Beyond Mistrust: Tweaking the Doctor-Employer Relationship

Friday, June 05, 2009

By Dr. Sodzi Sodzi-Tettey, General Secretary Ghana Medical Association

TetteyFollow the intrigues of salary negotiations between Ghana’s governments and the medical fraternity.  In Ghana and most African countries “health workers do not have any document that spells out the terms and conditions of their service” We at and IMANI have long argued, that access to health care cannot be a sanctioned human right when the basic infrastructures and reasonably well-paid doctors and nurses are non-existent. Add absence of good drinking water and good food and the real poverty profiling of diseases stare activists for free access to healthcare and health products in the face.

The proceedings of the last few weeks, starting from the industrial action of junior doctors in Komfo Anokye and culminating in the work-to-rule schedule adopted by the Council of the Ghana Medical Association (GMA) are a culmination of the mistrust that has come to typify the doctor/employer relationship.

More than the political motives read into it by some, justified somewhat by years of apparent silence on the doctors’ front only to take up arms on assumption of office of a new government, it is deep-seated mistrust that accounts for the recent industrial actions.

Throughout the GMA’s interactions with the Minister of Health, Hon George Yankey, I could not help noticing the two extremes from which both sides were approaching the issues. Initially not sufficiently appreciating the depth of mistrust developed by doctors for their employers/politicians over the years, the Honorable Minister would reel in shock when the truth finally dawned on him. He seemed to have taken it for granted that ensuring the prompt payment of 20 months arrears of fuel allowance, that good intentions and sweet political talk were more than enough to calm our front. The doctors, coming from years of lies, deceit and betrayal from their previous ‘masters’ were obviously in the mode of we have seen and heard it all before. 

In one brutal meeting with our immediate employers (Ghana Health Service and Teaching Hospitals), Dr Opoku-Adusei the Vice President of the GMA would drop the   famous quotable quote “We respect you but we do not trust you!”

In the event, I became convinced that the key to unlocking the present crises and laying a solid foundation for any future productive work was tackling this huge challenge of mistrust. Failing this, all labour unions in the health sector and the political/policy elite stood at perpetual risk of being imprisoned by a bitter past that would inevitably taint any promise held by the future. It really is to the credit of both parties, their ability to strike creative compromises for a phased-implementation that guaranteed immediate industrial harmony while adopting a framework for future collaborative work.

But I take it for granted that you are well versed in the fundamental issues fuelling the mistrust, a sin for which I intend to make amends shortly. To do so well means to take us back to the beginning of salary reforms in 2006 under the previous government. It is a story of how doctors have been lied to and deceived every step of the way with the resultant effect that today, the doctor is believed to earn what he does not with an unfortunate albeit entrenched public perception of their greed anytime they have raised queries about unfair labour-management practices. Doctors in turn have become frustrated at a seemingly unsympathetic public while developing profound mistrust for the politician.It is my intention to prove the basis for mistrust and to proffer suggestions on how to move this process forward if our collective integrity as leaders is to be safe-guarded.

2006 Negotiations

The GMA had absolutely no hand in the constitution of the government side of the joint negotiation team in 2006. For all practical intents and purposes, the selection of a team made up of Managers of the Ghana Health Service and the Teaching Hospitals some of whom were doctors was the uncontested decision of  government. The GMA really was not bothered who they negotiated with, confident in its negotiating position after its own exhaustive market analysis.

When the other health workers later kicked against figures based on their discovery of what was going to doctors, the least we had expected Minister Quashigah to do was to secure the integrity of his own negotiating process and simply examine the substance of the health workers’ concerns against the work done by the consultant appointed by government. Rather, the Minister of Health subverted the whole process by publicly  undermining his own Committee by among other things claiming that they had worked in a rush and tacitly lending credence to the accusation that the doctors had shared the chunk of the monies among themselves. We who had gone into the negotiation process with clean hearts and minds were now being accused of greedily apportioning all the monies meant for the whole sector into our insatiable bosoms.

You may consider this the first blood drawn.

Although negotiations ended in April 2006, it was not until June 2006 that implementation actually started.  But within those three months, a lot of interesting things happened. The doctors seriously agitated for the implementation of what they had negotiated. Other health workers had appealed to the National Labour Commission calling for equal pay for equal work, later corrected by the NLC to equal pay for work of equal value.

It was at this point that the government drew second blood.

Certain then pro-government newspapers suddenly came into possession of a so-called salary structure for doctors and published that doctors were going to earn in the region of 50-60 million old Ghana cedis. These were outright lies, but they succeeded on two fronts; tipping public opinion heavily against doctors which remains till today and tipping over the other health workers into industrial action. I would always maintain that the GMA made a tactical error by gagging itself, refusing to engage constructively with the public and not realizing that what was in progress was a fierce contest for the hearts and minds of the general public. Some argued that it would all go away. Today we still suffer its hostile effects. Today, even though the pay slip of the current GMA President, a specialist shows a take home of 1600 GHC, even probing neutral journalists find this hard to believe let alone the over 600 net income of the junior doctor. Of course it didn’t help that at the IEA Encounter, the NPP’s Presidential Candidate in answer to a simple question on NHIS challenges, would twist the sword by claiming that Ghanaian doctors are the second highest paid in Africa. Perhaps, he didn’t check on the Gambian situation.

This brings us to how the combination of third and fourth blood was drawn from the doctors. At the negotiating table in April 2006, GMA had adopted unambiguous positions on the broader conditions of service. The GMA also asked to know whether basic salaries being negotiated were inclusive of fuel allowance. The following answers were provided: “The government has not mandated us to negotiate on conditions of service but basic salaries only. We hope to engage you on the conditions of service by October 2006. Fuel allowance is not part of this basic salary we are negotiating.” The implication was that doctors and other categories of health workers would continue to receive their fuel allowance.

The October thing never happened and till date, very atypical of the norms of employment etc, health workers do not have any document that spells out the terms and conditions of their service; what happens for example to the doctor in Komfo Anokye working in the Tuberculosis Clinic who has developed tuberculosis of the spine and is running around paying heavy sums for his management? In this country, doctors have been known to die from infections caught from the hospital only to find that there was no provision in their conditions of service for their care.

What happened was worse. Sometime after the negotiation, our intelligence unit sighted a memorandum announcing a policy purporting to “monetize all allowances” including the fuel allowance! Following this the fuel allowance which we had been assured was not a part of our basic salary was unilaterally abrogated. Only God knows the amount of agitation and near-strike that got it reinstated two years later. That was not all. The negotiation created two new positions of senior specialists and consultants. At the time there were no doctors within the health service in those categories and the government side of the negotiation agreed that there was need to appoint qualified senior colleagues to these positions.

A few months after the negotiation, I came into possession of a letter signed by Ministry of Health officials “freezing all promotions in the sector.” From its date, it became obvious that it had been crafted on or around the time negotiations were on going. Good faith? Bad faith? You openly promise to promote my people and then freeze their promotions behind my back!

Fifth blood was drawn with its roots buried in the circumstances surrounding the signing of the Memorandum of Understanding. One would have thought that once an agreement was reached in April 2006, both parties would immediately put pen to paper and outline a decent process for orderly review of salaries and conditions of service devoid of industrial acrimony. The politicians were apparently not in a hurry. First of all, the immediate employers of doctors felt their hands tied with the antagonistic posturings of their Minister and would not sign. The matter was pursued to the substantive Minister. He would not sign. GMA followed it up to the Castle where we would again be given the run-around.

In the end, after two solid years what it took were threats and more threats and what I would say some dynamic leadership from Chief Director Alhaji Nurudeen Jawula. Almost at the brink of an industrial action, government summoned us to the Ministry’s conference room. Imagine my amusement on reaching there. Everybody who had had anything to do with the issue two years back was seated. In under two hours, the knotty points had been unraveled and the agreement signed.

It took us two years to sign what we eventually accomplished in hours!

Of course it was this MOU that stipulated that all sides remain quiet for two years before any talk of a salary review, an agreement which was followed with religious zeal by the doctors. Last quarter of 2007, doctors started reminding all parties of the need to kick-start the salary review process. We kept mounting pressure and followed it up at the NLC which then ruled in 2008 that by October 30, 2008 all discussions pertaining to salaries and conditions of service ought to be concluded. Did the rule-of-law people respect the law? Apparently not!  After a series of formal and informal approaches had failed to yield any useful response, the GMA held a high-profile press conference on the eve of the expiration of the NLC’s deadline. The next day, the politicians hurriedly scrambled us to the negotiation table with an agenda for salary review!

Today, we have agreed on a review effective January 2008. Arrears are to be paid in two tranches starting July 2009. We have also agreed to a time table that says by July 31st 2009, doctors and other health workers should have concluded discussions on terms and conditions of their service. To my mind, this should pave the way for the adoption of a Collective Bargaining Agreement that should bring some order to the chaos. Of course we would continue to engage constructively on the issue of the single spine salary structure.

National Labour Commission

Throughout all these, the attitude and actions of the NLC have been more hypocritical than helpful. They make rulings to affect us when we have sent no case to them. When we actually send a case to them, they prove totally helpless in enforcing two rulings faulting government for the illegalities involved in unilaterally abrogating the fuel allowance and in not abiding by the rules of engagement. When the storm breaks as it often does, they are often the first on air to label it illegal. Sometime last year, amidst serious agitations, despite copying them every single letter pertaining to these issues, they had the moral courage to announce on Citi FM that they knew nothing about it. Really? Recently, they labeled our work-to-rule actions illegal. What they conveniently forgot to add was that three weeks prior to the work-to-rule, GMA leadership had appealed for compulsory arbitration. Were the conditions that prevented them from arbitrating on the matter different from the conditions persisting at the time they judged our actions to be illegal?

I have never seen such hypocrisy in my life before. I hope the newly constituted NLC will act with greater circumspection and even-handedness.

Way forward

To move forward, it would be very important to take the best of whatever has worked in the past as we journey into the future. The public is tired of the chronic industrial tension on the health front, the GMA Council recently confessed ‘its unhappiness at having to adopt such measures’ and the political/bureaucratic leadership would like to be remembered for something other than bad faith.

This thus presents a unique opportunity for us all to apply ourselves to the process of building credible systems in which negotiations on salaries and conditions of service can be done with civility. In this fractious labour-management relationship, healing is only possible if all sides make a conscious effort to abide by the timelines agreed upon. In other words, we are hardly ready for any stories about Accountant General’s endless problems with computer software etc. By July, just pay our people as agreed upon and by all means, let the discussions on conditions of service begin!