By Beti Baiye and Asari Ndem (Lead Writers)

Madam Atim Okon Jimmy, the Officer in Charge (OIC) of the Ikot Offiong Ambai Primary Health Centre (PHC) in Akpabuyo Local Government Area (LGA), Cross River State, is proud of the changes she has implemented in the PHC, with the support of the Basic Health Care Provision Fund (BHCPF). The facility received 900,000 naira in 2022. “We used the funds to repaint the entire clinic, buy a pumping machine for the borehole, buy tables, stock the clinic with essential drugs among other things,” she explains.

Nigeria’s Primary Health Care (PHC) system is plagued with many problems, with underfunding being a major contributor to the system’s underwhelming performance. The Basic Health Care Provision Fund is an initiative designed to reduce out-of-pocket expenses for essential services, increase utilisation of primary health care, particularly among vulnerable populations such as pregnant women, children under the age of five, the elderly, and the disabled, and improve service readiness at the PHC level.

The Fund provides direct financial investments to support critical upgrades to primary healthcare infrastructure, ensure the availability of skilled staff, and ensure a consistent stock of essential medicines and health commodities; while also covering the cost of a Basic Minimum Package of Health Services (BMPHS) obtained from PHC providers, which is provided to beneficiaries for free.

“It is for people like her”.

Sharing an experience that best describes the impact of the BHCPF, Madam Jimmy recalls when an octogenarian in the community, who was also hypertensive, fell sick. With no funds and no one to take care of her, neighbours rushed her to the clinic. “Thank God she was enrolled, and basic healthcare gave us hypertension drugs. So, I treated her for free and sent her home. A few days later she called to tell me she was feeling better. People like her are really benefitting from the programme.”

A social mobilisation officer works with key stakeholders in the community to sensitise the public and drive enrollment. Going forward, Madam Jimmy intends to work with the Ward Development Community (WDC) chairman to identify the actual vulnerable people in the community, as some people may falsely claim to be vulnerable. Ikot Offiong Ambai PHC currently has 93 enrollees, but some have yet to pick up their cards.

A lifeline for Ikot Nakanda PHC

Ikot Nakanda PHC, also located in Akpabuyo LGA, has a newly painted exterior. Still, the interior is in bad shape with missing doors, holes in the ceiling, broken fittings, and missing louvres in the windows. Mrs Nene Yellow-Duke, OIC of the PHC, reported that the facility was well-maintained until October 2020 when food and palliative relief were discovered in warehouses across Nigeria. In Ikot Nakanda, some young people went on a rampage and vandalised the PHC, stripping it of anything they could carry — generator, fridges, inverter batteries and the water pump.

Unable to function as before, service delivery at the PHC suffered significantly. However, the BHCPF has been a lifeline for the facility. “We received the basic health care in 2022 and used it to buy some small, small things like forceps, standing and baby scales, bundles of zinc to replace the ones that were removed, buckets of paint, wood to fix the doors and roof and paid the ad hoc staff,” says Yellow-Duke, adding that the funds have also enabled them to hire a security guard to keep an eye on the facility at night.

Currently, 74 of the poorest and most vulnerable community members are enrolled in the state’s social health insurance programme. They receive free health care for minor conditions at the facility, while complicated cases are immediately referred to the nearest general hospital.

A “special marriage” between MDAs

Cross River State has 196 wards and, to ensure that at least one PHC in each ward met the criteria for national approval to implement the BHCPF, in 2020 the state renovated the facilities, increased staff strength by hiring ad hoc staff, drilled boreholes, provided electricity, and worked with community members to fix the access roads. Princess Ekaette Ekpenyong, BHCPF Desk Officer at the Cross River State Primary Healthcare Development Agency (CRSPHCDA), reveals that 191 facilities were approved to receive BHCPF funding. She remains hopeful that the remaining five facilities will receive approval by the second quarter of 2023.

The management of the BHCPF at the state level is the responsibility of three Ministries, Departments, and Agencies (MDAs): the State Health Insurance Agency, the Ministry of Health, and the CRSPDA. These MDAs make up the state oversight committee (SOC) which convenes quarterly to discuss challenges and seek solutions for better coordination. According to Princess Ekpenyong, this partnership is sometimes referred to as a “special marriage.”

“We are grateful for the BHCPF but…”

Aside from the activities of the SOC, monthly supportive supervision, which involves visiting each facility to guide quality improvement, is critical to ensuring the smooth implementation of the programme. Princess Ekpenyong, the BHCPF desk officer oversees this activity. However, funding for this task is sometimes lacking. She therefore works to train other programme officers on the BHCPF, so they can provide supportive supervision while visiting facilities for other programmes. “I try to duplicate myself in the programme officers, that way If I am in Bekwarra, another me should be in Yakurr or Ogoja,” she says.

Each PHC can only enrol a maximum of 140 vulnerable people under the Basic Minimum Package of Health Services. Madam Jimmy believes that this figure is insufficient given the high population of her catchment area, which exceeds 17,000 people.

In addition, although she understands that the BHCPF focuses on supporting health service delivery in facilities and cannot be used for large projects such as constructing a new facility, building a staff quarter, or buying a fridge, she appeals for funds to expand the PHC. The facility’s current size is inadequate, and there is ample land available for expansion.

Nene Yellow-Duke estimates that over ten million Naira is required to restore the Ikot Nakanda PHC to its former glory. She is pessimistic about the possibility of this ever happening but hopes to be able to acquire a generator or an alternative source of power supply to replace the one that was stolen in 2020 as she and her team sometimes have to deliver babies at night using a torchlight.

The BHCPF is currently attempting to bridge funding gaps for PHC while supporting better quality healthcare delivery in primary health centres nationwide. The experiences recorded in Ikot Nakanda and Ikot Offiong Ambai indicate that the funds were successfully implemented, opening up more opportunities for better service delivery in rural communities across Nigeria. Quality service delivery in primary health care is frequently hampered by a lack of funds to hire health workers, stock essential medicines, and maintain infrastructure.