This is the second part of a two-piece series on community-led development in Nigeria. In Part 1, Devex visited Enugu state, where authorities have put local communities in charge of million-dollar development funds.
IBADAN, Nigeria — Providing health care in a country as vast as Nigeria can be a challenge. At the core of its decentralized system are 10,000 primary health centers that help bring services closer to communities. But the country’s booming population means that in many cases, centers initially built to serve a few hundred residents are now serving hundreds of thousands.
The primary health centers are currently undergoing a much-vaunted “revitalization” program, with the aim of ensuring that minor ailments can be treated locally, instead of being referred to bigger hospitals.
“Patients want free services and community leaders want the center to be profitable and self-sufficient.”— Shola Odewale, volunteer and retired nurse
But the federal government’s plan relies heavily on buy-in from state governments, which are legally responsible for primary health services. While some are following orders, others have different priorities. Analysis by civil society organization BudgIT shows that nearly half of the states are struggling to pay workers’ salaries and fulfill election promises such as road construction and job creation, issues that are absorbing the attention of many governors more than improving the quality of health centers that already exist.
Meanwhile, the pressure on clinics continues to grow. While the services they provide are meant to be free, many find themselves forced to charge fees in order to carry on operating.
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In some places, local communities are taking things into their own hands. Residents are pooling resources and getting involved in the operation of the health centers to help them meet the scale of demand — laying the foundation for increased health coverage for their community with minimal new investment from government.
A busy health center
At the Alakia/Isebo Primary Health Center, about 140 kilometers outside Lagos, pregnant women need to arrive by 9 a.m. to have a chance of being seen that day. Already, around 80 women would usually be in the waiting room by that time, staff estimated.
Every month, nearly 100 babies are delivered at the government-owned health center, which does not have a doctor on its payroll but is largely operated by nurses, laboratory staff and assistants. While workers have a direct line of communication with the state government, requests for funds often get lost in chains of bureaucracy, they said — resulting in a lack of medicines and products, and poorly-maintained equipment.
Staff told Devex they had to actively pursue public-private partnership with the local community to ensure the facility continued to function. And residents, realizing the alternative would be expensive private hospitals, swung into action.
“Our wives and daughters are the ones using the health center, not the governor’s wife or daughters. If the health center does not function, we are the ones that will suffer most,” Baba Alaga, head of the landlords and homeowners’ association in the community, told Devex.
Every last Saturday of the month, the association’s members meet to discuss community affairs, including the state of the health center. The meeting is regularly attended by nurses who provide updates on challenges at the clinic, and revenues raised from fees.
At a recent meeting attended by Devex, nurse Abimbola Ogundipe drew attention to the much-needed repair of the ultrasound machine, and a technician for it following the departure of staff. The community agreed to raise the funds for the repair, asking each homeowner to contribute 500 Nigerian naira ($1.40). For staffing needs, they advised the center to contact the ministry of health for a permanent solution. But in the interim, an arrangement was proposed that would see the former technician return on Wednesdays to perform scans and train one of the nurses.
Going through homeowners has become a tried and tested way of getting households actively involved in issues affecting the community, with one representative responsible for each home attending a regular meeting. Decisions and funding needs are passed back to households and tenants, meaning everyone in the community is involved in some way. In some places, households commit to making a regular contribution to support their local health center; in others, they step in to cover specific costs when needed.
In return for their support, the clinics’ management can offer residents subsidized services. At government-owned hospitals, childbirth services typically cost around 5,000 naira ($14). At private hospitals, it could cost up to 30,000 naira ($84). But at Wakajaye Health Center, which has a similar arrangement with local homeowners, deliveries cost 1,500 naira ($4) — and women who are still unable to afford that can liaise with the landlords’ association to agree to pay at a later date.
Local woman Bilikisu Ahmed told Devex this convinced her to attend antenatal clinics at the health center. “Before I became aware of the arrangement ... I was planning to deliver my baby at home with the assistance of our pastor’s wife,” she said. “We would have gone to the health center only when something was going wrong. Now we no longer need to take such risks.”
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But such arrangements have not been without their difficulties. One issue is the reluctance of patients to pay for services they receive at health centers their community has already contributed to. Even subsidized fees can be a huge burden in a country where around half the population lives in extreme poverty.
“When [patients] know that the health center is getting revolving funds from the community, they automatically believe that they are entitled to free treatment and free drugs,” said Shola Odewale, a retired nurse who volunteers at a number of health centers. “We’ve had cases where patients and their relatives insulted us because they were asked to pay a fee that is very small when compared with what they should have paid if they had gone elsewhere.”
Health workers find themselves stuck in the middle, she explained, between “patients want free services and community leaders want the center to be profitable and self-sufficient,” with proceeds from fees reinvested in the clinic.
Odewale believes it is the responsibility of landlords to ensure the entire community understands the arrangement, and to explain to family members and tenants why they need to pay for services. But she added that the government should also be more proactive in ensuring the quality of primary health services can be maintained.
Government officials who spoke to Devex blamed the country’s rapid population boom, which “has exploded,” as a senior official from one state’s primary health care board put it. “There is no money. There [are] a lot of things that we know should be done but there is no money,” he told Devex, adding that the government welcomes the active participation of homeowners in running the health centers, which he said complement its own efforts to improve them.
Itunnu Adelowo, programs director of the African Development and Empowerment Foundation, believes such arrangements can be a sustainable way of ensuring that health services are accessible and affordable: "Top government officials are not directly affected by nonfunctioning primary health centers. The communities are, and ... they own the responsibility for their health and that of their children and wives.”
Baba Alaga, too, had some sympathy for struggling authorities. "It is not that they are not doing anything. They [are] doing a lot but it is not enough,” he said.
“We want them to do more but we have also come to realize that the government has a lot on its hands and the little we can do to keep the health center functioning could go a long way to ensure that our community has a place where the sick can be treated and our pregnant women can deliver their babies safely and cheaply.”