By Alfred AJAYI
THE implementation of the Basic Health Care Provision Fund (BHCPF), a flagship intervention by the Federal Government aimed at improving service delivery at Primary Health Care (PHC) facilities, commenced in 2021 amidst positive reviews from stakeholders in the healthcare sector. Despite initial successes, BHCPF implementation in Anambra state now faces significant challenges, including an unfriendly economic climate, undue interference by authorities, poor public awareness, and low utilisation rates among enrollees. This report which covers facilities across five local government areas, highlights the urgent need for measures to address these issues.
Virginia Okwunalu clutched a well-worn handbag with a smile stretching into the corners of her eyes. The sexagenarian had trekked to the Ozalla village Primary Health Centre (PHC) in Aguata local government area (LGA) of Anambra state, a familiar path worn smooth by countless visits for her persistent headaches.
This time, though, there was a flicker of hope in her eyes. She is one of the 112 beneficiaries under the Basic Health Care Provision Fund (BHCPF) in the PHC.
The BHCPF was conceived as a lifeline for Nigerians seeking primary healthcare. In Anambra state, it has brought relief to many, like Okwunalu, who now access the much-needed medical care at her local health centre with ease.
“They diagnosed me with high blood pressure, but thanks to the programme, I finally got the medication and treatment I needed for free,” she said.
However, despite its initial promise, the BHCPF is now facing a multitude of challenges.
Findings by Radio Nigeria revealed that underfunding, persistent shortage of healthcare workers, and dilapidated infrastructure are eroding the gains made thus far. These factors, coupled with undue interference and poor monitoring, threaten to undermine the BHCPF’s potential to deliver quality healthcare to residents of the state.
Economic blow to BHCPF
Established to enhance access to primary health care in Nigeria, the BHCPF derives from an annual grant of at least one per cent of the Federal Government’s Consolidated Revenue Fund, along with contributions from international donors and the private sector. The fund is meant to provide routine daily operational cost of PHCs and ensure access to health care for all, particularly the poor, thus contributing to overall national productivity.
In Anambra, the BHCPF took off in 2021 on showing early signs of success in improving healthcare access. Official data since the programme’s inception shows that it has facilitated 1,407 deliveries, including 99 cesarean sections.
“Since the programme’s inception, we have also recorded 55 deaths, mainly among the elderly, and no maternal deaths among our beneficiaries,” the managing director, Anambra State Health Insurance Agency (ASHIA), Simeon Onyemaechi said.
However, despite these promising statistics, the programme now faces significant obstacles threatening its sustainability. Operated through gateways like the National Health Insurance Scheme (NHIS) and National Primary Health Care Development Agency (NPHCDA), the scheme initially provided N300,000 quarterly disbursement to each PHC, addressing long-standing service delivery issues, according to officers-in-charge (OIC) of facilities visited across five LGAs of the state. However, with inflation soaring to 33.95 per cent as of May 2024, the real value of these disbursements is rapidly diminishing.
The officer -in – charge (OIC) overseeing Model PHC in Nkpor-Uno, Idemili North LGA, Grace Anyaora acknowledged the programme’s benefits but stressed the growing financial strain.
“We used BHCPF funds for crucial upgrades like our incinerator and iron doors,” she explained. “We have not concluded but costs have skyrocketed. For instance, the iron that used to cost N45,000 is now over N100,000. Whatever we can do with the next disbursement, we will do it and use the meagre amount left for other pressing needs.”
Ifeoma Obi is the only government employee at Nise PHC in Awka South LGA. “We managed to do some renovations of our facility with BHCPF funds, but escalating costs mean we can barely cover essential maintenance like painting. For instance, we did the burglary proof in the labour room to provide security and comfort but we couldn’t conclude.
“But when I called the artisan to come to complete the remaining burglary proof left, he said each one would cost N30,000, which is double the initial cost. Not only that, we have an erosion problem that is fast destroying the foundation of the facility and our assessment has shown that N300,000 cannot salvage the situation. Without these repairs, we cannot effectively serve the community.”
At Model PHC Umunna, Odoakpu in Onitsha South LGA, the OIC, Judith Ofomata shared similar concerns. “Our facility’s current state betrays its name, with an uninhabitable kitchen and an exposed roof covered by tarpaulin. There is nothing model about the facility,” she lamented. “The allotted disbursement of N300,000 falls short of addressing our pressing needs. Recently, we went to buy cement and rods for the facility, but the prices were exorbitant.”
The chairperson of the Ward Development Committee (WDC) at St. Monica Health Centre in Woliwo, Onitsha, Ijeoma Okafor, stressed that there is a need for an upward review of the quarterly disbursement. “N300,000 is no longer sufficient for meaningful impact. They should double or triple it, please.”
Undue interference by authorities
Amidst these challenges, complaints about undue influence from the local government health authorities and the State Primary Health Care Development Agency were widespread among the PHCs visited. This interference has been found to contradict the autonomy that the BHCPF stipulates for OICs and members of the WDCs, particularly the chairperson, in developing appropriate business plans and determining the needs of the PHCs under their wards.
One significant area of concern revolves around the Drug Revolving Fund (DRF) which was designed to ensure a continuous supply of medications at health facilities. While BHCPF guidelines stipulate that State Primary Health Care Development Agencies should directly disburse funds received from the NPHCDA to health facilities, findings show that health facilities in the state are allegedly required to make some payments back to the State Primary Health Care Development Agency (ASPHCDA) for drug procurement after receiving funds from the state agency.
Each facility is required to transfer N50,000 per quarter to the agency’s account, along with additional payments for name tags. These levies, combined with transportation costs to the agency’s headquarters in Awka, further depletes the limited resources of primary healthcare centers (PHCs).
“In June 2024, PHCs under the BHCPF had to transfer N100,000 back to the agency’s account. This covers for the two quarters in 2024. Another N12,802 was paid for name tags,” said Okafor, St Monica Health Centre WDC chairperson.
Healthcare facilities are also obligated to return drug sale proceeds to ASPHCDA. To meet these demands, some facility heads said they sometimes resort to using their personal funds, leading to financial strain.
“I had to reduce the prices and used them (drugs) on the mothers who couldn’t afford them. That’s why I’m still paying off the debt,” Ofomata, Officer-in-Charge at the Model PHC in Umunna, Odoakpu, Onitsha lamented.
The WDC chairperson for Nkpologwu PHC in Aguata LGA, Emmanuel Nwosu said, “Just yesterday (as at interview time), my OIC reduced money for one woman who could not afford the cost of the drugs, but she will have to use her own money to pay the Agency according to the directive.”
For context, if N100,000 was collected from each of the 329 benefitting facilities, the agency would have realised a total of N32.9 million. Additionally, if all facilities paid N12,802 for name tags, the agency would have collected an additional N4.2 million.
The BHCPF guidelines provide opportunity for individual facilities to identify reputable pharmacies close to them where they can procure drugs themselves. But this intended flexibility contrasts sharply with the current procedure in Anambra, where ASPHCDA procures the drugs for facilities, a development which has been blamed for inflating costs and supplying irrelevant medications to healthcare facilities in the state.
Awareness and health insurance utilisation still low
Despite the BHCPF’s aim to expand health insurance coverage, utilisation rate among enrolled beneficiaries is still low. Only 18.1 per cent of residents accessed services under the health insurance component between January and May 2024, according to state data. While this marks a gradual increase from previous years, it remains significantly below the target. The utilisation rate were 14.4 percent in 2021, 18 percent in 2022 and 17.8 percent in 2023.
The health insurance component, which is meant to insure vulnerable residents, has witnessed a slow uptake sparking controversy between authorities at the national level and the State Health Insurance Agency, (ASHIA).
Onyemaechi ASHIA’s managing director explained the challenges. “Health insurance works on the principle that not everyone gets sick at once,” he said. “But with healthcare costs rising, it’s difficult for facilities to handle a sudden influx of patients.”
He also pointed to the financial strain on primary healthcare centers. Each facility serves around 110 people with a government subsidy of N570 per person. “If all patients sought care simultaneously, the funds wouldn’t cover basic services like tests and treatments,” Onyemaechi said.
“Consultation fees, medication costs like paracetamol or anti-malaria drugs, and other related expenses add up quickly. If everyone were to visit the facility every month, the N62,700 paid to each facility wouldn’t cover examinations and other services.”
Meanwhile, a cross-section of respondents including civil society activists, who spoke to this medium, attributed the current utilization rate to some factors such as limited awareness, lack of buy-in from critical local stakeholders, lack of engagement and ownership by WDCs.
Other factors are unimpressive state of most PHCs, perennial problem of understaffing and unfriendly attitude of health care workers to beneficiaries, poor road infrastructure, exorbitant transportation cost, and prevailing economic hardship.
However, one notable challenge Onyemaechi emphasized is the requirement for enrollees to have a National Identification Number (NIN).
“Three to four years ago, they insisted that we can only enroll those who had their National Identification Number (NIN). We went to the communities but we couldn’t get people who truly were poor, who had NIN. They pointed us to the National Social Register and most of the names there did not reside in our communities. We ended up using the same register and NIN for registration. But the reality is that most of them did not need the health insurance,” he said.
“So, the CEOs of state health insurance schemes resolved that if the insistence on NIN continues, utilisation will remain poor. We suggested community-based targeting approach and clustered the registration around the health centres. The NHIS accepted that. That is why utilisation rate in Anambra increased to 18.1 per cent.”
PWDs not accessing services
While the scheme has successfully reached children, pregnant women, and the elderly, interviews with OICs suggest a lack of participation among people with disabilities. This is attributed to the disability-unfriendly nature of most facilities and the lack of trained manpower to address their specific needs.
Available data from the Anambra State NPHCDA coordinator, indicates that only 303 out of 37,030 beneficiaries under the scheme are PLWDs, compared to 4,450 pregnant women, 10,091 children under five years, 7,430 aged persons, 1,431 indigent individuals, and 13,325 other beneficiaries.
Reacting to concerns around access for PLWDs, Onyekachi Ololo, programme manager for Justice Development and Peace Caritas (JDPC), Nnewi, said:
“Access for persons with disabilities goes beyond provision of ramps and lifts. How many facilities in Anambra have assistive devices? We cannot achieve Universal Health Coverage if this significant percentage of the population is left out. Any data that excludes them is manipulative, false, and misleading.
“It’s a disservice when citizens are not engaged, and the government portrays a skewed perspective by highlighting only a fraction of interested persons as representative of the entire population. The government should prioritise sensitisation and awareness creation.”
Poor monitoring and supervision
The BHCPF guideline prescribes routine monitoring and periodic evaluation of activities related to the Fund by the respective gateways and their state counterparts. Implementation reports (programmatic and financial) are to include successes, challenges, and limitations for all planned activities in the initial proposals.
The guideline equally charges the National Health Insurance Scheme to conduct quarterly monitoring and evaluation exercises with state health insurance agencies. The Ministerial Oversight Committee (MOC), the State Oversight Committees (SOCs), the Local Government Health Authority (LGHA) Advisory Committee, the Ward Development Committee (WDC), and Primary Health Care Centre (PHC) Management Committees are all provided for to ensure smooth and effective implementation of the program.
However, local government monitoring teams have been accused of not adhering to these protocols.
“We have LGAs imposing the kind of repairs and procurement of equipment and other commodities on the OICs. The WDC chairmen are excluded in the planning and implementation,” said Obiora Agbakwuru, the NPHCDA State Coordinator in Anambra State.
Agbakwuru’s statement was corroborated by Obi, Nise PHC OIC. She said, “I can recollect vividly when I wanted to repair the facility’s faulty borehole with the BHCPF money, they insisted that I must use the money for something else.”
In response, the Head of Planning, Research and Statistics (PRS), ASPHCDA, Casmir Mabia, said that the agency is doing its best in terms of monitoring, adding that the local government health authorities are expected to fill the gap.
“The agency cannot be in every facility. We don’t have adequate manpower to do so. It is the job of the local government health authorities to visit the facilities to see how they function and the challenges they have. They will write their reports to the agency and we will take appropriate decision.”
Sundry systemic challenges
Other issues affecting BHCPF implementation in Anambra State include inadequate infrastructure and poor staffing. In response, the state executive council recently approved the upgrade of facilities.
Since Governor Chukwuma Soludo assumed office two years ago, the state government has for the first time employed over 480 health workers to cater for the acute manpower shortage in its primary health care system.
Although commendable, this effort is grossly inadequate for a state with 618 functional PHCs and 329 BHCPF facilities, which have suffered serious depletion of their health workforce for decades.
“You hardly see a health centre with two government nurses. The common staff you would see are volunteers, and people are losing confidence. Government should employ more staff including nurses,” said Lawrence Anuruekwe, Ezinifite health centre WDC chairman.
“I also want to advise that government should stop using Officers-in-Charge (OICs) as program managers on too many projects or programs. Because they are often away for programs while their facilities suffer seriously,” he said.
According to Obi, there is an urgent need for massive recruitment of health personnel beyond the recent recruitment of health workers by the state government.
“This is even more important because of the free antenatal and delivery services government is running. More women are coming and the workload in killing.”
Compounding these challenges is the pervasive issue of poor data management and reporting. Inaccurate and incomplete data, delayed reporting, and ineffective data analysis hinders program evaluation and decision-making. Agbakwuru stressed that these deficiencies impede the ability to track program performance and identify areas for improvement.
“In Anambra, implementation is clogged by inaccurate or incomplete data collection, and delays in reporting. These challenges can lead to inefficient tracking of program performance and difficulty in identifying areas for improvement,” he said.
Many people including the commissioner for Health, Afam Obidike, accused some OICs and members of the disbanded WDCs of corruption, an allegation re-echoed by Mabia.
“I approve the business plans for them. Sometimes, they change the approved business plans with correction fluids. I once asked for business plan at a facility and the OIC told me it was at home. There at home, they will clean, rub and change it with the existing items in the facility.
“Some of them have been repairing borehole in their previous business plans. When you see their previous business plans, you will confirm what I am talking about. Some WDC chairmen are bribed to sign cheques for a purpose they don’t know. When we did redeployed staff, some of them went with the cell phone of the facilities, BP apparatus, name them. We started dragging with them before we could recover them.”
Concerning irregularities and corruption of some local government health officials, he said:
“I caught one LGA that is collecting money claiming to be settling some people, directors using my name. I told the OIC to call the person. Immediately she came and saw me, she was shocked.
“Before you know it, a lot of people started calling me. I insisted I am only concerned about the improvement of the place. The OIC actually performed well when I went through their records and performance. Go there today, you will smile.
Agency denies allegations
After a long wait for reactions from the executive director, ASPHCDA, Chisom Uchem, she directed Casmir Mabia to respond to queries from this reporter. Mabia justified the collection of N50,000 per quarter from each PHC.
“During the last assessment, we discovered that some OICs were not buying the drugs they were paid to procure. Some of them didn’t even have common paracetamol and vitamin C.
“We got the state Drug Revolving Fund (DRF) to supply drugs to them so that they have enough drugs to go round. But very soon, the drugs will be supplied by the DMA (Drug Management Agency), which the state is planning to put in place. DMA supplies them the drugs and they pay.”
On the allegation of violating the provision of BHCPF guidelines which empowers only the OICs to purchase drugs for their facilities, Mabia responded, “You cannot call it violation because the guideline provides an option. We do not have a standard registered pharmacy in each of the wards. Many of the pharmacies even in the cities are not registered or qualified.”
The PRS head also responded to concerns about the drugs supplied by the agency. “I am happy that they agreed that the drugs we gave them are quality ones but the price is high. We have a representative of NAFDAC in our DRF committee and we pay to test the drugs. If they do not give their patients quality drugs and adequate treatment, they go to private hospitals and will never return to the PHCs.
“The last time they complained about the prices of some of the drugs, they were asked to return them to the agency. We took them to secondary facilities and they were sold. All we are doing is to make our PHCs busy and active and we direct them to sell the drugs according to the cost.
“They should not add their own because we pay them data money, salary and give some of them accommodation. The state health insurance agency is also giving them monthly capitation. What are they using the money for? When you ask questions, they give you data that is not in existence.”
The commissioner for Health, Afam Obidike, was unavailable for comments regarding the BHCPF programme. On July 16, 2024, he referred inquiries to the executive secretary, ASPHCDA.
The way out?
Addressing the lingering issue bedevilling the healthcare sector in Anambra requires more synergy of purpose between the local, state and the federal government. A good place to start, according to Agbakwuru, is for the state to adhere to the stipulated communication and feedback mechanisms mainstreamed into the BHCPF for easy implementation and collaboration.
“Sticking to the guidelines and other regulations would aid the quick disbursement of funds. The delay last quarter was due to irregularities such as delayed retirement, reports of deductions by some state primary health care boards including Anambra, and reports of procurement of basic needs by the state instead of the facilities’ OICs. If this is resolved, it means we are on the right track.”
The executive director, Civil Right Concern, (CRC),Okay Onyeka, an advocacy group, said the BHCPF will be better implemented if state government commits more financial resources to the fund.
“The government still needs to provide the needed infrastructure for it (BHCPF) to work well effectively. The government has not been able to implement its own budget to complement the N300,000 quarterly disbursement.
“Even the State Primary Health Care Development Agency does not have the budget to build infrastructure. The health ministry does all that. You see that if government does not really devote more funds, it will not work.”
Onyeka also recommended regular training for the Ward Development Committee members to increase BHCPF’s efficiency in their communities.
“Without BHCPF, most of the facilities would have actually collapsed. We must ensure that the WDCs members, who are helping with BHCPF implementation, are trained and their capacity built to mobilize support even from their communities.
Addressing the challenge posed by the DRF, Ehiahuruike advised that PHCs be allowed to purchase their own medicines to reduce costs and ensure that the drugs meet specific standards required.
“I know the agency wants PHCs to get quality drugs. But it should allow the PHCs to buy their drugs while it follows up with proper oversight,” he said.
Meanwhile, Mabia enumerated some steps to improve BHCPF implementation in the state.
“We should change WDCs chairpersons every three years. If the National Primary Health Care Development Agency audit states for sending money to facilities. You also audit all facilities and not a negligible number of them for receipt and utilization.
“Recruit auditor and put one in charge of the local government. After six months, change the auditors. Even the audited report should be verified. That way, corruption at the facilities will end and you get accountability and good performance for BHCPF.
“WDC chairman should not have the final say in anything. Every decision should be taken as a body which comprises of woman leader, youth leader, treasurer, secretary, CSO, and traditional leader in each of the wards. So, how many will the OICs bribe and with how much?”
Commenting on staffing shortages at the facilities, Mabia said, “Each administration is supposed to be recruiting at least 1000 health workers to bridge the gap. But apart from Ngige, Peter Obi and Willie Obiano did not recruit into the PHC sector. But Governor Soludo has broken the jinx as he recruited over 480 health workers. We are hoping that he will do more.
“Those recruited by Ngige will soon leave the service and the gap will become wider. It is the ones that Governor Soludo is recruiting that will remain. If the governor continues, the gap will be closing up gradually.”
This report was made possible with support from the International Budget Partnership (IBP), and the International Centre for Investigative Reporting, (ICIR) under the Strengthening Public Accountability For Results and Knowledge (SPARK 2) project.