musa Yar’Adua Administration, a post youth service Physicians started his/her career on Grade level 12, while other graduates entered the public service on Grade Level 08. By Civil Service growth rate, it would take any other health profession graduates almost ten (10) years to get to Grade Level 12 which is the entry point for Physicians who still turn around to dictate what others can earn with tacit Government endorsement.
On pages one (1) and four (4) of the Guardian Newspapers of Tuesday, December, 2009, a statement was credited to the President and Secretary of the Nigeria Medical Association (NMA) where they appreciated the approval of Consolidated Medical Salary Structure (CONMESS) for its members by President Yar’Adua, and also “welcomed the approval of Consolidated Health Salary Structure (CONHESS) for other health workers but insisted that the TEMPORARY existing relativity of 4:2:1.72, in emoluments be maintained as any deviation from this is unacceptable to the NMA and will trigger industrial unrest in the health sector”.
A regime of discriminatory wages will continue to encourage a vicious cycle of industrial disharmony in the health sector. The antagonistic position of NMA on promoting discriminatory practices in the health sector through collaboration with the Physicians Chief Executive Officers of hospitals and Federal Ministry of Health contravenes the provision of International Labour Organisation Convention 111 which forbids any forms of discrimination in Employment and Occupation. It requires ratifying member states to declare and pursue a national policy designed to promote, by methods appropriate to national conditions and practice, equality of opportunity and treatment in respect of employment and occupation, with a view to eliminating any discrimination in these fields.
Some of the fallouts of this practice against other health workers include de-motivation, a boost for the unfortunate brain-drain syndrome in the health sector, etc. Brain drain continues to ba a major challenge in the healthcare practice especially in the public health sector as less than 40% of health professionals produced in the last twenty (20) years practice onshore.
4. Imbalance in the Directorate structure of the Federal Ministry of Health
The exclusion of other healthcare professions in the organisational structure of the Federal Ministry of health should be redressed accordingly. A situation in which Physicians dominate the eight (8) of the ten (10) departments in the Federal Ministry of Health has put other health professionals in a disadvantaged position. It has often led to the exclusion of other professions in the policy formulation organ of the Ministry. More than 90% of members of the Top Management Committee of the Ministry are Physicians. The policies of the Ministry, therefore, have only the input of physicians. Ironically, the Ministry has been turned to Federal Ministry of Physicians. This is contrary to the Akinkugbe’s Report on Health Sector Reform.
This is why Physician/CEOs have refused to implement Consultant Cadre for Pharmacists in most of the Federal Health Institutions (FHIs). These Physician/CEOs have truncated Drug Revolving Fund (DRF) Scheme in most Public Health Institutions in the Country.
Physicians have equally jeopardised the practice of Medical Laboratory Science cadre in a preponderance of our hospitals in Nigeria. It is very common to hear Physicians say they do every other person’s job, but nobody can do their job. No wonder many of them illegally stock drugs and dispense to patience and operate Pharmacy Department in their clinics without Pharmacists. It is also important to put on record that Physicians create a widening dimension in quackery in all the health professions by training unqualified personnel to handle professional responsibilities especially in the private hospitals.
Again, we refer to the World Medical Association’s medical ethics manual on the relationship with other health professionals “Chapter Two on relationships with patients began with a discussion of the great importance of respect and equal treatment in the physician-patient relationship”. The principles set forth in that discussion are equally relevant to the relationship with co-workers “non-discrimination is passive characteristic of a relationship. Respect is something more active and positive with regard to other healthcare providers whether Physicians, nurses, auxiliary health workers, etc, it entails an appreciation of the skills and experience in so far as these can contribute to the care of patients. All healthcare providers are not equal in terms of their education and training, but they do share basic human equality as well as similar concerns for the well-being of patients”.
5. The Poor Implementation of the National Health Insurance Scheme (NHIS) now National Health Insurance Authority (NHIA) The original concept of the National Health Insurance Scheme was to bring quality healthcare to the doorsteps of every Nigerian and above all, streamline the role and responsibilities of all healthcare providers. At the commencement, the Physicians introduced in-house laboratory and pharmacy facilities and smuggled global capitation into the scheme where a Physician can now carry out laboratory test and stock and dispense drugs without the intervention of the experts in that field. Physicians prescribe and dispense the drugs to enrollees of the scheme especially in the private health facilities. The only reason why NHIS/NHIA has not met its goals almost after seventeen (17) years is that, the Physicians hijacked the scheme and sidelined other healthcare givers. Today, we have a lofty scheme being driven by only Physicians at the detriment of the patents.
6. Non-adherence to the Rules that set up Drugs Revolving Fund (DRF)
At Public Sector level, the out of drug syndrome continues to be a major area of challenge. The DRF which was strongly recommended to tackle the challenge of drug availability and procurement in Public Hospitals has been deliberately truncated by the Physician/CEOs of the FHIs with the active collaboration of the Federal Ministry of Health through the office of the Minister of Health.
Generally, the militating bane of the DRF is the alleged diversion of the funds to other endeavours by the Chief Executive Officers of the hospitals. The way out of this quagmire in public interest is for the in-coming Administration to support legislative action to entrench the DRF concept in Nigeria’s Public Health Institutions.
7. Poor Implementation of Interventionist Agencies
Most of the interventionist health agencies like National Programme on Immunization (NPI), National Agency for the Control of AIDS (NACA), Roll Back Malaria (RBM), etc, are populated by Physicians, and they have very poor drug procurement and management systems because of non-involvement of Pharmacists. In fact, at a point, some Physicians styled themselves “ARV Doctor” at National Agency for the Control of AIDS (NACA), because Physicians were dispensing Anti-Retroviral (ARV) drugs after diagnosing and prescribing the ARV drugs. It was a common knowledge then in the civic space that, of the huge financial mess NACA was thrown into which catalysed the exits of Professor. John Idoko, the then Director General of NECA.
The Challenge of the state of Health in Nigeria
The primary challenge of the health sector in Nigeria is that it has yet to be given a priority as a key requirement for human capital development which should be a stimulant for growth in productivity and national income. Therefore the persistent low budget allocation which averages 5% of the national budget and constitutes about 3% of the Gross Domestic Product (GDP) is a far cry from the African Union (AU) and World Health Organisation (WHO) recommendation of 15% (Budgit 2021). Indeed with the largest population and biggest economy in Africa, Nigeria’s performance in the health sector has implications for the economy specifically in respect to its external reserve, employment, capacity development and of course its internal security.
So even as there is free entry and exit for private sector in health service provision at all levels, the high cost and general poor facilities in the private sector, the push for profit as against quality provision of services, the inability of the private sector to invest sufficient resources, the prevalence of mass poverty and inequality across all sector and location, the growing poverty among the working class all these and more make a holistic privatization of the health sector inhuman, provocative, insensitive and against the provision of Nigeria’s 1999 constitution (as amended).
As it has become the tradition with every neo-liberal policy implementation, we know well that this will lead to a further cut in the already lean budget allocation to the health sector, loss of jobs, more poverty, inequality and more social crises.
Indeed this has been the trend with every policy on privatization in the last three decades, this is clearly the hall mark of the dictators of neo-liberal policy, and this is another level of engineering social destruction of the people and the country.
Below is the immediate prayers by JOHESU/AHPA to address the myriad of challenges facing the public health sector in Nigeria:
1. Upgrade the Tertiary Healthcare Sub-sector: The tertiary health sub-sector should be upgraded to enable it carry out the function of providing healthcare, producing skilled personnel, and carrying out research that can add social and economic value to Nigeria.
2. Overhaul the National Health Insurance Scheme: The National Health Insurance coverage needs to be overhauled first to expand the coverage to capture more people especially women in the informal sector and all retirees above the age of 60 years should continue to have access to the NHIS. We demand that quality health care delivery to be legislated as a right of citizens and not an exclusive preserve of the rich.
3. Ensure Adequate Financing for the Health Sector: We align with the constitutional provision that the fundamental responsibility of government is the welfare of its citizens, and for us the core of that welfare is in the quality of health enjoyed by the citizens. We believe that Nigeria is endowed with sufficient resources to adequately fund the health sector, which must be seen to be affordable, accessible and available from the rhetoric of the policy texts.
While we are not averse to the participation of the private sector in the provision of health service, we are mindful of the fact private sector is most likely to be motivated by profit and will therefore price health services out of the reach of the common citizens.
We therefore demand that government’s presence in the health sector should be seen as a social responsibility towards its citizens to aim at reducing poverty and inequality. Thus we recommend a national development reform of the public financial management system aimed at strengthening budget design, allocation and spending.
We also demand that government increases funding to health sector to at least 15% as is prescribed in the Abuja Declaration on Health starting with an annual increment of 2%. The increased funding should specifically target trainings and skilled personnel development; health information; medicine and technology. More resources can be allocated from blocking leakages and corruption in the health sector.
Given the role of healthcare in increased productivity and income cum poverty alleviation, we demand that additional sources of funding to health should come from special 0.5% tax on individuals who earn a minimum of N60million annual income and 0.1% for business/corporation that earns a minimum of $1billion Naira after tax profit.
We need to prioritize health as a core of human capital which affects and is affected by other socio-economic indices. We would therefore need to strengthen program based budget spending and allocation to the health sector to align with national development priorities.
We demand the participation of stakeholders in the health sector including workers to be empowered to engage in budget design, monitoring and evaluation. This process will strengthen transparency, accountability and consequently increase resource efficiency.
4. Round Pegs in Round Holes: We demand that qualified professional health administrators be selected from across different medical specialties to run tertiary and secondary health institutions in Nigeria. This is the practice in many countries with verifiable results in effective and efficient public health outcomes.
5. Full Implementation of the National Health Act, 2014: One of the products of the synergy of Health Professional Associations was the enactment of a National Health Act, 2014. On paper, we have a Health Act that should guarantee better funding of healthcare through the 1% Basic National Healthcare Consolidation Fund (BNHCF) of the nation 30% of this will be dedicated NHIS, 10% for consumables, vaccines and essential drugs while 5% will be for training of health personnel.
For the first time, separation of professional roles is well spelt out and all professional associations, as well as Health Sector Trade Unions, have documented roles in the enabling act. Unfortunately, up till now, Federal Government has not commenced implementation of this Act to the detriment of consumers of Health.
The National Council on Health, which now has statutory roles, would have been the ideal template to foster harmony if all professional associations and Trade Unions are allowed to participate as stakeholders.
Drawing a parallel from the World Health Professional Alliance (WHPA) comprising the FIP, World Medical Association (WMA), Federation of Nurses and Midwives and Federation of Physiotherapist, we might just be able to mobilise all the professional association including NMA and Trade Unions in the health sector to a round-table discussion which may guarantee better days ahead in our healthcare.
Government at all levels needs to show more responsibility and sensitivity in relationship management in our health sector particularly because Section 42 of the Constitution of the Federal Republic of Nigeria, 1999 as amended prohibits discrimination against citizens of Nigeria on the basis of social, gender, religious or professional affiliations. A situation where an administration appoints two Ministers and a Permanent Secretary to head a Ministry that already has seven (7) out of ten (10) Directors belonging to one profession in a multi-disciplinary sector is, to say the least, both disrespectful and distasteful to all concerned.
6. Convocation of Health Summit: The incoming administration should consider immediate convocation of Health Summit to provide a platform for all stakeholders in the health sector to discuss and make far reaching recommendations on how to address the enormous challenges in healthcare delivery in Nigeria.
We acknowledge that Health systems are dynamic necessitating constant change to respond to emerging challenges. However, any meaningful reform should prioritize making healthcare affordable, accessible, and available across class, gender and location. This Change process to improve service delivery and the quality of health often referred to as Health system reform must be broadly available in coverage, inclusive in access and easily affordable especially to workers and their family, pensioners and the 87million Nigerians living in poverty.
Let us be guided by the saying that “health is wealth” which goes for the individual as much for the nation. Let us be guided by the primary responsibility of governance as enshrined in the Constitution of the Federal Republic of Nigeria, 1999 (as amended), that the security and wellbeing of Nigerians is the primary responsibility of government. Let us also be reminded that the security and development of a nation is premised on the quality of its human capital ditto education and health. None of which should be priced out of the reach of the ordinary citizen.
Comrade (Chief) Matthew O. Ajorutu
Ag. National Secretary
For: National Chairman, JOHESU