Grace Diashe says has not had a sound sleep since November last year when she started work as a nurse at a rural health centre.
The 47-year old mother of three is the only qualified health worker at the only health centre in Edikwu-Icho, a swampy community of about 2,500 people in Apa Local Government Area of Benue State.
Dominated by Tiv speaking people, the agrarian community is cut off whenever it rains, as five-foot deep flood water covers the only road that links it with the outside world.
Mrs. Diashe recounted to PREMIUM TIMES her experience on a day she went to the local government headquarters to replenish her centre's drugs stock.
"I was on my way back and the rain was heavy. When we got to a hill, the okada man (motorcycle taxi operator) said he could not go any further. I had to carry the drugs on my head and started wading through the flooded road under the rain. I fell several times and the flood would have carried me away," she said.
Edikwu-Icho village has no electricity. But the health centre has a rechargeable lantern and a small electricity generator, which Mrs. Diashe and her assistants use only for deliveries or emergencies at night.
According to the nurse, the centre attends to about 15 patients from the community and its environs daily. In a month, she said, she takes about 25 deliveries.
"We lack staff, drugs and equipment," she lamented.
Assisting Mrs. Diashe at the centre are three community extension workers. They all work 24 hours with no shifts.
"I only have three health attendants assisting me. If I am carrying out delivery and I encounter challenges, I refer the person to Aliade, which is far," she said.
"If there is a doctor here, he would handle these issues and save lives. But which doctor will come here? It is hard to get a qualified doctor to agree to work in this kind of community with no light, basic amenities and terrible road covered with flood water," she said.
THE ABANDONED PHC
To help tackle the health challenges in the community, in 2014, the National Primary Health Care Development Agency, NPHCDA, allocated a primary health care project to Edikwu-Icho.
The agency awarded a N22 million contract for construction of the facility to Ogason Construction Ltd. The roofing and painting of the building excited Mrs. Diashe and her colleagues. But the excitement lasted only a while.
Going by the blueprint of the NPCDA, a PHC will have one or more doctors, a pharmacist, a staff nurse and other paramedical support staff to provide outreach services such as immunisation, preventive and basic curative care, monitoring and evaluation services, as well as maternal and child health services.
Poorly equipped labour room in Edikwu Icho health centre. (Photo taken by Ebuka Onyeji)
By the time PREMIUM TIMES visited in August, the project in Edikwu-Icho had long been completed but abandoned. The building was under a thick bush with the gate under lock and key.
So the only functional health centre in the community has thus remained the one where Mrs. Diashe works. It was built as a Millennium Development Goals project by the President Goodluck Jonathan administration.
"If they had completed all the work in that place and equipped it, we would have moved over," the health worker said, pointing in the direction of the abandoned PHC.
Apart from Malaria drugs, immunisation kits and other health packages usually donated by non-governmental organisations, there are no other drugs for Mrs. Diashe to dispense to her patients.
The situation in Edikwu-Icho mirrors the challenges health workers face in several health centres across Nigeria, especially in rural areas.
The federal government in January this year said it had concluded plans to engage 200,000 voluntary health workers to improve delivery of immunisation, antenatal care and other health services in rural areas. The announcement followed the flag-off of a scheme to revitalise about 10,000 healthcare centres across Nigeria.
But about 10 months later, all the eight primary health care centres PREMIUM TIMES visited in Niger, Benue and Nasarawa states in North-central Nigeria had no doctors, drugs or equipment. The few health workers at the centres attended to multitudes of patients, often working no shifts.
Completed but abandoned health centre built by NPHCDA in Edikwu Icho community, Benue state. (Photo taken by Ebuka Onyeji)
According to experts, the high maternal and child mortality rate in Nigeria reflects the widespread lack of qualified health workers, and simple and cost-effective interventions at the primary health care centres in the country.
MORE WORRYING CASES
The sorry state of Nigeria's PHCs is also reflected in Maito, a village in Wushishi Local Government Area of Niger State. Bats hung from the roof of the dilapidated building, with the droppings of the rodents spreading a heavy stench over the facility.
The centre was constructed by NPHCDA through a contract awarded to Sycamore and Vie Ltd. also at N22 million. But since the building was completed, it has not been equipped or staffed and was overgrown by weeds and occupied by goats when Premium Times visited in August. The people of Maito had thus continued to rely on an old, dilapidated clinic.
A nurse at the clinic, Mariam Mohammed, told PREMIUM TIMES she had decided to leave her job due to the neglect of the centre by government.
"It is not proper to treat a sick person here," she said. "Some people will come here, look at the environment and go back."
Dilapidated building at Maito Primary Health centre, Wushishi LGA, Niger state. (Photo taken by Ebuka Onyeji)
"The ceiling of our injection room fell down. As you can see, it is wide open. I have to cover my nose throughout the day because of the stench.
"I don't want to contact disease because of treating people. We have complained about this condition. If nothing is done, I will leave," Mrs. Mohammed said.
The health workers at the PHC in Adawa Mbiaise Ullam in Gwer East LGA of Benue State got tired of complaining and decided to contribute money to help the local government.
"Up to 25 health centres in this local government contributed N70,000 and gave to the authorities to supply us drugs since we are not getting them free," Samuel Ajonu, a health attendant told this newspaper.
"But since March when we made the contribution, we have not heard from them or seen the drugs."
Mr. Ajonu said the centre has two volunteer nurses and "an OIC (officer in charge)" visits every fortnight. He said inadequate drugs, equipment and qualified staff top the challenges of the centre.
"There was a time an 18-year-old girl was unable to deliver," Mr. Ajonu recalled. "We were rushing her to the clinic at St. Vincent's Hospital but the child came out on the way. The girl had a severe tear and had to be stitched. If we had proper equipment and a good doctor, this could have been averted.
Health centre in Adawa Mbaise Ullam in Gwer East Local government, Benue state funded by Millennium Development Goals Project. (Photo taken by Ebuka Onyeji)
"We don't have enough staff, no lab technician. It is even hard to do immunization here because most times, I will be the one to do everything," he said.
There were 11 health workers, including nurses, at the primary health centre in Ubbe/Ogba in Akwanga Local Government Area of Nasarawa State. A new building awarded at N18 million by NPHCDA to Swaleys Nigeria LTD was abandoned.
The nurse in charge of the existing centre, Grace Edero, told PREMIUM TIMES: "If they had completed that clinic, we would have moved in there because this one no longer contains us."
"Drugs and equipment brought for the abandoned health centre were stockpiled in the chief's place. When we approached him to give them to us to treat people, he said he does not know us and cannot release them.
"They are there rusting while many people are in need of those drugs and equipment," Mrs. Edero said.
The chief was attending a burial somewhere outside the community when the reporter called at his residence.
The health workers in Ubbe/Ogba also complained about poor pay. "We only get paid by percentage," a nurse said.
Abandoned PHC at ubbe/Ogba Akwanga LGA, Niger state. (Photo taken by Ebuka Onyeji)
NPHCDA awarded a N96 million contract for rehabilitation of the PHC in Muye in Lapai LGA of Niger State. The structure was well built, with a large open ward, labour room, children and female wards, doctors office and staff quarters. It also has an ambulance, a solar power facility and a sturdy gate post.
When this reporter arrived the centre at about 3:30 p.m. in August, the centre was wide open but with nobody around at the facility. A probe around the village led to a male nurse and an assistant running the huge facility.
"The centre has no doctors, qualified midwives, pharmacists or nurses. There were also no security persons or labourers. "We don't even have a driver for the referral vehicle," Ibrahim Abdullahi, one of the workers said.
"We treat at least 15 people daily and we don't have shifts. That's why we leave the place open and go home to attend to personal needs because we cannot be here every hour. It is just two of us."
Provision of health care providers is the responsibility of the federal and state health ministries, according to the National Health Act of 2014.
The federal government through the health minister, however, has the bulk of the responsibility.
"The minister, with the concurrence of the National Council shall determine guidelines that will enable the state ministries and LGAs to implement programmes for the appropriate distribution of health care providers and health workers.
"The minister shall make regulations with regards to human resources management within the national health system," Part 5 of the law reads.
Through the NPHCDA, the federal government says it is ready to do more to ensure PHCs work optimally, especially to meet the Universal Health Coverage, UHC component of the Sustainable Development Goals.
Speaking at a programme in Abuja, Faisal Shuaib, the Executive Director of NPHCDA explained that primary health care is important for achieving UHC.
He said improving efficiency requires oversight of PHCs in LGAs with partners. He said a programme was being introduced at local levels to promote efficiency.
Faisal Shuaib [Photo credit: Thisday Newspaper]
"This programme will engage 20 women per ward that will be trained over three months to provide simple intervention for health service delivery," Mr. Shuaib said at the event organised by the Premium Times Centre for Investigative Journalism and its partners.
It, however, appears the programme Mr. Shuaib talks of is yet to take off. Findings in the course of this report show that most PHCs in rural Nigeria are understaffed, while the few hands there are overworked. A nurse attends to an average of 50 patients in a week, often working day and night.
WHAT NEEDS TO BE DONE
Henry Ewunonu, a pathologist in Abuja, said what has to be done to deliver quality health care to more Nigerians is clear.
"Every health facility has standard requirement on human resources. That is what separates hospitals from PHCs and health posts and so on.
"There are two national health strategic development plans. One is ongoing while another one is in the making. None of these plans have actually dwelt on human resources for health. That is the standard nomenclature for health, manpower. None has addressed it," Mr. Ewunonu said.
"We have never as a nation done a situation analysis on this. Given our size, what should be the number of doctors, nurses, pharmacists at every health institution?"
According to Mr. Ewunonu, adequate distribution of human resources for health is the responsibility of the federal and state health ministries.
"Part 5 of the National Health Act addresses the issue of human resources. It is the duty of the Honourable Minister of Health, in conjunction with the commissioners of health in the states that will sit down and plan for human resources for health in there various domains in such a way there will be a balanced distribution.
"It is responsibility of government because the ministry of health has the powers to formulate policies and make regulations while NPHCDA is the implementing arm of the government."
Mr. Ewunonu, a medical doctor, told this newspaper that another issue bedevilling adequate distribution of staff at the grassroots level is poor standard of living.
"Everybody wants to live in the city. You know what life is like in the villages. What will make that doctor to leave AMAC and decide to go and work in Karshi village? No light, no water and again insecurity.
"That is why Nigerian Medical Association advised the government to map out plans for rural practise allowance. It is done in many other parts of the world. This will entice doctors to move into these rural areas."
In her reaction, the Commissioner for Health in Benue State, Cecelia Ojabo, in whose state Mrs. Diashe's PHC lies, declared support for government's plan to put PHCs under one roof, saying it was a key to proper distribution of staff.
"Right now, we are on the verge of bringing all PHCs under NPHCDA; that is putting all PHCs under one roof. When we do that, then we will be in the position to evenly distribute the workers", Mrs. Ojabo told PREMIUM TIMES.
While the government tarries on its actions, the PHC in Edikwu-Icho remains abandoned and Mrs. Diashe continues to strive to help members of the Benue community in the makeshift facility.
(This Investigation was carried out with the aid of a grant from the International Centre for Investigative Reporting, ICIR).