BHCPF is meeting the government's target of strengthening primary healthcare facilities for effective service delivery, but the efforts still look like a drop in the ocean.
Ibrahim Ibrahim, 40, was bleeding profusely from deep cuts on his head, thigh and ankle inflicted by some cattle herders who invaded his melon farm. He had been rushed to Okpatta Primary Health Care Centre in Agbashi Ward of Doma Local Government Area, Nasarawa State, after the attack on 30 June.
Community health workers on duty stopped the bleeding, stitched and dressed the wounds, and administered analgesics before referring the patient to another primary health care facility at Arumangye.
It was the melon season and a time for harvesting in Doma, a community outside Lafia, the state capital. Farmers relocate to their farms for between two weeks and two months to harvest and process their melon, known locally as Egusi.
Mr Ibrahim and his family were doing this when, around 11 p.m., the herders attacked them. While his children and wife fled to call for help, he stayed to defend his farm. But he was overpowered by the attackers and might have bled to death, but for the timely attention he received at the nearby primary healthcare centre.
"I'm sure I would have died before my family could take me to another place if nobody was at that hospital. They were able to stabilise me, stitch the wounds and give me painkillers," Mr Ibrahim said of the quality of service he received at the public facility.
Reaching grassroots with BHCPF
Mr Ibrahim's story is part of the successes of the Basic Health Care Provision Fund (BHCPF) in providing emergency medical response services to rural communities and the vulnerable in Nigeria.
Just like Mr Ibrahim, 60-year-old Habu Sanusi, a resident of Aramangye, is impressed with services at the primary health care centre in the community. For him, the PHC is t his family hospital.
"The clinic is doing okay. They do their best whenever a case of sickness is reported to them, and if it is above them, they normally refer patients to the general hospital in Doma. My family has been using it for a long time for childbirth, malaria and other minor illnesses," Mr Sanusi said to this reporter.
The Federal Government established the BHCPF, in 2014, under Section 11 of the National Health Act; to provide funding to improve access to primary health care. The Fund provides a Basic Minimum Package of Health Services (BMPHS) aimed at increasing the fiscal space for health, strengthening the national health system, particularly at the primary health care (PHC) level and ensuring access to healthcare for all.
However, the actual implementation of the law, including the release of funds, did not commence until 2018.
The BHCPF seeks to achieve at least one fully functional public primary health care facility in each political ward. Nasarawa State, in north-central Nigeria, has 769 PHCs, with 147 captured in the BHCPF since 2021. This represents one PHC per ward in the state.
According to the Director of Planning, Research and Statistics, Nasarawa State Primary Healthcare Development Agency (NPHCDA), Stephen Sasetu, the facilities have received funding for four quarters.
"Nasarawa State came on board last year. As a result, we were able to fulfil the criteria to start receiving funds," Mr Sasetu said in an interview.
"The facilities have received funding for four quarters. Two quarters last year and two quarters this year. For Nasarawa State, 147 primary health care centres, one PHC per ward, are currently benefiting from the BHCPF."
"It is not much. It is just about N100,000 for each PHC every month," Mr Sasetu said. "In a quarter, it is N300,000."
He explained further that there is a guide on how to spend the fund, which specifies that 35 per cent goes into supporting payment of human resources and 25 per cent for drugs.
The federal government has paid N500 million to the Fund in Nasarawa State through the Federal Ministry of Health. At the same time, the state has also started contributing 0.5 per cent of its consolidated revenue to the fund.
Mr Sasetu confirmed this but noted that its contribution is below the prescribed one per cent.
"For Nasarawa State, there have been some contributions, but it is not matching yet. By matching, I mean you know from the federal allocation, it is one per cent of consolidated revenue. So the state should also do at least one per cent, but that is not the case in many states, if not all," he said.
Funds still insufficient
In the state, the BHCPF is meeting the federal government's target of strengthening primary healthcare facilities for effective service delivery. But the efforts look like a drop in the ocean.
Aishetu Adeka, the officer in charge (OIC) of the Arumangye PHC, confirmed that the facility receives the funds regularly.
She, however, said the funds are insufficient because of the increasing cost of drugs and facility maintenance.
According to her, patients are to be treated with N570 based on the provision of BHCPF. However, she said this is not always enough to attend to cases reported by patients.
Contrary to the claim by state authorities that each primary health care receives N100,000 every month, Ms Adeka told our reporter that Arumangye PHC in Doma Ward received N67,830 per month.
She said N52,000 (75 per cent of the amount) goes to procuring drugs while the remaining N12,000 goes into the facility's management.
"For me, it is insufficient because drugs are costly these days. And then you say when I have a patient with malaria, I should treat them with N570, which cannot solve that problem, and talk less of having typhoid fever," Ms Adeka lamented.
"So before you know, one client uses up to N3,000. When we complained to them, they said these 119 patients are not coming in the same month, so we should not talk about it."
Ishaku Rabi, who heads Alarama PHC, told this reporter her facility receives the same amount but also argued that it is insufficient to run the system.
"Yes, we receive the money. It is N67,830. There is also equity of N57,750."
But while reacting to the amount each facility receives, Mr Sasetu clarified that "the BHCPF has two gateways, and they receive 100k (N100,000) from our gateway and a variable amount from the NHIS gateway depending on the number of enrollees. Our gateway caters for human resources and infrastructure while the NHIS gateway caters for indigent patients," he added.
Peoples' verdicts
Though Nigeria may be far from achieving universal health coverage, which is the target of the BHCPF, it is making progress as primary healthcare facilities benefiting from the scheme continue to render quality services to communities.
This reporter met Abu Amina at Tunga PHC in Awe Local Government Area of Nasarawa State. She had just got a drug prescription for an undisclosed ailment. "Their service is good. The workers always attend to me when I come around," she said
Ms Abu is not alone in praising the scheme's impact. Hauwa Sani, who rushed her daughter to Angwan Waje PHC, Keffi LGA, at about 11:20 a.m. with a fever, was all smiles after the community health workers at the centre treated the baby.
This reporter observed how the health workers promptly controlled the baby's temperature and told the mother her baby would be alright.
The story is not different at Tudun Kofar PHC in Keffi Local Government Area. A resident, Musa Bashir, described the services at the health centre as great.
"They give us drugs for free; they do some tests for free. Like this place you see, that looks small, and it is tremendous because if they bring drugs, their drug finishes before other facilities," Mr Bashir said.
"If they don't give malaria drugs or conduct other tests, then the drugs or kit has finished, but once it is available, it is given."
Mr Bashir, whose wife delivered their son at the facility earlier in the year, said he only paid N1,500 during delivery.
"My wife and son use it. My son was delivered there. You know the tests done during antenatal are many, so some are free, and some are not."
David Christy, who recently had her third child at Wamba Road PHC, said she has not had to pay for anything since she started using the clinic.
"Since I started my clinic there, I haven't paid for anything. I am happy. I like the hospital very much," she said.
This reporter observed that PHCs across five LGAs in Nasarawa State were experiencing a facelift, but the extent varied from one to the other. Mr Sasetu said this is because each PHC decides which of its needs is a priority or needs funding.
"Under the BHCPF, especially in Nasarawa State, facilities are autonomous. What it means is that they get their funds directly, and then they can determine their needs.
"What an agency like ours does is regulatory. So before they can utilise the money, they will do a work plan and send it for approval. The work plan will detail what infrastructure touches they want to do, and what drugs they want to procure, and it will be backed up by certain evidence."
Healthcare services in Nasarawa State, based on this reporter's findings, have improved from what they used to be. These findings tally with the One Campaign report on the state of primary healthcare delivery in the state (2019-2021). In the report, Nasarawa State was listed among the top 10 states out of the 36 states in Nigeria to get quality healthcare.
Not yet Uhuru
Despite these cheery testimonies of satisfactory services, some PHCs still face challenges. One of the issues is structure.
Although some PHCs like Baure in Awe LGA, Aloshi in Kaena LGA, Angwan Nupawa in Doma LGA and others in Keffi and Akwanga LGAs are experiencing a facelift, others still have leaking roofs, wards with bad windows and insufficient rooms, among others.
In Tabu PHC, Akwanga LGA, Lamie Mobutu, the officer in charge, was seated at the facility entrance carrying out some paperwork because she does not have an office.
"We need structure because there are so many units that we don't have. Even the officer in charge does not have an office," a staffer of the clinic who would not reveal her name said.
At Iwagu PHC, Kaena LGA, the wards had broken windows without nets, which is not healthy for the health workers and patients as the wards are prone to mosquito attacks.
While there are water tanks in all the PHCs visited, most were not functional, forcing workers to buy water for their use.
"The only issue we have is water problem. The tank is bad, so we buy from vendors," a worker of Kafin Moyin PHC, Awe LGA, whispered.
It was the same water issue at Aloshi PHC, Kaena and Alagye PHC in Doma.
Gift Akuki, the deputy officer in charge, said the overhead water tank has been bad for some time. "We told the man that came to renovate the place but he only painted it and left, saying that was what he came to do."
The source of power is also another issue. While some communities have a public power supply, others rely on solar panels or generators.
In Iwagu PHC, Kaena LGA, the water supply is limited because the solar panel is faulty.
"Our solar panel has issues. Before, we could pump to fill the tank, but now it is bad, and we can only get half the tank sometimes if we are lucky," Ramatu Sule, one of the Community Health Extention Workers (CHEWs), said.
In Gwanje PHC, Akwanga LGA, the facility depends on generators because there is no light and the solar panel is faulty.
"We don't have light. We depend on generators, but we need light for 24 hours, and the solar we have sometimes does not work," Moses Andrew, a junior CHEW, disclosed.
The situation is not different at Tabu PHC, which relies solely on a generator to pump water.
"No light completely. Before, we were using solar, but it had a fault, and we have not fixed it, so we are using a generator for now," Lamie Mobutu said.
There is also no means of transportation for patients when the need arises. These facilities rely on community members who have cars or motorcycles to help bring patients during an emergency.
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"We convey our patients with cars from volunteers. We don't have an ambulance here, so we talk to people to help us convey the patient from here to that hospital," Rislanu Suleiman, a CHEW at Kafin Moyin PHC, narrated.
The lack of means of transportation or an ambulance is a significant challenge at Alagye PHC, Doma LGA, where Gift Akuki, the deputy OIC said, "we arrange with those people who have cars. They are the ones that help all our women."
In Tunga PHC, the officer in charge, Deborah Joseph, explained that they use motorcycles to convey patients to Awe general hospital, which is about a 30-minute motorcycle ride away.
But Mr Sasetu explained that these arrangements have proven to be more sustainable in developing countries with a scarcity of resources.
"For the case of ambulances, it is being followed through a Federal Ministry of Health and NPHCDA intervention. However, because this is a capital-intensive project, the PHCs rely on arrangements by spirited individuals or the transport union as part of their community efforts to move patients requiring emergency attention," he said.
Another issue observed was negligence. For example, there were no personnel at some PHCs during this report.
At Ampana PHC, Awe LGA, we found the facility empty with just one patient lying on the bed with no idea where the health workers went.
About 20 minutes later, no one had returned to the facility, leaving it open to anyone.
The situation was not different at Agaza PHC, which had no evidence of life except for one woman sitting at the facility's gate during our visit. The deputy OIC, who came in several minutes later, had to be called on the phone.
Meanwhile, the state agency overseeing BHCPF is aware of some of these challenges. Mr Sasetu told this reporter that the challenges could only be tackled one at a time.
"We are aware of these challenges, and we are tackling them as we get the necessary resources. But with almost 800 facilities, I am sure you would agree that we cannot address them all at once," he said.
"For a complete revitalisation of each PHC, you will need between N80 to N100 million to bring them to the minimum standard. That is why we need all stakeholders. What NPHCDA is currently championing is for corporate organisations and well-meaning individuals to adopt one or more PHCs."
He said a revitalisation programme that addresses the problems of infrastructure facing some of the facilities was ongoing.
"This is a part of the PHC revitalisation programme, which is a collaborative effort by relevant stakeholders to make at least one PHC fully functional in each ward of the state, that is 147 PHCs in the first instance," Mr Sasetu said.
On the issue of negligence, the director said necessary sanctions would be imposed if confirmed.
"Once we get a report and verify the report, we will sanction accordingly. Kindly provide us with the names of the PHCs if you remember."
This report is supported by the International Budget Partnership and the International Centre for Investigative Reporting (ICIR).
