IT is only when corruption is eliminated from primary healthcare that it can contribute to achieving Universal Health Coverage (UHC).

“To gain firsthand experiences of corruption in primary healthcare, we spent over 320 hours in several primary healthcare centres (PHCs) and in offices of institutions that oversee PHCs. We complemented this work by closely engaging community members about how they are treated in primary healthcare facilities.  We also amassed evidence from over 2000 interactions with diverse stakeholders on health sector corruption in PHCs in Nigeria using qualitative and quantitative research methods. Based on what we found, we can confidently say that corrupt practices are common and prevalent in primary healthcare, and until they are addressed, Nigeria will struggle to  achieve Universal Health Coverage (UHC)” – Researchers in the area of accountability and transparency in health (from the Accountability in Action Project), at the Second of a Series of Webinars on Health Sector Corruption organised by the Global Network for Anticorruption, Transparency and Accountability in Health (GNACTA), a WHO Initiative to establish and improve accountability and anticorruption in health.

The nature of corruption in primary healthcare

When corruption is mentioned in Nigeria, everyone immediately thinks about the politicians. The focus is mostly on “grand corruption”, which entails carting away huge sums of money and using political positions to gratify undue private interests.

It is least common to find persons looking the way of “petty corruption” because they usually do not make the headlines, are often committed by persons not in highly placed positions and tend to be normalised as acceptable behaviour.

Sadly, the overlooked petty corruption could be worse than grand corruption, obstructing how people access key social services, including primary healthcare.

Now, imagine the absence of a health worker in a remote health facility at a critical time when a pregnant woman in the neighbourhood goes into labour. Consider also that a poor woman may be prevented from getting life-saving routine vaccines for her baby because she cannot afford N200 to give to the health worker for a supposedly free immunization. Can you also imagine that this N200 naira may be enforced by an officer-in-charge (OIC) of a facility who can only retain her place by sending remittances to those who put her in charge of a very viable health facility? And not sending such remittances would mean redeployment to a less viable health facility.

Nigeria’s health sector is listed among the most corrupt sectors in the country, and the sector is characterised by a lot of petty corruption at the frontline and managerial levels. From our study, corruption at the frontline, particularly in primary healthcare, manifests mostly as absenteeism, employment-related infarctions, informal payments and use of placeholders in PHC facilities.

It is usually reinforced by several factors, which include negligence/irresponsibility of authorities, unclear/absent rules and regulations, weak empowerment of citizens to participate in the development of health programmes and policies, and a lack of a health-focused anticorruption approach informed by research evidence.

These lapses must be addressed if primary healthcare must be free from corruption and to live up to its purpose of offering quality and timely health services to the grassroots.

Spending too much money on a corrupt primary health sector will not guarantee Universal Health Coverage

By UHC, we mean that quality healthcare is available to every one according to their needs, and no one needs to be denied access to healthcare services because of lack of money or ‘break the bank’ to have access to quality healthcare.

To many, UHC is realisable when money is spent to build and equip many health facilities, enrol citizens in health insurance, employ more health workers, etc. While investment is critical to attain UHC, spending more money on a defective system where corruption is the order of the day certainly amounts to being wasteful.

Corruption in PHCs is more concerning for Nigeria because the country spends only about five per cent of its annual budget on health at the federal level, compared to countries like South Africa and Rwanda, which spend within the region of 15 per cent of their annual budget on health. What this means is that if there is any country that should be mindful of wastage of allocated resources to the health sector, Nigeria should be leading in front. So, it is plausible to say that Nigeria is not getting value from the modest amounts it spends on health, and this must be addressed.

Relatively plenty money for small health – time to balance the scale!

By relatively plenty, we only refer to the diverse sources of funding for health in Nigeria, including standard budgetary appropriations. Currently, US$2.1b has been allocated to the health sector by the federal government, which is in exemption of appropriations to the health sector by state governments and the huge sums provided to the sector by donors and the private sector.

Albeit there is a need for more health investments in Nigeria, but what is currently obtainable should be enough for the country’s health system not to be ranked in the bottom-ten, and the country’s UHC index not nosediving into poor scores of about 38-40 per cent.

A Lancet publication mentioned some countries, such as India, similar to Nigeria in population, health spending, and poverty levels, yet doing better in health outcomes.

So, what is wrong with Nigeria?

The Basic Health Care Provision Fund (BHCPF) instance

Across the over 8500 wards (the least governance unit) in Nigeria, one facility was selected by the government for funding through the BHCPF scheme.

This funding comes from one per cent of the consolidated revenue of the government, which evidence criticised as being too small, rather favouring four per cent. Through this funding, the selected primary healthcare centres will be revamped and very poor people in the wards are expected to be enrolled for free health services that fall within the basic minimum package of health services.

Note that as of June 2022, about N29 billion (US$38m) was recorded to have been disbursed to the selected health facilities. However, there are concerns that the current value of health services in primary healthcare and partly in secondary level does not match the investments so far due to corruption and weak accountability.

From our field encounters, we can confidently report a few inappropriate experiences:

• (a) awareness regarding the BHCPF has been low, and its modus operandi weakly understood among service users.
• (b) contrary to the BHCPF operation that should provide 100 per cent free eligible health services to enrollees, we found some enrollees happily paying ‘reduced prices’ for such eligible services in PHCs.
• (c) some of the BHCPF-funded health facilities are locked.
• (d) kickbacks from disbursed funds are shared between some facility managers and authorities, etc.

Based on these few experiences, we are concerned that the value of the disbursed BHCPF to the PHC system and its end users is grossly undermined.

Recall that experts argued that one per cent of the government’s consolidated revenue for BHCPF was too small, yet even the one per cent value is threatened by petty corruption at the points of service delivery. 

Anticorruption in primary health is a matter of urgency

We cannot continue to look away while scarce health resources that should benefit low- and middle-income earners in particular are pilfered. There is some low-hanging fruit that we can aim at to improve the situation:

• (a) dedicated rules and regulations specifically applicable to primary healthcare staff.
• (b) breakdown of policies and programme operations in non-technical ways and terms for the public.
• (c) dedicated hotlines for the public to report unfair treatment and corruption experienced in PHCs, and treating such reports with urgency.
• (d) intense discussions between policymakers and academia for setting up an anticorruption agenda and accountability framework for the health sector.
• (e) establish and/or strengthen facility- and community-based monitoring mechanisms and
• (f) paying attention to the needs of health workers to improve job satisfaction, etc. Without these mechanisms, Nigeria stands a great risk of completely losing its primary healthcare to corruption, with very telling consequences for citizens.

Contributors and acknowledgement

(1) Dr Prince Agwu (2) Dr Tochukwu Orjiakor (3) Dr Aloysius Odii (4) Ms. Pamela Ogbozor (5) Prof Dina Balabanova (6) Prof Obinna Onwujekwe (7) Accountability in Action Research Team (8) SOAS-ACE Research Consortium (9) Medical Research Council (10) GNACTA (11) Foreign, Commonwealth, & Development Office (FCDO) (12) Health Policy Research Group, University of Nigeria

For correspondence: obinna.onwujekwe@unn.edu.ng; prince.agwu@unn.edu.ng