Fresh Row Over Leadership Of Hospitals
SUNDAY, 10 MARCH 2013 00:00 FROM: EMEKA ANUFORO, ABUJA SUNDAY MAGAZINE - NEWSFEATURE

GOING by recent events in the health sector in the last few days, the gladiators over who manages hospitals are back to a familiar terrain, this time with renewed vigour.
Now, both sides are defending their propositions in such an intense manner that if nothing is done soon to calm frayed nerves, the nation could be heading towards a situation that nobody can predict. Indeed, the Ministry of Health and health workers under the Joint Health Sector Unions (JOHESU) seem to be at the end of their tether and are literally feeling very much on edge.
The tension started building once again late last year when the Association of Medical Laboratory Scientists of Nigeria briefed newsmen where it identified mismanagement as the biggest problem of the Nigerian healthcare system and called on government to formulate laws that would bar doctors from being chief administrators of hospitals in the country.
Shortly afterwards, in December, 2012, Assembly of Healthcare Professional Associations and the Joint Health Sector Unions (JOHESU) had a protest march in Abuja rallying at the National Assembly where they, among other issues, called for a new law to ensure that only seasoned administrators were the only ones to be appointed to be chief executive officers of hospitals in Nigeria.

The Minister of Health, Professor Onyebuchi Chukwu has dismissed the position of the health workers calling it a ‘non issue’. He described the hospital as the terrain of doctors and wondered why doctors should be prevented from administrating their ‘terrain.’
Assembly of Healthcare Professional Associations and the Joint Health Sector Unions (JOHESU) are made up of National Association of Nigeria Nurses and Midwives (NANNM), Medical & Health Workers Union of Nigeria (M&HWUM), Senior Staff Association of Universities, Teaching Hospitals, Research Institutes & Associated Institutions(SSAUTHRIAI), Nigeria Union of Pharmacists, Medical Technologist and Professions Allied to Medicine (NUPMTPAM) and Non – Academic Staff Union of Educational and Associated Institutions(NASU).
Two weeks ago, JOHESU issued a statement calling on government, to among other things, remove the Minister of Health, Onyebuchi Chukwu and bring in a minister who would ensure a level playing ground for all the stakeholders in the sector, alleging that the minister was in league with doctors to ensure that their demands are not met.

Chairman of the group, Dr. Ayuba P. Wabba, said: “A major grouse of our coalition is the continued exclusive role of medical practitioners as the Chief Executive of hospitals. We have argued in line with international best practice, that the skills required for that administrative office are quite distinct from the clinical skills of a medical doctor. The facts on ground prove that they have grossly mismanaged these institutions because they do not possess the administrative training and experience required for the office. International best practice is to have professionally certified and experienced health service/hospital administrators manage the institutions.”
JOHESU views were echoed by the National President of the Association of Medical Laboratory Scientists of Nigeria, Godswill Chikwendu Okara, who asked Nigeria to adopt the practice in more advanced countries, where he said the situation applied.
Okara said: “The issue of management and administration of health care services is a professional occupation and we have professionals called health service administrators. By the colonial history of Nigeria, we inherited a lot of things from Britain, the United Kingdom. As we speak, the United Kingdom healthcare is administered and managed by professional health service administrators and that was what it was in Nigeria up till 1985. Before 1985 we had professional health service administrators, who in teaching hospitals were called house governors, they were the chief executives of teaching hospitals before that designation was changed from house governors to directors of administration. Just as you have health care professions and professionals, you have health services administrators as a professional group and they offer that service. This is the international best practice the world over.
“The healthcare industry is such a complex, multi-professional and multi-disciplinary industry that you want to see a situation where each professional group busies itself, providing the services to the best of its ability, while you leave the administration and management of personnel, resources, financial resources and other material resources to those who are specially trained in that area. That way, you would have the best of the system.”
He went on: “Take a survey of Europe, America, and Asia, there is not a place where you have a medical doctor as the Chief Executive Officer of any hospital. None! One medical practitioner in Lagos was very down to earth, very honest and sincere about all these and made it clear that in Germany where he trained, that no medical doctor heads a hospital as a chief executive.
“That is the standard practice all over the world. Nigeria decided just by military fiat to change that without proper consultations. Imagine that somebody will be in the theatre operating all his life and one day he is appointed to become the chief executive of the hospital. Such a person has no administrative or managerial training, no experience, nothing whatsoever in managing an establishment and he would get there and start running the place as if he is operating in the theatre.”
He said unless Nigeria addresses the issues dispassionately, the decline in the Nigeria health sector would continue.
His words: “Because people don’t have administrative and managerial training and experience, they don’t have regard for government rules and regulations. Government in its wisdom charged the National Council on Establishment with the responsibility of articulating schemes of service. Before they do it, they embark on a nationwide job evaluation exercise. It is a very rigorous process that cumulates into bringing out the scheme of service and when you come to hospitals, some chief executives of hospitals will arrogate to themselves better knowledge than the National Council on Establishment. They want to set aside the scheme of service of various professional groups. These things are causing a lot of disaffection and upheaval in the health sector. They stagnate professionals in their career progression and prevent them from getting to the zenith of their profession, whereas they implement the scheme of service for their medical practitioner colleagues fully.
“What you see now is that the healthcare industry has been over politicized. In 1985, the late Professor Olikoye Ransome Kuti, of course working in concert with the Nigeria Medical Association, prevailed on the military government of General Ibrahim Babangida arguing that the hospitals were better managed by medical doctors and of course because of the respect the military administration had for him, they listened to him and enacted decree 10 of 1985. And we do know from comparative analysis that ever since, our healthcare service in Nigeria has been on a steady decline because the management has gotten into the hands of people who have no management or administrative training or experience.”
He told The Guardian: “They have taken it over from people whose professional calling and training it is. Out of the countries of the Commonwealth of Nations, Nigeria health service was ranked 4th in the 60s and 70s. Since 1985 when the doctors took over, it has been a sad story of continuous decline. Over politicization has been intense up to a point that often you will see the doctors would be busy fighting among themselves who will emerge Chief Medical Director or Medical Director of the hospital. It has become like partisan politics which never was the case in the past, when professional health service administrators were in charge, it didn’t matter who you are, it didn’t matter what name you are called, whether consultant or whatever. All that mattered was the rules and regulations guiding the healthcare industry as initiated by the government. They kept to the letter and spirit of those rules and ensured that everybody worked by the rules and regulations of the service. Your business was to provide services to the patient. If you defaulted you will be called to order. You will face a panel. But what you see now? Doctors have now come together and hijacked administration and people can do anything and get away with it so long as such a person is a doctor.
“There was a particular case at the National Hospital Abuja where a doctor was accused of committing something that was unethical, something that bothered on crime, diverting anti-retroviral drugs that donor agencies had given to Nigeria to be given to patients free. This doctor was selling the drugs. The guy was given marked money by security agents and was caught red handed. The National Hospital set up a panel. The Medical and Dental Consultants raised an argument on why a non-medical doctor should head a committee to try a doctor. You can imagine that kind of thing. Nothing came out of that case up until today.
“Because of what is going on now, any doctor can get away with blue murder, simply because their fellow doctors are in charge, nothing happens. Schemes of service for various professional groups in the health sector are trampled upon, swept under the carpet because they feel that they are in charge and that nothing would happen. That is why the whole place is in perpetual turmoil. If we must get back to where we missed it, we need to allow management and administration of the healthcare sector to be professionalized. That is, for the healthcare management and the administrative leadership to be professionalized instead of the partisan politicization we are seeing in the healthcare sector today.”
He called on the National Assembly to repeal the contentious decree 10 of 1985 which makes the chief executive of the hospital a medical doctor should be repealed and re-enacted, and that the designation Chief Medical Director should be changed to Chief Executive Officer and that the position should be professionalized.
He continued: “For instance, the Medical and Dental Consultants have formed virtually a union and they want to dictate what goes on in the hospitals because they feel that the Chief Medical Director is their colleague and from their consistency or from their union, and because of that, they want to use that office as a platform for projecting their interest and suppressing whatever they feel is a threat to them. It has now gotten to a point that they went to the extent of influencing the Minister for Health to issue a circular in December 2010 directing that no other health professional cadre should be appointed a consultant in the health industry; that it is only medical doctors who should be appointed consultants. In the course of discussing with the Ministry of Health about that circular, we called their attention to a circular dated March 29, 1976 where the government outlined the criteria for the appointment of clinical and non-clinical consultants and payment of clinical supplementation which has now been called specialists’ allowance to both groups of consultants.
“So dating back to the 70s, we have had other health professional cadres and professionals being appointed consultants. We have many medical laboratory scientists who are consultants in various teaching hospitals and medical schools; we have physiotherapists and so on and so forth. And now, in the 21st century, the Ministry of Health is saying no other healthcare professional cadre should be called consultants, other than medical doctors. It has now gotten to the point that they passed a circular that made the management board of various hospitals to revoke the consultancy of other health professions who were previously appointed consultants. These things are at the heart of the instability and the acrimony or disharmony we are seeing in the health sector. And unless they are addressed, things will continue to go wrong in the sector.”
Health Minister, Chukwu, in an interview with The Guardian opposed the call for the review of the decree to restrict doctors to medical practice and barring them from administration.
He said: “The Chief Justice of Nigeria is a lawyer. What is the problem? And the Chef Justice is both the administrator and the technical expert as far as the judiciary is concerned. So, why should it be different in medicine? The hospital is the only place that is totally the doctor’s territory. Every other person there is in support system. And it is so in different areas. You have doctors who are working in the bank. In the bank, we have the economists, we have those who did finance and accounts; we have the accountants and financial experts. They are in charge in the banks. You also have doctors because some of them have established hospitals. The doctors working there are doing support work.
“In the oil and gas sector, it is the zone of the engineers, chemical engineers, petroleum engineers, mechanical engineers and electrical engineers. The main business there is to get out the oil, refine them. There are doctors and pharmacists working there. But they are in the support group. We have chartered accountancy firms. Accountants are in charge there, but there are other support groups.
“You have drug manufacturing industries. In the drug manufacturing industries, that is the zone of the pharmacist. Anybody going there, a doctor or an engineer going there to struggle will only be a support staff to the pharmacist.
He went on: “When you go to hospital, who do you go to see? Let’s not do something that is different. Go to any country. It is the doctor. The Director General of the World Health Organization has always being a doctor. And if WHO that is not even a hospital insist that a doctor should be their Director General, why should Nigeria do its own different? What is wrong with us in Nigeria? I have not had a single Director General of the World Health Organisation that is not a medical doctor since its creation. And that is not a hospital. Don’t we think that that is for a reason?
“I have visited the largest hospital in the world in terms of bed space, a hospital that has 2, 300 beds in Vienna Austria. It is a government hospital. The person managing it is a professor from the university. He is a pathologist. I don’t think people who are genuine are really serious with the argument.
I think probably the issue is everybody is jostling for power and it is all about negotiation and there is absolutely nothing wrong with people negotiating. But for me as minister, I think we need to do what is right for the country. I have been showing good example. I have been fair to everybody concerned. As Chief Medical Director, I was the first to introduce internship in optometry. I have directed all our hospitals to start internship in optometry.”
His words: “I am the first minister to appoint a pharmacist Director Health Planning and Statistics in the Federal Ministry of Health. So, I am not biased. I am thinking we need to be sensible.
“That is the only place the doctor has his own house. The hospital is his terrain where he can exercise his professional authority and put his stamp there. That is the hospital.”