Oyo: Where primary healthcare centres gasp for breath

Efforts at improving healthcare services in Oyo State through the 721 Primary Healthcare Centres (PHCs) have been hampered by a shortage of workers and quackery. There is a nexus between the increased workload on staff, and the high incidence of mortality and morbidity from preventable diseases. Stakeholders insist that these lapses must be timeously addressed as they are forcing the public to patronise unlicensed practitioners and substandard medical facilities, ROTIMI AGBOLUAJE reports.

When Temilade Moshood was two months pregnant with twins, she registered for antenatal care at Gbagi Primary Health Centre (PHC) in Lagelu Local Council of Oyo State. But despite registering early and regularly attending check-ups, the incompetence of a health worker and a severe shortage of staff turned her delivery into a nightmare.

“Ordinarily, the facility should be manned by at least 10 health workers, but when I got there, there were just two (one nurse and the matron). They seemed overworked. The matron was inside attending to one woman, who was also in labour. It was too obvious that there was a shortage of workers,” Moshood recalled.

“I registered for antenatal care in Gbagi PHC after it was confirmed that I was pregnant with twins, I regularly attended the facility until my delivery date. When I started feeling labour pains during my last trimester, I went to the health facility as instructed, and I was taken to the labour room by a nurse. After delivering the first baby, we waited for the second one, but the nurse seemed unsettled and unsure. Despite my attempts to push, the second baby didn’t come out. It got to a point where the nurse was confused and admitted she didn’t know what to do. She was asking questions like ‘What kind of situation is this?’

“In a panic, my husband, who was agitated asked the nurse to do something fast. At that point, part of the baby- a hand was already sticking out while the other hand was trapped inside of me. My husband quickly rushed me to the nearest private hospital, where I went through a C-section to deliver the second child, and it was there that I was told that the baby couldn’t make it. The quack nurse made me lose my child. So, I went home with one of my twins.

“Losing a baby is traumatic, sad, and painful. The government needs to do the right thing by employing competent workers for the PHCs to prevent avoidable deaths. Also, there must be consequences meted out to health workers, who are negligent in carrying out their duties of saving lives,” Moshood emphasised.

Another tragic tale is that of Omowunmi Owolabi, who suffered from neglect by nurses in September 2009. Stricken with severe malaria, high fever, and relentless vomiting, Omowunmi was taken by her mother to the Oniyanrin PHC in Ibadan North Local Council.

“The nurses were preoccupied with something else despite our plea for quick medical attention,” Omowunmi recalled.

“It was more than two hours before one of the nurses finally attended to me. The nurse told us that we had to wait for a card to be issued before treatment began. My mother begged for at least first aid, but it took a long while before they responded.”
Omowunmi eventually collapsed and was taken to another hospital, where she spent hours in a coma.

Reflecting on the experience, she said: “It was the worst day of my life. I keep wondering what would have happened if my mother had not rushed me to another hospital. Many people face similar neglect from so-called medical professionals, ending up worse off, or even losing their lives due to such negligence.

“Approximately four health workers were present. It was early in the morning, so I cannot attribute their behaviour to fatigue or exhaustion unless they worked overnight. I assume it was purely a lack of zeal to do the right thing and a lack of proper monitoring and supervision,” she added.

Temilade and Omowunmi’s experiences are more than mere happenstances; they highlight a broader issue in Oyo State’s primary healthcare system, which includes inadequate manpower and burnout among health workers.

Manpower shortage aids burnout, quackery
ACCORDING to findings from the Administration Department and the Record and Research Unit of the Oyo State Primary Healthcare Board (OYSPHCB), as well as, the Office of the Executive Secretary of OYSPHCB, the state has 721 Primary Healthcare Centres (PHCs) staffed by only 2,149 workers across the 33 local councils. This staffing level is grossly inadequate when compared to the 24 staff members per PHC stated in National Primary Healthcare Development Agency (NPHCDA) guidelines.

The NPHCDA also maintains that each PHC should ideally be staffed with a medical officer, community health officers (CHO), nurse/midwives, Community Health Extension Workers (CHEW), a pharmacy technician, Junior Community Health Extension Worker (JCHEW), environmental officer, medical record officer, laboratory technician, and supporting staff such as health attendants, security personnel, and general maintenance workers.

Sources within the OYSPHCB, who requested anonymity, since he is not authorised to speak with the press, revealed that there has been no mass recruitment of qualified personnel into the primary healthcare system for 19 years.

This has resulted in severe burnout among existing staff and a rise in quackery, as facilities struggle to meet the growing demand for services.

Despite the Basic Health Care Provision Fund (BHCPF) being implemented in 342 facilities, the core issue of understaffing remains unresolved.

The Executive Secretary of OYSPHCB, Dr Muideen Olatunji, noted that while 10 per cent of the BHCPF is allocated for staff engagement, the number of workers remains insufficient.

At various facilities that The Guardian visited across five council areas, health workers acknowledged the benefits of the BHCPF but stressed the persistent staffing shortages.

In Ibadan North Local Council, Tunrayo Adijat Bello, the Deputy Officer in Charge of Agbowo Primary Healthcare Centre, said: “We have seven permanent staff and two ad hoc officers from the BHCPF scheme. Ideally, we need at least 18 staff to run three shifts smoothly.”

Mrs Helen Aderinto, Chief Nursing Officer at OluwoNla PHC, revealed: “We have 10 staff on the government payroll, but we should ideally have 24. The work overload is affecting my health. I am not the type that usually falls sick, but now I fall sick regularly due to the huge workload.”

The Chief Nursing Officer at Alegongo PHC, Mrs Bukola Ajala noted: “With only seven state-recognised staff, we need 15 to manage three shifts effectively.”

At the Olorunda Aba PHC, a Community Health Officer, Mrs FunmilayoAdeyemi said: “We have three permanent staff and six volunteers. Ideally, there should be 15 health workers here.”

The situation is similar in Ogbomoso South and Iseyin local councils. Mrs. Abigail Adegboyega, nurse and officer in charge at Adebayo Alata PHC, in Ogbomoso, revealed that her facility, with eight staff members, needs at least 20. “We are struggling with severe staff shortages. The current number is insufficient for providing adequate care,” she said.

At Arowomole PCH, also in Ogbomoso, Mrs Falilat Amoke Oladele, the only permanent health worker, is supported by a corps member, and one BHCPF worker. She lamented the situation adding that the facility requires 10 permanent staff for it to function efficiently.

“We desperately need at least 10 permanent workers to manage the facility effectively but I am the only permanent worker here. I am literally doing the work of eight people. There is no way I won’t be overstressed and my productivity impacted,” she said.

The Head of Ilogbo PHC in Ogbomoso, Dr Abel Ojo, reported that with only three permanent staff and six volunteers, including one BHCPF worker, the facility operates far below its required strength. “Ideally, we should have 24 permanent health workers to run this centre properly. The workload is beyond normal. We are suffering here and we do three shifts and work on Saturdays,” he stressed.

In Iseyin Local Council, Mrs Hamzat Rianat Adenike, who is the head of Faramora PHC, said: “Our facility should have 12 permanent staff, but we only have four. This shortage impacts the quality of care that we can provide.”

At Oke-Ola PHC, also in Iseyin, Mr Raji Yusuf Adekunle, a nurse, and the only permanent staff is assisted by about three volunteers.

He commented: “With just one permanent staff and several volunteers, it’s challenging to keep up with the demands of the centre.”

Service shortfall worsened by health workers’ strikes
THE staffing crisis in these health centres has been further worsened by a series of strikes that have taken place this year. So far this year, three major labour unions in the health sector have gone on strike over issues including the lack of new recruitments, delayed promotions, and inadequate hazard allowances.
On March 4, 2024, the Nigerian Union of Allied Health Professionals (NUAHP) in the state staged a seven-day warning strike.

The Unit Chairman, Mr Olanrewaju Ajani, explained: “We took this action because the state government failed to meet our demands for a new hazard allowance, promotion letters for qualified members, and more recruitment.”

On May 21, the state council of the National Association of Nigeria Nurses and Midwives (NANNM) commenced an indefinite strike.

According to the state chairman, Dr Adeyemi Samuel, and the state secretary, Aina Emmanuel, the group’s demands include mass recruitment for various health institutions and the implementation of a 25 per cent CONHESS salary adjustment.

“The shortage of nurses and midwives is critical. We need immediate action to improve healthcare delivery,” Samuel stressed in a press release.
Adding to the unrest, on June 24, 2024, the Medical and Health Workers Union of Nigeria (MHWUN) went on a seven-day warning strike. MHWUN President John Fabunmi said: “Despite our repeated reminders, the government has yet to address our concerns about staff shortages and other critical issues.”

This mounting frustration over working conditions is affecting both staff and patients.

According to Mrs Aderinto of OluwoNla PHC: “Patients are complaining about our slow pace of service delivery. As a result, some go to unlicensed pharmacy stores to buy drugs, or they take herbs prescribed by quacks. When the drugs don’t work, they return here for better treatment. We attended to one such case on July 24.”

High prevalence of quackery in Oyo
MEDICAL quackery in Oyo State has become a significant issue and is worsened by the shortage of qualified healthcare workers, and the resulting burnout among existing staff.

Burnout among medical professionals often diminishes the quality of care that they can provide. This inadequate staffing results in longer waiting times, and reduced access to healthcare services, pushing desperate individuals toward unqualified and unlicensed practitioners, according to experts.

The Oyo State government has been actively combating this problem, yet the problem persists. Recently, the state government sealed several clinics and hospitals in Ibadan and Saki. These closures were part of a broader effort to eliminate unlicensed and unqualified medical practitioners.

According to media reports, the state’s Task Force on Private Health Facilities, led by the then Commissioner for Health, Basiru Bello, shut down five facilities due to the engagement of quack staff and a lack of proper approvals.

According to Adewale Moshood, a medical researcher and Team Lead at Cure My Nation Initiative, and Oluwatosin Adeluwoye, a former lecturer at the Department of Science Laboratory Technology, Lead City University, Ibadan, the shortage of licensed healthcare professionals at the primary healthcare level creates a fertile ground for quack clinics to flourish. These unregulated facilities promise quick and affordable treatment that is appealing to individuals who cannot afford to wait for care in overburdened and understaffed hospitals.

Reflecting on the impact of quackery, Dr Temitope Farombi, a Consultant Neurologist at the University College Hospital (UCH), Ibadan, shared a personal tragedy: “I lost my sister to a quack in 2005. She got pregnant and delivered a baby, but the quack forgot a swab inside her, causing an infection. Instead of referring her to a specialist, they performed a D and C, rupturing her womb. She bled to death three weeks after delivery.”

She stressed the severe consequences of quackery, including poor health outcomes, health complications, loss of lives, and distrust in the health system, adding that the public health implications of quackery are often untold.

Dr Farombi said that patients treated by unqualified practitioners face increased risks of misdiagnosis, inappropriate treatment, and complications from unsterile procedures.

“This does not only endanger individual health but also worsens the burden on legitimate healthcare facilities when patients eventually seek help for worsened conditions. In addition, the proliferation of quack clinics also undermines public trust in the healthcare system and complicates efforts to implement effective public health measures.”

Reacting to these unsavoury findings, experts maintain that the state government must invest in its workforce and strengthen enforcement actions against illegal medical practices.

Specifically, a Consultant Radiation and Clinical Oncologist at the Federal Medical Centre, Idi-Aba, Abeokuta, Dr Bolaji Lateef Salako, called on the state government to employ qualified and competent health workers to curb quackery.

He warned that the shortage of workers at PHCs cannot be dissociated from high incidences of mortality and morbidity from preventable diseases, and increased workloads, amongst other issues.

“It is evident that our healthcare facilities are understaffed. This is one of the major reasons we are losing many people to the cold hand of death. Our health workers are overstretched thereby leading to low productivity and untimely death”.

The Founder of Pabokede Initiative for Child Protection and Family Life Education and former lecturer at the College of Medicine, University of Ibadan, Patricia Abokede noted: “Many quacks exploit the ignorance and shortage of manpower to provide unprofessional healthcare services. Quackery has led to increased maternal and infant mortality and morbidity.”

She recalled handling a case where a boy’s genital was mistakenly severed by a traditionalist. The boy’s parents could not afford the N5,000 circumcision fee at a government medical center and opted for the traditionalist’s services.

“I once handled the case of a boy whose penis was chopped off due to quackery. The parent could not afford N5,000 for circumcision at the government medical centre and decided to visit a traditionalist who cut off the innocent boy’s penis.”

These tragic outcomes are not isolated incidents within Oyo State’s healthcare. Chronic understaffing of PHCs, particularly in rural and hard-to-reach areas plays a significant role in the state’s dismal health statistics, particularly maternal and infant mortality rates.

The state’s maternal mortality rate stands at 262 deaths per 100,000 live births, which, while lower than the national average of 576, is still high. The infant mortality rate is 41 deaths per 1000 live births, according to 2018 data estimates.

A UNICEF report under the Accelerated Action for Improving Maternal, Newborn, and Child Health (IMPACT) initiative further reveals that Oyo State is characterised by high neonatal mortality and low immunisation rates. The state ranks third, after Kano and Jigawa in terms of neonatal deaths, contributing to more than a third of all infant deaths in Nigeria.

Despite some progress in child health since 2011, the report stressed that approximately 38 babies die each day in Oyo, primarily from sepsis and birth asphyxia, with fewer than four in 10 children fully immunised.

Moreover, researchers in 2022 estimated that the maternal mortality ratio in selected local councils averaged 489 deaths per 100,000 live births.

The researchers identified the scarcity of qualified healthcare workers, which forces many residents to turn to unqualified practitioners, as a key factor exacerbating the risks associated with childbirth and early childhood, especially in underserved areas.

‘Recruitment into PHCs is ongoing’
THE Executive Secretary of the Oyo State Primary Healthcare Board, Dr Muideen Olatunji, acknowledged the staffing challenges in a recent interview, revealing that Oyo State PHC data indicates a need for 13,574 health personnel to meet the obligatory healthcare needs of residents.

Olatunji explained that while recruitment efforts for Primary Healthcare Centres (PHCs) are ongoing, the process has yet to reach completion.

“We have started the process since 2021. We are ready for the next stage. The primary healthcare board is supposed to recruit for PHCs. I cannot predict when the process will be concluded,” he said.

Addressing the issue of quackery, Olatunji stressed: “There is no quackery in the system. Even if the facilities are short-staffed, there is no quackery in the government establishment. It may be outside the government establishment.”

Olatunji lauded the Basic Health Care Provision Fund (BHCPF) for its role in addressing manpower issues but advocated for increasing the fund from one percent to between 2.5 and 5 per cent to better meet the public health sector’s needs.

This report is supported by the International Budget Partnership IBP and the International Centre for Investigative Reporting (ICIR)