Beautiful infrastructure but poor staffing, lack of drugs hinder PHC services in Borno communities

The sunrise over Zabarmari village was beautiful in Jere Local Government Area of Borno State, but it offered no comfort to Fatima Sani, a 22-year-old woman in labour.

Her baby was coming, but the nearest health centre – her only hope – was closed.

Fatima had done everything right. She attended prenatal care and knew when her baby was due. Sadly, she never expected to travel 20 kilometres for delivery, passing three closed health centres along the way.

Tragically, after a long struggle, Fatima lost what would have been her firstborn at Maryam Abacha Women and Children’s Hospital in Muna, a community along Dikwa Road, Maiduguri.

While relatives mourned and cried, Fatima’s sister-in-law, Aisha Mustapha, a 28-year-old resident of Zabarmari, through tears, shared the heartbreaking news of their “journey for a safe delivery ending in a devastating stillbirth”.

Before the child’s death Fatima had earlier attended the Dalaram Old Maiduguri Primary Healthcare Centre- 15 kilometres away from her community. As of 2p.m the PHC had only community healthcare workers on duty who couldn’t handle the childbirth.

Desperate for help, Fatima had to travel another six kilometres, even as she had provided all the items requested by the PHC.

“They started basic care and gave her an IV drip we bought,” Aisha explained. “But then, their shift ended—they don’t work at night. We had to go somewhere else. They recommended Maryam Abacha Hospital”.

This reporter’s visit to Zabarmari PHC confirmed what residents feared: it’s not there when people need it. The PHC, meant to serve over 15,000 people, was deserted by 1 p.m., with only security officials at the gate. Signs outside the health facility advertise childbirth services, HIV care, and more – but it’s all useless as all the doors are closed.

Similarly, the Shuwari community boasts a well-built primary healthcare (PHC) centre, but operation hours remain a critical concern. Operating under the Jere LGA PHCs and managed by the Alliance for International Medical Action (ALIMA), the facility serves residents for less than 10 hours daily.

Babagana Mustapha, a 28-year-old community health worker at the PHC, said: “Nighttime emergencies are impossible to handle, and we urge the government to address this limitation.”

Also, in Muna IDP Camp PHC, limited operating hours (8 a.m. – 3 p.m.) further complicate matters. According to 28-year-old Falmata Usman, even for childbirth, you might need to buy items, and sometimes they refer you to the Lake Chad hospital. “People go where they can find solutions,” said Falmata.

Hundreds of internally displaced people (IDPs) call the Muna camp home, with over 2,000 relying on its sole health facility. While this reporter found the clinic clean and well-ventilated, two non-functional motorcycle ambulances outside painted a contrasting picture.

Laudable infrastructure, limited services

Nigeria has clear guidelines for its Primary Healthcare (PHC) centres. These guidelines outline staffing, equipment, medicine, and even operating hours needed to bring essential care to communities. PHCs offer more access to qualified professionals, making healthcare available to more people.

According to the approved budgets of the Borno State Government, the state had invested over N7 billion in its Primary Healthcare (PHC) programme from 2020 to 2023, with significant allocation towards infrastructure and additional midwife recruitment in 2021.

In May 2023, Leadership reported that Borno State won a $1.2 million award for ‘PHC leadership’. The award, funded by the Bill & Melinda Gates Foundation and Aliko Dangote Foundation, aims to strengthen the state’s healthcare sector.

Despite the injection of funds in Borno State’s Primary Healthcare (PHC) system, access to essential drugs and services remains a significant concern in some communities.

This reporter visited 10 PHCs in Maiduguri Metropolitan Council and Jere Local Government Area, including Auno, Dalaram, Zabarmari, 707, Wulari, Nana Kashim Premier, Mairi, Shuwari, Muna, 202, and Yerwa.

Sadly, some still fall short of Nigeria’s Minimum Standard for Primary Healthcare despite investments in infrastructure.

The Zabarmari PHC tragically illustrates this failure.

It wasn’t just Fatima who suffered from delays, unprofessionalism, lack of essential drugs, and a critical shortage of doctors. Such preventable tragedies remain far too familiar. The World Health Organization (WHO) directly links these problems to needless maternal and newborn deaths.

“This clinic is one of the oldest around,” says 30-year-old Zabarmari resident, Babagana Mustapha. “It should have been upgraded with better staff by now. I only take my kids there for headaches, and only in the morning. For anything serious, I go all the way into town,” Mr Babagana explained.

The Zabarmari PHC needs a basic ambulance tricycle for faster transport to better hospitals. Without doctors, a quicker transfer could still make a difference. This raises serious concerns about access to emergency care.

Auno, a small community outside Maiduguri, in Jere LGA, also shares a heartbreaking reality: its PHC is under-equipped.

“We lack doctors and necessities like water,” admits Zanna Sheriff, head of the Auno PHC. “I often spend my money on water for deliveries and other essential needs”.

Similarly, in Auno, Lawan Goni, a 60-year-old resident, was forced to take his sick son to a distant town hospital for malaria treatment. “I don’t regret the trip,” says Goni. He knew his son wouldn’t receive the care he needed at the local PHC.

Maryam Idris, a 30-year-old resident near the Auno Health Centre, feels frustrated. Despite the centre’s convenient location, she’s stopped visiting due to what she sees as inadequate drug supplies.

“They hardly ever give out medication,” she explains. “They might give you a prescription for a week’s worth of drugs but then tell you to buy them yourself.” This has been a major problem, especially when her two-year-old daughter was sick. The centre could only offer paracetamol, leaving her questioning if they didn’t have more resources.

Lack of essential drugs

It’s important to understand that primary health centres do have limitations. However, they are meant to give special attention to those most in need – pregnant women, children, the elderly, people with disabilities, and those in poverty.

Nana Kashim PHC manager, Yakawu Mustapha, acknowledges the centre tries to do this, even with limited resources.

Mr Mustapha said they prioritise the most vulnerable members of society, providing them with free services. However, she explained: “The PHC is meant to serve the immediate community as other PHCs are serving other communities.” This means they turn away other community members in need.

PHCs are meant to offer almost free healthcare for the most vulnerable, but the reality is often different. Some residents still end up paying for essential drugs or services they can’t afford.

Aisha faced this challenge at Dalaram PHC.

She said they lack basic birthing supplies like gloves and lotion – things every delivery needs. “They charge here, and we had no money,” she said. Thankfully, older women helped her negotiate fees, and she paid N2,500 for the supplies for an unsuccessful childbirth.

Even the Maryam Abacha Women and Children Hospital, managed by the Borno State Health Management Board and meant for specialised care, wasn’t free. “They asked where we came from,” Aisha recalled the desperation. She even showed Fatima’s prenatal records to get a bed. Still, Aisha paid for essentials like gloves and syringes.

“Some I had to buy outside”, she added. A N2,000 discharge fee was paid for Fatima, but the delivery ward worker needed help to provide a receipt, leaving them confused.

According to a report by Dailytrust, two years earlier, the government had reaffirmed its commitment to healthcare reform, proudly announcing new staff quarters, recruitment drives, and additional maternal supplies for free care at the Maryam Abacha hospital. Yet, reality presented a stark contrast.

Halima Isah, 28, lives in the 202 Housing Estate and sometimes gets prescriptions to buy drugs outside the PHC. However, she’s never charged fees for services at this facility.

This reporter observed women at the 202 PHC who travelled up to 10 kilometres to get there. Rukayya Sani, 27, from Wadiya, said she prefers this location because it’s free, unlike the PHC in her community, where she pays for certain things. Safiya Goni, 30, from Custom Area, also confirms paying for some services in the PHC located in her community.

Meanwhile, Husseina Liman from Mairi was referred to the 202 PHC and told that “everything was given free.”

However, Ummi Mustapha, a nurse at 202 PHC, said: “Drugs and all essential services in this facility are free of charge; not even client cards are being sold.” She’s saddened to hear that other PHCs charge for services.

Ms Mustapha believes that other PHCs charging for items like syringes and gloves are why people from nearby communities come to the 202 PHC instead. She said all allocations of drugs and other medical items are equally distributed across PHCs in Borno State. “So there should be no reason for charges.”

A midwife assistant at the Shuwari PHC, Aishatu Abba, said the centre doesn’t have necessary items to give the women after childbirth. She said the PHC also has no water.

“We can’t give the patients standard health care because we don’t have the essentials in the PHC,” Mrs Abba said.

Similarly, when in February this reporter visited the Muna IDP camp PHC, which was renovated and maintained by the State Primary Health Care Development Agency with UNICEF support, residents complained of a week-long absence of medications.

“Doctors prescribe medications for patients to purchase, although previously drugs were provided here,” said Abbah Modu, a 40-year-old Muna resident and PHC cleaner.

The Muna IDP facility has two small buildings, a delivery room, a consulting area, and a pharmacy that attend to hundreds of IDPs who are yet to be resettled by the government. Residents like Falmata shared their frustration.

“Despite a severe fever, sometimes all I get is paracetamol,” she said. “Most of us head to the Lake Chad hospital instead. They often prescribe drugs we must buy ourselves”.

Seeking answers

This reporter wrote to the Borno State Primary Health Development Agency (SPHDA) for an official reaction to the report.

After a follow-up, the reporter was directed to the agency’s Director of Planning, Research and Statistics. However, the director said he would only speak with clearance from the Borno State Ministry of Health. This reporter also submitted a proposal to the Ministry’s ethics committee but was yet to receive a response as of the time of filing this report.

Similarly, efforts to interview the officials in Jere LGA in charge of PHCs yielded no results as a letter seeking clarifications and possible interviews was not replied to.

A staffer of the LGA, who asked to be anonymous, said the director might be available after a scheduled tour with the new Jere LGA chairperson.

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However, Shettima Abdulazeez, Director of PHCs in MMC LGA, did address staffing issues.

He admits healthcare worker shortages are a global problem, including in Maiduguri. However, he insists that MMC facilities are working and are accessible for the public.

Mr Abdulazeez emphasised that facility’s workers are well-trained and that they refer complex cases and follow up with patients.

“We want people to know they can freely access these facilities. We have about 26 functional PHCs in MMC,” the official said.