In the first part of this series I discussed the issue of ‘superiority’ debacle that is currently plaguing the health sector in Nigeria. It was one of the three issues that I had identified and hope to address. The other two issues are welfare (including salaries) and career progression. In the next few paragraphs I will discuss these other issues as dispassionately as is possible while continuing to reiterate that this is a way of saying ‘enough is enough’ in the health sector; and that for the benefit of all Nigerians, a culture of international best practices must be entrenched in the sector.
With regards to welfare packages, this also happens to be a major bone of contention between the NMA and JOHESU. While it is difficult to make categorical statements regarding salary structure in the health care sector (considering that I am not privy to the minute details of the current salary structure for doctors and other health workers), I will however provide a comparative analysis of the payment structure for the different cadre of staff across the world–looking at a few selected countries including the United States and United Kingdom. This should, hopefully, constitute a blueprint for further discussions.
Having examined the salary structure as obtained in other parts of the world, I present in the table below a summary of the earnings for the different professionals in the health sector from six different countries. Even though there can be wide variation in salaries depending on a number of factors including qualifications, skills, experience and type of practice i.e. private or public sector, the dataset presented below represents the highest average salary per annum for each of the professional groups. It will appear that remuneration of health care personnel is directly correlated to years of study and this is reflected in the pay scales.
Table 1: Showing the highest average salary for different health professionals in six countries.
Country Doctors Pharmacists Nurses Lab scientist Physiotherapist
USA $248,075 $110,339 $80,103 $103,453 $91,242
UK £101,736 £88,368 £34,196 £46,452 £40,157
Canada $237,440 $159,321 $85,315 $115,682 $95,965
Australia $183,994 $91,631 $80,579 $98,926 $86,897
South Africa R689,162 – R276,401 R563,311 R289,294
India Rs1,208,271 – Rs 676,108 – –
What I found quite interesting however is that among the health care workers, the nurses, on the average, seemed to earn the least in all the countries mentioned even though the difference in salary is not particularly marked in comparison with laboratory scientist, and physiotherapists. In most countries, the highest earning professionals in the health sector are the Doctors and Clinical Pharmacists. But again, the highest average salary for Nurses, Pharmacist and Doctors is distributed in a ratio of 1:1.4:3.1 in the United States of America and 1:1.8:2.7 in Canada. The ratio between Pharmacists and Doctors relative to Nurses is however less steep in the United Kingdom (1:2.5:2.9). Despite that occasional disparities are observed, on the whole this dataset is a substantially true reflection of the earnings of health care professionals across the globe.
So, what is the relativity in Nigeria? Does it reflect this global pattern? I doubt it. I am informed that relativity is one of the highly contentious welfare issues and a leading contributor to the incessant strikes in the health care sector. Within the health care system alone are two salary structures; CONHESS (Consolidated Health Salary Structure-for Pharmacists, medical laboratory, nurses and other health workers in the health sector of the Federal Public Service), and CONMESS (Consolidated Medical Salary Structure-for Medical and Dental officers in the Federal Public Service). There might be others that I am not aware of. It will appear that while NMA is asking for relativity ranging from 1:1.1 (at CONMESS 3) to 1:1.5 (at CONMESS 7), JOHESU is at variance with this proposition. But judging by the relativity highlighted above as per the other countries, can the demand by the NMA be considered unreasonable?
The question now is what is the way forward regarding remuneration in the health sector? I will suggest that the entire health system comes under a unified salary structure. Entrance into this system should be determined by a number of factors including, but not limited to; the number of years of undergraduate study (this would be fair if number of months or semesters spent in school is considered instead of the usual number of years spent. That way the argument by doctors that the MBBS degree is not run on the semester system can be mitigated); number of years of postgraduate study; rarity and relevance of individual skills; job evaluation and the responsibilities that come with the job. These should form the basis upon which relativity should be established at entry for all cadres of staff and it should be maintained across the entire salary structure and should also reflect in all bonuses and allowances. Additionally, equitable work hours between all staff should be ensured. I found it very strange when I was told that nurses run 8 hourly shifts, have days off and some get as many as 7 days off duty after running 5-7 days night shifts. Doctors on the other hand do not run shifts and do not get a single day off even after being on call all through the night. I was also informed Laboratory Scientists and Pharmacists do calls for essential services. This anomaly should be addressed if all must be treated fairly!
On the issue of career progression, one of the contending issues is whether or not other health care workers have the right to be called ‘consultants’. Doctors do not seem to agree that such a terminology should apply to other workers in the field of patient care. But do the Doctors have the right to insist that other health care workers cannot and should not attain the status of ‘consultants’ in their filed? Well, before now I didn’t know, but now I do. The answer is no, Doctors don’t have the right to prevent other health care workers from attaining the pinnacle of their career. So, who is a consultant and what does it mean for each of the health care workers?
Generally speaking, a consultant is a professional who provides expert advice in a specific area of endeavour. More specifically, a consultant Medical Doctor is a senior physician who specializes in one of the many fields of medicine and can be considered experts in their respective field of endeavour. To become a consultant, after medical school (in Nigeria, after housemanship and National Youth Service) the doctor undergoes another 5-8 years of further training in a particular field. Such a person is then referred to as a consultant. But what is the case with other health professionals? Are there consultant Nurses, Pharmacists or Laboratory Scientist for example? The answer is yes even though it is important to state that this is not the norm even in developed societies but the exception.
I will begin with the medical laboratory, especially as it relates to clinical chemistry. In the USA, laboratory scientists with BSc, MSc, and PhD (and with board certification by the American Board of Clinical Chemistry which is akin to the National Postgraduate Medical College of Nigeria or the West African College of Physicians (Laboratory medicine)) can indeed be appointed as consultants. So, why is the case different in Nigeria? Part of the problem, like I understand it is that regulation of laboratory practice and training of laboratory scientist in Nigeria is run parallel to that of pathologists. And because laboratory scientist do not seek board certification (or fellowship) of the respective colleges of postgraduate medical training in Nigeria (like their counterparts in the USA do with the American Board Certification) then it is impossible to objectively assess and accept their expertise in what they do. Truth is, if there are laboratory scientists in Nigeria who have put in years and have attained the requisite qualifications (like mentioned above) then there is no reason why they shouldn’t be appointed as consultants in what they do. But like I said, this applies mostly to the USA and to clinical biochemistry. This however does not apply to other aspect of laboratory medicine including Surgical or Anatomical Pathology or Haematology where due to the nature of the job, the person must be a Medical Doctor.
I also came across Nurse Consultants in my research. Like it is with the Laboratory Scientist, this applies to Nurses who have attained high levels of education (in the NHS, the education and training requirements to be appointed Nurse Consultant include; Diploma or Degree in Nursing plus Masters level education in advanced clinical practice plus a PhD (or working towards one) plus postgraduate training and assessing in clinical practice and ‘may have additional qualifications related to a specialist area) and experience. “All nurse consultants spend a minimum of 50% of their time working directly with patients. In addition, nurse consultants are responsible for developing personal practice, being involved in research and contributing to the education, training and development of other nurses” (this is from the NHS website).
Truth is, if people want to be appointed to serious positions then they must have the necessary qualifications to perform at such a level. We must imbibe international best practices in the health care sector.
Consultant Pharmacists do in fact exist in some parts of the world (most especially the United States of America). Their role appears to be largely limited to senior care i.e. they mostly serve as ‘consultants’ in nursing homes where they offer advice on medication use to the elderly. They however also offer advice to health care facilities and insurance providers. To be a Consultant Pharmacist, one needs to have a specialized doctorate known as the Doctor of Pharmacy, or Pharm D. While these professionals are licensed to offer advice on drug use including drug-drug interactions, they are however not licensed to prescribe drugs to patients neither are they licensed to make diagnosis.
In summary, it will appear that health care systems across the world have continued to evolve to address the challenges that come with the complexities associated with multidisciplinary and interdisciplinary approach to patient care. We need to evolve at our own pace in Nigeria. While it is good to have thoroughly trained professionals across all cadre of health care, it is imperative that government ensures that whatever it spends our hard earned money on is good value for money. It will make absolutely no sense to create bogus and redundant workforce that add no value whatsoever to morbidity and mortality indices. Moreover, appointment to consultant status shouldn’t be automatic but be based on need i.e. if a hospital believe that it is good value for money to have a consultant cleaner then why not? The same applies to a Consultant Neurosurgeon. It is in this regard that I will suggest we continue to debate on what healthcare system is befitting for Nigeria. Perhaps it’s time we considered the private-public partnership (PPP) in health care. That way, people will be employed, retained, and promoted based on their unique skills, knowledge and what they contribute to the health care team. Government on the other hand must adopt a holistic approach to tackling the crisis in this sector. The current approach of random signing of MOUs is not the way to go. It breeds impunity and nurtures distrust. A better approach will be to once and for all, in conjunction with all stakeholders including NMA, JOHESU, National assembly and health care think tanks, institute a thorough and comprehensive reform of the system. That way Nigerians can breathe a sigh of relief.
For us, it’s time to say ‘enough is enough’ to persistent Strike Action by Health care Workers/Professionals!
Sahfeeyah Musa is a member of Thought Leadership Forum. She writes in from United Arab Emirates.