By Arinze Chijioke
In this investigation, Arinze Chijioke looks at how billions of naira supposedly invested on primary healthcare and epidemic preparedness by the Kano state government failed to save lives during the outbreak of cholera in the state.
Although he was the third child in a family of seven, Aminu Ashiru knew too well that the bulk of the responsibility of caring for his aged mother and siblings after his father’s demise in 2016 rested on his shoulders. While he waited for his certificate, upon graduation from the Federal College of Education, Bichi, he started a phone business and catered for his family with the little he made.
“The hope was that after the result comes out, he will get a better job and give the family a good life, he was our light,” Ayuba, younger brother to Ashiru said outside their compound in Kanawa, one of the communities in Bichi local government Area (LGA) in Kano state.
Sadly, all of that didn’t last long as Ashiru died in the heat of the cholera outbreak that claimed hundreds of lives in Kano state. He died in August 2021 after a meeting with his friends at 8pm.
As the meeting progressed, he started complaining that his stomach was rumbling and that he needed to go home. His younger brother and some friends accompanied him and when they got home, Aminu started stooling.
“No one knew what the problem was and we did not know what to do. We prayed that he would get better but it got worse and this time, he started vomiting too,” Ayuba told Solacebase.
Unknown to the family, it was cholera. Although they did not know what it was, they knew he needed medical attention. Sadly, Kanawa did not have any primary healthcare centre to attend to him.
Ashiru’s family waited till the next morning and took him to the Bichi General Hospital, a 20 minutes’ drive from Kanawa where he was administered medical treatment including drip and other medication he needed. But it was late already. He had lost every strength he had.
He later died at the hospital and was brought home for burial.
Bichi General Hospital
“Our political leaders know that we don’t have a hospital here,” a distraught Ayuba said. “They have made several promises during campaigns but we have not seen them and now, I have lost my brother.”
The Kano Cholera outbreak
Aminu is one out of at least 369 deaths recorded following the cholera outbreak in 2021. Between March 2021, when the outbreak started and June 22 of the same year, 119 deaths were recorded in a caseload of 3,209 across 33 of the 44 local government areas (LGAs) in the state, with Gaya and Bichi LGAs having the highest number of infected persons.
A cursory look at the cholera figures shows an appalling trend of poor epidemic preparedness by the government. In July 2021, the number of cholera casualties rose from 119 to 169, out of 5,221 cases in the 41 LGAs hit with the outbreak. In August, the figure rose to 173 out of 5,316 laboratory-confirmed cases.
A month after, 329 people died with the number of laboratory-confirmed cases rising to 11,475 across the entire 44 LGAs in the state. Sumaila LGA ranked highest with over 2,000 cases.
While Bichi and Gwarzo LGAs had the second and third highest cases, Kunchi and Dala LGAs had the least number of cases. As of January 2022, 368 deaths were reported out of a total of 12,116 cases. Sumaila and Bichi being the worse hit.
This figure makes Kano the second most affected state with cholera in Nigeria and one alongside three other states- Bauchi, Jigawa and Zamfara- that together account for 53% of all cumulative cases in Nigeria.
After Aliyu Rabiu, 25 had Tuwo (a local delicacy made from corn) one Friday in July 2021, his stomach started rumbling and felt the need to use the toilet. Soon he started passing watery stool and he ignorantly concluded it was the food he ate. He took Flagyl but the rumbling didn’t stop.
He could not sleep that night and because there was no hospital in Kanawa, his village, he endured the discomfort. The next day, Rabiu started vomiting and became weak. The next day, his family took him on a bumpy ride to the Bichi General hospital where he was eventually treated.
“When we got to the hospital, I was given six drips and other medication I needed and the next day, we came back,” Rabiu said.
Ado Danladi, officer-in-charge at Bichi General Hospital said that the hospital alone recorded over 1335 cases with 10 deaths. He said that the number of patients who came from various villages was overwhelming, and it became difficult for the hospital to cope with administering the right treatment to everyone.
To deal with the challenge, Danladi said that the hospital had to discharge patients with not too critical conditions to accommodate more patients in need of urgent attention. He said that most of the medical supplies that were used for treatment were donations from private individuals, including the Emir of Bichi.
While noting that the outbreak which started in March 2021 lasted for over three months causing pain amongst residents of the LGA, Danladi said, the story would have been different if all the communities had access to basic healthcare and adopted good hygiene practices.
“We stopped people from coming to see patients because we had discovered that members of some families got infected after they left the hospital. We had to disinfect our offices.”
No access to healthcare despite government spending
At the heart of high cholera-related deaths in Kano state is the widespread dearth of medical supplies such as fluids, drugs and other essential facilities, in addition to poor staff-to-patient ratio, decayed infrastructure and lack of adequate facilities to accommodate patients in communities with PHCs.
This is despite the billions the state government claims it has invested in the primary healthcare sector and epidemic preparedness.
Speaking to Solacebase, Dr. Laz Eze, Chief Executive Officer (CEO) of Talkhealth9ja, said that the PHC sector remains functionally weak, despite the huge investments over the years by the federal and state governments as well as contributions by development partners.
“The people do not get sufficient value for the resources and this means that there is yet no adequate investment of resources in the sector,” Eze, who doubles as the founder of MakeOurHospitalWork Campaign said.
For instance, in 2016 the state government appropriated N714,022,969 for the Primary Healthcare Board. It also said it spent N63,000,000 on Drugs Management Agency across the state.
In 2017, N500,000,000 was approved for the procurement of medical equipment to primary healthcare centres across the state. An additional N801,312,000 was appropriated for the procurement of specialised surgical and medical equipment for various PHCs in the state.
Also in 2017, N400,000,000 was appropriated for the renovation and rehabilitation of Primary Healthcare centres in the state while an additional N1,590,000,000 was appropriated for the upgrading of PHCs to Cottage hospitals.
In 2018, N899,554,803 was appropriated for the state Primary Healthcare Management Board. In the same year, N600,000,00 was budgeted for the procurement of medical supplies. In 2020, N2,087,478,996 was also appropriated for the State Primary Healthcare Management Board while N91,364,000 was appropriated to the drugs management agency.
Between 2015 and 2021, the state government purportedly spent over N1.4 billion on epidemic preparedness. A breakdown of the spending shows that in 2015, 2016, 2017 and 2018, the state government spent N30,245,000, N574,647,808, N20,000,00 and N50,720,000 respectively.
In 2019, N10,000,000 was allocated for the control of cholera and other epidemics in the state. In 2021, the state said it created a budget line of N300m and an additional N88m (N2 million per local government area) for epidemic preparedness.
Apart from its own spending in healthcare, Kano state has also benefitted from several intervention funds intended to improve primary healthcare, including receiving the highest allocation of N948 million from the Federal Government’s N6.5 billion Basic Healthcare Provision Fund (BHCP) in 2019. Sadly, this spending has not translated into improved access to healthcare for most rural populations of the state.
Chiromawa and dearth of medical supplies
The Cholera outbreak in 2021 was overwhelming for the primary healthcare centre in Chiromawa, another community in Bichi LGA. At the heart of the challenge for the PHC was the lack of medical supply for patients.
Bichi was among the LGAs that benefitted from N2.54 billion approved and released for construction and upgrading works at four health facilities in the newly created Emirate headquarters.
Abubakar Nasir, temporary medical officer at the PHC said that although the government provided supplies, including drips and drugs, they were not enough compared to the cases that presented at the hospital. He added that on several occasions when the PHC ran out of supplies, it took the intervention of some community members to provide them.
“At Chiromawa, we recorded over 882 cases and 8 deaths. If a patient needed four oral rehydration therapy, the hospital only provided two while they bought the rest themselves.”
Sale Abdulahi is one of the community leaders in Chiromawa. He said that they had to write to the local government and other private individuals when cases began to surge and it was apparent that the hospital could not handle it.
“Our hospital did not have the necessary supplies to deal with the cases. Some patients had to buy drugs themselves,” Abdulahi said. “We would have lost more people if private individuals did not step in to support”.
Old facilities inside the Chiromawa PHC
He said the government needs to ensure that hospitals are always equipped and ready to tackle outbreaks such as Cholera which often hits local communities more. He noted that he and other leaders in the community have since spoken to people about the need to stop open defecation, improve their sanitation and hygiene practices and be mindful of the water they consume.
The PHC in Garfa, one of the communities in Sumaila LGA does not have accommodation for health workers. As a result, they must travel from different locations to attend to patients. When Solacebase visited the PHC, patients sat on the floor as they waited for workers to arrive.
At Garfa PHC, patients wait for health workers who come from far distances because they do not have a place to stay inside the hospital.
Apart from accommodation for workers, the Garfa healthcare centre does not have bed spaces where patients can receive treatment when they come around. At night, during emergencies, families always travel to the Sumaila General Hospital which is several kilometres away for healthcare.
The centre is also struggling with a shortage of staff and lack of medical supplies all of which made it difficult for it to attend to patients in the heat of the cholera outbreak in the community.
Hamisu Usman oversees Garfa health centre. He said that he had to refer patients to the general hospital in Sumaila due to the lack of equipment for testing and drugs and other medical supplies.
“When they came back and we needed to attend to them further, they had to buy supplies themselves because the ones we had were not enough. We want to work for our people, but because there are no places where we can stay and they can stay too, it becomes difficult,” he said.
He noted that the health centre has about the highest number of visitors in the entire local government, yet it is the smallest in size and lacks the basic facilities for healthcare delivery. He explained that several people, particularly pregnant women have lost their lives as they journeyed to the General Hospital in search of medical care.
He added that members of the community and the leaders contributed and got solar energy sources for the centre to be able to work in the evening hours because the government could not provide electricity.
Husseina Abdul still recalls how her family had to take her to Sumaila General Hospital when she was down with cholera in 2021 because the health workers at her community’s PHC were unavailable.
“It was late in the night and those who were working had already left the hospital. As we journeyed, I did not get myself because it was long.”
When they got to the hospital, Abdul said there were too many people and they had to wait for some time before she was finally attended to.
“I was weak and did not know I will survive, “she said. “We bought everything we needed and when I came back the following day, I became well again”.
Ibrahim Garba, the traditional leader of Garfa said that the government needs to expand the PHC to be able to accommodate health workers and patients when they come for treatment, as well as increase the staff strength at the hospital.
“We have had several emergencies at night, but we could not call health workers because they don’t live here. Primary healthcare centres are closest to the people and should be able to cater to their needs always.”
Malam Ibrahim Garba
Kano Government fails to respond to FOI request
On July 4, 2022 Solacebase sent a Freedom of Information (FOI) application to the Office of the Executive Secretary of the Kano State Primary Healthcare Management Board , requesting percentage releases on primary healthcare, amount appropriated and spent on epidemic preparedness. On July 15, 11 days after, the office acknowledged the request but failed to provide the information.
However, a source who is a member of the management staff of the agency, disclosed that the government was overwhelmed by the outbreak of Cholera in 2021 adding that access to healthcare remains a challenge in some parts of the state due to the lack of adequate infrastructure, health workers and medical facilities.
“One of the ways of achieving universal health coverage is through ensuring that PHCs across communities are functional,” he said. “But that has not been the case as maintenance remains a challenge”.
The source explained that there was also the challenge of inadequate provision of Cholera treatment centres which should further support the fight against the outbreak.
The source told Solacebase that the primary healthcare management board has since started vaccination to prevent further outbreaks of the disease across three local government areas in the state in collaboration with the World Health Organization, WHO.
“These include Bichi, Bebeji and Tofa. We will extend it to other areas in the state depending on the availability of vaccines.”
The source admitted that “beyond providing functional PHCs across the entire LGs, the state government needs to also provide the people with portable drinking water and toilet facilities to curb open defecation and sensitise them on how best to avoid further outbreaks.”
Way forward for PHCs
In other to get PHCs in Kano and across the country working as they should, Eze told Solacebase that there ought to be community ownership and active participation as required by the National Health Act 2014 and the Ward Health System policy of the NPHCDA.
He said that governments must also hire an adequate number of health professionals and ensure their retention through regular training, supportive supervision, appropriate remuneration and a good work environment.
While some experts believe that weak administration at the local government level is a major contributor to the dysfunctional state of primary healthcare centres in the country, Eze says the state government is to blame as it is responsible for the governance of the centres through the state primary health care development agencies.
“There should be more financial investment and efficient utilisation of available resources as well as the availability of essential medicines at all times,” he said.
Recall that Secretary of the Oversight Committee of the Federal Ministry of Health, Dr Chris Isokpunwu, had announced that the federal government had disbursed N56 billion for the Basic Healthcare Provision Fund (BHPF) as of June, 2022.
He said that with the releases, about 7,000 Primary Healthcare centres get operational funds on a quarterly basis to provide for essential medicines, transportation for vaccines and other medical consumables in the health sector. This is below one-third of 30,000 facilities across Nigeria that are said to be functional.
Eze said that there is also the need to strengthen the health data management system and use of data for decision making and the massive sensitisation of citizens and communities on common preventive diseases, and their roles in primary health care.
This publication is produced with support from the Wole Soyinka Centre for Investigative Journalism (WSCIJ) under the Collaborative Media Engagement for Development, Inclusion and Accountability project (CMEDIA) funded by the MacArthur Foundation.