Doctors’ strikes, such as those occurring regularly in Nigeria, tend to be met with public outcry and appeals for them to abide by their ethical obligations under the Hippocratic Oath. writes ethicist and medical law specialist Sylvester Chima. But the issue is more complicated than that.
Chima, associate professor & head: Programme of Bio & Research Ethics and Medical Law, College of Health Sciences at the University of KwaZulu-Natal, writes in The Conversation:
Doctor and healthcare worker strikes are a global phenomenon reported both in highly industrialised and developing countries, a growing concern for international and local health authorities, representing a barrier to achieving the universal health coverage as envisaged by the World Health Organization.
that WHO envisions “a sufficient capacity of well-trained, motivated health workers” to assist in achieving the United Nations sustainable development goal of ensuring “healthy lives and promote well-being for all ages.”
In a recent paper, I examined the issue of whether health care workers are ethically or morally justified in striking:
The key points I raise are:
- Doctor and healthcare workers strikes are ethical and supported by national and international laws and regulations.
- The social contract between medicine and society has been altered by the rise of consumerism in healthcare and ought to be re- evaluated.
- The main reasons for strikes are poor wages and working conditions, infrastructural deficiencies, personal safety and security, frequent policy changes, poor leadership; leading to disempowered and disillusioned staff.
- The impact of strikes by doctors and health care workers can be minimised by providing emergency and critical care to patients based on minimum service agreements before strikes.
The primary consequence of these strikes is not increased patient mortality, but disruption of healthcare service delivery. The impact can be minimised by providing emergency and critical care to patients based on minimum service agreements before strikes.
In view of this, Nigerians need to move beyond the issue of the legality or illegality of strikes to urgently find a lasting solution.
All stakeholders involved in health provision should put their differences aside and map a way forward to tackle the sector’s systemic issues. Health care is in crisis in Nigeria. The country canʼt afford continue poor funding of the health sector – and incessant strikes.
Behind the protests
Constant strikes have become the bane of Nigeriaʼs health sector. In August 2021, the National Association of Resident Doctors embarked on its fourth strike within one year, claiming the government hadnʼt implemented a memorandum of understanding agreed upon after previous strikes in 2020 and 2021.
Doctors and other healthcare worker protests occur at national, state, and local hospital levels. Reasons include power struggles and leadership tussles among staff, and struggles for dominance or equal pay within the sector. They are usually supported by groups like the Joint Health Sector Unions and others purporting to protect membersʼ interest.
But there are additional reasons, like poor staff welfare; salary and leadership/management conflicts, and the governmentʼs inability to implement agreements.
These factors were reflected in the communique issued by National Association of Resident Doctors in March 2021, before they began their strike the next month.
Doctors’ strikes are usually met with public outcries, and appeals for them to abide by their ethical obligations under the Hippocratic Oath.
My view, however, is that itʼs not that simple. Doctors are employed under agreements such as the recent Medical Residency Training Act, 2017. This means they are employed under rules that apply to all public sector employees. Even in the private sector there are constitutionally protected bargaining rights binding on all employers and employees.
Long-term resolution
Resolving the perennial doctorsʼ strikes in Nigeria requires fiscal and ethical solutions as well as a moral commitment to improving health and welfare of all Nigerians.
All stakeholders involved in the regulation of the medical profession in Nigeria need to come to the table.
I recommend an all-stakeholders’ conference as a good start. A conference between all healthcare workers unions and associations and government employers (both federal and State) in Nigeria is long overdue.
It would, firstly, enable all groups or unions representing the sector to air their views. This would create the space for them to arrive at a unified decision binding on all healthcare workers rather than the current patchwork of grievances and actions.
The conference would need to involve a wide range of actors. This would
include:
• the National Association of Resident Doctors, which represents about 16,000 trainee doctors – thatʼs 45% of registered doctors in Nigeria;
• the Nigerian Medical Association representing medical doctors in public and private practice;
• the Medical and Dental Consultants Association of Nigeria, which represents all registered specialist/consultant doctors;
• the Medical and Dental Council of Nigeria, responsible for registration and regulation of all medical doctors and dentists and deployment of House Officers for Internship;
• the Joint Health Sector Unions, which represents more than 90% of all other healthcare workers groups in Nigeria. These include physiotherapists, occupational therapist and laboratory scientists.
The conference should also involve those regulating and funding the medical profession in that country, a such as government employers from both the federal and state levels.
The conference agenda would need to include a commitment to resolve all outstanding issues, such as the 10 items raised in the National Association of Resident Doctors communique of demands of April 2021. It would also need to establish a minimum service level agreement to provide basic healthcare services during strikes.
Other issues requiring a permanent solution include increased funding for the sector by both federal and state governments. The federal government should commit to increasing health expenditure to at least 5%. According to World Bank statistics from 2018, Nigeria spent only about 3.89% of its budget on health.
This is far short of the 15% of budgetary expenditure for health agreed by African Heads of State during the Abuja Declaration in 2001.
Increased funding for the sector would help the government honour agreements and memorandums of understanding between itself and all healthcare workers. It would also ensure the effective implementation of laws such as the Medical Residency Training Act.
This would go a long way towards reducing the incessant doctor and healthcare worker protests and also move Nigeria closer to meeting global commitments to healthcare provision, including universal healthcare.
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