By Arinze Chijioke
After Enugu State was adjudged the second highest performing state in primary healthcare service delivery in Nigeria between 2019 and 2021 by ONE Campaign, an international organization, Arinze Chijioke travelled to communities across the three senatorial zones in the state to investigate the state of primary healthcare. His findings, which seem to question the criteria for the award, are presented in this report.
One evening in 2019, Eze Clementina, the Officer in Charge at the Amalla Orba Comprehensive Health Centre in Udenu Local Government got an emergency call from the hospital. A resident of the community, Chiamaka Sunday (not real name) had given birth and had retained placenta – which occurs when the placenta or parts of it remains in the womb for more than 30 minutes after childbirth.
Clementina, who was a nursing midwife at the time had returned to her house in Igboetiti, another local government after the day’s work when Sunday got into labour and was brought to the facility by her husband.
“Quickly, I left my house and when I got to the hospital, I did manual removal of the placenta but she had already lost some blood and was weak, ”she said. “It would have been different if I lived inside the hospital.”
To get to the Amalla Orba health facility where she works, Eze spends more than two hours from Igboetiti. She said it should not be more than a one-hour drive if the road was good.
Decades ago, the story was different. Workers at the hospital had a quarter where they lived and always attended to patients at every time of the day. Members of the community, especially women always came for ante natal, safe delivery and other infant health services and treatment.
Now, all of that have changed. The facility, which according to an elder in the community, Odoh Festus, was constructed in 1979 has become a shadow of its old self, with dilapidated structures and leaky roofs and a complete lack of basic health facilities.
Eze has managed to sleep at the facility, on a rickety bed a few times. But she finally stopped after she saw a snake one evening when she came to work. It had jumped down from one of the doors immediately she opened it. Now, nobody lives at the facility.
In August this year, ONE Campaign, an international organization that is said to be non-partisan, non-profitable and fights extreme poverty and preventable diseases particularly in Africa recognised Enugu State as the second highest performing state in primary healthcare service delivery in Nigeria between 2019-2021.
To arrive at the decision, One Campaign worked with other notable organisations such as the National Advocates for Health, Nigeria Health Watch, Public Private Development Centre, World Bank and other partners.
Presenting the award of recognition to the Executive Secretary, Enugu State Primary Healthcare Development Agency (ENSPHCDA), Dr. George Ugwu, the Country Director of One Campaign in Nigeria, Stanley Achonu, was quoted as saying that Enugu State had done EXTREMELY WELL in Primary Healthcare Service Delivery to deserve the award.
Ugwu claimed that the governor, Ifeanyi Ugwuanyi, has since 2015 “consistently made primary healthcare service delivery a priority in line with his rural development agenda and that the positive results of his administration’s huge investment in the health sector are becoming obvious and being cherished at national and international levels.”
However, while ONE CAMPAIGN commended Ugwuanyi for making primary healthcare delivery a priority of his administration, access to primary healthcare yet remains a challenge across communities in the state, especially for pregnant women who must travel several kilometres.
What is most worrying is the fact that the roads leading to some of these communities are deplorable and before women get to the hospitals, they have complications, either resulting in their death or that of their babies.
In communities such as Amalla Orba, where there are existing health facilities, there is dearth of medical supplies and personnel to attend to people. In other communities, there is a complete lack of healthcare facilities.
No patient visits Amalla PHC anymore
The last time Eze attended to a pregnant woman at the health centre was in 2020. That night, she recalled how water started dropping on the bed inside the labour room-where the woman lay- immediately after she was delivered of her baby and it started raining. She had to be taken to another location.
Since then, pregnant women have stopped coming to the facility. They now visit private hospitals where they pay exorbitant prices for healthcare, or the newly constructed type-3 Primary Healthcare Centre located some miles away from the community where they battle with crowd.
“You don’t expect any woman to come to a place where she would be beaten by rain after giving birth,” Eze said. “Each time we come to work, we stay for some time and leave because there is nobody to attend to, nothing is working here.”
The Amalla Orba health centre – which only has five registered nurses – has since been overtaken by bushes. Its structures are dilapidated, with broken ceilings, faded paints and broken windows. The toilets are in bad condition and workers often use surrounding bushes when they feel a need to pee or poo. To clear the bushes, they contribute N12,000.
Additionally, there is no power supply, even though a solar power project that is supposed to provide power to the hospital is located right there. There is no water, except when it rains.
Inside one of the rooms, there is a refrigerator that is supposed to be used for the storage of drugs. But it does not function and so, whenever it is time for Immunization – which is the only activity that goes on at the centre – and there are medical supplies, Eze stores them at the Ohom Orba model primary health Care and only gets them when the need arises. The facility does not have a perimeter fence, making it easy for everyone to access it at any time.
Festus said that workers and the community had written on several occasions to the government demanding a revamping of the facility to meet the health needs of the people. Yet, nothing has been done.
He said that the government needs to renovate the health centre, provide medical supplies and personnel because it will serve thousands of households giving that it is located at the centre of Orba community.
“Many women especially would prefer to come to the health centre because that is where they will be taken care of better without paying through their noses unlike at private establishments or the new health centre where they have to deal with the challenge of crowd.”
Enugu govt and pledge to revive primary healthcare
Over the years, the Enugu State government has spent billions of naira in revamping primary healthcare centres across the state. However, access to healthcare remains a challenge for many residents in the state.
In 2016, the state government benefitted from the Saving One Million Lives Initiative Program-for-Results (PforR) Project, a flagship of the Federal Government which was conceived in 2012 but repackaged in 2015 following a $ 500 million credit from the World Bank.
The programme is intended to save the lives of mothers and children by increasing access to utilisation of evidence-based, cost-effective and high impact maternal, child and nutrition interventions in Nigeria.
With the fund, the Enugu State Government promised to make sure that rural people had access to quality healthcare at their doorsteps by provide at least one PHC facility at each ward across the State. Sadly, there is still the prevalence of non-functional healthcare centres across communities in the State.
In 2019, Executive Secretary of Enugu State Primary Healthcare Development Agency, (ENS-PHCDA), Dr George Ugwu, said that the State Government had selected one PHC facility in each of the 291 wards in the state for renovation and upgrading to enable them to provide quality and affordable healthcare to the people. This was after the government paid its N100 million counterpart fund for the Basic Health Care Provision Fund (BHCPF) to enable the state benefit from the initiative.
Ugwueme PHC under lock and key
Travelling to Ugwueme, a community in Awgu Local Government is always a bumpy ride. The road leading into the community can do with some repairs, making it difficult for cars and motorcycles to travel on it, especially when it rains. Oftentimes, motorcycles get stuck in the mud as their owners try to navigate the bad road.
This is exactly what members of the community endure at times of health emergencies as the community’s healthcare is not functional. Constructed nine years ago, the Agulese Ugwueme health centre does not serve the people. The government hardly sends personnel, medical supplies and equipment to attend to the health needs of the people.
Oftentimes, pregnant women are driven on the terrible road to the University of Nigeria Teaching Hospital, Ituku Ozalla, which is about 5 kilometres away but remains the closest standard health facility to the community.
As a result of lack of access to healthcare and the distance to the UNTH coupled with poor state of the road leading to the community, several women have lost their lives due to complications during pregnancy.
“A journey from UNTH to Ugwueme that should ordinarily take about 20 minutes takes more than 45 minutes because the road is bad,” said spokesperson of the Global Ugwueme women initiative, (GUWI), Uzoamaka Ogor.
She explained that the health centre in Ugwueme has been under lock and key for years and that the predominantly agrarian community has written to the government and members representing the area. Yet, nothing has changed.
President General of Eziobi, one of the two sub-communities that make up Ugwueme, Nelson Okoroafor, said that the people of the community feel abandoned and un-cared for by the government.
In 2017, an erosion control project was nominated by the Senator representing Enugu West Senatorial District, Ike Ekweremadu, with a budget of N40 million. Sadly, the project which would have seen the construction of the road under the supervision of the Anambra Imo River Basin Development Authority (AIRBDA) has been abandoned.
“Whenever we went to meet him about the road, he always promised to intervene immediately,”Ogor said.
In 2019, after women in the community noticed that nothing was happening, they started contributing as low as N200 monthly to fix the 5km road. Since 2019, they have raised over 40 million through contributions, borrowing and other donations.
With what money they raised, the women bought bags of cement, trips of sand and stones and together, they have been working to fix bad portions of the road. Ogor said that Member representing Aninri/Awgu/Oji River at the National Assembly, Toby Okechukwu, helped with a portion of the road.
She said that the government needs to step in and revamp the existing health centres in Ugwueme and complete the road project to give the people a sense of belonging.
Only Immunization goes on at Ugwuaji health centre
Inside the health centre in Ugwuaji, one of the communities in Enugu South LG, the cries of little children rise to a crescendo. At intervals their mothers present them to be vaccinated against polio.
Like the Amalla Orba PHC, Immunization is the only activity that goes on inside the Ugwuaji health centre which bears a semblance to a forgotten camp having suffered years of neglect by the state government.
Inside the compound housing the facility, it is common to see human faeces scattered at various locations and with no gate, it is accessible to anyone. The government only recently constructed a fence that is supposed to provide protection for the facility.
A tour of the centre showed that although it has toilet facilities, they are not functional and so, patients always use bushes around or go back to their homes when they are pressed. The walls of the facility are cracked with cobwebs everywhere. The surrounding is unkempt with overgrown bushes.
The Officer in Charge at the health centre, Onyia Christiana, said that the facility has also had a perennial challenge of water and power supply. Although there were rods constructed for ceiling fans, none has been installed since the facility became operational in 2009.
Christiana said that she and other workers contributed to buy a gallon that is used to store water. She said that they also contributed to buy chairs for the facility as they used to seat on available foams whenever they came to work.
Another health worker at the PHC, Nnenna Agu, said that many residents in the community do not even know that there is a health centre because of its location and condition.
She explained that the centre is unable to offer delivery services because of its dilapidated state, adding that during pregnancy, many women now visit maternities which are widespread in the community.
“When they get there, they pay through their noses because most of the facilities are privately owned,” she said. “Nobody would want to come to a facility that is un-cared for and further risk their lives.”
Speaking further, she said “We should be able to help women deliver their babies as a primary healthcare centre, but we don’t even sleep here at night and no woman will accept to sleep in this condition.”
Poor state of PHCs force dependence on TBAs
Nigeria accounts for 20% of all maternal deaths in the world, with at least 800 of every 100,000 live births resulting in the death of the mother. And lack of access to healthcare, which includes distance to health centres and hospitals, availability of and cost of transportation and poor roads and infrastructure are among the three delay factors that contribute to maternal mortality in the country and elsewhere.
A common thread runs between the communities visited and that is the fact that some women in these communities are having to depend on Traditional Birth Attendants for survival during pregnancy and delivery due to the lack of access to healthcare.
While the World Health Organization (WHO) recommends the use of skilled birth attendants to improve the likelihood that pregnancy complications will be managed and risk of maternal mortality reduced, lack of access to healthcare in communities such as Ogor’s continues to increase the rate of dependence on TBAs, with about 65% of deliveries said to take place at non-formal settings like TBAs.
And data from the Nigeria Demographic and Health Survey shows that this dependence is one factor that accounts for the persistently high rate of maternal mortality in Nigeria.
Chief Executive Officer (CEO) of Talkhealth9ja, Dr. Laz Eze, said that the existence of TBAs is a sign of primary health systems failure, adding that although their presence is better than nothing, it should not be encouraged.
“No matter how many times TBAs are trained, their quality of service can never be same as those of midwives or community health extension Workers, “he said. “Disadvantages include paucity of knowledge and training in managing deliveries, understanding complications and referring patients with complications often leading to deaths of many women.
To tackle the culture of over-dependence on TBAs, Chief Executive Officer (CEO) of Talkhealth9ja, Dr. Laz Eze, said that there is the need for the government to hire adequate number of skilled primary health care workers, provide good working environment, proper remuneration and supportive supervision for them to work effectively and efficiently.
“Every PHC should have at least 4 nurses/midwives according to the Ward Health Systems policy, “he said. “Community Health Extension Workers (CHEWS) and Junior CHEWS can also be trained to provide skilled antenatal and childbirth services.”
Government is revitalizing one PHC per political ward
When contacted, the Executive Secretary of Enugu State Primary Healthcare Development Agency, (ENS-PHCDA), Dr George Ugwu said that the agency, together with the state government remains determined to revamp the primary healthcare system in the state.
“We are revitalizing at least one PHC in each political ward across the state to deliver quality healthcare to the people,” he said. “We have a lot we are doing because we have generated a lot of interest around it.” We also have our challenges.”
All efforts to get the commissioner for health, Emmanuel Obi, to comment on what the state government was doing to revamp the primary health sector failed as he neither replied to a text message sent to him nor returned several calls made by this reporter.
This Report is part of activities by the Ikenga Media & Cultural Awareness Initiative (IMCAI) under the Collaborative Media Engagement for Development Inclusivity and Accountability Project, a multi-level intervention for media independence and government accountability, managed by the Wole Soyinka Centre for Investigative Journalism (WSCIJ) and supported by MacArthur Foundation.