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From Nwimo Chukwudike, Awka
Antonia Okafor, an auxiliary health worker, can barely contain her frustration at the Umueze-Anam Primary Health Centre (PHC) II, in Anambra West Local Government Area, Anambra State.
It has been 15 months since she was employed by Anambra State Primary Health Care Development Agency (ASPHCDA), under the Basic Health Care Provision Fund (BHCPF), but her experience is making her doubt the capacity of PHCs to provide quality healthcare services in her locality.
Okafor said: “So many things are going wrong here, especially in the delivery of healthcare to the people. I am bothered that we do not have some equipment that is required to render some services.
“To be sincere, in this facility, we do not have equipment like weighing scales, and the Mid Upper Arm Circumference (MUAC) for assessing whether a child is malnourished or not.
“Again, there is no electricity in the community and no generator to attend to patients at night in the facility. We resort to the use of kerosene lamps and ‘after NEPA’ (makeshift light).
“Most times, my phone is off as there is hardly a way to charge phones in this area, except we go and pay N100 for it to be charged at charging centres.”
Otherwise, when there are emergency cases, she cannot be reached. She also noted that the services being rendered in the health centre are not enough.
“Some drugs are not here. For me it is uncalled for that patients come to a health centre and my facility head will say, ‘go and get this drug, we don’t have it.’
“The routine drugs administered to pregnant women are not complete. There is no accommodation provided for the health workers in our PHC.
“I have some antenatal care (ANC) patients coming here but their routine drugs are not complete. Even the pregnant women I attended to yesterday, I gave them drugs but the drugs are not complete.
“In the night, I can’t be here because there are too many mosquitoes. No patient agrees to stay here because there is no mosquito net,” she added.
A World Health Organization (WHO) report in April this year revealed that malaria killed no fewer than 200,000 Nigerians and afflicted 61 million others around the world. It also disclosed that Nigeria loses over $1.1 billion (N645.7 billion) yearly to prevention and treatment of malaria as well as other costs.
The absence of mosquito nets reported by Okafor exists in other PHCs in the state. Notable are the 25 facilities visited by Daily Sun in July in Anambra West, Orumba South, Oyi, Anaocha and Awka South council areas. respectively. None of the facilities, as at the time of this investigation, had mosquito nets.
According to a Lancet Global Health Commission report, a total of 376,039 deaths occurred in Nigeria in 2016 as a result of insufficient access to qualitative healthcare systems.
WHO, in 2020, reported that adult mortality rate for Nigeria was 34.25 deaths per 100,000 population. Thus adult mortality rate of Nigeria increased from 25.75 deaths per 100,000 population in 1975 to 34.25 deaths per 100,000 populations in 2020, an average annual rate of 3.29 per cent.
The Civil Society Legislative Advocacy Centre (CISLAC) recently reported that many Nigerians, especially those in the rural and semi-urban areas, rely on primary health centres (PHC) for healthcare services and only 20 per cent of the 30,000 facilities across the country are functional.
Despite policies of successive Nigerian governments and political leaders to improve and expand primary healthcare, Nigeria’s primary healthcare system remains in a deplorable state.
Decaying facilities littered the locations visited in Anambra State, despite an allocation of N300,750 to each of the 332 PHCs in the state for maintenance, procurement of healthcare equipment and provision of transportation facility under Basic Health Care Provision Fund.
Anambra still has PHCs with aging and deplorable infrastructure. The public-owned primary health care facilities suffer from delay in budget flows, which slows down repairs and investments in infrastructure and services.
When Daily Sun was led round Nteje PHC, Oyi LGA, by a junior staff, all he saw were dilapidated structures and abandoned facilities in every corner.
Entering the gate and looking to the right, there was a collapsed fence. A water pump lay damaged and abandoned. To the right was a dilapidated borehole and tricycle procured for routine and emergency transport at the facility.
In the back of the building was a ramshackle toilet, an obvious danger to patients and staff who make use of it.
An auxiliary nurse at the centre, who declined to be named, said the PHC lacked water due to the spoilt borehole. She also complained that mothers in the PHC were afraid of their babies being stolen as locals pass through the dilapidated portions behind the facility’s main building, day and night, on their way to their businesses.
She also said the facility uses kerosene lamps to attend to childbirths and other night treatments due to absence of a sound generator and the inability of the PHC to pay electricity bills.
The reporter’s observations in the PHC typified the deplorable state of PHCs in the state. At Nawfia, Adazi Nnukwu, Neni, and Ifite Awkuzu, the PHCs lacked water. Some relied on rainwater running down the roof of buildings.
The reporter also met tricycles meant for rapid response to emergencies and routine daily operations at Isulo, Nteje and Ogbunka facilities disused and abandoned due to poor maintenance.
Basic Health Care Provision Fund
The Basic Health Care Provision Fund (BHCPF) was launched in 2014, enshrined in the National Health Act, to remove financial barriers in accessing primary healthcare services, particularly for the poor and vulnerable.
BHCPF is a pool funded with at least 1 per cent of the country’s consolidated revenue and other funding sources, including donor contributions.
The fund is disbursed through three gateways: the National Health Insurance Scheme (NHIS), the National Primary Health Care Development Agency (NPHCDA) and the Nigeria Centre for Disease Control (NCDC). Anambra is among the states that qualified to access BHCPF for meeting the requirements.
The requirements stipulated for Primary Health Care Under One Roof (PHCUOR) include a functional Local Government Health Authority (LGHA), an established State Primary Health Care Board (SPHCB), baseline assessment of primary health care facilities, an instituted state steering committee and the TSA with N100 million opened.
The NPHCDA, in early August 2019, reported that 15 states and the Federal Capital Territory (FCT) benefitted from N51 billion, a fund mapped out for BHCPF. The agency’s head of public relations, Mohammed Ohitoto, confirmed in media reports on August 8, 2019, that N5.8 billion was released to NPHCDA from the fund, which was subsequently shared proportionately to the 15 states.
The fund from the BHCPF is mandated to be expended for the renovation and maintenance of PHC infrastructure, furniture, and equipment and to support transportation for vaccine collection and routine community outreach services and other daily operational costs.
Interestingly, investigations by the reporter revealed that, out of the total N813 million received by ASPHCDA, between 2020 and June 2022, N601,500 was paid on June 1, 2020, to 176 PHCs enrolled under the scheme in the state, covering the first and second quarter.
In March 2022, the ASPHCDA transferred N300,750 each to an enlarged list of 332 PHCs due to the increase in the funds released to the state.
Fund paid for renovation of 332 facilities
An account of expenditure tendered to the Anambra State House of Assembly by Dr. Chioma Ezenyimulu, executive secretary of ASPHCDA, showed that the agency disbursed a total of N357,952,281 to the 332 PHCs enrolled under basic health fund in the state for refurbishment of their facilities.
“Each political ward has a functional primary health care facility and the primary health care centres have been renovated with the money from the Basic Healthcare Provision Fund,” Ezenyimulu said.
“A total of N813,007,488.79 was paid into the Anambra State Primary Healthcare Development Agency/CBN account. The money transferred to the PHCs was itemized into groups DFF-N299,547,00, midwives — N23,509,00, CHIPS — N18,409,885, Operation – N16,886,396.
“The total expenditures from the report are N357,952,281, while the balance in the bank is N455,055,207.79.”
She said the account signatories were chairmen of the ward development committees and the officer in charge. She also noted that the NPHCDA authorized disbursements.
Still no improvement
By the reckoning of the state legislators who went on a fact-finding tour of PHCs to assess the implementation of BHCPF, over N800 million in funding was accessed between 2020 and 2022 but it was yet to “reflect on the lives” of PHCs statewide.
Chairman of the House committee on health, representing Aguata constituency, Carter Dike-Umeh, complaine: “In most of the constituencies, we are yet to see any PHC that has been refurbished.
“The best we can give to residents is access to basic healthcare. We have to get it right this time around as it concerns primary healthcare in Anambra.”
He said 30 members of the House of Assembly, including the Speaker, could not find any functional PHC in their respective constituencies.
Giving his personal assessment of the implementation of the fund, Dike-Umeh said he went round communities in his constituency and was yet to see evidence of the fund on the PHCs.
“Some primary healthcare centres in my constituency, Umuchu, Ward 2, and Akpukpa, are made functional through community efforts. There is no reflection of the Basic Healthcare Provision Funds in the facilities,” he said.
The lawmaker reported that the people were shortchanged and narrated how an unnamed WDC chairman, on one occasion, told him that a facility gave him only four packs of paracetamol and forced him to transfer money to a certain account.
He maintained that the state authority had derailed from the implementation process of the BHCPF and introduced another format that would bring money into to their private pockets.
Why policy is poorly implemented in some facilities
Despite the disbursement of N300,500 every quarter, many OICs lack adequate knowledge to prepare and implement work plans, according to head of health department in Anambra West LGA, Peter Igwema.
Igwema said: “The BHCPF that came to Anambra West, our people actually utilized it. You know it is a new technology and it is not that the rural health workers in the area did not utilize the fund very well but some of them do not know and do not do what they have in their business plan. So, it is a challenge on us.
“Another problem is that some of them usually do under-budget without properly going to the market to check the prices of the materials. Like someone who said he would use N43,000 to buy a new generator only for him to later discover that it was not enough. So, they now needed to use the money to repair the old generator in their facility.”
But the claim contradicted the report of the officer in charge (OIC) at Agulu PHC, Josephine Okoye, who posited that the funds were not released quickly enough to the PHCs to purchase the materials after they had conducted their market surveys on the materials included in their work plan, hence a change in price in the market altered the stated price of the items in the work plan.
Okoye said: “They do not give us enough time to conduct a proper market survey. So, after conducting the survey in haste, by the time we return to the market for the purchase, we see that the prices have increased and that puts us at great danger because we had already included them in our work plans.”
Igwema noted that OICs in his area had received only three quarterly disbursements, with a fourth one due in July when Daily Sun visited, adding that some OICs used part of the fund to pay for construction of placenta pits, wiring, ceiling repairs and painting in facilities.
He said: “The Umueze-Anam PHC II is only one among the PHCs that is poorly accommodated in the area because it was merely situated at the community hall as a health post before it was upgraded to PHC.
“Apart from that, other facilities have wards where patients can stay. Another place is Mmiata-Umuonuora ward. They are the only two centres without structures.”
This reporter discovered that since 2021 when the BHCPF implementation began, none of the 21 health centres visited by the reporter has mosquito nets to keep malaria-carrying mosquitoes away.
“The issue of mosquito net, the OICs wanted to capture it in their business plan but our Oga said no because the government is about to share mosquito nets to them.
“So, that is why the PHCs do not have mosquito nets. We are waiting for the consignments that are coming to disburse the nets to them,” Igwema said.
Limited choices
One of the OICs in the PHC visited, who did not want to be named, complained that they were being compelled by the agency to buy certain things that were not exactly the priority of the facility.
“We are not allowed to write the things that are of pressing need to our facilities. If the agency could allow us to write things we need to do, it would be better. But for someone to tell you this is what you have to do is not fair. For instance, we are mandated to allocate a particular amount for sensitization and mobilization.
“There are lots of leaking roofs in the centre that ought to be made paramount and protect the sick from being exposed to raindrops. This and others should be put in before we begin to talk about sensitization of community members.
“I’m tired of the BHCPF because of the disturbances it brings for primary health. We are not being allowed to use the fund the way we want to and to use it to provide for some of the deficiencies lacking in our PHCs. We are meant to undergo rigorous processes to purchase needed items, which, sometimes, affect the implementation of the programme,” another OIC in Orumba South told the reporter.
On her part, the OIC at Model Primary Health Care Centre, Amatutu, Agulu Anaocha LGA, also identified vagaries of market prices as a problem.
“Our challenge in implementing the programme is that they do not give us enough time to conduct proper market survey. So, after conducting the survey in haste, by the time we return to the market for the purchase, we see that the price has increased.”
Sharp practices
The Ward Development Committee chairman of Otuocha Ward 2, Christopher Okeke, disclosed that the WDC chairmen and OICs of the PHCs who were both signatories to the accounts were being compelled to sign cheques under duress, while unknown persons collect the monies and instruct them to return to their locations with the promise to supply drugs to their PHCs.
Meanwhile, the drugs the PHCs paid for were drugs donated by the World Health Organization and other donor agencies free of charge to health facilities.
Similarly, Rita Uche, the WDC of Redemption PHC, Fegge Ward 3, Onitsha, recounted before lawmakers how she inquired why she was being made to sign cheques to be cashed by “strange persons”, and she was told to remain silent and that the order was “from above”.
The Anambra State Health Insurance Agency (ASHIA) is a component of the BHCPF established to enable citizens to enjoy unhindered access to subsidized quality healthcare services across the state. The scheme was set up with the aim to reduce mortality rates by increasing access to elaborate healthcare service especially in the hinterlands where rural dwellers grapple with low-income earnings.
But hospitals used in the implementation of the scheme indulge in sharp practices, thereby shortchanging and over-charging beneficiaries, contrary to its original essence of providing subsidized healthcare for citizens.
Peter Ugokwe in Oyi LGA told the reporter that health workers asked enrollees to choose between ASHIA drugs and drugs provided by the hospitals just to compel them to pay extra for drugs already paid for by the health insurance agency. Some hospitals on the scheme have been sanctioned for this practice.
Impending fines for operating below standard
The state is looking to set up a “monitoring and accreditation” agency to ensure health facilities operate in line with generally accepted standards. The state has around 2,000 health facilities-1,500 of them private and catering to at least 70% of residents.
Regardless, the Anambra State Government through the Commissioner for Health, Dr Afam Obidike, has emphasized that the state needs to know what is going on in the primary healthcare centres in terms of service delivery.
To ensure service delivery in the state, Obidike further explained that government has set up required standards for operations of the PHCs in the state. He also said plans were underway to set up a taskforce to monitor the services delivered by health facilities, evaluate their performance based on set rules and upload data to a central portal.
“Government will pay unscheduled visits to hospitals and facilities across the state to ensure requisite operational standards. Facilities operating below standard would be blacklisted and fined,” he said.
He, however, debunked claims of sharp practices in the delivery of health care services in the state.
There were reports that ward development chairmen and officers-in-charge were compelled by unknown authorities in the state to engage in shoddy practices that negate the implementation of Basic Health Care Fund in the state.
Also gathered were claims that some hospitals used in the implementation of the Anambra State Health Insurance indulge in sharp practices thereby shortchanging and overcharging beneficiaries, contrary to its original essence.
The commissioner told Daily Sun that such practice did not exist in the state, and insisted that the State Health Insurance Scheme was among the best in the country.
He explained: “It’s true that we cannot be everywhere at every time to monitor activities of health workers in the state but we have our records. People are aware of our telephone lines which they can call to report the services that are rendered under our insurance scheme.
“I am fully involved in that scheme. We are making it very transparent and since the new administration came on board, four months ago, we have ensured strict close supervision of the PHCs.
“We have state oversight committee and also the involvement of civil society organisations and currently, we are reviewing their work plans to ensure that things are done the way they should be.”
Obidike affirmed that most PHCs in the state were still operating below standard but insisted that the stated government was tirelessly working towards improving the condition of the primary health centres.
“We are just four months in the office and I would not doubt or cover-up the state of primary healthcare in Anambra State. But one thing I can say is that we are working tirelessly to ensure that the state of the PHCs are improved,” he stated.
Noting that the shortage of health workers in the state was a global phenomenon, he assured that the government was already on its way to recruiting professionals that would provide health services across the PHCs in the state.
