Primary health care centres are important to epidemic preparedness and disease outbreak response. But sadly in Nigeria, they don’t get the funding needed to get them ready to perform optimally. JUSTICE NWAFOR looks at the funding for the National Primary Health Care Development Agency (NPHCDA) and how it affects epidemic preparedness in the country.
Alulu is somewhat a difficult community to describe. Some say it is lively, while others don’t see it as such. For most residents, especially those who were born and have lived most of their lives here, it is lively and holds all the trappings of a good community: calm and safe, with very fertile land for farming. Nkwo-Nta, the community’s market, bustles with business every week. Traders from nearby communities travel down here to exchange cash for wares.
The rhythmic hoot of largely rickety vehicles and motorcycles laden with fresh fruits and vegetables whispers life into the air. And the billows of dust that trail their jerky maneuvers of potholes add to the sight. Well, women with foodstuffs-heavy bicycles don’t find it funny — there’s nothing glamorous about being covered in dust, after all. So they take revenge by hurling audacious abuses at the drivers. This is a typical market day.
But for a stranger, who this reporter was on his visit to Alulu in April this year, it is an extremely dull community. As of the time of visit, there was no power supply. The quietness that pervaded the air was loud, especially on the long, untarred road — which was almost deserted, save for a handful of women farmers struggling with their cassava-heavy bicycles — that led to the community.
“Oga, what is the problem”, Grace Okafor asked, leaning on her bicycle, as this reporter hopped off the motorcycle that brought him — which had screeched to a halt on the sandy side of the lonely road — and approached her.
After nodding severally to the explanation this reporter offered, she smiled despondently and pointed to a deserted building a few metres away. “That’s the hospital”, she said.
But there was a caveat, “You’d not see anybody there”, she warned.
Grace has been married for an upward of 10 years in the community and she finds where the healthcare centre is located very dull. She would later tell this reporter that she had never utilised the services of the PHC.
“The place is usually locked and you don’t expect me or anybody to go there when there’s nobody to attend to us”, she said in Ngor-Okpala dialect of Igbo language.
She recalled when she needed the services of the hospital a few years back but could not get it: “I was pregnant with my third child. That evening, I felt my baby coming and my husband rushed me with his bike to the hospital, hoping they would be around but the place was locked as usual. It was around 6 pm. He had to take me to the private hospital outside the village”, she said.
“I was lucky I did not lose the baby”.
The Alulu PHC is meant to serve Grace and other residents of the community. But they opt for private hospitals outside the community, like the one at Ogbo community, Aboh Mbaise, in the same Imo State where they spend up to N1,500 each to get to. Alulu is in Ngor-Okpala LGA.
On a second visit to the community, this reporter met the PHC eventually open at about 2 pm. The most senior nurse on duty, who preferred not to say her name, said they fail to operate every day because people rarely visited the hospital. But Grace said that the poor turnout was because the hospital lacked basic facilities. The senior nurse, however, did not deny the fact that they lack adequate facilities at the hospital, as she said the conditions are not just right for them.
No toilet facilities and water at the PHC. Drugs are scare, and bed space, too. No power supply. The one-room, which serves as the ward and all that could be sought after in a hospital, has just four six-spring beds and tiny mattresses on them.
This is not peculiar to the Alulu PHC. Most PHCs in Nigeria, especially in far-flung communities where a little above half of Nigeria’s over 200 population reside, lack basic facilities to enable them to meet people’s healthcare needs.
Experts say most of the over 30,000 PHCs in Nigeria do not meet the standard for functional PHCs all over the world. In fact, Nigeria’s immediate past Minister of Health, Isaac Adewole said only two in every 10 (20 per cent) primary healthcare facilities in the country were working.
This has ripple effects. First, it will continue to worsen Nigeria’s health indices. On the other hand, it will make the system unready to respond to the outbreak of epidemics and pandemics.
It is a worrisome sign of unpreparedness for outbreak of epidemics.
Healthcare infrastructure at the heart of epidemic preparedness
Primary healthcare centres are not just primary to the delivery of healthcare services to people, especially those in far-flung communities but to the success of vaccination campaigns.
Disease outbreaks will not stop. This means that response to outbreaks will continue. And, for effective response to the outbreaks to take place, consistent, adequate funding is required. But over the years, healthcare in Nigeria has been chronically underfunded, leading to deteriorating and utterly embarrassing healthcare infrastructure. Sadly, these pieces of infrastructure were supposed to be the backbone of the responses.
The poor shape of the infrastructure has two significant impacts: First, it will continue to place Nigeria in an unready situation to respond to outbreaks. On the other hand, it will leave the country spending more in its eventual response. For instance, the Commissioner of Health in Nigeria’s south-western state of Ogun, Tomi Coker, told Nigerian Tribune late last year that not funding healthcare adequately to respond to disease outbreaks in the state impacted the swiftness of the state’s response to Covid-19 and made it spend more money on things it could have bought at relatively cheaper prices.
Functional PHCs as trust-builders, enablers of successful responses
Vaccination campaigns are not new in Nigeria. In fact, recently, the World Health Organisation (WHO) hailed Nigeria’s polio vaccination campaign and declared the country polio-free, even though cases of vaccine-derived polio have been reported recently. But the dynamics of polio vaccination is different from that of the Covid-19, which is ongoing. For the latter, the effectiveness of PHCs has a huge role to play. The National Primary Health Care Development Agency (NPHCDA) has adopted a number of PHCs as Covid-19 vaccination sites.
What this means is that people would have to converge at the centres to get vaccinated. For example, in Atisbo LGA with a 2,997 km2 area, one of the largest LGAs in Oyo State, the NPHCDA designated three centres — Ago Are Model Primary Health Centre, Agunrege Primary Health Centre and Tede Comprehensive Health Centre — as shown on its website.
In a less large LGA with an area of 84km2, Ideato South LGA in Imo State, the NPHCDA designated two centres — Ntueke Primary Health Centre and Dikenafai Maternal Child Health Centre.
Interestingly, according to data from the Nigeria Health Facility Registry (HFR), there are 25 public health facilities in Atisbo — 22 primary and three secondary. In Ideato South, there are 17 public health facilities — all primary. Out of these numbers, NPHCDA decided to choose three and two, respectively.
Notedly, most of the vaccines need to be stored in extremely cold temperatures: Pfizer BioNTech (stored in a freezer at -80°C to -60°C); AstraZeneca (stored in a refrigerator between 2 to 8°C) and Moderna (stored in a freezer at -25°C to -15°C). Undoubtedly, if PHCs were in excellent condition, the NPHCDA would not have hesitated in designating them vaccination sites and then make the vaccine more accessible to people in far-flung communities.
On the flip side, having the PHCs in good condition helps to build trust among locals, preparedness and response capacities and keep the health system of any country robust, the WHO says.
In this complex, there is another layer to the preparedness and function of PHCs in rural areas, Dr Laz Ude Eze, a public health physician and health policy advocate says.
“Most of the functions of PHCs have to do with the environment and prevention. They have to do with environmental and occupational health; educating people about general wellbeing, health behaviours and practices so that there would not be any cholera outbreak to respond to,” he said.
For Dr Francis Faduyile, former president of the Nigerian Medical Association (NMA), the PHCs have not been living up to expectations because of inadequate funding. He says not just the Federal Government, which has not funded agencies like NPHDC adequately, but the state governments which have not done much either and then the local governments which, basically, should have controlled the PHCs, but are, unfortunately, inactive.
“What we are seeing is the abandonment of health by the local government and the states.This is why we are having a lot of pressure on the Federal Government which should focus on the tertiary and the super special,” he stated.
NPHCDA: Heavy responsibility with lean funding
The NPHCDA was established to coordinate vaccination campaigns and make public health services available by ensuring communities have access to health facilities, services and basic health insurance. But with the heavy responsibilities, inadequate funding has largely clipped its wings.
Nigerian Tribune analysed the capital budgetary allocation of NPHCDA from 2012 to 2018 obtained from the office of the Accountant General of The Federation. Sadly, the analysis revealed that the highest allocation to the agency in the years under review was in 2018, N23.303 billion but less than half of the budgeted amount, N9.526 billion, was released to the agency. The incomplete release of budgeted funds was not just for 2018. It was also witnessed in other years apart from 2015 when N9.964 billion was budgeted and the same was released.
The second highest allocation was in 2012 when N21.685 billion was budgeted but N17.305 billion was released. The next year, the budgeted amount went south to N18.202 billion while the total releases stayed somewhat stable at N14.010 billion. The southward trend continued in 2014; N17.525 billion was allocated and less than half of the amount, N6.915 billion was released.
The trend continued in 2016; N15.694 billion was released but the total releases improved remarkably — N15.317 billion. 2017 was significantly different as N19.382 billion was budgeted and N17.691 billion was released to the agency. For context, funds released to ministries, departments and agencies (MDAs) in Nigeria usually come in tranches and sometimes lack uniformity. For example, in 2018, the NPHCDA had its total releases come in two tranches: the first was N4.330 billion and the second was N5.196 billion while in 2014 the releases came in three tranches. N1.933 billion was first, N3.471 billion second and N1.510 billion third.
Further analysis revealed that from 2012 to 2018, a total of N125.756 billion was allocated to the NPHCDA for capital expenditure but only N90.730 billion was released. This means N35.026 billion was not released to the agency. This would not have been a huge cause for concern if the health outcome indices of Nigeria were not so dire and if the sector had been receiving adequate funding in the recent past.
Further data obtained from the budget office showed that in 2019, the allocation declined a little — N18.43 billion. It got better in 2020 at N25.34 billion but declined again to N24.44 billion in 2021. From 2019 to 2021, N68.22 billion (about $166 million) was allocated to the NPHCDA.
The irregular release of budgeted amounts for healthcare worries Dr Faduyile.
“I have since realised that budget sum does not mean performance. It’s just on paper and I can tell you that the released amount from the budgeted sum is really appalling”, he said.
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