By Alfred Ajayi
Oluchi Uyaemesi is a native of Mgbakwu in Awka North Local Government Area (LGA) of Anambra State. Oluchi had a deep-seated disdain for the Primary Health Centre (PHC) in the community, which she has known for over 15 years. She was again on a visit to the PHC to see a friend whose child was on admission when Radio Nigeria visited.
This time around, her testimony has changed as she was all praise for the facility.
“Before, this ward was tattered. I couldn’t even advise people to come here due to dirty and bushy surroundings. But now, it is neat. Also, their gate was bad but they have repaired it. You can now open and close it. People were falling on their steps because they were very bad, but now, even old people, children and pregnant women can climb them easily.”
Oluchi was also impressed by the realization that the centre no longer suffered from its out-of-stock syndrome regarding drugs, its major characteristic many years ago.
“I was surprised recently. I needed a drug and someone told me to go to the maternity. I came and got it here,” she enthused.
She added, “Also, my friend was ill with tuberculosis. She went to other places, even private hospitals, for treatment. She finally came here and was treated properly. It’s a sharp departure from the past.”
The Mgbakwu PHC, like several others that Radio Nigeria visited, had accessed a total of N1,203,000 from the Basic Health Care Provision Fund (BNCPF) since 2021. Virginia Nduka, the officer-in-charge (OIC), had this to say:
“Everything was upside down when I came. We couldn’t close our gate. But, with basic health care money, we repaired it. We put the step of our frontage in order. We repaired the broken floor in the staff quarters. We bought bed covers. They gave us three waste bins, lab kits, drugs and equipment.”
Patronage at the centre has been on the rise by both the aged and heavily pregnant women. However, the needs there are still many to be met.
“This place needs an ambulance. We still have a fallen fence to re-erect. Our compound needs a serious touch. It is always messed up anytime rain falls. I need more staff,” the OIC pleaded.
These testimonies are in tune with the very goal of the Basic Health Care Provision Fund (BHCPF), launched by the Federal Government in 2014 under section 11 of the National Health Act, as a catalytic funding aimed, among other objectives, at improving access to primary health care through the removal of financial constraints, especially for the indigent ones, most of who reside in rural communities.
The Fund is one of the initiatives in the country targeted at achieving the Universal Health Coverage (UHC) and is sourced from one per cent of the Consolidated Revenue Fund (CRF) from the federal government, grants by international donor partners and funds from any other source, including the private sector.
Having demonstrated its commitment to the initiative through the payment of its N100 million counterpart contribution, Anambra State joined the benefiting states in 2020 and currently has 332 primary health centres benefiting from the initiative being implemented through three gateways – the National Primary Health Care Development Agency (NPHCDA), which provides operational cost (Decentralized Facility Financing – DFF), Human Resource for Health (HRH) for PHCs through the State Primary Health Care Board (SPHCB), and the National Health Insurance Scheme (NHIS), which insures the most vulnerable Nigerians to access the BMPHS through the State Social Health Insurance Agencies (SSHIA).
BHCPF to the rescue
The Mgbakwu testimonies are found replicated in several other communities of Awka North Local Government Area, including Isuaniocha, Urum and Amansea. Nwanneamaka Nwankwo, who brought her week-old baby for immunization at the PHC in Isuaniocha at the time Radio Nigeria visited, recounted the history of the place:
“Three or four years ago, they were not doing well. That is why I never came here to give birth. I was going to Urum at a private hospital. But, I come here now because they are now doing well.”
The centre’s OIC, Ifeyinwa Mesigo, took the reporter round the facility to see the items gotten with the money so far disbursed by BHCPF. “We did not have a good consultation room, no chairs for patients, no placenta pit, drugs and even test kits. We didn’t have fire extinguisher and our roof was leaking.
“But all those needs have been met. We also repaired our generator. Now we put on a generator for women in labour,” Mesigo noted.
Despite all that had been achieved, some concerns still remain.
“The toilet is giving me trouble. Some parts of the roof are still leaking. We are five here but only two are employed by the government. It has not been easy. I do most of the things,” she said.
Onyeka Attansey, chairman of the Ward Development Committee (WDC), who was at the PHC on a routine supervision, affirmed: “Basic health money is helping us very well. Our committee closely monitors what they are doing here.”
Insecurity undermines benefits of BHCPF in Aguata
The brutal attack by unknown gunmen on Aguata Local Government Secretariat, Ekwulobia, in April this year has grave consequence on the Aguata PHC situated within the same premises. That incident had since attracted heavy presence of military personnel. Five minutes after the reporter’s arrival, gunshots from the soldiers rent the air for almost one minute. It was a scary experience, capable of discouraging residents from patronizing the health facility.
This suspicion was later confirmed by the centre’s OIC, Ijeoma Onuora. “The presence of the military people drives our patients away. We need this facility to be demarcated with a separate gate. Once it is 7pm, the military people will block that gate, and labour cases are mostly at night.
“Before, we were recording up to 26, 30 deliveries in a month, but now we record four, five. Also, during immunization, we were having a hundred plus in a day. But now, we struggle to record between 50 and 60. We had a lot of patients before. But now people come mostly for out-patient cases,” she regretted.
Despite BHCPF intervention, the ancient mud structure, built before the civil war, is no longer good for habitation. However, the working condition is improving with a good outpatient toilet, newly constructed soak-away pit, medical instruments, laboratory kits and drugs. Nevertheless, something is still not right.
“I am the only government staff. All other persons are volunteers and casual workers. Our building is too old and does not appreciate renovation anymore. We need a brand new structure,” the OIC explained.
At the PHC Ula, Chinemerem Obi was delivered of her new baby hours before the visit. “Their service is good, Thank God, I am strong and my baby girl is equally strong.”
Located in a serene environment, the un-walled nature of the facility worries both the personnel and patients. Statistics of clients on first visits, which is boldly pasted on the wall, revealed that from 156 persons in 2018, the number of first time clients drastically reduced to 55 in 2019, but slightly rose to 57 in 2020 and 63 persons in 2021. This is contrary to the envisaged increase in patronage as a result of the BHCPF.
The OIC, Roseline Nwankwo, said, “We still have problem of light and water. Our toilet is not good. I am the only one working there. Also, we need this place to be fenced,” Roseline pleaded.
Acute manpower shortage in Anambra East
Apart from other challenges being gradually addressed with the BHCPF, PHCs in the Anambra East Local Government Area have peculiar problems, especially in the area of manpower. Esther Nwafor is the OIC and only staff at the Ikenga-Nando PHC, a recently built facility, with good location, which remains largely inaccessible to residents until recently.
“People were jumping the gutter to come here before. I assisted many of them, especially pregnant women, children and old people who come to check their BP. When basic health money came, we did the culvert. We also built a drug shelf, made office table and chairs, bought a generator, a BP apparatus and we have excess of drugs.
“Before now, I might not have a single patient in a week. But now, I have up to seven people in a day.”
However, water supply is still a huge problem for the facility, which also does not have staff quarters.
Bridget Chigbata, a Community and Health Extension Worker (CHEW), heads the Ivite-Aguleri PHC, a big structure sitting on a large expanse of land. According to Bridget, the place was in a messy condition some months ago.
“The OPD and labour room were not habitable. But we used the money from basic health to tile them and two other rooms. We bought a big cupboard to keep the drugs, got a water pumping machine, made chairs and tables, and changed some of the old windows to modern ones.
“Since they started giving us the money, people have been coming both for delivery and treatment.,” Agnes Ndibe, a volunteer, who took the reporter on the tour of the facility, added.
At Otuocha PHC, Kamelita Onyeka, the OIC, stressed the difference BHCPF has made at the facility.
“With the money from BHCPF, dilapidated floor was renovated, while delivery bed, blanket, bed sheets and mattress covers were also bought. The facility now has a placenta pit and a generator, while its leaking roof has been repaired.
“But our challenges are enormous. I pray that the money will be paid for the third quarter so we can do some other necessary things,” Kamelita said.
Manpower problem is also evident at the PHC Nnewi-Umuleri, where Maureen Emejulu, a Community Health Officer is in charge, assisted by only one junior CHEW and two other volunteers. Its roof, once destroyed by windstorm early this year, has been fixed and placenta pit dug, with the fallen fence reconstructed.
For the Chairman of the Ward Development Committee, Peter Obiora, the succour offered by BHCPF was long in coming, though judiciously used. “Since we built the health centre and handed it over to the government, nothing tangible has happened until recently.”
Leaking roofs in Onitsha
“If you have come here some weeks ago, you would not be able to sit down. It was leaking seriously. I was always sad when I remembered coming to work,” a lab technician at Saint Monica Anglican PHC, Fegge, Onitsha, lamented on the deplorable condition of the facility before now.
The facility bought a generator, repaired its borehole and now has drugs as well as fire extinguisher and other things. However, the OIC, Okwudilichukwu Udeze, still finds lack of placenta pit, and fence very upsetting. “For now, we pack the placenta and wait for the truck carrying waste to come around before we dispose of it.
“One night, a group of boys wanted to invade the place and do whatever they wanted to do. The person escaped through the exit door at the back into the church. We need a fence here,” she submitted.
The Saint John Anglican PHC, located within the premises of the church at Fegge, Onitsha, was also faced with the problem of leaking roof, which badly affected the out-patient department and the ward. Nonye Nwama, the OIC, was happy that the leaking roof has been fixed.
They also replaced the faulty BP apparatus and produced a signpost for easy identification, while some fans were purchased. The soak-away pit was equally cleared and repaired, but the facility is still in dire need of attention.
The Health Insurance Gateway
One of the three gateways for implementing the BHCPF is health insurance, targeted at ensuring that Nigerians, regardless of places of residence, enjoy basic minimum package of health services. The insurance aspect takes care of issues of quality, equity, affordability and access. Chika Okpara is one of the beneficiaries of BHCPF under the Anambra State Health Insurance Agency (ASHIA).
The number of beneficiaries, according to data from the agency, has risen from 28,342 persons in 2021 to 38,400, a development achieved through efficiency savings made by ASHIA. Chika said during an interview at the Ula Primary Health Centre, Ekwulobia,
“I have been enjoying it. Before now, when you come, they complained there was no drug. But now, they are giving me all the drugs I need free.”
Mary Ugwumba, who enjoys the service under the Okpoko PHC 2, saw it as the best gift from the Nigerian government to her.
“Any day we fall sick, we go there. They will check our BP, attend to us and give us drugs. They don’t collect one naira. I call on government to help other people to enjoy it. It is a good thing.”
Since patients are meant to be treated free of charge at all levels of health care provision, utilization rate among the enrolled is now at 9 per cent, from the paltry 3 per cent recorded within the first year of implementation.
The Executive Secretary, ASHIA, Dr Simeon Onyemaechi, spoke of efforts which led to the increase: “It was worrisome. So, we invested in sensitization and education of the people, and this has helped. The current 9 per cent utilization rate is not wonderful, still. However, all over the world, for health insurance, you do not have utilization rate above 25 to 30 per cent.”
Dr Onyemaechi is optimistic that the rate of utilization will continue to increase as the agency intensifies public enlightenment.
“That first year, we didn’t spend up to N2.5 million on secondary and tertiary services. But, this second year, we have spent almost N20 million. You can see that utilization is growing and we are not resting on our oars,” he said.
It was gathered that the state government has inserted in its 2023 budget the equity fund of 0.5 per cent Consolidated Revenue Fund for vulnerable citizens, an indication that the number of beneficiaries of the BHCPF is expected to further increase. “We should be looking at, minimum, extra 12,000 lives added to the BHCPF. That will really put us up on the path to attaining Universal Health Coverage by the year 2030,” the ASHIA ES said.
Allegations of corruption
As at the time of the visits, retirements for the second quarter of this year had been completed. Retirement is a major requirement for continuous access to BHCPF.
Several other measures have been put in place towards instilling accountability and integrity in the implementation of the programme. One of them is the setting up of oversight committees at the federal, state and local government levels, while Ward Development Committees (WDCs) work closely with the heads of the facilities in utilizing the funds.
But these layers of monitoring and supervision have not totally insulated BHCPF from allegations of corrupt manipulations. Regrettably, the supervising institution, ASPHCDA, has been accused of requesting for certain percentage of the money disbursed to the PHCs. This violates the BHCPF guideline which shields them from the unholy activities of middlemen.
Peter Obiora, WDC of Nnewi-Umuleri PHC, was full of lamentations as he recounted his experience. “After basic health paid us N600,000, the agency gave us just over N200,000. This is not a secret thing. I told them during our appearance before the House Committee on Health. But, others were afraid to say something.”
All the OICs spoke of paying such money to the agency, but one of them, who spoke only on condition of anonymity, disclosed something more damning: “We have paid two times this year and they have not brought anything here.”
However, the agency was said to have purchased and distributed some items to all the PHCs. The items included drugs, fire extinguisher and test kits. Nevertheless, many of the OICs complained that some items brought to them are not their most pressing needs, while the prices of some of the drugs are too high, especially for rural dwellers.
Reactions of the Executive Secretary, Anambra State Primary Health Care Development Agency (ASPHCDA), Dr Chioma Ezenyimulu, to the allegations, were sought unsuccessfully. She was called three times on September 17, 19 and 26, 2022.
She did not pick her calls and never returned any of them. She also ignored SMS messages sent to her.
More legislative oversights underway – Health Committee Chairman
The House Committee on Health had recently, after a fact-finding meeting with the Executive Secretary ASPHCDA, staff of the agency, OICs of PHCs, chairmen of WDCs, and other stakeholders, disapproved the agency’s utilization of over N800 million received from BHCPF within two years. The Committee Chairman, Dr Carter Ume, submitted that the agency breached and abused the protocols, rules and regulations guiding the operations of the BHCPF.
“Investigation is still ongoing and this fact-finding exercise is not aimed at sabotaging or witch-hunting anyone, but is in the interest of the people of the state.
“In most of the constituencies, we are yet to see any PHC that has been refurbished. So, we will carry out an oversight function to see how the BHCPF monies were used since 2020. What is on the ground is not measuring up with funds so far provided,” Dr Ume sadly submitted.
The Executive Secretary had earlier, while defending the 2022 Revised Budget of the agency before the Committee on Finance and Appropriation, disclosed that the NPHCDA had deposited N805,049,047.79 to the 332 facilities under the BHCPF in the state.
Ezenyimulu swiftly denied authorizing the Ward Committees to withdraw money from banks, and also denied other allegations of abuse of NHCPF’s protocols and regulations.
Breakdown of the money as given by the ES is as follows: N300 million distributed to the 332 health facilities across the state and N23 million spent on the engagement of 60 midwives, while N16 million was expended on operations of the Agency. N18 million was equally spent on Community Health Influencers and Promoters Services (CHIPS), bringing the total expenditure to N357 million.
A balance of N455 million, she revealed, was in the bank as at the time of the oversight meeting.
We want more – OICs, others plead
Despite the shortcomings associated with its implementation, the BHCPF is adjudged by many as the best thing that has happened to the basic health care system in Anambra State. This justifies the cravings by OICs and chairmen of WDCs for sustenance of the BHCPF and greater attention from the state government to those facilities.
The 2006 Minimum Ward Health Care Package for primary health care prescribes that every PHC must be staffed by one Public Health Nurse, one Community Health Officer, four midwives, two senior Community and Health Extension Workers, six Junior Community and Health Extension Workers, one laboratory technician, one medical record officer, one pharmacy technician, two security men and two caretakers.
However, the reality in the state is a derailment from the above standards. The OICs, some of whom are the only government-employed staff in their facilities, appealed for new recruitment that will lessen the workload on them. “They are just punishing us. Go to general hospitals. They are many there doing nothing. That is why they have time to run their private outfits,” one of them lamented.
At the moment, Anambra State does not have up to 21 doctors to man its healthcare centres at the local government level. There are many local governments without any doctor at all. In terms of infrastructure, some of the facilities are dilapidated beyond renovation.
One of them is the Aguata PHC, Ekwulobia, where the OIC called for a new structure: “This old mud house no longer needs renovation. We need a brand new building. Government should help us.”
We will soon recruit for health centres – government
The government of Anambra State says it is as concerned as the citizens about the deplorable situation of most primary health centres in the area. The Commissioner for Health, Dr Afam Obidike, said efforts are on towards finding a holistic solution to the problem of manpower in the state health institutions.
Dr Obidike assured in a telephone interview with Radio Nigeria that recruitment into the PHCs will resume after a similar exercise is concluded for the general hospitals.
He said, “Currently, we are trying to recruit for the general hospitals first. Nineteen of them don’t have doctors. Friday and Saturday, we did the interview for the doctors, lab scientists, optometrists and consultants. We are going to have another one on Tuesday, Wednesday for the nurses. After that, we will get to the health centres.”
Although the immediate past administration of Governor Willie Obiano uplifted three PHCs in each of the 21 local government areas, the number is a drop in an ocean, according to Onyekachi Ololo, Programme Manager, JDPC, Nnewi.
“In all, 63 out of 638 PHCs in the state were renovated. That is grossly insignificant. Also, BHCPF is not enough to make the PHCs what they are supposed to be. However, it is an indicator that we are moving instead of standing still,” he opined.
This report is supported by the International Budget Partnership (IBP) and the International Centre for Investigative Reporting (ICIR).
