Colleagues, please listen to me before you STRIKE me!

Dear Nigerian Doctors,

Joint Health Sectors' Unions (JOHESU) were on strike for about one week last month (August 2013) shutting down public hospitals across Nigeria except for skeletal services rendered by you. But what worried me most is the stand of colleagues during the strike and the current threat that you too would use the same device that you largely condemned other health workers for using if the government agrees to the demands of JOHESU. (There were some words of reason and call to understanding from MD of FMC Gombe and CMD of Gwagwalada Specialist in the media).

But words coming out from the majority of leadership of the Nigerian Medical Association (NMA) and from colleagues in the medical profession were very coarse to say the least. In engaging with the discussion about other health workers you find people saying/writing things like “anti-doctors”, “our enemies” “eliminate”, “fight-to-finish” and so on. That there were some skeletal services provided by colleagues during the time of the strike was more to frustrate the strike of the other health workers than it was about genuine interest of patients or the general public’s health. A friend quoted the following on his blog said by a lady which seem to capture the position of most people on social media except of course the striking health workers:

‘I am asking you if you would take your pregnant wife to a hospital to be attended to by a nurse. I know you won’t. A nurse is a nurse. If you are admitted in a hospital she will nurse you, but not treat you. Everyone that goes to hospital wants to see a doctor. A doctor checks you and tells you what is wrong and prescribes what you will take. If there is an injection, the nurse will do it. But if you need an operation, a doctor does it. If you need drugs, you go to a pharmacy and get it. A pharmacist is dealing with drugs, not patients. When you have a drug unit, give it to a pharmacist to head, not a doctor. When you have a laboratory, give it to a laboratory technician to investigate samples on doctor’s orders. Don’t give it to a doctor. When you have a ward with patients, a nurse is who you need to administer drugs on doctor’s orders and to nurse the patients. But when you have a hospital, you have to give to a doctor, not a pharmacist or nurse or what have you. I know everyone is important in a hospital, but a doctor is the doctor. I am sure you don’t want a nurse operating on your wife.’

This understanding of leadership is rather curious. It seem to suggest that we agree that leadership should be about control and therefore power over the resources of particular spaces based professional knowledge.  Should it follow then that since Mine and Quarry Engineers know more about cement production they should not allow Dangote (who is not an engineer) as their CEO? Leadership is much more than knowledge and control of resources. Leadership especially in delivering public services is first and foremost about responsibility and accountability.

The question is what are our health institutions for?

For example, looking at Teaching Hospitals and Federal Medical Centres because they form the battlegrounds for most of the inter-professional disputes. Could the CMDs/MDs as the CEOs of the scores of tertiary hospitals bring forward any verifiable data about the core purposes of their hospitals?

Are these centres supposed to reduce preventable deaths? How much of that has each achieved in 2012? How much more could they have achieve? How much did it cost the society?

Are they supposed to reduce suffering? How much of that did our hospitals achieve in 2012? How much more could they achieve and at what cost the society?

Are these centres supposed to produce future health workers? How many do we need and how are they filling in the gap and at what cost to the society?

Are they supposed to produce knowledge through research? What do we know about the many things that are killing and maiming us and what solutions have they managed to produced and at what cost?

All indicators are suggesting that our health is deteriorating as the health budget sour in Nigeria. Here, one might argue that increasing spending on the health sector is damaging our health and reducing our survival?

What exactly is the purpose of our health institutions?

My position is not that the JOHESU strike is justified or in the interest of Nigerians and not because they will genuinely offer better results. But that the current framing of what leadership is within the health sector is rather cynical. And that need to be thoroughly worked out before embarking on another endless and meaningless cycles of strikes and counter strikes.

Building a Health System from Bottom Up

Building a Health System from Bottom Up

This was first written by me on 13/08/12 with the title “How do we fix our health system IV?” From the title it can be seen that it is a fourth in series of reflections on our health system. Earlier parts are posted on my blog http://misaddiq.blogspot.co.uk/.

Health is too important to be left in the hands of doctors only! Provocative? Yes and deliberately so. Hopefully, this will nudge all those hesitating to join in the debate to say or write something.

Who then should fix our health system?

With health workers you get more health facilities irrespective of the purpose such facilities serve. Many of our health facilities are probably damaging health more than they are helping to ameliorate health problems. Does the health worker have a vested interest in disease? Yes in lots of case in our setting. This may sound unreasonable because of the discourse about the ethics of the medical professional. But a critical eye will reveal that there is no incentive for the typical health worker to do something to stop increase in disease burden. Almost everyone I know has a story about their experience with our health facilities. We have stories about open-and-close, diversion of patients to private hospitals, fight over ownership of patients especially in peripheral hospitals. Recent media report about a ‘doctor’ removing someone’s kidney in Bauchi should still be fresh in our minds. Even public health professionals fall short when it comes to working to address the many health problems we face. ‘Perdiemitis’ and ‘work-chops’ have dominated the psyche of everyday practitioner, especially in this era of proliferation of international NGOs.

Health is too important to be left in the hands of bureaucrats either! Our institutions have grown too complex and had become the substance of attention rather than the vehicle to govern the sort of social relationships that are necessary for a strong health system. Our different ministries of health and health agencies have their own agendas and often totally different from the initial role that they were set out to perform. If you shut down the ministries of health across most part of the country the main people that will shout are the employees of such ministries. It will have very little impact on the health of the public. The recent battle of wits between Lagos State government and NMA is a good lesson in this regard even though Lagos is on the next street when it comes to public services compared to other states. Are these institutions therefore really part of our health system? They focus on their visions, missions, strategies and other managerialist jargons that do not mean anything to even the workers in the health institution not to talk of the sick or dying patient.

With health maintenance organisations (HMOs) you end up paying very high for the lowest quality of care available. Their key concern is their bottom-line and not your health. So also, the different health insurance institutions who will charge you all they can get as premium when you are healthy and use the money to find out ways to refuse you the health care you need when you are ill. Evidence from countries that have adopted health insurance whole sale have shown the system to be retrogressive and had not stopped people from paying out of pocket for health services at the time of need.

In Nigeria, almost all our health strategies and plans were developed by people that are related in one way or the other with the medical industry and heavily influenced by external bodies that lack the slightest understanding of the social context of our health problems. Health Ministries are run by the elites of the medical profession and their patronising politicians. Any surprise then that our health system don’t work for us? The politicians will ensure that the elite clinicians get the cathedrals and latest toys they want while they the politicians get to sign ‘juicy’ contracts in the typical Nigerian way.

Where then do we turn to?

Fixing the health system is a task for every single one of us. Each individual or groups of individuals affected by a health problem are the experts of that problem. What others can do is support them in addressing the problem based on what the index individual or group felt meaningful. Because it is a task for everyone it often ends up being a task for no one especially with a severely disable (read: refuse to be able) state. Therefore, fixing our health system is a political issue rather than a technical one. I have avoided the typical technical approach to defining the problems in the last 3 series deliberately so that this point is adequately highlighted. Oddly, the only promising group that can potentially do the job are politicians. Not the typical Nigerian political class though, but the numerous genuine grassroots political activists that are already volunteering their time and resources in solving different social problems in our neighbourhoods. What is needed is a more organised way of going about it. Health systems that work across the globe do so because it is taken up by genuine politicians who are interested in bettering their societies.

Currently, in the dominant discourses about health systems, politics is often analysed as barrier to technical solutions developed by ‘experts’. Our technical documents are dotted with talks of ‘lack of political will’, ‘political interference with the plan’, ‘political instability preventing implementation’ etc. as the problem. However, evidence suggests that rather than a barrier politics is necessarily an integral part of any meaningful health system globally. The German wellness funds, the UK National Health Service, the Ghanaian rapid rise in coverage of health insurance, the Costa Rican health and social security system are all excellent products of political action rather than some technical prescriptions.

The model - A health savings collectivity

This is about building communities and establishing trust using health as the basis. Based on my engagement with people during this fieldwork and generally, I have come to understand that they can do extraordinary things when health is the issue of concern. Someone said to me nobody wishes even their enemies ill-health. The stories I shared about some of my interviewees especially the extraordinary risk taken by one of the Achaba during the recent curfew in Kaduna in the earlier series highlights this point.

I have argued in the earlier series that individualism does not work with health, some collectivity is essential. Ideally this should be state-lead. However, we have a withdrawn state. Furthermore, all the potential candidates that give sense of collectivity in our setting (e.g. religion) have failed in one way or the other. Family is too small a unit to balance out savings and needs (not risks as insurance people would like it). Therefore, some innovation is needed. As I argued in the first series it is necessary to evolve (1) a set of mutually agreed values (in this case with respect to health) that govern our relationships and safeguard our rights outside our immediate families, and (2) a set of agreed ways of enforcing our agreements.

The ‘savings’ in the subtitle may suggest funds as essential element of this health collectivity but that need not be the case. The most important value is reciprocity – people willingly agreeing to actively take part in solving each other’s health problem. Reciprocity should remain the basis of assessing success not the size of the savings or contribution of individual members or the collectivity. Money should be treated in this regards for what it really is, which is essentially a medium of transaction to be used in translating – trust, empathy, solidarity, remorse, difference, loyalty and whatever values defined within the collectivity as important and also as a means of enforcing these values.

Under this arrangement groups can be formed in our communities consisting a minimum of 20 households (the higher the better up to a limit – familiarity is also important) to agree to share the total cost of illness of any of its members. Members are to contribute based on means and not some fixed amount as in health insurance. Members know each other well enough to be able to understand what amounts are within the means of each member and which member is not able to contribute at all and should be exempted from paying but allowed to benefit from others kind help. Those that are not able to pay can contribute in some other ways depending on what works for each group. My experience have shown that majority of the people appreciate kindness and try to reciprocate in one way or the other. I come to understand from my interviews that people in the area where I am working (a predominantly Muslim settlement) prefer to go to a Christian missionary hospital in the town because they are attended to and have their problems addressed before they are asked to pay. My interaction with the hospital reveal to me that although some people do default, but the majority come back and pay and that the numbers that are defaulting are not high enough to prevent the hospital from running their services effectively.

In the first place this collectivity is purposefully set up as a vehicle to prevent individuals from exposure to the financial inadequacies that prevent meaningful action to solve health problems. It is prepaid so that members do not start looking for money at the time when they needed to focus on the best course of action. It is a collective effort so it relies on much more than the sum of capabilities, resources and networks of individual members. It is a sort of mutual assistance scheme that is founded on health needs.

Members of each collectivity hold regular (monthly, fortnightly) meetings and make their own decisions with regard to the design and funding of benefits, as well as their constitutional arrangements. Besides providing the money to meet health expenses, members can also use their capabilities and other resources within their network to directly solve the health problems, mitigate it from its root cause, and address structural issues that lead to the problem in the first place. There is huge incentive in the form of savings to motivate the group to work towards a lasting solution to the health problem as the benefits are tangible. Multiple collectivities can form mutually beneficial partnerships in solving some problems. Ideally the collectivities should be based on geographical proximity but with increase sophistication and depending on the sophistication of its membership geographical proximity may be done away with.

As each group address one problem and move on to another, knowledge and experience is generated and shared and subsequent similar problems can be addressed more efficiently.

There are lots of barriers to setting up this type of system and one is sure to meet with political resistance from the state. However, as I have mentioned above, building a health system is a political action and therefore adequate preparations can be made for backlash. What do you think?

Muhammad Saddiq

13/08/12