Home Health Beautiful but Useless: Budget Constraints, Dead Structures Cripple Primary Health in Nigeria

Beautiful but Useless: Budget Constraints, Dead Structures Cripple Primary Health in Nigeria

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By Kolawole Omoniyi

Waddiya PHC Under Lock Over Manpower Challenge

In the rainy season, the road through the Bardo community in Jigawa State favours only bullock carts. They carry farm produce. They are also the only means to transport ill persons and pregnant women from Bardo to Ajaaura Primary Health Care Centre, some 15 kilometers away.

Rahama Sabo and her husband, Sabo Sarkin, went on that journey from Bardo when she went into labour to give birth. They spent two and a half hours before they reached the Ajaaura health center.

Bullock Cart in Bardo Community

“The baby’s legs had already come out before we got to the hospital,” Sabo recalls of the journey with his wife in labour.

“Blood was flowing to an extent that the clinic almost rejected us before we were eventually considered after narrating our ordeal.

“It was a futile effort because my wife and the baby died shortly after our arrival around 10 pm.

“This wouldn’t have happened if Bardo PHC is a 10 10-minute trekable distance from my house was functional,” Sabo explains.

Yes, just 10 minute’s walk from the Sabos is a newly painted health center in Bardo, Taura local government area of the state. But it is not functional.

Newly Painted Bardo PHC without Infrastructure

Women Buy Fairly Used Ambulance to Curb Mortality Rate

For 10 years, the center has stood, pretty as a physical structure, but it lacks manpower, furniture, and basic amenities to serve Bardo’s 10,000 population, says Saminu Usman.

He is the in-charge of the facility and the lone worker running skeletal services for over 20 years in the area. Usman usually locks up the facility when he is on break or embarking on other official tasks.

Umar Harisu, the community leader says Rahama’s death is the sixth maternal mortalities on recent record in Bardo, directly related to the unserviceable primary health care center.

While the center remains nonfunctional, women in the community devised a means of getting transport across the 15 kilometers to Ajaaura.

“To avert recurrence, some community women recently contributed N1,000 each and bought a fairly used car to be conveying their fellow pregnant women to Ajaaura PHC,” says Harisu.

The state government did not bother making the Bardo PHC functional. Instead, it provided a defective ambulance to complement the women’s car.

ambulance provided by the state government
The car bought by the women

Bardo PHC is not alone. Many primary health facilities in the state lack manpower. They rely heavily on voluntary and casual workers, as well as other ad-hoc staff temporarily engaged by international donors or nongovernment organizations.

One of such projects being implemented by the Global Alliance for Vaccines Initiative hired Yasin Nafisa—and she is the only midwife at Garin Ciroma PHC. Over at Yalawa PHC, the only midwife is also employed by the same project.

She is from Niger state. Twice every year, she gets a cumulative period of three months of annual leave. When she is on leave, there is no one to replace her.

“I will be here for three years for the GAVI project’s lifespan. I usually make sure that my leave does not clash with my colleague at Yalawa PHC so that we don’t leave the entire community in danger.”

Also, at the Yalawa PHC, the only available midwife was engaged by GAVI project as confirmed by Hashim Usman, the deputy in-charge of the facility.

Top Health Worker Gets N10,000 Stipend Monthly

The situation is similar at Kiri PHC. Kamisu Yahaya was only recently engaged as a casual worker and put on an N10,000 monthly stipend after working at the center for four years without pay. He is now the deputy in charge.

“The only government worker here is the in-charge,” Yahaya says. “Even me I just started collecting N10,000 monthly from money we are realizing from our patients. Other voluntary workers do not receive a dime.”

This explains the awful situation of the PHCs in the northwest of the country. But the states in the other five geopolitical zones are no different.

Northeast Nigeria Suffers Similar Fate

As it is in Bardo, Jigawa, it is in Malamari, Borno. For several years, Malamari—just 10 kilometers from the state capital Maiduguri—did not have a PHC. Three years ago, a PHC was built—without infrastructure to function.

Malamari PHC Under Lock

It has remained under lock for years. Alongside it, maternal and child mortality has risen 30% in the village.

“There have been cases of death because most of the villagers are not financially buoyant enough to access healthcare in the city,” says Bulama Abba, the village head.

Awana was a victim months ago, after a bout with malaria. His grandmother Zainab Musa recalls the night she lost her grandson.

“His malaria illness became worse at night, and we didn’t have the transport means to take him to the city,” she says.

“He was declared dead on arrival at the Borno Specialist Hospital the following morning.”

Zainab Musa

The challenges of transportation and finance are daunting for Malamari, but the community is also besieged by the insecurity in the state, brought on by Boko Haram terrorism.

“There is a midnight curfew. So, without a security escort, nobody would be allowed to visit the nearest hospitals,” says Bukar Tela, chairman of the Civilian Joint Task Force in Malamari. The force provides security in the area.

Husband Takes Delivery of Pregnant Wife at Home

Against the odds, some women in the Waddiya community in the Mafa Local Government Area of Borno have resigned to fate—they opt to give birth at home. The only PHC in the community was under lock due to inadequate manpower. 

Waddiya PHC

Falmata Umar is one of the women who had no choice but to give birth at home, with the support of her husband. She holds her healthy infant in her arms.

Falmata Umar

“I was supported by my husband to give birth to this baby at home just like other women in this village are doing because our hospital is not working,” Umar says.

In the north-central region of the country, Niger is not immune to the numerous challenges bedeviling PHCs across the country.

For several years, residents of Ashuwa traveled 20 kilometers to Yangalu just to access medical care. In 2012, the state government built a PHC to end their plight.

Five years later, the joy disappeared as the center fell into decay, says Usman Galadima, the community’s leader.

Ashuwa PHC

 Health Workers Abandon Ramshackle Facility, Render Home Services

“We rely on self-medication and there is no antenatal care for our pregnant women. They mostly deliver at home because our road is not motorable.” He laments

Elsewhere in Mashegu LGA of Niger is the Karamin Rami PHC. The facility is in growing deterioration. Health workers posted there have no place to work.

Muhammed Babagi, the officer in charge of the facility said the dilapidated PHC has relegated them to treating patients at home on invitation.

Patients’ Relatives Must Fetch Stream Water Before Treatment – Official

Like in the north, PHCs in the south of the country also bear the brunt of daunting challenges.

For instance, in Ogun State, failing structures, bat infestation, inadequate manpower, and lack of basic amenities to the challenges of the PHCs in the state.

Tonigbo PHC in Ijebu East LGA is already in deplorable condition. It relies on rainwater for its water use. When rains have gone, health workers mandate patients’ relatives to fetch water from a stream 3 kilometers away before attending to their loved ones.

“We decided that relatives of our patients especially pregnant women should be fetching water from the stream because there is no potable water in the entire community,” says Oluwayemisi Igbosanu, the in-charge of Tonigbo PHC.

Oluwatoyin Amusa, a farmer, was among the residents who recently fetched water before his wife in labour was delivered at the facility.  

“If we don’t fetch water the delivery will be put on hold, it’s a normal practice here,” he says.

Bat Infestation Sacks Healthcare Givers, Patients

Many PHCs in Ogun State are battling bat infestation. Colonies of bats invading spaces for health care have sacked patients and staff at the affected facilities including Ojelana, Atoyo, and Tonigbo PHCs in Ijebu East LGA.

The bat faeces litter corners, have damaged ceilings of the visited facilities and rendered the health centers inhabitable for years. 

Bat Faeces Littering PHCs in Ogun State

The Ojelana facility – serving 41 communities and operating 24 hours daily before – is now a ghost of itself due to the unbearable odour of bat droppings and decayed infrastructure, according to Mrs. Bunmi Ibrahim, the only worker at the center.

“We do take delivery here since the establishment of the center in 1981, but now we took only one delivery throughout last year [2023],” she says.

The situation is bad, even patients desperate for labour do not want to stay.

“Recently, a pregnant woman was brought here for delivery, and I allocated one of the rickety beds to her. I thereafter went out to get some delivery items but to my amazement, she sneaked out before I returned.” She explained.

Hold PHCs Administrators Accountable, Official Begs Journalists

In an official reaction, the Executive Secretary of Ogun Primary Health Care Development Board, Dr. Elijah Ogunsola, said the state government is currently renovating at least one PHC in each of the 236 political wards in the state.

“We have renovated close to 100 now and it’s an ongoing project as some of them will be refurbished this January 2024.

“On other challenges, you people [journalists] should help us hold the PHCs administrators accountable, we pay them N100,000 monthly to run their activities apart from their internal incomes, so I wonder what they are using the money for if they don’t have water,” he said.

Oil-Rich Community Patronizes Mushroom Chemist in Place of PHC

In the south-south geo-political zone, the Umuechem Community in Etche Local Government Area of Rivers State lacks functional healthcare facilities despite their rich crude oil contribution to Nigeria’s economy.

It has over 250 oil wells. But grasses have taken over the vicinity of the only cottage hospital. Its roof was blown off in a windstorm.

 A building with a grass field

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Umuechem PHC

Over in Orwu and Ogida communities, pregnant women solely depend on chemist shops for antenatal, delivery, and postpartum care due to the deplorable condition of the Orwu/Ogida PHC.

Residents say there has been no replacement for several years since a midwife at the center retired and the building fell into decay.

“Vaccinators are only using the facility during immunization exercise,” they complain.

At Obite PHC in Ogba/Egbema/Ndoni LGA, Synger Azubike, a resident said they are spending about N3,000 on transportation to access healthcare at the closest facility.

Reacting, Kinikanwo Green, the Executive Secretary of the Rivers State Primary Health Care Management Board, admitted the outlined challenges.

He said the board is working on general maintenance and renovation of the dilapidated PHCs and employment of more health workers.

Appreciable PHCs, Limited Workers, Amenities

In the south-east, the aesthetics of buildings housing most of the 600 PHCs in Anambra are appreciably stunning. However the PHCs also face inadequate health professionals and lack of water and power supply.

PHC in Anambra State

These challenges are well pronounced at the visited PHCs in Amanuke, Urum, and Isuaniocha, all in Awka North LGA and Nteje PHC in Oyi, Ifitedunu PHC in Dunukofia and the PHC Abba in Njikoka LGA.

Most of the PHCs have just about three workers—a staff on the government payroll and two volunteers—to cater to the entire community. They also lack isolation spaces to be used during outbreaks of contagious diseases.

Exorbitant Hospital Bills and high drug prices Force TBAs’ Patronage

Some of the villagers also lamented the exorbitant charges and high prices of drugs at the facilities. The charges and prices are pushing pregnant women to patronize traditional birth attendants.

Phar. Uchem Chisom, the Executive Secretary of the Anambra State Primary Healthcare Development Agency admitted the challenges.

He said the state planned to boost its health workforce by recruiting 500 workers for the PHCs, in addition to two medical doctors, for each of the 21 LGAs in the state.

Chisom blamed the PHC authorities for the exorbitant charges and for sourcing drugs on the open market instead of utilizing the state’s central drug store.

Dead PHCs Force Patient’s Influx at Tertiary Health Institutions

Tertiary health institutions are suffering the pinch of the struggling PHCs across the country. They are admitting about sixty percent of patients with minor ailments that should have been managed at the PHC level.

Dr. Abdullahi Kabir Suleiman, Deputy Chairman of the Medical Advisory Committee at the Aminu Kano Teaching Hospital (AKTH) confirmed that an such overwhelming influx is complicating their service delivery.

“We do receive about 50-60% cases that should have been handled by the PHCs but I will not blame the patients because they don’t get what they want at the PHCs.” He says.

He is doubtful over the ability of the PHCs to withstand an outbreak of any serious disease such as Ebola or Cholera due to their deplorable conditions.

Eighty Percent PHCs Nationwide Are Deplorable

Nigeria has some 34,076 PHCs. They account for 85.3% of total hospitals and clinics across the country, yet the deplorable nature of most of the PHCs is subjecting rural dwellers to untold hardship.

According to Nigeria Health Sector: Market Study Report, commissioned by the Embassy of the Kingdom of the Netherlands in Nigeria (2022), about 80% of the 34,076 facilities are still non-functional.

Consequently, the report – compiled by PharmAccess Foundation’s Nigeria Office (PAF) – estimated 2,300 children aged under five and 145 women of child-bearing age die daily.

State of Emergency Declared

The different tiers of government are aware of these daunting challenges as evident in the recent declaration of a state of emergency in Nigeria’s health sector on 16th November 2023 by the Minister of Health, Prof. Ali Pate.

Making the declaration at the 64th National Council on Health in Ekiti State, Pate said the nation’s health facilities are in bad shape, hence there is a need for an urgent intervention.

Despite the state of emergency declaration, an analysis of the 2024 budget allocation shows the health sector still failed to meet the African Union target of 15% of the national budget.

Although the sector got the highest-ever budget allocation of N1.33 trillion in 2024, the amount is equivalent to 5.46% of the N28.7 trillion national budget.

This is about one-third of the 15% Abuja Declaration Commitment as 15% of the overall budget vote would have amounted to N4.125tn, leaving a funding gap of N2.622tn.

FG Allays Fear Over Low Health Budget

Reacting in an exclusive interview with our correspondent, the Executive Director of the National Primary Healthcare Development Agency (NPHDA), Dr Muyi Aina, said there was no cause for alarm despite the low budget.

Dr. Aina, who assumed office in October 2023, admitted the aforementioned challenges but reeled out the long-term goals and strategies of the present administration toward addressing the situation.

“There is a huge budget from the federal government, we also have Basic Health Care Provision Funds (BHCPF) which is 1% of the nation’s income and we do get substantial support from development partners which is not trivial,” Aina said.

“So, what we are doing is to better harness the resources that the donors and partners are bringing to maximize the results.”

Shortly after the “state of emergency” declaration, the federal government launched the Nigeria Health Sector Renewal Investment Programme where the 36 state governors and development partners signed an agreement to ascertain results.

Upgrading of One Per Ward PHCs to Global Standard

There are over 8,000 political wards across Nigeria. Dr. Aina said the government is committed to the ongoing upgrade of one PHC per ward to the global standard and even double the figure before the end of the four-year tenure of the administration.

He also identified the production of frontline health workers and skilled birth attendants as one of the biggest limitations to scaling up PHC activities across the country.

“The Federal Ministry of Health is making moves to overhaul the human resources for health supply for our PHCs workforce and midwives development program.

“We have begun the process of upscaling 120,000 frontline workers to have basic skills and they will be deployed to PHCs nationwide.

“There are several ongoing interventions that directly address the recent upsurge in the prices of medication and the government is pushing very aggressively toward local drug productions that can lower cost.”

When those conditions are in place, the PHC in Bardo would hopefully not simply be newly painted but would be able to save the lives of people like Rahama and her baby.

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