SAIDU Aisha, 35, almost lost her son in 2020 when the infant was running a high fever, and there was no equipment at the laboratory of primary health care (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 that they could not do there.”

Aisha 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 local primary health care for tests and other medical services.

However, nearly two years after this sordid experience, Aisha is full of praise for the government for making drugs available at the primary health centre. 

“Now there are drugs at the centre,” Aisha says.

What changed? The change was brought about by government intervention. The PHC  at Nasarafu is among 274 focal PHCs in Niger State under the federal government’s health intervention programme, the Basic Health Care Provision Fund (BHCPF) in Niger State. 

According to Adamu Bashir Fatima, the officer in charge (OIC) of the centre in Nasarafu, the health facility could not dispense drugs and conduct laboratory tests before the BHCPF.

“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 write out tests for patients, and they go to the General Hospital to do the testing,” Fatima says. 

“But now, we have enough drugs bought with the fund from the BHCPF allocated to us. 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 did not do before.”

While Aisha now has praises to sing about the change that the BHCPF has brought about, many Nigerians, particularly vulnerable poor ones in the remotest parts of the country, do not have the same experience. The scheme has not made any appreciable difference in many PHCs, the closest medical facility to most Nigerians.

For example, at a PHC in Onuebonyi in Izzi Local Government Area of Ebonyi State, the facility is located in the community’s town hall, with cardboards demarcating it from the rest of the hall. The facility has no toilet except one still under construction. 

It has no water supply and depends on rainwater for all its services. The facility has a lab technician, a Community Health Extension Worker, CHEW,  a community health officer and three volunteers. It has not nurse or doctor.

“When we came here, there was only a hall. It is the BHCPF that helped us demarcate everything here. Even drugs, seats, this tank and the toilet and bathroom which are still in progress. We even built a placenta pit,” says a volunteer CHEW,  Blessing Obasi, who stands in for the officer-in-charge.

The Director of PHCDA Izzi local government area, Philomena Ibor said their major challenge is the lack of human resources.

“It’s affecting all the selected facilities because the highest they will have in our own selected facilities is two, and they are CHEWs,” says Ibor.

“We don’t have nurses. The nurses/ midwives they employed as adhoc staff ran away because of non-payment of their allowance. So, we are feeling it so much, like in this place now if the officer in charge goes to rest nobody will help her.”

The PHC in Onuebonyi typifies the experience of a few states that have not fully taken benefit of the Fund and thus do not have enough funds to provide healthcare at these facilities.

The implementation of BHCPF started in the year 2020 with the state government paying the initial 25 per cent counterpart fund of hundred million naira that enabled the state to access the direct facility fund (DFF) in two tranches in 2020 to the tune of 601,500 as well as one and two tranches in 2021 and 2022 respectively, apart from the funds coming from other gateways. 

However, it is yet to pay another counterpart fund since then, according to the Focal Person BHCPF in the state, Leonard Alegu

However, the Ebonyi State commissioner for Health, Umezurike Daniel, said that the issue of counterpart funding would soon be dealt with.

Background…

To bridge gaps in primary healthcare delivery services, particularly for the poor and vulnerable, the Nigerian government in 2019 rolled out the Basic Health Care Provision Fund. Called BHCPF, it is enshrined in the 2014 National Health Act. 

It is a pool funded with at least one per cent of the nation’s consolidated revenue and other funding sources, including donor contributions.

Almost three years into the implementation of the Fund, journalists, with the support of the International Budget Partnership and the International Centre for Investigative Reporting, visited hundreds of PHCs across 120 local government areas in twelve states of Nigeria to assess the impact of the fund.

The states are Anambra, Ebonyi, Cross River, Akwa Ibom, Ogun, Oyo, Kano, Jigawa, Gombe, Bauchi, Niger and Nasarawa.  Read the reports here.

For the fund to get to beneficiaries, it is disbursed through three gateways: the National Health Insurance Scheme, the National Emergency Medical Treatment, and the National Primary Health Care Development Agency (NPHCDA).

Funding through the Gateway of the NPHCDA are for essential drugs, vaccines, and consumables, targeted at the maintenance of primary healthcare facilities, equipment, and transport, and, lastly, towards human Resource interventions for primary health care.

Five per cent of funding for human resources through the NPHCDA is for midwives. The federal government in 2009  had introduced the Midwives Service Scheme, MSS. 

The MSS was intended to increase the availability of skilled birth attendants, especially in rural communities, as well as improve the uptake of antenatal care, postnatal care, routine immunisation, and other primary health care services. 

It was also designed as a collaboration among the three tiers of government – federal, state, and local governments. 

Its major hallmark was having midwives deployed to primary health centres in wards across the country.

Community health extension workers, or CHEWs, were also recruited and deployed to MSS facility to support the midwives and mobilise the community residents to seek health care services. 

In June 2022, the federal government said about N56 billion had so far been disbursed from the BHCPF. The fund, among other things, provided for more than 1,500 midwives, says the Secretary of the Oversight Committee of the Federal Ministry of Health, Chris Isokpunwu, 

“It also provided for human resources for health, and more than 1,500 midwives have been engaged with the fund.”

The MSS appears to have had a significant impact, but nearly a decade later, the primary health centres are facing a shortage of midwives after the exit of the scheme.

In states like Ebonyi, the scheme is almost non-existence. “…midwives they employed as adhoc staff ran away because of non-payment of their allowance,” says the Director PHCDA Izzi local government area, Philomena Ibor. 

The state Focal Person for BHCPF in Ebonyi State, Leonard Alegu, who confirmed the situation, says preparations are underway to remedy the situation.  

In 17 PHCs visited across five local government areas in Nasarawa, more than half of them have no midwives—and the few that did have one, at most two.

The experience is no different in Oyo state.

Jigawa is also suffering from a dearth of midwives. However, the government introduced a ‘sustainability scheme’ to bridge the exit of MSS in the state.

As of October 2021, only Lagos, Kogi and Rivers states were not verified to access the BHCPF.

Among the 34 verified states, only 31 were authorised to receive funds, according to data from NPHCDA. 

The funds are paid quarterly.  But delay in funds release, as well as implementation, has been causing operational challenges for benefiting PHCs.

In Ogun the scheme was launched in October 2021, two years after the federal government but PHC’s could not access the fund until the first quarter of 2022. 

Gombe State also launched in 2021, and in  July of the same year, Bauchi launched its BHCPF scheme.

Nassarwa, Cross river and Jigawa all commenced in 2021 while Ebonyi was in 2020.

However, despite the late commencement, health workers and residents in the states say the BHCPF scheme has raised optimism among the people since its implementation. 

Lack of structures is a militating factor observed across the states.  In Bogobiri the heart of Calabar, the Cross River State capital,  the health facility, which is a BHCPF beneficiary and  caters for areas including Etim Edem Park, Watt Market, Bogobiri, Barracks road and more, is basically a table with a mountain of books on it, and a few white plastic chairs all placed at the entrance of the hall within the premises of the Apostolic Church 

There is no building, no storeroom, no labour room, and the health workers operate at the benevolence of the church, which stands opposite a mosque in this community of mostly Muslims. 

“We have operated like this for about five years now,” says  Mary Henshaw, who is in charge of the facility. 

It comes amidst allegations of misappropriation of funds by the Director General of the Cross River State Primary Health Care Development Agency, a doctor, Janet Ekpenyong.

In one instance, she was accused of directing that 80 per cent of the capitation to health centres be paid to a company owned by her husband.

When contacted, Ekpenyong said the money was meant for the purchase of laptops for the facilities and that she presented the company “because the laptops will be cheaper from them”.

In Ala community in Ogun State, the present location of the PHC is a portion of the community hall, and it has been like that for years even though officials say work has commenced at the permanent site. 

Officer In Charge of the Ala PHC, Ajimot Ajoke Ayodele, said they had to manage the facility and still take delivery of pregnant women in one of the dim-lighted and poorly ventilated small rooms at the centre. The general ward is so small that it could hardly take a handful of people at a time.

The assessment also witnessed pockets of Community effort geared towards tackling the problem of lack of structure.  In some communities in Ebonyi in one instance, residents rented a building so that the health worker can operate from it, in another the resident provided land as well as transportation.

Leaky roof is another factor militating against the effective implementation of the BHCPF.  In Creek Town PHC, Odukpani LGA, of Cross River, the officer-in-charge collapsed all the wards into the only standing building in the PHC as a heavy storm destroyed the maternity ward building about two years ago.  

Services were also stopped at Onigbaketun Awotan PHC in Oyo, which the residents described as very functional before the roof was destroyed in a rainstorm.

In Niger state, a handful of the BHCFPF benefitting PHCs were able to fix the roofing and ceiling problem,  but not all as the OIC of Bonu PHC Yahaya Jibrin noted it as a challenge.

“For about six years now, we’ve not had a public supply of electricity, but through the BHCPF, we have that. We also have solar lights provided to support our operations” says Ibidun Ajibade, a staff at Igan health centre in Ijebu-East LGA, Ogun state.

Not all BHCPF benfitting PHCs have electricity, as power is still a challenge. In places like Nasarawa were alternative power supply – solar – were provided,many of them were found to be non functional. 

In Oyo, the matron of Alakia Model Health Centre in Egbeda LGA Oluwaseun Adedeji while appreciating the government support via the BHCPF says “We also need mosquito nets and a new generating set. The toilet needs wiring, and the leaking laboratory needs attention.”

For the workers at the PHC in Bansara, Ogoja LGA and the facility in Okundi, Boki LGA in Cross River state, water is a big challenge.  Same also in Oyo Ikumapayi PHC, Olodo, in Ibadan, a newly refurbished facility but it still lacks many basic facilities such as essential drugs, medical equipment and clean water. 

In Billiri LGA in Gombe, 1,682 residents registered for the programme, and 203 of them were posted to Kelkel PHC to access health services. However, the PHC is in a deplorable state, with some structures on the verge of collapsing and there is no running water. Officials say they rely on unclean water from water vendors for medical activities and personal use. 

Health officers not on sit, and lack of drugs is also a common reoccurrence in many of the facilities visited. Mujibat Abdulrasaq, a 35-year-old mother suffering from malaria, says she made several visits to the Centre at Owode, in Ogun State only to hear the same words each time – “Come back another time, the drugs are not available now”.

“They either tell you to come back tomorrow or next week to get the drug, even with your basic card, and there is no assurance that if you come back the next day, you will be lucky to get the drug,” she adds.

There were similar complaints in Uyo by Emmanuel Essien whose wife is 8-month pregnant.

“Whenever you go there, it is either the officer has travelled to Calabar for a meeting, or they don’t have drugs. We are always asked to buy drugs from the chemist. Sometimes the woman is just rude and is shouting at us,” he says.

Health officers spoken with say shortage of staff means they will not be able to effectively man the facilities all day.

In Nasarawa the OIC of Ashupe PHC, Esther Ila Anjebe says she is the only staff at the facility.  She contends with administrative, health as well as still carryout outreaches as well as immunisations services.

Some primary healthcare centres in Gombe State have no qualified midwives or medical doctors that could attend to emergencies despite being under the BHCPF scheme. For instance beneficiaries under Sansani PHC are taken to the General Hospital Kaltungo for emergencies and sundry services.

Lack of awareness of the scheme

In Ogun State, a health officer in one of the PHCs said the majority of their beneficiaries are not aware of the BHCPF, adding that most of them patronise drug vendors as well as alternative healthcare practitioners.

Checks show that some of the cards for the enrollees are still at the centre, yet to be picked up.

Many officials confirmed receiving the funds – although not all the tranches – but they say  the  Funds are still insufficient.

The OIC of the Arumangye PHC in Nasarawa Aishetu Adeka, confirmed that the facility receives the funds regularly but it’s insufficient because of the increasing cost of drugs and facility maintenance.

According to her, patients are to be treated with N570 based on the provision of BHCPF. However, she said this is not always enough to attend to cases reported by patients.

She says she receives N67,830 monthly, N52,000 (75 per cent of the amount) goes to procuring drugs while the remaining N12,000 goes into the facility’s management.

“For me, it is insufficient because drugs are costly these days. And then you say when I have a patient with malaria, I should treat them with N570, which cannot solve that problem, and talk less of having typhoid fever,” she laments, “So before you know, one client uses up to N3,000. When we complained to them, they said these 119 patients are not coming in the same month, so we should not talk about it.”

A curious factor militating against the implementation of the BHCPF in several PHCs  is the non-availability of chequebooks. 

Yar Kasuwa and Ungwar Gini PHCs in Kano confirmed receiving funds but are unable to access it because banks have not issued them with chequebooks. 

“We have not been able to access funds for the BHCPF because we are yet to get our cheque book from the Kano State Primary Healthcare Management Board, (KSPHCMB),” says the OIC of Ungwar Gini PHC, Maryam Abdullahi.

The PHCs have become playgrounds and marketplaces for residents. 

The KSPHCMB says it has asked the banks for a refund.

Difficulty accessing funds due to operational challenges is a recurring issue. Akarami Nuhu Aliyu, an official of Kano State Contributory Healthcare Management Agency (KSCHMA) at Yaryasa PHC, claimed that he was among trainees for the project at Yaryasa before it was allegedly hijacked.

According to him, the scheme was diverted due to an alleged unresolved personal dispute between Magaji Ubale, the former officer in charge of the Yarsaya PHC, and his former head of department (HOD), Medical, Suraju Sabayuki.

“All enrollees on this list are people of Yaryasa, but due to the diversion, only officials of Jali facility can access the BHCPF Bank account,” he says.

At Tsohon-Gari Health Clinic in Tudunwada LGA, the 298 enrollees in the Tsohon-Gari ward have been denied access to the BHCPF benefits in the last two years following the death of the second In-Charge, popularly called 2-IC of the facility, Sani Salisu.

Umar Abdu, the In-Charge of the PHC, said Salisu, who was one of the signatories to the BHCPF account, died on October 14 2020.

He claimed to have written a letter to the KPHCMB in September 2021 with Salisu’s death certificate enclosed to secure approval to have Salisu’s name replaced, but to no avail.

Tsohon-Gari PHC’s case is similar to that of Middle Road PHC in Fagge LGA, where the death six months ago of the ward development committee chairman, Yau Muhammed, halted the project at the facility.

How government is tackling the challenges

The executive secretary of Ogun State Primary Health Care Board (PCB) Ogunsola Ayowole Elijah, attributed the issue of alleged corruption regarding the sale of drugs meant for basic healthcare schemes at prices above the rate approved by the agency as an act of overzealousness on the part of the PHCs officials concerned. According to him, the agency is on the lookout for such PHCs.

“We have a monitoring team and our monitoring team are in two folds. We have programmatic monitors and the financial monitors and our auditors and accountants” he says.

In Oyo, the Executive Secretary of the  State Primary Health Care Board,  Muideen Olatunji, said the government is working to address the challenges of infrastructure and personnel.

“We are working round the clock to ensure that we get the required complementary staff. The state government is trying to think outside the box on the other methodologies we can adopt to get people working there without foreclosing on recruiting other staff, which the process has commenced. More personnel will come” he says.

He adds that the government has started the procurement of drugs to tackle the issue of it deficit. “In the last three months, that has been what we have been doing. All facilities get a regular supply of drugs,’’ he says.

In Gombe Idris Nuhu Ahmad, Desk Officer of the BHCPF in Balanga LGA, worries about the coverage of the scheme using the one PHC per ward system.

He says 2,326 people are registered in the ten health facilities across the LGA.  “There are 58 health centres in the whole LGA. But only ten facilities are running the programme, and we felt that the number is grossly inadequate, considering the large landmass of the LGA.”     

The Gombe State Commissioner for Health, Habu Dahiru, says they are looking to solve the human resource issue by “focusing on the schools and colleges that produce the medical doctors and other health workers where the nurses, midwives and CHEWs were produced.”

“We will provide them with enough equipment to get accreditation and enroll more students. They will be subsequently posted to the healthcare facilities. So, that will solve the problem of shortage of human resources,” he explains.

This, he says, is in addition to the retraining of existing staff.

In Bauchi, there were concerns about the enrollees selection process used by the Bauchi State Health Contributory Management Agency (BASHCMA).

To be selected for the project, it takes a combined effort of the ward heads, traditional rulers, the In-charge of the PHCs and Ward Development Committee Chairmen in the local governments to identify the vulnerable. Since the community leaders live with the people, it was assumed that determining the vulnerable persons amongst them won’t be hard.

But an official alleged that most of the beneficiaries selected were relatives and friends of politicians, government officials and traditional rulers.

However, state officials say that the process was fair and transparent. Mansur Dada, the Executive Secretary of BASHCMA, debunked the allegations of favouritism in selecting beneficiaries.

Dada said that the agency allocates 155 beneficiaries to each PHC in each ward of the local government but admitted that the figure was inadequate.

NOTE: This report is a summary of individual investigations carried out in the 12 focal states. Read the detailed investigations HERE.

This report is supported by the International Budget Partnership (IBP).