A worker strike puts Nigeria’s health-care flaws in spotlight

Why We Wrote This

Nigeria’s president has routinely left the country for medical care. Meanwhile, hospital workers struggle with difficult conditions. Now they're on strike but are wrestling with the ethical implications of the president's choice as well as their own.

Crowds gather outside Murtala Mohammed Specialist Hospital, in Kano, Nigeria, November 29, 2014.

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A strike by public hospital workers in Nigeria is entering its fourth week, with only doctors showing up and care sharply curtailed. It symbolizes a health-care system that, despite Nigeria’s status as Africa’s largest economy, lags far behind global standards. A 2017 study ranked Nigeria 140th of 195 countries in health-care quality. Patients and staff at public hospitals complain of the low standard of care, with institutions often missing equipment like X-ray machines as well as more basic supplies such as gloves and gauze. Adding to the dissonance is the prevalence of “medical tourism” trips by elites including President Muhammadu Buhari, who was London-bound for treatment last week. The situation is ethically fraught: The strike erodes care for now, but the goal is to improve wages and morale for workers who say pay is inequitably divided between doctors and other hospital workers. “I support this strike now,” says Emmanuel Uwazuruike, a taxi driver who’s had bitter experience with the hospital system in Abuja. But he adds, “When they strike, it is ultimately the poor who will suffer.”

When the presidential jet roared down the runway at the international airport in Nigeria’s capital last week, it was leaving on a familiar mission. The country’s president, Muhammadu Buhari, was bound for London, where he regularly travels for medical treatment.

Since taking office in 2015, in fact, Mr. Buhari, who is 75, has spent about six months in Britain for visits with his doctors. His so-called “medical tourism” has drawn sharp criticism from many at home, who have often asked why he doesn’t have enough faith in his own country’s hospitals to use them himself.

But this time, the contrast between the president’s care and that of ordinary Nigerians was particularly stark. As Buhari’s plane whisked him away, it passed over a country of ghost hospitals. A strike of nurses, pharmacists, and other workers over wages and working conditions at federal public hospitals was dragging into its fourth week. Doctors were the only staff on duty, and most institutions were turning away all but the most urgent cases. 

The dissonance has drawn renewed attention to the longstanding crisis of care in Nigeria’s creaking public hospitals. The country has just one doctor for every 5,500 people, well below the World Health Organization’s standard of 1 every 600.

But the strike has also raised questions of just how far a strike can go in fixing the problems that ail the health system of Africa's largest economy – and who, exactly, stands to gain and lose when health workers walk off the job. 

Medical strikes “are a fraught ethical issue,” says Ike Anya, a Nigerian public health expert and the co-founder of the popular blog Nigeria Health Watch. And that’s particularly true in a country like Nigeria, where those who use public hospitals often have no other options for medical care.

 “But there are other ways to see it as well – for instance, poor staff morale also does nothing to help your health outcomes in the long term,” Mr. Anya says.

Nigeria’s health outcomes, by all accounts, demand improvement. In a 2017 study of global health care quality, Nigeria ranked 140th of 195 countries. Both patients and staff at public hospitals complain of the low standard of care, with institutions often missing equipment like x-ray machines as well as more mundane supplies like gloves, needles, and gauze.

And when workers in those circumstances feel no one in power is addressing those issues, “a strike often becomes the only way to get government to pay attention,” Anya says.

Turning people away

For Margaret Obono, who heads the pharmacy department at the National Orthopedic Hospital in Lagos, striking would never have been her first choice. But it was a response, she says, to the overwhelming frustrations of working in a hospital where she regularly had to turn patients away because she didn’t have the medicines they needed.

“No pharmacist wants to be the one to tell a patient treatment is not available [because of money],” she says.

Strikes have repeatedly roiled Nigerian hospitals over the past decade, mostly concerning pay, which many health workers say remains unconscionably low and inequitably divided between doctors and other hospital workers. Nurses and pharmacists generally earn about $400 a month, and unions say government has repeatedly backpedaled on agreements to raise wages.

“We have been waiting years for a salary adjustment that has never come,” says Biobelemoye Joy Josiah, chairman of the Joint Health Sector Union, which called the strike.

For its part, the government says it knows the health care sector is “troubled,” but says workers must be more patient. (Negotiations between the two sides are continuing this week in hopes of ending the strike.)

Shortages and bribes

To many Nigerians, meanwhile, the rot goes far deeper than anything a workers’ strike could solve.

Emmanuel Uwazuruike describes walking into a public hospital in Abuja in 2013 with his wife, who had just gone into labor. Before she had even been given a bed, the nurses on duty handed Mr. Uwazuruike a list – towels, gauze, sanitary pads, gloves. It was all the supplies he would need to provide for his wife’s delivery.

“But when I came back from buying everything, the nurses told me I must also give them some money, too, or they won’t deliver the baby,” says Uwazuruike, who works as a taxi driver. He handed over another precious fistful of Naira notes, and then the nurses disappeared, he says. Hours passed, he says, and his wife grew weak and listless. Finally, the doctor informed them that she needed an emergency C-section, and wheeled her off. 

A harrowing hour later, a nurse burst into the waiting room. He had a son, she said, a healthy baby boy. His wife was dead.

He never found out the details, he says, but he suspected that if the family had access to a better hospital or more attentive health care workers, it might not have happened.

“So I support this strike now, but I am also frustrated by our doctors and nurses, too,” he says. “And when they strike, it is ultimately the poor who will suffer.”

An unfulfilled promise

Like many Nigerians, he also watched in anger as, in the midst of the strike, Buhari once again left for England. During his presidential campaign in 2015, Buhari had promised to end the elite’s infamous “medical tourism” to richer countries.

“We will certainly not encourage expending Nigerian hard-earned resources on any government official seeking medical care abroad, when such can be handled in Nigeria,” Mr. Adewole, the health minister, said in 2016, speaking on behalf of the president at a conference.

“Most countries’ presidents use their own health care systems – it’s an embarrassment that ours doesn’t,” said Nelson, a cybersecurity analyst in Abuja, as he jiggled his young daughter on his hip outside the doors to a public hospital on a recent afternoon. (He gave only his first name over concerns about his family’s privacy).

Meanwhile, across town, the grounds of Abuja’s National Hospital, normally crowded with a cacophony of patients, visitors, and informal hawkers, were nearly empty. Inside the emergency ward, two young doctors played games on their smartphones, the only noise the hum and thwack of an air conditioner in the background.

The hospital was open, but without nurses, pharmacists, or other support staff, it could see only a few cases a day.

“Normally in a shift you’d see maybe 50 patients,” says Emmanuel Okeke, a junior doctor here. “Now we are seeing maybe five, so we worry – we wonder where the rest are going, if they’re going anywhere at all.”

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