Adeniji Abdulrafiu Ajani, a Chief Nursing Officer and President of the National Association of Nigerian Nurses and Midwives (NANNM), spoke in this exclusive interview with PREMIUM TIMES’ Ayodamola Owoseye and Idris Ibrahim on some of the challenges the nursing profession is facing in Nigeria.
PT– Nurses in Ondo State recently went on strike. What was the stand of the National Association on this?
Adeniji – I don’t know why you picked Ondo, but I know that all over the land, there is crisis. There is no harmony and good development in the health sector. So, if any state chooses to embark on a strike, we have justification for it. As for Ondo, they have a number of issues they have been trashing with the state government which has not been well attended to.
One would have expected that Ondo, being ruled by a medical doctor (former Governor Olusegun Mimiko whose tenure ended in February) who should have known about the nitty gritty of health care services, did not actually do what they are expected to do to maintain industrial peace and harmony.
The resources accruing to the state’s health sector (were allocated) in a lopsided manner, leaving some people with empty stomach while some people are flourishing in affluence. You will agree with me that this is injustice and where there is any form of injustice and where harmony is being tampered with, progress will be retarded. There is no way we can prevent crisis in such a state.
PT – The issue of doctor, nurses’ crisis in health institutions I believe is one of the lopsided policies you are taking about. What causes it and how can it be resolved?
Adeniji – Healthcare services is a team work and the health sector is a multi-sectoral industry that entails a wide range of specializations and professionals.
Each specialized professional, by virtue of preparation even in the university, all work in a common sector and the entry qualification is basically the same: Physic, Chemistry, Biology, English and Mathematics basics. Then when you get into the preliminary studies in the university, you find out that you have many things in common up to a level before specialization.
But today in Nigeria, we have placed too much emphasis on a sub-group and it is leading to injustice and crisis even in the training institutions. We have more than 100 universities in Nigeria today offering Medicine, but less than 25 for nursing sciences. Meanwhile medicine and nursing is a geo-profession.
They need to grow hand in hand and the government is spending colossal amount of money on Medicine, neglecting Nursing while there is nothing to show for it as the health indices in the country is going down.
It cannot be solved until we look at the fact that health is a multi-sectoral and multi-disciplinary sector and that every person that works in the sector deserves due regard, respect and to be given actual position and involvement in policy formulation and policy execution in the country.
The Nigerian populace themselves are committing a crime of giving too much attention to only one professional group, whereas a tree can never make a forest.
PT– You made a statement that the difference between you and the doctors is education. But we realize that most of the nurses in Nigeria graduated from midwifery schools.
Adeniji – It is good that you asked a question that is giving most people confusion in this country.
A midwife is a specialist, a general nurse is a generalist, a psychiatrist nurse is a specialist and so on like that. These are professional qualifications.
The same person who is a degree holder can be a midwife, a general nurse and a midwife, a general nurse and specialized nurse, all the other specializations we have in Medicine, we have in Nursing.
The question about a midwife, if you go to the university, even if you have your masters and you are a professor of Nursing, you cannot practice as a professional if you have not sat for the professional examination being organized by Nursing and Midwifery Council of Nigeria. You are a quack. The difference is that one is a professional, the other one is an academician.
You can only be a professional when you sit for that professional examination. The moment you sit for this professional examination with your degree, and then you have a higher pedestal of recognition, entry point and remuneration.
PT– There is a bone of contention between doctors and other practitioners in the health sector that the position of the Chief Medical Director in health institutions should only be for doctors?
Adeniji– The health sector is not for a single healthcare profession. What we have promoted in this country is birth right and mediocrity, not merit and this is what is tying us down to the level of low development, even underdevelopment.
What we have presently in Nigeria is that if you are not a medic, with discipline in Medicine and Surgery, you may find it difficult to become a CMD. But elsewhere, it is a team approach where everyone is allowed to compete.
CMD is all about administration. You don’t take patients to the admin office or office of the CMD to operate upon. We use the brain, our acumen, and expertise in understanding human being and management and if this person has basic professional qualification, this person should not be debarred from taking up any position of leadership. So, there is no crisis but there is misplacement of justice and wherever there is a misplacement of justice, there will be disharmony because it has already been established that whether you know your left from your right, once you are a medical doctor, it is your birth right to become the CMD, so people are not even trying again.
It is the right of other people that they are asking for and nobody should see it as crisis. Rather, we should address it, either I am a professor of Paediatric Nursing, or a professor of Paediatric Medicine, if it comes to our clinical area, my own area of specialization and practice is separate. Though we work together in the same sector, we have to collaborate. But when it comes to administering that sector, I am not a sub-human being and he is not a super human being.
That is why we have challenged the Nigerian setting. Let’s see how other people will rule this health sector. Since 1960 that we had independence, even before 1960 that we have been having our health care policies, its implementation, its review, putting another policy into place up to the sustainable developmental goals that we are having today and the universal health coverage, if they have been doing it well and not lacking administrative acumen, our health sector supposed not to be like this.
The domination is holding the growth and development of the health sector. I have seen cases where nurses have superior position on health matters but because they are not doctors, they are not given the privilege to do anything and this must change, beginning with each and every one of us. For you to become a minister of health in this country, your legislators will ask, “Are you a doctor?”
I am still hoping to become a medical director in this country or even minister for Health as obtainable in other places like Kenya, where the minister for health is not a doctor. There was once in Africa, the minister of health in Botswana who happened to be a nurse was the overall chairman of the ministers of health in Africa and they won’t come home and say anything about such.
PT– One of the problems the nursing profession is facing in Nigeria is brain drain. Why are many nurses running out of the country?
Adeniji – You have touched on a very vital point that is the pillar of healthcare service all over the world: human resources for health.
What we call brain drain is a colonial mentality. I don’t take it as brain drain. Where is the brain draining to? This is labour mobility, movement of experts and people that are professional from areas whereby they are not valued to areas where they are valued.
Don’t make a mistake about it; it is not only for money. Most of the specialized nurses elsewhere have freedom of practice and they practice with joy which is not so in this country.
There is no freedom of practice for nurses in this country. I see the brain drain as a positive development. Nigeria has contributed to the human resources development for health all over the world: U.S., UK, Canada, Australia and elsewhere. The minimum wage in some of these places in a month is better than what a Nigerian nurse will earn in a year.
About two years ago, a midwife from Nigeria was given an international award. Nobody came to Nigeria to mention it. But if it is a doctor, because the Minister of Health is a doctor, the Minister of State is a doctor, Permanent Secretary is a doctor, and all the directors in the ministry are doctors, almost all the directors in the ministry are doctors and you wonder what they are doing there, wasting colossal money that government has spent on them. It so bad that even the minister of labour is a doctor.
Talking about statistics, the federal government is the highest employer of nurses and they have less than 20,000 nurses, while all the states employed nurses are not up to 15,000, not to talk of the local governments where most of the exploitation is coming from. Most of the people you see putting on white in the private sector are not professional nurses.
The government has no accurate figures of nurses in the country. That is why today, they say Nigerian nurses and midwives are about 245,000. Where did they get that figure? Without prejudice to any state, statistics from the north is very bad as you can see some local government without a qualified nurse.
Nigeria’s statistics is for 100,000 Nigerians, you have 1.2 nurses. But by my own statistics, we have less than 0.9 nurses to 100,000 Nigerian citizens.
Another reason for the mobility is job satisfaction. Some Nigerian nurses do tie phone on their heads to carry out clinical duties. How do you want a midwife in a labour room to actually give episiotomy, which is a surgery and then repair it with the touch light of the phone?
There is going to be state of emergency in the health sector and that is why when we talk about medical tourism, some people have genuine reasons to go outside this country. Because when you see a midwife attending to 200 antenatal cases, then you will say that many people are dying.
Nurses rank higher in the statistics of health workers with high blood pressure and work hazards. For example, a nurse at Federal Medical Centre, Abeokuta, in the case of Lassa fever taking care of the person without enough infrastructures, she died.
PT – There have been so much complaints about lack of equipment and infrastructure. What is the association doing about getting a better working standard?
Adeniji– The professional association is not an employer of labour, but we are there to ensure that people employed are not exploited and there are quality services.
The association has not relented in negotiating that the government should provide adequate facilities, infrastructure and equipment because it takes basically four things for a health system to run. The policies and the laws that we say are lopsided have to be in place. It takes physical structures. It takes the personnel and then the scene in which they want to deliver the services. All these four are very important in the health care system and key to how effective the healthcare services will be. Even in our letter that is being treated in the inter-ministerial level today, if you see what nurses submitted, infrastructure, equipment and personnel is number one on the list.
You suffer a lot of psychological pain when you see some patients dying because there is no equipment; you are helpless. We are fighting it and we are negotiating with government to provide adequate infrastructure for health sector. But we also appeal to nurses on the field.
Our members are dying of stress due to lack of infrastructure. We cannot continually sacrifice the few ones available. For example, everywhere now, there is a fear of any haemorrhagic fever outbreak and there is no personal protective equipment (PPE) even in federal government hospitals. Look at what happened at FMC, Abeokuta. It was a dilapidated structure that was earmarked as an isolation unit, which will even predispose the health care service providers to danger.
Go to some places where some people are even taking delivery, the beds are sagging, the linen are not clean, no instrument, you improvise to the extent of even improvising your hand as a clip for the umbilical cord, which is putting the patient at risk. The floors are nothing to write home about, most of the floors of where deliveries are taken have chipped off, which is a source of infection. Look at the galipot they are using, most of them are rotten. And that is why when we are confronting the government at any time, infrastructure development and human resources for health is always at the forefront.
PT – What is the take of the association on the Community Health Workers working as nurses and the so-called auxiliary nurses whom some private hospitals use as their major nurses? How are you regulating their activities?
Adeniji – You have touched a very great issue and that is quackery and quack practices in the country.
Apart from the professional association, NANNM, we have the Nursing and Midwifery Council of Nigeria (NMCN), which is a government parastatal and a regulatory body in setting up laws and regulations. And I lay claim to say the association particularly is participating in ensuring that these laws are up to date at all levels of professional regulation.
Organised quackery in this country is an issue of those who call themselves nurses and are not nurses. A nurse and midwife is such person who must have undergone academic training maybe in the school of nursing or in the university and submit to the regulatory body’s qualification and verifying examination.
Even if you go outside this country to study Nursing and you train to the level of PhD in Nursing, when you come to this country you must sit for that examination before you have the right to touch the patient in the ward.
Quackery is not a thing we have to play with. I need to mention that no single individual, whether you are a professor of Medicine or Nursing, can train a nurse because to train a nurse to the point of certification entails various disciplines and period of exposure and facilities.
Most of the private clinics in this country do not have half a section of what it takes to train a nurse and they will now deceive these people to come and learn how to be a nurse, which is not possible.
The association is urging the public to also collaborate with us to flush out these bad eggs. We have a Nursing and Midwifery Committee domiciled in the office of the Director of Nursing Services in all states of the federation.
This body has been empowered by law to go about with the involvement of the professional association at the state level and curb quack and quackery practices, maintain standard and regulate the practices of nursing profession. Anybody caught would be tried in the law court and option of fine is not considered but a jail term, that is for anybody that is either found guilty of training a quack or he/herself is a quack.
As for Community Health Workers (CHW), what I think the government is doing is to sacrifice merit at the door of mediocrity. This happened as far back as 1981 during the era of Prof. Olikoye Ransome Kuti. The health sector system allows for CHW to attend to a patient to the point of their ability, then refer. But today, these people are charged beyond what they can bear.
It is not bad to allow CHW to work as they are part of the health care system, but they must know their limit, especially in the primary health care setting. Actually, everybody has a role to play but when somebody is trying to play the role of other persons, it is bad and that is what is creating issues.
What we are saying in essence is that we need people to report this professional malpractice. If you report it, the association is ready to take it up. Every state of the federation has the office of National Association of Nigerian Nurses and Midwives and office of the Directorate of Nursing Services in federal here. We will not hesitate to take legal action against anyone that is trying to kill instead of healing. No health professional is expected to do the work of another professional; we all have our different training, certificates and licenses.
PT – On Female Genital Mutilation (FGM), the circumcision is most often carried out by nurses and we all know that there is a campaign against the practice. What is the association saying to its members on this?
Adeniji – Most ones that are surgically accepted are the male circumcision. Nurses have always campaigned against female mutilation, though we have some religions that speak in support of the mutilation.
In fact, I know what Islamic religion advocates is not mutilation, but because you don’t know the limit of it a nurse, we campaign against any form of female circumcision.
We have to however watch it because the issue of mutilation, it is not everybody that is circumcised that is mutilated. What we are saying is that when you now go to about the third-degree circumcision where all the sensitive organs are removed, this is mutilation and this will affect her sex life and increase the chance of dying during child birth.
PT – It is noted that in nursing, the ratio of female to male is higher. Why has this been so and what is the association doing to encourage men to take up the profession?
Adeniji – The ratio is low and the Board of Nursing and Midwifery Council in Nigeria has already regulated that male can do midwifery in this country today because that is the most affected area.
Currently, we have the ratio of about 1 to 50, male to female. The health system in the county has been dominated and waylaid by the doctors believing that if you admit more male into nursing profession, there will be hot competition for them.
And of course, if you know what you are doing, why are you afraid of competition as we are both trained in the act of human physical sciences; only that the training of the nurse permits you to know so that when a doctor is making a mistake, you correct them, we are not licensed to put such areas into practice.
Unfortunately, people with their private clinics in town employ male nurses to consult for them. But in the public sector, they believe that the more male nurses you have, the more liberated the profession is from the shackle of subjugation and repression.
The ratio is politically motivated and there is a lot of propaganda about it. Even to admit into schools, they ask the male what they are coming to do in the nursing profession. The profession does not have gender coloration.
PT – Nurses are meant to be wonderful people. But when there is a bad egg among the nurses, who do we report to and what is the verdict for them?
Adeniji – An arrogant nurse will be subjected to professional disciplinary committee. Nurses are not expected to be arrogant but they can be proud of their career. If you see any one that is so arrogant to the extent of indulging in neglect malpractices, report the people and then the professional association will try that person for misconduct, because we have ethics of the profession, anybody that works against the ethics is meant to be tried.
Nigerians do not report and we have always encouraged them to do so. You can report in the nursing audit section in any of the hospital or Servicom or the office of the Head of Nursing Service in that organisation or better still the NANNM in that institution or to the Director of Nursing Services in the state where the Nursing and Midwifery committee is domiciled.
They can set up a committee to look into the complaint. Although we always tell the nurses that as a care giver, you must absorb a lot of disrespect.