It Takes a village: Making Primary health Contracts Work
By Seember Nyager
In the space of a few months, my classmates and I lost two beautiful women to medical complications during childbirth. This is not uncommon and most Nigerians have a friend, a colleague, a family member who has suffered a similar fate. The statistics devastate. According to the United Nations, 10% of global maternal mortality is from Nigeria. To break it down further, 111 women die daily from childbirth in Nigeria. A part of the challenge is that our tertiary health care institutions are overburdened with cases that ought to be attended to at the primary health care level. This may partly explain the Nigerian Government’s decision to ensure that there is a primary health-care centre (PHC) within a 5 mile radius in each community.
And so in every year, new PHC contracts across Nigeria are awarded. In 2014, for example, according to data available on Budeshi provided by the National Primary Health Care Development Agency (NPHCDA), the federal government awarded 89 contracts worth 2.6 billion Naira for the construction of PHCs. Two years on, when it is safe to assume that these contracts have been fully executed, we randomly select 40 of these PHCs and conduct a basic performance assessment to understand how well these PHCs are contributing to improved access in the communities where they are located. Our assessment makes it strikingly clear that it would take much more than construction contracts to improve primary health care access. Primary health care access would require adequate planning, coordination across government tiers and sectors and a system that enables public accountability.
Breaking the Silos
The provision of primary health care services is a responsibility administered by the third tier of government; the local government. The federal and state governments provide various levels of support to the local governments particularly by constructing PHCs. In 2014, at least 89 contracts worth 2.6 Billion Naira were awarded by the federal government through the NPHCDA. From the perspective of procurement monitors, 5 of the 6 PHCs visited in the south-western region of the country (Lagos, Oyo, Ogun and Osun states)are operating fully but these 5 PHCs are the exception. The majority of the PHC construction contracts visited have been completed but are not functional and in some cases, it is impossible to locate the PHCs.
In Benue state for example, four out of the six PHC construction contracts awarded in 2014 were completed in 2015 but till date, none of them has been commissioned. This is also the case with an earlier reported primary health care centre in Abuja and is similar to the PHCs in Yaryassa, Tudun Wada Local government area of Kano state which is open but unable to provide any medical service because there are no medical facilities or personnel.
While the NPHCDA rightly situates the responsibility for primary health care as one to be administered by the local government, we discovered that for some of these PHC contracts, such as the Abuja PHC earlier referred to, the area council which is the equivalent of a local government, knew nothing about its development until the structure was being erected. The result is that till date, the PHC is non-functional because there was no plan at the local government level to staff and maintain the PHC.
Without disregard to the structure of autonomy between the federal, state and local government, it is wasteful for PHCs to be built by the federal government with insufficient coordination across the tiers of government to ensure that the structures are actually utilized to provide health care access.
The Missing PHC in Burutu Local Government
Under the Nigerian procurement law, a contract cannot be formalized without available funds to meet the obligation and so if procurement data indicates that a contract is awarded there is a presumption that the contract award is cash-backed.
In some instances, there is a liaison between the federal and the local government to provide primary health care centres. This was the case in 2013, when community members of Burutu Local government in Delta state specifically requested that the federal government’s NPHCDA provide them with a primary health care centre. Thereafter, the NPHCDA wrote back to the community to inform them of plans underway to grant the request by building PHCs in the identified local governments including Burutu. The community was informed at a later date of the published tender for the PHC and then no further information was received. A few years after this request is made and using Budeshi data provided by NPHCDA, procurement monitors visit Burutu in August 2016, and they are told that no such PHC was built in 2014; indeed the last PHC built in Burutu was in 2002. The absence of a PHC built in 2014 in Burutu local government is confirmed by the very community member who had written to NPHCDA in 2013 requesting for a PHC. In the presence of the chair of the legislative house committee on health and several other representatives from public institutions, the Burutu community confirmed that no granite stone touched the soil for the construction of a PHC in Burutu in 2014 or any year after that.
The challenge is that procurement data for Burutu, provided by the NPHCDA indicates that the contract was awarded in 2014 to Baking Consults Ltd for over 21 million Naira.
Burutu is one of several PHcs that could not be located but for which contract award data is available and under our procurement law, a contract cannot be formalized without available funds to meet the contract obligation. And so if procurement data indicates that a contract is awarded, there is a presumption that the contract award is cash-backed.
It takes a Village
When PHC data suggests that contracts have been awarded and there is no contrary information from the agencies to suggest that such contracts were terminated, our minds go to the worst possible scenario. The resources have been diverted.
Such impressions can be avoided with a commitment to making contract-related data available at every stage in the process that leads to full implementation of the project. The exact location of the contract, the specifications of each contract, the milestones for payment, should be publicly accessible, in a way that links the various contracting stages, so that stakeholders across board, are empowered to follow the money right to service delivery. That way, we are able to trace how well our public contracts are meeting our health needs. From the current report that links procurement data to PHCs, the executive and the legislature are duty-bound to further investigate these state of affairs, set the records straight, ensure funds expended have been utilized for the purpose for which they were provided and ensure that this viscious cycle of non-functioning PHCs does not recur. .
The concept of PHCs in Nigeria envisages collective ownership by the community. In truth, getting value from health procurement requires mechanisms for coordination across the public sector, across tiers of government towards improved health access. It also requires informed citizens at every level, knowledgeable about government’s plans and providing feedback on implementation. True to its original concept, improved access to primary health care is not the sole responsibility of the health department at the local government; it takes a village. In our case, it takes a nation.
Our comprehensive report that links procurement data to primary health care centres in 7 states is available here
Also published on Medium.