By Susan Edeh
Despite the Federal Government’s intervention in providing support to Nigerians at the grassroots through the Basic Health Care Provision Fund (BHCPF), which seeks to strengthen health care services, many people in Bauchi State are yet to benefit from the scheme. Susan Edeh, who visited Primary Health Centres (PHCs)in five local government areas in the state, reports.
Since 2021 when Bauchi State started the Federal Government initiated Basic Health Care Provision Fund (BHCPF), Mohammed Amina and her children have not been part of the free scheme.
Amina, who lives at Maiwa Community in Zaki Local Government was disappointed when she could not benefit from the programme due to her inability to enroll since the programme’s inception last year.
Experts believe that improving access to quality reproductive health services improves maternal and child health.
Though the mother of three and her kids are within the vulnerability ratio −getting health care services is far beyond her family’s reach. So she was not aware when other women started enjoying the programme.
However, she said someone informed her recently, and she was excited that her three children and herself could benefit from it until health officials turned her down because she was not selected by her district head to benefit from the health intervention.
Like Amina, 24-year-old Abdulkarim Wasila, a resident of Rimin Zayam in Toro Local Government, is also not benefitting from the scheme. She was asked to foot her medical and drug expenses when she gave birth to her fourth child early this year at the Zayam Primary Health Care Centre. Wasila said she did not know when people in her locality were enrolled for the programme.
The Federal Government initiated the Basic Health Care Provision Fund (BHCPF) under section 11 of the National Health Act as catalytic funding to improve access to primary health care.
Alongside inadequate financing, essential medicines supply gaps and a myriad of service delivery challenges, the insufficient number of skilled healthcare workers is a major challenge to providing quality healthcare services as well as to the attainment of the health-related sustainable development goals, a study on maternal and child mortality reveals.
To bridge this gap, the Federal Government is using 1 per cent of its consolidated revenue under the BHCPF to increase public spending on health and reduce out-of-pocket expenditure by the ordinary Nigerian.
In July 2021, the Bauchi State Primary Health Care Development Agency launched the healthcare services under the BHCPF. The aim was to serve the vulnerable residents across 323 PHCs, including women of reproductive ages like Amina, under-5-children like her three children, the aged, and the poorest of the poor.
The flag-off took place in the Liman Katagum area of the state. The health programme targets 100 million vulnerable Nigerians nationwide. Bauchi State has received N1.1billion from the Federal Government to implement the scheme.
Initially, BHCPF targeted 45,000 out of the four million residents of Bauchi who fall within the vulnerable bracket.
However, over a year after it rolled out, about 52,000 residents registered under the scheme. Despite this figure, more than three million vulnerable residents are paying from their pockets for health care services at the primary level.
How lack of awareness excluded eligible beneficiaries from BHCPF
A poor awareness campaign first blighted the well-thought-out health policy- when residents who ought to be on the scheme became aware, it was already too late for them to enroll.
Many childbearing women are unaware of the project in the state.
Nasiru Sabiya, who lives in the Tashena community in Zaki Local Government, would have had her third child delivered at a health facility. Still, the limited reach of the programme denied her the opportunity.
She gave birth to her three kids at home with the help of traditional birth attendants. “During my expected delivery date, I asked my husband for money for the delivery items, he was broke, and that made me give birth at home,” she said.
Fifty-five-year-old Yahaya Mohammed, a farmer and resident of the Sirko community in Misau Local Government Area, and his family are not beneficiaries of the BHCPF.
They patronise local patent medicine stores and traditional treatment centres close to his house.
This is because Mohammed was unaware of the scheme when his district head selected others as a beneficiary.
He said a friend informed him recently that there is a programme by the government which caters to the health needs of people like him at the grassroots.
When the father of four visited the PHC in his area for malaria treatment, health workers announced that his name was not on the list. They told him he could not benefit from the program.
Mohammed left the facility looking sad and discouraged, knowing that others were beneficiaries and he was not.
Mohammed is not the only resident of Misau who is not benefitting from the scheme. Dahiru Mohammed, a resident of the Tafawa-Balewa LGA,told this reporter who visited him in his house that paying for health services is financially draining as he is now old, and the profits he realises from the grains he sells are what he uses to feed his family.
“It is not all the time that I make profits from selling grains. Sometimes, the market is poor, and I have to manage. Despite my meagre resources, I still pay for health services for my two wives and even children whenever they are sick,” he said.
Many poor residents in the local government area still spend their money to access health care in private health facilities, patent medicine stores and traditional medicine sellers.
Amina, a petty trader, would have had her three children enrolled among the beneficiaries to save her little resources, but the limited spread of the programme denied them the opportunity.
She said, “Most of the time when my children are sick, they won’t go to school for the period. For example, one of my kids could not attend classes for about three months last year because of malaria and typhoid.”
The Bauchi State Health Contributory Management Agency (BASHCMA), which is the agency responsible for the enrollment of the beneficiaries, allocated 155 beneficiaries for each facility per ward in all the local government areas covered during the field visit.
This allocation pattern and poor awareness campaign explain why Yahaya Mohammed and Mohammed Dahiru could not access health services for free because both of them, peasant farmers, did not know when the programme commenced.
“The enrollment of beneficiaries is gradual because the programme is just starting and cannot accommodate everyone at once,” Bello Nasiru, who is in charge of Tashena PHC in Zaki Local Government, clarified.
“For now, the number allocated to us by BASHCMA per PHC is 155. Previously, it was 137, but we added 18 more beneficiaries. This is why you see that some vulnerable persons are not beneficiaries yet. I am optimistic that with additional funds from the government, we will be able to add more vulnerable persons.”
Residents said they were unaware of the programme that the government initiated to provide them with health care services at no cost.
One such is Garba Hassan, who has struggled to contain aged-long asthma. Garba, a peasant farmer, said that he has been managing his health condition since a young age and has spent a fortune treating himself.
He is, however, unaware of the programme as he continues his life battle with asthma.
“As you can see now, I am currently on medication. Whenever the attack comes, it is unbearable, but I have been very fortunate to be alive up to this moment. Sometimes when there is no money, I resort to taking traditional medicine to keep me going.”
Random selection leaves many out of the scheme
Some health officials said the vast number of vulnerable is why many of them could not be accommodated simultaneously.
“It is impossible to accommodate everybody in the health care programme because the number of people we register at the health facility is being allocated to us by the regulatory body, BASHCMA and not from the PHCs,” said Garba Gumau, a desk officer in Misau town Primary Health Centre.
Gumau noted that the population of beneficiaries is increasing and “posing a challenge to the full implementation of the health scheme across the local governments”.
However, there are concerns that the selection process used by the Bauchi State Health Contributory Management Agency (BASHCMA) to determine those who benefit from the scheme favoured some individuals at the expense of others.
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.
“We were surprised to discover that most of the beneficiaries selected were connected to politicians, government officials, traditional rulers and village heads,” said the health official who pleaded not to be named.
“As long as you know somebody, you will be considered, but the real beneficiaries that need this health intervention were not captured.”
However, state officials say that the process was fair and transparent. Mansur Dada, the Executive Secretary of the Bauchi State Health Contributory Management Agency (BASHCMA), debunked the allegations of favouritism in selecting beneficiaries based on their relationship with some government officials and traditional rulers.
Dada said that the agency allocates 155 beneficiaries to each PHC in each local government ward but admitted that the figure was inadequate.
He explained that the agency formed a committee that selects the beneficiaries. According to him, members of the committee include WDC chairpersons, the officers in-charges, the traditional rulers and the health desk officers of each facility, adding that the agency gave the committee the criteria for selecting the beneficiaries.
“We have given the committee criteria for the selection of the beneficiaries. We told them that 40 per cent should be women of reproductive age, 40 per cent should be children under five years, then the remaining 20 per cent should include the disabled, the aged and the poorest of the poor. So this the criteria we gave the facilities, it is not a random selection,” he said.
There are many grounds to be covered concerning the number of beneficiaries. For instance, in five local government areas of Toro, Warji, Misau, Zaki, and Tafawa Balewa, only 12,400 out of 1,718,973 residents are under the scheme in 80 PHCs.
The number of enrollees is a far cry from the total population of the five local government areas. More people in the building areas are yet to be covered. At the same time, according to information from the state agency, many said they were unaware of the scheme in which N570 is what the government spends monthly on a beneficiary.
The inability of many at the grassroots level to benefit from the project threatens the attainment of Universal Health Coverage (UHC) which is the main aim of BHCPF.
The chart below shows a breakdown of the enrollees per local government, primary health centres, population and monthly capitation.
Impacting locals, changing the faces of health care facilities
Despite the alleged lopsidedness in selecting the beneficiaries, residents say the scheme is impacting their lives as it is impacting healthcare facilities at the grassroots.
Eighteen-year-old Kabiru Mallam and 12-year-old Mohammed Hauwa are sickle cell patients and beneficiaries of the Basic Health Fund Provision Programme. They have been battling the disease all their lives.
Kabiru’s mother, Aishatu Mallam, said that coping with Kabiru’s health condition was difficult anytime his health worsened. However, since the basic health care programme came, both Kabiru and Hauwa now get their medications free from the Primary Health care centre in their community in Zaki Local Government Area.
“We are no longer buying medications for him because it is now free of charge,” an elated Aishatu told this reporter.
“Sometimes, when the crisis is beyond the Primary Health centre, they refer us to the general Hospital free of charge. His condition has improved. We are grateful to the government for bringing this health scheme to the state.”
Tijani Bilkisu, a mother of six and a resident of the Ribina community in Toro local government of Bauchi state, commended the Federal Government for the health intervention, saying that she is now accessing health services for free which was not the situation in the past.
“I am not feeling fine; nevertheless, I am happy that when I get to the health care facility, access to health services is for free,” an elated Bilikisu said.
“If I need to do a test or get drugs that will be prescribed for me, it is for free. This was not the situation in the past, but this health intervention has eliminated my spending on health services.”
Bello Hajara, another resident of Katanga community in Warji local government, spoke to this reporter at the Antenatal unit of the Katanga PHC Warji local government.
According to her, she had all her deliveries at the health facility without paying a dime for it, adding that accessing healthcare services for free has reduced her family’s spending for health services because the monies are now for other profitable ventures for the family.
The story is true for some facilities that the scheme has also transformed.
For instance, Jibrin Hassan, the officer in charge of Sakwa PHC in the Zaki Local Government area, explained that all the units in the facility, such as family planning, immunisation, and antenatal care, have been functioning optimally since the implementation of the health scheme because people were accessing the services for free.
Hassan disclosed that many patronise health care facilities at the grassroots “because they perform at the optimal level and the services are free”.
“Before the implementation of the health scheme, this facility was like an isolated place,” Hassan said. “People hardly come to the facility to access services. We hardly record five to 10 patients daily, but the story has changed. We now record between 50 to 70 patients daily. This is very impressive.”
During this report, this reporter observed that many women and children, particularly pregnant women were at the health facility to access health services.
There were adequate consultancy units, labour rooms, laboratories, admission units, and family planning and pharmaceutical units at the facility
Hard-to-reach PHCs facilities in sorry state
Unlike PHCs located in major towns, many of those in the hard-to-reach communities in Bauchi State are in bad shape despite receiving the quarterly allowance of N300,750 under the BHCPF. But, they lack basic medical equipment and drugs.
Since the programme’s implementation in July 2021, the health facilities have received the quarterly allocation four times, which amounts to N1,203,000. They, however, have little or nothing to show for it.
To access the fund, each facility will present a business plan of what it would like to do with the money. According to findings, a typical business plan of the health facility is meant to take care of utility and maintenance, pay ad-hoc staff, Community Health Extension Workers, consumables, and office furniture, among others.
But, the facilities in the hinterlands are not only understaffed, but the few available personnel also abscond from their duty due to a lack of supervision and evaluation.
For instance, grasses have overgrown the PHC at Bununu town in Tafawa Balewa Local Government, which is about 25 kilometres away from Tafawa-Balewa town.
The over 20-year-old paint on the wall of the facility is falling off. The sanitary conditions at the dilapidated PHC were poor. Findings revealed that the health facility is understaffed and lacked adequate essential drugs and commodities with no power supply when this reporter visited.
“We do not have a doctor or nurse. There are only four Community Health Extension Workers (CHEWS), and one is retiring soon. There is no midwife, no laboratory technicians and no pharmacist. We need more staffing in this facility,” said Iliyasu Halima, a deputy officer in charge of the facility.
“There is a shortage of drugs such as Amoxicillin and Metronidazole tablets, Ciprofloxacin and Metronidazole, amongst others.”
Halima reeled out a long list of other items lacking at the facility, like IV fluids, surgical gloves, syringes, Dextrose Saline and Artemether.
The facility has no delivery beds, drip stands or mattresses, among others.
The situation is not different at the Kantanga PHC In Warji Local Government Area, which is 125 kilometres from the state capital.
It is in dire need of renovation as the structure is worn out, with the paint on the building wall already peeling off. The facility has no fencing and no power supply at the time of the visit.
Inside the facility, there is no patient consultation room; the office of the officer-in-charge serves the purpose.
There are no ceilings in the ANC and OPD sections of the facility, only an open roof. The two units are in one office because of inadequate rooms.
The facility had one small female and male ward that could hardly admit three persons simultaneously. The beds and mattresses in the wards were old, with no bed sheets.
“The centre also has no ambulance. When there is a need for referral, we tell the relatives to provide a means of transporting the sick person. So, they hire a bike or vehicle to convey the patient to the general hospital,” Adamu Dahiru said.
“There was a day the blood pressure monitor we were using in this facility gave an inaccurate result in diagnosing a patient. The equipment was old. That was just one of many equipments lacking in this facility.”
He said that the facility has no midwife, laboratory technicians, pharmacists, and only five CHEWs and seven volunteers, adding that the CHEWs are in charge of antenatal and delivery at the facility.
Authorities explain why PHCs are not renovated
The Executive Chairman of the Bauchi State Primary Healthcare Development Agency, A doctor, Rilwanu Mohammed, when contacted on these challenges, explained why the facilities in the rural areas had not been renovated.
Mohammed said that under the implementation of the Basic Health Care Provision Fund program in the state, PHCs receive N300,750 every quarter from the National Primary Healthcare Development Agency, known as the NPHCDA gateway.
He said that the money provides operational costs and human resources for the PHCs.
“Before the launching of the Basic Health Care Provision Fund, some of the dilapidated health facilities were not captured during the N-SHIP Program, that is why you cannot compare them with the ones in the town,” he explained.
“Some structures existed for more than 20 years, so you cannot expect an overnight transformation. The programme came into operation in 2021, and the N300,750 is not to renovate PHCs. The PHCs use it for payment of contract staff, health facility consumables, payment of cleaners and other maintenance within the facilities.”
Also, Mansur Dada, the Executive Secretary of the Bauchi State Health Contributory Management Agency (BASHCMA), believed that the 52,000 vulnerable persons enrolled in the scheme were grossly inadequate for the state’s population below the poverty line.
Dada assured Bauchi residents of the Federal Government’s commitment to capturing 83 million Nigerians under the new National Health Authority Act signed two months ago.
This report is supported by the International Budget Partnership and the International Centre for Investigative Reporting (The ICIR).