It is a tepid January evening at the University Teaching Hospital, Ilorin, North-Central Nigeria, and the Harmattan dust is in the nostrils of everyone. A group of resident doctors are gathered at an emergency general meeting, called on the eve of an impending strike. Intense submissions and debates are punctuated by laughter and silence. After hours of deliberation, one question looms unanswered: What is the way forward?

This is the way things often go: Debates go back and forth and the options are examined, discarded and re-examined. If they decide on another strike, it would be the fifth in 12 months. Many are fed up; posting rotations have been shredded, Membership and Fellowship examinations have been missed. Many young doctors came to residency dreaming of a future as a specialist in medicine or surgery: a life that comes with professional angst and financial security in equal measure. Within a short while, a spate of industrial action has seen these doctors rue their decision to pursue postgraduate medical training in Nigeria.

Doctors in Nigeria are being cheated of their rightful wage, which, in most cases, amounts to less than USD500 a month.

What is ‘skipping’?

The current dispute dates back many years. Recently, however, the Ministry of Health instituted some unpopular policies, such as the implementation of the controversial ‘No Work, No Pay’ rule. This is not a new law, and while the ministry insists that this will bring sanity to a sector that lost more than three months to industrial action last year, the doctors, on the other hand, point to the failure on the part of the ministry to honour extant agreements, especially those involving the placement of doctors on appropriate cadres, generally referred to as ‘skipping’. Also, many doctors employed by the state governments have not received their full salaries in over a year. The doctors are asking: ‘What is the redress for work done without pay?’

Read: Kenya: Jailed doctors’ union officials released but strike continues

This matter of wage irregularity has polarised the country across the Niger. Most centres in Northern Nigeria pay their doctors accordingly, while many in the south insist that skipping is illegal. Skipping is a sacrosanct civil service rule that doctors were initially exempted from when a new salary scale was introduced. However, there is a court order that clearly states that all health-care workers (doctors inclusive) should benefit from skipping. Doctors have been fighting for their legitimate wages for over three years and have been maligned by government officials. Among other issues, skipping was deemed responsible for the shutdown of the health sector for more than two months during the Ebola outbreak in 2014. The then Minister of Health, Onyebuchi Chukwu, on instruction of the then President of Nigeria, issued the mass termination of the appointment of the more than 16 000 resident doctors undergoing training in tertiary health facilities. This was a laughable move and was upturned within a fortnight—but the battle line had been drawn.

During the Ebola outbreak in 2014, the Minister of Health, Professor Onyebuchi Chukwu told the doctors they remained sacked.
Photo: Dailypost

Identifying with the aggressor

Doctors in Nigeria are being cheated of their rightful wage, which, in most cases, amounts to less than USD500 a month. A review of the salary structure of other health workers eroded the financial relativity and seniority designed to maintain a professional hierarchy in the health sector. In a recent interview the Minister of Health, Prof. Isaac Adewole, disagreed, stating that doctors could not cherry-pick across salary scales. “If you don’t want your salary, say so and move to another salary scale. You cannot stay in a salary scale and say they should give you the entry point of another one.”

Read: Ghana Doctors’ Strike: 500 patients dead in 17 days

Prof. Adewole should know better. As the secretary general of the National Association of Resident Doctors (NARD), he fled the country in 1984 at the height of current president Muhammadu Buhari’s military dictatorship, following an unpopular strike that irked the authorities. The association was proscribed and Adewole returned from political exile only after that regime was overthrown. But these are distant memories now as this man orchestrated another futile mass sacking of doctors in June 2016 while they were seated at the dialogue table with the Speaker of Nigeria’s House of Representatives. The minister and his henchman, Wapada Balami, who heads the Department of Hospital Services, appear to have set themselves on a collision course with the aggrieved doctors, ambling from one provocative policy to the other and leaving the health sector worse off.

Most doctors do not know their final destinations yet, but many have concluded, like Femi, who is selling his car to fund his exams, that ‘Anywhere is better than home’. Even after internship, many doctors are unable to progress to postgraduate training or secure decent jobs

A nation at war

Nigeria’s health-care system is ranked among the worst in the world. The World Health Organisation in 2015 ranked Nigeria 187th out of 190, only ahead of Democratic Republic of Congo, Central African Republic and Myanmar. This is no surprise as, despite numerous agitations by the Nigeria Medical Association and her subsidiaries, the National Health Act is yet to be fully implemented. Universal coverage by the National Health Insurance Scheme remains elusive due to the mismanagement of scarce resources and the lack of political will.

Surgeons at work. Bori Hospital. Photo: david/Flickr

Nigerian doctors, whose training was mostly state-subsidised, discover that there are no jobs available for them after exiting medical school. The mandatory one-year internship, which used to be an easy rite of passage, now requires many young doctors to traverse the breadth of the country armed with letters of introduction from royal fathers, senators, politicians and influential medical elders addressed to Medical Directors who have entrenched nepotism and cronyism over merit.

‘I suffered before I got this house job placement,’ Dr Oduno sighs. ‘I waited for over a year and travelled to many states for interviews, only to find out they already knew who they would choose beforehand.’

He could not get a place in the eastern part of the country, where he had graduated. Many consider him lucky; others have had their temporary licences expire without even commencing an internship. Even after internship, many doctors are unable to progress to postgraduate training or secure decent jobs.

USAMRUK Malaria Diagnostics and Control Center of Excellence microscopy training – Nigeria, Africa, September 2009. Photo: US Army Africa/Flickr

Consequently, a wave of disillusionment is washing young Nigerian doctors onto far-away and fairer shores. Many social media groups exist where these doctors exchange and review material on foreign exams. On one, dedicated to the UK licensing examination, PLAB, there are over 800 members studying for the next round of exams scheduled for March 2017. Others are focused on the USMLE, UAE and Australia routes. These doctors have concluded, like their predecessors did in the early 1980s, that the country does not appreciate their skills. In the US alone, there are over 4 000 practicing doctors of Nigerian origin. The figure in the UK is much higher. This imminent exodus of doctors guarantees a looming catastrophe in the ability of a health sector already bedeviled by poor infrastructure to address outbreaks of infectious diseases, natural disasters and the human crisis in the Boko Haram-ravaged North East.

Ultimately, this brain drain means that Nigeria is training doctors for far richer nations who can afford to pay them and provide better working conditions. This is cheaper for these nations, considering how expensive it is to train one medical doctor. Last year alone, over a hundred young doctors emigrated to Saudi Arabia. Most doctors do not know their final destinations yet, but many have concluded, like Femi, who is selling his car to fund his exams that, ‘Anywhere is better than home’. The stakeholders do not seem to care. A look at the health indices of Nigeria mirrors that of a nation at war – at war with itself.

Resident Doctors protest against poor working conditions.

A war to end all wars

A week later, the doctors are recalled to another emergency meeting, where it is announced that the National Association of Resident Doctors had declared a seven-day total warning strike. One commentator observes that the President had left the country for the UK on a medical vacation. Another asks the question: “What is the way forward?”

Two weeks after the warning strike ended and as the expiration of the 21-day ultimatum issued by the doctors to the Federal Government looms, the health sector is bracing itself for the impact of yet another national shut down of activities. In a letter to the National Assembly, the President has extended his medical leave indefinitely. Many fear this will be the war to end all wars and that casualties will be colossal. Whatever victory either side gains, one thing is clear: The cost will be measured in the weight of the blood of recession-ridden Nigerians.