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Badilisha Lugha KISWAHILI

Unprecedented Doctors` Strike: Morality, professionalism and rule of law at crossroads

11th March 2012

Medical practitioners-cum- professionals, including, physicians, surgeons, nurses, Physiotherapists and other care givers world over enjoy relatively high social status, respect and trust. Medicine has always been considered a “noble profession”. The image of a doctor has always suggested integrity, loyalty and compassion – key aspects of a physician’s professional identity.

All over the world communities have always acknowledged medicine's vital role in healing the sick and permitted unique powers and privileges to those who practiced it. In return, the societies expect medical professionals to selflessly serve the sick and suffering with devotion, commitment and integrity consonant with the “Oath of Hippocrates” written nearly 2,500 years ago.

The oath enjoins medical professionals, including doctors to, among other things, a commitment to service (duty) and to commit to the best interests of their patients (beneficence). It declares a respect for human life and as pointed out by the sociologist Margaret Mead, “a dedication to life under all circumstances” Moreover the oath enjoin directs doctors to place the needs of the patient above the doctors’ own needs (altruism) and the doctors are required by oath to suppress their own self- interests when the welfare of others requires it to suppress requires.

The role of medical doctors, including physicians as “healers” dates back to the oath of Hippocrates. To the doctors, the Oath serves as a public statement about the noble and professional obligations, and it is an affirmation of the social and personal responsibilities of the profession. Is the group of striking doctors in Tanzania really abiding by the cardinal principals of the medical professionals enshrined in the Oath of Hippocrates upon which the code of behavior and conduct rest?

The medical doctors are professionals per excellence. Professionalism is defined by the American Board of Internal Medicine as “constituting those attitudes and behaviors that serve to maintain patient interest above physician self-interest.” The word profession is derived from profess which means 'to proclaim something publicly'.

The act of 'profession' of commitment to an ideal to which the professional should conform is the essence of a profession. During Medical graduation ceremonies medical doctors profess by the act of “Oath taking” to the public which marks the transition from being a student to becoming a professional.

An occupational acquires a professional status if, among other things, there is a code of ethics and conduct which regulate the behavior of the professionals, and if the practitioners enjoy relatively higher status in society than other job cadres.

The oath not the medical degree, professes the way the newly acquired competencies are to be employed. Without the oath the Doctor is just a skilled worker. On graduation Medical Doctors essentially profess two things: to be competent to help the patients and to have the patient’s best interests in mind.

Such commitment invites trust from their patients. Medicine has always been considered a “noble profession” The image of a doctor has always suggested impeccable integrity, loyalty and compassion which are the essential ingredients of the medical doctor’s professional identity.

To what extent is the group of striking doctors abiding by their professional duties, norms and ethics? Undoubtedly, professionalism has been compromised. It has virtually vanished in the battle between somewhat the “politicized” self-interests (of some doctors) and government but at the unprecedented suffering of the innocent public particularly the sick and those in need of the doctors’ attention and care.

The principles of patient welfare, empathy in patient care, social justice and fiduciary relationship which are at the heart of the medical profession have been abandoned. While the doctors and their professional associations are preoccupied with struggles on issues of payment, strikes and political power, professionalism is seriously threatened in the health sector.

Democracy, the rule of law and human rights are critical pillars for good governance. The Tanzania government recognizes the right to strike to be one of the principal means by which workers and their associations may legitimately promote and defend their economic and social interests.

I am sure the Tanzania government is aware that the strike action is a right not simply a social act. However, the strike action is not executed in a vacuum. There is a government legislation which governs the conduct of the right to strike and strike action.

The Employment and Labour Relations Act, 2004 imposes restrictions on the right to strike for workers in the public and the private sectors employed in essential services in the strict sense of the term (the interruption of which could endanger the life, safety or health of the whole or part of the population), or in situations of acute national crisis.

The legislation restricts persons engaged in essential services, including health services and associated laboratory to go on strike. Moreover the law spells the procedures that should be followed to resort to a strike action.

Employees or their associations (i.e. trade unions) have the obligation to first and foremost to give prior notice, to engage in conciliation and to have recourse to voluntary arbitration. Collect me if I am wrong, Doctors in Tanzania and elsewhere perform an essential service, consequently, by International Conventions which the Tanzania government has ratified and by virtue of our own legal framework, the doctors are restricted to go on strike.

Are the Doctors and their Professional Association ignorant of the legal framework governing the right to strike in Tanzania? My answer if absolutely No, doctors are well informed practitioners and their literacy competence in reading and interpreting correctly pieces of legislation cannot be doubted.

In the light of the preceding context as well as taking into account the essence and principles of the doctors’ conduct embodied in the Oath of Hippocrates, professional and legal requirements, one is inclined to conclude that the Doctors’ unprecedented strike action is acutely unjustifiable and fundamentally illegal. This does not mean that the demands they have articulated are wrong. No, not at all.

Some of their demands are genuine and are in the public interest. The employer has an obligation to offer a just pay or remuneration to an employee and the employer has the responsibility to perform his/her duties according to the set performance standards and quality.

The employer is obligated to create healthy working conditions for the employee to deliver a quality service. By all rational measures the doctors’ demands are all right. However, the strategies, mechanisms and “anomic” means which they have decided to use in pursuit of their interests and demands are politically untenable, administratively wrong, professionally flawed and socially unpopular at least in the Tanzanian context.

Their approach does not sit down well with the political culture and core values of the Tanzanian society. Social dialogue, respect to authority, tolerance and trust are but some of the values that would inform a productive strategy.

It is inconceivable that the Medical Association of Tanzania (MAT) even failed to appear before the statutory organs of the United Republic of Tanzania created for labour dispute and grievance handling, i.e. the Commission for Mediation and Arbitration (CMA). Are the Doctors above the law in Tanzania? This conduct is detrimental to the enforcement of the rule of law principal which is one of the strongest pillars for good governance.

The government needs time to aggregate the demands into implementable decisions and policies. The government, including the Executive and Parliament in a way deserve credit for the manner it has handled the doctors’ strike. The government has listened and responded positively to the genuine demands of doctors. The Prime Minister kept is doors open for the leaders of the doctors on strike. The relevant Parliamentary Committee also listened and acted swiftly to avert the appalling situation in hospitals.

The court of law, which is The Labour Division of the High Court, issued a judgment which declared the strike illegal and ordered the Doctors to go back to work immediately. Some striking doctors decided to ignore the ruling!! Is such behavior acceptable in Tanzania? The latest intervention has been made by the Head of State and Government, the President of the United Republic of Tanzania, Dr. Jakaya M. Kikwete notwithstanding the 72-hour ultimatum he was issued by a group of doctors on strike to rescind the appointment of the Minister and Deputy Minister responsible for the Health and Social Welfare portfolio.

The President went the extra-mile to have a dialogue with the doctors on an illegal strike and who are conducting themselves contrary to their professional code of ethics and the rule of law! The doctors who decided to put the lives of their parents, children brothers and sisters at ransom!! The doctors who easily forgot the fact that their better paid (more than twice, I am told) than their academic peers in other professional and occupational areas.

I trust that the Doctors will “pull up their socks”, appeal to common sense, reflect critically on the Oath of Hippocrates which they swear in public to up-hold to the letter and spirit for the purpose of serving the innocent lives of the people they are entrusted to serve with passion and devotion, and consequently go back to work.

The President, as a politician, has demonstrably showed them that he cares and has readiness to forget and forgive in the name of public interest. Our beloved doctors please should heed to the public call and go back to work without further conditions.

It is my fervent hope that the Doctors will end their strike as soon as possible. However, they owe Tanzanians and specifically the patients they left without care in hospitals and those who lost their lives an apology. They must say Sorry. This will never ever happen again.

The government on the other side must draw some useful lessons from the Doctors unprecedented strike action saga. The accusations that are put forward against the undesirable manner and approach used by the top leaders in the Ministry of Health and Social Welfare to handle the demands of the 229 Medical interns at Muhimbili National Hospital (MNH) who were agitating to get paid their allowances amounting to 8,776m/= (Daily News, March 7, 2012:3) must be thoroughly investigated and the responsible leaders, if any, should be taken to task. The behavior and approach that the leaders of Ministry resorted to was one of the root causes of the crises between the doctors and government.

Anecdotal evidence point to a systemic weakness and incompetence in the Ministry regarding the manner it handles crises and conflict situations. In the recent past the Institute of Social Work (ISW), an entity under the Ministry was closed and a group of more than 30 employees, mostly experienced and competent lecturers were fired! The manner in which the Principal of the Institute was removed from office leaves a lot to be desired.

The leadership style of Hon. Dr. Hadji Mponda and Hon. Dr. Lucy Nkya, the interdicted Permanent Secretary, Blandina Nyonis in handling crises situations generates more heat than light. I am not surprised that the Doctors are demanding their immediate removal from office. However as I have already alluded to elsewhere, I do not at all support the act of “forcing” by giving an an ultimatum to the Head of State to take action in consonance to the striking doctors’ directives.

This is not a Tanzania behavior. We must learn to respect the authority of our democratically elected President. The striking doctors should always remember that evolutionary decisions have more productive than revolutionary decisions.

The government should develop and build a sustainable culture of preventing incipient crises situations than waiting to resolve them. The English wisdom that “prevention is better than cure” is instructive, I am sure if the government had a tendency of reviewing the pay packages for the doctors and other professionals in the public service regularly, much of the problems could be avoided.

The government also needs to be aware of the crises triggers. Some informed members of the public believe that the “decision” of the Legislative branch of government to agitate for the increase of “Sitting Allowance” from Tshs 70,000/= to 200,000/= per day during the Parliamentary sessions was a wake-up call for other professionals, including the Doctors to carry out their own job evaluation exercise perhaps without permission of the appropriate authority, President’s Office-Public Service Management (PO-PSM). My knowledge on human resource management permits to point to the importance of “equity principal”, that is the perceived of the relation between what a person does (inputs) and what a person receives (outcomes).

Moreover, individuals judge equity in compensation by comparing the effort and performance they give with the effort and performance of others and the rewards those others receive. In this regard I welcome the idea of Hon Ndugai, the Deputy Speaker for the government to consider the possibility of establishing a Permanent Fair Wages and Salaries Commission to set pay levels for all people in the public service, including politicians on the basis of relative worthiness of the job one holds.

The government should recognize the devotion, professionalism, commitment and a sense of duty demonstrated by the non-striking doctors who were all out to serve the lives of the people in hospitals. Moreover, it is high time the government, as an employer of public servants, decided to enforce the terms and conditions of employment as spelt out in the Employment contracts of Doctors in Public health facilities and other professionals.

Any breach of contract should receive zero tolerance. Absence from duty without a good cause amount to a disciplinary offence and it is punishable. Employees should also learn to respect their professional ethics and terms of engagement in the public service. The rule of law must be seen to prevail in the public service.

Moreover, a more stringent legislation which should categorically outlaw strike action by doctors’ strike and other professionals in sensitive positions is needed. In this regard we expect the Medical Council of Tanganyika to do the needful in accordance with the law governing the conduct of medical practitioners.

We recognize the good work that credible Civil Society Organizations (CSOs) play in the effort to bring about good governance in the United Republic of Tanzania. Civil society organizations in Tanzania have always played a pivotal role in enforcing accountability, agitating for the respect of the rule of law and human rights.

They have been front liners in policy advocacy, people emancipation and “conscientization” of the citizenry as well as in complementing or supplementing government effort in the delivery of public services. However, the decision of some CSOs to take side in the Doctors’ strike leaves much to be desired.

Champions of human rights must recognize that the right to life is the first and foremost right. Everyone's right to life should be protected by law. No one shall be deprived of his life intentionally or by any other reason save in the execution of a court sentence. I must hasten to declare that I oppose in strongest sense the death penalty irrespective of whatever offence.

The doctors have the key to life. They are life savers per se. While some CSOs were somewhat correct in demanding government accountability, however, they were at the same time duty bound to be fair by also demanding the doctors and their Association to serve the lives of the sick and all those in need of Medicare services in public hospitals.

The CSOs in Tanzania should borrow a leaf from their Ghanaian counterparts, who during the October last year Ghanaian Doctors’ strike action said that “The Ghana Coalition for NGOs in Health describes the life-threatening action as ‘totally illegal and against the labour laws of Ghana’ and has called for doctors to end the strike or face legal action, citing Section 164 of Ghana's Labour Act which outlines that unresolved disputes should be settled by compulsory arbitration after the matter had been referred to the National Labour Commission (NLC)”.

Another progressive CSO in Ghana, namely the Movement for Development Ghana (MDG) equated the Doctors’ strike action to “manslaughter and pre-meditated murder”. We expected our progressive Civil Society Organizations to go to the court of law, in the name and interest of good governance, human rights, the rule of law and democracy to question the legality and morality of the strike. Instead the CSO’s accusing finger was solely pointed to government alone. Both government and the group of doctors on strike should share the blame.

The Oath swearing by Doctors is not merely symbolic but hangs continuously on their necks. The integrity of CSOs world over depends, by and large on their ability to illuminate and stand for truth. In this regard the Doctors have a bigger share of the blame than government.

In this saga, innocent people have lost lives. We have lost our beloved ones. The right to life has been violated. Article 14 of the Constitution of the United Republic of Tanzania is very emphatic on the right to life. It stipulates that “Every person has the right to live and to the protection of his life by the society in accordance with the law”.

It is my fervent hope that serious CSOs activists and responsible citizens in defense of good governance, human rights and the rule of law will seriously consider taking legal action against all individuals in government and MAT who are responsible for the loss of innocent lives as a result of the unprecedented strike action.

The doctors have the right to fight for decent compensation and benefits but they should refrain from pursuing their employment rights at the expense of the people’s precious lives. The life of every Tanzanian is precious to Tanzania. The government is required to enforce the rule of law and regulate the behavior of its employees consonant with the public service code of conduct and ethics.

The Medical Universities as well as other medical tertiary training institutions and regulators of professionals and practitioners in the medical and health sector should place special emphasis on ethics and the rule of law in their learning and training curricular.

MAT should strive to implement continuous professional training programmes for its members. The principles enshrined in the “Oath of Hippocrates” should be emphasized. Only the medical professionals and staff who are all out to abide by the professional and code of conduct should be licensed to practice. Strategies must be devised to promote and enforce ethical conduct.

The Civil Society Organizations, the Faith Based Organizations, the Imams, the Bishops, the clergy in its entirety and the elderly should continue to add their voice to the call on doctors to at least on humanitarian grounds rescind their unlawful decision and return to work.

Much as the government has decided to increase the pay packages of the doctors, an initiative and a decision which deserves support, it should also endeavour to combat incidents moonlighting and day lighting the undesirable behavioral patterns that some few doctors exhibit.

Dr Benson Bana is Head of Department of Political Science and Public Administration at the University of Dar es Salaam.

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