National Association Of Resident Doctors (NARD)/ Federal Government: The Story So Far

Chronicle Of Recent Activities Of NARD: The agitations for a better training and conditions of service for resident doctors in Nigeria dated as far as the last 15 years. However the intensity of the latest struggles increased because of the increasing disconnect between the leaders and the led in Nigeria.

You may all recall that the association, having issued a 21day ultimatum to the FG and having gotten no favourable response from FG, embarked on a nationwide 2 day warning strike between the 2nd and 3rd of March 2010 and later proceeded on an indefinite strike on the 15th of April 2010. The strike was however suspended on Monday 26th April 2010 to stem the spiralling bloodshed and pave way for further negotiations with the FG.

You may also recall that our demands and the premise for them are as follows:

1. RESIDENCY TRAINING ISSUES:  Core to the demands of the Resident Doctors is a call for a restructuring, repositioning and deliberate funding of the residency training programme to increase its potential for providing quality specialist manpower for advanced healthcare delivery in Nigeria. NARD is uncomfortable with the current state of the residency training programme as we suspect that wholesome neglect and systematic bastardization has made the programme to be unable to meet its intended purpose of producing world class medical specialists to meet local needs and reduce the capital flight and the diminished sovereignty of a nation whose citizens have to seek specialist medical treatment in foreign countries. NARD is also worried that a situation where by specialists are trained only within the tertiary hospitals without appropriate community exposure at their level may not augur well for a country like Nigeria with a teeming rural population. They also express concern over a situation whereby different training institutes recruit resident doctors based on ‘available space’ and sometimes the whims of the Hospital Management without recourse to local and national needs.

2. In the area of funding of the Residency Training Programme, NARD is uncomfortable with the situation whereby the Federal Ministry of Health (FMOH) had systematically reduce the allocation for funding of residency training in its budget to the extent of zero allocation in the last 4 years. Meanwhile allocation for bogus projects like building unmanned Primary Health Centres (PHC) across the country was increasing, for instance, this project gulped N36 billion in 2007 and another N26 billion was initially budgeted in 2010 before the new administration decided to review it.

Furthermore, NARD observes that the lack of funding has led to the abolishment of the hitherto mandatory one year overseas clinical attachment for resident doctors, a programme that ensures that the Nigerian specialist has not only a thorough understanding of the theory and practice of his specialty locally but is also well grounded in contemporary innovations and developments in his field and that he/she can import and disseminate the scarce skills for local use (so that you and I who can not afford N70 billion treatment in Saudi Arabia can receive such care locally in your village be it Iseyin, Ogaminana, Uguru, Umueziukwu, Sabongida-Ora or Ahoda). The abolishment was not based on evidence that the imported skills that the scheme assures are no longer needed or that they can be gotten locally but because Government has more important issues to use money for than developing her own human capital.

The lack of funding has pushed many hospital management who had to provide some skeletal support for residency training to do so at the expense of the patients. Centres had to astronomically increase their service charge to beef-up IGR to support residency training (now you know why you have to pay through your nose in these hospitals). This situation, NARD believes has the potential of taking health-care out of the reach of the already overstretched and unacceptably impoverished Nigerian citizen. It may also reduce significantly the patronage of such teaching hospitals by patients and thus reducing the availability of patients for training and research.

This is why NARD demanded that FMOH should set up a high-power stake- holder committee with a clear mandate to look into the full ramifications of the residency training programme with a view to restructure and reposition the programme along the line of issues raised in an earlier position paper drafted by NARD and submitted to FMOH. The Association further demanded that The FMOH should make a definite statement of commitment to earmarking a clear cut budget for funding of the residency training programme in the overall budget of the Ministry in the 2011 budget.

While it is heart warming that the FG has inaugurated the Ministerial committee on Review of Residency Training in Nigeria on Monday 9th August 2010 at the Transcorp Hilton Abuja, it is unsettling to know that NARD had to go on strike to enforce their participation in issues of national planning. The committee is expected to make far reaching recommendations on the residency training programme including the modalities for the hitherto mandatory and extremely relevant one-year overseas clinical attachment for resident doctors, a programme that ensures that the Nigerian specialist has not only a thorough understanding of the theory and practice of his specialty locally but is also well grounded in contemporary innovations and developments in chosen field. In addition, we are of the view that findings of the committee in the area of a proposed minimum entitlements of a resident doctor as well as the current burden of resident doctors in Nigeria will assist greatly in determining what amount should be allocated so as to avoid an arbitrary allocation of funds. The hope is that when the committee completes their job in 6 weeks, specific, deliberate and evidence based budgetary allocation for residency training programme in the 2011 budget will be a reality.

To this end, we have also written to the Chairman of CCMDs to submit that it is advisable that all CMDs put on hold all form of internal restructuring, modification, or policy overhaul that may be going on in their various centres currently, pending the determination of the implications of the findings and submissions of the Ministerial Committee on such changes that such centres may be currently proposing.

3. CONSOLIDATED MEDICAL SALARY SCALE (CONMESS): You may be aware that after a protracted negotiation that nearly culminated in a nationwide strike of the entire Nigerian Medical Association, the FG eventually circularised the CONMESS in September 2009. The circular (circular no SWC/S/04/s.410/ 220, dated 29th Sept 2009) was released after two years of agitation and was fore-dated to Jan 2010 in a last minute effort of FG to avert a nationwide doctors’ strike then.  Then for 5 months into the year 2010 the CONMESS was not implemented until a NARD strike. The initial excuses, as rhetorical as they may sound were that a sustentative Minister of Health was yet to be appointed and later that budget has not been passed. In any case the CONMESS eventually commenced with the June Salary with the January-May arrears still pending. The Federal Ministry of Health (FMOH) pleaded that the arrears had been captured in the 2010 supplementary budget and would be paid as soon as budget is passed.

The Ordinary General Meeting (OGM) of NARD that held at the University of Calabar Teaching Hospital on the 26th of June 2010 having expressed her frustration and disappointment at the non-inclusion of the arrears of the Consolidated Medical Salary Scale (CONMESS) in the main budget of 2010, resolved to suspend a planned strike action and wait till the passage of the supplementary budget in which the CONMESS arrears was captured. The decision not to go on strike then, was premised on the fact that NARD considered the fate, pains, and suffering of the Nigerian masses though we knew that patriotism is within the limits of responsible governance. NARD also decided to give the Minister of Health, Prof. Onyebuchi Chukwu, a former NARD president who has demonstrated an uncommon integrity in his public and private life, the benefit of doubt.

We however at this juncture, wish to point his attention to the fact that the National Assembly on Wednesday 21st July 2010 passed the much awaited 2010 supplementary budget and that the time is ripe for him to keep his own side of the bargain to pay the January-May arrears of CONMESS in bulk immediately. NARD demands a full payment of the January-May arrears of CONMESS within 21 days of the passage of the budget (i.e on or before Friday 19th Aug 2010) to avoid fresh industrial disharmony within the health sector.

Similar to this is the reluctance of the State Governments to implement CONMESS in their Teaching Hospitals. We all know that the provisions of the statutes establishing State Teaching Hospitals in Nigeria dictates that emolument of Doctors in such centres shall be at par with what is obtainable at the Federal level.  The refusal of some State governments especially Ogun, Lagos, Oyo and Ekiti States to implement CONMESS in their State-owned Teaching Hospitals is already taking its toll. For instance there is an ongoing mass exodus of doctors in the employment of some state government to the service of the Federal Government. This development is not unconnected with poor conditions of service and unpaid salaries. Recently doctors resign en-masse OOUTH Sagamu Ogun State while Oyo state Government could not get more than 3 doctors to pick up appointment letters out of the 100 that were offered jobs because of the appalling conditions of service and poor pay package. These situations portend serious danger for healthcare delivery in the State and the nation at large. 

NARD is concerned that if the location or distribution of human resources is skewed along the line of the higher bidder or greener pastures we may yet have a local 'brain drain' and a final collapse of the dilapidating primary and secondary health care delivery system in the country. That is why the implementation of CONMESS at state levels should be the new priority issue in the mind of the leadership of NMA, NARD and indeed Government through the Federal Ministry of Health (FMOH). We believe that NMA, NARD and indeed Government must put a framework in place to address the widening disparity in wages between State and Federal Health workers in the overall interest of the nation’s health care delivery.

However, suffice to say that the timeworn argument of State Governments being at liberty to pay whatever their State legislatures can conveniently give their workers is no longer tenable. This is because the health of the Nation is a Global issue that transcends the artificial boundaries of States. A health care delivery crisis in a State will ordinarily spill to other States either in the form of a spreading epidemic or exodus of healthcare seekers to neighbouring States. The import of this is that a weak healthcare delivery system in any State or region should be the concern of all.

This is why NARD is expressing her full support for the agitations of doctors in the employment of State Governments for a better condition of service and will not hesitate to join in solidarity if the State Governments are not willing to yield to their demands.

Therefore, As a show of solidarity for members of this association working in State owned Teaching Hospitals with whom we jointly commenced the struggle for the implementation of the CONMESS circular, but who are yet to enjoy the provisions of the CONMESS circular; NARD resolved to proceed on a 5-day solidarity strike starting from Monday 9th August, 2010. However the strike is structured in such a manner that essential services will be provided in the course of the strike. The State owned Hospitals would be on total and indefinite strike until their State Governments open negotiations with them.

A similar scenario played out with the Teaching Allowance and the superior, evidence based and well researched argument from NARD as well as the support from NMA National secretariat came to the rescue.

4. RELATIVITY IN WAGES WITHIN THE HEALTH SECTOR: The last concern of NARD was the diminishing relativity in wages among doctors and other health workers. It is generally acknowledged worldwide that hospital services is a team work but with doctors playing the leading role as head of the team. It is for this reason that NARD is asking that this leadership role be reflected in the remuneration of workers in the hospital environment. Over the years, there had been different scales for remuneration of health workers. But the worst appears to be Consolidated Salary, which lumped together all health workers under the same scale irrespective of the fact that there are doctors, pharmacists, medical laboratory scientists, accountants, administrators etc in the hospital environment. The consolidation policy also consolidated all allowances including those that were hitherto exclusive to doctors into the pay package of all health workers. Therefore, with Consolidation the wages of nurses, accountants and other administrative staffs increased, that of doctors decreased in relative terms. This was without recourse to the practice in other parts of the world whereby wages of workers were calculated based on such guidelines like length and rigorousness of training, working hours, exposure to hazard, degree of scarcity of skills etc and not how much agitation and threat of strike the trade union can muster. It is on this note that NARD demanded that the FMOH should make a definite statement of commitment resolving the issues of relativity in remuneration within the health sector by immediately constitute a committee to review wages within the health sector using appropriate and internationally acceptable yardsticks.

It is interesting to know that the FMOH eventually agreed to set up a committee to look into the best ways to harmonise the wages in the health sector with a view to correcting any breach in relativity. The report of the committee is being expected.

In conclusion, NARD subscribe to the fact that the level of restiveness and propensity for strikes in the health sector is worrisome and unbecoming, we strongly believe that a mutually respective, unfettered and sincerely open channel of communication and a robust and open-minded dialogue between stakeholders (like NARD) and the FMOH is probably the first step in the quest for a sustainable industrial harmony within the health sector. A situation where major stakeholders like NMA, NARD and other similar bodies are not carried along in decision making, policy formulation and the eventual disposal of issues that affects them directly will not and can not foster peace and capacity development in the health sector.

This is one of the reasons why we can not fail to identify with the commendable efforts the Minister, Prof. Onyebuchi Chukwu, have put in place in bridging some of the information gaps since his assumption of office. We will want to encourage him to remain open to constructive advice and even criticisms.

Dr. Olayinka Atilola