Tertiary health institutions in the country are facing intense pressure as they are besieged by patients with minor ailments that should have been handled at the primary or secondary health care centres.
BDSUNDAY findings show that this is happening primarily because across many states, primary health care centres (PHCs), which ought to be the first port of call for every citizen seeking medical care, are either ineffective or moribund.
Nigeria’s health care delivery system, according to experts, is organised in three levels according to the three tiers of government. Primary health care (health centres at local government, ward and community level) is directly under the local government areas; the state governments are in charge of secondary health care (general and state hospitals), while the Federal Government is in charge of tertiary health care (federal teaching hospitals, medical centres and specialist hospitals).
These three levels of health care delivery are meant to work as a chain through a robust process of referrals, with the primary health care being the entry point and the first element of a continuing health care process.
However, BDSUNDAY findings show that many patients in Nigeria have turned this process on its head, bypassing the PHCs and making tertiary health facilities their first port of call even for minor health challenges.
Malachy Okpe, a chief pharmacist at the University of Nigeria Teaching Hospital (UNTH), Enugu, tells BDSUNDAY that patients with ordinary cases of malaria and typhoid that can easily be taken care of at the PHCs are piling unnecessary pressure on the teaching hospital personnel who are trained to handle critical cases that have defied the lower cadres.
Okechukwu Egboluche, a senior optometrist at the Department of Ophthalmology, Federal Teaching Hospital, Abakaliki, Ebonyi State, confirms to BDSUNDAY that the pressure is indeed very heavy as people with minor cases that should have been handled at the lower cadre troop to the teaching hospital.
“It’s been there for years and it’s still happening till now. Many times you see people with common ailments like malaria, typhoid, even conjunctivitis (Apollo) and such minor cases coming to the teaching hospital. It’s so common and it’s also an alarming situation, but somehow you have no option but try and attend to the health needs of the patients when they come around,” he says.
Egboluche believes this is happening because most patients have lost faith in the primary health care centres which, he says, are nonexistent in many places and, where they exist, have not functioned optimally over the years due to neglect, poor funding, inadequate equipment and lack of personnel. Many health care professionals, he says, do not also apply to work at the PHCs because their counterparts at secondary and tertiary facilities are better remunerated. The PHCs, where they exist, are often manned by youth corps members who are fresh out of school and therefore inexperienced.
“When patients go there and discover they can’t get adequate care, the next option is to go to where they believe they will be properly taken care of. There is this belief that the tertiary health institutions are where the best brains are. So instead of taking chances with the primary health centres, people just go straight to the tertiary health centres,” he adds.
The pressure is also negatively affecting the overall productivity and professional development of the personnel at the tertiary health institutions who should have been handling specialist cases as well as even medical students who use these facilities as training grounds.
“If the specialist focuses on those difficult, specialised cases for which he or she has been trained, he learns more, his knowledge in handling such cases improves, his expertise grows. But when you are still bombarded with very normal cases that should have been handled at the lower levels, it affects your professional development too. Moreover, tertiary hospitals are meant to be training grounds for medical students, but when we keep having to deal with minor cases, the students learn nothing,” he says.
“The patients themselves are suffering. For instance, because of the large number of patients, some patients could come as early as 7am, but before you see some of them it might be 3pm. At the end of the day everyone suffers,” he adds.
But while many states cannot boast of functional PHCs, BDSUNDAY further research shows that Lagos, Anambra and Rivers States are shining exceptions, while Ogun, Kebbi and a few other states have also made commendable efforts. And in states where PHCs are functioning optimally, our findings show that the pressure on tertiary institutions in those states is drastically reduced.
In Anambra State, Charles Ebulue, a public health physician and resident doctor at Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital (NAUTH), tells BDSUNDAY that because the PHCs and general hospitals in the state are working optimally and delivering excellent services to the people, the pressure that used to be experienced at the tertiary health facility in the state is almost nonexistent now.
“Where the PHCs and secondary health facilities are not functioning optimally because of inadequate funding, infrastructural collapse, etc, you see patients moving straight to the tertiary health facilities. But in Anambra where I work, the case is different,” says Ebulue.
“All the PHCs and general hospitals in Anambra today are functioning optimally, especially since the coming of Governor Willie Obiano who built on what former Governor Peter Obi began. Cases of malaria, meningitis and suchlike, even maternal care, immunisation and all that, are all happening at the primary health care centres. It is only when there are complications that they refer to the higher levels. As such, the load on the tertiary facility is reduced. At the tertiary centre we see more of the specialised cases. I know because I work at a tertiary health facility and sometimes we do ancillary work at the PHCs,” he says.
Ebulue adds that the problem the PHCs have had is partly that of inadequate personnel. Many nurses and doctors don’t like living in rural areas because of absence of basic infrastructure, such as electricity, good roads, etc, he says, adding that the case is different in Anambra.
“In Anambra today, every community seems to be a town, and you see doctors living in rural areas. The state is well connected through a good network of access roads. In terms of remuneration too, Anambra is paying very well. You can’t owe medical personnel and still tell them to go to the rural area and attend to patients. When they are adequately motivated, you see people working in those areas,” he says.
Similarly, in Lagos State, BDSUNDAY visits to a number of PHCs show they are fully functional. At Satellite Primary Health Care Centre located within the precincts of Oriade Local Council Development Area, over 10 health workers were seen attending to the various needs of over 50 women, mainly pregnant and nursing mothers who have come to receive antenatal or postnatal care, immunise their babies or for other needs. When BDSUNDAY sought to speak with the health worker in charge, she said she was not authorised to speak to the press and referred this writer to either the doctor in charge or the Lagos Primary Health Care Board at Yaba. Our visit to the doctor’s office yielded no fruit as the doctor’s secretary said he was off to a meeting at Alausa, the state secretariat.
However, a nursing mother with her baby strapped behind her said she came to immunize her child.
“If you had come earlier, you would have seen the crowd yourself. The centre couldn’t contain everybody, we had to use the council hall. And it is like this every day,” she said.
Oluwole Health Post at Apapa Waterside had closed for the day when BDSUNDAY visited the place a few minutes past 4pm, but the doors were still open. Our enquiries, however, show that the centre is fully operational. It opens for business around 8am and closes at 4pm; it treats mostly patients with minor ailments and does not admit outpatients.
At Layeni Primary Health Care Centre in Ifelodun Local Council Development Area, where BDSUNDAY stopped over at about 6pm, a senior health worker on night duty who spoke anonymously said the health workers at the facility were overwhelmed with work because of the large number of patients they had to see every day.
“There are times when we attend to over 100 patients in a day. People come with minor ailments, and we attend to women who come for antenatal care, immunization, health talks, family planning, and so on. Like now, we have about four women who just put to bed. But we don’t admit sick patients because there is no doctor on 24-hour call,” she said.
Though Layeni PHC runs a 24-hour service, the doctor on call resumes at about 9am and close at 4pm. No doctor was around when BDSUNDAY called.
But our further enquiries show that the inefficiency of PHCs may not fully explain why some patients prefer tertiary health institutions. This is as some patients still go directly to teaching hospitals, even in states where the PHCs are functioning optimally. In Lagos, for instance, many patients still troop to Lagos University Teaching Hospital (LUTH) and Lagos State University Teaching Hospital (LASUTH) without recourse to either the primary or secondary health facilities. In spite of a standing rule that only patients with referrals are to be attended to, patients without referrals still get treated somehow.
“Sometimes it’s a matter of choice. At other times it’s a status symbol; some people believe they are too big for the PHCs and the general hospitals. But we cannot be going from house to house to compel people to patronise PHCs for medical care. They know the procedure. If people go to the secondary or tertiary health facility instead of the PHC, I think it’s because they want the best. Sometimes I also go to LASUTH myself. You can’t question people’s choices,” says a health worker who does not want his name in print.
Since his appointment last year, Isaac Adewole, minister of health, has at several fora decried the pressure being piled on tertiary health facilities as a result of the poor state of the PHCs, saying there was no reason why any Nigerian with minor ailment, such as diarrhea or fever, will go to the teaching hospital.
“The tertiary institutions are not meant to treat malaria or skin rashes, but to attend to critical issues. We are determined to take away over 70 percent of patients from the teaching hospitals, but the heads of tertiary institutions must find a way to relate freely with these cadres for effective healthcare delivery. We won’t abandon those cadres so that the sequence of referral could be protected,” he said while commissioning some recently completed projects at the Federal Teaching Hospital, Ado Ekiti.
He has also said several times that the Federal Government was making efforts to strengthen primary health care in order to cut the heavy burden on tertiary hospitals having to deal with a flood of minor ailments. Specifically, the minister promised that government would “make functional” 10,000 PHCs in two years – 5,000 in 2016 and another 5,000 in 2017 – to be delivered at the rate of one per day over 110 days starting from May 1, 2016.
“We want the Primary Health Care Centre (PHC) to be the first port of call so that it will be able to offer the basic care that ordinary Nigerians will require,” he said in Abuja during an interactive meeting with the House of Representatives Standing Committee on HIV, AIDS, Tuberculosis and Malaria Control.
BDSUNDAY checks, however, suggest that it has all been empty promises as no single block of PHC appears to have so far been delivered in any part of the country. An online search by BDSUNDAY brought up only reports of the minister’s promises and not a single report on delivery.
Meanwhile, Nigeria Health Watch, an online health advocacy group, has faulted the minister’s promise of creating “functional” PHCs, saying creating functionality is about creating systems that work.
“Systems cannot be created overnight. We can build, refurbish, staff, equip primary health care centres, but making them sustainably functional is a complex task that cannot be managed from Abuja. The role of the Federal Government should be that of a catalyst, guide, instigator, but not to deliver primary health care directly,” it said.
Nigeria has a total of 21 federal teaching hospitals, 13 specialist hospitals and 22 federal medical centres (FMCs), mostly situated in the state capital.
CHUKS OLUIGBO
