(In this second part of his investigation into the terrible state of PHCs across Nigeria, Ebuka Onyeji reveals the rot in the system, and the factors leading to the current situation. You can read the first part here).
‘Out of service’ read the network signal on the journalists’ phone at exactly 6:35 p.m. one recent Tuesday evening just as the driver, possibly 18 years old or thereabout, swerved into the muddy road.
After several twists and turns, the vehicle came to what seemed the end of the road. A river? That’s the first suggestion that came to the reporter’s mind. Stretched at a distance of more than 70 meters, almost twice an Olympic-size swimming pool, the drench of the day’s rain formed a pool of flood water ahead. This is where the water is rushing to as there was no gutter on both sides of the road.
To the amazement of the journalist-passenger, the youthful driver accelerated into the pool. The vehicle began to soak and abruptly stopped almost midway into the pool. It took the combined effort of the passengers who had alighted and some locals to push the vehicle over to the other side of dry land.
This is the only route in and out of Adikwu-Icho community in Apa Local Government Area of Benue State. A night’s rainfall means the flood pool will get as deep as 4 ft. However, if it rains more than a day, movement becomes impossible because you will need a boat to cross, which is not always handy.
Luckily, the car ignited again after some touches and the driver eventually pulled over by a structure “This is the place you are looking for,” a passenger pointed to an old building, “That’s the Primary Health centre.” It could be hardly seen because it was already dark and it was still raining.
Although the journalist was given a warm welcome and a place to spend the night, there was a sense of urgency in the facility. Two women were in labour.
The labour room is quite scanty with very few equipment at least to cover emergency obstetric care services. It also had no functional ambulance to aid referrals. Relatives of patients have to provide their own transport in the event of an emergency.
The husband to one of the expectant mothers, who identified himself simply as Basil, recounted their ordeal in bringing his pregnant wife to the health centre.
“It was not easy, me and my brother had to carry my wife who is already in pains because of the pregnancy on our shoulders to cross that flood and get to this side. There was no car or motorcycle that can cross that place because of the water and it’s already night, I just hope and pray she delivers safely,” Basil said.
Clad in white apparel and gloves, a nurse, Grace Diashe, was busy trying to start the standby small generator which powers the facility during deliveries or emergency at night as there was no electricity in the community.
Adikwu-Icho is home to about 2500 people who are predominantly farmers with more than 200 small houses, a typical rural setting.
The silence of the morning was punctured by cries from the new born babies. Buckets were arranged under the roof edges of the building to collect rainwater. This is a tell-tale sign of insufficient water supply. There is not even a borehole in the facility.
About 30 feet away is another health care centre. This one, a beautiful bungalow painted in yellow and ox-blood. It is a N22 million project contracted to Ogason Construction LTD in 2014 by the National Primary Health Care Development Agency, NPHCDA. But since it was roofed about a year ago, it has been under lock and key and now covered by bushes.
Such health facilities are meant to be the bedrock of public health services in the country. In 1978, Nigeria, along with other World Health Organisation’s member countries adopted the declaration instituting the primary health centres as the basic structural and functional unit of public health delivery system.
There has been three major attempts at achieving people oriented PHC in Nigeria. The first attempt was made between 1975 and 1980. A second attempt, led by the late Professor Olukoye Ransome-Kuti, was between 1986 and 1992.
NPHCDA was established in 1992 and it heralded the third attempt.
Despite these attempts, Nigeria’s primary health care system remained dogged by multiple challenges.
The new health centre complex in Adikwu-Icho is well built but not yet accessible. There were also no equipment and infrastructure when this reporter visited.
Locals blame government and contractors for not involving locals in the project as well as for not planning fo an access road.
Paul Adama, the community’s general secretary, said although the community provided land for the project, it was not carried along during execution.
“We don’t even have the number of the contractor and I don’t think the work he did so far is commensurate with the contract amount,” Mr. Adama said.
“This our road has been like this since I was born. During dry season it can be manageable and motorable but becomes waterlogged in raining seasons because there is no channel for the water to flow out. The community has been cut off because of this flood.
“We have complained severally but nothing has been done. We have two polling units here, the government only come during election period. After their campaign promises, we vote them but they will not do anything.
“With this road, tell me how many qualified health workers will be willing to work here. We don’t have light, good school and other basic amenities,” he added.
The functional health centre, where Mrs. Diashe works, services the health needs of the community. It is a Millennium Development Goals, MDG project of the Goodluck Jonathan administration. This is where the reporter spent the night.
Here, one qualified nurse and three health workers struggle everyday with the challenge of attending to thousands of residents with limited drug supply and no standard equipment.
Worse still, child delivery, pre and post-natal care remain the biggest challenge, health workers say.
Giving a rough mental statistics, Mrs. Diashe estimates deliveries taken in a month to be up to 25, although she was careful not to reveal fatalities.
“We don’t have a lot of things in our labour room which makes delivery difficult. We don’t have enough qualified staff, we need a doctor.
“If am carrying out delivery and meet an issue I cannot handle, we normally refer the person to Aliade but it’s always a challenge because of this road. If we have a doctor here, he will handle all these and will save the life of the mother and child.
“Pregnant and nursing mothers in the community normally resort to traditional means due to these challenges,” Mrs. Diashe said.
LIKE BENUE, LIKE NIGER
Far away in Niger State, it took the efforts of three men to open the rusted door of a PHC in Gbaye village in Shiroro LGA of the state only to be welcomed by a host of bats occupying the roof of the building. That was after meandering through tall bushes that have taken over the entire compound.
Painted blue outside and yellow on the inside, the facility is well built, with each room well spaced in line with the standard expected of a typical health centre. But the complex was then left unused, and allowed to become a serene home for bats, who seemed unhappy at the sight of strangers.
In some rooms, the PVC ceilings had fallen apart, allowing the bats to have unhindered access to every part of the building.
Yakubu Soma, the security guard at the complex, simply turned the entrance of the building to a farmland.
He complained of not being paid despite his efforts in trying to rid the place of bushes. “I was brought about two years ago by an Alhaji (contractor) and he gave me N40,000 to stay and take care of the place but since then, he has not come here or even paid me.
“I remove the bushes that fill this place up without being paid. I am tired of staying here. I don’t have money to buy chemical to remove these bushes again,” Mr. Soma said through an interpreter.
A member of the community, Ittah Dahiru, however, said the place was locked up by the contractor who told him he was being owed by the government despite completing almost 90 per cent of the project.
A 33 minutes phone conversation with Musa Gwadebe, the contractor, gave a new perspective to the controversy.
Although data available on Budeshi, a public procurement data platform, showed that the contract was awarded for N37 million, Mr. Gwadebe said he only received N7.5 million.
PREMIUM TIMES further learnt that the contract was awarded by NPHCDA, with execution oversight by Abdullahi Rikko, the member representing Shiroro constituency at the House of Representatives. The contract was awarded to one Ibrahim Abah.
It was further learnt that Mr. Abah, who does not own a construction company, used his brother’s company, Abamatu Resources, to corner the contract. Abamatu Resources in turn subcontracted Mr. Gwadebe to execute the job.
The laws guiding procurement however states that a contractor must own a company and show evidence of previous similar jobs done within before he or she can be considered.
“We got the contract in November 2014 and we only received N7.5 million through Abamatu Resources account. As the work progressed to 65 per cent we requested for more money after evaluation of work done but we were told by the person in charge to finish the job as quickly as possible so they can pay us the full balance (N30m).
“I then got a loan from the bank and used my house as collateral so I can complete the project on time. We completed the work in March 2015 before the general elections and since then we have been making requests for our money and up till now (more than 2 years) it’s yet to be paid.
“We have traced our file to the audit department of NPHCDA but all we were told is there is no money.
“The certificate of my house is in court and I’m about to lose it to the people I borrowed money to complete this project. We locked the building up,” Mr. Gwadebe said.
The head of audit department at NPHCDA who simply identified himself as Yemi said the board was unable to pay the contractor because the money allocated for the job had since been returned to federal government’s account.
“At the end of every financial year, all the money for contracts that was not used will bounce back to FG’s till another budget is released and that is why we couldn’t pay the contractor. His money returned to the government.
“We have written to the government to release liabilities to us but they have not responded and that is the issue,” Yemi said.
In the midst of all these, however, the well-built PHC in Gbaye village keeps decaying while the people it was meant for are in dire need of its services.
A NATIONAL PROBLEM
The Gbaye case mirrors the situation in several Primary Health Centres, PHCs, built in the last three years across the country by the federal government. Incomplete or completed, many remain unused, in spite of huge need for them.
In most cases, this is because money was appropriated, contracts awarded and construction commenced without a laid out plan to track the project, its sustainability, due consideration of road network and its accessibility to the people as well as proper liaison and linkages with state and local governments where they are sited.
According to the data from Budeshi, the NPHCDA awarded 91 contracts for the construction of PHCs in 2014 and 2015.
The data showed that the new PHCs were awarded mostly at the uniform sum of N21, 986.893.00 to different contractors in many states raising the red flag on whether NPHCDA carried out competitive bidding before the contracts were issued.
WHO IS TO BLAME?
According to Utache Johnson, an official of NPHCDA, it is expected that the local government authorities periodically inform the board on the progress and challenges of PHC’s within their jurisdiction.
“We are working with contractors and House of Rep members representing each local government. The House members are the ones that normally initiate PHC projects in their various locations. Our job is to execute PHC projects, we now expect the local government authorities to inform us what is needed in these facilities in terms of drugs, staff and equipment so we can come in,” Mr. Johnson said.
On abandoned and incomplete projects, he said the agency has field monitors and project supervisors who go to the field to monitor and evaluate the work done on the sites and “if the work is abandoned, incomplete or not commensurate with the money released, then we now involve the EFCC and other anti-graft agencies to investigate the people responsible and they will be charged to court and made to pay.”
Henry Ewunonu, a pathologist and member of the Nigeria Medical Association however believes it is the responsibility of the health ministry and the state health commissioners to tackle the challenges facing health centres across the nation.
“It is the duty of the honourable minister of health in conjunction with the commissioners of health to plan for human resources, distribution of equipment, drugs and consumables as well as maintenance of the facility. It is not just about building a PHC but making plans for its sustainability. In Gambia, some PHCs are mud houses but they are well equipped and functional.”
The Commissioner for Health in Benue State, Cecelia Ojabo, blamed previous administrations for abandoned, incomplete and non-functional PHCs across the country.
“This is what we inherited from previous administrations, as soon as we bring PHC under one board we will take over those premises. We can’t leave them abandoned and habited by snakes and other reptile. We will take ownership of them and staff them.
“We will complete the uncompleted ones and open the locked ones for public use. This government doesn’t believe in uncompleted projects,” Ms. Ojabo said.
Faisal Shuaib, the Director-General of NPHCDA, in an exclusive interview with PREMIUM TIMES, admitted that the state of PHCs across the country is unsatisfactory..
“As of today, there is no single person in Nigeria who would tell you he is happy with the status of primary healthcare in Nigeria, unless that person is not in touch with reality.
“Our primary healthcare services are sub optimal in most places and that is why we still have high maternal and child mortality indices globally”, Mr. Shuaib said.
Reacting to the first part of PREMIUM TIMES investigation which mirrored the terrible state of Primary Health Centres across the nation, Mr. Faisal said his agency is already taking stock of PHCs in poor condition across the nation.
“From the people we sent out to carry out a detailed assessment of all of these facilities across the nation. To say, which are the poorly renovated health facilities, which are the dilapidated health facilities, which are the facilities started and completed and those started and not completed? So that we don’t keep having people year in year out, saying they want to start a health facility that will not be completed. Such unfinished projects are littered everywhere in the country.
“So we are taking stock of them all and prioritise each of them. If a National Assembly member comes to us to say, ‘I want to build a PHC’, we will tell them that next to your village is an uncompleted one, ‘can you complete that and probably share credit with your predecessor for ensuring that the health care facility becomes functional?’
“We also want to be able to sit here at NPHCDA with all the photos of the PHCs to be able to show people who want to see the state of health facilities in their villages. To tell them the number of staff there, the last time it was renovated, if it is a 9 a.m. to 5 p.m. PHC, or is it a five-star PHC? Such rankings will be available to them. That is the kind of assessment we are doing, so that we move away from a situation whereby we have PHCs that have not been taken over and equipped.
“We are like 50 percent of the way in terms of getting all the data that we need to know their locations and status,” he said.
In January, the federal government flagged-off a scheme to revitalise about 10,000 healthcare centres across Nigeria, starting with 109, one in each senatorial district.
But about 10 months later, all the eight primary health care centres PREMIUM TIMES visited in Niger, Benue and Nasarawa states in North Central Nigeria had no doctors, drugs or equipment.
On how far the government has gone in the implementation of the revitalisation of 10,000 PHCs, the NPHCDA director said his agency could not renovate 10,000 PHCs within one year. “What we did is in every senatorial district, we get one PHC and this brought us 109 PHCs so far.”
WOMEN, CHILDREN SUFFER FROM NON-FUNCTIONAL PHCS
A visit to a PHC in Ambana village in Lafia, Nasarawa State provided what appears a clearer picture of the rot in the primary healthcare system.
The PHC is occupied by destitutes, with their belongings littering the abandoned building.
Contracted to Bright steel structures & Co Ltd for N21,986,983.95, the PHC, which was meant to be the bedrock of health services in the community, is in ruins. This has led to continued death of children and women especially during child bearing, residents say.
Two children died of unknown diseases on the day our reporter visited, locals said.
According to the emir of the community, Abubakar Ambana, two women and four under-five children died the previous week.
“We can only go to general hospital in Lafia which is not close and we cannot beat emergency situation, that is why we lose people,” Mr. Ambana said.
Although Ambana is not far from Lafia, the state capital, its people still lack access to modern healthcare. Child delivery is often done the traditional way.
Aisha Mohammed, a mother of three, said all her children were delivered at home by ‘Ungozoma’ a traditional midwife. She said she doesn’t have any problem delivering in a hospital, only that none is in her community.
Musa Kabiru, an elder in the community, said efforts had been made to reach out to Meyan Ma, the House of Reps member representing the community who initiated the project. But it was unyielding, he said.
“When we try to meet oga (Meyan Ma) they say he is in Abuja. We want the government to help us. Our children, mothers and elders are dying,” Mr. Kabiru said.
Nobody was found in Meyan Ma’s house in Lafia and his phone was unreachable.
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.
However, apart from poverty and cultural practices, shortage of primary healthcare services are forcing women in Nigeria to seek the help of untrained traditional birth attendants, despite the serious risks involved.
Some 30 minutes drive from Ambana is another PHC in Ubbe/Ogba, Akwanga LGA of Nasarawa. It was like a recap of what obtained from the last PHC in Ambana, only that the building did not even get to roof stage.
The alternative health centre servicing the community is just some meters away. There are 11 health workers including nurses here, who are forced to use the old, small facility because the new one under construction has been abandoned. The contract for the abandoned PHC was given to Swaleys Nigeria LTD for N18,420,948.
“If they had completed that clinic we would have moved in there because this one no longer contains us,” Grace Edero, the head nurse said.
She, however, complained that equipment and drugs brought for the abandoned project had been in the custody of the chief of the town who refused to hand it over to the health workers.
“When we approached him to give to us so we can use them to treat people, he said he does not know us and could not release them.
“They are there rusting away while many people are in need of those drugs and equipment,” Ms. Edero said.
It is even worse at Maito village, Wushishi Local Government Area of Niger State. The stench oozing out from the nearly dilapidated health centre there can make a healthy person develop serious health challenges.
Directly opposite the decomposing centre stood forlorn two incomplete blocks of building adjacent each other. The buildings are NPHCDA projects of PHC for Maito village which has been long abandoned. It is now fully occupied by goats, hence the use of an old dilapidated building as a health centre.
“What you are perceiving is coming from dead bats all over the roof,” Mariam Mohammed, the only health attendant at the facility explained covering her nose with a veil.
“It’s not proper to treat a sick person here, some people will come here and see the environment and go back and that is a challenge. The ceiling of our injection room fell down. As you can see, it’s wide open.
“I have to cover my nose almost throughout the day because of the smell. I don’t want to contact disease while treating people. We have complained about this condition and if nothing is done, I will leave.”
Apparently, residents shun the facility not wanting to add to their health challenges. Surprisingly, child delivery is done there according to the nurse.
About N96 million was awarded to rehabilitate a PHC in Muye, Lapai LGA of Niger State. It was quite well built with a large open ward, labour room, children and female wards, doctor’s office and staff quarters, an ambulance, solar power with a well-built gate post.
Of all the PHCs visited, this was the only one that could be rated as standard and open to the public to render health services.
The reporter who arrived at 3:30 p.m. met the centre still open with no one in all the wards and rooms in the facility. It took further probe inside the village to meet the two health workers, a male semi-qualified nurse and an assistant manning the facility.
The facility does not have doctors, qualified midwives, pharmacists, nurses, security or labourers to keep the place clean or even a driver to drive the referral vehicle, Ibrahim Abdullahi, a local health attendant, said.
“We treat at least 15 people daily and we don’t have shifts that’s why we leave the place and go home and attend to certain needs because we cannot afford to be here every hour, it’s just two of us.
“We have meeting every month at the Lapai secretariat, we complain of the staff situation but nothing has been done,” Mr. Abdullahi said.
This paper further learnt that the rehabilitation of the centre was awarded when a member of the community was the director of NPHCDA. However since the contract was completed, it has not been commissioned.
Meanwhile, locals faulted the state of the road leading to the community as part of the reasons the facility lacked quality staff.
Muye is at the far end of Niger State and has a boundary with Kogi State. It will take a commuter N1000 to get to the Muye village from Lapai, the nearest town. Not because it’s far but due to the terrible state of the road.
“Most of the staff brought down here always leave, we have not being able to sustain a worker for long due to these challenges, the impact is that people with serious ailment can’t be treated here,” Mr. Abdullahi said.
There is a glimmer of hope for the country’s decaying primary health care. The federal government has initiated a N28 billion health fund that will target the revitalisation of at least one primary health Centre in each of the 774 local government areas.
The Minister of Health, Isaac Adewole, inaugurated the special intervention which he said will formally roll out in 2018.
Patients and health workers in PHCs like Mrs. Diashe in the Adikwu-Icho health centre hope the government keeps its promise this time around.
++++ You can read the first part of the investigation here. +++++
(This investigation is supported by the John D. and Catherine T. MacArthur Foundation and the International Center for Investigative Reporting).