In 2001, African leaders met in Abuja, agreeing to commit 15 per cent of their yearly budget to health sector. But Nigeria has never met that target despite the consequences of inadequate funding of healthcare system. Though the 2024 budget for health in Lagos, N151.66b, is higher than what it was in 2023 (N149.35b), the 2023 health budget was 8.45 per cent of the entire N1.768trn budget while the 2024 health budget is 6.75 per cent of the total N2.246trn state financial plan. Gbenga Salu writes there is misplaced priority in the state’s health sector with PHCs underfunded and inadequate staff to discharge their function.

Deborah Abiodun had a swollen breast, however, rather than go to the Primary Healthcare Centre (PHC) in her local council, Amuwo-Odofin, she headed straight to the nearest General Hospital in her council, which is in Ajeromi-Ifelodun.

This, naturally, should not be. The standard is when the primary healthcare system cannot handle a situation it is referred to secondary, and thereafter, to the tertiary level.

There are many Lagos residents like Abiodun, who do not patronise PHCs because of the poor services they offer, which discourage residents from visiting these facilities when they have one ailment or the other.

From the state government’s statistics, the PHCs have been experiencing a consistent drop in attendance.

According to the Lagos State Primary Healthcare Board, while in 2020, 2,133,457 patients visited, it dropped to 1,966,926 in 2021 and further dropped to 1,902,376 in 2022.

Similarly, the Lagos State Primary Healthcare Board said that total General Out-Patients Department (GOPD) attendance revealed that in 2020, only 588,891 patients visited, which dropped in 2021 to 562,268 and further dropped to 522,439 patients in 2022.

According to the Lagos State Primary Healthcare Board, the state has 320 functional PHCs cagetorised into Primary Health Centre, Health Posts and Comprehensive Health Centres.

The Health Posts operate for just eight hours majorly, and manned by community health extension workers or nurses, with no doctors covering them. Also, the Primary Health Centres run for eight hours too while the Comprehensive Health Centres operate for 24- hour with doctors and nurses on-call, as well as, all other cadres of staff.

Of note is that most of the Health Posts and PHCs operate only for five days in a week, usually, Monday to Fridays.

And the PHC in Gberefu, Badagry Local Council is one of the over 300 facilities that the state government put out. But the PHC is just among the statistics, it has been under lock and key for many years now, forcing residents of the community of over 15,000 to rely on quacks and traditional birth attendants, among others, to access healthcare.

The community members said they have suffered unnecessary deaths including that of pregnant mothers and their babies, just because they need to travel long distance or take the alternatives to access care.

Surprisingly, in September 2023, bulletin of the Lagos State Primary Healthcare Board (LSPHCB) sighted by The Guardian, the agency listed the PHC in Gberefu as one of the 320 functional primary healthcare facilities with 51 of the facilities designated as health post while others were categories as Primary Healthcare Centres and Comprehensive Primary Healthcare Centres.

But a female resident of one of the sub-communities in Gberefu, Funmilayo Ebifemi, stated that almost all the pregnant members in the area rely on traditional birth attendants because the option of going to the hospital is very expensive, as it requires going to town for delivery.

According to her, it means, making arrangement with a bike man and a boatman ahead of time when the due date is drawing close.

She also said that the pains of commuting on the sandy road on motorcycle is also a huge challenge and dangerous at that hour; reason many women just invite traditional birth attendants to their homes when they go into labour to help take delivery of their babies or they take deliveries themselves.

Ebifemi talked about her sister, simply identified as Mrs. Tanimola, who had a pretty difficult time giving birth to her baby, because she went into a prolonged labour.

Ebifemi revealed that two traditional birth attendants tried to take delivery of her sister’s baby before she lost her baby, while her sister almost died too.

If Tanimola was lucky not to have died, that was not the case with Mrs. Bose Aiyeolowo, who lost her life and that of her child during childbirth because she went into prolonged labour.

When it was morning, an auxiliary nurse was invited when the traditional birth attendant available that night could not help in delivering the baby. But at the end, she and her baby died.

Aside from the Gberefu PHC, there are many others that are not well taken care of, with residents going through tedious process tpo access healthcare.

A Lagos resident, Tayo Oguntade, said shortage of personnel especially doctors and nurses are why many prefer going to general and teaching hospitals for healthcare.

A recent state assembly’s deliberation corroborated the experiences. The situation has not changed much even after the assembly’s plenary.

When the lawmakers resumed after the 2023 general election, a ‘Matter of Urgent Public Importance’ relating to scarcity of PHCs in some areas, poor facilities and inadequate health personnel was discussed.

Contributing to the discussion, Noheem Adams, said the 327 PHCs in Lagos were not enough for the about 22 million resident, calling for additional PHCs and employment of more personnel.

On his part, Temitope Adewale said while a ward should have a PHC, Ifako-Ijaiye with seven wards and five centres has just two that are fully functional, just as David Setonji, noted that PHCs are the most critical health facility because they are closest to the people.

To give the deliberation more effect, the assembly set up a five-committee to drive the outcome of its submission. Ironically, the talk about poor PHCs came two months after the same lawmakers deliberated on upgrading five general to tertiary hospitals.

That nothing much was achieved from the lawmakers’ discussion is reflected in the Commissioner for Health, Prof. Akin Abayomi’s statement last week during a ministerial briefing, when he said: “Out of our 300 plus PHCs, about 100 require deep renovations and we have commenced with the first batch of 20 PHC renovations in various locations across Lagos and will continue till all our existing PHCs are in good physical condition.”

However, the National Primary Health Care Development Agency (NPHCDA), in a document on minimum standards for PHCs in Nigeria, said a PHC should be a detached building of at least 13 rooms, connected to the national grid and other regular alternative power source, have a clean water source, a sanitary waste collection point
and waste disposal site, fenced with generator and gate houses
as well as staff quarters within the premises. It also stated that the accommodation should a-two units of 1-bedroom flats.

The NPHCDA further said the building should have sufficient rooms and space to accommodate: waiting/reception areas for Child Welfare, antennal care space, Health Education and ORT corner, staff station, two consulting rooms, adolescent health service room, pharmacy and dispensing unit, two delivery rooms, maternity/lying-in section, in-patient ward section, laboratory, medical records area, injection/dressing area, minor procedures room, food demonstration area, a kitchen, a store, and toilet facilities (Male and Female).

The NPHCDA added that personnel in each PHC should include one medical officer—if available, one Community Health Officer (CHO), four Nurses/midwifes, three Community Health Extension Officer (CHEW), one pharmacy technician, six Junior Health Extension Officer, one environmental officer, one medical records officer, one
laboratory technician, two health attendant/assistant, two security personnel
and one general maintenance staff.
NPHCDA also said operating hours should be 24 hours, with each PHC having one ambulance vehicle, a bicycle, mobile phone, computer, internet services, one motorcycle, and one small motor boat for riverine area.

No wonder, the World Health Organisation (WHO) estimated that scaling up PHC interventions in low and middle-income countries can potentially save 60 million lives and increase average life expectancy by 3.7 years by 2030.

In Lagos, the political and health leaders recognise this. Speaking on the importance of primary healthcare system, the wife of the Governor, Dr Claudina Ibijoke Sanwo-Olu, said the state government perfectly understands importance of a strong, efficient and accessible Primary Healthcare System to the overall goal of safeguarding the people’s health.

She further said that no government worth its salt should downplay or trivialise Primary Health System. Being the first point of call for the people in our communities, we cannot afford a situation whereby the PHC system is not effective and functional.

Similarly, the Commissioner for Health, Professor Akin Abayomi, stated that a functional Primary Health Centre is the foundation and bedrock of a vibrant healthcare system.

Yet despite this, with over 20 million residents, Lagos has just 415 federal and state public health facilities. The state actually has just 327 functional PHCs with many of them not working at maximum capacity.

The recommendation is to have at least a PHC in a ward. Lagos based on its own delineation has 377 wards. So, not taking into consideration its population, the state ought to have on the average 377 functional PHCs.

Oyo State with less population than Lagos has 351 PHCs in its 351 wards. In Kano, there are 765 PHCs and 44 general hospitals in its 484 wards, while in Kaduna, there are 1068 PHCs with 256 wards. Akwa Ibom has 461 PHCs in its 392 wards just as Delta State has 447 PHCs in its 270 wards.

The Professor of Public Health and Community Medicine at the University of Medical Sciences, Ondo State, Michael Chiemeli Asuzu, maintained that the problem with Nigeria is that the health system is wrong, as too much emphasis is placed in tertiary healthcare, noting that primary healthcare in Nigeria is voodoo, with nothing in place.

“There is no community healthcare, they are just building health centres. Health centres do not mean primary healthcare. Health centre is the minimum place for medical care. Healthcare is given by people who are not doctors, doctors only superintend over what they do to make sure that they do not create problem for medicine but that they follow the line of medicine. Anything that can be done at the rural level, they do.”

Speaking specifically about Lagos, he insisted that there is no primary healthcare anywhere in the state, noting that what may be available is just minimal primary medical care.

“If they want to do it, they should do it properly. We have no primary healthcare in place; they should stop talking about primary healthcare. If they want to implement primary healthcare, they should learn how to do it and do it.”

According to Asuzu, while it is good for governments to build PHCs, they should operate on the back of primary and community healthcare.

He added that central to community healthcare are the community nurses and midwives, who are very senior midwives that retired from a busy hospital but now posted as community nurses/midwives to look after nursing districts.

“When they see a patient or a pregnant woman, they can tell you the whole story of that pregnancy because they have experience.

“For every 5000 to 7000 people, there should be a community nurse/midwife because Lagos is highly densely populated. If it is rural area, it should be about 2000 people. You can have a clinic nurse at the health centre with a doctor or medical assistant. The community nurse/midwife is someone who has been trained to work almost like a doctor to see simple cases and treat them with doctors visiting at intervals, depending on the load of service.

“When you do this, the general hospitals and teaching hospitals will be able to function the way they are supposed to function. Not now that everybody goes there.”

On his part, a public health specialist, Omotayo Olojede, said that Lagos has lots of health facilities at different levels of care, both private and public. “Whether this is enough given the population of Lagos is another conversation entirely but in terms of absolute numbers, there are many health facilities in Lagos.

“However, what may be lacking in these health facilities is quality service delivery. The implication of this is that many needed services are unavailable at these facilities and residents may be forced to seek alternatives, sometimes away from conventional medicine.”

But since December 2012, it is expected that countries and sub-nations’ policy driving health care should be geared towards Universal Health Coverage (UHC).

This was following the United Nations General Assembly resolution imploring nations across the world to fast-track progress toward Universal Health Coverage (UHC).

According to the World Health Organisation (WHO), the UHC means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship.

It added that it covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course.

WHO stated that the delivery of these services require health and care workers with an optimal skills mix at all levels of the health system, who are equitably distributed, adequately supported with access to quality assured products, and enjoying decent work.

And Olojede aligns with WHO’s position when he said that the purpose of UHC is to ensure every individual receives the healthcare they need without financial hardship. “This is based on the fact that a healthy population is key to human capital development and economic progress. However, evidence suggests the NHIS, almost 20 years after its establishment has only achieved coverage for about three per cent of Nigeria population (See NDHS 2018 for more information).

“Although, various state governments have established health insurance schemes in the last few years, a more holistic approach may be needed to achieve UHC. While health insurance may have catered for financial accessibility to healthcare services, policies and programmes need to be implemented to address other dimensions of access to healthcare such as physical accessibility (availability of services within reasonable reach) and acceptability (willingness to seek services).”

Also, a Professor of Public Health at the University of Ilorin, Tanimola Akande, stated that UHC is all about making quality healthcare accessible to people whenever they need, ensuring equity, and also making sure there is financial protection for those accessing healthcare.

“This is the best approach to have improved health outcomes in all countries. Therefore, government policies and programmes should be geared towards achieving UHC.”

So, it is expected that the drive by the Lagos State government would be to the actualisation of the UHC in the state. Surprisingly, while the WHO targets to achieve UHC by 2030, Governor Babajide Sanwo-Olu in 2019 said that the state has set a six-year target of 2025 to capture all residents of Lagos under the UHC to make healthcare affordable and accessible.

And central to achieving this goal are the PHCs, which are not well attended to. Rather than making the PHCs functional, the state government is investing hugely in other tier of health sector. For instance, the state government is building a seven-storey children hospital in Lagos Island, a 1500-bed space mental health hospital, and planning to convert some general hospitals to teaching hospitals, as well as setting up a medical university. This is aside the state having established six health districts with each man by a permanent secretary.

But some stakeholders said that the government is only putting the cart before the horse, saying the state government should have focused on ensuring functional primary healthcare centres and not just expanding investment in other tier of healthcare.

Olojede, who commended the state government for investing in health infrastructure at the secondary and tertiary levels, said it should not come at the expense of commensurate investments in primary care and quality service delivery.

“These secondary and tertiary facilities will easily be overwhelmed if primary care facilities do not function properly. It is important to note that from political standpoint, it is more beneficial to spend on tangibles (build hospitals, provide expensive equipment etc) than to invest in projects and activities (such as training and re-training, staff welfare, improved governance structure, mentorship, monitoring, evaluation and learning) that improve the quality of service delivery.”

He added that the PHCs are the most accessible for many and the cheapest alternative, reason they are key to achieving UHC and government spending to ensure quality service delivery at these facilities must be considered an investment rather than a cost.

Similarly, Asuzu said that it is a misplacement of priority for governments to be building more general hospitals and tertiary hospitals when the PHCs are not functional or operating at capacity.

“The WHO has said a country whose health system is not based on efficient and functional primary healthcare has no health system. Nigeria has no primary healthcare working anywhere and they are building teaching hospitals, specialist hospitals, what nonsense is that.”

But the commissioner of health insisted that the ministry of health is making all efforts to improve quality of care to its citizens at the primary, secondary and tertiary levels, which in lay terms means the 300 plus PHCs, the 30 plus general hospitals and the teaching hospital through good governance structures.

“And at the same time setting the standard and regulating what is transpiring in the private sector and any types of practices that border on delivery of health to our citizens such as complimentary and alternative medicine practices inclusive of traditional and indigenous knowledge systems.

“To this we have the health sector reform laws, numerous governing boards and agencies established to carry out the duty of good medical governance.

“Working closely with the LAHA, we are constantly reviewing our laws and developing new laws to keep up with the changing dynamics of global health practices.

“The Lagos State government as a whole has put measures in place to introduce improved selection criteria into all our critical positions such as MDs, MOH as well as governing board membership, as we aspire to place round pegs in round holes. The consequential higher caliber of leadership is beginning to pay off with improved service delivery and standard of care across our health care systems,” Abayomi stated.