Reasons For The Doctors' Strike

By Kwabena Kusi-Mensah in JUNIOR DOCTORS IN GHANA

There’s been a lot of rancor from almost anybody who can grab a radio microphone or TV camera about this strike action embarked upon on 8th October 2011 by the Ghana Medical Association. Interestingly though, most people have not paused for even a second to ask: “but WHY are the doctors on strike?”...they usually just launch straight into the doctor-bashing bit of their tirades; can’t be bothered with such rubbish concepts as ‘giving the benefit of the doubt, innocent until proven guilty etc’. Well so for those of you who care to know, here are a four of the major reasons the strike was called for. Read and judge for yourselves...

You may have been hearing the charge “the current SSSS is ‘unscientific’” a lot from the GMA side of the debate. Well here is the reason why...

1. For the Single Spine Salary Scheme (SSSS), all jobs were evaluated based on a 13 point criterion to give some objective basis for the value to be placed on each job. Some of the criteria included things like level of training, level of experience (here's where the number of years you've worked comes in), amount of physical effort, amount of mental effort, hours of work, risk exposure etc. And in some of the categories, other people scored higher than doctors (e.g. the mortuary man scored highest in risk exposure, and also a Chief Medical Assistant (CMA) scored 15 points for level of experience while an MO (Medical Officer) scored about 5). Putting all the points together, a Chief Medical Assistant (a Medical Assistant is a person trained [for about one and half years to 4 years depending on whether the person entered training with a SHS certificate or a diploma from nursing school] l to perform simple, basic diagnostic functions and act as a stop gap measure for areas where there is no doctor) for example got 669, while the MO got 791. So the number of points you get determines where you'll be placed on the spine. Every level has a 'high' and 'low' so e.g. 20L and 20H. Interestingly by this scientific criteria (which THEY (FWSC) drew up) the Specialist (i.e. a West Africa Part 1 holder) was on 25H, the highest level, so our Senior Specialists and Consultants didn't even fit unto the spine...essentially meaning the value of their work was too high to be quantified by the SSSS scale. [And that, by the way, is another reason why people suspect they are just trying to adjust the scale artificially and basically squish the spine up for doctors to make us all fit onto it ‘by force’]. Well somehow, the FWSC published the figures after a couple of months after the negotiations and the Chief Medical Assistant had been placed on 22H and the MO at around 20H thereabout- two places below the Chief Medical Assistant who had scored just 669 compared to the MOs 791. When GMA protested and asked for an explanation why, no one responded. They wrote to Ministry of Manpower and Labor, FWSC, NLC, MOH, Office of the president, not even one letter was replied until the strike begun. And the explanation that finally came was: "they've worked longer". And of course GMA countered with "but that has already been captured in your evaluation! The Chief Medical Assistant scored much higher than the MO on the ‘level of experience’ criteria and yet the MO still outscored the CMA in the overall total!” So then they said it was due to "soft factors" and GMA basically asked, “what the heck is that?!” Then they came back and said "intrinsic factors", and GMA asked, "okay what are some of those factors?” No response. Up till now, nobody- not FWSC, NOBODY has been able to give a reasonable response or explain the rationale behind that anomaly. And that was how the first meeting between GMA and FWSC broke down last Monday...

2. After they used the 13 point criteria to calculate your base pay, they were supposed to calculate a second part of your pay called the MARKET PREMIUM. The Market Premium was supposed to be made up of 3 factors: the extra hours you worked (because SSSS was for every Ghanaian worker so it was calculated based on a Mon-Fri, 8-5pm, 40 hour work week, so all extra duty hours wasn't captured in the raw SSSS base pay); also your scarcity (i.e. how few/many your are, thus the demand for your services as per market forces) and one other factor called ‘Incentives’. They did this for everyone, valued it and added it to their base pay. For doctors however, they took out the scarcity factor (because they said that it was the scarcity that was resulting in our extra duty hours...which of course is highly debatable) and also the incentives factor (for no apparent reason and with no explanations), and left only the extra duty hours standing by which to evaluate us.

Now when they came to calculate our market premium based ONLY on the extra duty hours (unlike everyone else where they used ALL 3 criteria) they asked us to bring our proposal. So we did a survey and realized different doctors work different numbers of extra duty hours, so we calculated and struck an average which came to about 289 hours a month. The FWSC slashed it down to 201 (over here somehow decided to arbitrarily subtract the time we'll use to eat, the time we'll spend in transit to the hospital, bathing time, even our so called "conjugal time" (i.e. the time we will spend having sex with our partners) and subtracted it from the 289 hours we got. There was no objective/scientific basis for determining the time span for these randomly chosen activities (for example, how do they know how long each doctor can last during the so-called “conjugal activity”?!). We didn't protest. Now even with this 201 that was left, they went back in caucus and decided that “doctors are on physically present at the hospitals for only about 100 of those hours, the remaining time they’re on call and so we will pay fully for the 100 hours they’re physically present, and pay only 25% of the time they’re ‘on call’”. This worked out to roughly about 120 hours that they were going to pay for, in other words expecting the remaining 80 or so hours to be for free. No reasons where offered for why/how we were expected to work these 80 or so hours for free. We protested and protested...to no avail...

In addition to all that (so far as the Market Premium issue is concerned), when they settle on your extra duty hours, they're supposed to multiply it by a certain factor to arrive at the monetary value which they'll pay you for those extra hours. We started at around 2.1 or so but were prepared to make a concession of 1.62 with FWSC during the negotiations. When they came back with the final figures, it had been slashed to 0.81 for junior doctors and 1.0 for senior doctors. So GMA protested, and of course they didn't mind us. So when the strike started and we met FWSC, they brought the exact same 0.8 which had started the strike in the first place unchanged. Clearly they were not really serious about negotiating it would seem. So the GMA executives got agitated and enquired whether the FWSC was serious about negotiating at all. This was at the Wednesday 13th October 2011 meeting. The outcome of this meeting was reported to NLC on Monday 17th October, 2011, after which the FWSC and GMA were given another 48hrs by the NLC to try and broker an agreement. In fulfillment of this directive, GMA and FWSC met again on Wednesday, 19th October, 2011. At this meeting the position of FWSC on the market premium moved from 0.81 for the lower levels to 0.82 and then finally to 0.85. The upper level proposal was moved from 1.0 to 1.02 and then finally to 1.05. The GMA’s position was moved from 1.62 to 1.5 for upper levels and a proposal of 1.0 was also tabled for lower levels. Failing the ability for them to come to a consensus, it was at that point that the GMA said, "okay since we obviously can't agree, let us indicate in the minutes that we agreed to come down from our 2.1 to 1.62, you came here with the exact same 0.8 which caused the strike in the first place, then you moved up to 0.82, then to 0.85 and we rejected it all. Then let us both sign the minutes, and then release a press statement based on these minutes saying that we couldn't come to an agreement for these reasons". Mr. Graham refused to sign the minutes (which incidentally was taken by THEIR OWN SECRETARY AND LAWYER!) and walked out of the meeting in anger...

3. As per the rules under single spine, every 5 years everyone is supposed to be promoted (unless of course you do something really horrible not to deserve that promotion). Now on the Nurses track and everyone else's track, their promotions came with multiple pay leaps, sometimes 2 or 3 places leap forward. So for example, after 5 years a nurse could leap from say 20H to 22L pay grade. But for doctors, the leaps were strictly in only half bar increments...so from 20H to 21L after 5 years. And when GMA asked Graham Smith why (in the words of one of the GMA executives) "the nurses where galloping along the nation's spine and doctors were being made to crawl inch by inch", again, no reasonable explanation was offered talk less of a scientific one... All they said was that doctors are “already skewed towards the top”. Again, the GMA felt that was totally unscientific, unobjective and unacceptable as a reason for this unfair treatment.

4. A District director of Health was not originally captured on the SSSS. When they realized this, the FWSC hurriedly and arbitrarily decided to just fix the DDHS at the level of a consultant (without any job evaluation as per the 13 point criteria used for everyone else). And the practice is that, any Health worker can become a DDHS...nurses, Lab Technologists etc. So the GMA protested that that was neither a fair assessment nor a scientific one, and made the counter proposal that, it was okay to let any health worker become a DDHS, but that they should go there with whatever pay grade they are currently on, and then have a special package for being a DDHS added unto that pay. So that if a PNO for example at say grade 22H becomes a DDHS, a fixed package is added to that pay for her being a DDHS. If a (medical) specialist at 24L becomes a DDHS, in the same way the same fixed package is added to his pay. When he/she steps down or is sacked or whatever, he/she stops receiving the special package and goes back to his original salary. Because, the argument was made that, in any case, that is what is done in EVERY OTHER SECTOR of our economy! So for example, the Vice Chancellor of any public University doesn't have a change in his salary. He receives whatever he was getting before at whatever level he was, and an extra package is added unto his pay for being VC. When he vacates that post, he leaves that extra package behind. So it doesn't make sense that in all the other sectors, in all the Ministries, that is what is done, but suddenly when it comes to Health they want to do things differently. Again, they totally rejected the proposal and good old Mr. Graham Smith and his cohort could provide absolutely NO REASON why....

As for the Counsel of State fiasco:

The GMA went there as per their invitation, only for the CoS to start chastising them even before they had spoken. Meanwhile some of the members of the CoS had gone on air the night before and totally condemned and rubbished the strike, when they KNEW they had a meeting with the GMA the following day. So after the chastisement, Dr Adusei (the GMA Veep) stepped in and finally explained in detail all the reasons for strike. The CoS was silent after that...they couldn't say a single word back. So the chairman just told them that they would talk to the President and try to resolve the issue.

So after about 24 hours they called the GMA executives that they wanted to meet them again. So the GMA executives were quite happy thinking there was finally a break through. Only for them to get there to be told that they had been unable to reach the President. And then they told them (with a subtle hint of intimidation) that it was a losing battle GMA was fighting and that they were going to be forced into compulsory arbitration at the NLC and that once it got there, they would be breaking the law by not calling off the strike and so would all be liable for jail time.

So the GMA Execs just thanked them for their "warning" and just left the place...only to meet the journalists outside (before, the media had been invited by the CoS to sit in on the meeting but the GMA protested and insisted on the media men leaving the premises which the CoS agreed to). So Dr Adusei was surprised and asked one camera man "ah, are you still filming" only for them to report that he had assaulted a media man and refused to let him film...

So far the GMA has also met the following groups of bodies, showing clearly that if anybody is more than willing to dialogue and compromise, it is the GMA: 1. Ghana Conference of Religious Bodies for Peace on Monday, 17th October, 2011 2. The Parliamentary Select Committee on Health on Tuesday, 18th October, 2011 3. The Council of State on Wednesday, 19th October, 2011. It is worth noting that all these bodies have promised to facilitate the resolution of the issues as soon as practicable.

It is interesting to note that underlying this clearly unfair treatment to doctors is this notion that "healthcare is a team effort, and as such all members of that team are equal and should therefore be rewarded more or less the same". I beg to differ. I make the counter argument that, fine, if healthcare is a team effort and "we are all part of the team" and so are all equal, then are hospital drivers not part of that team? How about cleaners? Pantry workers? Health Extension workers? How will the Director of Nursing for example feel if we decided to pay the "chief Cleaner" who has served for 30 years, more than her because she has served only say 20 years? Would she protest (and rightly so) because her level of training, and the sophistication of problems she is trained to solve is far higher than that of the cleaner or the driver? Does anybody now understand the frustration the Medical Doctor feels when he is being ranked below the Medical Assistant, Nurses and other health workers? Since the strike begun, ALL other health workers are at post (including the Medical Assistant who has been ranked higher than the Medical Doctor) and yet the healthcare system has essentially ground to a complete halt. One CEO of a public hospital is reported to have lamented that if this strike continues for another week, he will be unable to pay the hospital workers who are paid from the hospital's Internally Generated Funds. So who then is the health worker that can mainly (note: I said 'mainly' NOT 'exclusively') be credited with generating revenue for the healthcare system? Perhaps we should heed to the submission of certain so called "social commentators" and journalists out there and let the 'experienced' senior nurses and Medical Assistants simply take over the running of all our hospitals and just stop training doctors (its far cheaper to train them anyway compared to doctors, since our "economy cannot support doctors") since by their assessment, these other health workers can do the same thing doctors do anyway- let’s try that and see how high the mortality rate in Ghana climbs, and THEN maybe people will begin to appreciate the value of doctors.

And one more thing, just for the record I would like to reiterate a point made out there by some of our noble colleagues about the training of doctors in Ghana. Nobody buys stethoscopes, textbooks, lab coats or any other equipment for ANY medical student in Ghana! We buy them ourselves! And the cost the we incur personally so far as our education is concerned- the Academic facility user fees, the residential facility user fees, the fees we pay for exams, our feeding, textbooks, handouts etc- by far outstrips the tiny subsidy per student the government is supposed to pay for a medical student's training (which in any case is paid for ALL publicly educated university students)!

Please, if we are going to have a civilized discourse as a nation let us have one by all means. But enough with all the lies, spin doctors and propaganda. Let us make the facts clear for all to see, and then let us have our conversation from there. And that is what this article is all about.