Thought Leadership

Stories of hope and despair: A personal perspective of Primary Health Care in Nigeria

When we recently called on you, our readers to send us your accounts of encounters with the health sector in our country, we were not quite sure what to expect. But the piece below took us completely by surprise. This beautifully written account of the primary health care system in Nigeria from the perspectives of government, private and corporate sponsors is an eye-opener to the challenges AND hopes of our health sector. Enjoy, send it round, and send in your own posts!

Stories of hope and despair: A personal perspective of Primary Health Care in Nigeria
By Olufemi Sunmonu, M.D
I am a physician practising in the UK.  Born in Nigeria, but I have lived most of my adult life abroad in pursuit of a better education (with pleas from my parents, urging me to return to Nigeria when I was finished, growing fainter each year).  Sometime in the last 2 years I decided on a new direction within healthcare.  I had heard a lot about the state of healthcare in Nigeria, (especially how much worse things were now, compared to the state of affairs 30 years ago) but the only encounters I could remember were as a child being chased around a hospital room by large needle-wielding nurses.   As an adult all I could go on were the anecdotal tales from home that ranged from the comical to the horrific, the most disturbing being the almost quarterly reports of unexpected and undiagnosed deaths amongst friends and family back home.  
So in March 2010, I decided to go see for myself and took a three-week trip to Nigeria. I visited some rural and urban clinics in Abuja, Port-Harcourt, and Eruwa. My first stop was Dutse Makaranta, a satellite town about 40 minutes outside Abuja and home to a few thousand workers who commute to the city to make a living.  It is a hillside town composed of semi derelict houses and shacks with up to five people sharing a bedroom.  The town is flanked on one side by uninhabitable mountain terrain and enclosed on the other by the only paved road I could see.  The Dutse Makaranta primary health centre is located on the other side of the road, highly visible to the entire town.
My first impressions were mixed; there was no discernible path leading up to the facility (not really a major issue except you never expect to be walking across rocks, sand and trash to get to your doctor). Generally, the wards were clean but almost all the equipment was in need of maintenance.  I was greeted by a friendly midwife who offered to check my blood pressure.  I would like to preface the next part of this by saying I was informed that this was a slow day to visit the clinic.  There was no one else present; no doctors, no nurses, no community health workers, no pharmacist, no lab technician.  I was assured that these people did indeed exist but I could not get a firm answer on WHEN they would be around. 
I can comfortably attribute the midwife’s presence to a newly rolled-out Midwife Service Scheme which has a strict compliance regime enforced by field officers. The Scheme itself (of which an outline is beyond the scope of this blog) is a testament to the commitment of the practitioners I met, who have a clear view to improving the state of healthcare in under-served communities.  Unfortunately, the narrowness of the scheme’s scope means that you have an excellent midwifery service at a local clinic where there is no guarantee of the presence of a doctor, nurse, or pharmacist.
Eruwa, a quiet rural Community in Oyo State is home to the Awojobi Clinic; my next stop.  About a 5 hours drive from Lagos, the clinic was located off a main road seemingly in the middle of nowhere.  However, on my arrival, the waiting area was full of patients.  With 56 beds, it is more of a hospital than a clinic. It is run by Dr Awojobi, a home-grown surgeon who trained at University College hospital Ibadan and deferred the opportunity to spend a year abroad because of his belief (which he reiterated fervently when we met) that Nigerians can solve their problems with little or no external help.  Of note is that Dr Awojobi has been running this clinic for over 25 years.  He is the only doctor, his wife is the radiographer, there are 2 Registered nurses, 10 community health workers and the rest are secondary school leavers trained on the job to do specific tasks. The clinic itself is a testament to the self-reliance that he sees in his countrymen.  To overcome the problem of an erratic and sometimes non-existent water supply, they built a series of water reservoirs to collect rainwater and satisfy hospital water requirements for 4 months out of the year during the dry season. 
Other low cost innovations include solar panels to power lighting and minor equipment (Diesel consumption is now down to a gallon a day), large windows to maximise natural light use, A coal furnace using corn cob husks from local farmers to power the autoclave (locally manufactured from a household gas cylinder) and to distill water, and a manually operated hematocrit centrifuge fashioned from the rear wheel of a bicycle, locally manufactured intravenous fluids at 10% of the market cost (UCH Ibadan used to produce all of its own  intravenous fluids in the 70’s).  They even built an industrial size washing machine powered by a small diesel generator. I would like to point out that all these innovations were made possible by the contributions of the local community, friends and family.  Dr Awojobi sees roughly 600 new patients a month.  Most workers have multiple roles (X-ray tech, porter, handyman). Salaries are decided upon by consensus amongst workers and all employees are included in
consultations on what to do with profits (if any).  This was undoubtedly one of the most impressive standalone systems I’d come across thus far; an unassuming rural clinic which employs principles of sustainability found in any global social enterprise: maintaining a low cost base, stakeholder engagement, maximising efficiency, innovation and transparency.
My final stop was Obio Clinic in Port Harcourt, Rivers State.  Here, I found hope.  The Obio clinic is a facility that not too long ago was essentially non-functional.  With the implementation of various initiatives, it serves as a model-in-progress of health care delivery as it should be.
The clinic is one of 27 that are being supported by Shell Petroleum Development Company in the South of Nigeria.  I am well aware of the scepticism with which the involvement of an oil company will be greeted with, but I would ask that we set this aside in order to examine this health care model. The clinic is essentially a partnership between the local government, private enterprises and the local community.  The clinic is owned by the government, which also employs and pays the staff as with any other community health centre (Dutse Makaranta in Abuja, for example).  A health insurance scheme has been implemented in this community by partnering with Health Care International, and the community is represented in this partnership by the inclusion of a respected local leader who is fully involved as a member of the health advisory board. But what does all this translate into on the ground? The clinic has a fully stocked pharmacy and a drug/reagent revolving fund where drugs and other essential supplies are replenished with capitation monies paid to the hospital as part of the community health insurance arrangement.  Staff members are motivated and fully engaged in their practice as they are paid on time and provided with necessary training and support.  There is a constant supply of electricity and running water.  The premises are immaculate due to systems put in place to inspect and maintain them regularly. Innovative solutions such as an oxygen concentrator, and reagents that do not require refrigeration are utilised. With the use of burnt brick and internal wall tiling, the external and internal walls are virtually maintenance-free as they do not require painting or repainting. Frequent meetings of the advisory board ensure that there is transparency and oversight. I can already hear the howls of “but they are using shell money to survive”. Granted there was an initial cost that had to be fronted by a private company, but this would not have been necessary if some of the mechanisms I have described were implemented in the first place.  The focus should be more on the utilisation of private sector processes and not the money.  The Company plans to exit this scheme shortly as it should be able to run independently with the delivery system that’s been put in place. 
My little expedition is admittedly a tiny window into the state of primary health care in Nigeria, but I did come away feeling more knowledgeable about some of the problems it faces. We have problems related to access, cost and quality that are unique to our continent, and as such we need innovative approaches to resolve them.  
I saw that innovations with alternative energy can help with some of our infrastructure dilemmas we face, and the pooling of risk (such as in private health insurance schemes) can significantly reduce or eliminate the issue of cost.  However, without the judicious management of resources these efforts will be essentially fruitless.   My hope is that anyone thinking about healthcare in Nigeria approaches it comprehensively, and thinks not only about preventing and treating illness but also about infrastructure (and its maintenance), creating community stakeholders, health promotion, consumer attitudes and the quality of the care being provided and how it can be safeguarded, as well as the management of people and resources.

None of this is rocket science, but it sounds suspiciously like a business and like any failing business, healthcare in Nigeria, it is in need of reform.  In doing my part to address some of these issues, I will be working with the sustainable health foundation, a Non Governmental Organisation committed to sustainably improving healthcare in under-served communities in Nigeria.

Thanks Femi for this – We all have a role to play – individuals, the private sector and governments. There are too many challenges to solve, and they cannot be solved without a collaborative effort that involves all stakeholders……………..aluta

Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has…Margaret Mead

By Chikwe Ihekweazu

Chikwe Ihekweazu is an epidemiologist and consultant public health physician. He is the Editor of Nigeria Health Watch, and the Managing Partner of EpiAfric (, which provides expertise in public health research and advisory services, health communication and professional development. He previously held leadership roles at the South African National Institute for Communicable Diseases and the UK's Health Protection Agency. Chikwe has undertaken several short term consultancies for the World Health Organisation, mainly in response to major outbreaks. He is a TED Fellow and co-curator of TEDxEuston.

7 replies on “Stories of hope and despair: A personal perspective of Primary Health Care in Nigeria”

Thanks for the trip ‘home’ to Eruwa. – Wonder if Dr Awojobi related his experiences prior to starting his clinic when he tried to run the State’s District Hospital in Eruwa with similar innovations and a belief that fees and imprest/petty cash should serve the clinic not the bureaucrats in Ibadan – anyway, those frustrations led to the development of his clinic – but he should be credited with trying to make the public system work first!

William Brieger

exhilarating, exciting and de javu————- the answer ‘Whole System change of failing health systems’ ——— as illustrated by the instructive three examples blogged by Dr Sunmonu that shows what can be done using local ingenuity. Wonderful.

Joseph Ana

Great perspective of our primary care system.
Who said we cant have a clinic like the one in Obio, PH if our heads have the will to do so? Like the writer said, it’s not so much of money but the right attitudes and policies in place.

The empty clinic in Dutse gives a picture of the attitude of the govt. staff. I am sure the clinic is empty cause the patients know they wont find any medic there not vice versa (the staff absent cause there were no patients).

I am in awe of Dr Awojobi!

This piece contributed by Femi reminds me of my experience while serving the country under the National Youth Service Scheme in Ondo State in 1999. I was posted to Baptist Hospital, Ile-Oluji in Ondo State and prior to my arrival, the over 30-bed structure didn’t do much to alleviate the health needs of the people. During my one-year service year, we worked together as a team and improved the services rendered. We commenced a Drug-Revolving Scheme and engaged some new staff also. There was support through donations from community-groups of the town in North America/Canada. Treatment of common communicable diseases, provision of antenatal , intra-partum and postnatal services, immunization were the core activities. We were able to recruit more staff and did commence medical outreaches to the Cocoa farms around the town. This was also possible despite the “Free Health Care” provided by the then Alliance for Democracy – led government.
However, 2 years after i left, services were down due to absence of committed human resources and materials.
The aspect of community insurance would have been the best for communities like this for sustainability.
Now, i have moved into public Health sector and do understand the numerous challenges facing the country.
The situation is not likely to be better except legislations are in place.
Where is the Health Bill?

I agree with the writer’s conclusion that what made the difference in the three facilities visited was not necessarily money, but the right attitude.
Which is why I disagree a lot with the endless agitation for improved pay when no one is pushing for inculcation of the right attitude in our health professionals.
Where were the service providers in Dutse PHC?

I worked in Obio for ten months. Working there was fun! When i resumed work in oct 09, i was shocked! well maintained facility, but very poor staffing! had to work as the only doctor there for about 4 months. Then came along the community health insurance scheme! Wonderful concept, implementation was a bit shaky at the onset. But with time, everything went on well! ANC registration soared to over 200 new bookings monthly. the delivery register too is getting filled up in no time. Six doctors run the shift at the hospital ensuring that the hospital is covered for 24hrs!nurses, midwives and CHEWs were posted en mass to the center.New equipments were brought in; A cardio-tocogram machine, ultrasound machine, we were also give a well equipped operating suit! It was ‘WOW’. All I’ll say is …Obio is one project down, 26 more to go!

By the way, its been upgraded to a cottage hospital!

Nice piece femi,i can say that i trained under dr Awojobi during my outsideposting in medical school at the university of Ibadan and graped the concept of appropraite technology,using available resources and technology to achieve standard result!!!!!

I am also part of the vision for the Obio health centre now Obio cottage Hospital from Inception uptil now.I was instrumental in drafting of the MOU and served as a the secretary in the Board of trustees.I was also previledge to be the originating CMD of the hospital at inception of the Community Health Insurance scheme.
The scheme is a public private pertnership initiative involving the state Govt,Local Govt,The Community,Private Organization(SPDC) and Health care International (a health Insurance Company) managing it.
It uses the concept of managed care which involves risk pooling of human and financial resources.
With Bulk purchase like a whole community, the cost for the scheme becomes highly subsidesed and the scope of disease covererge becomes very wide.Pre existing condition and chronic diseases and geriatrics can adequately be covered and not excluded.
Though the scheme is challenging but we are responding and not reacting to the challenge.Obio is actually a pilot from which we are deriving vital statistics and information for a more robust community insurance scheme for the entire nation of nigeria and Africa at large

This scheme can and will work in any community that is willing even without extensive subsidization from multinationals.

We hope to spread this concept across our nation as we have already stated now in rivers state(3 hospitals now!)We are willing to partner with any community or organization that calls on us for such!!!!!!!

Kunle Megbus

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