THE TROUBLE WITH THE NIGERIAN HEALTH
SECTOR
For a longtime now I have come across so
many articles and reports in the national dailies
and in online social media on the rife in the
health sector which centers mainly on the row
between doctors and non-doctors working in
the healthcare system. Most of these reports
and articles, mostly lopsided, have one common
denominator, presenting the Doctor as an
enemy of the people and the manner of their
submissions is such as to draw undue
sympathy from the unsuspecting public. But for
the neutral members of the society who have
had cause to have sufficient contact with the
hospital environment, I’m not talking of some
quasi journalists, they need not be told, if there
are, who the Angels and Demons are.
This article is not aimed at indicting or
exonerating any of the two combatant parties
as both have had a fair share of the blame, and
honestly, the deplorable state of our healthcare
system is not as a result of the performance of
the health workers, but it is a component of an
overall failed system called Nigeria which the
current government is still trying to salvage
amongst other difficult challenges. Considering
the lines along which the divide has been made,
I shall delve into an inquest of some of the key
issues at stake, mostly those that affect the
general public, and this I will do by placing the
Nigerian Doctor on one side to be reviewed
alongside a few of the numerous “health
professionals” working in the healthcare system
with due consideration to the most important
person in the system, the Patient. I shall
concentrate mostly on the tertiary healthcare
institutions where the bulk of the rivalry is most
felt.
The Patient and the Hospital:
Let us begin from the beginning. A healthy
person falls sick and needs to regain his health
and function properly. He says to himself, “I
don’t feel well enough, I need to see a Doctor.
May be I should go to the hospital tomorrow”.
He sets out of his house with this principal aim.
On getting to the hospital, he first gets to the
reception, obtains a card at the Out Patient
Department and then proceeds to see a Doctor
(usually a Medical Officer) if his condition is
one that necessitates a Specialists attention, he
is then Referred to another Doctor, the
Specialist (Consultant) for further treatment. On
getting to the point of referral, the Record staffs
assist him in opening a folder containing case
notes, and in the process of this, a Doctor
(Consultant) is assigned to him. The entire
processes of obtaining a card and folder have
no direct effect on the patient’s condition but
helps ensure proper documentation and
recording within the hospital. He is then
directed to the designated Specialist or
Consultant Clinic where he is received by a
Nurse who does further documentation and
records his vital signs which may or may not
be repeated by the Doctor. Then the patient
enters the clinic to see the Doctor, his primary
aim for coming to the hospital ab initio.
The Patient, the Doctor and Other Health
Workers:

The Doctor begins by taking a complete history
of the patient which includes his current
complaints, previous health challenges, living
condition, social habits, family history, drug
history, financial capacity, religious and cultural
beliefs, and then proceeds to do a complete
physical examination of his entire body system,
at the end of which the Doctor would have
verified the patients complaints and identify any
other problems unknown to the patient, before
arriving at a Provisional Diagnosis. He then
counsels the patient, draws up a treatment plan,
which is to be strictly adhered to provided the
patient is within the hospital environment, and
automatically takes full responsibility for any
problems encountered along the line. He finally
schedules him for a follow-up visit to ascertain
his response to treatment. This process of
history taking creates a personal relationship
between the Patient and the Doctor and this is
where the confidence of a patient on the
Healthcare system of a Nation is built; the
Doctor-Patient Relationship.
The treatment plan of the Patient, drawn by the
Doctor, may or may not include; the
investigations (or tests) both laboratory or
radiological to be carried out, the drugs to be
dispensed and the appropriate prescription, the
additional care to be rendered outside the basic
nursing care and the treatment orders to be
followed, some of which he does himself (or via
his subordinate Doctors) and others by the
Nurses. There is no stereotyped outline of what
must be done for every patient; investigations
to be carried out, treatment to be administered
or drugs to be prescribed lies solely at the
discretion of the Patient and his Doctor.
Apart from the Nurses, all other “Health
Professionals” come into patient care when the
Doctor’s plan involves them. Clearly, a patient
has no business with the Radiographer if the
Doctor’s plan does not involve radiography,
neither does he have any business with the
Pharmacist if the patient does not require any
drugs, of course, not every patients require
drugs. Therefore, it is safe to assert that if
Patient Care is the sole interest of everybody in
the Health sector, then the Doctor takes the
Central stage in this service to Patients and
must carry the Nurses along at every point in
time, and together they look out for any other
“Health Professional” that should be roped into
patient care. Why then should the Doctor take
the Central stage? Very simple. He has been
trained thoroughly to do so. Invariably, the
Doctor is naturally the undisputed leader of the
Health team and only two classes of people can
challenge this standing; the criminal minded
ones pursing their selfish interests and the dim-
wits incapable of any logical reasoning.
On the Headship of the Hospital:
Over time, the functional head of the tertiary
hospital setting has been the office of the Chief
Medical Director, CMD, and part of the Act
establishing the hospitals specified that this
position be held by a Medical Doctor. However,
there has recently been a loud cry from other
“Health Professionals” under the auspices of the
Joint Health Workers Union (JOHESU) for the
chance to also partake in the “enjoyment” of
this office, as if to say it is a political office, a
“National Cake” which should be shared equally
to everyone in the scene, whereas, it is the
most sensitive of all positions in the hospital
setting, one with huge implications on the
health of patients. The Medical Doctors on the
other hand, insist that the office of the Chief
Medical Director and the headship in general, of
the Hospitals is their exclusive reserve.
How true is this claim by the Doctors? Again, it
is very simple. Healthcare is all about patient
care, and in rendering care to the patient who is
the main focus of everyone, the Doctor is the
arrow head. He brings together the activities of
all in the health care delivery system to bear
fruit in the health of the patient. He has a
broad-based and yet in-depth medical
knowledge that enables him to function as a
leader in patient management and take
responsibility for the outcome. It is then indeed
a funny ideology to expect the Doctor to
maintain leadership of Patient Management and
then cede the leadership of the Hospital
Management to a Non-Doctor. Right thinking
people would agree that whoever takes the
blame should take the lead. Leadership is about
responsibility, and Doctors embrace such
responsibility mainly as it involves lives which
they have sworn an oath to protect.

Furthermore, JOHESU, a body comprising of
other “health professionals”, support staffs and
in fact all in the Hospital setting except
Doctors, claim to be equal and allied to
Medicine. But my question is, how is the
clerical staff allied to Medicine? How can a
support staff head the core members of the
organization? Also, why should a “profession”
that is “allied” to Medicine surmount Medicine?
Can a Non-Lawyer become the Attorney General
of the Federation? Why isn’t the office of the
Vice-Chancellor made open to every staff in the
University system since ASUU and NASUU both
consist of “professionals”? How would ceding
hospital leadership to JOHESU improve the
health indices of our country? These are people
that do not deal directly with patients, people
that do not really understand the agony of
patients which Doctors do. The saddest part is
the extent they can go to press home their
irrational demands. We have a documented
occurrence of how they turned off power supply
to the Intensive Care Unit during a JOHESU
orchestrated strike action in a southeastern
Teaching Hospital leading to death of patients
on life support. This was an attempt to
frustrate the Doctors’ effort to keep hospital
services running while they were “striking”. How
can people who have displayed this level of
irresponsibility be allowed to head the Health
sector? Again, God forbid!
It is a common saying that Doctors are “proud”,
and I insist, they have very just reasons to be,
and when it comes to arrogance, the patients
can tell who amongst Doctors and Nurses are
more approachable. Doctors are a selected
class of elites and comprise the best brains of
the society. Yes, the entry requirements into the
profession and the medical training ensure that
only the bests emerge as Doctors. As such, the
government has to understand that any
arrangement that sees a Non-Doctor in a
sensitive position to head Doctors in any Health
related issue would be met with fierce
resistance and the never ending tussle it will
ensue will have detrimental effects on our
nation’s healthcare delivery. In the interest of
peace and decorum, the Federal Government
have to dig in and ensure that the status quo is
been maintained. The ear that will hear needs
not be the size of a raffia palm.
On conferment of Consultancy on other “Health
Professionals”:
A Consultant (Medical) is the title for a senior
hospital-based physician or surgeon who has
completed all of his/her specialist (Residency)
training and has been placed on the specialist
register (Fellow) in their chosen specialty. This
level of Doctor joins the Civil service as a
Consultant and automatically leads a team of
Doctors comprising Residents, Medical Officers
and House Officers who train under him.
Currently, there has been an outcry by JOHESU
to also be awarded Honorary Consultancy
based on the fact that Doctors are been
appointed as Consultants, why not they too.
The concession of the government to this
particular demand has led to the entire hospital
going berserk in some centers. This was done
against the warning of the Nigerian Medical
Association that the introduction of such “alien”
practices would be detrimental to the lives of
patients and the results are showing.
At the Nnamdi Azikiwe University Teaching
Hospitals, it is been said that a “Consultant
Pharmacist” invaded the wards with his team,
cancelling patients prescriptions and also
demanded that a Consultant Cardiologist
remove a key drug in an inpatient prescription,
on grounds that the drug has some known
adverse effects. Another report have it that in
Abuja University Teaching Hospital, the Ante-
Natal Clinic was invaded by Nurses who
decided to consult patients and make
prescriptions, of which the Doctors left the clinic
and the Patients were confused. Patients who
sought to see their Doctors were told that there
was a “Consultant Nurse” who does whatever a
Consultant does. Also, in University College
Hospital, Ibadan, stories had it that a
Consultant Plastic Surgeon was barred from
reviewing the surgical wound he created post-
operatively because a “Consultant Nurse” had
reviewed the wound earlier and was satisfied
with her findings.
Let us address one of these occurrences. It is
grave ignorance for a Pharmacist to tamper
with a drug prescription simply because he has
looked through his drug formulary and have
identified a known adverse effect of the drug
when he/she has no knowledge of the
processes involved in the making of diagnosis
and prescriptions. Patient management is highly
individualized. To make a prescription, the
Doctors put many things into consideration viz;
patient’s history and examination, financial cost
of the drug, benefits against the risk of using
the drug, other drugs to be administered etc.
Sometimes the side effect of a drug is the
desired effect needed in one patient but would
remain a serious adverse effect in another
patient. But no, the Pharmacist didn’t think in
that line before cancelling prescriptions. I am
not saying every doctor’s prescription is
infallible. No. But if a pharmacist wishes to
express concern over a patient’s prescription,
he should discuss with the Doctor to sort out
their concerns.
This whole consultancy for non-doctors arose
as a result of their quest to have better
remuneration. I am not opposed to better
remuneration for other health workers, but
looking for cheap means to it at the expense of
the lives of patients is grossly unacceptable.
Why would you want to be a Specialist
(Consultant) when you have no specialty, or
you have a specialty in an area whose service is
not needed? Even if a non-doctor must be a
consultant that does not automatically make
him/her a Doctor. We all know how to become
a Doctor and age is no barrier.
If non-doctors must immutably be made
consultants, their duties and jurisdictions must
be clearly spelt out and understood by all
involved. A Consultant Nurse should be confined
to Nursing Practice and she will be expected to
enhance it, not to invade Medical Practice. She
must ensure that the management plan of a
Doctor is properly carried out, even if he is a
House Officer. Unfortunately, the idea of non-
doctor consultant emanates from the desire of
these other “health Professionals” for position
and better pay than the desire to meet any
specific needs. For instance, a ward Nurse that
does her duties properly becomes a Consultant,
what extra services and improvement does that
bring to nursing care? The fact that there exist
non-doctor consultants in a few foreign
countries does not explain why the government
should channel huge sums of money into the
payment of honorarium to consultants that add
nothing to the existing system but chaos. The
NMA have identified these unhealthy health
policies and should do all it can to prevent it
from killing Nigerians.

On relativity of Wages:
Another very important object of discord is the
demand by JOHESU for a unified salary scheme
for everyone in the health sector and that will
see a close approximation of the eventual
earnings of all in the sector. What else can be
sillier? Need I remind us that in every
organization there is usually an established
strata. Even in heaven, there are Angels and
Arch angels, and the angels are content with
their positions and would not want to usurp the
duties of the Arch angels either. People cannot
obtain different qualifications, different expertise,
subserve different needs and end up earning
similar pay. No. That cannot happen. Why
would a non-specialist insist on being paid
specialists allowance? Why would a Non-doctor
terrorize the government because he wants to
be paid like Doctors? Where in the world is that
obtainable? Relativity is sacrosanct and must
be reflected both on the basic salaries and all
allowances.
Granted. Doctors are few. Very very few. The
World Health Organisiation recommends that a
Doctor should consult not more than seven
patients in a clinic session and should pay
maximum attention to their needs, but our
environment see us in a situation where a
Doctor consults over 40 patients in one clinic
session, yet, he is underpaid compared to his
colleagues even in nearby Ghana. There are less
than 30,000 Doctors currently practicing in
Nigeria subserving over 170 million Nigerians,
and there is a dire need for more, but that will
not push the Medical schools to take in
everybody and churn out unqualified people as
Doctors, neither will the Nigerian Doctor allow a
Non-Doctor to tamper with the lives of patients.
Doctors swore an oath to preserve lives and the
NMA must see to it that the lives of Nigerians
are safeguarded. If the Hippocratic Oath is to
be taken serious, then the NMA must win this
battle.
More often than not, we are clear on the
knowledge that it is injustice to treat equal
people unequally, but it fails to come to our
minds that, it is graver injustice to treat
unequal people equally. This is not pride, it is a
statement of fact. Doctors and Non-doctors in
the Health sector are not equal and they cannot
be treated as equal. There is a reason why
some students work harder than others to
become Doctors. Some sat for JAMB several
times to achieve that, although many fail to do
so and even some do fail out of medical school
and end up as “other Health Professionals”. To
eventually anticipate to be rewarded equally
with those who triumphed where you failed is
simply madness. The government must see to it
that relativity is maintained. For if a Nurse or
Pharmacist consults patient, not regarding
quality of the consult, earns equally with a
Doctor and even get a chance to head the
Doctor, why then would one need to work
harder to become a Doctor when he can easily
become a Pharmacist? Tampering with
relativity is a conscious attempt at breeding
mediocrity, again at the expense of lives. If the
Nurses and Pharmacists accept to be paid
equally with the Lab “Scientist” and Janitors,
it’s their own cup of tea, but paying Doctors
and Non-doctors equally? God forbid!
On the Physiotherapists’ demand to make first
contact with Patients:
According to Prof. K. E. Obidike, there are three
reasons why patients go to see Doctors. Firstly,
is to ascertain the causes of their complaints
and resolve them. Secondly, is to identify any
other health problems unknown to the patient,
and again, resolve them timely, and finally, to
have a baseline documentation of the patient as
a reference for subsequent health issues. The
second reason especially, answers the question
as to why a Physiotherapist cannot make first
contact with patients. Medicine is holistic, and
the initial assessment of a patient takes the
entire body system into account not just the
presenting complaints. Therefore,
Physiotherapists should remain Physiotherapist
s and should come into action when consulted.
Simple.
On adoption of Foreign Healthcare Structure:
The fundamental idea behind the establishment
of Tertiary Healthcare centers (Teaching
Hospitals) in Nigeria was primarily for training
of Medical Practitioners, Research, and
provision of specialized healthcare at very
affordable rate. It is not a business venture, and
if this aims and objectives are to be met, then
the hospital must be made to operate under the
very Act that established it. Comparing our
Healthcare practices with that of foreign nations
without a review of the aim and objectives viz-
a-viz that of our country is practically insane.
Granted, a few hospitals in Canada are headed
by Non-Doctors, and there are few Non-Doctor
Consultants with well-defined jurisdictions in a
few foreign countries, but that does not in any
way directly improve their health indices. After
all, high quality health care is still not
affordable for a large proportion of Americans
despite their very potent health insurance
system.
Our very first interest should be to assist the
government, which some members of the health
sector have chosen to distract, to ensure there
is affordable healthcare services to all its
citizenry, seek ways of improving the training of
the medical personnel and carry out Research
programs that will elevate the quality of
healthcare delivery in our own nation. Yes. We
can go abroad and observe what obtains from
there, but instead of disrupting order in the
already existing system, by trying to blindly
implement it over here, we can see how best to
fit a few of them into our system and get the
best out of it. The Government should
concentrate on policies that will better the lives
of the larger population of Nigerians, not those
that pacify some disgruntled group of
individuals fighting for position and their own
other personal interests.
There are many other issues that do not only
need Government attention, but also its speedy
response. Some of these areas include: the
appointment of Directors in the hospitals which
distorts the chain of command in the hospitals,
induces anarchy and expose patients to
conflicting treatment and management
directives; the passage of the National Health
Bill, and extension of Universal Health Coverage
to cover 100% Nigerians and not 30% as
currently prescribed by the National Health
Insurance Scheme; the appointment of the office
of the Surgeon General of the Federation
alongside many other pressing needs. These are
health issues of paramount importance and the
Government cannot afford to be lackadaisical
about them. No. Not this time.

My Recommendations:
First of all, JOHESU is an amorphous body
comprising of different entities with varying
agitations, concerns, qualifications, expertise,
and eligibility status and should not be
confronted in that front by the government. Our
government has to recognize the various
constituents independently and verify their
individual complaints as some parts of it have
no moral standee to withdraw its services
because of the unmet demands of another. For
instance, The Medical and Health Workers Union
(MHWU) comprising of Clerks, Messengers,
Record Officers, Admin staffs, Janitors,
Engineers, Security etc., an association of
different people with absolutely no training in
any Health related courses should not dare to
aspire for headship positions in the hospital let
alone been prevented from doing so. We do not
have to give reasons why they should not.
Therefore, the five different associations and
unions under JOHESU should be made to make
their specific submissions independent of one
another for clarity.
Secondly, the Nigerian Labour Congress and
Trade Union Congress should look beyond
Unionism and focus on the ultimate goal of
everybody in the health sector which is
adequate Health care for the Nation. They
should relinquish their parochial stand in the
dispute between JOHESU and NMA, and as well
desist from all forms of hooliganism and
attempt to bully the Government and NMA on
this matter.
Finally, the Government should resist all
attempts to coerce it into yielding to the
demands of one party in the dispute when the
matter is still in court. There should be absolute
regard for the Rule of Law. And all previous
“concessions” should be stalled, and pending till
a decisive ruling by the court.
We can go on and on to address so many other
issues in the health sector that require attention
but I have decided to throw light at just some
parts of it before the Doctors under the
auspices of the Nigerian Medical Association,
an association of all certified Medical Doctors
practicing in Nigeria down their tools as
proposed come July 1st, 2014. Before the
health of the nation would be thrown into the
hands of Non-Doctors in the Health sector that
usually prefer the exclusive services of Doctors
when they and their loved ones take ill. Before
the general public begin to lash out on Doctors
and blame them for lives lost as a result of the
forthcoming massive industrial action. The onus
lie on the general public to call out on the
Government to resolve these life threatening
issues before the Doctors take to this hurtful
last resort of theirs.
God bless Nigeria.
By,
Basil, C. B. – M.B.B.S (Nigeria),
Department of Clinical Chemistry and Metabolic
Medicine,
Benue State University Teaching Hospital

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I apologize for the rather lengthy paragraphs but Nigerians have sought to understand the reasons behind the doctors strike. Well here it is from a doctor's perspective. Found it on facebook and it provided immense insight. MOD pls could this see the frontpage do people get to see it?

Very insightful. But probably better suited for health forum. MOD do the needful