By Elijah Akoji
Five years after the Basic Health Care Provision Fund was initiated in Jigawa, its implementation has helped transform the primary health system in the state. WikkiTimes’ Elijah Akoji shows how it works in this report from five primary health centres in Gwaram, Gwiwa, Dutse, Rigim, and Roni council areas.
Raziya Muhammed’s husband died in 2021 of kidney disease. At 27, she was a widow and seven months into her first pregnancy.
For her survival in Dingaya community in Gwaram LGA, she lived at the mercy of her siblings, battling the challenges that came with a first pregnancy. Her diet suffered, and she had no access to antenatal care. She almost lost the pregnancy.
“I had several difficulties carrying the pregnancy until the pain became persistent and I was rushed to the clinic,” she recalls.
“It was at that point I was registered and given a card, and all the pregnancy drugs given to me in different colours were all free. I was told the government would pay for me, I was so excited,” she says.
“Till I delivered, I was never asked to pay a dime. Even when I was to deliver, a free car rushed me to Dingaya PHC with the help of the District Head of my ward, which is like three kilometres away from my house. All of these, I later came to discover is a government programme targeted at helping pregnant women under the Basic Health Care Provision Funds,” Raziya adds.
The Basic Health Care Provision Fund (BHCPF) has set guidelines. It is on record. A specific objective is to achieve at least one fully functional public or private primary health facility in each political ward; then scale it up to 30 per cent of all wards over the next three years; ramp it up to 70 per cent in five years, and then 100 per cent in seven years.
It also looks to achieve three fully functional public and private secondary health facilities benefiting from the BHCPF in each state; then moving up to 50 per cent of all states over the following three years and 100 per cent within five years.
The scheme also aims to establish effective emergency medical response services in all 36 states and the Federal Capital Territory in five years, including national ambulance services.
It also plans to reduce out-of-pocket spending by 30 per cent in five years and increase financial risk protection through health insurance, as well as increase life expectancy to at least 60 years over the next 10 years.
Five years on, the Jigawa story
Jigawa in northwest Nigeria is among the states listed to have qualified to access the BHCPF in 2019, WikkiTimes can report. The state is dominated by rural farmers, but in the last five years, it has enjoyed growing transformation across its primary health care system—with a health insurance programme that covers access to its primary health centres.
The National Health Insurance Scheme (NHIS) is one of the gateways under BHCPF, and receives 50 per cent of the fund from the total consolidated fund. This scheme provides a defined Basic Minimum Package of Health Services (BMPHS) to all Nigerians in eligible primary and secondary health care facilities, most especially pregnant women.
Visits to health centres across Gwaram, Gwiwa, Dutse, and Rigim Local Government Areas, LGAs, give a light of hope as residents shared their satisfactory experiences. That is, except in Roni, where some residents across some communities still decried poor access to quality health services. Their major frustration WikkiTimes understand is in the several kilometres they have to travel to seek care.
Aliyu Inuwa, 47, in Farin Dutse ward, works in Gwaram LGA Education Department. He is both a civil servant and a farmer. His hope was restored when he visited Farin Dutse health centre with his ailing daughter Hauwa, and she was treated without him paying any money.
“It was a big relief for us. She suffered severe typhoid, which started when I had no money or even grains to sell, and we were only hoping on God when her health became critical,” says Inuwa.
“We rushed her to Farin Dutse Health Centre, where she was immediately admitted and attended to; she was given several drips, injections and some antibiotic drugs like ciprofloxacin. It was not the usual best way as you find in urban areas because there were some drugs they could not give us as they don’t have them like antacid, because of her stomach ache, all other drugs were covered by the NHIS. That came as a sign of hope for me.”
Under the “One Ward, One Health Centre” scheme of the state government in 2015, Farin Dutse PHC is among the newly constructed health centres in Jigawa.
In Soro ward, Maryam Kalifa, 39, was six months pregnant when her husband died. Already with two children, she lived in fear, wondering how to manage her family needs, ignorant of the health cover. But she had the courage to smile again when she began hospital visits for her drugs and antenatal care during her third trimester.
“The district head asked me to go to the hospital and register with the nurses and they will attend to me,” Kalifa recalls.
“Although we had a sensitisation prior to my husband’s death that pregnant women can visit the clinic free of charge, I never knew it was true because the government for a long time had not given us anything for free.
“On getting to the clinic, I have given some yellow [possible folic acid tablets] drugs. This I never took when I was pregnant with my two children before this last one, I and some other women were attended to till we gave birth. Two nurses helped me through till my delivery date, I am still surprised as we have never had such care before. Even when the child was taken ill months after delivery, all the drugs I was given I never paid for them,” Kalifa adds.
The biggest benefit for the facility through the BHCPF is in the deployment of midwives and community health workers, recounts Muhammad Bashir, officer-in-charge at Soro PHC,
“We usually receive N300,000 every quarter from the Primary Health Care office in Dutse. It is from this money we do some renovation, buy some essential drugs and treatment kits,” he says.
“We have a staff midwife and one community health worker. Also, the state government supplies us some essential drugs monthly which include [anti]-malaria drugs, [IV] drip, calcium, vitamin c, riboflavin, vitamin B and D, alongside [anti-]malaria injection and tetanus injection which are all for pregnant women, while our NHIS function as well, and most community people are benefitting from it.”
Salamatu Ibrahim is a midwife at Soro PHC, among midwives recruited by the state to man health centres. She is grateful for the opportunity but the workload of being the sole midwife attending to a growing population of women is causing her to lament.
“Being the only one attending to these women, and women who come from other communities under Soro Ward, the work is hectic—and if only the government can add at least one other person so we can have two shifts,” she says.
“We are paid monthly—N60,000, but without accommodation, I cover about 25-30km daily to get to work. It is from this money I transport, feed, and also take care of myself. How about the health risk—riding on a bike over an untarred road? We just hope the compensation will come one day better than what we get now.”
The district head of Soro, Bala Shehu, shares the concern—and the reality that even improved situations are not always the best.
“The rates of maternal and child mortality have reduced since women started getting free medical attention compared to when they have to pay to get some of the drugs prescribed during antenatal,” he says.
“We cannot get it all, but the government has tried in the aspect of registering pregnant women for free. It is a burden most men usually avoid because they don’t have money, leaving the women to suffer, raising money to take care of themselves and their pregnancy.”
Rigim Emirate where pregnant women now deliver safely
In the last 15 years, Ringim LGA topped the charts in maternal and child deaths in Jigawa. But its residents say that is changing, as pregnant women at least can access medical attention free of charge.
In Kyarama Ward WikkiTimes met Jamila Yunusa, a mother of six who is nursing her last child. She is among the women registered under the NHIS scheme in Kyarama Health Centre. She shared her recent experience, and how she was taken care of at the clinic throughout her pregnancy, although she gave birth at Rigim General Hospital.
“We were asked to come to the hospital every Thursday, so those days we don’t go to the farm; instead, we assemble at the clinic where a nurse usually comes to talk to us on how to stay healthy during the pregnancy,” she recalls.
“I was given all drugs including folic acid and calcium, free of charge during the antenatal. When it was almost time, I had to stay with my sister in Ringim town, so it was just easy for us; I delivered at Ringim General Hospital, and when I returned home it was still free medical care with drugs.”
The PHC’s officer-in-charge, Nuhu Ibrahim, expressed satisfaction at the government’s commitment to the BHCPF program.
“We have never had a time when we have ever received money from the state government to carry out repairs and rehabilitation,” he says.
“The BHCPF comes to us directly, and we use it accordingly in the areas of priority. We involve the community head, ward development committee, and other relevant stakeholders in whatever we are doing and then we report back to the agency in Dutse,” Nuhusaid.
Ahmad Bello, who chairs the Ward Development Committee of Kyarama Ward, affirms Nuhu’s claim, but he notes that help is also needed in one area—providing a doctor.
“Our major problem now is the fact that we don’t have a doctor,” he says.
“If the government can look into this, it will help us as a community, because Kyarama health centre, accommodates people from other communities.”
Sankara and Yandutse wards share the same fate as the people of Kyarama, in Ringim LGA.
Adamu Bala, who is the officer-in-charge of Yanma PHC in Sankara ward, delights in how his PHC has benefited from the Fund
“Since the idea of the fund started and we got our first payment from the agency, we attended to some pressing issues like repairing the labour room and some leaky roofs,” he says.
“We now have a staff midwife staff and a community health worker who is even from the community; she doesn’t need to travel kilometres away like the staff midwife and me. It has been a source of relief for us and we hope to benefit more.
“For women, the emergency transport scheme initiated by the state government has really helped to reduce the high rate of maternal and child mortality in the state. This, I believe, is all from the health care provision fund as they all started almost the same time,” noted Bala.
Financial disbursement, the Jigawa portion
The National Primary Healthcare Development Agency in 2020 claimed that 34 states were verified, including the FCT, while Kogi, Lagos, and Rivers were not verified.
In the same year, the agency also said that out of the 9,211 political wards in Nigeria, 6, 287 have been registered across 31 states, including Jigawa state.
Interestingly, public records show that out of the 287 PHCs across the political wards in Jigawa, 239 have been accredited to receive funds from the BHCPF.
According to records from the Nigeria Health Facility Registry, Gwaram has 57, Gwiwa 23, Dutse 41, Rigim 27, and Roni 20 primary health care centres, accounting for 95.8 per cent of the PHCs in Jigawa State.
When passing the 2018 budget in May, the National Assembly earmarked N55 billion for the BHCPF. As stipulated in the National Health Act, funding from donor organizations and other sources also forms part of the BHCPF.
The NHIS is supposed to receive 50% while NPHCDA gets 45%. The remaining 5% goes for outbreaks and emergency response to the Nigeria Centre for Disease Control.
This money flowed from the CBN to NHIS/NPHCDA/NCDC down to the PHCs.
Some N12.7 billion was disbursed; NHIS received N6.5 billion while N5.8 billion went to NPHCDA with the NCDC receiving N327million
Jigawa was among 15 states to comply with the criteria, with each receiving its first fund from the N5.8 billion disbursed to the NPHCDA in 2019.
These criteria include baseline assessment of BHCPF health facilities, capacity building of health workers in the state to ensure health workers can effectively carry out their functions, verification of all levels of implementation in the state, and authorization for disbursement to eligible PHCs.
There was no disbursement in 2020, but 2021 was another good year for Jigawa, as it was also among the states that received funding from the BHCPF.
The BHCPF was formally launched in Jigawa on the 16th of March 2021, the same year, N14.9 billion (N14,980,223,026) was disbursed, to be shared among 22 states, including Jigawa state.
The fund received in 2019 according to Kabir Ibrahim, the executive secretary of Jigawa State Primary Health Care Development Agency, was rolled over to the next year.
“The fund came in in November 2019, considering other modalities to be put in place, it was rolled over to 2020 which is during the COVID-19 pandemic period. This was even before the actual launch of the programme by the executive governor of Jigawa state.”
Jigawa state was among the first 15 states to access the BHCPF in 2021 and registered a total of 46,204 persons under the NHIS.
In 2021, Jigawa State received N554 million for basic health care under the National Health Insurance Scheme whose funding is part of the BHCPF.
Records show that 45,476 beneficiaries were registered at a premium of N12,000 per individual in the state. Across 287 political wards, 157 slots are allotted to each PHC with priority given to women and children under five years.
Also, in 2022, N28.59 billion was distributed across the 36 states in Nigeria and the FCT in BHCPF. Jigawa received the highest funding of N1.64 billion, which was shared alongside Katsina, Borno, and Sokoto, with Kano topping the list.
For the NHIS, Jigawa State received a total of N730.1 million in 2022, making it the state with the highest share.
A facility without doctors—the Gwiwa/Dutse experience
Idris Danladi, the officer-in-charge of Shafe PHC, asks a multi-million-naira question.
“Now that we now have a functional health care facility newly constructed by the government of Jigawa State, also being a beneficiary of the BHCPF, how long will it take before we will now have one doctor in each PHC?”
All the health centres visited share a similar problem: none has a medical doctor. They are manned by community health workers and midwives working alongside the officer-in-charges.
In Laila PHC in Dabi ward, Tijjani Aliyu, the officer-in-charge of the facility, shared his experience handling emergencies at the height of a cholera outbreak.
“We were faced with a very terrible condition sometime last year. The outbreak of cholera caused a lot of panics, and there was no way we could admit patients. We had to refer them to the General Hospital for admission and treatment. So many died,” he recalls.
“Jigawa State was second-worst hit by the outbreak after Kano State. If there were to be a well-trained medical doctor, so many of the patients wouldn’t have died; they would have been admitted and treated immediately. PHCs need a medical doctor; I wish it’s part of what the BHCPF is meant to provide.”
Ghamo, Kudai, Madobi, Sakwaya, and Limawa, were among the health centres visited in Dutse Local Government Area. And there is something striking about them.
They operate in a council area subsumed by the state capital but they share the same experiences as others more remote in Gwiwa, Roni, Gwaram, and Ringim – well-constructed health centres, with community health workers and staff midwives but without a medical doctor.
However, the absence of a doctor is forcing residents of the communities to congest the General Hospital in the nearby capital Dutse.
A clear example is the case of Kudai PHC, where residents prefer to be taken to the General Hospital rather than be admitted to the health centre.
Despite being registered under the NHIS in Kudai PHC, Sani Auwal, a teacher with Ungwar Gabas primary school, prefers to go to the General Hospital in Dutse, where he will not only get [IV] drip but drugs.
“All we get at the health centre is drip upon drip [intravenous infusions],” he laments.
“We have always wished for good drugs and even injections. Sometimes when we take this drip, we get readmitted in a few days, there are usually no drugs to give to patients except the usual [anti]-malarial drugs. I am diabetic, and I need to see a doctor regularly, so I don’t mind going to the General Hospital in Dutse.”
In Limawa community, the Usman Dan’Yaro family are beneficiaries of the scheme, and they shared their experience with the impact of the programme.
“We are typical farmers. Most times it is usually a trying time for us, especially dry season, climate change has made the whole thing worse as rainfall comes with flooding that usually destroys our farmland, so this health assistance has helped my family so well; we access drugs free of charge, except for some that are not available. We do most of our tests in the lab and when the result comes out, they treat us for free,” Usman says.
Residents of Roni LGA, are yet to feel the impact of BHCPF, apart from the successes being shared in the news by beneficiaries across other LGAs in the state.
Auwal Danbala, the officer-in-charge of Gora PHC, attributes the slow implementation of the BHCPFin his community to the poor orientation of health workers and shortage of skilled workforce.
“Even though we just have two community health workers, and one staff midwife, we are yet to have full training on the programme. Apart from the enrolment of pregnant women and children under the age of five, the absence of training is making the implementation of the programme slow in Roni LGA; workers are yet to understand the gateways of the programme,” Danbala said.
Fatima Abdullahi has been forced to buy drugs on several occasions even though she has been enrolled to benefit from the programme.
“I am just a farmer who just depends on what she gets from the farm to survive, sometime around the rainy season I was so sick, and I was rushed to the hospital, unfortunately, I have to buy all the drugs, no one was given to me for free at Gora PHC,” Abdullahi says.
Amira Isa, on several occasions, had to visit the General Hospital in Dagasawa community, where the PHC is located.
“Most times the officer-in-charge finds it difficult to come to work because he lives about 15 kilometres away from Dagasawa, and considering the large number of people who visit the health facility daily, I prefer to visit the General Hospital in Kazaure where there are available health workers, who live within the premises of the hospital and are willing to attend to a sick patient,” Isa says.
“We are doing our best”
Jigawa state Governor, Muhammad Badaru, does not concern himself with the microdetails of the Fund.
“I don’t know anything about the programme and I am not involved in any of their activities in the execution of the programme,” he said when approached.
“Kindly go and meet the executive secretary and tell him to provide you with all the information you need to report the programme and let me know your findings,” Badaru said.
Kabir Ibrahim, the executive secretary of Jigawa State Primary Health Care Development Agency recalled how a budget line for the Fund was created with an allocation of N480 million. The money came from repurposing funds meant for free services for maternal, newborn and child health.
Based on a premium of N12,000 per beneficiary, this was to ensure coverage of 40,000 vulnerable people in Jigawa. The state also made a commitment to supplement this funding with an additional N400 million to leverage progress made in rolling out the BHCPF funding to vulnerable populations in the state.
“The gesture is to allow the BHCPF to cover a further 30,000 plus people. This opportunity for further funding provided a strong incentive for Jigawa state Contributory Health Care Management Agency (JICHMA) and State Primary Health Care Development Agency (SPHCDA) to kickstart the BHCPF program promptly in 2021,” he said.
“The fund is usually divided into two portions, for the primary health care and National Health care Insurance Scheme. Ours is channelled into two, which are the operational cost and running cost. From the running cost, we carry out activities such as facility renovation and rehabilitation, the midwives scheme, and the emergency transport scheme. The operational cost includes the general operation of the programme.”
The Executive Secretary, Jigawa state Contributory Health Care Management Agency, Nura Ibrahim, commenting on the operation of the programme, expressed his satisfaction.
“Since we kickstarted this programme, it delights my heart that no one has come to complain about deprivation or denial, we have enrolled over 49,500 people, and this cut across PHCs in the rural areas. Even though no programme is 100% perfect due to challenges, we can confidently say this project is going successfully,” Sambo says.