By Justina Asishana

Lack of drugs, inadequate water, sanitation and hygiene (WASH) facilities, as well as staff shortage in health centres have been the bane of good healthcare delivery at the grassroots level. JUSTINA ASISHANA visited some local government areas in Niger State and reports on how much the Basic Healthcare Provision Fund (BHCPF) has changed the narratives.

Saidu Aisha, 35, almost lost her son in 2020 when the infant was running a high temperature fever, and there was no equipment at the laboratory of the Primary Health Centre (PHC) in her community to conduct a test on the sick boy.

“At the time, there were also no drugs at the health centre,” said Aisha, a housewife who lives in Nasarafu Ward in Bida Local Government Area of Niger State, North-Central Nigeria.

“After examining him, the health worker on duty wrote on a paper the type of tests we needed to run, saying that they could not do them there,” Aisha added.

The woman and her son spent hours in a long queue at the General Hospital where they went for the tests. After that, they shuttled between the hospital and the PHC for tests and other medical services.

Nearly two years after the sordid experience, Aisha is full of praise for the government for making drugs available at the PHC.

“Now there are drugs at the centre,” she enthused.

Drugs are essential to medical care to improve patients’ health and quality of life. They can save lives and improve health. On the other hand, the scarcity of drugs in a health care facility has drastic implications for patients.

If drugs are in short supply, their prices may rise, imposing financial burdens on patients and their families, and causing mortality if the sickness is severe.

According to Adamu Bashir Fatima, the officer in charge of the centre in Nasarafu, the health facility could not dispense drugs or conduct laboratory tests before the availability of the Basic Health Care Provision Fund (BHCPF).

The PHC at Nasarafu is among the 274 focal PHCs in Niger State under the Federal Government’s health intervention programme.

Due to shortage of funds and drugs, Fatima said, she and her colleagues at the facility used to merely prescribe medications for patients and direct them to conduct tests outside the facility.

She said, “Before the basic healthcare provision fund, we had no drugs. We did not receive any funds from the government, so we ran the health centre as we could. We would write out tests for patients and they would go to the general hospital to do the tests.

“But now we have enough drugs bought with funds allocated to us from the BHCPF. We have also brought some equipment.

“Then, it was only pregnancy and malaria tests that we could carry out. Now we test for hepatitis, typhoid, urinalysis. We check blood pressure and sugar level, which we could not do before.”

The Federal Government had initiated the BHCPF under Section 11 of the National Health Act 2014 as catalytic funding to improve access to primary health care.  The fund is meant to provide free minimum primary healthcare to the poorest and most vulnerable Nigerians through accredited PHCs in each of the 36 states of the federation and Abuja.

According to the National Primary Health Care Development Agency (NPHCDA), the overall aim of the BHCPF is to significantly move Nigeria towards achieving Universal Health Coverage (UHC).

The fund aims to achieve, at least, one functional public or private primary health care (PHC) facility in each political ward.

In addition, the fund seeks to have the same in, at least, 30 per cent of all wards over the next three years, 70 per cent within five years, and 100 per cent within seven years.

Focal PHCs wear new looks

Most of the 274 focal PHCs across Niger State accessing the BHCPF are wearing new looks of blue and milk colour to depict their renovation. Entering some of these PHCs, a visitor will see some new ceilings, new roofing and, in some cases, an extension of the buildings.

For instance, residents described the Maternal and Child Health Centre in Central Ward in Kontagora Local Government Area as a “hospital under the tree.” A one-room building was the only thing to show as a health facility.  They do delivery, family planning services and palpitations in the one room.  They carry out other services like general consultation, malaria testing with RDT kits, and immunisations under the tree.

Primary health care centres are the foundation of the health care system meant to solve short-term and uncomplicated health issues. But many facilities had previously suffered neglect and lack of qualified health workers.

The PHC at Central Ward in Kontagora has seen transformations. Bernice Eigbochib, the supervisory officer at the Central Ward PHC, says they have used funds from BHCPF to transform the facility.

They constructed a building that now houses the reception area, the male and female wards, the laboratory, the pharmacy and other rooms for delivery, family planning and the staff toilet.

“They called us ‘hospital without a roof’. Before now, we were operating under the tree while any delivery or private services to women like family planning and palpitation were done in that small house,” Eigbochib recalled.

Residents testified to the improved infrastructure and services at the facility. For example, one of the women at the hospital, Hassan Habiba, said she gave birth to her second baby at the hospital.

“It is closer than going to the general hospital. This PHC is where most of us in the community come to for treatment. It is closer than taking a motorcycle to the general hospital,” Habiba said.

She expressed happiness about the positive change. “The change is beautiful; now, it is not just one room, there are plenty of rooms.

“Also, we can carry out our tests here and buy drugs conveniently. It is much cheaper than going to buy at the pharmacy. Although sometimes they run short of some drugs, but before you know it, they have restocked and we can get them easily.”

WASH facilities upgraded

Before now, patients who visited the Maternal and Childcare Centre in Mokwa, headquarters of Mokwa Local Government Area, often went into the bush to defecate because there was no toilet at the facility, said Abubakar Victoria, the officer in charge of the centre.

The absence of a toilet, residents, particularly the women among them, said discouraged them from using the facility. Amina Mafura, whose house is close to the health centre, confirmed that she witnessed it when workers were constructing the toilet.

She said, “There was no toilet there before. There was a time when I needed to do a pregnancy test, I had to go to the back of the building to urinate to get the sample for the test. Imagine going to a clinic and rushing back home when you are pressed and going back to continue what you were doing. It was as bad as that.”

The story has, however, changed as funds from the BHCPF have enabled authorities to provide toilet facilities.

“The funds have been beneficial to us. For example, we didn’t have patients’ toilets, so we built one, because when patients came, we usually felt ashamed that they would go outside to excrete or urinate, thereby exposing themselves,” Victoria said.

She recalled that the health centre was on the verge of collapse but for the intervention through the BHCPF.

She added, “We were lacking outpatient cards but now have many. We have repaired the chairs and tables for the offices.

“We also bought drugs because we didn’t have drugs. We used to spend our money to buy drugs and recover it after selling to the patients.

“We also didn’t have laboratory testing equipment, but now we have bought some. Before now, we could only do pregnancy, malaria and HIV tests. Now we test for sugar level, blood group, urinalysis, blood pressure, typhoid and other tests.”

During the visit, one of the patients at the PHC, Isah Mahmud, said he never knew the facility was receiving any funds.

Mahmud said, “The health centre used to be an eyesore. I was surprised to see some of the changes it has gone through, especially with the laboratory and the toilet.

“To be honest, I never knew where the fund was coming from, but I was happy to see the changes”, he said.

How BHCPF rescued Gabas Kudu Maternal and Child Health Clinic, other facilities

The Maternal and Child Health Clinic in Gabas Kudu Ward in Lapai Local Government Area was a no-go area two years ago. According to residents, the PHC was uninhabitable and bat-infested. The sorry and almost haunting state, residents said, discouraged them from using it.

But the fund from the BHCPF was used to give the centre a facelift. Those who spoke with this reporter said renovation work on the building began last year and they are currently enjoying health services there.

According to Fatima Saidu Mohammed, a Community Health Extension Worker (CHEW), “With the fund, we have been able to undertake massive renovations, upgrade the laboratory, get a generator, get more ad-hoc staff and get security to secure the building.

“Before, whenever rain fell, everywhere was filled with water because the roof was leaking. But we have been able to repair the roof, paint the building and do the windows as we had lost a lot of our things to burglars,” Mohammed said about the work done so far.

“We bought equipment and reagents for testing and bedsheets for our beds. Patients did not like sleeping on our beds because there were no bedsheets and the mattresses were not okay. We can now boast of enough drugs,” she added.

A member of the ad-hoc staff in the facility, Ibrahim Adamu, said that the toilet facilities were unusable before, but now they have been fixed. He also pointed out that they are no longer short-staffed as the funds enabled them to pay the staff and provide volunteer allowances.

Hamza Hulera and Mary Jonah, both residents of Gabas Kudu, who were at the facility at the time this report was being filed, commended the work done on the PHC. Hulera noted that the change seen in the facility was commendable, especially the fact that residents can get all their tests done there instead of visiting the general hospital.

Jonah, on her part, recalled how bats almost took over the PHC, which made it to have a horrendous smell. She said all that has changed with the renovation that has taken place.

The nursing mother said, “Before, I couldn’t use their toilets. I would prefer to go home whenever I needed to use the restroom.

“But, everything looks nice now. They said they are getting some money from the government.”

Despite engaging five ad-hoc staff to ease the centre’s running, Mohammed says the clinic still needs more health workers to enable it to run night shifts, especially in times of emergency.

The funds have also impacted Arewa Yaman Comprehensive Health Centre. Officials said they used part of the funds to renovate the once dilapidated building, including its fence.

“We now have better client flow because we have upgraded our services. For example, before, we did not have adequate drugs; now we have enough drugs and carry out different laboratory tests,” Abdulkadir Mohammed, a health worker, told this reporter.

He said the facility can now take care of accident victims as they have procured dressing forceps using the funds, while there is an improvement in the procurement of drugs. The health centre currently operates 24 hours, according to him.

The officer in charge of the maternity ward, Aliratu Mohammed Bobi, said they had been able to get more beds, sheets and delivery coaches with the fund, which makes pregnant women comfortable visiting the hospital.

Ndagi Halima, who brought her six-month-old son for routine immunisation, was upbeat when she registered at the health facility for ante-natal. She was confident the facility was good enough after the face-lift.

Halima said: “I gave birth to my other children at the General Hospital because this place was nothing to write about. “I did not visit it because of the way it looked.

“But some of my neighbours told me about the changes and I decided to try it. The service was up to my expectations. The bedding was good, and all drugs were available.”

This reporter was shown around the facility wearing a new look. It looked like the building was newly painted. The beddings at the maternity ward have BHCPF written on them, just as there are same inscriptions on the chairs.

How residents can get drugs and services with N7,200 under BHCPF in Niger PHCs

Getting drugs by residents at the Arewa Yaman comprehensive health centre has become much easier. Alhassan Amina, a mother of two who was at the facility to get malaria drugs, commended the availability of drugs at the centre and the affordable nature of yheir prices.

Amina said the health facility’s improvement was commendable, noting that many women prefer the facility to the General Hospital at the moment.

She said she had enrolled for the Niger State Contributory Health Scheme (NiCARE), under which she gets most of her medications.

Amina added: “Tests are done, freehand medicines are collected without payment after paying the premium of N7,200.

“Before now, the place was not good, and I wasn’t coming here. There were no bedsheets, most of the ceilings were off, the smell that was coming out of here at that time, I cannot just explain it.”

“I couldn’t use their toilets. I would prefer to go home whenever I needed to use the restroom. But everything looks nice now. I learnt they are getting some money from the government.”

The premium of N7,200 under the NiCARE covers the drugs, treatment and tests annually. After paying the premium, patients do not pay for drugs or tests.

The NiCARE programme is under the NHIS gateway of the BHCPF. Anyone not covered under NiCARE will buy his or her drugs at the facility, which are always available.

For the BHCPF, the funds make the facility to be able to stock up their pharmacy with drugs which would be sold to the patients at affordable rates, and the funds would be used to restock. So unless one is covered under NICARE, one cannot get free drugs, an official explained.

 How the BHCPF works

Under the Basic Health Care Provision Fund (BHCPF), there is a National Health Insurance Scheme (NHIS) gateway that ensures that the most vulnerable Nigerians have access to the BMPHS through the State Social Health Insurance Agencies (SSHIA).

The BHCPF receives 50 per cent via the NHIS Gateway to provide the Basic Minimum Package of Health Services (BMPHS) to citizens in eligible primary and secondary health care facilities.

According to the policy, health insurance helps to provide improved health care access for low-income earners.

It is meant to provide social health insurance in Nigeria, where healthcare services of contributors are paid from the shared pool of funds contributed by the participants of the scheme.

Niger State Contributory Health Scheme (NiCARE) is the Basic Minimum Package of Health Services (BMPHS) that provides insurance for the populace. The scheme covers vulnerable groups. In contrast, those not within the vulnerable groups can pay N7,200 for the informal sector, while those in the formal sector pay N3,600 monthly from their salary.

Fatima Umar Koloche, a health worker at the PHCC Makala in Bida Local Government Area, said there are 124 enrollees for NiCARE in the health facility. In contrast, Shehu Tijani, the officer in charge of the Masaha PHC in Kontagora, noted the facility has 100 people already enrolled.

Most of the health facilities visited complained about the slow approach of the Niger State Contributory Health Scheme Agency in charge of administering NiCARE to enrolling the people in the community, while several others pointed out that the numbers enrolled were just like a drop in the ocean. Koloche said that out of eight settlements the PHC covers, only two benefit from NiCARE.

“In the ward, some communities complain that those nearby have not enrolled because those enrolled are from communities far from the PHC.

“We are appealing to them to enrol more community people so those around us can benefit from the funds,” she said.

Victoria Abubakar, who supervises the Maternal and Child Healthcare Centre, Mokwa, disclosed that out of the 13 settlements, only four had been enrolled.

“We often get those who have not been enrolled coming to participate in the free services. When we explain, they start shouting and demanding that we cannot register them.”

Dr Mohammed Usman, the Executive Secretary of the Niger State Contributory Health Scheme Agency, said in an interview that the agency had enrolled 46,196 residents of the state who are in the informal sector.

Usman added that over N295 million had been paid to primary and secondary health care facilities across the state as of the second week of August.

He said further that 182 PHCs across the state was actively offering NiCARE services while 23 secondary health facilities had been accredited, noting that there were plans to add more PHCs before the end of the year.

Usman said: “NiCARE covers common and rare ailments that bother the state’s residents. It also covers delivery, caesarian and other operations, laboratory tests, ultra-scan and x-ray services.  The coverage is for up to 155 illnesses.

“We engaged the services of private organisations, which we call third-party agents, to be involved in the enrolment as the state is large and we cannot cover it alone.”

“For now, we are working with the informal sector but are yet to commence with the workers because the government workers are having issues trusting the government with their money due to previous programmes where the monies were deducted from source but not remitted.”

He said the agency proposes N3,600 monthly for government workers, covering the worker and six family members. At the same time, those in the informal sector, which include farmers, traders and others, pay N7,200 per person for one year.

“The payment covers all ailments. You don’t pay anything, not even for a card. Once you go to the hospital and are prescribed drugs in the benefits package, the facility must give that drug. Unlike the NHIS, where you pay a percentage, with NiCARE, you pay nothing.

“The facilities are faring better because PHCs across the state, before the BHCPF, had not been receiving money from the government. Now some of them get up to N300,000 in a month. If they have about 1000 people, they will get N570,000. For each enrollee monthly, we give the PHC N570.”

Duma PHC where BHCPF is used to fix only ceiling, tiles

While several beneficiary PHCs have shown different positive ways in which the BHCPF has impacted them, the PHC in Duma Zago Ward of Lapai Local Government Area cannot be said to have benefited from the intervention fund.

Unlike others that have received facelifts, the Duma facility remains a colourless structure that could not be identified with the cream and blue colours that are the usual features of renovated PHCs.

For a visitor, the facility could easily pass for an abandoned building. It has a bench and a table both of which had seen better days, and a waste bin that stands behind them.

The components and posters show the building as a healthcare facility. Yet, there is also a new structure that is under construction but has been abandoned too.

The old building has four rooms. One of the rooms serves a dual purpose: consulting room and office of the officer in charge. One of the remaining three rooms serves as a ward, the other is the labour room, and the last is the store housing files and other things.

The ceilings looked like they had just been repaired with cardboard materials. The office used as a consulting room had a chair, table and a bench where the patients would sit.

Alhaji Faruk Ndako, the officer in charge of the facility, was not at his desk when the reporter visited. However, Tofida Aishetu, a CHEW, disclosed that the facility had existed for more than 60 years without renovation of any kind.

She revealed that the uncompleted building meant to serve as part of the facility had
been abandoned due to a lack of funds.

But Aishetu was unaware of the Basic Health Care Provision Fund (BHCPF).  She had to
call in Mohammed Usman, a Junior CHEW, because she could not say if the health
centre had benefited from the fund.

Usman disclosed that a former officer in charge of the PHC had received such funds.

However, according to him, the unnamed officer only fixed the hospital’s ceiling while
the new officer in charge added some tiles to the walls and floors of the toilet and labour
room.

“We were selected for the programme and collected some batches. The former in charge
was handling everything. Before he left here to Kawu, the work he did in our presence
was ceiling and tiles,” Usman said.

In addition to its dilapidated status, this reporter observed that the PHC does not have
adequate drugs to dispense and no laboratory. It also has no pipe bore water.

Patients who came around were told to buy drugs from outside the facility.

“We do not have drugs apart from malaria drugs. So if there is a need for the patient to
take drugs, we would write out the prescription and tell them to go and buy it,” Aishetu
said.

“We do not do tests because we have no lab and equipment. We only carry out malaria
tests because we have the kits. There is no water, and we always go out to look for water. The toilet is manageable.”

Findings revealed that authorities failed to ask the former officer in charge of the health
centre to account for the funds allocated to the centre. Instead, they transferred him to a remote PHC as a punishment.

The officer also could not account for drugs allocated to the health centre. As a result, expired medications were discovered in his office when he left the facility.

Usman told this reporter that his former boss kept the drugs away and did not dispense
them to needy patients. “He never gave out drugs to people, and when we asked him
about the drugs, he would not give any tangible explanation,” he said.

This is already defeating one of the objectives of the BHCPF scheme, which is to achieve
at least one fully functional public or private primary health care (PHC) facility in each
political ward. The Fund seeks to have the same in at least 30 per cent of all wards over
the next three years, 70 per cent within five years, and 100 per cent within seven years.

The current situation at the health care centre is frustrating as locals believe the facility
is not fit to be referred to as a health care facility because of its neglect over the years
and its current unhygienic condition.

Ahmed Duma, a youth leader in the community, said the facility had not seen any renovation before.

He lamented that residents pay through their noses to access healthcare services at the PHC.

The District Head of Duma, Alhaji Abdullahi Isah, said that due to the state of the health facility, the community had tried to undertake some work in the new structure. Still, lack of finances has limited the communal efforts. However, Isah said the district would contribute and try to ensure work continues in the new building.

We have a robust monitoring mechanism- NSPHA Executive Secretary

While reacting to the irregularity at the Duma Zago PHC, Dr Ibrahim Ahmed Dangana, the Executive Secretary of the Niger State Primary Healthcare Agency (NSPHA), insisted there are several accountability mechanisms in the system.

“If a PHC is found wanting in any quarter, we will not receive authorisation to disburse funds to that PHC. However, we have utilised our funds and retired them, and we have the authorisation to disburse other funds this quarter,” Dangana said during a press conference.

Dr Dangana said all PHCs are adequately monitored, noting that no defaulting PHCs have been brought to his attention.

“Before each fund is disbursed for every quarter, they have to present their business plan and the implementation documents to ensure that the funds have been judiciously utilised,” he explained.

He, however, said there had been no report about any anomalies in the fund usage.

According to him, the Director in charge of Primary Health Care in the local government councils is responsible for the monthly supervision of the fund implementation.

At the same time, the state team does its supervision every quarter. A team, he said, monitors, evaluates and tracks the activities of the PHCs and the usage of the funds.

This report is supported by the International Budget Partnership and the International Centre for Investigative Reporting (The ICIR).