Doctors’ strikes don’t have to be deadly
Medical staff are tired of working in dire conditions and having to preside over death
Kenyan health workers may be gearing up for a second strike in less than two months. Strained health budgets in countries across East and Southern Africa could lead to this kind of industrial action becoming more common as workers fight to balance their rights with those of their patients.
A March agreement between government and the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) put an end to a 100-day strike by doctors and nurses that paralysed the country’s public health sector. As part of negotiations, government agreed to recognise the union and grant doctors salary increases of between 40% and 50% — according to the union the average salary of a Kenyan doctor before the increases was about R18000. The health ministry also said it would implement a 2013 deal that promised more public-sector jobs and a 2% annual increase in funding for health departments within 60 days.
But almost half this time has lapsed and doctors have still not been paid, says Alex Thuranira, secretary general of the Nairobi branch of KMPDU. According to Thuranira, more than 1400 qualified doctors remain unemployed — World Bank data shows that Kenya had just over 8 000 doctors in 2011.
He argues that empty promises may force the union to prepare for a second round of strikes.
“There is still time for the government to act, but if they have not done anything when the 60 days are up [in mid-May], expect a crisis,” he warns.
Considered as essential service providers, health workers are legally prohibited from striking in many countries, including Kenya, Zimbabwe and South Africa. But tight budgets and dire working conditions have resulted in industrial action by these workers in all three countries in the past decade.
In February, Zimbabwean doctors contested the country’s shrinking health budget and demanded a salary increase of almost 150% during a three-week strike. Doctors returned to work before their demands were met in an effort to curb rising deaths as a result of the strike.
Government also agreed to create 260 new posts in the health system to accommodate new junior doctors. But these posts have been funded only until the end of 2018, according to Zimbabwe Hospital Doctors Association president Edgar Munatsi, who says healthcare is still not a priority in Zimbabwe.
In 2001, African Union countries agreed to allocate at least 15% of national budgets to health as part of the AU’s Abuja Declaration. Zimbabwe allocates less than 7% to health. The department received $281.9-million as part of the 2017 budget, but Minister of Health David Parirenyatwa reportedly told senators in February that he needed $1.3-billion annually to fund health services.
Munatsi argues the country has to prioritise health or risk losing doctors to better pay and working conditions in neighbouring countries.
He says the government needs to create opportunities for the development of doctors. New medical graduates, who have completed state-mandated internships, are not absorbed into the system to specialise.
A lack of opportunities for recent graduates is also part of Kenyan doctors’ frustrations.
In 2013 Kenya’s health service was decentralised in an effort to increase access to health care. Health service delivery became the responsibility of counties, but policy and capacity building remained in the hands of national government.
Now, doctors are being governed by counties that do not understand the importance of human resources in healthcare, argues Nelly Bosire, a former KMPDU official.
Thuranira alleges the decentralised Mia Malan miam@mg.co.za or @miamalan Laura López González laural@mg.co.za or @llopezgonzalez Adri Kotze adrik@mg.co.za or @adrikotze Ina Skosana inas@mg.co.za or @inaskosana system also makes doctors vulnerable to discrimination in a country in which ethnicity is often used to further political agendas.
Thuranira explains: “Before devolution, doctors who completed their internships would be posted at a specific hospital. Now, doctors apply to a county that could reject your application based on ethnicity, leaving many doctors jobless.”
Health workers say this could be the reason for the country’s healthworker shortage.
Trauma doctor Onyimbo Kerama remembers his time as one of two doctors in a public hospital in Kenya where he was responsible for 100 patients daily. “There was a pregnant mother who came to the hospital. The distance she had travelled was shocking. She did not want a caesarean section and there weren’t any doctors to help her give birth. By day three the child was dead. All we could do was make sure the mother was fed and comfortable.”
Kerama chose to leave Kenya because of poor working conditions and now practises in the Democratic Republic of Congo.
The Kenyan government allocated just over $588.8-million to health in its 2016-2017 budget. This constitutes just over 3% of the country’s national budget. Although health budgets increased by 2.2% from the previous year, Bosire says it is not enough to address the management and human resource crises.
The Zimbabwean and Kenyan ministries of health could not be reached for comment.
The conditions fuelling recent strikes are unlikely to change but the South African Medical Association (Sama) says a minimum service agreement to allow doctors to provide a basic package of medical services while striking could help workers to keep patients safe while advocating for their rights.
South Africa’s 2009 health-worker strikes brought the public sector to a standstill in part because the country had failed to implement a 2007 agreement called the Occupation Specific Dispensation, to increase the salaries of specialist workers. As part of negotiations, Sama was adamant that the health department concede to a minimum service agreement.
But, says Sama chairperson Mzukisi Grootboom, the government did not entertain the conversation.
He explains: “Doctors are advocating for their patients, not only for themselves. There’s always a tension between your responsibility as a doctor and your rights as a citizen.”
Healthcare workers eventually returned to work after the national health department agreed to pay salary increases promised under the Occupation Specific Dispensation.
South African national health department spokesperson Popo Maja says such an agreement would have to be legislated. He says unhappy doctors should not strike, but rather opt for mediation and arbitration by an independent commissioner or approach the courts.
Russell Rensburg is the health systems and policy manager at nongovernmental organisation Rural Health Advocacy Project. Like Grootboom, he argues that South Africa needs a minimum service agreement to protect patients during future negotiations.
Rensburg warns that the country’s next labour dispute will likely come as a result of austerity measures.
In January he told Bhekisisa that, although provincial health budgets have almost doubled in the past 15 years, they have not kept pace with the rising cost of employee compensation. He argues that this has led to fewer health posts as provinces try to contain costs with official or unofficial hiring freezes.
Rensburg warns that South Africa’s health budget will not be able to accommodate further increases for health workers.
In Kenya, as tensions mount and clinicians question whether another strike will happen, the country lacks the kind of minimum service agreement needed to safeguard patients.
Thuranira says the union will push for such an agreement if the strikes continue.
Strained negotiations during the 100-day strike have left the government sceptical of any suggestions from the union, he says, making this potentially life-saving agreement unlikely.
Bosire says health workers had a minimum service agreement in 2011 but that striking doctors believed it undermined efforts. “We are dealing with a cold-hearted government. If they think they can cheat the public into thinking some level of service is provided, the industrial action will have no effect.”
A strike is always the last resort, Bosire says.
“It hurts to know one of my patients couldn’t have her chemotherapy because of the strike. It’s not about the money, but about a functioning work environment. We are tired of presiding over death.”