Dilapidated Infrastructure, underfunding overwhelm BHCPF implementation in Madobi PHCs


*LADIDI Ado’s journey into motherhood took shape amidst the challenges of a semi-functional primary healthcare centre in her village, Agalawa, of Madobi Local Government Area (LGA) within the Northwestern state of Kano. This chapter began as she ventured into bringing her third child into the world.

Unlike her previous two births, which unfolded in the familiarity of her home, guided by the hands of makeshift midwives (unguwarzoma), Ladidi’s hesitation towards hospital visits wasn’t born out of reluctance but rather out of despair over the health disparities that make it difficult for people like her to access good and affordable health care services in rural areas.

The primary healthcare facility in her village, Agalawa Health Post, was intended to be accessible to vulnerable people in the remote village and to bridge the gap in the health disparities that are being suffered by the people in rural areas.

But the health post echoes sounds of neglect and struggle to the level that even those it intended to serve are leaving it for an alternative.

With broken ceilings sagging under the weight of time and shattered windows, the building wore the scars of abandonment.

To add insult to injury, only two staff members work in the health facility, which is intended to look after hundreds of women and their children.

Photo: Signs of neglect at the Agalawa Health Post
Photo: Signs of neglect at the Agalawa Health Post

“This is the problem,” she said. “If you rely on this health post, you may miss it all. So, women in this village find alternatives. They look for a local midwife and use traditional means to deliver their babies,” she said.

Locals have said that staff work mostly two days a week and close in the afternoon before the official hours assigned to them.

At the time this reporter was at the health post, which was around 2:00 pm, the facility was already closed, and the only staff who worked that day had gone.

 Photo: The damaged roofing of the Agalawa Health Post.
Photo: The damaged roofing of the Agalawa Health Post.

For Ladidi, this time, her pregnancy brought forth unforeseen complications. Two weeks past her expected delivery time, she found herself waking up each day to the endless nightmares of troubled times.

“It was a new chapter for me, unlike my previous pregnancies,” she recalled.

Amidst the highs and lows of Ladidi’s prolonged labour, the local midwife acknowledged the gravity of Ladidi’s situation, admitting that her expertise was no match for the challenges at hand. The only viable option left was seeking aid at the same health post they initially abhorred.

Transportation, however, was a rickety motorcycle owned by her husband. Ladidi embraced her growing discomfort in the backseat, clinging to hope as the motorcycle danced ups and downs through the uneven roads. The journey became a dual trial, testing both her physical endurance and emotional resilience.

Approaching the health post, Ladidi’s contractions surged. The motorcycle accelerated, racing against time. But to their greatest disappointment, the health post was already closed. The only two staff members working, all coming from distant locations, have already left.

“By the time we reached there, I had already forgotten what was going on. I was semi-conscious,” she said.

Ladidi’s husband decided that he had to take her from Agalawa to Kafin Agur, where another and bigger healthcare centre is located. It was a tortuous journey, and before the hospital’s embrace could be reached, Ladidi gave birth to her newborn on the road.

“It was an unforgettable memory. I still feel like we should have stayed at home instead of giving birth on the road or, to be more precise, in the hut by the road,” she said.

Burji Health Centre: Neglected, in ruins

The experience of Ladidi and her husband was somewhat similar to that of Jummai Abdullahi and her daughter Amina, who entered the intense final stage of her labour, and a sense of urgency gripped them. The nearest hope for medical attention lay many kilometres away from their house at the Burji Health Centre, a once-vital healthcare institution now plagued by dilapidation and neglect.

As they embarked on the journey to the hospital, the struggles of the primary healthcare centre mirrored the larger crisis facing not only Madobi but Kano state in general.

Dilapidated infrastructure, understaffing, a lack of essential medical equipment, and budget constraints have crippled this vital community health facility, leaving residents without access to crucial medical services.

Photo: damaged patient room at the Burji Health Center. Credit: Aliyu/HumAngle
Photo: damaged patient room at the Burji Health Center. Credit: Aliyu/HumAngle

Upon reaching Burji, Jummai and Amina found a closed hospital deserted in the dark hours of the night. With a heavy heart, Jummai and Amina returned home, facing the agony of the night intensifying and a pregnant woman.

After returning home, in the poorly lit confines of their home, Amina gave birth with makeshift midwives, including her mother and neighbours. In the aftermath, Jummai reflected on the terrifying experiences of many women in her village.

It wasn’t only about operational hours due to the lack of staff; it was also about how the hospital patients’ rooms have become dilapidated with no beds and other necessary medical equipment that could be used to attend to patients.

Patients who seek medical attention in this facility are often subjected to substandard conditions, with leaky roofs and inadequate sanitation facilities. These deplorable surroundings not only compromise the dignity of patients but also pose serious health risks.

Rain has damaged more than half of the roofing in the hospital patient room at Burji Health Center. The ceiling, long bereft of any maintenance, sagged in resignation, weighed down by the heavy burden of neglect and raindrops. Sunlight streamed through the countless gaps, casting erratic patterns of light and shadow on the abandoned hospital beds with no sofas.

Free, but abandoned

In May 2023, the Kano State Assembly passed the long-awaited Free Maternal and Child Healthcare (FMNCH) Bill into law. This made the state the first in Nigeria to enact the law, and it was welcomed across the state in a celebratory mood.

There are a total of 1183 health facilities across the 44 LGAs of Kano state. Of this number, 1142 are primary healthcare centres, amounting to 97 per cent of the total health facilities in the state. Most of them are struggling to provide basic healthcare to people, especially in rural areas.

Madobi LGA  has a total of 20 of them, most of whom are struggling to provide the basic services required of them. None of the 10 buildings visited during this investigation even met the minimum requirement for providing healthcare services. None of them has a good and functional patient room, and most of them have no water source or hygienic toilets.

The National  (NPHCDA) specifies that all functional PHCs should be built on 4,200 square meters and with at least 13 rooms, with good roofing, netted windows, functional toilets, clean water supply from a motorized borehole, a disposal site, contain staff accommodation, and be painted a green color.

However, none of the PHCs has all of the above. In Birji, for example, the roofing has been damaged by rain, and there is no water source, and the staff working in the facility have lamented that the distance and lack of accommodation are affecting their productivity.

On the Federal Ministry of Health website, Burji Health Center offers antenatal and eight other medical services for in- and out-patients. But the reality, according to a staff in the hospital who requested anonymity, is that none of the services mentioned get fully done. “It’s just on paper,” he said.

“In ANC (antenatal care), for example, there’s only one staff working, and sometimes the number of patients is so large that she can’t respond to them all,” he explained, adding that even if there’s a will from the few staff they have, they can’t handle the services promised to be given.

The hospital sees an average of 20 patients a day, he said, most of them receiving antenatal care, while a few come for immunization. However, it has no proper maintenance to receive patients in very critical conditions.

Amidst this desolation, only seven staff bear the weight of their roles with a sense of resignation. All of them hailed from distant places.

The problem is not limited to Madobi. In 2020, Connected Development (CODE), a non-governmental organisation in Nigeria, conducted an assessment of 49 health centres across Kano’s 44 LGA and found that “all the PHCs assessed seem to lack some component of the basic requirements as outlined by the NPHCDA minimum standards for PHCs.”

Photo: An abandoned toilet at the Birji Health Center in Madobi.
Photo: An abandoned toilet at the Birji Health Center in Madobi.

While the website of the Kano State Primary Healthcare Management Board has listed Burji and Kafin Agur Health Centers as operational for 12 hours a day, this investigation has found that the claim is false.

At Kafin Agur, this reporter found that the health center was closed before 2 p.m., and at Birji, the staff confirmed that they operate for less than 8 hours a day.

BHCPF intervention not enough

In 2019, an attempt by the federal government to save the ailing primary healthcare centres in Nigeria was introduced through the Basic Healthcare Provision Fund (BHCPF).

READ investigations on BHCPF and the state of primary health centres HERE

The BHCPF is a health intervention scheme established under the National Health Act (2014) to provide basic healthcare services to the poor and vulnerable. The intervention was touted as the savior of ailing primary healthcare centres. However, the grand vision collided with a stark reality, leaving the ambitious project gasping for breath.

With N948 million at the start of the project, Kano state was at the top of the list of beneficiaries, with 381 PHCs receiving funds under the programme and later expanded to 484 PHCs across the entire 44 LGAs in the state.

However, research has shown that in Kano state, despite getting the lion’s share, the project has faced many challenges in the four years since its implementation started.

Challenges to the implementation, such as insufficiently skilled health professionals, a lack of data management capacity, low community participation and awareness, delays in releasing funds, poor infrastructure, and a weak financial management and accountability system, have become stumbling blocks to the success of the project in Kano State.

In Madobi LGA, one PHC was selected from each of its ten wards. They are PHCs in Kafin Agur, Daburau, Burji, Maraya, Dan Murna, Gora, Yakum, Chinkoso, Rikadawa, and Cikawa.

However, this investigation has found that all the health facilities are facing one or more of the challenges mentioned above, making it difficult for the successful implementation of the BHCPF in the local government area.

In Kafin Agur, for example, there are three major components that are being supported by the project, all within a meagre amount of 300,000 Naira per quarter and expected to be shared across 10 priority areas.

“First of all, this health centre has only six staff, including two casual workers,” A staff at the healthcare centre said.

“The first thing we do with the funds is pay the allowances of the two casual staff working on the project,” he explained.

“We are also expected to renovate some rooms and buy drugs for the hundreds of beneficiaries under the project,” he added.

Photo: Sign post at Kafin Agur PHC renovated using BHCPF.
Photo: Sign post at Kafin Agur PHC renovated using BHCPF.

According to him, the meagre amount that’s given to the hospital per quarter can’t cater to the needs of the hospital, especially as prices have already gone up.

“Inflation has affected everything, including the drugs that are being given to the BHCPF beneficiaries in this ward. What used to be 100 naira has now tripled or even quadrupled its price,” he lamented.

There are 343 beneficiaries from Akilu Memorial Health Centre and over 270 from Kafin Agur PHC.

According to him, most of the time, the drugs get finished before the end of the three months, even before most of the project beneficiaries finish visiting the hospital.

Mallam Bashir Sunusi, the Director Planning, Monitoring and Evaluation at the Kano State Primary Healthcare Management Board (KSPHMB), admitted that not only in Madobi, most of the PHCs in Kano are struggling to survive even under the BHCPF.

“Let’s be realistic,” he said. “The BHCPF hasn’t come to alleviate all the problems that the PHCs are facing.” He explained that the money is insufficient but it serves as a catalyst to help the PHCs work.

“Every month, the PHCs are expected to spend 100,000 across 10 priority areas and that’s 10,000 for each in this inflation,” he said. But, according to him, there’s a form of flexibility in spending the money. The PHC can take the money where it’s less critical and put it where the PHC needs critical attention.

Photo: List of the priority areas under the BHCPF program.
Photo: List of the priority areas under the BHCPF program.

But there’s a good side. The intervention, despite the meager amount, has helped repair damaged ceilings and renovate the patient’s room. “We also buy the medicine, although in a small quantity, to give to the beneficiaries,” he said.

Photo: A table showing the BHCPF intervention in Kafin Agur.
Photo: A table showing the BHCPF intervention in Kafin Agur.

But this is not the major problem. The selection of the beneficiaries who receive the drugs was, from the beginning, the biggest controversy.

Some residents have accused local politicians and traditional rulers of hijacking the project for themselves. Habibu Lawal, for example, has claimed that some of the people put on the list of beneficiaries at Akilu Primary Health Center in Madobi don’t deserve it.

“The project’s aim was to target the weak and vulnerable, but it has been hijacked,” he claimed. “People who are in obvious poverty are not benefiting, while people who have known some people are at the top of the list,” he said.

Amidst these allegations, some of the people selected have not been attending the healthcare facility. “That’s the irony,” said the staff at the health facility.

“While others are lamenting that their names haven’t been on the beneficiary list, others are not coming to benefit despite having their names on the list,” he added.

This reporter has tried reaching out to the authorities at the local government level to comment on the overall report findings or allegations, but they said they were not authorized to speak without permission from the Kano.

But recently, the BHCPF management in the state conducted a reassessment of the beneficiaries and found some of them missing. “We are waiting for replacements,” the staff at the Kafin Agur PHC said.

On the dilapidated state of the PHCs, Mallam Sunusi said the state government is aware of their conditions and activities have already started to see them working again.

“There’s a plan to take one PHC from each ward across the 44 LGA and renovate it to a standard and the plan has already been approved by the state government,” he said.

    Mallam Bashir Sunusi explaining how the BHCPF project is going in Kano State.
    Mallam Bashir Sunusi explaining how the BHCPF project is going in Kano State.

    On the BHCPF project in Kano, Sunsi said it’s not entirely in the state’s hands because even the money that’s being sent is coming directly from the CBN to the PHCs through the Direct Facility Financing (DFF) program.

    “We have minimum control over it. Ours is to monitor and evaluate, and I’m telling you that the money being sent isn’t sufficient even though BHCPF hasn’t come to solve all the problems but to catalyze the solutions,” he explained.

    *Names with asterisks have been changed to protect identities.

    This Investigation is supported by the John D. and Cathrine T. MacArthur Foundation and the International Centre for Investigative Reporting

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