Healthcare delivery in Nigeria, South Africa under threat as doctors plan to ‘check out’

A female doctor examining a child in an African hospital

By Tom Chiahemen (ABUJA) –

Unless the governments of Nigeria and South Africa realize the implications of the current revolt by their doctors, health care delivery in the two leading nations in Africa could soon face serious danger with inescapable consequences on the lives of the people.

This is because while doctors in South Africa are planning to leave the country due to the National Health Insurance (NHI) scheme, the Nigerian government is about to begin implementation of  a “no-work, no-pay” policy against resident doctors who have been on strike for almost a month to press home their demands for improved pay and other conditions of service.

Already, Saudi Arabia, which has always been in dire need of medical professionals, has quickly moved in to recruit Nigerian doctors in Abuja, as resident doctors’ strike continues.

Indeed, Trade union Solidarity has published its latest report on the NHI, showing that a significant number of healthcare workers plan to leave the country due to concerns around the new system.

Mmamoloko Khubayi, South African Health Minister

The report was compiled by the Solidarity Research Institute and is based on an opinion survey conducted among healthcare workers, according to BUSINESSTECH.

While the health workers were asked to share their knowledge and insight on opinions concerning the NHI, the survey drew a response from 1,410 healthcare workers in three separate studies conducted in 2018, 2019 and 2021.

Across the studies, the overarching response from healthcare professionals is one of uncertainty and mistrust around the NHI, with general sentiment towards the system being overwhelmingly negative.

“Almost all the respondents have serious concerns regarding the state’s ability to manage and administer the NHI,” Solidarity said. “The total administration and management of funds and decision-making will be in the hands of the state.

“Most are seriously concerned about the fact that the state can determine and enforce tariffs, place of work, type of diagnostic tests and type of medication and treatment.”

Solidarity said that respondents’ opinions are likely shaped by the observed mismanagement and maladministration at institutions such as Eskom, the SAA and the SABC. The NHI will be significantly larger and more complex, must serve a population of more than 55 million people, and will have to manage and execute many contracts, it said.


When asked whether they are already taking steps to emigrate because of the NHI plans, 13.7% of the respondents said they have already started the emigration process.

However, once the NHI is in effect, the number of healthcare workers intending on leaving the country increases to over a third (35.9%). By contrast, only 15.3% of healthcare workers are confident they will stick around once the NHI is in full effect.

Between 2012 and 2017, the government rolled out NHI pilot projects in 11 health regions across South Africa, Solidarity said.

“These projects cost about R4 billion, and it was found that none of the NHI pilot projects contributed to improving health care. The main reasons for this were poor infrastructure and equipment, vacancies and too few health care workers, and poor financial planning.”

A South African Doctor

55 out of 75 medical practitioners who served in 17 clinics participated in a Department of Health study after the trial run to determine their experiences.

More than 60% of them were convinced that the NHI would not improve the quality of service delivery, and most of them indicated that they would not want to work under the NHI.

Solidarity said that four factors might lead to the destabilisation of the healthcare sector in South Africa:

  • A shortage of specialists, doctors, nursing staff and other healthcare workers;
  • Financial management of the NHI;
  • Purchasing and distribution of medicines and equipment;
  • Maintenance of infrastructure and equipment.

“In recent years, the media has been inundated with reports of shortages of well-trained staff, doctors and specialists, equipment shortages, lack of maintenance of equipment and infrastructure, and negligence claims of between R80.4 and R98 billion that have been instituted against the state from the public health care sector.

“Although it has been argued that some of the claims involve corruption, service delivery has been negatively affected, especially if the pattern were to increase.”

One of the many troubling questions is for whom medical practitioners will work, Solidarity said.

“Will everyone be employed by the NHI, or will they have to enter into compulsory contracts with the state? Almost 86.6% of the respondents indicated that medical practitioners should be able to work for themselves in private practices and that it should be their own choice for whom or where they work.”

Not in favour 

More than 85% of the healthcare workers who participated in the study indicated that the implementation of the NHI would lead to healthcare workers leaving the country.

“South Africa will therefore be left with a shortage of medical staff, which implies that quality and specialist healthcare services will be extremely scarce. All South Africans will suffer because of this, and access to healthcare will consequently diminish instead of healthcare becoming more accessible,” said Nicolien Welthagen, a senior research psychologist at Solidarity.

Healthcare workers have indicated that they have no confidence in the government or its ability to manage such a system effectively. According to them, this will destabilise healthcare in South Africa, and it will be detrimental to the quality of care provided.

“Healthcare workers have specifically pointed out that the government is incompetent and that a system such as the NHI will only create another opportunity for further corruption by the government as this will give them access to more funds that can then be looted.

“Healthcare workers are also of the opinion that the Covid-19 pandemic made it abundantly clear that the government does not have the ability to manage a system of this magnitude,” Welthagen said.

The report also shows that healthcare workers believe that the government should focus on improving the current public healthcare system. Cooperation with the private sector should be encouraged rather than centralising and controlling the entire healthcare sector.

Most healthcare workers do not want to work with or for the government. They do not trust the state and do not want to be accountable to the state or be told how to do their jobs.

“The fact that so many healthcare workers could leave the country is a major cause for concern. This will plunge South Africa’s healthcare into a crisis for which there will be no solution. We cannot allow the state to continue with its plans to implement the NHI and thus alienate and push away our healthcare workers,” Welthagen said.

In Nigeria, the Government has written to Chief Medical Directors and Managing Directors of Federal hospitals, asking them to begin the implementation of no-work, no-pay policy.

The government’s directive was contained in a letter dated August 26, 2021 signed by the Director of Hospital Services, Federal Ministry of Health, Dr. Adebimpe Adebiyi, according to Global Village Extra.

Dr E. Osagie Ehanire , Nigeria’s Minister of Health.

The letter, obtained by the online news medium, was titled “Application of Section 43(1) (A) of the Trade Dispute Act, Cap T8, Law of the Federation of Nigeria (LGN) 2004 (no work no pay) partly.”

It reads, “The ministry is in receipt of the letter from the Ministry of Labour and Employment informing the ministry of the laws governing the ongoing strike by the Nigerian Association of Resident Doctors and the need to immediately apply the provisions of the Section 43 (1) (a) of the Trade Dispute Act on ‘special provision with respect to payment of wages during strike and lockouts’ known in labour parlance as no-work-no-pay with effect from Monday, August 2, 2021 when the strike was commenced by NARD members.

“Consequently, on the above, I am directed to inform you to commence the implementation of the no-work-no-pay policy on the striking doctors including other workers that may embark on strike consequently.

“This directive is in line with Section 43 (1) (a) of the trade dispute act which inter alia states ‘where any worker takes part in a strike, he shall not be entitled to any wages or remuneration for the period of the strike.

“And any such period shall not account for the purpose of reckoning the period of continuous employment and all rights dependent on continuity of employment shall be prejudicially affected accordingly.

“You are to compute the financial implications of the no-work-no-pay from the salaries of resident doctors and any other health worker that participated in strike using the attached template and forward same to the IPPIS office through the Federal Ministry of Health for implementation.”

The Nigerian resident doctors have been demanding, among other things, payment of arrears of the resident training fund amounting to N5.42 billion (about $13.2million); 2014-2016 salary shortfall/Skipping (which matter is still in court, with the government challenging the skipping of work by medical personnel); removal of NYSC (National Youth Service Corps) and Resident Doctors from the scheme of service and; fate of doctors employed without due process.
Nigerian resident-Doctors

According to a BBC report, hundreds of medical doctors gathered at a location in Abuja during the week for a recruitment process being carried out by some consultants from Saudi Arabia.

Nigeria’s state police, the Department of State Security (DSS), denied today, reports that its personnel shot and dispersed doctors who had gone to the venue to participate in the Saudi recruitment, which is attracting mostly medical consultants, Intensive Care Unit (ICU) doctors, Pediatricians and other categories of personnel.

The government has also threatened to “punish” the doctors if they fail to resume work in obedience to an order by Justice John Targema of National Industrial Court that the three-week strike be suspended.

Despite the threat, the recruitment exercise by the Saudi officials went ahead this week at one of the three-star hotels in Abuja, signaling another danger for Nigeria where youth unemployment has continued to pose a serious threat.

Uyilawa Okhuaihesuyi, NARD President

Citing “bad working conditions in public service,” the Nigerian doctors revealed in an interview with the BBC that the consultant from Saudi Arabia offered them salaries far above what they were earning, including other welfare benefits.

Reacting to the development, President of the National Association of Resident Doctors (NARD), Uyilawa Okhuaihesuyi, acknowledged that what was happening was not good for Nigeria but that he would not blame the doctors who were attending the Saudi recruitment interviews.

 According to Okhuaihesuyi, the failure of the Nigerian government to take the welfare of health workers seriously was the cause of the revolt.


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