— Uchenna Igwe
A federal government initiative aims to improve rural healthcare services in Akwa Ibom state, but the state governor’s delayed assent denies citizens access to benefits.
“Mma nurse, please help me,” Eno Francis Udo bellowed, as she stormed into the Primary Healthcare Centre (PHC) in Okon, Essien Udim Local Government Area of Akwa Ibom State, carrying her son, Peter. A nurse on duty rushed to Mrs Udo, who had now found a cushion on the wooden bench, clutching her infant.
“He was hot and feverish last night and I gave him paracetamol, but it became worse this morning, with coughing,” she said, panting. The nurse whipped out a thermometer, checked the child’s temperature and after confirming he had been fed, administered an antimalarial injection while his mother held him steady.
Over the next two days, five-year old Peter would receive injections and drugs to aid his recovery from malaria, at no cost. However, his mother would have to cater for other drugs that were prescribed, including a cough suspension.
“ACT and treatment for malaria is free here, so patients do not have to pay. But for other drugs, they have to go and buy themselves,” Ima Ukpong, officer-in-charge (OIC) of PHC Okon told TheMail. Most of the free drugs were donated by the US President’s Malaria Initiative (PMI) through the USAID, and a nongovernmental organization, Jhpiego.
When they can, PHC staff stock up pharmacies with drugs and essentials from their personal pockets, in a bid to make the drugs readily available for patients at a cost. Apart from availability, patients who spoke with TheMail said it saves them from risks of buying counterfeit drugs.
“Most times it is better to buy the drugs at the health centre because you are sure that it is original instead of going by yourself to the chemist or pharmacy and buying fake,” Esther Monday said.
The situation is the same across the state. TheMail’s visit to centres PHCs in Essien Udim, Uruan, Abak, Eket and Esit Eket council areas revealed that apart from antimalarial drugs and antiretrovirals (ARVs), patients bear the burden of the cost of drugs and other medical treatments, despite the implementation of the Basic Healthcare Provision Fund (BHCPF) in the state.
The federal government introduced BHCPF under the National Health Act (NHAct) 2014, to provide free minimum basic healthcare to the most vulnerable populations through Primary Health Centres (PHCs) across Nigeria, and reduce personal out-of-pocket payments and associated financial risks, through health insurance.
The initiative is funded with a minimum of 1 percent of the Consolidated Revenue Fund (CRF), grants from international partners and other donors. The fund is disbursed via three gateways: 50 percent for the provision of Basic Minimum Package of Health Services (BMPHS) to citizens via the National Health Insurance Scheme (NHIS), 5 percent for treatment of medical emergencies and 45 percent to improve PHCs service delivery through the National Primary Health Care Development Agency (NPHCDA).
Of the 45 percent, 20 percent will serve the provision of essential drugs, vaccines and consumables for eligible PHCs, 15 percent for the maintenance of PHC facilities and equipment and 10 percent for the development of PHC staff.
For the NHIS Gateway, citizens and healthcare providers are expected to be enrolled as beneficiaries of the BHCPF, to enable them access preventive, protective, promotive, curative, and rehabilitative health services at designated PHCs. However, these health services shall be funded through the State Health Insurance Agencies and State Health Insurance Schemes (SHIA, SHIS), at an agreed premium.
In 2018, President Muhammadu Buhari flagged-off the Basic Health Care Provision Fund (BHCPF) with an appropriation of N55 .1 billion from the Consolidated Revenue Fund (CRF), in addition to $2 million from the Bill and Melinda Gates Foundation, $20 million from Global Financing Facility (GFF) and £50 million donated by the Department for International Development (DFID) to cover 2018 – 2023.
Akwa Ibom Governor’s Delayed Assent Frustrates Access to Basic Healthcare
Despite the federal government fulfilling its commitment to protect citizens from expensive out-of-pocket payments for healthcare through the BHCPF and National Health Insurance Scheme (NHIS), sadly, the Akwa Ibom state government has failed to keep to its own part of the bargain.
In June 2017, the Akwa Ibom State House of Assembly (AKHA) passed into law a bill for the establishment of the Akwa Ibom State Health Insurance Agency (AKSHIA) and Scheme. Onofiok Luke, the then speaker who co-sponsored the bill, said it was conceived because citizens of the state deserve access to good and affordable healthcare services.
“Indeed, we cannot guarantee sustainable development until we are able to holistically guarantee improved healthcare services through making available laws that will guarantee government’s insurance in the health sector. It is for this reason that this house thought it imperative to create a health insurance scheme and an agency to manage the scheme”, he said.
But five years later, the agency is yet to take-off following a delayed assent to the bill by the state governor, Udom Emmanuel.
Dismayed by the development, civil societies organization (CLO) in the state had urged the House of Assembly to override the governor and pass the bill into law for the benefit of the state, invoking the provision of Section 100(5) of the Constitution of the Federal Republic of Nigeria, 1999 (as amended).
Findings by TheMail showed that huge budgetary allocations had been made for the establishment of the state Health Insurance Agency by the Akwa Ibom State government from 2017 when the bill was passed till date, to the tune of N1.8 billion.
Specifically, the sum of N700 million was budgeted as a take-off grant for the agency in 2017, N500 million in 2018, N250 million in 2019 and N50 million in 2020. The project got an allocation of ₦200 million in 2021 and got ₦100 million in 2022.
Efforts to obtain details of releases in those years were not fruitful. A freedom of information (FOI) request directed to the Akwa Ibom State Ministry of Health, was not responded to.
Coordinator of the National Health Insurance Authority (NHIA) in Akwa Ibom State, Williams Ebiokobo, said the BHCPF designed to benefit the aged, physically challenged, pregnant women, children under-five and people in rural communities across the state, had been left untapped due to the non-existence of a state health insurance agency in the state – a condition required for enrollment of citizens in the scheme.
“From the establishment of this agency, the government will pay its counterpart funds or through equity funds, then indigenes will have access to our health facilities even if they are out of the state,” Mr Ebiokobo said.
While citizens in Akwa Ibom continue to wait on their governor’s assent, their compatriots in states like Niger, Jigawa and Nasarawa are enjoying access to free drugs, medical treatment and other benefits of enrollment on the BHCPF, following compliance by their state governments.
PHCs Wear New look with BHCPF
While the Akwa Ibom governor’s delayed assent to the AKSHIA law continues to deny citizens of access to free health services under the BHCPF, the fund has contributed to revitalizing Primary Healthcare Centres in the state, particularly with improving infrastructure through the NPHCDA gateway.
Multiple reports have documented the decrepit conditions of PHCs across the state, bearing tales of insufficient drug supplies, understaffed, ill-equipped and dilapidated facilities, occasioned by neglect, lack of political will and poor health financing.
However, since its launch in Akwa Ibom State in the second quarter of 2021 and subsequent disbursement of funds in the 2022, about 231 PHCs have benefited from the fund, receiving about ₦611,000. In the five LGAs visited, beneficiary PHCs were observed to have received facelifts.
At PHC Nwaniba in Uruan LGA, renovation works have been carried out courtesy of the Fund. Staff replaced the bad doors and windows, repainted the building and repaired the PHC’s borehole. A member of staff, Mfon Charles, commended the government for introducing the scheme.
“The doors and windows which were bad before have been changed and the borehole that was not working before,” she said. “As you can see the building was also repainted to make it look better.”
The Fund served a similar purpose at PHCs Ekpene Ibia and Ndon Ebom, covering the cost of painting, repair of ceilings that were previously falling off and replacing the rickety wooden doors and windows doors with metal ones to improve on security at the facilities. It also facilitated the purchase of a Sumo pump and a new signpost at PHC Ekpene Ibia.
“The fund we got has really helped to fix many of our needs here. Like the former door that fell off one morning after I had night delivery, we have changed it and others to iron doors which are more durable to protect the vaccine cooler, solar batteries and freezer from theft,” Anthonia Attah, who heads the facility, said.
Before the advent of the BHCPF, only the PHC Adiasim was in good shape in Essien Udim LGA, having been recently demolished and rebuilt to standard by a philanthropist in the community, Engr Oliver Ebong, in 2018. Mfonobong Sam, the OIC of the PHC, said she did not have full knowledge on how funds from the BHCPF were utilised as she was “just posted there in March 2022”.
The BHCPF is also responsible for the recent renovation of the previously dilapidating structures at PHC Odoro Ikot I and II – the other beneficiary-PHCs in the Essien Udim LGA. Catherine Icho, the OIC, thanked the government for the initiative, adding that it had improved conditions at the PHC.
“If you see this health centre before, the roof was leaking and falling off, before I used the money to buy zinc, ceiling and the new doors,” she said.
She lamented shortage of staff, lack of water and power supply at the facility and appealed to the Rural Electrification Agency (REA) to repair the solar power generator it donated to the facility.
In Abak LGA, BHCPF has equally brought succor to beneficiary-PHCs. At the operational base, Ime Udo, the monitoring and evaluation officer, commended the government for the Fund, as it had improved the condition of many of the PHCs. He however said that “more needs to be done”.
Blessing Ime, who used to attend antenatal care at PHC Ibanang Ediene, expressed her delight over the renovation at the PHC.
“Before we could not use the toilet when we come here, but now they have repaired it,” she said. The broken roofs and ceilings that previously bedevilled the PHC in 2021, had also been replaced, courtesy of the BHCPF.
Head of facility at PHC Midim, Itohowo Duncan, was also full of praise for the BHCPF. Through the Fund, the facility, which had been ravaged by termite, had been rescued.
“The fund has helped to transform this place. We have replaced the doors and the wood in the ceiling that were destroyed by termite and fumigated the place from the ceiling up and down,” she said. A generator was also purchased to provide power supply at the PHC, putting an end to the long years of borrowing the village head’s generator.
There were signs of recent renovations at PHC Afaha Obong, including the newly installed gate, windows, iron doors, ceilings and electrical equipment. The OIC, Mfon Nseyo, said “the fund has assisted in rehabilitating the PHC.”
From Ikot Okudomo to Ikot Ukpong, Mkpok and Afaha Atai, there are tales of rehabilitation of PHCs in Eket LGA, courtesy of the BHCPF.
TheMail observed that all the beneficiary facilities had been renovated, wearing the yellow and green painting, a common characteristic among them.
Nwaiwu Florence, a patient at PHC Idua in Eket LGA, acknowledged recent changes at the facility courtesy of the BHCPF intervention.
“The last time I was here for my vaccine last year, this place was not like this. I noticed that the broken floors, bad roof, doors and windows have been worked on. They have also purchased more seats,” she said.
At the PHC Idung Iniang, the OIC, Mfon Batta, urged the government to sustain the project so that some of the challenges facing the facilities can be a thing of the past.
“This is the first renovation of this PHC since it was built. If they can continue like this before you know, many of the issues we have been having will be solved,” she said.
The story is no different for PHCs in Esit Eket LGA. TheMail found that all the beneficiary-PHCs had received various levels of renovation, and could be easily identified by their recently painted yellow and green walls.
The PHC in Etebi was doubly lucky. A new building was recently constructed by the Minister of the Niger Delta, Godswill Akpabio but the old building in the facility also got renovated through the BHCPF.
Charlie Hannah, the head of the facility said the PHC had been selected as a beneficiary of the BHCPF “before the new building was constructed by the minister.”
Unlike many of its kind, the PHC has water and power supply, just like the PHC Iko-Effak Akpautong, another beneficiary of the BHCPF.
Apart from the renovation of the building and purchase of furniture, a new generating set was recently purchased for the PHC Ikpa Town. According to the OIC, Ekaette Bassey, the decision to make the purchase was made to tackle the facility’s long-drawn challenge with epileptic power supply.
Findings by TheMail revealed that the development strides at the PHCs is a product of the synergy with their respective Ward Development Committees (WDCs) – a group of community members selected to support heads of the PHCs in administration of the Fund.
There is also a culture of record-keeping for accountability by the heads of the PHCs. Each maintains a folder where all documents – including payment receipts, pictures of PHC previous condition and bank statements – are kept.
Selection of Beneficiaries Brews Controversy
The selection of PHCs to receive the Fund in the state has sparked some controversy, stemming from the inequitable distribution of beneficiary-PHCs across the LGAs. TheMail gathered that some LGAs received more beneficiaries, while others had fewer.
In Uruan LGA, for instance, only three out of nine PHCs were selected to receive funding. Of the 19 PHCs in Essien Udim LGA, only three were selected as beneficiaries, while 10 out of 14 PHCs were selected in Abak LGA. In Eket LGA, 11 of the 15 PHCs benefited from the Fund, just as nine out of the 13 PHCs in Esit Eket LGA were selected.
The criteria employed in the selection of beneficiaries remains a mystery to many.
“It is unfortunate. Here in Essien Udim, only three out of almost 20-something facilities were selected. So, I wonder what criteria they used in selecting the facilities. How come other local governments have more beneficiaries and we have just three?” one of the nurses, queried.
There are also concerns that some dilapidated PHCs critically in need of intervention, were left unattended to.
A visit to the non-beneficiary PHCs across the five LGAs revealed that most of the facilities are grossly understaffed, ill-equipped and dilapidated.
Facilities like PHC Mkpatak and the PHC Operational Base, Ikot Ebak in Essien Udim LGA, reek of dilapidation and long years of neglect, especially PHC Ekpenyong II which is totally in shambles.
In Abak LGA, the ceilings of many of the wards and offices at the PHC Operational Base are prevented from crumbling with the support of sticks, just as the health post at Abak Itenge requires urgent intervention.
There is a need to provide intervention for PHCs in Esit Urua and Ikot Abia in Eket LGA, which operate from single classrooms in schools – Apostolic High School Esit Urua and Government Primary School Ikot Abia, respectively.
Others requiring attention also include the PHCs Odoro Nkit, Ntak Inyang and Akpasong in Esit Eket LGA.
Government Revenue Burden Threaten PHCs
Despite efforts to improve rural healthcare with initiatives like the BHCPF, findings by TheMail revealed that PHCs across the state are burdened with the mandate of revenue generation by LGA councils.
PHCs are tasked to remit revenues to their respective LGA councils. Councils maintain revenue registers at every facility, with which PHC staff are mandated to record the details of every patient and the fees collected. Charges differ across LGAs. At PHCs in Uruan LGA, adults pay ₦100, children ₦50, while pregnant women pay ₦100 and ₦200 after delivery. It is slightly different for PHCs in Essien Udim LGA, where pregnant women pay ₦500 before and after delivery, and Eket LGA, where adults are charged ₦50.
Revenue collector’s registers seen by TheMail showed evidence of revenue payment by PHCs across the state. For instance, between April and June 2022, PHC Nwaniba remitted ₦5,070 to the Uruan LGA council, and ₦1,910 in July. In August 2022, Essien Udim LGA received ₦4,050 as revenue from PHC Odoro Ikot.
The story is largely the same in all the PHCs across the five LGAs visited.
It was also found that despite their contributions to revenue, PHCs receive no support from LGA councils in form of imprest or subventions to assist the facilities for better service delivery, instead, staff often rely on personal contributions and sometimes, donations from kind-hearted members of communities, to run the facilities.
We are Doing our Best- Government
Chairman of the Akwa Ibom State Primary Healthcare Development Agency (AKSPHCDA), Dr Martin Akpan, said the poor state of the PHCs resulted from long years of neglect under the control of the local government councils. He, however, noted that the state governor, Udom Emmanuel, was doing his best to revive the primary healthcare system in the state to deliver quality healthcare to citizens.
“We must recognize the fact that these problems did not just start overnight. It is a product of neglect over the years. We just have to be thankful to the current governor, Deacon Udom Emmanuel, who has given visibility to the primary healthcare sector. Before now the PHCs were under the local government system. Everything was in shambles.
“It was just a couple of years ago that the FG decided to enact the National Health Act, which shifted the responsibility of the PHCs from LGAs to the state government under the provision of the Primary Health Care Under One Roof (PHCUOR). We are still in the process of the migration from the local government service commission to the state agency which will take care of these problems,” he said.
Dr Akpan said the health of Akwa Ibom people was a strong priority for the governor which informed his decision to set up the state primary healthcare development agency to give attention to the PHCs, assuring that the governor was committed to setting up the state health insurance agency in no distant time.
“Health insurance is a part of the BHCPF. Now we have 45% (NPHCDA gateway), we still need the 50% which is even more than what we have already and you know his excellency understands and is working on it. I think what is left now is the nitty-gritty of setting up the agency so that they can have their own board and management. We are reminding the governor and from the feelers we are getting, I don’t think it will be long from now because everybody knows the importance of health insurance because it is very close to the governor’s heart,” he said.
He revealed that plans were underway by the state government to engage quality health personnel to address the issue of staff shortage. He said the AKSPHCDA was not involved in the selection of the beneficiary-PHCs, but noted that PHCs that were not previously captured, especially the most affected ones, will be considered in the second phase.
*This report is supported by the International Budget Partnership and the International Centre for Investigative Reporting (The ICIR)