© 2018 - International Centre for Investigative Reporting
INVESTIGATION: Moribund primary healthcare centres are fuelling infant, maternal mortality
Despite the multibillion-naira interventions of the Federal Government to curb the rising rate of maternal and Infant mortality in the country, women and children still die daily in the rural areas of the country due to inaccessible and non-functional health centres, REGINA OTOKPA reports.
Modupe Ogunleye is a certified medical record officer with a private hospital in Lagos. On her way to work every day, she shakes her head in suppressed anger when passing by the Agunfoye Imota Ijede Community Primary Health Centre.
For 26 years, the primary healthcare centre in Ikorodu Local Government Area of Lagos State has been under lock and key. Not even the official unveiling of the public health facility on July 29th, 1993 by the then Chairman, National Directorate of Food, Roads and Rural Infrastructures, Air Vice-Marshal Larry Koniyan (Rtd), could initiate the commencement of public health delivery in the PHC, which has now been overrun with thick bushes.
Each time Ogunleye passes through the dilapidated building, her heart skips a beat when she remembers the number of lives that could have been saved if the PHC was functional. In cases of emergency, residents of the community have to evacuate patients to far away health centres in Gbogbo or Bayegu areas of the local government. Many, she said, died before they could get medical attention.
Although the initial amount released for the construction of the health facility in 1993 is not known, in 2014, the National Primary Health Care Development Agency (NPHCDA), once again released the staggering sum of N18,420,948.00 to Strasbourg Investment Nigeria Limited, to construct a Primary Health Care (PHC) in Agunfoye, Imota Ijede.
The second PHC was never built, and neither was the existing centre completed and put to use to reduce the impact of health issues ravaging the Community.
At numerous occasions, mothers have had to back a sick child and trek all the way to Bayeju of Gbogbo because they don’t have money for transportation. If they are lucky, no complications or death may arise but in most severe cases in need of immediate attention by a health official, the risk is too grave that the story does not always end well.
“But most importantly, we need health workers to come and enlighten the women on the importance of immunization and family planning commodities in the community PHC,” laments Ogunleye.
State of Primary Healthcare Facilities
Between 2004 to 2014, the Federal Government awarded over 1250 contracts valued at N30.59bn to various contractors for the supply of equipment and construction of PHCs across the country. Between 2014 and 2015 alone, the NPHCDA awarded 91 contracts for the construction of PHCs at a uniform sum of N21, 986,893.00 to different contractors.
However, despite the release of billions of naira since 2004 till date towards the attainment of a functional health system in the rural areas, a large number of the PHCs have either been abandoned or not fully functional.
The result is that millions of Nigerians living in rural areas are denied access to basic healthcare capable of trimming down the rate of maternal and infant mortality in the country. A visit to Kano, Enugu and Lagos states, revealed a dismal picture of the state of primary healthcare infrastructure in the country.
In 2014, the Federal Government approved the construction of PHC’s in Rumo and Yaryarsa communities in Kano State at the sum of N22 million, each to Drumlyn Nigeria Limited and Milagari Global Servces Ltd respectively. But the project was started and abandoned halfway. More than three years after, the buildings have been swallowed by bushes, have become an abode for reptiles. Effort by this reporter to locate the contractor was abortive as the address was non-existent.
Shaking his head in disgust while leaning on a ramshackle building which used to be a health centre, a resident of Rumo, Zaharadeen Usman said, “When there is a serious issue we take the person to Sumaila General Hospital about 38 kilometers away. Sometimes before people succeed in getting a vehicle to convey their loved ones who are sick to the hospital which is usually from N1,000 and above, they die before they get there because it is very far from here. Most times I use my bike to take them to the junction where they can get a car.”
For residents of Rumo and 25 surrounding communities who cannot afford the cost of transportation, they look for care with traditional ‘doctors’ and ‘mid-wives’ whose ‘professionalism’ are well advertised in the communities. And when it results in deaths, as it most often does, it is attributed to some ill-fortune or divine destiny.
The story is only slightly different for the residents of Yaryasa whose PHC was commissioned on the 8th of April. 2015. But unlike the case of Rumo, the new but abandoned PHC at Yaryasa was expected to have four patient wards and 12 rooms, but has only one functional room. This room is used as a dispensary where drugs are prescribed without running the necessary tests due to absence of basic equipment. In serious medical cases, residents are subjected to the rigors of accessing health care at the Tidun Wada General Hospital located about 24 kilometers away.
The wife of the Sarikin Yaryasa, Hajara Jemilu, lamented that the lives of many women and infants in the community were at risk as a result of the various complications arising from difficulty to access basic health care promptly. Hajara could not hide her disappointment when she said, “The health workers don’t live here, they start work from 8am to 2pm in a small office in the hospital but they don’t have drugs there, they only write drugs for us to buy and if the disease is beyond their control they refer us to Tudun Wada general hospital which is about N100 from here.
“For most families here, we have difficulty getting to the hospital. If our husbands don’t have the N100, we have to go round seeking for whom to borrow from to enable us go to the hospital. There was a time my son was sick, when I couldn’t get the money at all, I backed my son to the hospital in Tudun Wada Things are difficult and for most of the women here, we refer to the traditional birth attendant. We have 14 of them here but they don’t give drugs.”
Residents told the reporter that in the last 10 years, they have had to seek medical attention outside the community. Since the hospital was commissioned, they claimed it had never dispensed any government-supplied drug. The drugs dispensed are those bought from donations by the community.
The situation at Ehandiagu-Eka-Alumona community, Enugu State, is even more pathetic. The community has a well-equipped primary health care facility donated by Marie Stopes and the United Nations Children Education Fund (UNICEF), however, the PHC is located far away from the communities and does not get many patients due to the terrible state of the road.
According to one of the nurses, Mrs. Jecinta Ugwuja, since the commissioning of the health facility on the 9th of July, 2011, only few women and children patronize the facility for ante natal services, child birth or even child immunization because the bike fare to the facility costs over N500. Moreover riding on the road requires expertise and patience by the rider to navigate the bumpy road to ensure the passenger does not fall on the ground.
“The women in this community respond to health care poorly. Most of them prefer to go to traditional birth attendants or resort to treating their families with local herbs when they fall ill because of the nature of the road.
“A good number of women are dying there. Some while giving birth, some days or few weeks after child birth.”
Another PHC in the state located at Amechi Idodo which was expected to serve Ezeobodo, Obinagu, Ohanu, and Eziama communities is not only in a grossly dilapidated shape, but located in a forest of bushes.
Ngozi Ogbu has been the only nurse at this PHC for over seven years. She affirmed that a lot of women and children have died from the four communities as a result of health complications arising from late access to health care. Further providing reasons behind the extreme low patronage of the health facility, she noted that the facility is far from the communities and anyone coming would spend at least N200 on transportation-money that is hard to come by for most residents.
“In the past seven years, there have been many issues of complications, the people here especially women are suffering. We have a Health committee whose duty is to go round health facilities to supervise activities but they don’t do their job. Since I started work here over seven years ago, not once has anyone come to supervise me,” she stated.
Effects of Non-Functional PHCs
Primary Healthcare Centres are the most crucial in providing basic health care services to the people at the community level. Ordinarily, a PHC should offer effective delivery of healthcare services made possible through the availability of adequate infrastructures, diagnostic medical equipment, drugs and well trained medical personnel.
However, coverage and quality of healthcare delivery is perpetually threatened by poor planning, inaccessible healthcare centres, poor funding, lack of adequate health care personnel, lack of drugs and essential interventions, poor environment and bad roads.
Over the years these factors have hindered women and children from accessing basic healthcare services and unfortunately, the resultant effect has been loss of countless women and children to preventable deaths.
Without access to essential interventions, 71.20 per cent of 1000 children die at birth and about 814 out of 1000 women lose their lives while giving birth. This means that five women die of child birth every hour in both rural and poor urban centres and over 400,000 women die annually in Nigeria from child birth related complications. While one in 15 babies will die before their first birthday and about one in eight before their fifth birthday.
A recent World Bank report noted that in 2016, nearly ten percent of new born deaths in the world occurred in Nigeria. Based on its ranking, Nigeria emerged third out of five countries accounting for half of all new born deaths in 2016.
According to the Senior Director of Health Nutrition and Population at the World Bank Group, Tim Evans, it is unconscionable that in 2017, pregnancy and child birth are still life threatening conditions for women.
Based on a United Children’s Emergency Fund (UNICEF) report, he argued that the death of new born babies in Nigeria represents a quarter of the total number of deaths of children under age five, majority within the first week of life due to complications during pregnancy and delivery. Similarly, a woman’s chance of dying from pregnancy in Nigeria is 1 in 13, where less than 20 per cent of health facilities offer emergency obstetric care and only 35 per cent of deliveries are attended by skilled birth attendants.
Lamenting these figures, the minister of Health, Prof. Isaac Adewole said, “Nigeria is next to the worst which is Chad. While Nigeria contributed only 2.4 percent to the global population; it is unfortunate that we contribute 14 percent to global maternal mortality, a trend which needs to be reversed.”
Not deterred by the figures, Adewole is optimistic that Nigeria could achieve below 100 ratio by the year 2030 and 300 maternal mortality rate in 2018, only if government strengthens the various social intervention programmes.
Federal Government’s Response to Community Health
Several interventions have come and gone but amongst the notable ones is the National Primary Healthcare Revitalization Initiative, flagged off on January 2017, for the revitalization of 10,000 healthcare centres in the 774 local government areas in the country. The scheme is aimed at availing poor Nigerians with qualitative and affordable health services with at least one functional PHC per ward to deliver a number of services.
The Midwives Service Scheme, (MSS) was also launched to mobilize midwives to selected primary healthcare facilities in rural areas to increase availability of skilled birth attendants and boost safe delivery services. The Minister of Health, Prof. Isaac Adewole, also Inaugurated a task force on accelerated reduction of maternal mortality in Nigeria in July 2017, even as the National Primary Healthcare Development Agency (NPHCDA), launched the eHub to ensure all primary health care centers in the country were brought under one roof to tackle all issues confronting effective primary health care delivery at the grass roots.
These interventions are aside the $1.5 million the Federal Government released to each state government to ensure quality health care delivery for women and children through the Saving One Million Lives initiative.
Taking his commitment to improving health care delivery at the rural areas a step further, President Muhammadu Buhari only recently directed the ministry of health to ensure the Community Health Influencers, Promoters and Services (CHIPS) Programme, was launched in all the states including the Federal Capital Territory, to enable the less-privileged and the rural dwellers have access to health services. But the Executive Director NPHCDA, Dr. Faisal Shuaib, immediately responded that plans are presently underway to roll out about 200,000 CHIPS agents, who would move from house to house to provide first aid care and health education to people.
The CHIPS programme is part of the federal government’s effort to provide effective primary health care services to the citizenry, aimed at improving and providing equitable coverage for essential health services especially for maternal and child survival, and also designed to improve on the Village Health Worker (VHW) concept established by the NPHCDA and endorsed by the federal government.
“They will play roles of effective demand generation and health behaviour change communication, provide basic emergency services to households, support community surveillance, collect and transmit household level health-related information on a regular basis and so much more,” he said
Why are the PHCs not functioning?
Despite these interventions especially President Buhari’s Primary Health Care Revitalization Programme, over 90 percent of the PHCs located across the country are still not functional. In addition, most of the PHCs are either cited at extreme locations, or in places with lack of motorable roads that impede access. In health centres that are accessible, many are characterised obsolete equipment, lack of manpower and basic hygiene that all serve as turn off to most residents. As a result, the staggering statistics of women dying during childbirth has remained constant despite these initiatives.
The Chairman National Immunization Financing Tax Team (NIFT), Dr. Ben Anyene, argued that government’s failure to prioritize the health of Nigerians was reason behind the nonfunctional state of over 60 percent of health care facilities across the country and the increased infant and maternal mortality rate in the country.
According to him, it behoves on state governments to address the challenges in primary health care centres by cutting down the expenditures on frivolities, security votes and increase its investment in health.
He stated: “60 percent of health facilities in this country are not functioning, If we remove the private facilities we will have problem not to talk of Patent medicine vendors. It is lack of seriousness, commitment and understanding of what government is all about.
“To be a government of healthy people you have to invest to make sure they are healthy. 70 percent of our health problems are in the primary healthcare sector, it presupposes that 70 percent of our investment should be there but 70 percent of the federal is at the tertiary level, there is a mismatch.”
The Head Public Relations Unit of NPHCDA, Mr. Saadu Salahu, who corroborated Anyene’s conspiracy theory, disclosed that a huge percent of the facilities have gone moribund. “As of now, we have 30,000 of such primary health care centres in various parts of the country, but the record is that less than 10% of them are functional.”
Salahu further argued that the problem of ownership was also part of the problems confronting an effective and efficient PHC system in the country. According to him, the local government chairmen see the construction of PHCs as the responsibility of the state or federal government. He however clarified that while primary health care is the responsibility of local governments, NPHCDA is only saddled with the responsibility of ensuring standards and giving technical and financial support to further strengthen and develop the PHCs.
“NPHCDA is not in charge of healthcare centres. The Local government build primary health care centres; state governments build some primary health care centres, some partners build primary health care centres, individuals and senators can also build a primary health care centres.
You build the structure, you provide them drugs, you even give them equipment and when it is handed over to the local government who in turn hand over to the community takes over begin running it.
“We only regulate, we support states technically, we help them develop the work plan, we make the vaccines available, we train them on maternal and child health intervention and we train their staff to improve their capacities to develop and strengthen their primary health care system.”
However, few weeks ago the minister of Health, Prof. Isaac Adewole, disclosed that the federal government is collaborating with the state and local governments on primary health care to enrich ownership and participation.
This is perhaps the much needed wake-up call for government to do something urgently to ensure all modalities are put in place to increase coverage, enforce discipline and monitor quality of health care services at the grass roots.
This would help secure more lives, and ensure that no woman dies while giving birth and that no woman is denied information or health care that can save their lives and the lives of their unborn children.
This investigation is supported by the John D. and Catherine T. MacArthur Foundation and the International Centre for Investigative Reporting.