How inadequate manpower cripples primary healthcare in Nasarawa 

MANY Primary Healthcare Centre (PHC) employees in Nasarawa State are either contract staff or volunteer community and health extension workers (CHEWs) who earn between N3,000 and N10,000 monthly. Many have been working for over 10 years, hoping to be absorbed into the state civil service.  

In this report, The ICIR’s Marcus Fatunmole, who visited 17 PHCs in five local government areas (LGAs) of the state, reports how the state PHCs struggle to provide services because of low and poorly remunerated human resources. 

Many PHCs in the state do not have nurses. Checks by The ICIR showed that until recently when the government recruited some nurses and midwives, there were less than 20 nurses and 30 midwives in over 700 government-owned PHCs in the state.

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The shortage of trained midwives and nurses cripples services and threatens the state’s Basic Health Care Provision Fund (BHCPF), launched in 2021, and other services at the PHCs.

It also prevents the state from achieving the Federal government’s Midwives Service Scheme (MSS) targets.

The BHCPF funds the Basic Minimum Package of Health Services (BMPHS), increases fiscal space for health, and strengthens the national health system. Similarly, the MSS ensures the availability of midwives at PHCs to boost services, especially antenatal care and births, thereby reducing high maternal and child mortality in the country.

Salamatu Dangana, officer-in-charge (OIC) of the Shafan Kwotto PHC in Toto Local Government Area (LGA), Nasarawa State, was lost in thought when the reporter got to her office on the afternoon of September 17. 

Salamatu was thinking about how she would pay the employees working at the facility for the month. 

PHC Shafan Kwotto, Toto Local Government Area of Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

“You met me laying my head on the table, not that I was sleeping, but I’ve been thinking about how I will pay my staff. 

“Government said all services rendered should be effective. How can the services be effective when people are not motivated? It is a big challenge that we are facing,” the OIC said. 

Another officer-in-charge of a government-owned PHC at Ashupe community in Obi LGA, Esther Anjebe, said she has been the only one running the facility. Founded in 2002, the facility remains in a single room of a rented, unplastered house it has occupied since its creation. 

Nobody wanted to go to the PHC and work because the community is far from town, Anjebe told The ICIR.

She only agreed to work at the clinic because the community is her husband’s village. She said she left another PHC where she was the head when the government created the clinic.

The government has since abandoned the village clinic for her, she claimed. Anjebe is on the government’s payroll. 

The rented house accommodating PHC Ashupe in Obi Local Government Area of Nasarawa State for nearly 20 years. Photo credit: The ICIR/Marcus Fatunmole

In a video interview, she said she used her money to buy most of the tools she used at the clinic “as part of her sacrifices for her husband’s people.” 

The ICIR reporter observed that the government acquired a vast piece of land in the community where it has abandoned a building meant for the PHC. 

The building, on which work had stopped over 10 years, has been overgrown by bush. It has become a dumping site for the villagers. 

The PHC Ashupe permanent building abandoned by the Nasarawa State Government. Photo credit: The ICIR/Marcus Fatunmole

Human resources for health, especially midwives, are lacking across Nasarawa PHCs, and contract staff confirmed that poor wages and inadequate human resources affect their work.

None of the 17 facilities visited by The ICIR had a trained nurse.  The PHCs are at Bukan Sidi, Tundu Gwandara and Angwan Toni in Lafia LGA; One and Two in Obi; Deddere, Agwade and Ashupe in Obi LGA; and Marabban Gongo and Sisinbaki, Model in Wamba LGA, Sabon Gida and Kokona PHCs and PHC One Garaku in Kokona LGA, as well as Shaffan Kwotto, Shaffa-Abakpa and Model Toto PHCs in Toto LGA. 

Inside the PHC Ashupe, Obi Local Government Area of Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

Eight of the 17 PHCs had no midwife. Some of those with midwives are contract staff. The contract nurses are among workers who receive between N5,000 and N10,000 monthly. 

The National Primary Health Care Development Agency (NPHCDA) recommends that a PHC should have four midwives/nurses. Besides, the NPHCDA demands that a medical officer be available at PHCs, where possible, and a Chief Health Officer (CHO).  

A woman in labour abandoned PHC over staff shortage, then lost her baby 

Habiba Abubakar, 35, was in labour and approached the Agwade PHC in Obi LGA for delivery in mid-October. 

She registered for antenatal and attended antenatal meetings at the PHC. 

When she came for delivery at about 3 pm, she met only a male caregiver on duty. She didn’t allow the caregiver, a CHEW, to take her delivery. 

Virtually all PHCs in Nasarawa State have a new signpost like this, regardless of the state of their infrastructures and human resources. Photo credit: The ICIR/Marcus Fatunmole

The woman returned home, where she gave birth to her child through neighbours’ support; she lost her baby hours after birth. 

The male health worker, who identified himself as Jerry, said the only two CHEW women at the PHC had closed by 3 pm, leaving only him at the facility. 

FG’s Midwife Service Scheme not functioning in Nasarawa 

In 2009, the Federal government launched the MSS to improve human resources for health, thereby reducing maternal and child deaths by upscaling services such as antenatal and immunisation, among others.  

List of contract staff at the PHC Shafan Kwotto, Toto Local Government Area, Nasarawa State

The three tiers of the government in Nigeria drive the MSS.  

In Nasarawa State, there are mainly CHEW and J-CHEW (junior health extension workers) at the PHCs. CHEWS, who have worked for many years, manage most of the PHCs. 

The chairman of the state chapter of the National Association of Nigerian Nurses and Midwives (NANNM), Tammah Shawulu, a nurse, told The ICIR that there were less than 10 nurses and about 30 midwives in the state’s PHCs as of late 2020.  

Nasarawa State Governor Abdullahi Sule

Shawulu commended the state governor, Abdullahi Sule, for recruiting graduate midwives and nurses from the state’s School of Nursing and Midwifery in 2021.  

Shawulu told the reporter, “We have been on their neck that PHCs must have a nurse because this is a challenge, especially midwives. We have been having problems with human resources, which causes high maternal deaths.” 

He explained that many nurses and midwives in the state are jobless, making it imperative for the government to recruit more workers into the PHCs. 

“We are not happy. It is not healthy enough because there is a high death rate, especially among pregnant women when they come for delivery. They don’t have good management because professionals are not at the PHCs. 

PHC One, Obi, Obi Local Government Area of Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

“For over 10 years, you cannot see any newly employed health workers. The old workers are retiring, and new ones are not employed. We believe that a nurse must be at every facility. That’s the guideline.” 

He said that the Governor Sule-led government promised to engage all graduates produced by the school in the next three years. 

The state Commissioner for Health, Ahmed Yahaya, confirmed the recruitment and the governor’s pledge to the reporter. 

Generating revenue to pay workers

Many PHC heads who spoke with the reporter said they paid their workers from their generated revenue. Some PHCs generate between N125,000 and N150,000 monthly, while a few earn less than N100,000. 

One of the state’s PHCs struggling to survive is Shafan Abakpa in Toto Local Government Area of Nasarawa State .Photo credit: The ICIR/Marcus Fatunmole

They make the revenues from the card they issue to patients, from births, and from payments made for treatments and other services. 

The PHCs pay their security staff, cleaners, contracted CHEWs and J-CHEWs and laboratory assistants, as well as fuel power generating sets, and pay for electricity. Some that do not have water buy from vendors.  

But every PHC rendering BHCPF service has a fund to pay their workers because they receive a monthly allocation for the programme from the government.  

PHCs benefiting from the fund also use part of the money they receive for maintenance, purchasing drugs and other services. 

PHCs categorisation in Nasarawa State 

Nasarawa State categorises its PHCs into Model, Basic and Clinic. Some council areas have one or more model PHCs, which are very big and provide broader services than others. 

There are more workers at the model PHCs, and the government pays many of them. They provide BHCPF services. 

The basic health centres are also called PHCs in the state. Some political wards in the state have nearly ten basic PHCs, out of which one provides free health services for children, pregnant women, the poor and people above 85 through the BHCPF. 

Model PHC Wamba, Wamba Local Governmetn Area of Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

Clinics are more in the villages. They provide essential services such as immunisation, antenatal care, delivery, and treatment of basic ailments. 

According to the National Primary Health Care Development Agency, NPHCDA, the PHCs are Nigeria’s cornerstone of health policy. They are the first point of contact most Nigerians have with the health care system.  

State primary health care agency tactically turned down The ICIR’s request for an interview 

The ICIR reached the Executive Director of the Nasarawa State Primary Health Care Development Agency to speak on the effectiveness of the MSS and BHCPF in the state. However, the agency referred The ICIR to get permission from the NPHCDA in Abuja before granting an interview. 

Nasarawa State Primary Health Care Development Agency. Photo credit: The ICIR/Marcus Fatunmole

The ICIR wrote the NPHCDA, but the agency failed to respond to the letter four weeks before writing this report. Incidentally, the NPHCDA’s Executive Director, Faisal Shuaib, is from Nasarawa State. 

PHCs workforce 

Shafa Abakpa PHC was built about 25 years ago. It had two CHEWs on the government payroll as of September 2022. The facility had no J-CHEW or midwife. 

A man of over 60 years works as a security guard at the PHC. Married with seven children, he is among the workers paid N4,000 monthly by the clinic. 

One of the patients’ wards at the PHC Daddere, Obi Local Government Area of Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

The OIC at the facility, Obatta Alhassan, started work at the PHC as an attendant in 2001. According to her, the PHC generates less than N20,000 monthly, from which she pays the workers. 

Similarly, the 40-year-old PHC One at Garaku in Kokona LGA has a midwife and six CHEWs. While the midwife is on the government payroll, four of the CHEWs are not. Its OIC, Pauline John, said the PHC attended to 565 patients in August. 

The Model PHC Wamba has no nurse. Only a midwife. There are nine CHEWS at the centre, six of whom are contract staff. Among the three CHEWS paid by the government are the OIC, Deputy OIC and one other worker. 

Contract CHEWS receive N10,000 monthly, and J-CHEWS earn between N5,000 and N7,000. 

The Model PHC in Toto has one midwife and five CHEWs on the government payroll. Two of them are contract staff. The two J-CHEWS at the PHC are also on the payroll. 

According to its assistant OIC, Hamisu Danladi, the PHC attends to an average of 200 people monthly. 

Contract CHEWs at the PHC receive N5,000 monthly. 

Our pains: Contract workers lament 

Hassan Aliyu Bala has worked at the Tundu Gwandara PHC for eight years and has lived on the N5,000 the facility pays him. He deputises for the OIC, Aliyu Bala.  

He told the reporter that life was not easy, given his meagre salary. 

Health workers, women and children at the PHC Gwandara, Lafia, Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

Mary Agbawu is spending her second year at the PHC as a CHEW. She is married with kids but also lives on the N5,000 stipend the PHC pays her. Like most CHEWS, she has a professional diploma in Community Health.  

“We are enduring the programme; we have no option. Before, the hospital paid us N6,000 or N7,000 monthly. We appreciate it because we have nothing to do,” said a CHEW, Mattew Peter, at the PHC Agwade. 

According to Peter, CHEWS used to work five days a week, but it had changed to six days. 

 Several other CHEWS, J-CHEWS, lab assistants, and other workers at the PHCs visited by the reporter complained that life was becoming more unbearable because of rising inflation and poor pay. 

They confirmed that the trauma of economic hardship they face affects their outputs in the workplace. Besides, about five workers said some basic skills trained midwives and nurses could display in the workplace were missing at the PHCs. 

Health workers and some women with their children at the PHC One, Obi, Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

A few workers also noted that the patronage of unskilled midwives at home was high, thus promoting maternal and child deaths. 

Apart from inadequate human resources and infrastructural deficits, experts believe patronage of unlicensed health facilities results in high maternal and child mortality. 

“If a woman puts to bed, we use a torchlight or lantern at night,” one of the workers at the PHC Toto told The ICIR 

State budget for health in 2022 

Nasarawa State’s budget for 2022 is N110.8 billion, out of which it earmarked N2.76 billion for the health sector. 

In 2021, the total budget for the Ministry of Health was N2.8 billion. 

One of the dirty pillows at a ward in PHC Toto, Toto Local Government Area of Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

Appropriation for the state PHCDA was N570 million in 2021 and 921.3 million in 2022. 

The ICIR reports that the agency got only N74.7 million of the N570 million appropriated as of October 2021. The amount represented 13.1 per cent of its approved budget. 

The government’s failure to release funds for the agency could be part of the reasons it does not employ and pay workers. 

According to the Health Facility Registry, the platform where Nigeria keeps its hospitals’ data, there are 988 PHCs in Nasarawa State. 

State government reacts 

The State Commissioner for Health, Ahmed Yahaya, a pharmacist, admitted there was a shortage of human resources across the state PHCs. 

He said the governor directed his ministry to improve access to primary health care services across the 13 local government areas by engaging more midwives. 

Nasarawa State Commissioner for Health, Ahmed Yahaya. Photo credit: The ICIR/Marcus Fatunmole

“His Excellency has directed that over 200 workers, worth over N800 million, will be taken in batches to fill in the gaps across the board over time. We have taken the first batch of graduates from the School of Midwifery. Their names have been sent to the Primary Health Care Development Agency so they can be deployed in PHCs across wards in the state. 

“We have a midwifery school; the state has absorbed the first set. We are also picking the next three sets. We are sending our memo to the governor for their absorption. Our target for the absorption of these midwives is for them to be posted into the primary health care facilities.” 

On CHEWS’ management of the PHCs, he said: “I’ve just explained to you that inadequacy of human resources is enormous everywhere. We do task shifting and task-sharing at the PHCs.” 

He said the government used people with skills and experience to work at the PHCs. 

The commissioner said he was unaware that PHC workers earned N3,000 as a wage. 

PHC Toto, Toto Local Government Area of Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

“I don’t know anybody being paid N3,000 in the state. Personally, (I think) those people do it voluntarily and have a way of getting some stipends. Volunteers are not part of those that I presented to you as part of human resources for our facilities.  

“But casual, there are. During the N-SHIP programme and other activities, most of the excess fund that comes after the service is provided through health financing; a certain percentage goes to them to take care of those workers.” 

The commissioner explained there were differences between workers employed by the government and those working as volunteers or casual. 

PHC Kokona, Kokona Local Government Area of Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

He added, “The names of all the voluntary and casual workers have been made available. The intention is to move them into the state civil service. That effort is also ongoing. The governor has directed the state Ministry of Finance to provide a quantum of money that might be needed to absorb those people into the full-scale payment of the state salary scheme.” 

Data on the global shortage of nurses and midwives 

The World Health Organization (WHO) notes that approximately 27 million nurses and midwives work in health facilities globally. 

Nurses and midwives account for nearly 50 per cent of the global health workforce. 

    Health workers at the PHC One Garaku, Kokona Local Government Area of Nasarawa State. Photo credit: The ICIR/Marcus Fatunmole

    There is a global shortage of health workers, in particular nurses and midwives, who represent more than 50 per cent of the current shortage of health workers. 

    The largest needs-based shortages of nurses and midwives are in South East Asia and Africa, according to the WHO. 

    WHO estimates that nine million more nurses and midwives are needed globally by 2030 before the world can achieve Sustainable Development Goal Three on health and wellbeing. 

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

    Marcus bears the light, and he beams it everywhere. He's a good governance and decent society advocate. He's The ICIR Reporter of the Year 2022 and has been the organisation's News Editor since September 2022. Contact him via email @ [email protected].

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