Zimpapers Logo

Christopher Farai Charamba: THE INTERVIEW
Junior doctors at some public hospitals this week went on strike to protest uncertainty over their placement upon completion of their internship, on-call allowances and other non-monetary incentives. Christopher Charamba (CC) spoke to Ministry of Health and Child Care Permanent Secretary Dr Gerald Gwinji (GG) on the situation and what the ministry was doing to end the strike.

CC: To begin with Dr Gwinji, there is a doctors’ strike at public hospitals. What is the ministry’s understanding of why doctors have chosen to take this option?

GG: The doctors have put three issues on the table. One was the issue of uncertainty in terms of continuity of work after they have completed their senior residential medical officer internships.

The second, which is related to the uncertainty of posts, was the issue of open practice certificates which allow them to practise freely and unsupervised. The third was the issue of duty-free certificates.

Now with respect to those issues, we have had discussions around them and it appeared that the main issue there was around that of posts. In terms of this, we were already working towards making sure that we create posts. But we were doing this methodically and the answer was expansion of our establishment.

The alternative if we could not expand the establishment was to trade in some of the posts that take longer to fill, like some of the specialist posts, for Government Medical Officers (GMOs) and House Medical Officers’ (HMOs) posts while we worked towards progressively getting an expanded establishment from Treasury.

But having now had people who were qualifying in February this year, with a potential of us absorbing only a few of them, we then sought to speed up this process and said can we create new posts for GMOs and HMOs. And indeed Treasury did concede to that fact, creating 250 posts for the group that will cover 2017 and 2018.

CC: You say Treasury created these posts and the striking doctors have said the Health Services Board (HSB) read a letter to them to that fact but did not show them the letter physically as proof. Is there some evidence that you have presented to the doctors to assure them that Treasury has created these posts?

GG: I think every system has a way of communicating and in this situation, Treasury writes to the employer, which is the board and the board writes to myself and I communicate. I had communicated, and gave assurance of the number of posts but they were not satisfied.

We conceded and said if you want to see physically the letter that came from Treasury, let me make arrangements for you with the HSB so that you can go and physically see the letter.

Part of the executive and part of the membership which are non-executive went and physically saw that letter late on Thursday afternoon and read it. It is not Government standard practice that every letter is copied from the highest level to the lowest level. There are levels of communication and my duty is to follow what the HSB has given me and transmit that in writing and I had done that.

But seeing that we had a challenge on our table, yes, we bent over backwards and said go and physically inspect this letter which they did and I don’t think the executive and part of the non-executive membership that went to inspect can deny that.

CC: According to reports, junior doctors are on strike, so too are those in the districts and now there was communication circulating to the effect that some registrars have said they are also downing tools until the strike has reached a conclusion. My understanding is that this means there are only consultants left in the hospitals. What sort of contingency measures is the ministry putting in place in the absence of all these doctors?

GG: Firstly, the institutions that are affected are largely Parirenyatwa, Mpilo and Bulawayo Central Hospital and not the district hospitals or provincial hospitals. Those are not affected. There we are speaking about GMOs and HMOs who are already in the posts they are fighting for.

Yes, they might have issues around on-call allowances as well but they already hold open practice certificates anyway. So those issues are not pertinent to them.

This largely affects junior residential medical officers (JRMOs) and senior residential medical officers (SRMOs) who are still in internship.

Now having said that, there is a hierarchy of working in the system. There are JRMOs, there are SRMOs, there are senior house officers, there are junior registrars, senior registrars and then consultants.

One level tends to feed into the other. But for you to get to the upper level, you must have passed through the lower levels, which means you know exactly what happens at the lower levels. You are not hamstrung in terms of the skills that you need to receive a patient and finally treat them.

What may overwhelm you there are the numbers and it would make sense for the registrars to say we are overwhelmed.

Therefore, instead of attending to outpatients where we normally see 100 patients, let’s not attend to outpatients, let’s attend to emergency patients and still see a few patients. That to me would make sense rather than saying we are downing tools because there are no JRMOs.

In essence in means you are joining the strike. Because downing tools means you are not at work.

So yes, we have heard that at one institution they have indicated, not to the clinical director, but to the head of the department, that we are now getting tired, we are a bit overwhelmed and this is the position that we might take until issues are resolved.

Let me say it has not been concluded, there was just an indication as people become more and more tired. But the strategy there would be to work around what you do. Do you need to keep the whole outpatients’ department open? Do you need to see the cold cases or you confine yourself to emergency cases?

This is something we can announce to the population that for now, please, if your condition is not acute and not an emergency one, please maybe try to see a general practitioner and maybe not come to a central hospital, go the nearest district hospital and so forth. That’s what we’d tend to do.

Naturally whenever one, two, 10 or 20 doctors leave there is some rearrangement of service that has to happen and that’s what the clinical directors are working on. It means a bit of strain on the remaining staff and a bit of rearrangement on the services that are provided.

Some services may be stopped temporarily while we attend to those we think are acute and urgent for life saving.

CC: On the issue of on-call allowances and non-monetary incentives, what is the ministry’s position? Is it something you are planning on addressing and if so how are you going to go about doing so?

GG: Conditions of service issues are always a constant matter on the table between any employer and an employee, I think you’ll appreciate that.

But in our situation, given the circumstances that are there, yes we were not matching what’s in the region in terms of salaries for our health staff, across the board, not only doctors.

That, however, is largely still determined by the economy in which we are working and the framework that is put before us by Treasury. So yes, this issue has been put on the table, our call allowances are not enough and there is a distortion in the system.

We addressed that in the previous administration in terms of saying, let’s rearrange how you get your call allowance. The initial proposal was that we will be comfortable with about $10 per hour for on-call allowance and that will translate to approximately $720 for an average of 10 calls per month for JRMOs and SRMOs.

That was in principle agreed by ourselves as ministry, the board and Treasury. But Treasury then crunched the numbers and said at that time they could not afford the full $720.

We renegotiated the position and came down to approximately 50 percent of that and that is what is pertaining now, with room left for further increment up to the agreed amount of $720.

That has not happened largely because nothing has changed in terms of empowering Treasury to actually fulfil that. If you notice, salaries are now spread across the month, bonuses are paid in the next year. That’s the condition in which Treasury is operating and really we did not expect them to be able to meet that $720 in these last two years.

Yes, everybody anticipates the economy to grow and so forth, but it didn’t grow that much. In principle though Treasury has agreed that perhaps this is the level that we should remunerate our doctors in terms of call allowances.

It is an outstanding matter which they said let’s continue discussing. However, the major issue is about posts and the uncertainty come March 1 for some of us.

That’s what we quickly addressed and said ok, let’s look at these other matters while you provide the service. That’s the position that we expected colleagues to then follow. Yes, continue putting pressure on us, but let’s continue giving service to our clients as well.

CC: And the issue of non-monetary perquisites such as the removal of duty on the importation of cars?

GG: The removal of duty for importation of cars is not as simple as it sounds. It’s not a duty free service as such. What happened was prior to 2009 this arrangement was put in place but it was not supported by the requisite changes in Statutory Instruments to enable Zimra to allow individuals who are not in certain categories to receive vehicles duty free.

Their provisions are duty free for vehicles that are coming into Government service, for instance, not going to individuals. So in that framework, which was still not very clear to people, people imported vehicles but Zimra did not give them the requisite paperwork to complete the registration. After 18 months or so they were following up repossessing these vehicles.

We negotiated with Treasury that the understanding was that this would be duty free but Zimra is saying someone must pay duty. Having negotiated with Treasury, they put into our budget for that year some money to meet that duty obligation. So we were paying duty as minsitry to Zimra.

They did that for three years, putting money in the budget, where we would then offset the duty that was being paid by the doctor. After the three years, Treasury then said I think we need to go back to the usual way of doing business in which we provide this service so that it is accessible to all civil servants.

That was through CMED, by providing facilities for them to offer civil servants loans to purchase vehicles. But that did not materialise largely because CMED remained unfunded for that facility.

So, here we are. It’s been removed but health workers are still expecting that we will get “duty free”. This is the position that we have been explaining to them and we said let’s sit down, we still want yourselves to get vehicles facilitated by Government in one way or the other. Let’s come up with some innovative way of doing it other than taking funds that are meant for medicines to go to pay duty for vehicles.

That’s what we had put on the table and I think discussions have been going on around that while we wait for Treasury to appropriately equip CMED with the necessary funds to run the usual vehicle support for civil servants.

So that is the position and we have repeated that to the previous administration of the Zimbabwe Hospital Doctors’ Association (ZDHA) and this current administration. It is on record. We do have a document which says how we will administer the vehicle importation assistance and there are steps that we all agreed to. The issue is funding.

We actually even made the calculations, how many can we reasonably put, from the junior doctors, senior doctors, nurses, laboratory scientists? The overall figure that we came up with together with ZDHA was about $550 000 per year to take the number of health professionals and assist them and then next year you do the same. But it is a question of how do we fund the facility that is now outstanding.

CC: On to practising certificates, the doctors have argued that if there are no posts for them, can the ministry not issue them with the practising certificates so that they can seek employment elsewhere? Is it a feasible option and if not what are the complications around that issue?

GG: It is a feasible option provided we can’t provide the posts. But once you have provided the posts, you then wait for the requisite period to give open practice certificates. Let me say, open practice certificates are eventually given.

If you go out into the districts or provinces, you get your open practice certificate after one year. If you remain at a central hospital, you get your open practice certificate after two years. As a Government medical officer as an incentive to populate our district and rural hospitals that OPC comes after one year.

Now in this instance, posts have been provided so I think that bit falls off. It would have been an alternative option, provided no one is offering posts anymore and the Government has not provided those posts. But now the posts are provided.

CC: Some come the first of March, the doctors will have posts?

GG: Come the first of March, in essence we have actually made the preliminary distribution of all these posts and we have submitted that proposal to the board to consider. That there are so many posts at Parirenyatwa, at Harare, at Mahusekwa, at Binga District Hospital and so forth. Very detailed so that come the first, people know exactly where to look for placement.

The system also is, when we have finished your SRMO internship, you are given the list of places that are available and it is up to you to seek placement at any one of those places.

If a place has got room for 20, then the first 20 who present themselves there have filled those posts. The 21st person even if they intended to be at Parirenyatwa, for example, then have to find elsewhere until they have made administrative arrangements for movement.

So, that process is already in place and we expect that come the first we then put this across that here are the places, please indicate to us, within the month where you would be placed so that all your administration is then moved to that institution.

CC: Then there was the issue of the threats that were issued by clinical directors that those who did not report for duty, by 9 o’clock would be dismissed from their posts. What is the ministry’s position, is that a practical solution to the crisis that is taking place?

GG: Firstly, it is really interpretation of the administrative letter that any manager would push to try and rearrange their workflow. What the clinical directors did was say, we need to know who is on duty. The current duty roaster and the one done prior during the industrial action no longer holds because you do not know who is coming and who is not coming.

So, if by 9 o’clock we go around and see who is there so that we create a duty roaster. If you are not available for that duty roaster you will not be put on that duty roaster. Now, should you want to come back on to that duty roaster, let’s say the industrial action is over or your issues have been addressed, you have to report to say I have come back, can you put me back on duty roaster.

So, in the language that was used by some of the clinical directors it was interpreted that the application to go back on the duty roaster was tantamount to having been dismissed. And I clarified that no one is dismissed, you have not each individually received dismissal letters, this is just an administrative action by those who are managing a service saying how best do I manage in the absence of some of my staff.

Really there are no threats and I did reassure the executive in our meeting on Thursday morning that those threats, no one is fired and no one is dismissed.

CC: Looking at the situation now is there an indication from the doctors who are striking on when they are going to report back for duty?

GG: I think it is only fair that, when you put two or three issues on the table as the compound issues and you have discussed those issues to a reasonable conclusion that you stick to those issues. What we are seeing now is addition of more issues.

We have resolved one issue; another issue crops up. I don’t think that is a very comfortable position for the service itself. We needed to make sure that people go back to work by addressing their immediate compound thing and uncertainty about having a job at the end of February.

That has been addressed and we hope that the other issues will then be worked on methodically, through Treasury, through the board, through ourselves as the ministry and the concerned representatives of the doctors themselves. How do we find the best solutions forward?

As we speak now they seem to have taken the position that until everything is addressed we will not go to work. But we continue to plead with them that they need to consider the clients that are on the table. They have made their point on a number of issues and I do not think that they can come and say we have refused any of them. We simply laid down the predicaments to them.

Rather than saying their requests are unreasonable, we said yes that makes sense but this is the situation. We all know what the environment is like. I asked when they last had a meaningful salary increase and that speaks to the issue of what therefore is available for the other monetary rewards that should come to employees.

As the board addresses these issues they are not only addressing one sector, they are addressing the whole health sector. Their plan is very clear, their requests are very clear but they are putting those requests in an environment where they are constraints and they cannot manoeuvre without challenges to get whatever it is that they would have put on the table for health workers.

CC: Are there any possible options that the ministry has to furnish these hospitals with doctors and health service providers in the meantime while the strike continues?

GG: Well, the ministry employs by far the largest number of health professionals, some in training and some at different stages of their professions. It is not feasible at all that you can replace a group of doctors who have withdrawn their services on a one-to-one basis.

You can only strategise around covering certain strategic areas. To do that we then fall back upon sister services, those are Government agencies that offer health services. We request for their professionals to cover certain issues and already some have got their professionals at different levels in the system.

Some work in general hospitals. Some are JRMOs, SRMOs, registrars and consultants in the very same facilities but they would have come from sister organisations who offer health services. So yes, we will certainly if this gets prolonged we need to ask for that assistance as we normally do.