Primary health care system in Nigeria is dogged by multiple challenges despite billions of naira spent over the decades on health facilities by government at different levels.
Less than 20 percent of the 30,000 public PHCs in the country is fully functional, a recent survey by a nongovernmental body, CISLAC, said.
Going by the blueprint of the National Primary Health Care Development Agency (NPHCDA), a PHC should have one or more doctors, a pharmacist, a staff nurse and other paramedical support staff to provide outreach services.
It should also have a well-equipped open ward, labour room, children and female wards, doctor’s office and staff quarters, an ambulance for referrals and drugs and equipment for immunisation, preventive and basic curative care. The centre is also to provide monitoring and evaluation, as well as maternal and child health services.
More Promises, Less Action
The challenges PHCs across the country are facing prompted the Nigerian Senate in February to call on the federal government to put primary health care facilities across the country in good shape. The Senate asked its appropriation committee to ensure that funds were set aside to make the PHCs functional.
However, the Minister of Health, Isaac Adewole, in an interview with PREMIUM TIMES on January 31, stressed that provision of healthcare in Nigeria is a concurrent responsibility of the three tiers of government. Mr. Adewole appealed to the National Assembly to stop creating new PHCs so that existing ones can be put in good shape.
“We are also appealing to the National Assembly not to create more PHCs because having a building is not synonymous to a health centre. A building without human resources, equipment and drugs is not a health facility. Everybody wants to build a PHC in his village, but who will run it? So we are begging them to stop creating,” he said.
In January 2017, President Muhammadu Buhari flagged off a scheme to revitalise PHCs across the country to enhance the access of Nigerians to qualitative and affordable health services.
Under the revitalisation plan, the government through the NPHCDA and the Federal Ministry of Health wants to make at least one PHC fully functional in each of the wards across the country. In the first phase of the plan, the government selected a PHC in each of the 109 senatorial districts. State and local governments as well as development partners are expected to compleament this gesture by also selecting some PHCs for revitalisation.
In all, the government hopes to revitalise 10,000 PHCs.
“It’s not FG that is revitalizing, what we said is that we want to see 10,000 PHCs revitalized in Nigeria because if 10,000 is done, it will cover about 100 million people.
“We only did this to stimulate the governors and many of them have taken it up. At the last count, Niger has done 40. We did three in Niger and we call them model PHCs. President Buhari commissioned one in Kuchingoro. In Kaduna the governor has done 255. I’ve commissioned in Kebbi, Abia and other states. What we are asking the governors to do is to invest and partner with us.
“I can also tell you as of today, the World Bank has done about 1500 PHCs. The EU is committed to 774. The British government is doing 950. FG is committed to 110 last year. This year we will do more. So, over all, we are adding them together and we will now ask the states ‘how many they’ve done, where are they located?’ We are also doing an inventory of the PHCs done by ALGON.”
In December last year, the federal government initiated a N28 billion health fund that targets the revitalisation of at least one PHC in each of the country’s 774 local government areas.
Mr. Adewole, who inaugurated the special intervention, said it would be formally rolled out in 2018.
While the government shuffles plans, shortage of primary healthcare services continues to force women in Nigeria to patronise untrained traditional birth attendants, despite the serious risks involved.
According to a survey conducted by the Civil Society Legislative Advocacy Centre (CISLAC), in Nigeria one in 13 women dies during pregnancy or childbirth.
Although many of these deaths are preventable, the coverage and quality of health care services in Nigeria continue to fail women and children. At present, less than 20 per cent of health facilities offer emergency obstetric care and only 35 per cent of deliveries are attended by skilled birth attendants.
American businessman and co-founder of Bill and Melinda Gates Foundation, Bill Gates, at the expanded National Economic Council meeting held at the Presidential Villa, Thursday described Nigeria’s Primary Health Care system as ‘broken’ 40 years after the first attempt by the government to make it functional.
“The evidence for this can be found in the epidemic of chronic malnutrition or stunting,” Mr Gates said.
While noting that a strong primary care system takes care of 90 percent of people’s needs, he lamented that Nigeria is the most dangerous country for child delivery.
PREMIUM TIMES exclusively obtained the list of the 109 PHCs the government said it was rebuilding.
Earlier, the newspaper sent reporters to visit PHCs randomly selected — at least one PHC in each of the six geopolitical zones. The reporters found almost all the PHCs they visited in a terrible state, unless the handful revamped by donor organisations and some state governments.
North East: Borno State
Gamboru Health Centre is located in Limanti area of Maiduguri in Borno central senatorial district. Inscribed on some of the furniture is Borno State PHCDA.
The medical personnel would not speak on record because they were not authorised to speak. But they told PREMIUM TIMES that the facility was recently renovated by UNICEF. A plaque showed that the organisation undertook the project.
“We know the organisation carried out many renovation last year”, said one of the senior nurses.
The state executive secretary of the state PHCDA, Suleiman Melee, said the federal government was yet to start work on any of the three PHCs it selected in the state.
“Of course there are minor repairs in some places but they were done by the state government or development partners. As at today, none of the three selected PHCs (by the FG) has been renovated,” Mr. Melee said.
North Central: Nassarawa State
Agwatashi PHC in Obi local government in Nasarawa South senatorial district is one of the three centres in the state earmarked for revamping by the federal government.
A tour round the facility showed that it is functioning and well-equipped. It boasts of equipment such as a cold room, staff quarters and a well-stocked drug store. The situation of this centre is way different from those at other centres visited, indicating the world of difference a speedy and faithful implementation of the rehabilitation scheme can make to primary health care delivery in Nigeria.
“The facility does not lack basic amenities, it is fully-equipped because this facility is supported by the Decentralised Facility Financing (DFF). Most of the funding sent to this facility is by the DFF and we make judicious use of it, as you can see”, the officer in charge, Ayuba Adole, said.
There is a functional borehole supplying water round the clock and a generator to supply electricity mostly at night whenever the inverter is out of service.
There were two security men, six medical staff, six voluntary staff and one NYSC member. Mr. Adole, however, said lack of trained medical personnel and ambulance for transportation of transferred patients were major challenges of the centre.
South East: Ebonyi State
The PHC in Ngbo is one of the three selected for renovation by the federal government in Ebonyi State. Ngbo is a village in Ohaukwu Local Government Area of the state.
A staff of the centre who refused to give her name for fear of victimisation said a Federal Government official visited the hospital last year and collected a list of what needed to be done at the hospital.
“I was surprised when a few months later a contractor showed up and repainted the building and changed a few wooden doors to iron doors. He also built a generator house and left. That was all they did. No supply of drugs or any equipment. They even did a poor painting job,” the staff said.
The hospital, the staff said, has a functional solar electricity system and also a generator, courtesy of the state government.
Our reporter who visited the hospital saw signposts of various renovation jobs done in the past by the federal government through the Subsidy Re-investment and Empowerment Programme (SURE-P). These include renovation of the hospital, construction of a motorised borehole and a staff quarters. The staff confirmed that some of those works were actually done by SURE-P.
South West: Ondo State
The PHC system in Ondo State is yet to feel the impact of the revitalisation scheme, as the centres are facing huge funding and facility challenges, PREMIUM TIMES can report.
The PHC visited is located in Ijare, Ifedore Local Government Area in the central senatorial district of the state. It is listed as one of the PHCs selected by the Federal Government but the revitalization plan is yet to be carried out.
A building meant to boost the capacity of the centre to accommodate more patients was abandoned due to lack of funding. The facility is understaffed and lacks basic materials required to care for patients. The facility also lacks adequate manpower, it has no resident or visiting medical doctor.
The clinic runs on the Performance Based Funding (PBF) system but hardly has enough fund to buy even reagents for its laboratory or drugs for its pharmacy. It was gathered that the centre is giving about N600,000 a quarter by the state government to pay its ad hoc staff and for running costs. Due to insufficiency of fund, the ad hoc staff had not been unpaid for two months when PREMIUM TIMES visited.
One of the staff who spoke to PREMIUM TIMES off record, as they were not authorised to speak to journalists, said the last time the centre was renovated was in 2009 by the government of former Governor Olusegun Mimiko. PREMIUM TIMES also learnt that during the administration, women were delivered of babies at the centre free of charge and sometimes got gifts.
But at the moment, they are charged a token for delivery materials the hospital could not provide.
“We cannot send away patients because we do not have the materials to use. We have to do the little we can, just to ensure they are taken care of,” one of the staff said.
The Executive Secretary of the state Primary Health Care Board, Akanbiemu, told PREMIUM TIMES that PHCs in the state were funded by the state government in collaboration with the World Bank.
“I am aware that the Federal Government is proposing an intervention in the states, but we are still waiting for that. We know it is coming but we are yet to have it in place,” he said.
North West: Kano State
The PHC in Shuwaki is one of the three selected for renovation by the federal government in Kano State. Shuwaki is a village in Kunchi Local Government Area of the state.
As the reporter approached the facility, it became clear that it was still awaiting any kind of makeover. A part of the main gate was falling apart, grass covered the entrance to the main building and the paints were peeling off the walls. The dilapidated PHC was built about 18 years ago and is the only health facility in the community. But it has been provided no equipment or personnel to play the role for which it was built.
“We do not have a doctor or nurse,” the officer in charge of the centre, Ado Mohammed, told PREMIUM TIMES.
According to Mr. Mohammed, the workforce consisted of five Community Health Extension Workers (CHEW), one Junior CHEW and a lab technician.
Mr. Mohammed said lack of water supply was one of the big problems. “We buy water from our own pockets,” he said.
Power supply is epileptic and the centre has no generator or inverter. The centre also has no ambulance.
Aisha Sani, a laboratory technician has been at the centre for over five years. “Since I have been working in this facility, no renovation has been done. The way I met this place, that is the way it is. No water, the toilet is very bad and no resources at all for a standard health centre.”
Mrs. Sani said she stopped running HIV tests at the facility when the authorities stopped providing test kits.
When PREMIUM TIMES put its findings to the Executive Director, National Primary Health Care Development Agency (NPHCDA), Faisal Shuaib, he explained that the revitalisation scheme will be implemented over the course of several years.
“All of that is happening. Maybe some of the health facilities that you have gone to have not been handed over to the communities because we do not even have the human resources.
“We have started the process of mobilising about 1,600 basic midwives who will be deployed to help manage some of the health facilities. We are looking at also getting funds from the Basic Health Care Provision Funds which hopefully will provide the resources to equip and provide commodities for some of these health facilities,” he said.
Mr. Faisal said it will be a misunderstanding of the plan of government to say just 109 centres would be revitalised.