March 18th 2010 Emily Spry: Doctors and Nurses on Strike

Here in Freetown, both the doctors’ and nurses’ associations have decided to go on strike with immediate effect.

The strike has been precipitated by the Free Healthcare Initiative, which is due to remove user fees for healthcare for pregnant and nursing women and children under 5 years old on the 27th April 2010, Sierra Leone’s Independence Day.
The issues behind it have, however, been brewing for a lot longer.

In the Children’s Hospital, user fees are low compared to many other Hospitals, although still prohibitive for most of the poor families who live in the slums around the Hospital.

Thanks to the contribution of Cap Anamur (German Emergency Doctors) and other partners, patients at the Children’s Hospital pay a one-off consultation free of 15,000 LE (3.8 USD). If they are admitted, drugs and other consumables (IV lines, dressings etc) are free, though many laboratory tests and blood transfusions are still charged for.

The Free Healthcare Initiative was announced by the President in November 2009 and is supported by donors and NGOs including DFID, Save the Children and various UN agencies. Since the announcement, a progressively more frenetic atmosphere has been building up at the Ministry of Health and Sanitation, the Ministry of Finance and in all health-related organisations across the capital. With six weeks to go to the launch, major decisions are still to be taken and many crucial issues are still to be resolved.

The plan is that all user fees for the three vulnerable groups are to be abolished. Huge consignments of drugs and consumables are being shipped in and will (inshallah) be distributed to the patients who need them. Salaries are to be raised for all staff, with incentives for hard-to-fill rural posts. Performance-based incentives are to follow next year.

So, what on earth are the doctors complaining about?

Firstly, doctors and nurses are extremely poorly paid, even by the standards of neighbouring countries, such as Liberia. Junior doctors, when they are fortunate enough to be “absorbed” onto the Government payroll after graduation, are paid around 100 USD per month.

I am paying 550 USD per month for a bedsit. Even taking into account the fact that I have the luxury of relatively constant light and water, and the inevitable “whiteman tax”, it is clear that living in Freetown is not cheap.

Moreover, the user fees actually contribute significantly to the doctors’ income at present. The consultation fees are put into a pool and shared out according to seniority. The Children’s Hospital medical officers get up to 200 USD per month from the user fees pool.

So, using this example, to avoid an income loss with the Free Healthcare Initiative, these doctors will need to be paid roughly three times as much as they are at present.

Moreover, it is the intention of this policy to substantially increase access to healthcare. In other words, there will be more patients and therefore more work. For a doctor who sees 40 or 50 patients a day in outpatients, this is not a very appealing prospect, especially if combined with a loss of income.

The whole initiative is brave and fascinating. There is consensus among those involved in the planning that it has already forced a lot of progress in the healthcare sector here that might never have happened otherwise. For example, cleaning the payroll of “ghost” workers and improving the process for absorbing new staff (previously many worked as “volunteers” for years, awaiting laborious process at various Ministries).

However, it is also a risky strategy and there is a lot of work still to be done, prior to 27th April and after the launch. The drugs may have started arriving in Sierra Leone, but if the doctors and nurses aren’t satisfied, I am not sure what will happen.