Despite government policies and interventions as enumerated by the state's health commissioner, Tomi Coker, PHCs face challenges in service delivery in Ogun State
When Temitope Akinpelu was in labour one evening in August 2014, she was taken to the primary health centre (PHC) in Ibeku, the community where she lives in Yewa North Local Government Area of Ogun State. But not a single personnel was around at the facility.
The hairdresser, who is in her early 30s, recalled how her husband frantically combed the community for the health worker who was supposed to be on duty. The search took about an hour before Mr Akinpelu returned to the hospital with the health worker on his motorcycle.
And while the patient was being attended to, her relatives who went with her to the hospital were conscripted to run errands for the overwhelmed health worker, including fetching water from their home. The family also provided every item used for the delivery.
However, the delivery became too complex for the health worker who had to seek help from a man said to be a 'doctor' in the community. Mrs Akinpelu eventually lost the child - her firstborn, 24 hours after the delivery.
The baby might have died as a result of prolonged labour which according to the World Health Organisation (WHO) is a common cause of maternal and perinatal mortality and morbidity.
"The experience discouraged me from using any PHC. I have since had three other children, including a set of twins, but they were all delivered in a private centre run by a midwife," Mrs Akinpelu told PREMIUM TIMES
Nine years after Mrs Akinpelu's experience, the situation has not improved at the Ibeku PHC, this newspaper found.
Constructed in 2004 by the administration of former Governor Gbenga Daniel, the hospital is registered on the website of the Federal Ministry of Health as a functional facility. However, it looked like an abandoned structure when our reporter visited it. The doors and bed frames in the ward were broken, mattresses lay scattered on the floor and the entire premises was littered with animal droppings.
One health worker, two PHCs
Near Ibeku in the same Yewa North Local Government Area is another PHC in Agbon-Ojodu. The condition of that facility is a replica of that of its neighbour. It is smelly, with a leaky roof and cracked walls. But at least the health worker on duty was present when our reporter arrived there. However, Remi Onilude, a Community Health Extension Worker (CHEW) who says she has less than one year left in service, also happens to be the official in charge of the Ibeku PHC.
Mrs Onilude said despite the lack of major equipment in the labour room of the Agbon-Ojodu PHC, she attends to pregnant women and refers complicated cases to Oja-Odan PHC or Ilaro town - about 10 kilometres away.
Due to the poor state of the facilities, many residents of the two communities, including pregnant women, have turned to private healthcare providers or travelled many kilometres to the city to access care.
Many other PHCs across Ogun State are similarly hampered by skill and workforce gaps, poor infrastructure and lack of basic amenities, our reporter found in the course of this report.
Required versus available resources
The investigation took this reporter to 14 health centres in four LGAs, including Yewa North, Sagamu, Ifo and Odeda. The findings show the poor state of PHCs in Ogun, especially those located in rural areas. The challenges are inadequate manpower and poor infrastructure.
The Ibeku PHC that Mrs Akinpelu used in 2014 still has no Skilled Birth Attendant (SBA) in 2023. It is one of the majority PHCS in Ogun, and indeed across Nigeria with no SBA.
The National Primary Health Care Development Agency (NPHCDA) recently confirmed that only 463 (1.8 per cent) of the 25,380 PHCs in Nigeria have the required number of Skilled Birth Attendants (SBAs).
This data indicates a huge gap and growing concern over the availability of skilled health workers in primary health centres across the country, which is critical in fighting maternal, perinatal and neonatal morbidity.
Shortage of skilled workers and poor facilities continue to limit service delivery by PHCs in the country, endangering the lives of the people, especially women, and children in rural communities.
According to the NPHCDA, there is an inadequate number and proportion of the various cadres of healthcare workers necessary for the provision of services in the health facilities. The agency, in the publication titled; "Minimum Standards for Primary Health Care in Nigeria," says an ideal PHC should have a minimum of 24 staff.
It recommends that a standard PHC should have one medical officer "if available"; one community health officer (CHO); four nurses or midwives; three CHEW; one pharmacy technician; six JCHEW; one environmental officer; one medical records officer; and one laboratory technician.
For supporting staff, NPHCDA states that PHCs should have two health attendants; two security personnel and one general maintenance staff.
Apart from personnel, NPHCDA also recommends that PHCs should have a well-equipped open ward, labour room, children and female wards, doctor's office and staff quarters, an ambulance for referrals and drugs and equipment for immunisation, preventive and basic curative care.
But virtually all the PHCs visited in Ogun State lack well-equipped laboratories, suction machines for new babies and other equipment needed in standard health facilities.
Realities across other Ogun PHCs
Also in Yewa North, Apetu Health Centre and Oja Odan Rural Health Centre do not have the required personnel, necessary drugs and medical equipment in place.
A nurse at the Oja-Odan centre, who requested not to be named, said "Inadequate personnel is a major issue at the facility. It is demoralising for the few people who have to do more than a week on duty."
The inadequate personnel means the existing hands have to be overworked.
"As you can see, I am not looking well. It is because I have been on a work marathon due to inadequate staffing. Though we have a head nurse and a few volunteers, work is demanding. So I don't blame the health workers who leave the country for opportunities abroad," she said.
At the Apetu centre, the pharmacy is shut and the wards are in a deplorable state.
Samson Olowobese, a resident of Oja Odan, decried the state of the community's PHC, urging the government to invest more in health facilities.
Mr Olowobese said some of the workers have taken advantage of the situation to establish their private midwifery or health centres.
"It is not favourable for our women. Now, most women don't bother going to PHC to deliver anymore. One of the challenges we have here is that the few workers posted here, some have established private hospitals and they don't give their all to the government PHC. So I urge the government to always come and check our health centres unannounced," he said.
At the PHC in Maidan community, Ifo LGA, there are two community volunteers and a nurse.
"We don't have drugs and no refrigerator to preserve vaccines," one of the community health volunteers, who does not want to be named, told PREMIUM TIMES.
The Chairman of the Maidan Community Health Committee, Ashafa Kaseem, lamented the situation at the health centre.
"We don't have enough personnel and our PHC lacks the necessary infrastructure and amenities, including running water. For instance, we had to contribute money among ourselves to get prepaid metres for the electricity supply at the PHC. We still have some debts on our bill."
"We implore the government to come to our aid. PHC should be well equipped and staffed because if not we are endangering the lives of people who can't afford private facilities."
A community leader in Ibeku, Ruth Akiosi, told PREMIUM TIMES that health workers posted to the community do not stay because of the poor state of the facility - the leaking roofs and lack of necessities like running water and electricity.
A slightly different story
Unlike in other PHCs, the facility in Olambe, another community in Ifo LGA, has six workers, including a nurse, midwife, and CHEWs. But it too does not have the required medical equipment and most of the available ones are no longer functioning. The delivery couch in the facility's labour room and other major amenities are also in poor condition.
The only patient our reporter met at the facility, Funmilayo Olayanju, had just delivered a baby at midnight. She commended the workers but lamented the state of the wards and the beds.
"The delivery was smooth. I paid N20,000 but I cannot use the baby bed because it is bad and I have to share my own bed with him," she said.
Taiwo Taiwo, a pathologist and member of the Olambe Health Committee, a community initiative, said manpower is not enough and the workers available cannot function optimally without the right resources.
"They don't have enough tools. I know the officer in charge here is very skilled but if they have a case they can't handle they look for a doctor or transfer the patient," she said.
In Ajuwon, also in Ifo LGA, residents complained about the unavailability of a doctor and the "unfriendly" attitude of the staff at the local PHC.
Kemi Adedotun, a retailer near the health facility, said the PHC can deliver basic services like vital checks but not anything serious.
"It is the only PHC we have in the whole of Ajuwon and even people from Alagbole also come here. But the place is too small and doesn't have a standby doctor," she said.
Another resident, who identified herself simply as Faith, spoke of her experience when she took her one-year-old son to the PHC after neighbours "helped revive him from febrile convulsion."
A febrile convulsion is a seizure that occurs in children aged between six months and six years when they have a high fever.
Her experience showed that the health officials at the public facility were more concerned about money than treating the sick toddler.
"It was in the night, they insisted they must see an alert before they could attend to him," Mrs Faith told this reporter. "That was my first time there and it was too bad that they didn't even attend to me until they confirmed the alert."
A mother of three, Grace Oduola, another retailer with a shop close to the PHC, said she gave birth in the facility seven years ago but that was the last time she visited it.
"I won't even go there in an emergency. One of my customers lost one of her twins, she was delayed and when they eventually transferred her to a general hospital, she lost one of the children," she said. "They don't have a specialist doctor that can attend to someone. When I wanted to give birth, there wasn't enough personnel."
Work environment
Out of the 14 PHCs visited in the state, only those located in Obantoko and Osiele in Abeokuta, and in Makun, Osete, and Ayegbami in Sagamu are in good condition and have some personnel, befitting buildings, and a good work environment.
At Osiele PHC, the officer in charge, Taiwo Alebiosu, said the PHC has about three nurses, including midwives, a permanent doctor, a lab scientist, four pharmacy technicians, two CHEWS, two health attendants, a gardener, and a security officer.
"For the past three weeks, we have had about 20 to 25 deliveries. If we notice that they need surgery, we refer them to a general hospital or Federal Medical Centre, Abeokuta, to prevent severe complications," Mrs Alebiosu said.
"Women come from about 52 villages for care and they are registered immediately because we don't want them to patronise private birth attendants who are mostly quacks. We also educate them on immunisation and we administer the required vaccination for babies."
At Obantoko PHC, one of the senior nurses who spoke with the reporter urged the government to recruit more people and provide more equipment.
Access to healthcare
Many residents who spoke with PREMIUM TIMES complained about the deplorable state of roads in major parts of Ogun State, especially in Ifo, Yewa North, and some places in Abeokuta; and the impact on health services.
Taiwo Clement, a teacher In Ibeku, said when pregnant women with complications are referred for surgery, it is always difficult to get them there due to the deplorable condition of the main Ibeku to Oja Odan road.
He said the lack of an ambulance in the community makes it difficult for residents to access quality health services.
"We have a huge population here and so if there are complications, an ambulance can help to the venue for surgery so we don't lose the patient," Mr Clement said.
Similarly, the roads across Maidan, Ajuwon and Lambe are also in deplorable conditions, making it difficult for the PHC workers to refer patients outside the communities.
Demola Adeagbo, a community leader in Maidan, blamed the condition of the road for many auto accidents."Residents opt for quacks when PHC can't serve them and the road networks are also bad," she says.
Ogun govt reacts
When PREMIUM TIMES contacted the Executive Secretary of Ogun State Primary Health Care Board, Ogunsola Elijah, and the state's Commissioner for Health, Tomi Coker, both officials refused to speak on the specific situations in the PHCs visited. Instead, they highlighted the efforts of the state government towards bridging the skills and workforce gaps at PHCs in the state.
In a telephone interview with this reporter, the commissioner said there are 531 registered PHCs in the state, but that "there are a lot of others that aren't recognised because they were built by the communities themselves without consultation with the government."
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On inadequate personnel in PHCs, Mrs Coker said the government recently interviewed 80 medical doctors, 20 of whom were engaged and have resumed work.
"The state government is not unaware of the human resource for health gap which is not peculiar to Ogun State but a national menace. The state is tackling the menace through the constant recruitment of doctors, midwives/nurses, and CHEWs, who are paid from schemes implemented across our health facilities such as BHCPF and the Expanded Midwifery Scheme.
"There is constant attrition of health workers under the above-mentioned scheme but the state government ensures constant replacement of such workers every six months."
Mrs Coker added that to ensure that the effect of the brain-drain syndrome on the health system is limited, the government started a training programme for community midwives, who she says will be trained for two years at the College of Midwifery.
The commissioner said the state government has also embarked on massive infrastructural upgrades of PHC facilities across the state using a phased approach with at least 40 per cent of health facilities in each LGA already renovated.
She said other interventions implemented to provide qualitative health service delivery to citizens in the state include: "Equipping of renovated PHC centres and the deployment of electronic medical records across the three tiers of the health sectors for easy referral of patients."
Implication on Residents
On the inadequate number of Skilled Birth Attendants in the PHCs, a professor of Public Health, Tanimola Akande, said the implication is that access to quality health care will be very low.
"It is therefore a long road towards achieving Universal Health Coverage in Nigeria. The poor health indices may take a long time to reverse," he said.
Onaeko Wemimo, a public health expert, said medical officials are reluctant to work in rural areas because of a lack of incentives from the government.
Mr Wemimo emphasised the importance of SBAs in PHCs to detect birth-related problems in women early when the situation can still be controlled.
"But with the trend in the preventive measures of childbirth, lack of infection prevention measures exposes them to infection and unavailability of certain services such as weighing of the baby, which is the precondition to many actions to be taken medically."
He said 1.8 per cent of PHCs having SBAS "is an alarming percentage as research has shown that countries with high rates of SBAs have lower rates of maternal mortality, while those with lower SBAs have higher rates of maternal mortality."
For Sakeenah Odunaye-Badmus, a family physician at LASUTH and former medical attendant at Agege Primary Health Centre, brain drain in the sector is a contributing factor to poor PHC services in the country.
"We need to understand the fact that a primary health centre is the closest to the grassroots and the closest to the community. People will not walk into a teaching hospital because of some headache or malaria and the primary health centre is supposed to speak to this," Mrs Odunaye-Badmus says.
