Unpacking junior doctors’ strike – What are the issues?

Collective, organised, cessation or slowdown of work by employees to force acceptance of their demands by the employer is commonly known as a strike.

In 2016, English doctors staged their first strike in 40 years over government plans to reform pay, conditions of service and working anti-social and dangerously long hours. This shames our own scenario where strikes by junior doctors are now a frequent occurrence.

December 1, 2018 marked the start of yet another strike, this coming hardly six months after the previous one in March 2018 and another around the same time in 2017.

We are now getting into the third week of the strike confirming a significant escalation in the dispute with government.

Technically the strike has no time frame and could go on for as long as no agreement is reached.

This is hurting the economy and our people. Junior doctors form a critical component of the health delivery value chain in public hospitals especially. Their absence breaks this chain.

A junior doctor is a qualified medical practitioner working whilst engaged in postgraduate training.

The period of being a junior doctor starts post qualification as a medical practitioner following graduation with a Bachelor of Medicine, Bachelor of Surgery degree and start the internship programme.

After completing two years internship and one to two years in a district hospital one can get an open practicing certificate which allows them to work in private or even outside the country as a General Practitioner (GP).

Junior doctors have gone on strike over sub-standard conditions, including poor working conditions, low salaries and shortages of basic medicines and equipment.

Most of these have been outstanding for a long time and could be related to poor performance by the previous minister of Health who should have done better in view of his long stay at the ministry.

The lack of drugs and medicines and lack of appropriate equipment has complicated issues. This has been the case over the past twenty years and no immediate solution is in place for these operational challenges.

On-and-off talks over the past years have failed to produce final agreement with the backing of Zimbabwe Hospital Doctors Association members, a grouping representing junior doctors.

The doctors are disgruntled over their salaries eroded by the hyper-inflation gripping Zimbabwe in the new dispensation era.

They argue their salaries are almost worthless and demand salaries in US dollars as stipulated in their contract of employment. Government acknowledges this but simply does not have the capacity to pay in US dollars.

They are also demanding an improvement in working conditions, incorporating protective equipment at work and that their locum allowances are paid.

The introduction of non-medical chief executive officers at health institutions is another issue.

They argue that their lack of medical knowledge is exacerbating their working conditions and that that non-medical personnel running hospitals are not only incompetent but also corrupt contributing to confusion and stock outs of critical consumables.

The doctors accuse government of failing to procure adequate hospital equipment and essential drugs to allow them to provide quality service to patients at district and central hospitals.

They also complain over poor salaries compared to their counterparts in the region.

It is argued that a junior doctor earns $369 per month before allowances increasing to almost $750 with allowances confirming they are not a priority for government.

Nearer home in SA an equivalent doctor earns about $2 500 and in the USA and UK $4 400 and $2 800 to $3 250 respectively. Our present economy cannot sustain these levels but more can still be done even under present difficult times.

Doctors are calling for government to lift the blanket freeze on recruitment of health workers with immediate effect to alleviate staff shortages. This has caused doctors going for 36 hours without proper sleep. The major demands are:

1. Payment of salaries in United States dollars (USD) — This has since been dismissed by government owing to lack of foreign currency. The evidence is fuel queues, shortage of medicines and drugs and other challenges relating to imported essential goods.

2. Salary increments to match the higher cost of living even in RTGS (Real Time Gross Settlement) — Again, government says insufficient funding makes it impossible.

3. Medical supplies and obsolete equipment — Government says some few medications and drugs have been secured at National Pharmaceuticals (NATPHARM) while the USD $25 million consignment from India is being awaited.

Consumables like gloves, syringes, strapping and protective clothing are reportedly mostly unavailable making their work environment frustrating and unsafe exposing staff to infections. Drugs are unavailable including basic painkillers like paracetamol and antibiotics like amoxicillin which burdens doctors as minor ailments end up complicating.

4. Review of On-call allowance — Government has failed to honour its promise to increase on call allowance to $10 per hour as agreed in 2014 after yet another strike.

In 2014, government promised to increase on-call allowance from $288 to $720 monthly and is still outstanding. It was increased from $1.25 to $7.25 an hour in May 2018 following another strike.

5. Maternity leave to be paid regardless of time served in government — government is agreeable and the ministry of Labour and Social Welfare is in the process of acquiring proper legislation.

6. Duty free import of vehicle — Doctors had requested that they import vehicles using their own funds but be exempted from paying duty as is the case with senior government employees but nothing has been agreed.

7. Vehicle Loan Scheme — Dates back to the colonial era when doctors were able to access brand new vehicles from Willowvale via loans offered by government through CMED. This facility no more exists. After the March 2018 strike doctors were availed funds to buy ex-Jap second hand vehicles starting September 2018 at approximately $10 000 RTGS per doctor in which only 10 percent of them participated although $1.2 million of this remains unutilised. The doctors cite inflation. Government says the funds are still available and ready for release.

8. Contract extensions for some health professionals — government agree.

9. Long working hours — The freezing of posts has contributed to long working hours. The doctor to patient ratio is too high. Government has however, allowed the unfreezing of 402 Nurses posts to help with improving health staff shortages.

10. Donor funding — apparently discussions are underway with a possibility of the money coming in the form of United States Dollars.

11. Non- monetary incentives — This includes stands, houses or flats. Over the years not much has been done about this issue despite doctors’ requests. It is something this government should give more serious attention.

Doctors remain adamant that this situation could be avoided only if government got its priorities right.

They cite the purchase of brand new vehicles for chiefs, the purchase of new vehicles for district intelligence officers while district medical officers are not treated the same way.

Executive perks for ministers, directors, permanent secretaries seem to be government’s priority at the expense of critical areas like health.

The Zimbabwe Hospital Doctors Association secretary general Dr M.A Bhebhe sums up the current impasse by urging doctors to keep pressing on with the strike and not take heed of threats of dismissal by the employer.

Some of the grievances have been outstanding for a long time and it is important some resolution is reached. The doctors are of the view that failure to address issues and threats confirm desperation to get them back at work.

The doctors are in the process of making sure districts, provincial hospitals and possibly nurses and other healthcare provision staff join in.

Yes, previous strikes have ended up in some kind of compromise before it can still repeat. A compromise deal must be reached in the interest of the general public.

It is them who are most affected by this. Government must negotiate in good faith and so should the doctors. Let us focus on issues and not politics.

Minister of Health Obadiah Moyo has made some effort and this is acknowledged by the Zimbabwe Hospital Doctors Association but it simply has not been enough. The extended length of this strike at short notice ramps up the dispute limiting government’s contingency plans.

The most affected hospitals are Parirenyatwa Group of Hospitals, Mpilo Central Hospital, United Bulawayo Hospitals, Harare Central Hospital and partly Chitungwiza Central Hospital. In short the direct effect will be unnecessary deaths.

The Health Services Board needs to be more visible and pursue long lasting solutions.

The minister must impress on the importance of healthcare delivery. His open door policy is acknowledged but resources must flow in to address the situation in its entirety.

The target of allocating 15 percent of the national budget to health as per Abuja agreement was missed. Doing so would make the minister’s job easier.

Zimbabwe has over the years failed to meet this benchmark although the allocation in the latest 2019 budget is the highest healthcare ever received at almost $700 million (nine percent). With Abuja health should be $1.2 bn instead of $700 million.

Our per capita health allocation stands at about US$41 in 2019, up from US$31 in 2018. Sub Saharan Africa’s average spending on healthcare is 13 percent but countries like Rwanda allocate 23 percent.

The challenges of foreign currency availability feed into medicines and drug supplies and ultimately their pricing.

These together with equipment and skills are moving targets needing constant attention.

There are reports that the minister has met with ZHDA, Health Services Board, ZIMA and Apex Council. Issues of car loans, fuel provision and medicines are agreed. There are also reports by the Zimbabwe Medical Association that negotiations were moving in a positive direction. Other reports talk of senior doctors joining in.

The new minister has an opportunity to correct past mistakes by his predecessor and lay a strong foundation to ensure strikes in the ministry are a thing of the past.

Are the doctors themselves split over the strikes?

It is not clear but what is clear is that strikes that have no timeframe are unfair to the public although this view is open to “long and difficult debates.” Early warning makes things easier and draws public sympathy. Short warnings have the opposite effect.

The following statement by the ZHDA secretary general Bhebhe sums it up.

“We also want to communicate to some cadres who have been going to work nicodemously sympathising with the employer’s methods to heed to the call by fellow Doctors. They are feeding on the hope that few might return to work and the fact that our seniors are dragging in their efforts to join the struggle. You are giving them hope and room to say such nonsense”

This suggests not all are on board. The right things must be done. Both parties must act in the best interest of the public. The position by ZIMA suggests a strong desire to negotiate an agreement.

Not immediately but progress is reported although there is talk of doctors going to the streets and senior doctors joining.

The government shows signs of acknowledging the existence of challenges that are driving the dispute but has no capacity to address them immediately.

It could take another 12 to 24 months or slightly longer before all the issues are resolved. We assume the Transitional Stabilisation Programme (TSP) which focuses on addressing the fiscal deficit delivers.

While for now the doctors might enjoy public backing in their fight with the government, they could risk squandering that support and angering patients by escalating the dispute.

For his part the Health minister may hope to exploit divisions in the ZHDA over the wisdom of strike action to force the junior doctors to back down. What the public wants is an honest and amicable solution to this crisis.

Whatever the grievances, junior doctors should continue to provide cover in settings that provide life or death care, such as accident and emergency, intensive care, maternity services, acute medicine and emergency surgery.

Doctors should never walk out from emergency departments.

We call on politicians on both sides of the aisle to refrain from poking their fingers in this genuine action so that focused and useful dialogue takes place between government and the junior doctors in search of a lasting solution.

Memories of the nurses’ debacle are still fresh in our minds.

• Gwinyai and Majongwe are from Health Decisions Consulting (Pvt) Ltd. DailyNews