By Deborah Dangana

Ali Falila, 35, a mother of four, reside in Mallam Anna village did not have any choice but to take her son, three-year-old Usman, to the Primary Healthcare Centre at Mallam Sidi in Kwami Local Government Area of Gombe State, even though she did not have any money. She was desperate and hoped she could talk health workers at the facility into treating her child and probably get paid later.

“My son has been down with malaria, and I brought him to the hospital for treatment, but I don’t have money,”Falilat said.

To Falila’s surprise, she was told that her son would have been treated for free if she had enrolled under a government scheme, the Basic Health Care Provision Fund (BHCPF).

She had never heard about the scheme and was shocked to learn of such a free health scheme. She said her family had always spent money to access healthcare services.

Like the mother of four, several Nigerians in rural communities, including young pregnant Fatima Mohammed from Musa Huduvillage in Mallam Sidi,  Kwami local government area have not heard about the BHCPF.

Fatima was at the hospital to treat malaria, but she and her husband, Mohammed, a peasant farmer, were struggling to offset the hospital bills. They paid for drugs prescribed for Fatima.

The lack of awareness of the BHCPF is already defeating the purpose of the scheme that the federal government initiated to make health care services available to the vulnerable at no cost.

A report on maternal and child health released by the National Primary Health Care Development Agency (NPHCDA) in 2019 revealed that Nigeria loses 2,300 under-five children and 145 women of child-bearing age daily.

In the report, the NPHCDA listed inadequate health facilities, shortage of critical human resources, inadequate power or water supply, commodity stock-outs, equipment inadequacy, weak standards/quality, and very low demand for critical services primarily driven by the loss of confidence in the system as the causes.

To address this situation, the Federal Government established 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.

The scheme, implemented by the NPHCDA, funds a Basic Minimum Package of Health Services (BMPHS). It is also to increase the fiscal space for health, strengthen the national health system, particularly at the Primary Healthcare Centre, PHC, PHC level, by making provision for routine daily operation cost of facilities, and ensure access to health care for all, particularly the poor, thus contributing to overall national productivity.

The World Banks 2018 report classifies about 89 million Nigerians as living below the poverty line.

A joint World Health Organisation, WHO,  and World Bank report also highlighted that over 500,000,000 individuals around the world might be pushed into poverty due to out-of-pocket spending on healthcare.

Many grassroots dwellers have not heard about BHCPF

Since 2021, as many as 25,565 poor and vulnerable people across the 11 local government areas of Gombe State have been successfully enrolled under the BHCPF to access free medical treatment from various health facilities, according to Gombe State Contributory Healthcare Management Agency, GO-Health.

The number of enrollees, however, appears to be insignificant compared to 3,472,223, which is the current population of the state.

The poor awareness of the scheme, some healthcare officers and other stakeholders argued, is partly responsible for the low number of beneficiaries.

For instance, Hajara Mohammed, whose niece, Harira, was admitted to Mallam Sidi PHC for anaemia, claimed she did not know about the scheme.

“Who did they enroll since we are omitted? I am hearing this for the first time”, a distraught Hajara said. Rashida, another resident from Mallam Sidi village, said the BHCPF scheme was strange to her, as she was not also aware of the scheme.

Many other villagers like 27-year-old Ahmed Hauwa complained about not knowing about the scheme and have been spending their money to seek healthcare services.

Rural dwellers do not usually use primary healthcare facilities as many believe it costs a lot to access medical treatment. But the scheme with which the government intends to deliver healthcare to the people at the grassroots level has not enjoyed enough publicity.

Hauwa believes that the government had forgotten the vulnerable as she appealed. Government should always remember the poor because there are a lot of poor and vulnerable that are experiencing different kinds of diseases but do not have money to go to the hospital.

‘A lot of people don’t come to the hospital because of lack of money. Even if I have N500 and come to the maternity with it, it will not be enough to buy a card, do a blood test, it will not do anything.”

“The way life is now, the government should help the poor, every assistance that comes is stopping only with our elites in the society, we are not benefiting from anything, or we hear rumours that there will be government assistance before it will reach us, we will later hear stories, it is not reaching us.”

While accessing free health care has remained a nightmare for many poor and vulnerable at the grassroots, others are enjoying free medical services under the BHCPF intervention.

In Bajoga, headquarter of Funakaye LGA, Asabe Yusuf Ahmadu said before she got enrolled, she spent a lot of money at Miyyeti Hospital to treat diabetics. She disclosed that she had spent about N180,000 seeking treatment for the ailment but now enjoys free medical services under the scheme.

On her part, Fatima Ali, a petty trader who is also a beneficiary of BHCPF and a resident of Bajoga, said she only spends transport money to the health care facility, as she gets everything free. When Ramatu Hassan was asked how she got informed of the scheme, she said it was through the village head.

Other residents like Aishatu Isa, Zainab Kabiru Daban-Fulani and Aishatu Abdullahi confirmed that they now enjoy free medical services at Daban-Fulani PHC in Kwami Local Government Area while appreciating government for lifting the financial burden on them.

Rufaatu Ibrahim Abdullahi, a scheme beneficiary at Mallam Sidi PHC in Kwami LGA, said she has been enjoying free health care service but that before her enrollment, she spent a huge sum of money when she was sick.  

Mohammed Usman, the Dukku PHCs Director, appealed for the continuity of the BHCPF scheme, noting that it has brought great relief to the beneficiaries.

Usman said the challenge they earlier had was that beneficiaries thought that because the government earmarked N570 for treatment per person, the amount would not be enough to settle their medical bills. He said, when they later understood that a person could undergo surgery without spending a dime, they began to rush to the facilities

Adama Maigana, a 62-year-old resident of Chiroma in Dukku Local Government Area, who enrolled under the Comprehensive PHC in Dukku, said she’s enjoying free medical services.

“Truly I am happy for this government program brought to us that is helping the poor and vulnerable because when someone is sick even if you don’t have money you will be thinking of going to the hospital but when they call us for this, we felt really excited, when you are sick and you come to the facility, you will see a doctor, do blood test all free without money, before you will be thinking of money for test, but now everything is free. We commend the government for this God bless and increase those behind this.

“Before I was enrolled I spend like N5,000 to N10,000 it depends on the illness weather you have money or not when you are sick you must look for treatment but now if you just come with your card and show them, they will do everything for you, we don’t have any drugs issues”

Sixty-five-year-old visually impaired Muhammadu Sani from Dukku, who enrolled in the Dukku Comprehensive PHC said the scheme is a lifesaver, especially for people with disabilities, PWDs. He called on government to remember other PWDS that are not yet enroll.

“I am excited for getting this free gift that the government is doing before we don’t have this, no previous government has done this but Inuwa’s administration we got this program that is helping people with disabilities my brothers those that got enrolled thank God and we pray that the way it is implementing this poliy, may God make it to expand more”

Zubana Danjuma, 26, a resident of Hashidu in Dukku LGA, who enrolled under the PHC in Hashidu, Dukku council area, said taking care of her health by the government has really taken away some burden on her family.

“My enrollment under the BHCPF has really help my life and family, I heard the program is for one year ending this month (July) but I want it to be continue, I also call government like the way I am enjoying this program that has being helping me, I appealed that those not enrolled should be enroll “

Auwal Umar Hashidu, aged 32, another native of Hashidu enrolled at the Hashidu PHC, said he has being enjoying free access to medical services since he got enrolled.

“Prior to my enrollment I spent a lot of money on health care especially this rainy season that malaria easily infect people. Sometimes N5,000 to N7,000. It depends on the illness but now I come to the facility I get everything free, from card, examination, test, to going to get drugs at the pharmacy everything is free”

The coordinator Primary Health Care centers for Dukku Local Government Area, Moh’d Usman, said the implementation of BHCPF has further enhance maintenance of clean environment at the facilities.

“With the introduction of BHCPF scheme, you know there’s token of amount given to facilities direct – just between them and the facilities, not in the department. So with this money, they are employing staff including cleaners, they also buy detergents with the little amount they are getting, they will pay their volunteers. That’s why you see the facilities are very clean”

Habiba Hashimo, a petty trader resident in Bage Ward of Funakaye LGA, whose husband died and is left with six children and is also about seven months pregnancy, said the scheme has a direct bearing on poor and vulnerable people like her.

“My husband died and left me with 7 months pregnancy and afterward labor began.  I delayed at home before coming to the Bage PHC center where I was enrolled but on arrival I was too tired and couldn’t push and was referred to Bajoga General Hospital and on reaching there, I was booked for operation because it was found the baby already die.”

She added “the surgery I went for, if not for BHCPF, I may have being a history now because my family wouldn’t have afford it but everything was done for me on the planter of gold for free without me nor my relatives spending a dim; all thanks to BHCPF”

The Facility Manager of Hashidu PHC, Ibrahim Tukur, said the BHCPF is a dream come through for them.

“We came there’s no staff in the facility but God helped us the BHCPF was introduced and we did business plan and it was approved. We then employed volunteer staff that we pay some allowance. Before the introduction of the scheme it was not easy on us because we were just 3 government staff here with the help of BHCPF we now have more than 10 (members of )staff”

“The scheme has improved the standard of our facility in terms of structure and it’s very hard if not impossible for you to come here and not meet any staff”

The BHCPF is a federal government intervention requiring counterpart funding from state government. It is a component of the National Health Act of 2014, which called for better investment within health sector. The Fund was first provided for in the 2019 fiscal budget by President Muhammadu Buhari with the sole aim of achieving Universal Health Coverage (UHC).

The BHCPF was designed as a fund to be financed from not less than 1% of the consolidated Revenue Fund (CRF) of the Federal Government and other sources including donor contributions bearing in mind that healthcare is the right of every Nigeria and the BHCPF will take Nigeria one step closer to universal health coverage.

The BHCPF programme was launched April 2021 in Gombe State, which has a total 627 PHCs with only 114 covered by the scheme.

The implementation of the scheme in the state has activated a 24 hour healthcare delivery  system at the focal PHCs across the state.

Since the program commenced, accessing health care for some enrollees has become easier thereby reducing the huge financial burden they usually incurred while accessing medical services.

The State Project Manager of  the BHCPF, Nurudeen Bello Kumo, said the scheme began full implementation in Gombe State in April 2021, when it received over N270 million (N276,105,335.49). The state has received over N177 million (177,629,639.00) in 2022.

Kumo said the BHCPF has given facilities autonomy and also enhances community participation and ownership. When asked why the fund was reduced in 2022, Bello said in 2021, poverty population formula was used while in 2022, the government used number of facilities being engaged in the programme.

Despite some successes recorded some enrollees are still spending from their pocket due to some challenges ranging from distance, attitude of some health workers after referrals, while others complained that the selection process was politically motivated.

A government health official on condition of anonymity said that in some wards, the selection process was not done properly as the targeted beneficiaries, mainly children under five, women of childbearing age the elderly, were not the ones enrolled.

“The truth is, the poor of the poorest were not the ones enrolled,” he said

Also speaking with facilities head, they said the scheme has increase the number of clients explaining that they receive N570 per patient. They said that they receive N300,750 for operational services quarterly from National Gateway of  the BHCPF, out of which they pay their contracted staff, do repairs, buy equipment, drugs and maintain the facilities, among others adding that, they have to do a business plan, which has to be approved before accessing the fund.

From our reporter’s observation on the visit to many facilities, facilities managers did well with the fund while others did not have much to show. But what is clear is that the scheme lacks proper monitoring and evaluation by government officials who do not track how the Fund is doing or impacting on the PHC and the beneficiaries.

For example, up till the time of the reporters visit, there was still confusion over the use of the cards issued to enrollees to enable them access free medical care. In some places, the enrollees, who did not even know about the scheme, had not collected their cards.

“A lot of the enrollees thought the card was to access covid-19 loans,” the facility manager of Tongo Ward, Abubakar Bappa Inuwa, told our reporter. He said it took them a lot of time before convincing enrollees to come and access the free medical care under the BHCPF.

Even for enrollees who had collected their cards and had probably benefitted from free health services before, there was still some confusion about what they could use their cards for. The facility manager of Kwami Model PHC, Hafsat Mohamed, said some enrollees come with their access card to seek for medical services for their children or relatives, whereas the card only gives access to the one person to which it was issued.

Shortage of manpower

In all the facilities visited, they lack adequately trained staff, although all the facility managers, despite contracting staff, appealed to government to add skilled staff. Base on findings, the issue of lack of adequate staff cannot be separated from the fact that some health workers perceive rural life as difficult and lack the desire to work in PHCs located in rural communities.

Reasons include lack of basic amenities that characterise rural areas; inadequate personnel and equipment, leading to difficult working conditions and dissatisfaction; lack of electricity and water, leading to poor quality of care and performance; and inadequate supply of drugs, which is a considerable constraint to service delivery. Alao, separation from families is another significant challenge for health workers who have to leave their families and to go and work in rural areas .

Benefiting Facilities Under BHCPF looking Clean  

The renovation of one facility per ward policy of the Governor Muhammadu Inuwa Yahaya administration has given most of the facilities under the BHCPF visited a face lift. Virtually all of them were painted army and lemon green.

The funds received by the Deba PHC in Yamaltu/Deba LGA has helped in improving on many things, including the environment, said the facility manager, Nasiru Ali Nature.

“This scheme did not only help the rural dwellers but also make working conditions comfortable; life without BHCP can only be imagined. We employ cleaners. That why you see everywhere is clean. Not only them. We contracted others like Laboratory Technician, among others,” he said.

“As far as the PHC is concerned, this scheme is a life saver. See, we brought wall fans, television, reconstructed our injection room and staff dressing room, bought PB apparatus, tyres for our ambulance, repaired of our borehole, and doors ,amongst others,” he added.

Referrals are a big problem

Despite the availability of free access to medical care, referrals across the facilities visited have been identified as one of the bottlenecks faced by enrollees.

Under the BHCPF, health workers at the PHCs have been urged not to treat hypertensive, ulcer and diabetes cases. They are instructed to refer them to General Hospitals, which are appointed as their referral centers.

The deputy facility manager of Lano/Kuri/Lambam Ward, Musa Jibril, said most of their patients are suffering from these excluded cases and Yalmatu/Deba has so many hard-to-reach areas. He further said, each time a patient is diagnosed with either of the cases above and they make referrals, instead of them traveling long distances to the general hospital, they prefer to buy medication from patent medicine sellers while others go for herbal medicine which are mostly cheaper and more affordable.

BHCPF PHCs running without midwives

When our reporter visited, the Facility Manager of Bage Ward in Funakaye Local Government Area Laraba Batari was finding it hard to sit down and rest because she is busy doing too many chores at the same time.

Aside being in charge, she’s also the only midwife although she is assisted by a Community Health Extension Worker (CHEW).

Batari said “It’s has not being easy for me, I work almost 24 hours, see my house here (Laraba’s house is inside the premise of the facility). I have to multitask. Prior to the implementation of the scheme, this facility delivered like 20 babies in a month but now we receive above 40. In a day, we can relieved more than five deliveries,” she added.

“Government staff are just 11 and sometimes is affects their planned outreach because they can’t leave the facility empty.”

Similarly, In Tongo PHC in Funakaye LGA, the facility manager, Abubakar Bappa Inuwa, said they do not have skilled birth attendants – only a Community Health Extension Workers (CHEWs).

Government response 

In responding to the myriad of challenges, when our reporter spoke with executive secretary Gombe State Primary Health Care Development Agency, Dr Abdulraman Shaibu, he advocated for increased funding for BHCPF so that more facilities will be covered.

“We are doing continuous advocacy to the federal government to increase the number of facilities at least two facilities per ward because one facility per ward policy is not enough to cater for the health need of the people, especially some wards that are larger and have population than others like in Gombe and Akko local government areas.

Increase the Fund to 2 percent of the consolidated revenue and that will skyrocket number of beneficiaries,” Dr Shaibu said.

On the alleged politicising or favoritism of the selection process he said that would be difficult.

“Objective tool is being use by GO-HEALTH as the selection was done through the social register domicile at the state Bureau of Statistics which is being used by GO-HEALTH to compute and classify people into vulnerable and those not as the selection is being done base on that,” he stated.

Reacting to the issue of lack of adequate staff in the facilities, Dr Shaibu said “the government has approved recruitment of 440 staff and we are going to complete the process in the next one or two weeks and they will be posted to the facilities across the state including midwives”

When asked on the findings by the reporter on some beneficiaries buying drugs he said “that doesn’t happen regularly but maybe sometimes”

* This report first published in October is supported by the International Budget Partnership and the International Centre for Investigative Reporting (The ICIR).