By Ogar Monday
In Bogobiri the heart of Calabar, the Cross River State capital, three health workers sit around a table covered with Cross River State’s blue and white cotton material and a heap of books spread across the length of the table.
This is supposed to be one of the primary health care facilities in the state, and it is one of the facilities selected to benefit from the Basic Health Care Provision Fund (BHCPF).
This health facility that caters for areas including Etim Edem Park, Watt Market, Bogobiri, Barracks road and more, is basically a table with a mountain of books on it, and a few white plastic chairs all placed at the entrance of the hall within the premises of the Apostolic Church.
There is no building, no store room, no labour room and the health workers operate at the benevolence of the church, which stands opposite a mosque in this community of mostly Muslims.
“We have operated like this for about five years now,” says Ms. Mary Henshaw, who is in charge of the facility, adding that all efforts to get a befitting building has proved abortive due to lack of finances.
Ms. Henshaw revealed that most of the health emergencies rushed to the facility have been referred to their mother facility at Ekpo Abasi, a distance of approximately 4 Kilometers and that women who needed to deliver at night had to find their way to the University of Calabar Teaching Hospital, as the ‘centre’ does not run a night shift.
And that was the fate of Malam Aminu Bin-Usman when his wife was due for their last baby.
“My wife wanted to give birth in the night, we couldn’t come here. We had to run around and go to the teaching hospital,” he said, adding that it was easier for him because he owns a car and that the trouble for others without personal vehicles can only be imagined.
Malam Aminu, who is a member of the Ward Development Committee (WDC), a group of influential men and women tasked with overseeing and mobilizing collective action at the grassroots, held that the greatest challenge faced by the facility is accommodation. According to him, accommodation problems have made it difficult for the facility to serve the community.
In June this year when Elizabeth Ugbong went to deliver her baby at the Primary Healthcare Center (PHC) in Bebuabie, in Obudu Local Government Area of Cross River State, she was asked to bring delivery items that included rolls of tissue paper and disinfectant. She was also asked to pay a bill of N18,000 – more than twice what the mother of three makes a month from the small hair-braiding business she runs from her house in the community of mostly farmers.
Speaking through an interpreter with her second child tucked in between her legs alongside a blue bucket she was using to wash clothes, Elizabeth added, “After giving birth, the hospital staff refused to let me go and take care of my children insisting that I must pay the N18,000 before I am freed.”
It took the intervention of her uncle who coughed out N10,000 after she had spent a week in the PHC before she and her newborn were discharged.
It was the same situation for Josephine Abang who had to cough out the sum of N11,000 to be allowed to give birth at the government-owned health clinic in Ohong, in Obudu, the local government of the State Governor, Ben Ayade.
But no receipt was issued for the N11,000 collected from her.
“I paid N4,000 for registration and I was later asked to pay N7000 when I gave birth.” The mother of one was on her way to the health facility for post-natal care and said she also bought “toilet tissues, Izal, and Dettol,” as the clinic staff insisted it was mandatory for her to provide them if she is to have her child at the clinic that serves the rural community.
The demand for money and other consumables by the health facilities before attending to patients runs foul of the intentions and objectives of the Basic Health Care Provision Fund (BHCPF).
CrossRiverWatch investigation further uncovered that despite authorities saying the scheme has fully commenced in the state, drugs required to treat patients for free are not available, and there is no sign that they have started receiving payments from the State Health Insurance Scheme (AyadeCare) for the smooth operation of the program.
Misappropriation Of Basic Health Care Provision Fund
Established under Section 11 of the National Health Act (2014), President Muhammadu Buhari officially rolled out the Basic Health Care Provision Fund (BHCPF) in 2018. The Fund, sourced from one per cent of the Federal Government Consolidated Revenue and contributions from donor agencies, is aimed at providing basic healthcare for Nigerians who cannot afford it, especially at the local health centres.
The fund is disbursed and implemented through three gateways: the National Primary Health Care Development Agency, (NPHCDA), which gets 45% of the funds, and in liaison with the State Primary Health Care Development Agency, which funds eligible PHCs in participating states.
The second gateway is the National Health Insurance Scheme gateway which gets 50 per cent of the funds and works with the state’s health insurance scheme (in Cross River, AyadeCare ) to insure the most vulnerable and help them access a basic minimum package of health services, and five per cent through the Emergency Management Treatment (EMT) gateway.
Facilities receiving BHCPF are to provide antenatal care, delivery, and postnatal care for pregnant women, immunizations and treatment for malaria, pneumonia, measles, and dysentery for children under five, malaria treatment, hypertension and diabetes screenings, and family planning for all adults.
On Tuesday, May 21st, 2019, Prof. Isaac Adewole, the former Nigerian Minister for Health while addressing the Senate said 14 states including Cross River had refused to participate in the program by not paying the required counterpart funding in the year the Cross River State Government had budgeted to spend over N1 trillion.
Adewole, who described the BHCPF as a “game-changer,” added that the fund has been structured “in a way that money will flow from the Central Bank to the primary healthcare facilities, bypassing all obstacles.”
Two years later, Governor Ben Ayade’s launch of the Basic Health Care Provision Fund and the State Health Insurance Scheme marked the commencement of the program that aims to provide free and affordable health care for the poor in Cross River State.
But no sooner had the health centres received funding into their dedicated bank accounts than a letter dated 6th April 2022, signed by Dr. Janet Ekpenyong, the Director General of the Cross River State Primary Health Care Development Agency, got to the PHCs.
The letter with the title “Letter Of Authorization To Withdraw Funds For Basic Health Provision Funds (BHCPF) Primary Health Care Gateway To Commence Activities”, gave approval to the health centres to withdraw the said funds and “commence activities of the Basic Health Care Provision Fund (BHCPF)” and authorized the PHC facilities to “withdraw funds for full implementation of the activities.”
The letter directed the facilities to use the funds as follows: “50 per cent for drugs/vaccines and other health commodities will be purchased centrally; 40 per cent for maintenance of facilities and transportation, and 10 per cent for Human Resources (security/cleaners).”
But immediately after they got the letter, another directive arrived from the Cross River State Primary Health Care Development Agency “asking us to transfer about 80 per cent of the amount to an account in Polaris Bank belonging to Alpha Jadek Enterprise,” a source in one of the facilities, who did not want to be named, said.
The source added: “We got the second letter with our names already printed on it. We were asked to sign the letters and take them to the bank for them to transfer the funds.”
Continuing, the source said, “What was left from the money was not enough for my transport to the facility let alone pay volunteers and employ security officers.”
A search on the website of the Corporate Affairs Commission (CAC) showed that the company, Alpha Jadek Enterprise, with Registration Number 3347838, is solely owned by a Commissioner at the Cross River State Sports Commission, Ekpeyong Ekanem Ekpeyong, who is also the husband of the Director General Primary Health Care Development Agency, Dr. Janet Ekpeyong.
The company registered on the 12th of April, 2021, has the Calabar home address of the couple at No. 10, Emmanuel Edem, Federal Housing Estate, as its address.
When contacted, Dr. Janet Ekpenyong said the money was meant for the purchase of laptops for the facilities and that she presented the company “because the laptops will be cheaper from them”.
Ekpenyong who added that the laptops have already been purchased said they are now with the State Health Insurance Scheme and will soon be dispersed to the facilities.
“For the health insurance, the initial funds was for them (the health centers) to pay 80 per cent of the funds to a company that was picked by health insurance to provide laptops. They have purchased the laptop. What is left is for health insurance to take the laptops to the health facilities,” she said.
The DG then contradicted herself when she said the funds, which ranges from N300,000 to N350,000, was for the facelift of the facilities and their “task shifting”, and that drug and vaccines are centrally purchased. She added that the facilities were still getting the funds for that.
But she failed to explain why facilities were transferring funds to an account with ties to her husband and leaving them with between N50,000 to N70,000, an amount the health workers say can barely cover their expenses.
She could also not answer the question as to why the purchase of laptops was a priority for PHCs where drugs and other medical essentials were unavailable.
Funds Misappropriation Is Against Public Procurement Law, 2007 – Lawyer
While the purchase was done by and approved by a State Agency, a legal practitioner, Barrister Obodokassi Agbor said the action constitutes a misappropriation of the BHCPF and is against the public procurement law of 2007.
According to him, “Section 15 (1) B of the Public Procurement Act2017, specifically states that entities that derive at least 35 per cent of the funds proposed for any procurement from the Federation share of Consolidated Revenue Fund are bound to follow the procurement law to the letter, and since the money in question is from the Federal Government, it’s not a hard case to make.”
Barrister Agbor added that the procurement law prohibits public office holders from awarding procurement contracts to themselves and their relatives.
“The Bureau in its Procurement Procedures Manual specifically speaks of fairness in procurement, and that all procurement should be impartial, consistent, and reliable and should offer all interested contractors, suppliers, and consultants a level playing field on which to compete and thereby, directly expands the purchaser’s options and opportunities, and by all means, awarding a contract in whatever guise to a company belonging to your spouse is not fair nor impartial,” he said.
Left With Little, But Huge Expectations
The amount left for the health centres after they have done the transfer to the Director-General’s husband’s company’s account barely scratches the surface of their needs. Most of the health centres visited were so cash-strapped with leaky roofs, no drugs and inadequate number of personnel. Despite the fact that the fund was meant to give the centres a facelift, the exterior of the facilities was barely painted.
After the health facility in Bebuabie, Obudu LGA signed off the transfer of 80% of their received funds to Alpha Jadek Enterprise as directed by the state primary health care agency, the head of the facility, Ms. Elizabeth Ugi said what was left in the centre’s bank account was around N70,000. She added that a needs assessment of the facility showed that they needed to fix the hand pump, change some of the louvres, change some of the doors, repair the leaky roofs and ceiling, provide for clearing of the facility and commence the payment of stipend to the volunteer ambulance driver, needs the amount left could barely cover.
The head of the facility who explained that she had to borrow some funds to be able to carry out repairs in the facility and make it welcoming to patients. She said she could have done more, if all the money where available to her.
In Creek Town, Odukpani Local Government Area, the officer-in-charge of the health centre who identified herself as Philomena Edem struggled to stabilize a convulsing child when this journalist arrived at her facility.
“We are doing the best we can with what we have,” she stated, “these villagers will rather take the children to a prayer house and only bring them here when it is late”.
Philomena, who has collapsed all the wards into the only standing building in the centre, explained that a heavy storm destroyed the maternity ward building about two years ago, forcing her to now attend to pregnant women in the only standing building in the facility.
“If I had enough funds I would have fixed the maternity ward, and bought a machine to clear this,” she said, pointing to the grass that has nearly overrun the facility.
“It has been tough running everything from here. Especially during antenatal. We usually have all the pregnant women in this small space. Fixing the maternity ward and getting the weed cutter is our priority and will help us here,” she added.
It is the same fate that plagues the PHC in Ibil Nkum Irede, in Ogoja LGA. During a visit to the facility, the officer-in-charge, Ogbang Pius, pointed at a dilapidated building that once served as quarters for the staff of the PHC, saying he had hoped to start work on the refurbishing the building as most of the facility’s volunteers come from outside town.
For the workers at the PHC in Bansara, Ogoja Local Government Area, water is the biggest challenge. A health worker at the facility who identified herself as Grace, said they have to trek a long distance to get water for the facility.
“The pumping machine is spoiled. So we were hoping to fix our borehole with the money. Volunteers have to fetch water from the stream that is a little bit far from here.”
At the facility in Okundi, Boki Local Government Area, Grace Undiandeye said what was left of the money was use to repaint the facility, clear the bushes and employ volunteers, but that there is no water in the labour room.
The facility also needs a befitting toilet in the labour room – the matron said it would have been provided if the money was enough.
No Staff, No Drugs
The last time Mrs. Blessing Sunday was in labour, her husband rushed her to the health center a few minutes away from their compound in Ukwel-Obudu, Obudu. The place was empty – no staff was on ground-and after several calls to the head of the facility went unanswered, the husband frantically rushed his wife to the home of a retired nurse who runs a small private clinic in the community. She was able to deliver her baby safely.
Mrs. Blessing is now pregnant with her second child and swears that she will never be seen at the health center.
Speaking in pidgin English, Blessing said that her experience is not peculiar to her, as most pregnant women in the community of farmers prefer to visit the private clinic than the public health center.
It was 9AM at Urua Uyo in Odukpani Local Government Area and the only health facility in the community was yet to open. A man speeds into the facility with his bike and nearly tumbles into a banner carrying the face of Senator Prince Otu, the state All Progressive Congress (APC) governorship candidate that is placed just in front of the health facility. He manages to maneuver the bike to a halt, takes one close look at the facility’s door, notices the key on the door, and speeds off, with white smoke and the noise from his engine trailing him.
“Whenever you go there, it is either the officer has travelled to Calabar for a meeting or they don’t have drugs. We are always asked to buy drugs from the chemist. Sometimes the woman is just rude and is shouting at us,” Emmanuel Essien, whose 8-month pregnant partner sat on a wooden chair close to him, said. “So we,” pointing to his partner, “decided to stop going there and instead go to the chemist and get whatever drug we want from there”.
At 2:12PM when this reporter returned to the health facility at Urua Uyo, the only staff on the ground is a community health volunteer who identified herself as Gloria. Gloria said the facility head had travelled to the local government headquarters and she is the only one on seat.
Corroborating Emmanuel’s experience, 64 year-old, Mrs. Okon Akabom said the health center has no drugs and the workers are rarely on the ground to attend to patients.
“There are no drugs and at times you will go there and you will not see anybody, and when you ask them they will say what is the essence of them coming to seat there while they didn’t give them drugs,” she said, adding that the situation has led many people including herself to resort to patent medicine stores whenever they need health care.
This report is supported by the International Budget Partnership and The International Centre for Investigative Reporting (The ICIR).