Health workers ask for decent work and a strong, public health care system—not applause

Updated: May 6

By our guest blogger Camilla Houeland


Writing in the UK Guardian in March 2020, the Liberian nurse and union leader George Poe Williams, feared that, like during the Ebola crisis, COVID-19 will lead to deaths that could be avoided unless we abandon austerity policies and build a strong public health system. The correct policy response would also require jobs in the public sector, and that health workers get proper working conditions. “We health workers are not heroes,” Poe Williams wrote. “We should not become martyrs at work. We are professionals. We need personal protective equipment so that we can maintain health while saving lives. We need adequate staffing and well-equipped health systems. We need strong public funding for our sector.”


During the Ebola crisis in 2014, health workers in Liberia made concrete choices about life and death: they had to choose between which patients to try to save and those who were likely to die; they had to choose between going to work risking infection (and death) or not going to work. At the time of Ebola, the National Health Workers Union of Liberia (NAHWUL), where Poe is now Secretary-General, fought for better resources and personal protective equipment (PPE). Today, Poe reflects that a lack of response from the authorities contributed to the fact that eight percent of Liberian health workers died.


The health sector in many countries was in crisis even before the COVID-19 crisis. Underfunding and understaffing of the public health system means that many in the world do not have access to health. The logical consequence should be to build a public health system, possibly with international development assistance.


Since COVID-19 went global, we have seen strikes from health workers around the world, which may seem unusual, considering medical staff are seen as essential workers and rarely go on strike.

Admittedly, some strike threats have been about pay. While “ghost workers” are reported on public payrolls in Kenya, i.e. names often of friends or the family of politicians, Nigerian doctors and Liberian nurses dropped off payrolls in 2020 and 2018 respectively. It is not uncommon for public employees in African countries not to be paid wages for work performed. Even when the Ebola virus came to Liberia in 2014, NAWHUL was in such a strike—or a slow-action—for the payment of non-paid wages, but it was interrupted to return to work to counter the Ebola virus.


Both the Liberians in 2014 and the Nigerians in 2020 combined payroll requirements with protective equipment requirements. In most cases this is what’s needed: training and protection requirements. This is also the main requirement of professional associations across Africa: that workers have PPE. It’s about fear of death and professionalism, not greed.


While health care professionals around the world are defined as essential and exempt from corona measures, they also have exceptions to labor rights. The right to strike for workers is restricted when or if it is ‘endangering the life, personal safety or health of the whole or part of the population’ as defined in international labor conventions set at the International Labour Organisation, ILO. But both the World Health Organization (WHO) and the Global trade unions federation for public employees, PSI (Public Services International) point out that in many countries, the limits on rights are far beyond the acceptable. This is just one of the reasons why healthcare workers often have wages below living wage, such as in the UK, the United States and in Liberia. A living wage defines the minimum income needed for workers to be able to meet their family's basic needs. In 2014, the salaries of health workers in Liberia were described as "ridiculous" by a Norwegian Africa correspondent. Across the world, the health sector, with a large number of migrants and a majority of women, is characterized by heavy work pressure and part-time and short-term contracts, while under-staffing and unsustainable shift schemes.

African heads of state are now confronted with a health care system they have neglected for years. African elites have often traveled abroad for treatment. Zimbabwe’s Robert Mugabe died at a hospital in Singapore. Nigerian President Mohammadu Buhari has traveled to the UK several times (one time for almost two months), while one of his predecessors, Umaru Musa Yar’Adua, preferred the hospitals in Saudi Arabia (he eventually died there). African heads of state are to blame, but we must also remember a long history of international demands. Underfunding of the health sector is also linked to borrowing requirements for public savings from the International Monetary Fund and the World Bank. As much as the IMF recommends increased investment in the Nigerian health care system, the World Bank responded true to nature when African leaders called for debt relief for public health: it should link to free market policies.


Through the Sustainable Development Goal 8, the international community has committed to The Decent Work Agenda. job creation; social security; labour rights and social dialogue. In 2016, the WHO recommended creating at least 40 million new jobs in health and social care, especially in poor countries, to reach the sustainability goals by 2030. This year came a new report from WHO that the world needs 9 million new nurses. In Nigeria alone, 500,000 to -600,000 nurses are needed. At the same time, the African Union, the United Nations Development Program and the International Labor Organization fear that the COVID-19 corona crisis could lead to the loss of 20 million jobs in Africa. It may look obvious for development to engage with job creation in public health.


In development and policy practice, the Decent Work Agenda is unfortunately is most often reduced to mean just job creation, and linked to the private sector only. The global union federation, PSI recalls that although the right to health is enshrined in no less than 150 countries' constitution, privatization has meant that access to health is unfairly distributed and dependent on class. Without private health insurance, which is often linked to formal work, the right for many becomes a theoretical exercise. In Africa, many of the 70% of the informal sector's workforce with weak or poor access to health. During the corona crisis we are reminded that this is not only unfair, but dangerous for the more privileged of us.


It is not only the health workers at PSI who insist that public health is more resilient, strong and fair. As we have seen, a partially privatized health care system is fragmented and unable to effectively coordinate infection control. To address the corona crisis, both Ireland and Spain have nationalized health enterprises. Health is one of the most important development goals. It should be linked to job creation and workers’ rights, and development discourses and practices need need to engage with the state as job creator and employer.



Source: The first version of this article was first published in Africa is a country

Norwegian version is published in Bistandsaktuelt

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