By Isaac Femi OJO

INVESTIGATION reveals a disturbing reality of the state of the primary healthcare system in Oyo state plagued with critical staffing shortages which is hampering healthcare delivery across the state. In a survey of six primary healthcare centres, both newly upgraded and long-established, it was discovered that most facilities were managed by a lone matron and a handful of nurses.

The crisis

On arriving at the Primary Healthcare Centres (PHCs) in Oyo State, their stark realities seem the same.

They all cut the pictures of chronic understaffing which leaves the vulnerable population of health consultations at significant risk with overstretched health workers struggling to meet the needs of their communities.

Some of them lament to the reporter that despite promises of improvement, the healthcare crisis in their facilities persist.

Upon visiting six PHCs across the state, the findings were remarkably shocking. Both urban and rural facilities were predominantly managed by a single matron acting as the Officer-in-Charge (OIC), supported by just one to three nurses seen as a nag undermining the very foundation of public health in that state.

At the Adifase PHC in Dogo Apata, Ibadan South-West Local Government Area (LGA) in particular, a facility serving over 710 patients monthly has only one heavily pregnant government-employed health worker. She looked overworked almost to the point of breakdown.

The reporter also saw that she had just one laboratory technician assisting her as their situation cuts the picture of a broader systemic issue facing the state’s healthcare system.

“This is how we have been running this place, we are just two staff and we are running three shifts, for the past three weeks I have not taken any off day,  I am tired, as you can see on my face, and you can hear it in my voice, for the past three weeks I have not taken any off, presently we have 100 pregnant women who come for antenatal check every week, so today, I attended to 50, to see the remaining 50 tomorrow, that’s how we manage things here.

The scenario was forlorn at Akeke PHC Bashorun at Ibadan South West LGA when this reporter got there.

Aside it being a very old facility with no modern touch, only one matron, one desk officer, a few ad-hoc staff, and volunteers serve a community of over 3,000 people.

The reporter met the facility deserted when he got there as he was told that most residents would rather seek medical care elsewhere due to the number of staff available.

in Ibadan South West Local Government is another old facility where just one matron, one nurse, a few ad-hoc staff, and volunteers serve a community of over 4,500 people from different ethnic groups.

Even at the slightly renovated facility of Adifase PHC in Dogo Apata, Ibadan South-West LGA, the reporter met only one matron, one lab attendant, one ad-hoc staff member, and a few volunteers, struggling to cater for the health care needs of hundreds who had come to seek medical attention.

Saja Isale Ora PHC at Ogbomosho North LGA was not different. It has just one matron, ad-hoc staff, and a few volunteers to attend to the needs of those who had come for health care.

By the time the reporter got to Ayete PHC in Ibarapa North LG, it was no longer a shock to see just one nurse employed through Basic Health Care Provision Fund (BHCPF)intervention and a few volunteers amid scores of health seekers.

The renovated Eleyele PHC, Babalegba in Ibadan North West LG facility had a slightly enhanced scenario with six government-employed workers, assisted by three nurses serving over 700 patients monthly, from 33 different communities.

On-site realities

Making efforts to document the crisis firsthand, the reporter encountered a series of distressing accounts.

A nursing mother at Eleyele PHC, Adeleke Abimbola, shared a touching narrative of her traumatic childbirth experience at Apete PHC, in Apete, attributing it to severe understaffing.

“I arrived at Apete PHC around 9.00pm on a Wednesday when my labour pangs began,” Abimbola recounted. “They assured me I would give birth by midnight, but as the hours passed, I received no special care. By the second day of labour pains, a nurse urged my husband to transfer me to a better-equipped hospital to avoid risking my life or that of our baby.”

Reflecting on her ordeal, Abimbola questioned the necessity of purchasing induction materials that were ultimately unused.

“Why did they sell me the injection and syringe if they knew they wouldn’t use them?” she lamented.

Commenting, the chairman of the Ward Development Committee at Akeke PHC, Kareem Nurudeen, in Bashorun, Akeke Olorounbo, Boripe layout, Ibadan painted the challenges faced in managing nighttime emergencies due to limited operating hours and staffing shortages.

“We had previously, and still urgently appeal to Governor Seyi Makinde to allocate more medical personnel to our facility, the last time we had government intervention was during the late Governor Alao Akala’s administration ” he emphasized.

“Local residents have lost confidence in our services; during emergencies, we often transport patients to distant hospitals to save lives.”

Nurudeen also expressed concerns about security, noting recent burglaries at the PHC. “In less than a year, thieves have broken in three times,” he stated. “The only item they haven’t stolen is the donated inverter freezer used for vaccine storage.”

Also lamenting,  the OiC of Eleyele PHC, Esther Amao, acknowledged the level of resourcefulness required to manage the centre effectively with limited manpower.

“We operate with just six government-employed staff, including three nurse/midwives, a laboratory technician, and a records officer,” she explained. “Additional support comes from three Basic Health workers and volunteers.

“At present, our staffing cannot allow us to operate three shifts despite serving 33 communities, but we use the support from ad-hoc and volunteers to run these shifts,” Mrs. Esther continued. “And this poses challenges in meeting the government’s healthcare delivery goals.”

A case of systemic failure

Venturing deep into rural areas reveals a stark reality at Saja Isale Ora PHC in Ogbomosho and Ayete PHC in Ayete town, where severe staffing shortages are palpable. The sole government staff worker at Saja Isale Ora PHC, Adetoye Funmilayo, highlighted the strain on resources.

“I am the only government staff here; everyone else is support staff, with two hired through Basic Health Care Provision Fund and others as volunteers,” she explained.

“This facility serves a large population of over 6,000 residents, and an additional 10 staff members would significantly ease the immense pressure we face in patient care. It’s a constant challenge; I rarely leave the clinic.”

At Ayete PHC, the recent death of a government staff member who replaced a retired matron has exacerbated the critical understaffing crisis.

In Ibadan, the OiC of Adifase PHC, Abiiade Omobolanle, appeared visibly fatigued after attending to over 50 pregnant women during the weekly antenatal clinic.

“We operate with just two staff members across two shifts now, down from three shifts due to staff fatigue,” she revealed. “I’ve been working for over three weeks straight; the exhaustion is evident, but the work must continue.”

Highlighting further challenges, a doctor and a researcher Bakare Kehinde disclosed instances where volunteers in PHCs refer patients to private hospitals for a commission, undermining public healthcare efforts.

Despite these crises, resident in Ayete, Ologuneru, Eleyele, and other communities admitted that men and women visiting PHCs for various ailments remain largely unaware of the staffing issues.

This sentiment was echoed by patients waiting for their turn, who expressed surprise upon hearing about staffing shortages, assuming all personnel were full-time government employees.

Absence of resident medical doctors exacerbate situation

Further complicating matters, the absence of resident medical doctors at the visited PHCs was noted, with an ad-hoc staff member indicating that a single doctor services multiple centres weekly.

The extent of the manpower crisis becomes most apparent during immunisation and antenatal service days, contrasting with quieter days when few residents seek treatment for general ailments.

A patient at Ologuneru PHC, Oluwakemi Afolarin, voiced her concern over inadequate staffing. “It’s clear they don’t have enough staff here; you can see how stretched they are,” she remarked.

Moreover, a significant number of pregnant women who attend antenatal services at PHCs across the state ultimately opt to give birth at private hospitals, undermining efforts to reduce maternal and under-five mortality rates.

Reflecting on her decision, a nursing mother who requested anonymity shared her reservations about delivering at a PHC despite accessing antenatal services there.

“I chose a private hospital due to concerns about lapses and negative stories from past deliveries at the PHC,” she explained.

Addressing these challenges, a Ward Development Committee (WDC) member in Ibadan South West, Jokotola Olayemi Eniola, emphasized the urgency of addressing maternal health issues.

At a  training session organised by the Justice and Peace Commission, Ibadan, Eniola urged the executive secretary of OYSHIA, Olushola Akande, to address the rising mortality rates among women delivering with unskilled traditional birth attendants in her community.

“I must commend the state governor for the regular intervention in healthcare delivery, particularly for involving us in the running of primary healthcare centres in our communities. However, we still need your help. The number of pregnant women who die after delivery in our community is becoming too high. How can you help us?” she asked the executive secretary, OYSHIA, during the training session.

Maternal mortality rate in Oyo state alarming at 262 Per 100,000

Oyo State’s maternal mortality rate is 262 deaths per 100,000 live births annually, according to the 2021 Multiple Indicator Cluster Survey (MICS) and National Immunisation Coverage Survey (MICS-6) released in August 2022.

While this figure is lower than the national average of 576 per 100,000 live births, it remains alarmingly high. The MICS-6, conducted by the National Bureau of Statistics (NBS) in collaboration with United Nations International Children’s Emergency Fund (UNICEF), identifies several contributing factors.

In terms of infant mortality, reports say Oyo State ranks third with 40 deaths per 1,000 live births. This places it behind Ogun State (68 deaths) and Ekiti State (67 deaths), but ahead of Lagos (15 deaths), Osun (17 deaths), and Ondo (31 deaths).

The under-5 mortality rate in Oyo State is also significant, with 57 deaths per 1,000 live births. This rate is higher than those in Lagos (15 deaths) and Osun (24 deaths) but lower than in Ondo (64 deaths), Ekiti (67 deaths), and Ogun (85 deaths).

The reporter found that these statistics highlight ongoing challenges in maternal and child health in the state, stressing the need for targeted interventions and improved healthcare infrastructure.

Gaps, progress of BHCP Fund

Established under Section 11 of the National Health Act, tBHCPF aims to improve access to primary health care across Nigeria.

In Oyo State, the initiative, led by agencies like the State Primary Health Care Board, initially intended to reach 45,000 individuals.

However, as of May 24, 2024,  the executive secretary of the Oyo State Health Insurance Agency (OYSHIA),Olushola Akande, confirmed that only 213,000 residents have been registered under the health insurance scheme.

Akande attributes the low registration numbers to negative beliefs about insurance among the elites.

The deputy enrolment officer at OYSHIA, Akintayo Fashida, reported that since the programme’s inception in 2021, over 80,000 individuals have been documented under the BHCPF in the state.

The recent disbursement in April 2024 saw 342 health facilities receiving N300,750 each, totaling N102,856,500, indicating some financial support to bolster health services.

Despite these efforts, awareness and enrollment among vulnerable groups remain low.

Many pregnant women, nursing mothers, and economically disadvantaged individuals are unaware of their eligibility for free health services under the BHCPF.

A nursing mother at Ologuneru PHC, Oluwakemi Afolarin, expressed surprise upon learning about the programme, underscoring the need for improved outreach and education.

At Adifase PHC, Abiiade Omobolanle noted the challenge of maintaining continuity in coverage, with few pregnant women currently enrolled due to recent births exhausting their health package.

She highlighted efforts to engage OYSHIA for enrollment but cited delays in response.

“I don’t have any pregnant women here under the Basic Health intervention.

Children under five are limited, and we only have adults enrolled in the intervention.

I told OYSHIA to come and enroll the new set of pregnant women since the initial expectant mums have delivered.

They told me to tell them to bring their babies to the secretariat for enrolment, but how do I find them? It’s hard; I don’t know their houses,” she said.

These insights reveal both the potential and current limitations of the BHCPF in Oyo State, emphasizing the importance of proactive outreach and streamlined enrollment processes to maximise its impact on public health.

Staffing falls short of standards

The National Primary Health Care Development Agency (NPHCDA) outlines comprehensive staffing guidelines for primary health facilities, stipulating a minimum personnel requirement per political ward.

Each facility was ideally stipulated to have one medical officer, accompanied by a community health worker (CHO), four nurse/midwives, three community health extension workers (CHEWs), one pharmacy technician, one junior community health extension worker (JCHEW), one environmental officer, one medical record officer, one laboratory technician, and supporting staff including two health attendants, two security personnel, and one general maintenance worker.

However, a stark disparity exists between these standards and the actual staffing observed in the field.

To further investigate the Oyo State recruitment policy and PHC employment data, this reporter contacted the executive secretary, of Oyo State Primary Healthcare Board, Muideen Olatunji. The doctor emphasized that, according to set standards, Oyo state PHCs require at least 14,000 medical staff to function effectively and meet the healthcare needs of citizens.

However, he revealed that PHCs across Oyo State currently operate with less than 5,000 personnel, highlighting a significant shortfall and the root cause of many issues.

Despite the interventions of the BHCPF and other programmes aimed at improving healthcare access, the impact has been minimal due to severe staffing shortages.

Akande acknowledged the impact of these problems on service delivery and stressed the need for patient-friendly care.

“The shortage of workforce is a major issue globally, with many facilities struggling to fill gaps in staffing. It’s not a fallacy, but despite these challenges, optimal performance is still achievable.

“For example, if one had a private hospital, a cost-benefit analysis would be necessary to determine how many doctors to employ in order to maximise delivery.

“This approach is common abroad, where businesses understand the importance of service delivery. The same attitude should be applied to public facilities. The gaps in public facilities are well-known, and people are struggling to get the care they need.

“However, some hospitals have taken advantage of the health insurance program and used the funds to employ doctors. These facilities understand that success is dependent on service delivery. Instead of waiting for the government to solve the problem, why not try to find solutions using the resources that are already available?

“If I hire someone, I want to ensure that they provide maximum delivery of their services. This is being implemented in other countries. There are several gaps in our facilities that are not being utilised efficiently. In addition, health insurance has provided opportunities to employ staff in every facility.

“Currently, there are hospitals that have employed doctors who are not assigned to that facility, and some facilities are paying their own doctors. This means that there is money being paid to them on a monthly basis. These facilities have a business to service delivery,” the Akande explained.

Similarly,  the  State executive director of the Primary Health Care Board, Muideen Olatunji, confirmed the staffing shortage but assured ongoing efforts to address it, citing retirements as a contributing factor.

In a recent discourse with journalists, Olatunji confirmed that the state governor, Seyi Makinde has so far approved the recruitment of 30 per cent of the personnel needed for the state PHC to function properly.

“We have successfully advocated for a 30 per cent increase in recruitment to the state governor, and this has been approved. We are now focused on finalising the protocol to ensure we have the resources to provide quality service.

“In addition to recruiting more personnel, we have engaged contract workers, including 2,120 midwives and 264 chief agents, to supplement our current workforce,” he further enumerated.

“Plans to fill vacancies and engage community health promoters were mentioned in a recent announcement,” said the chairman of the Oyo State Hospital Management Board, in response to the recruitment of healthcare professionals, Akin Fagbemi.

Stakeholders decry manpower deficiency

To garner more insights on the development, the reporter also spoke with stakeholders who identified the lack of large-scale recruitment since 1992 as a root cause of current issues.

A retired nurse and midwife, Grace Ademidun Oluwatoye, suggests engaging retirees and adopting successful models from countries like Brazil to improve access and service delivery in PHCs.

A medical doctor, Dickson Adeolu Adetoye of the APIN Public Health Initiative highlighted the staffing shortage’s effects on user fees, service hours, and patient outcomes.

He said, “The issue of manpower deficit is not confined to PHCs alone but affects all levels of healthcare.

“This manpower deficit is a serious challenge, exacerbated by the Japa syndrome, which is impacting human resources for health. The increasing number of retiring health workers, without adequate replacement, is compounding the crisis. While it is a national problem, it significantly affects Oyo State, diminishing the quality of services and impacting the remaining staff.”

Jide Bangbose from the Justice Development and Peace Commission (JDPC) Ibadan urged the state government to prioritize healthcare delivery at PHCs, which are closest to the people, by addressing the longstanding vacancies in health personnel.

Similarly, Gbadamosi Adenike, the new OiC  at Eleyele PHC, emphasized the need for a fair and merit-based selection process as the government prepares to activate the recruitment portal.

She said, “The governor’s recent approval to recruit 30 per cent of new personnel must emphasize transparency and fairness, ensuring that all candidates are evaluated based on their qualifications, experience, and dedication.”

Eleyele OiC, Gbadamosi, said there was the need to re-emphasize the importance of recognizing the contributions of dedicated Adhoc staff who have served at PHCs for many years.

“It is crucial that their contributions are acknowledged and considered during this recruitment process. We are committed to maintaining high standards to ensure that the most deserving candidates are selected, thereby strengthening our workforce and enhancing the quality of services provided to our citizens.

“We also hope the recruitment process will be closely monitored to uphold these principles, fostering a culture of excellence and integrity within our state’s workforce,” she argued.

This report was made possible with support from the International budget Partnership, IBP, and International Centre for Investigative Reporting, ICIR