Special Report: How personnel shortage, ‘internal brain drain’ threaten primary healthcare in Niger

Pregnant women for antenatal waiting for turn at Minna General Hospital

Primary healthcare centres in Niger State are acutely in need of doctors and midwives, thereby putting the few secondary and tertiary institutions in the state under severe pressure.

The situation stifles any plan by the state towards Universal Health Coverage (UHC) if not addressed. Providing adequate access to care for the entire population of the state will require enough professional hands, especially in the hinterlands.

To drive UHC and reduce out-of-pocket spending for health, the government in Niger – Nigeria’s largest state with the highest number of hard-to-reach communities – flagged off a Contributory Health Scheme.

Named ‘Nicare’, the scheme was signed into law last December. With a takeoff fund of N100 million, the government said it has designed a model and enrolment has been ongoing. What is remaining is for the insured to start getting services which are billed to commence next month.


But one of the many hurdles the scheme is bound to face is a dearth of health personnel to deliver services. The population of the state stands at approximately six million, but the health workforce is barely over 6,000, according to data from the Niger State Healthcare Development Agency (NSHDA).

This means roughly one health worker per 1000 population – far below the four or five per 1000 required for Sustainable Development Goals (SDGs).

Worst still, there is a severe internal ‘brain drain’. While the majority of doctors in the state work in a few urban areas, health facilities in the rural communities – mostly far-flung because of the large land mass – are largely staffed by retired nurses, community health workers, and on-and-off NYSC (National Youth Service Corps) doctors with little clinical experience.

A visit to several facilities and interactions with players in the health sector of the state last month during a local study tour by the National Institute for Policy and Strategic Studies, (NIPSS), puts a face to the gravity of the situation.

Abubakar Bello, the governor of the state, while receiving the NIPSS delegation had alluded to the challenge of unequal distribution of human resources.

Sharing an encounter (a year ago), the governor explained how health workers at the General Hospital in Minna, the state’s capital, are overworked by patients who throng the facility from far-to-reach hinterlands.

“Last year, I visited the general hospital, and the doctor there was overwhelmed. I arrived at about 10 p.m. and found that he has been working since 4 p.m. and even at that time; he still had about 40 patients to attend to. I looked into his eyes, and I can (could) tell that this man is tired,” the governor said.

Brain Drain

Mustapha Jibril, the Niger health commissioner, said hospitals in the cities are overstretched because of “internal brain drain”.

In the health sector, the phrase is used to describe the migration of health workers from rural to urban areas, where they believe there are more opportunities.

While primary healthcare facilities in the hinterlands remain dogged with multiple challenges – especially acute shortage of professional hands – the few secondary and tertiary care centres in the cities are overwhelmed and overstretched by patients who flock them daily from different parts of the state.

He said health workers prefer working in urban areas. He explained the government’s plan on tackling the challenge.

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“On human resources, we are trying to come with various policies that will enable us to send people to rural areas and make them stay there,” he said. “Health workers we are recruiting for those places have to sign an agreement that they will not leave or request for transfer over some time or they will be relieved of the jobs.

“We also make sure the people we picked are from the localities. We are doing specialised recruitment whereby people recruited will get specific allowances and are also paid ‘dislocation’ allowances different from what others get. This will serve as an incentive to make them stay,” he added.

‘Nothing has Changed’

Even though the governor was “disturbed” after that (2018) encounter at the general hospital and after “employing about 300 doctors”, caregivers in the facility are still short of hands to cater for the flock of patients as seen when the reporter visited.

Eight-month-pregnant Fatima Yusuf has no qualms travelling 25 kilometres from her home in Paiko town to the General Hospital for antenatal care. The facility was flooded by hundreds of pregnant women, but Mrs Yusuf, a student nurse, said she prefers waiting in long queues than visiting the health facility in her rural Paiko town.

Her reasons: there are no doctors and enough midwives even at the comprehensive PHC in Paiko.

The World Health Organisation (WHO) suggests that achieving 80 per cent coverage rate for skilled birth attendance and child immunisation – two basic primary healthcare targets – requires at least an average of two to five healthcare professionals – physicians, nurses, and midwives – per 1,000 residents.

But many PHCs in Niger are facing critical shortages, forcing pregnant women to abandon them for the General Hospital in Minna and the situation has completely overstretched the workforce of the facility which originally is meant to provide secondary care.

“The major problem is that pregnant women come from far-flung areas because the PHCs are not working,” said Mrs Yusuf. “Though deliveries used to be free here, the facility had to ask us to pay N5,000 to dissuade those coming from far places, but as you can see, that is not working. They just need to employ more staff.”

Juliet Abdullahi, a midwife at the antenatal clinic, said they work from morning till 7:30 p.m. and ”sometimes without shifts”.

The facility has about 120 midwives who handle over 450 deliveries per month, said Gambo Mohammed, the head nurse.

The structure of healthcare delivery in Niger had been altered by an unequal distribution of manpower which Aminu Magaji, the Chief Medical Director of the general hospital, said will disrupt any model of health insurance and scuttle the progress of UHC.

Mr Magaji explained that the facility was only meant to take referrals of complicated cases from PHCs but now bears the brunt of primary health delivery.

“We are overwhelmed,” he said. “This hospital is meant for the 30 per cent of the state’s population living in the city, but a chunk of the 70 per cent who reside in rural areas turn up here.

He said any plan to drive Universal Health Coverage (UHC) in the state should be driven by providing adequate manpower for PHCs.

“You can’t leave PHCs who are supposed to take care of 70 per cent of the population without doctors.”

He described as grave, the rate of out-of-pocket spending for health in the state, saying only 20 per cent of the population, who are federal civil servants are currently covered under the National Health Insurance Scheme (NHIS).

For Niger to achieve UHC, Mr Magaji said the government needs to rework a sustainable model for the mandatory state health insurance scheme that will cover over 80 per cent of the population who spend out-of-pocket for health.

“Out-of-pocket spending is worse in the PHCs.”

Niger has about 16, 788 settlements and about 4, 700 of them are in hard to reach areas, according to Mr Jibril, the health commissioner.

The commissioner said the government is focusing on revitalising “our PHC system as part of the integrated network of care because, through PHCs, we will be able to reach out to the 70 per cent of our population living in rural areas including hard to reach communities.”

Even without a dearth of health workers, most of the 1, 350 PHCs in Niger state are dysfunctional, according to the State Primary Health Care Board (SPHCB).

Mr Jibril said the PHCs had been abandoned for more than four decades until the government came in on the ‘PHC Under One Roof’ policy.

Under the policy, Mr Jibril said one focal PHC in each of the 274 wards in the states was revitalised for a start to provide basic primary services and care for enrollees when the state contributory health scheme commences.

Shortages in the Model PHCs

But a visit at three of the focal PHCs proved otherwise. None of them has a permanent doctor or an ambulance for referrals.

The model PHC in Paiko, which takes referrals from at least 15 smaller health clinics and posts in Paikoro local government only have three professional nurses.

The facility needs at least eight midwives to match the 50 patients it treats daily from the 9500 residents of Paiko town said Hadiza Mizare, the PHC board director of the local government.

Mrs Mizare said the facility is hoping the government will send a ‘youth corper doctor’ soon. She said, apart from getting referrals, “the PHC also refer critical cases to the general hospital in Minna, but the challenge is that there are no referral vehicles.”

Another comprehensive PHC in Beji is also arranging for an NYSC doctor as they have none.

The health workers said the facility does not have an adequate power supply to preserve immunisation products.

Here, the families of the patient will provide the vehicle for movement when the need for referrals arises.

Ripple Effect

The acute shortage of doctors and midwives is forcing many pregnant women who cannot afford bigger hospitals to rely on unprofessional hands and Traditional Birth Attendants (TBAs) – a situation Mr Bello, the governor decried, saying the state is “losing a lot of people during deliveries and the numbers are not encouraging.”

With one in every ten children born in Niger dying at birth, the maternal mortality rate stands at 352 per 100, 000, according to data from the NSHDA.

The community health workers at the Memorial PHC in Chanchaga Local Government of Minna said many pregnant women even prefer TBAs.

A health worker in the facility said “we do give them (pregnant women) advice that they should stop delivering babies at home because it’s very dangerous.

“There was this scenario that happened, the child of a patient died in her womb because her mother-in-law had insisted that she deliver at home. This resulted in prolonged labour and the baby died before they brought her here.

“We have (had) to struggle to bring out the dead baby and save the mother.”

Knotty Problem

The PHC problem in Niger is similar to that of many other states in Nigeria.

In an attempt to solve the problem, President Muhammadu Buhari in January 2017 flagged-off a scheme to revitalise about 10,000 PHCs across the country.

The aim was to ensure that minor ailments are treated locally, instead of being referred to bigger hospitals.

But more than a year after the plan was kicked off, PREMIUM TIMES’ investigation found that very little work had been done.

Prior to the time, a previous investigation by this medium, about 10 months after the plan was flagged-off, mirrored how health workers in rural PHCs are overworked due to acute understaffing.

PHCs are bedevilled with multiple challenges despite billions allotted to them over the years especially due to mismanagement.

The federal government is not directly and constitutionally responsible for primary and secondary care, according to the health minister, Isaac Adewole.

An analysis by civil society organization BudgIT shows that nearly half of the states are struggling to pay workers’ salaries and fulfil election promises such as roads construction and job creation, issues that are absorbing the attention of many governors more than improving the quality of health centres that already exist.

Besides, there is an element of misplaced priority. While thousands of PHCs lie unused, the government continues to build more across the country without any serious plan for equipping and staffing them.

Only about 20 per cent of the 30,000 PHCs in the country are functional, a survey by a nongovernmental body, the Civil Society Legislative Advocacy Centre (CISLAC), said.

Last year, American businessman and co-founder of Bill and Melinda Gates Foundation, Bill Gates, during a visit, described Nigeria’s Primary healthcare system as “broken.”

In May, Mr Adewole admitted that the collapse of primary and secondary healthcare has put teaching hospitals in the country under tremendous pressure, blaming the situation on poor funding by state governments.

Meanwhile, in Niger State, the poor state of PHCs have expectedly affected the output of both secondary and tertiary institutions who are now mostly reduced to “glorified PHCs,” says Abdullahi Usman, the Chief Medical Director of the Federal Medical Centre in Bida.

Mr Usman decried the situation, saying most secondary and tertiary institutions now have a PHC unit. “Even institutions such as road safety do not even know the difference between PHC, secondary and tertiary care institutions.”

He said the situation encourages out-of-pocket spending.

“People sell properties before they can travel out of their settlements to the hospitals in the urban areas which are usually costly due to out-of-pocket spending.

“This to me is where we should focus our attention on if we really want to achieve Universal Health Coverage in Niger state.”

The NIPPS local study tour of Niger state’s health sector was coordinated by NIPSS in collaboration with the Development Research and Project Centre (DRPC) through PACFAH@Scale.


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