Ebuka Offor, a petty trader who lives with his wife, Ada in the Umuchima community of Ideato South LGA of Imo State wakes up at about 1 am to the groaning of his wife who was expecting their first child. His first point of call was the Primary Health Care Centre (PHC) close by. Ideally, this local infirmary should provide Ada with comprehensive, affordable community-based care.
So, Ebuka propped his young wife all the way to the health centre only to meet the center closed. He was informed by people in the neighbourhood that the centre would not be opened till 9 am. He learns also that even when it finally opens, there is no guarantee that there will be a medic around at that time to attend to his wife in labour. The troubled couple were advised to seek attention elsewhere.
Mr Offor, has to choose between traveling with his pregnant wife for more than 5km to seek medical attention and resorting to local remedies with its accompanying risk on both mother and child. This is the plight of 49.66% of Nigerians living in the hinterlands where they lack access to basic health facilities.
Primary health care is the foundation of the National Health System. It forms the entry point to health care service delivery that comprises of promotive, preventive, curative and rehabilitative services. Though the PHC centers are owned and funded by the Local Government Areas (LGAs), their services have also been jointly managed by the state ministries of health, ministries of local government affairs, the Local Government Service Commission, the Civil Service Commission, the Ministry of Budget and Planning, State hospitals Management Boards, faith-based organizations, non-governmental organizations, zonal and state offices of the National Primary Health Care Development Agency, and the Federal Ministry of Health.
In order to address the numerous challenges of health care accessibility and to record progress towards the attainment of SDG goals, Nigeria adopts the ward health system, where each ward comprising 10,000-30,000 people have a health center that serves as a first reference point before accessing the health post located in each section or group of villages.
However, the current state of the PHC system in Nigeria is appalling. Only about 20% of the 35,000 PHC facilities across Nigeria meet the standard of having more than 25% of the minimum equipment package. The deplorable state of primary health care in Nigeria can obviously be attributed to poor funding at the state and local government levels. This is evident in the allocation of state and LGA budget to health being below 15%.
In the 2020 budget, only 4.14% of the proposed budget is allocated to health. This is not enough to meet the per capita health expenditure of US$ 34 recommended by the Macroeconomic Commission on Health. Besides, in an earlier Dataphyte analysis, 2020 budget for health implies that each citizen will get only N2,000 worth of healthcare service from the Federal Government coffers. Thus, the National Primary Health Care Development Agency still considers the resource allocation to the health sector at less than 5% of the total budget as unsatisfactory, being less than the WHO recommendation and the 15% Abuja Declaration target.
Though the total health budget seems to be increasing annually, from 250.06 billion naira in 2016 to the proposed 427.3 billion in 2020, it is clear that the increase all goes to the recurrent budget and at a detriment to the capital allocation that sees to infrastructural investment in health. At the LGA level, for instance, the available fund is meant to provide efficient health care services, but these financial allocations do not cater for much beyond the payment of salaries, with little or no amount left to sponsor health programs and outreach services.
The frequent problem of untimely approval of the budget and underutilization of funds that plagues Nigeria’s public sector is also seen in primary health care. In 2011 for instance out of the N63.4 billion budgeted for health (61.2%), N38.8 billion was released and only N26.02 billion (67%) was utilized, leaving a deficit of more than half of the budgeted amount.
In addition to these, a critically low investment in PHCs results in poor staffing of medical personnel, inadequate medical supplies and equipments at PHC facilities. Most PHC facilities in Nigeria lack the capacity to provide essential health-care services due to poor staffing and poor distribution of health workers, poor quality of health-care services, poor condition of health infrastructure, and lack of essential drug supply.
It is not a hidden fact that most of the PHCs are not adequately staffed as most of the health professionals shun the rural areas. The reason is not far-fetched. These areas lack the basic infrastructure that makes life easy and functional. Furthermore, these professionals don’t want to leave their families as well as some social responsibilities behind to work in rural areas.
Only a few health workers will want to go to health centers or posts in interior villages commuting on bad roads, working under poor hospital infrastructures, treating patients without access to needed drugs and essential health supply, and struggling with financial difficulties themselves due to lack of proper monetary motivation from their salaries.
These factors have a negative impact on job satisfaction, staff performance and health service delivery, and consequently lead to high staff turnover.
The difficult working conditions and high level of job dissatisfaction obtained by federal government employed health workers who most times are posted to PHC centers have only succeeded in increasing the number of medical emigration drastically, thereby increasing the amount of money Nigeria loses annually to medical tourism.
This is detrimental to the delivery of health care services locally, such as: control of communicable diseases (malaria and sexually transmitted infections including HIV/AIDS); child survival; maternal and newborn care; nutrition; prevention of noncommunicable diseases; health education and community mobilization.
While Nigeria’s deteriorating macro-fiscal context partly accounts for low levels of investment in health, even in good economic times, investments in health have been consistently lower over the last two decades compared to countries of similar economic status (World Bank, 2017).
Despite the government’s low investments in health, development partners, notably, WHO, the United Nations Children’s Fund (UNICEF), the World Bank, United Nations health agencies, the Partnership for Transforming Health Systems phase II (PATHS2) of the United Kingdom, Department for International Development (DFID), and FHI 360 of the United States Agency for International Development (USAID) continue to make notable investments and provide guidance to states on how to improve PHC service delivery through PHC under one roof.
To achieve President Buhari’s desire that Nigerians stop travelling abroad for medical treatment, the government needs to begin to reduce the healthcare deficit at home with concerted efforts to make the PHCs work. This will entail seeing to the prudent management of public health funds and foreign aids, provision of essential drugs and medical equipment and the constant electricity to power them. The mistreatment of the medical professionals also needs to be stopped immediately.
The unknown fate of Ada Offor who has fallen in labour and her unborn child at that local Primary Health Care centre is that of the majority of women and children in Nigeria. Ebuka Offor’s fear is the fear of the everyday Nigerian as they arrive at a public hospital building that offers no help for their low income pocket. This pain, panic and loss will continue to be the lot of the electorate if the government remains indifferent to their miseries.