NEOLIBERAL REFORMS IN THE HEALTH SECTOR AND TRADE UNIONS’ RESISTANCE
A Critical
Perspective on the Deepening of PPPs in Nigeria and Union Response
by Baba Aye[1]
Introduction
The past decade has witnessed reforms in
the health sector, at the heart of which has been a systematic ingraining of
neoliberal values, methods and thrust by the government in the framework of the
national health system. The trade unions have responded to this in several
ways. There have been quite some successes, won through struggle and
established with creative strategies and tactics. A number of challenges do
however remain.
With
a focus on the phenomenon of Public Private Partnership, this brief paper would
attempt to: locate the situation in the health sector within the broader
context of attacks on public services; identify critical elements of the
state’s offensive on the soul of public healthcare delivery; presenting trade
union responses, and; discussing the challenges and potentials before trade
unions in the sector.
Crises and the
enthronement of the “for profit” god in the 20th century
In the aftermath of decolonisation, great
premium was placed on the provision of public services by the new, native
rulers. This was particularly so with the social sector: health and then
education. Internationally, the dominant ideology of state intervention (as the
welfare state in Europe and North America) supported this as some form of
modernization.
Things
changed in the wake of the “neoliberal counterrevolution”, which itself was the
bosses-class’ response to the mid-1970s systemic crisis of capitalism.
Globally, 1978 marked a contradictory moment in humankind’s. On one hand was
the Ala Ata Declaration. On the other hand was the emergence of Ronald Reagan;
the flagbearer (along with Margaret Thatcher) of neoliberalism.
In
Nigeria, both elements of that movement played up half a decade later with the
Prof Olikoye Ransome-Kuti’s turn to prioritising primary healthcare delivery on
one hand, as Minister of Health while the Head of State, General Ibrahim
Babangida introduced the IMF and World Bank-designed structural adjustment
programme. Within a decade, it was clear in Nigeria and Africa as a whole that
the SAPs had failed generally and with regards to the health sector.
This
was the context for the launching of the UN Special Initiative on Africa
(UNSIA) in March 1996 “with a view to strengthening country-driven strategies
as the primary basis of donor assistance” with its “health sector
component…aimed primarily at coordinating the resources of the United Nations
system and and other health development partners (supposedly) to accelerate the
development and implementation of comprehensive health sector reform programmes
in African countries”[2]
(Lambo and Sambo 2003).
Interestingly
though, in determining the contextual factors for the need of health reforms
based on the UNSIA mandate, lack of economic resources ranked the least with 10
points (apart from “others” with 3 points), whilst “Health Services and Systems
(e.g. inequities in access, poor quality of services, inefficiencies in the
running of facilities, inadequate community participation, poverty/access,
existence of vertical programmes, uncoordinated service delivery by providers,
lack of drugs and supplies, inadequate financing, poorly motivated health
workers, institutional weaknesses, health systems not responsive to consumer
needs)” came tops with 33 points.
As
is the usual case with the ideologically driven agenda which neoliberalism is,
the international financial institutions and local bosses-class insist that the
remedy for our social ailment is more of the drugs that caused such in the
first place. Continued expansion of the for-profit
motive into social services, and in this particular case healthcare
delivery was presented as the solution. A major excuse was and continues to be
the need for bringing in more resources, which even from their findings is not
necessarily true, especially in resource-rich countries like Nigeria.
More of the same
in the 21st century: the different shades of PPP
Matters were not to get better in terms of
this policy direction. On the contrary, the spin doctors of profit before people got even more
sophisticated in delivering what essentially is a flawed, if not nonsensical
logic. As with the beginning, policy was the point of departure, both for
initiating and furthering the neoliberal agenda.
At
the turn of the century, NEPAD set the context for the formulation of the National
Economic Empowerment and Development Strategy (NEEDS) in Nigeria. Their NEEDS
was launched in 2003. Two years later, after eight months of “consensus
building” the Federal Ministry of Health’s National
Policy on Public Private Partnership on Health in Nigeria was issued in
November 2005. It was of course part of the NEEDSful agenda of the state to
foster private interests of the bosses, subsidised from our collective
patrimony.
It
is instructive to point out an ideological fraud in the very definition of “the
partners” assumedly envisaged for the PPPs in this policy. The public partners
are restricted to the executives and legislators at all tiers of governance
(including health parastatals as part of the executive bodies). But regarding
“private partners”, enterprises, chambers of commerce, labour unions, faith
based organisations, NGOs, philanthropists, club/societies and other civil
society organisations and cooperatives are lumped together as if water and oil
do mix. This fraud becomes clearer when we note that virtually everywhere the
PPPs have been well instituted, the labour unions have been attacked with the
kind of ferociousness that “partners” are quite unlikely to use in relating
with each other!
The
document also goes ahead to divide PPPs into two broad types: public-driven PPPs and private-driven PPPs. The two major forms
of public-driven PPPs in the sector have been facility management and outsourcing.
Private-driven PPPs in the main entails the establishment of new health
facilities that generally cost an arm and a leg in fees, making them to all
intents and purposes inaccessible to the poor working people. The irony of
things though is that thus far, most efforts at building such private-driven
PPP facilities have been much more of failures than even the demonised public
healthcare delivery system.
In
justifying the need for PPPs, the Federal Ministry of Health (FMoH) argues that
“(a)nnual public sector budgetary allocations to health are low, and often fall
below what is recommended by WHO”. Coming four years after the Abuja
Declaration of African Heads of States to dedicate not less than 15% of
budgetary provisions to public health, this is justifying the indefensible,
mores so as countries with much less resources like Rwanda for example, have
met this target.
It
goes ahead to note that “(i)n addition, actual expenditures often do not even
match approved allocations, as a result of bureaucratic and other barriers”.
One could very well read “other barriers” to mean corruption. Much more naira
than what is needed for full public funding of universal health coverage has
been looted by the bosses from the state’s treasury. So the problem really is
not so much lack of resources as that the system is designed to make the rich
richer by any means and the poor poorer by every means.
Outsourcing
by the FMoH goes by the euphemism of “financing options” and its policy on PPPs
set the stage for outsourcing in the following years, which we now still
confront.
For
efficiency gains, it identified the
following “Non-clinical Support Services” for outsourcing:
a.
Mortuaries
b.
Security
c.
Laundry
d.
Maintenance
of clinical equipment
e.
Amenity
wards
f.
Catering
g.
Cleaning/Ground
Maintenance
h.
Ambulance
i.
Engineering
maintenance
j.
Record
keeping
k.
Revenue
collection
l.
Administration
m.
Information
technology and technology transfer
Unfortunately,
the Nigeria Medical Association has been a croaky voice calling for the sphere
of this outrageous PPP to be expanded. It has continually learnt its support to
furthering the outsourcing of Supportive Clinical Services, particularly (radiological
and laboratory) diagnostics[3].
And more recently, it went the whole hog of supporting, going beyond support
for outsourcing to calling for full privatisation of some public health
facilities, supposedly so as to curb “medical tourism[4].
A
major reason why the medical and dental practitioners’ positions on this matter
is quite akin to those of the bosses in general is that as the (self-)
perceived bosses in the sector with
interests in the private sector, they tend to benefit from a widening of “private
public partnerships” with a leg in each leg of the partnership’s pair of
trousers.
Outsourcing
has resulted in job losses. In the Federal Health Institutions alone, over
33,000 jobs have been cut as a result. The jobs supposedly “created” with contract
staffing in different forms are not only much less, the wages and working
conditions of contract staffers are terrible to say the least.
Lives
have also been lost and the convalescence of several patients undermined. A
good example is the National Hospital Abuja, which is presented as the
country’s “apex healthcare facility”. Private sector caterers and hotels which
took over the work of the dietary and catering departments had to be changed a
number of times. This was because, in the absence of trained dieticians
generalised food would be served with dire, and a couple of times morbid,
consequences.
Trade
union rights are also compromised. Not only do the labour contractors refuse to
allow casual staffers to be organised, in “public” hospitals under private
facility management like Garki Specialist Hospital in Abuja, trade unionists
were sacked and the union banned. In these circumstances, managerial
unilateralism become law.
While
it is easy to condemn public healthcare facilities, such private-driven PPPs as
the establishment of new healthcare
facilities have more often than not floundered. The American Hospital which the
Association of Local Governments (Chairmen) of Nigeria (ALGON) was at the heart
of is yet to take off even the construction stage, five years after, despite
the commitment of N4.5bn to the “project”. Corruption is not strictly a public
sector affair. And indeed, even in the public sector, corruption is mainly
perpetuated by the bosses and it takes a virile trade union movement within the
publics to curtail such obscenities.
Similarly,
we are yet to see much done regarding the Cross River State Referral Hospital.
When the PPP agreement was signed by the state government with UCL Healthcare
Services Ltd, an international consortium two years ago, we were assured that
the facility would be ready by 2015. That year is coming to an end with hardly
anything to show for it.
Privatisation
by dispossession appears to be more attractive than building (and those –even
if on arguable terms, expanding)
healthcare delivery infrastructures. An ongoing case is that of the
privatisation of 1 specialist hospital, 10 general hospitals and 523 primary
health care centres by the Imo State government. When workers resisted last
month, occupying the facilities, combined teams of police and military
personnel were sent in to dislodge them. But the unions have persisted and a
reversal has for now been won.
Union response
The trade unions have been at the fore of
the fightback against privatisation in the health sector. This has been mainly
on the platform of the Joint Health Sector Unions (JOHESU) which was formed in
2008 and comprises 3 PSI (and NLC) affiliates and two other unions which are
both TUC affiliates. The formation of JOHESU that year was, at least in part, a
result of the sabotage of a campaign of resistance by PSI, from within the NCC,
in 2005.
In
a number of health facilities local JOHESU chapters have also been formed over
the past four years. With central coordination, they have been of great
importance in mobilising joint action against privatisation and other
anti-worker policies at the base.
In
terms of policy engagement, the national body of JOHESU successfully led a
struggle against the passage of the National Health Bill in a manner that
reflected the “professionist” chauvinism of medical and dental practitioners.
The National Health Act that was eventually passed entails a more balanced
essence, albeit with compromises on all parts. It has also aptly utilised the
mechanisms of collective bargaining and the law courts (National Industrial
Court of Nigeria) to win significant victories¸ which the state however refuses to heed.
Regarding
its anti-privatisation stance, JOHESU and its member-unions have been quite
vocal, but a more systematic approach is required. This should include in depth
research work on both the state of privatisation in Nigeria and the
construction of alternatives and a campaign thrust of work that would entail
the forging of alliances with the broader labour movement of sister trade
unions and civil society organisations.
The
Imo State experience is most likely a tip of the iceberg. The time to take
decisive actions for an all-out research-propelled and mass based
anti-privatisation struggle is now.
In lieu of a
conclusion
The expansion of neoliberal values,
policies and programmes of the bosses in the health sector cannot be separated
from the broader avalanche of assaults against the working class nationally,
continentally and globally.
Despite the self-evident failures of privatisation in its different guises, commercialisation and (within the broader social-economic system) deregulation, policies keep being rolled out on the basis of the same anti-poor working people’s basis, within and across countries.
Policies
have to be engaged and counter-policy policy influence established. But, while
this is necessary, it might not be sufficient. Building JOHESU was a major step
forward for working class’ resistance within the sector. Possible mergers of
unions could be a reasonable consideration for this movement to be stronger.
While
we should continue with the element of interpretation (i.e. the law courts), determining what ought to be and should be i.e.
anti-neoliberal policies which alone can lead to universal health coverage has
to be a major focus of JOHESU’s activities.
There
are great challenges but also obvious potentialities for progress. It is stil
morning yet on creation day.
[1] Being a leadoff
paper presented for discussion at the PSI-WAHSUN Regional Ebola Conference held
on November 19-20, 2015 at the Belle Cote Hotel, Abidjan, Cote d’Ivoire
[2] The parentheses are
mine BA
[3] See Elumelu 2014
[4] ”See the canvassing
of this by the Abuja NMA Chair Dr Zainab Mariam at the 2015 Annual Conference
of the doctors: http://www.medicalworldnigeria.com/2015/09/privatisation-of-public-health-institutions#.Vk67XL9XLIU
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