Ondo state's health commissioner, Banji Ajaka, when asked about the alleged frequent casualties at Ayetoro PHC, said "there is really no way you can prevent people from dying."
On 25 July, Emmanuel Aralu, a youth leader in Ayetoro in Ilaje Local Government Area of Ondo State in south-west Nigeria, welcomed his second child. But like many women in the coastal community, his wife shunned the local primary healthcare centre (PHC) for the delivery of the baby. Instead, "a nurse nearby helped out."
Mr Aralu's wife lives in Ayetoro but had embarked on a two-hour journey to register for antenatal service at the state's specialist hospital in Okitipupa, the headquarters of the neighbouring local government area (LGA}.
"The health centre in Ayetoro is not just bad, it is also costly," Mr Aralu told PREMIUM TIMES.
Although she had her antenatal visits at the specialist hospital in Okitipupa, on the day Mrs Aralu went into labour, she was in Ayetoro. But rather than taking her to the local PHC, the family called a 'nurse' to take the delivery.
Mr Aralu did not disclose the qualification of the 'nurse' or where she works from. However, dotting the community are patent medicine stores whose owners also serve as clinical consultants and traditional birth attendants.
"There are so many issues with the Ayetoro PHC," Mr Aralu continued. "It charges as much as N50,000 for delivery of babies and the only nurse there may not even be around for weeks. So how can I pay as much as that for my wife just to be delivered when I even enrolled her on a free programme at Okitipupa?"
While speaking with our reporter on the phone, Mr Aralu was interrupted by unidentified women who quoted different rates charged by the Ayetoro PHC for delivery, ranging from N25,000 to N50,000.
Death of 'Iya Ibeji'
Esther Adedoyin is a businesswoman whose shop has been ravaged by the recurrent sea surge that has been the woe of Ayetoro. After her shop was submerged the third time, Mrs Adedoyin said she no longer had enough money to eat, not to talk of attending to the health of the family who she said now faces a precarious situation due to the filthiness of the environment.
According to her, like many other members of the community, she would rather patronise a private healthcare provider in the community than visit the PHC.
She cited the example of a pregnant mother, who allegedly died at the PHC in 2022.
"Just last year, Aunty Taiwo, who we all called Mama Ibeji, was in labour at the health centre, but it was her corpse that her husband later went to pick. So many other cases like that," she said.
She described the deceased, married to a young man in the community also identified simply as Mr Abuki, as a hardworking woman.
Cases such as these may have qualified Nigeria to be ranked by the World Health Organisation (WHO) as the nation with the second-highest number of combined estimates of maternal and neonatal deaths and stillbirths globally as of 2020.
The WHO's latest estimates show that the world recorded 0.29 million cases of maternal deaths, 1.9 million stillbirths and 2.3 million neonatal deaths in 2020. Of these figures, Nigeria recorded an estimated 82,000 maternal deaths, 181,000 stillbirths, and 277,000 neonatal deaths, amounting to 12 per cent of the global figure, and coming just behind India which recorded 17 per cent of the global figure.
Akinlewa's painful story
Meanwhile, Ayetoro's traditional ruler and spiritual head, Oba Ojagbounmi Oluwambe, narrated how not too long ago, a young engineer who was alo a drummer in his church, Anthony Akinlewa, died at the PHC.
The monarch, who is referred to as the Ogeloyinbo of Ayetoro, described Mr Akinlewa's death as a very painful moment for the community.
"It was at night that he had breathing difficulties. On that day, when I came in he was still alive. There was nothing the health centre could do, so we struggled to find a boat and I gave them the key to my vehicle, which was packed at Ugbonla. But while they were riding in my vehicle to Igbokoda, he died," he narrated.
The monarch said the community's health centre "does not treat anything other than malaria," adding that "anyone who deserves cesarean sections, if not referred on time dies before they get to the hospital upland."
He said: "From here to Igbokoda takes an average of an hour, and as the leader of the community it is a big challenge that I always face. We have many casualties from health issues. Most of the complications we experience here are because there are no doctors and access to good health care is a very difficult thing.
"By the time somebody needs urgent medical care, we need to go and look for fuel, a 'driver' and a boat. We will then take the person up to Ugbonla or Ugbo, and start looking for a vehicle. It is a very serious challenge. A lot of people have died from that process while in transit. One of them was just Akinlewa. So many of them, especially those in labour, have died in such a circumstance," the monarch said.
Facing destruction, health hazards
In Ayetoro, the devastation caused by the rampaging sea surge has been monumental.
Apart from sweeping almost half the community's landmass under water - in the process destroying houses, schools, markets and factories - the angry waves have also dumped mountains of refuse on people's homes and pathways. The consequences have been homelessness, hunger and diseases.
Though the state has no data on the disease burden, the community's ugly experiences as shared above have been corroborated by narratives of healthcare workers in the area.
"Due to the peculiar nature of the environment, malaria, helminthiasis and tuberculosis are common here," said Tolu Alabi, a medical doctor at Igbokoda General Hospital (IGH).
Mr Alabi, who described helminthiasis as a worm infestation disease, said apart from being common to a coastal environment, unhygienic lifestyles also enables it to thrive.
The Igbokoda General Hospital is the only secondary health facility in Ilaje LGA, serving about 400 towns and villages. More than 90 per cent of the communities, including Ayetoro, are riverine.
It is also the hospital where patients from the PHCs across the LGA's 12 political wards are referred.
But Mr Alabi lamented that many patients from the riverine communities usually report late. "They only come when cases are almost out of hand and most times, the patients are messed up."
The people of Ayetoro, speaking on the filthiness of their community, said their once beautiful and well-paved streets have been reduced to refuse dumps by an "angry sea".
They blamed the oil-producing companies operating in the area for their plight, saying that the mineral resource has brought them misery rather than blessing.
They also blamed the late visits to the Igbokoda hospital on the "poor state" of Ayetoro PHC.
They said lives have been lost to poor handling at the PHC due to "unskilled staff, lack of facilities and non-availability of a stand -by boat to serve as an ambulance when patients are referred."
But at the general hospital in Igbokoda, the situation is also not encouraging, especially as it only has five medical doctors and 15 nurses in charge of about five departments, including theatre.
Mr Alabi said for two weeks at a stretch, he might not leave the hospital as he runs a 15-day 24-hour call duty, just like his remaining four colleagues.
When our reporter visited the facility on a Sunday, there was only a nurse on duty. Mr Alabi said apart from covering the male, female, and paediatrics wards, the only nurse would be moved to the theatre should there be any emergency case.
"So, it is very challenging here, and that is why we keep losing staff every now and then. We do not have water, no morgue, and the light we have is solar which goes off in the night, maybe because the solar panels are weak," the doctor said.
Sinking Ayetoro PHC
The 'new' Ayetoro PHC was reportedly built by the Niger Delta Development Commission (NDDC) about five years ago, replacing a dilapidated structure that once stood in its place.
But like every other building in Ayetoro, the PHC is also already giving in to the rampaging sea surge, as tadpoles in their thousands swarm around its marshy surrounding.
When PREMIUM TIMES visited the health centre, the most senior official on duty was a pharmacy technician, Regina Adekoya, who narrated the challenges confronting the facility.
According to Mrs Adekoya, the centre, which is headed by a qualifying nurse, also has a record officer, two community health extension workers (CHEW), a dental technician, and a laboratory technician.
In total, Ayetoro PHC has only seven workers, below the minimum of 24 personnel recommended by the National Primary Health Care Development Agency (NPHCDA).
According to the agency, an ideal PHC should have a medical officer "if available"; one community health officer, four nurses or midwives, three community health extension workers (CHEW), one pharmacy technician, and six junior community health extension workers (JCHEW).
Others are; an environmental officer, a medical records officer, a laboratory technician, two support staff health attendants or assistants, two security personnel, and a general maintenance officer.
We're helpless
Mrs Adekoya said apart from the shortage of staff, the PHC also does not have water, even though it is in a riverine community.
She also said that the frequent transportation of staff from Ugbonla by boat "without life-jackets" has been risky, noting that due to the difficulty of the terrain, the workers run a roster of "two weeks at work, two weeks off work."
Five passengers reportedly died in June in a boat accident between Ugbonla and the riverine communities. Also in 2021, a similar accident claimed two lives. This, the people blamed on negligence and failure of the government to enforce the use of life jackets.
Mrs Adekoya said though solar-powered electricity is installed for the health centre, the system is already weak, adding that the rusty facilities as a result of the sea incursion, also hampers service delivery.
Fees charged by PHC
But the official denied the claim of exorbitant charges by the hospital, revealing that the PHC has been a beneficiary of the Nigerian government's Basic Health Care Provision Fund (BHCPF) since the programme was rolled out in 2019 by former President Muhammadu Buhari.
Mrs Adekoya said the health centre receives N375,000 every quarter, making a total of N1.5 million annually.
The PHC, PREMIUM TIMES' findings revealed, is one of the 195 health centres benefiting from more than N1 billion already released to the state government as BHCPF fund.
Mr Adekoya said the management of the health centre uses the sum to cater for a total of 113 registered vulnerable people in the town, including pregnant mothers, children under five and the elderly.
She, however, confirmed that any patient not on the list of the 113 vulnerable as provided to the centre by the state government is made to pay for the services rendered.
"But we only charge N8,000 for delivery while the patient also provides delivery packs which will contain Oxytocin, tissue papers, mucus extractor, gloves, sanitary pads, among others," she said.
Mrs Adekoya said the facility, however, sells to mothers who do not have the delivery pack.
But the community has queried the list of 113 vulnerable, describing the number as grossly insignificant considering the town's population of more than 10,000.
Another source at the health centre, who does not want to be quoted for fear of sanctions, said the list of the vulnerable was generated from more than 1,000 who registered when the programme started.
"They just sent the list containing only 113 names to the hospital since 2019 or thereabouts, and this is the list we have been servicing since then. Many of them have since relocated due to the sea incursion. Some others have not even been here since we started," the source said.
Ondo govt speaks
The state's Commissioner for Health, Banji Ajaka, who incidentally once served as the chairman of Ilaje LGA before his appointment as the Chairman of the state's Health Management Board (HMB), said Ayetoro PHC is suffering from the consequences of the sea incursion in the community.
The commissioner, however, added that he was aware that workers at PHCs in the state have not been diligent in their work and that some of them were recently disciplined.
Thee commissioner said the state cannot afford to have nurses or midwives in all its PHCs. When confronted with the allegation of avoidable deaths at the facility, he said, "there is really no way you can prevent people from dying."
He also denied that Ayetoro PHC was charging as high as N50,000, saying as a beneficiary of BHCPF, the PHC receives more than N300,000 every quarter.
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"But it is true that the health centre should generate some money to maintain certain things," Mr Ajaka said.
"That health centre (Ayetoro PHC) used to be the most outstanding in the riverine but for the sea incursion. And on the personnel, it is not only the nurses or midwives that make up a health centre because you cannot have nurses or midwives in all the centres. But I will find out if somebody is there as a nurse or midwife. He or she is supposed to be there and work every day.
"And we have some other health workers with him or her. And the CHEW are also trained health workers. In fact, they are the ones trained to work at health centres and we have a lot of them. We are supposed to have a doctor traversing that area but... However, I am also aware that they (PHC workers) have not been doing their work diligently and in the recent time they were served disciplinary action. But we are still investigating them. But if they have issues, the community is supposed to tell us."
When asked about the inadequacy of doctors at the Igbokoda General Hospital, Mr Ajaka said the five that are currently working there are there because of his influence.
Mr Ajaka said; "Igbokoda general hospital used to have one or two doctors in the past. In fact, the maximum they have ever had was three. They are having five now because I am here.
"The fact is that they cannot have more than that number in that place for now. Okitipupa which is a state specialist hospital has about 10 doctors and it is their referral centre. All hospitals in other local governments including Ese Odo, Ilaje, Irele, and even Ore will refer to Okitipupa. Having five doctors in Igbokoda is because the commissioner is from there. If not I would have posted one of them out to other places where we don't have up to that number."
But is the state broke?
Ondo State is the major oil-producing state in south-west Nigeria. Coincidentally, Ilaje LGA is also the only local government area in the state where oil is being explored, which qualifies Ondo to rank among the country's eight beneficiaries of the 13 per cent derivation as enshrined in section 162, subsection 2 of Nigeria's constitution.
Apart from this extra source of funding, findings by PREMIUM TIMES have shown that since 2019 when the BHCPF initiative was introduced by the federal government, the state has received more than N1 billion to support a total of 195 PHCs to cater for the vulnerable as spelt out in the country's National Health Act 2014.
The money, according to the BHCPF guideline, is drawn by the states through four gateways, including the National Primary Health Care Development Agency (NPHCDA), National Health Insurance Agency (NHIA), Nigeria Centre for Disease Control (NCDC), and Emergency Medical Treatment Gateway.
From the NPHCDA alone, Ondo has drawn a total of N567.8 million. But the N27.9 billion accessed by the NPHCDA constitutes only 45 per cent of the total amount released by the government, while the National Health Insurance Agency (NHIA) is statutorily empowered to receive 48.75 per cent of the fund for onward allocation to the various state governments just like the NPHCDA.
But the extra funding sources available to Ondo State do not seem to have reflected in the conditions of the state's health facilities.
