The age-long battle of who-gets-what in Nigeria's health sector has once again put the Federal Government between two touchy ends and further endangered the very existence of the country's health industry.
Medical doctors and other health workers have been on a war path for long and the main contention is salary adjustment.
This may seem as an over-flogged issue but the rift is always reignited whenever any of the warring groups makes a demand on the government.
The battle took another twist on Thursday as medical doctors threatened to withdraw their services if the government accedes to the demands of other health workers who have been on strike for over three weeks now.
The nationwide strike was called by JOHESU (Joint Health Sector Union), a body that comprises all health workers except doctors, has left millions without care.
The strike crippled federal health institutions and last week, states and local governments health workers joined in a bid to force the hands of the government.
No fundamental agreement has been reached in the series of meetings between the government and the striking union asking for salary increase but there was a ray of hope.
Wednesday meeting ended with the government accepting to prepare an offer for the union.
"They said they want to make an offer to us but we don't know what it is yet until we study it and know if its what we can accept or not," the National Vice Chairman of JOHESU, Ogbonna Chimela, said.
"We are still meeting with them," the minister of health, Isaac Adewole, confirmed in a text message to PREMIUM TIMES.
The doctors under the Nigerian Medical Association (NMA) who apparently have been monitoring events, quickly reminded the government in a statement by its newly-elected president, Francis Faduyile, of its 2014 agreement with the government not to accede to demands of other health workers relating to salary adjustments and harmonisation.
"The NMA wishes to draw the attention of the Federal Government to our correspondence of April 21, 2014 on the above, in which we reminded Government of the collective bargaining agreement we had with the Federal Government of Nigeria in January 2014.
"It is also pertinent to once again remind Government about the concluding part of our letter no. NMA/PRE/SG/03/0751 of 21st March 2014, which states, "In view of the above, the NMA painfully wishes to inform the Federal Government of Nigeria that any award to the non-medically qualified health professionals that violates the January and July agreements of 2014 shall result in the resumption of the suspended withdrawal of service of 2014. Please take this as a notice sir."
In Nigeria's civil service, medical doctors already have a wide edge above every other skilled worker when speaking of salaries and benefits.
Initially, they entered the service at salary grade level 9, while other graduates started at 8.
Recently, they convinced government negotiators led by health minister, a medical doctor, to raise doctors' entry salary level to 12.
That seems already too much as it does not take four years -- which doctors may claim accounts for the variation in years of training with other disciplines -- to attain the four outstanding salary levels. It takes far more years.
Empty maternal care hallway at Asokoro district hospital as a result of the health workers strike
But JOHESU, which also includes pharmacists and medical lab scientists with long number of years in training, says it is not asking for parity. It wants a raise and other benefits.
Doctors have threatened strike if the government accedes. But are doctors asking for too much? Are they deservedly favoured or are they being greedy, as some JOHESU officials say?
JOHESU has several demands it is asking of the government but the doctors are particularly opposed to that of salary adjustment and harmonisation, the major demand that prompted the strike.
In 2014 when the government approved the Consolidated Medical Salary Structure (CONMESS) salary adjustment for doctors, both parties reached an agreement that the principle of relativity must be sustained should there be upward review of CONHESS salary scheme.
CONMESS is the salary structure for medical and dental officers in the federal public service while Consolidated Health Salary Structure, CONHESS, is the salary structure for pharmacists, medical laboratory, nurses and other health workers in the health sector of the federal public service.
Since 2014, other health workers have been asking for an upward review of the CONHESS salary scheme as was done for medical professionals.
The doctors who saw the move as an attempt by other workers to get the same pay with them have consistently kicked against it.
But the other health workers have repeatedly explained that they are not asking for same pay with doctors but an increase in their own salary structure. They say they are not averse to relativity.
"Before, medical doctors entered service on grade level 9 while the rest of us enter on 8 but after the 2009 negotiation of salary structure, medical doctors started entering service on grade level 12 while we enter at that same 8.
"So relativity had been established at the point of entry because they spent six years in school while other health workers spend five or four years, so you can see the years of training of the both groups are different that is why government allows doctors to enter service at grade level 12 while we enter at 8 to maintain relativity," Mr Chimela explained.
Other issues in contention
The genesis of disharmony among health workers can be traced back to 1985 when the late Olukoye Ransom Kuti was the minister of health.
Some of the major issues in contention apart from salary adjustments include:
The demand for the appointment of other health workers as Consultants.
The demand for the appointment of other health workers as Consultants.
The demand for headship of departments/units in the hospital by members of JOHESU
The demand for professional autonomy by JOHESU.
It however drummed support for the demands of JOHESU on skipping of CONHESS 10 and payment of arrears in compliance with National Industrial Court of Nigeria Judgment, and increased Retirement age.
Why our position is justified -- NMA
The newly-elected president of the association, Mr Faduyile, said the implementation of JOHESU demands will alter the existing relativity in the salary scale in the health sector.
"What JOHESU is asking is not just increment in there salary, they are asking for parity with doctors," he told PREMIUM TIMES. "We have being disadvantaged for more than 12 years in the health sector until 2014 when the government realised this and readjusted our salary scale which is CONMESS. We had an agreement with government through collective bargaining and they begged us to reduce the relativity and we have reduced it from 3:3 is to 1 ratio to 1.5: is to 1 ratio.
"This means over 50 percent reduction and in our lower level we have appropriated relativity. In 3 steps out of the 7 steps that doctors are paid in the service, there is parity of 1 is to 1. So what we are saying is that it is getting out of hand.
"Before, the salary ratio of doctors and other health workers used to be 3.3 to 1.0 but today we have cut it down to 1.5 is to 1.0 so that peace will reign but they just want it to be at par but we are saying we have given so much to that level of 1.5 and we cant go beyond that."
On the argument by JOHESU that relativity suffices at point of entry into service, the NMA president reacts:
"That they enter service at grade level 9 and we enter at 12 is not relativity, it does not appear here. Can a degree holder that enters service at grade level 8 and a PHD holder that enters at level 10 earn the same salary? No. A PHD holder should get more gratification and enter service at higher grade than his degree counter part.
"The relativity we are talking about here is not on the point of entry, point of entry is just about the degrees and level of education. We are talking about the ratio in the salary scale."
He admitted that doctor's wages will not be affected if the government accedes to JOHESU's demands.
"It will not affect our salary but it will be a bad morale to us. I am working as a doctor and am collecting N5 another person in service who did not go through the kind of training I went through and is not working as much as I do will still be collecting the same salary. Why am I going through all these stress then? In America even among doctors, their is relativity. An anaesthetic doctor can collect up to 5 times the salary of a pathologist.
"When CONMESS was implemented, JOHESU went and made up their own salary scheme which is CONHESS. They transferred all the figures and salary steps in CONMESS into CONHESS and that means parity. Doctors have to go back to government and tell them we have being short-changed and in 2014 when the government realised their mistake they readjusted our own salary and it is that same readjustment that the JOHESU is asking from the government.
"If that is done then it means we have gone back to that position where we were disadvantaged. They are asking that everything in CONMESS point for point, level for level must be the same thing with CONHESS.
"Nobody is against them from having increment in salary. what we are saying is that it will not be at the same level with doctors. Government should follow its own agreement.
"There is a special salary scale for medical doctors as well as other health workers and in that scale doctors earn a particular leverage over and above others.
"We must understand that JOHESU have the cleaners, the drivers, the typists, the administrative staffs, the hospital engineer. we have all other type of people who are supportive staff," he said.
On how much the doctors earn at entry level, he said, "Doctors collect about N150,00o, I am a consultant, I've been a consultant for more than 10 years and my salary is just a little above N500,ooo with all the taxes the money is even lesser while my counterpart in other African countries collect well above that and even a higher salary than supreme court judges. The judges collect nothing less than N2 million and for your information a neuron-surgeons in America collects more money than their president and we are working here, a typist is saying i must collect same salary with doctors.
He also spoke on JOHESU wages:
"I will take it in two folds. In JOHESU, we have both skilled and unskilled staff as members, that is, professionals and non-professionals. For the professionals, the least paid is on grade level 8 and if you put all his pay together because he's like an intern coming into the system, what he collects in a month is N120,000 If he (or she) is on call duty. But those who are not on call duty only get N90,000 monthly. As for the unskilled staff, they collect the minimum wage, which is N18,000."
If the government finally implements the salary adjustment for JOHESU, the least paid professional in the union according to Mr Chimela will have a 20 per cent increase on his/her normal salary.
"For instance, the least paid that collects N120,000 will now take home an additional N24,000 which will now make his/her total remuneration N144,000," he said.
On how the government is battling with the dilemma of implementing the demands of JOHESU without provoking the wrath of the medical doctors, the Minister of Health, Mr Adewole, in a phone interview with PREMIUM TIMES, described the government as a benevolent father.
"We look at both sides, you look at what your children is asking for, you make them see reason with you and consider your ability to pay. You also look at what will give them happiness and that is our duty and we will get the done."