INVESTIGATION: In Kano, Primary Health Centres are so bad women sometimes give birth on the road

In Kano State, about 280 primary healthcare centres (PHCs) and health clinics serve 44 local government areas (LGAs). Almost every year, the state government pats itself on the back for its work in the health sector, PHCs particularly, but residents and observers differ. Investigative journalist DANIEL OJUKWU probed the decay and disconnect between the state of the PHCs and the government’s position.

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Ahmed Kabiru (not real name) has worked at Yola Model Primary Healthcare Centre, Karaye LGA, Kano State, for over four years. Every time he walks through the centre’s entrance, he knows to keep to his left to avoid the collapsing right side of the building.

What often greets his arrival is a large waiting area, a makeshift doctor’s desk and patients crammed in some of the few available wards in the hospital. On one wall hangs a banner that reads the vision and mission statements of PHCs in Kano, while on the right is a red tape cordoning off the dilapidated parts of the facility.

What one sees on this banner quickly reveals itself as ironic when one turns their head to the right. Seven wards are sealed off and rendered useless as their walls are falling apart. FIJ found that because these wards had been abandoned by humans for over four years, forces of nature took over to create a more worrisome problem under the noses of the hospital’s staff and regulatory bodies.

Our reporter probed these wards and found deposits of rat faeces, cobwebs and stagnant bodies of water on the floors. These observations were made some metres away from where patients were being attended to, meaning one would be exposed to more health hazards by simply walking into the hospital. In the large waiting area, a banner carries the vision and mission statements of the Kano State Primary Health Care Management Board (KNSPHCMB).

The vision statement reads, ‘A health care delivery system that is Efficient, Affordable and Accessible by all residents of Kano State’, while the mission statement reads, ‘To implement appropriate policies and programmes, as well as undertake other necessary actions that will strengthen the Primary Health Care System in Kano State to be able to deliver Efficient, Effective, Qualitative, Accessible and Affordable health care with full participation of individual and Communities at all levels in spirit of Equity and Self-reliance‘.

For Kabiru, the irony of the banner’s message lies in ‘efficient’ — a word that appears in the two statements. According to the Cambridge Dictionary, ‘efficient’ means ”working or operating quickly and effectively in an organized way”. This hospital is clearly not working effectively; Kabiru said he met it that way when he started working there in 2018.

“I have worked here for at least four years, since 2018. Patients come here from Tudun Kaya, Yola and even Daura,” Kabiru told FIJ. “Here, we treat malaria, typhoid and other illnesses regularly.”

“Due to poor construction, the building is falling apart. We had a store for drugs in one part of the hospital, but when the building started breaking on that part, we had to move the drugs to an office.”

He said the hospital staff tried to manage parts of the building that were in fair condition, and if they got overwhelmed, they transferred patients. He also lamented how government agencies and other private organisations visited the hospital but never returned to change the situation. He mentioned how one organisation did some renovations in 2020, but he could not recall the name of the organisation, and the facility kept no records.

Kabiru said, “We manage the part of the building that is in fair condition. If we are overwhelmed, we transfer patients to Yola town.”

“I met the damage here when I joined. Sometimes, government agencies and other private organisations come here to see the damage, but they do nothing. In 2020, an organisation came around to see the centre and do some renovations, but I do not recall the name of the organisation.”

POOR CONSTRUCTION SINKS A HEALTH CENTRE

When FIJ asked to check the sealed-off wards, the hospital’s staff said they wouldn’t allow people in there because of the risks. Our reporter quickly understood why. In one ward, there were cracks in the walls. FIJ observed that wood was used to fill the walls of the building, and pipes were used in the building’s wiring.

Just outside that ward was a pool of stagnant water our reporter had to navigate through to get to other abandoned wards in the building.

What the hospital staff said was that the building had been that way for over five years and the government was aware.

POOR FOUNDATION, MATERIALS RESPONSIBLE FOR DAMAGE — EXPERT

Donald Ojimba, a civil engineer with Lions Construction, told FIJ that he could attribute the dilapidation to failure of the foundation on which the hospital stands. He said the building ‘settled’ faster than it should and its lifespan was shortened because the construction work was poorly done.

“The crack in the building is due to the failure of the foundation. The building settled rapidly,” he told FIJ. “The idea of foundations is to be able to withstand dead and live loads. Dead loads are loads that do not move. The building itself, roofing sheet and everything involved in the building are dead loads on the soil.

“Live loads are human traffic, water, wind and more. Foundations should be able to withstand these kinds of loads. If you construct a house on a soil that is weak, there is a high chance it will settle. This means it will go down until it meets firm ground.”

Explaining why only a part of the hospital was affected, Ojimba said it might have been constructed on uneven soil.

He said, “If one was to build on a five-meter-square area, the nature of soil one would find at different parts of the area might be different. The ability to cater for these types of soil makes for a good foundation.

“The construction in this hospital may have been done with good materials, but it rests on a poor foundation. Properly constructed buildings should last for 100 years, but this one cannot do that.”

He dubbed the use of wood in the building as ill-advised. He told FIJ that it was likely cheap labour and a terrible choice of contractors that led to that eventuality.

Ojimba said, “Wood decays overtime, so it is never recommended. This was just bad work and cheap labour. One may only use treated seasoned wood, which is applicable in colder climates than Nigeria. We simply use blocks and mortar during construction. There is no need for filling.”

WITH POOR BEDDINGS, RENOVATED PHC IN KUNCHI SERVES SACKED VILLAGE

Yakuza Sani, an indigene of Matan Fada community, Kunchi LGA of Kano, has used the Matan Fada health post for over 10 years. He grew up in the area.

He told FIJ that the hospital caters for pregnant women, children and other individuals not only from the community but Jigawa and Katsina states which are less than five kilometres away from the facility.

In 2021, the health post was renovated by the state government. More wards were added, and a cooler was introduced to preserve vaccines.

Sani told FIJ that the hospital catered for over 10,000 residents of the community, but a source privy to a renovation work done on the building, told FIJ that the number was a lot less, as activities of terrorists from neighbouring Katsina had forced residents out of the community.

“Sometime last year, terrorists attacked the village, and people fled. If you go around the village, you will observe there are not many residents,” the source told FIJ.

When our reporter toured the community, it became clear it was a shadow of what it used to be. Hours after he left, reports had it that terrorists abducted over 80 people in Katsina.

Back at the Matan Fada health post, our reporter found beddings in poor condition. Mattresses on the beds had also worn out and were lacking covers. The renovation work did not come near the beds.

When FIJ approached the hospital’s staff members, they declined comments and asked that our reporter visit the LGA secretariat to make findings.

In a short while, our reporter arrived at the secretariat, but another brick wall stood between FIJ’s questions and the answers to them. Here, no one was willing to speak or divulge information for fear of sanctions from the state ministry of health.

KANO HEALTH SYSTEM RATED HIGH?

On July 20, 2019, the Kano State Government published a statement titled ‘Kano Rated High at State Health System Strengthening Review Meeting 2019’.

It said in the statement that its performance in the area of health system strengthening programme “was rated high by stakeholders at the 2019 Mid Year Review meeting that was held via teleconferencing at Africa House, Government House, Kano, between the Kano State governor Dr Abdulahi Umar Ganduje, Aliko Dangote and Bill Gates, alongside other stakeholders with the representative from the National Primary Health Care Development Agency (NPHCDA)”.

Speaking at the event, Dr Tijjani Hussaini, Kano State Executive Secretary of Primary Health Care Management Board, said the state’s system-strengthening efforts had “evolved over the years with the primary aim of improving Primary Health Care (PHC) service delivery”.

From his presentation, the government has done well in combatting polio, and improving immunisation across the state. It has also been able to keep records of its activities in improving healthcare.

None of Hussaini’s comments in the statement signed by Abba Anwar, Chief Press Secretary to the Kano State Governor, was on the state of the facilities.

Seven months after this self-praise, a report by two civil society groups revealed the state was exaggerating its efforts.

ALL KANO’s PHCs LACK SOME COMPONENTS TO MEET NPHCDA’s MINIMUM STANDARD — NHW, CODE (2020)

On January 31, 2020, Nigeria Health Watch (NHW) and Connected Development (CODE) launched a report on their assessment of 49 primary health care centres in Kano.

They said the reason for the assessment was to determine “whether the state’s primary health care provision is in line with the minimum standards of primary health care as outlined by the Federal Ministry of Health”.

In the report, Vivianne Ihekweazu, Director of Programmes at Nigeria Health Watch, said, “Results reveal that all the PHCs assessed seem to lack some component of the basic requirements as outlined by the NPHCDA minimum standards for PHCs. Based on the minimum standards, some basic infrastructure and human resource are expected to be found in a PHC facility. This is essential in order to facilitate delivery of timely and efficient services to healthcare users”.

Hamzat Lawal, CODE’s chief executive, speaking during the launch of the report, said, “It is clear that there are gaps in service delivery and adherence to the minimum standards for primary health care. The resultant effect is poor behaviour among patients in the state.

“The consensus at the end of the launch of the report was that the local health authorities need to re-examine the services provided at PHCs and re-equip them with necessary infrastructure and human resource to enhance their service quality and readiness, in order to achieve universal health coverage (UHC).”

The verdict and the recommendation are in stark contrast to what the state government initially communicated as a scorecard for its efforts in the health sector. It also mirrored what FIJ observed in 2022, two years after the report was made public.

GANDUJE PROMISED PHC INFRASTRUCTURE, MINIMUM SERVICE PACKAGE

During a primary health care investment summit held at the Coronation Hall, Kano State government house, on July 28, 2021, Ganduje promised to improve on PHC infrastructure in the state, as well as commit to implementation of minimum service package.

He created a committee headed by Dr. Hussaini, and said this committee would update the state and government “on a regular basis on the achievements and successes recorded”.

Ganduje also said, “To ensure the PHC Investment Plan sees the light of the day, the state government is committed to invest resources and improve PHC infrastructure, such as health facility upgrade, procure and distribute best PHC equipments and employment of additional personnel”.

The governor hired 56 more doctors and sent them to different PHCs in different local government areas. Earlier in the summit, he referred to the 2019 summit, claiming that the state government “was able to fulfil most of its obligations during the summit, and some instances, surpassing the promises earlier made”.

This was untrue. The problems outlined by NHW and CODE in 2020 were still defining the state in 2022, but Ganduje was praising himself.

NPHCDA DATA

According to the NPHCDA, the minimum standards for PHC buildings are:

Building and Premises
— Minimum Land Area: 4,200 square metres
— Colour: Green
— A detached building of at least 13 rooms (see floor plan)
— Walls and roof must be in good condition with functional doors and netted windows
— Functional separate male and female toilet facilities with water supply within the
premises
— Have a clean water source from a motorised borehole
— Be connected to the national grid and other regular alternative power source
— Have a sanitary waste collection point
— Have a waste disposal site
— Be clearly signposted – visible from both entry and exit points
— Be fenced with generator and gate houses
— Staff accommodation provided within the premises: 2 units of 1-bedroom flats

                        FIJ did not find any of these minimum infrastructure requirements in effect at visited PHCs.

The document also outlines building plans for PHCs. This makes findings at Yola Model Primary Healthcare Centre more worrisome.

ABANDONMENT IN TAKAI, ROGO PHCs

When our reporter arrived Takai LGA, he made a quick stop at the community’s PHC.

It was a large building in a very large compound. The building did not appear as though it would concede to the forces of nature soon, but maybe that was because nature was not interacting with it enough.

Our reporter found that even though the gates were wide open, the building would not admit anybody, as they were locked.

Residents of the area told FIJ the hospital operated ‘sometimes’.

On the KNSPHCMB website, while some health centres are listed as operational for 12 hours, the Takai PHC is listed as operational for 24 hours. Our reporter found this to be false.

Alhaji Yusuf Ibrahim Abbas, the Fagacin Rano (a traditional title) of Takai, told FIJ that the hospital opened sometimes and closed sometimes, and that residents in need of immediate medical attention sometimes travelled long distances to seek alternatives.

He said, “We lack healthcare facilities and qualified doctors. The doctor we have lives in Takai, and he only comes occasionally. Even our pregnant women have to travel long distances to access quality healthcare before they can deliver. Our PHC lacks professional doctors.

“We hardly record cases of mortality because we have a good road network, but sometimes pregnant women deliver on the road.”

FIJ visited Beli PHC in the Rogo LGA of the state to see firsthand what was obtainable in another PHC.

Here, the doors were wide open, different from what our reporter observed in Takai. But when our reporter gained entry into this PHC, the place was in disarray, and there was no patient or member of staff on sight.

It appeared as though the place was abandoned, as it was unkempt. On the KNSPHCMB website, the Takai PHC is also listed as one that operates round the clock.

On closer inspection, our reporter found it lacking some of the minimum requirements for a PHC.

WE WILL FOLLOW UP ON FINDINGS —KNSPHCMB

When FIJ contacted Hussaini, he asked that our reporter send our findings to him via WhatsApp.

After we did, he said, “Thanks for the report, all forwarded to relevant officers. I will follow up with the team on these observations.”

FIJ also sent an email to the Kano State Ministry of Health, but as of press time, it was yet to be responded to.

This report was produced with support from the Wole Soyinka Centre for Investigative Journalism (WSCIJ) under the Collaborative Media Engagement for Development Inclusivity and Accountability project (CMEDIA) funded by the MacArthur Foundation.