When 39 weeks pregnant Aisha Usman got ill and needed to be rushed to a clinic one Tuesday night in March, her husband was bewildered and did not know what to do. The clinic is located about 15 kilometres away from their home in Gombe state, northeastern Nigeria, and they had no vehicle for transportation.
Mrs Usman endured the pain through the night and was rushed to Gombe’s Gujuba Primary Healthcare Centre (PHC) in the morning. When they arrived, her husband, Mr Usman, could not wait to hand her over to the health workers to check what was wrong.
“But to my greatest surprise no doctor was on duty to attend to her,” Mr Usman said. “We waited for about an hour before the health official arrived.”
At another time, three people were shot in a communal clash in Bauchi State. Police officials rushed the victims to Dajin PHC for medical attention but they were forced to wait since the “only health officer present was attending to another emergency.”
This is the experience at most primary health centres in Nigeria where a shortage of staff threatens public health services. For years, the country has failed to revitalise its health sector despite federal and state government promises, investigations by PREMIUM TIMES have found.
Our reporting revealed that PHC facilities in the country cannot provide essential healthcare services. The hospitals face problems including shortage of staff, poor water supply, poor power supply, inadequate equipment and poor distribution of health workers.
Despite the obvious decay in the healthcare system in Nigeria, the government has barely done enough over the years and the situation has not improved, especially concerning effective funding and staff strength.
‘Failed Revitalisation plan’
In January 2017, President Muhammadu Buhari flagged off a scheme to revitalise 10 thousand PHCs across the country. The president said the objective was to avail poor Nigerians of qualitative and affordable health services. He promised that the scheme would make at least one PHC fully functional in each of the wards across the country.
In the first phase of the project, the federal government in collaboration with the sub-national government and development partners said it will work on a PHC in each of the country’s 109 senatorial districts in Nigeria.
PREMIUM TIMES selected and visited three PHCs in the country’s northeast; the PHC in Dajin, southern Bauchi; Chigari, Adamawa central; and Gujuba, Gombe south senatorial district to check the level of work implemented following the revitalisation promise. The three PHCs are among the 109 the president promised to revitalise in the first phase of the project.
We found that despite the huge resources (N550 million) invested into the scheme by the federal government, the programme has failed to achieve the desired objectives.
The Executive Secretary of NPHCDA, Faisal Shuaib, did not respond to calls placed to have him comment on this report, nor did the agency’s public relations officer, Mohammad Ohitoto.
Minimum requirement of staff
The blueprint of the National Primary HealthCare Development Agency (NPHCDA) requires that a standard PHC has at least a medical officer, a community health officer, four nurses or midwives, three community health extension workers, a pharmacy technician, six junior community health extension workers, one environmental officer, one medical records officer, and one laboratory technician.
At the barest minimum, the agency expects all PHCs to have supporting staff, two health assistants; two security personnel and two general maintenance staff.
But, the facilities we visited in Adamawa, Gombe, and Bauchi were in a pitiable state and a far cry from the standard requirements. Currently, Nigeria has a doctor-to-patient ratio of one doctor to 5000 patients instead of the one-600 ratio recommended by the World Health Organisation (WHO).
Staff shortage at Chigari PHC
Except for the signpost on the roadside which announces the existence of the PHC, there is nothing there to indicate the hospital located at Fufore Local Government Area of Adamawa state. Shortage of staff has crippled the purpose of the clinic’s existence in the central district of the state.
Hammawa Bapullo, the officer in charge of the centre, told PREMIUM TIMES that the facility “desperately needs new hands” to assist them in carrying out their responsibilities. “Currently, we have nine staff working here; one attendant staff, one Community Health Extension Worker (CHEW), four technical staff and one Junior Health Extension Worker (JCHEW).”
This, Mr Bapullo said, is grossly inadequate to meet the number of patients we receive daily. “Over 100 pregnant women visit the facility every Tuesday and Friday for antenatal care,” he said, adding, “we need nurses or midwives, CHEWS and female JCHEWS for us to work effectively.”
“It may interest you to know that three of the nine staff I mentioned are not government workers. We had to hire two staff to assist us during antenatal. They are not government workers. We are the ones paying them.”
He said the centre is engaged in activities and getting support from the Nigeria State Health Investment Project (N-SHIP) programme. “Through the N-SHIP programme, we were able to paint the hospital premises and pay these workers a monthly salary,” he said.
Inside the clinic, the wards are bare of equipment and the government has done little to supply drugs and other necessary tools to make the clinic functional.
“As part of the revitalisation plan, a contractor came in 2020 and asked what problems we were facing and we outlined all the issues,” Mr Bapullo recalled.
“Specifically, we told him that we are not always happy whenever it rains because virtually all rooms are filled with water.”
“The contractor however said he ‘came for a minor project – and that the contract given to him was meagre therefore the only thing he could do was painting and installation of a new generator and solar inverter.”
Later that year, the Adamawa state government fixed the ceilings; painted the building; supplied a microscope, pack of containers, urine containers, disinfection soap, hand sanitisers, and hand gloves.
“But, nothing else was done apart from this. Now, the hospital is back to the (terrible) condition it used to be,” said Mr Bapullo.
The official told PREMIUM TIMES that the clinic needed an ambulance.
“At the moment we rely on volunteer drivers from the transport union,” he said. “They are the ones helping us to convey emergencies to the general hospitals in Fufore when there are referrals.”
“They have helped save the lives of many patients by transporting them here or taking them elsewhere sometimes under short notice. Some of them don’t even collect money.”
The chairman of Adamawa State’s primary healthcare development agency, Sulaiman Bashir, did not respond to several calls and text messages seeking comment for this report.
Medical Equipment Standard List for PHCs
Health standards are tools which are designed as a platform to strive towards the achievement of the highest quality of care possible within the resources available, NPHCDA said in its minimum standards document for primary healthcare centres.
“It is expected that these Standards would be used to guide the further development of PHC in terms of infrastructure, human resource availability and service provision as well as for the provision of qualitative PHC services and in ensuring equity in the availability and provision of the PHC services,” NPHCDA said.
According to the agency, the basic equipment list for primary health care facilities in Nigeria are anglepoise lamp, basket with lid for ORS, artery forceps (Medium), ceiling fan, bedpan (stainless steel), plastic chairs, bowls stainless steel with stand, stainless covered bowl for cotton wool, ceiling fan, dressing trolley, plastic chair (President), cup and medicine.
Others are a stainless covered bowl for cotton wool, dust bin (pedal), graduated medicine cup, stainless galipot (medium size), dissecting forceps, table infant weighing scale (Seward), dressing scissors, stainless instrument tray, dressing trolley, stainless kidney dish (medium size), drinking mug, and wooden long benches.
Others are an examination couch, foetal stethoscope, stainless galipot (medium), sponge holding forceps, stethoscope (Littman), suture needle, syringes & needles, latex gloves, disposable pack of 100 20 32 syringes & needles (100) 5cc, hammer, reflex 1 33 syringes & needles (100) 10cc, height measuring stick, thermometer, wooden long benches, vaginal speculum, and mackintosh sheet.
Also, the agency requires PHCs to have a nail scrubbing brush, water container with a tap, pen torch, screen mercurial sphygmomanometer, soap/disinfectant dispenser, stethoscope, scrub brush dispenser, nursery costs, urine dipstick for sugar and albumin, urinary catheter, umbilical cord clamp, drip stand and door nameplate among other items.
The NPHCDA long-list of minimum standards includes hundreds of other pieces of equipment for different units of PHCs.
Gujuba PHC, Gombe state
The shortage of medical personnel, impaired and inadequate infrastructure, and the unavailability of water and power supplies were observed to be the major problems facing Gujuba’s primary health centre in southern Gombe State.
Founded in 1995, the PHC was upgraded in 2012 as a Millennium Development Goals project by President Goodluck Jonathan’s administration. But it has been provided with no equipment or personnel to play the role for which it was built.
“We do not have a doctor or a nurse,” the officer-in-charge, Ruth Yunana, told PREMIUM TIMES. She said the workforce consisted of one Community Health Officer (CHO), three CHEWS, and one midwife.
“The CHEWS take deliveries of pregnant women and also attend to patients. When there is any case we cannot handle, we refer to Kaltungo General Hospital, which is not too far from this centre,” Mrs Yunana said, adding the centre needs new beds to admit patients.
“What we have now are the same beds that we’ve been using for the past 10 years and there are no mattresses. We also need delivery beds, examination couches, patient beds and a stable power supply.”
The issue of the lack of electricity supply is more pressing, thankfully a solar inverter was installed as a substitute, she said.
But when the inverter battery is exhausted – torchlights and phone lights are the main sources of light, in addition to sunlight (during the day). This light source is used during life-threatening situations that may occur at night such as childbirth.
Mrs Yunana said the centre attends to about 30 patients from the community and its environs daily. In a month, about 25 deliveries are conducted.
Like the PHC in Chigari, the Gujuba centre is also getting support from the N-SHIP programme: “The exercise has helped us. They built new wards for us, a pharmacy, staff quarters and immunisation shade,” the health official said.
She added that she and other staffers need more training to build their capacities “because there are so many cases that we should be able to treat, we don’t need a referral all the time.”
“Sometimes before sending a patient on referral, the first health official should at least start the referral treatment but we are not able to do that here.”
During a tour of the Gujuba facility, PREMIUM TIMES observed that the labour room is quite scanty with very little 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 transport in the event of an emergency. The female ward has only one mattress and two empty beds.
The NPHCDA requirement for the female ward of PHCs is to have an anglepoise lamp, artery forceps (Medium), bowls stainless steel with stand, plastic chair (president), stainless covered bowl for cotton wool, dissecting forceps, hospital bed, mattress and macintosh, stainless instrument tray, forceps jar, stethoscope (Littman), thermometer rectal, tongue depressor, vaginal speculum, etc.
None of these items was available when PREMIUM TIMES visited the clinic in late March.
Although the Gujuba PHC originally had a water facility (solar borehole), it got damaged and there are no plans to fix it, said an official, who asked not to be mentioned for job security. The staffer stated that healthcare workers have to request water from neighbouring residents for use at the PHC.
Gombe State is one of Nigeria’s worst performing states in PHC service delivery. For several weeks, Habu Dahiru, the state’s health commissioner did not respond to calls seeking comment for this report.
Why PHCs are not functional
The primary healthcare system in Nigeria was adopted as a sustainable grassroots approach meant to address the health problems in communities. By design, the PHCs should be the foundation of the country’s public healthcare system.
Many years down the line, the initiative is moving at a snail’s speed. Currently, Nigeria is ranking very low in global healthcare quality and access.
Last December, federal lawmakers set up a committee to investigate the non-functionality of PHCs in the country. The legislators were concerned that despite the revitalisation programme, only less than 20 per cent of the 30,000 primary healthcare centres in the country are in good working condition, while others are either completely grounded or ineffective in the delivery of primary healthcare services.
A report by the Centre for Journalism Innovation and Development (CJID) noted that most Nigerian PHCs lack basic healthcare services, essential drugs and services, and infrastructure and are located in unhygienic environments.
“The deplorable state of primary health centres in Nigeria is an example of the failure of the government to treat primary healthcare as the cornerstone of a stronger and resilient public health system,” CJID said in its report, titled, “Top 5 findings of PHCs in Nigeria.”
For PHCs to work effectively, CJID said, the key primary healthcare stakeholders – the people, the government and the healthcare workers – must make strong commitments.
The report said: “The people must demand involvement in the planning, implementation and evaluation of PHCs which affect them; the government must express, in practical terms, political will through adequate funding, capacity building and system support; and the healthcare workers can support through innovative utilisation of available resources and quality service delivery.”
Underfunded health sector
In the last eight years, about N3.2 trillion was allotted to the health sector.
The total government’s health expenditure was put at N237 billion in 2015; N250 billion in 2016; N304 billion in 2017; N356 billion in 2018; N372 billion in 2019; N441 billion in 2020; and N549 in 2021.
Out of the N14.77 trillion federal government budget for 2022, only N711 billion (4.8 per cent) was allocated to the health sector. A breakdown of the allocation showed that only N3,586 was earmarked for the medical care of each of Nigeria’s 202 million citizens throughout 2022, that is, N297 monthly, N67 weekly and N8 daily – not enough for antimalarial drugs in a country with dangerous malaria statistics.
In the Abuja Declaration, which Nigeria and 43 other African countries signed in 2001, a commitment to spending 15 per cent of annual budgets on public health was made; however, this has not been achieved over the years.
Not all failures at Dajin PHC, Bauchi State
Located at Tafawa Balewa Local Government Area in Southern Bauchi, Dajin Healthcare Centre is some 35 kilometres from the capital Bauchi.
The officer in charge, Mohammed Wurno, contacted his superiors but was not given the authorisation to speak to journalists on the affairs of the PHC. Another official agreed to speak off record, seeking not to be named because of civil service rules on press interviews.
Although the facility structure was completely dilapidated, it is now in a stage of gradual revitalisation, the official said. “It’s a work in progress and I can tell you that we are not where we used to be,” he said.
The official noted that their workforce is not perfect but it’s far better than other PHCs. “We have 5 N-power staff, 14 trained staff at various cadres, 1 CHEW on contract, 1 CHO, 1 environmental health technician, J-CHEW and a dental technician. You can hardly find these numbers at other PHCs.”
He added the facility has been relying on support from the Bauchi State government through the Integrated Health Programme (IHP). “They have supported us with several types of equipment: kits for the control of maternal and infant mortality; drugs and laboratory tools,” he said.
The facility is also receiving funds from the federal government through the Basic Health Care Provision Fund (BHCPF), according to the official, who has been working at the facility for over a decade.
The BHCPF was established under section 11 of the National Health Act as catalytic funding to improve access to primary health care.
It serves to fund a Basic Minimum Package of Health Services (BMPHS), increase the fiscal space for health, strengthen the national health system particularly at the primary health care (PHC) level by making provision for routine daily operation cost of PHCs, and ensure access to health care for all, particularly the poor, thus contributing to overall national productivity.
“We are using these funds to support some categories of people that receive free treatment. We are treating not less than 10 patients per day,” the official who sought anonymity said.
Like many other PHCs, the Dajin centre does not have staff quarters. “Our staff find it difficult to live around Dajin and we don’t have any accommodation for them,” he added. “Also, we need at least three more units and a functional store to keep our equipment. We have very few mattresses too but we are working to procure more.”
But, contrary to the wayside highlighted by the official, the Dajin PHC does not have a well-open ward, labour room, children and female wards and staff quarters as recommended by the NPHCDA. It is far cry from the minimum requirement of a PHC standard.
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