In this interview with EMMANUEL OBE, the Acting Director of Medical Services of Rivers State Primary Healthcare Board, Dr. Siyeofori Dede, says the challenges confronting primary healthcare in the state are being addressed with the new policy direction of the state government.
How many primary healthcare centres do we have in Rivers State?
Currently, we have 344 primary healthcare centres in the state.
Are they all functional?
Oh yes. They are. But you also have to understand that we have three types of health centres. So, when we are talking of functionality, functionality is at different levels. So, I will just explain that a bit. We have what we call the Type One health centres of Health Posts, the Type Two or health clinic and then the Type Three, which is the Model Health Centres. So, they render different kinds of services. For instance, the Type One, which is the Health Post, they don’t usually go to work every day. They are those health posts where they have designated days where they go and render certain type of health services like immunization, family planning and maybe, basic outpatients visits because it is usually manned by the community health workers. Then we have the Type Two where you can have a nurse that would head the place, you have additional services in addition to the services I mentioned. You have ante-natal services, labour delivery and few other services attached to it, maybe HIV services; more specialised services and tuberculosis and all that, you have that in the Type Two facilities. Those ones they are expected to go to work every day. Buy they work 8-4 everyday. It is usually not like round-the-clock. But some of them that have accommodation, yes, it’s fine. Then you have the Type Three, the model. These ones are supposed to provide comprehensive healthcare services round the clock. So, you have Sunday to Sunday. There will be somebody there to provide healthcare services in those facilities. And in addition to those ones, you now have services that the doctors attend to. We have doctors in most of our Type Three facilities. So, other services that the doctor can treat like hypertension, diabetes, more specialized services are provided in those Type three facilities.
A lot of the healthcare centres are in disuse, more especially the model healthcare centres built Strategic Health Programme. Some are already overgrown. In fact, the one at Ebubu in Eleme Local Government Area is a farm right now. You said earlier on that all of them are functional. Does it mean…
Sorry, you know that we’ve had a series of cases where some facilities are not in use for the moment for various reasons. One of them is insecurity. One of them is vandalism. We have cases where there is a lot of insecurity in the town and it is very difficult for our staff to go there to render services. In that case, they can try a method that we call hit-and-run, where they visit to provide the services and they go. But when it is really bad they stay away from those facilities because we know that first of all, it is safety first. I am sure you are aware that Ebubu is a town that had a lot of communal crises in the past. Another one is Obele in Emohua. There are several facilities like that. And when we don’t go for a while, they go in and vandalise. We even have facilities where OSPAC took these facilities because of insecurity. They were living there and were using it as their head offices. But as normalcy returned to those communities you would see that we have now taken over several of those facilities. OSPAC has moved out. We have renovated and our staff have started providing services in those facilities. So, for now we understand that we have those challenges and there are reasons behind them.
If you confine yourself to one or two that you went to and we have challenges, also bear in mind that we are working to ensure that all our facilities are fully functional. We have some one or two here and there. It is normal in every system. But we will not use those one or two, you understand to now say all of them in the LGA, you understand. Eleme you are talking about, Akpajo is there, Onne is there, Agbonchia is there. Ogale is functional. Of w now say we want to narrow ourselves to on, it will not be the true picture.
You have these 344 health centres. How many of them are in a state where they would need to be rehabilitated?
Yes. During the 100 days in office of the governor, even in his speech he mentioned ten facilities that we equipped and furnished. And some of them were really dilapidated like the one at Egberu. Egberu was gone. We had to go there and bring down everything. The roof, everything. And we practically finished that particular renovation. It’s a process it’s not a destination. It is not 100 percent but it’s not below average. We are getting there. I can tell you that we are between 60, 70 percent.
One of the complaints we got from the field was that the centres were understaffed. Where doctors were supposed to be in charge, they were not there. Even some of the areas, you won’t find nurses or midwives.
I’m sure you are aware across board there is gross shortage of manpower. It is not peculiar to health sector. People have retired, people have died, people have been transferred, people have left the country. All these things have happened. There is a gross shortage of manpower in the system.
The governor is fully aware of this. That is why he said that they are going to employ primary healthcare workers. Primary healthcare is at the centre of healthcare service delivery in any community and in any society. It’s very important. He has acknowledged it and he has said that he is going to engage shortly. I can tell you for free that he said so. I know that at some point the hospital management board had even started engaging. But I don’t think they have concluded. But he has promised us that they are going to engage.
And even currently, we have a midwife service scheme that we are doing in partnership with NPHCDA. All these are stopgap measures to address the shortage of manpower. In the midwife service scheme, we are going to engage bout 80 midwives and w are going to distribute them across the state in mostly areas…
How many would you need, like how many doctors, how midwives, how many nurses in specific terms because you would have been planning for it over a long time?
Yes. We have done our own needs assessment and we have got the exact number of doctors we need, nurses and community health workers, pharmacists and other healthcare workers. We have done it and we have that document. But it’s not here with me. So I can’t start giving you exact figures. But I want to assure that we have done needs assessments and that we are ready to employ shortly.
There is this issue of insecurity in a lot of those places. It’s either that the facilities are at risk, people are breaking into the place and stealing facilities or even personnel were being attacked by hoodlums and doctors stopped going to such places.
We had cases of insecurity. I mentioned it earlier. Primary healthcare is about community healthcare, or so to say. So, we always engage the community; the stakeholders in the community when we have these challenges we tell them. Nobody would willingly provide healthcare services in a community that is in crisis. So, we try to engage them and tell them to address these issues. They are to own primary healthcare because it is about community ownership. When they own it they will always protect us, the healthcare workers and also the facilities. When we have cases like this we engage the community and ensure that it is addressed and it does not recur. But when it gets out hand, we pull out our staff until the situation gets better and then we then send them back.
We are concerned that the people are not patronizing the centres despite assurances of free access and affordable services. There was a centre we visited at which for one whole month, no patient came. Are you worried?
I don’t know the particular centre you are talking about. But one of the key things that the current administration is going to embark on is community engagement. When we engage the community we tell them about the services that are being provided: immunisation, maternal, child. When we now tell them about that, you will now see that there is this buying by the community. So, we have a community engagement plan currently to address it. And it is going to be something to be adhered to. We will talk to market women, we will talk to the traders and churches. That is the community engagement plan that we have come up with. We understand that for whatever reasons, some people don’t go to the primary healthcare centres probably because they are not well informed. They have a different perception of how the facilities are supposed to function or the services they are supposed to receive from those health centres. So, we have come up with a community engagement plan and we are going to activate it shortly as well. I am sure that is what is also going to drive members of the community to utilize the facilities.
Does it cost anything to access services at the health centres?
Certainly. And also to add to what I said before, the current administration has also activated the health insurance scheme.
Does it go down to that level?
Yes. When we are talking of access to a facility, there are different barriers that can prevent someone from accessing. One is the physical barrier. Another one is the financial barrier. Then you can talk of the cultural, socio-cultural factors and all that. But the current administration realised that it is important we commenced a social health insurance scheme, a state health insurance scheme. The previous administration in its wisdom actually enacted the law. They did well by coming up with the social health insurance law, the bill that made into law. And now we are implementing that law. It is designed such that health insurance will be provided for the indigent. That is just one component of it. So, people that would not ordinarily be able to afford services in these health centres would now be able to because they are now under health insurance scheme that is going to be paid for them under the scheme. They will be able to now access services because that is one of the barriers. I am sure you know that is one of the reasons why people do not access those services. So, with the state health insurance, we are very very sure that more people will start utilizing these facilities.
The locals said one of the things that scared them was that they were asked to pay for services.
It is expected. Healthcare is not free anywhere in the world. It is either you under one community health insurance or you have to pay something for it. So, we have services that are paid for and we have services that are free. So, it will depend on the services that the individual had gone there to access. For instance, if the person is there to access immunization services, family planning services, HIV services, tuberculosis services, health education services, ANC services, these ones are free. Consultation is also free. But when you say you want to do investigations, you want to test for malaria, you want to check my blood level or I want to know if I am pregnant. Those tests you would have to pay for them. Then if after the doctor had seen you, you have gone through examination and you have done some tests and they look at the results, and they feel there is a need for you to buy some drugs of course. You have to pay for those drugs.
But what we try to do in our own health centres is to make sure that those drugs are at a very reduced rate so that the people that come there to buy drugs the quality first of all of those drugs are good and then, secondly people are buying them at a reduced rate that is competitive. Our facilities are actually more attractive because the rates are much lower.
So, yes. They have to pay for some certain services. Labour, antenatal, then delivery. Then delivery as well. During our programmes. We have different programmes, maternal labour and child health week, it is expected that a lot of these services that they pay for are actually provided for free. So we have different interventions at different times. It just depends to make healthcare services more affordable and more accessible to our clients in the communities.
There was also this issue of power supply. In one of those places, people said they could not come for delivery or any serious cases. Like you said, the model health centres should running 247 so that at any time, people can come forward for services. But you find out that there is not power supply in many of the centres…
You will find out that in a lot of those health centres, especially the model ones, they were given big diesel generators. And running those generators we consider the cost of the parts of the generators, and also the cost of diesel. It’s not sustainable when you consider the funds that we have. So, what this administration has done currently is to now start providing them with 5KVA petrol generators. A lot of our facilities are now on 5KV generators.
We understand that light is important and also water. If you don’t have light you cannot pump water. And those facilities should have potable water. So we make sure that a lot of our facilities now have water. We even have some facilities that have solar, that are solar-powered in addition to the generators. We understand the need to move from this petrol to a more energy friendly power sources.
And when you get to the health centre, you now accessed, now treated given what is the basic treatment. It is t that point that they will now decide whether there is a need to refer you to secondary or tertiary facility or say go home and come back in about two weeks. So, the broad range of ailments whether it is maternal or child health, ANC delivery, whether it is immunisation services, whether it is outpatient services like that hypertension, diabetes, arthritis, name it. They are all supposed to be services that are provided in our primary health centres. You remember that we categorised the three of them. So, mostly in the Type 2 and Type 3 facilities. So, when they go, they treat you and they now say this one should referred to the tertiary institution.
So, let us not say that there are some services that primary health centres should attend to. If you have anything beyond that don’t go there. It’s the first port of call for any health challenge. When you go there, they will check you, assess you and then now refer you accordingly.
Do they do deliveries, or just antenatal programmes?
Our Type 2 and Type 3 facilities do ANC, they take labours and they take deliveries. Beyond that they do what we call postnatal care after six weeks. The woman is still expected to come back and she will be assessed to make sure that she’s okay after delivery and that there no complications.
And just to also increase access to remove finance as a barrier to delivery because we found out that a lot of mothers come for ANC in our facilities but when it is time to deliver, we don’t see them. They would say they are going to where their mother was delivered. They go to TBA, traditional birth attendant of the community. We found out that that was a challenge. And some of them was as a result of finance as well. So, the board now said, okay if you go for four antenatal visits, your labour and delivery will be free. So, that money charge for that’s service is you will not be charged. So, it is also a message that has been sent out. A lot of people are aware. So, it has also helped to drive up number of clients traffic to our facilities.
Do you also do inpatient services?
Oh yes. Inpatient to an extent. In the ideal situation, we observe them for a day and then we now decide what to do. After then they decide what to do whether to send you out or to offer more care.
You talked about having different stakeholders coming together to provide healthcare services at that level. Who takes the lead, the community, the women leaders youth council, CDC or the agency?
The dynamics are different for different communities. But if we are talking of the stakeholders, who takes the lead? If you go to a community they will tell you. That’s our chief, that’s our women’s leader; that’s our youth leader. That’s our CDC. Oh! That’s our pastor. You understand. When you engage the community properly, do a proper community entry, you will know the stakeholders. It may just be just one old man somewhere or one old woman. So, we work with all of them. It’s not as if one person must take the lead. We work with them as a team and see how we can promote health in those communities.
How much international collaboration do you have and collaboration with international donor agencies?
Oh yes. We well know that healthcare is dynamic and changes with time. It is always for the better. We have always found ourselves in a situation where our parent boy, that s the World Health Organisation (WHO), UNICEF, we work with.. We have several donor implementing agencies that we partner with to ensure service delivery. That is not just technical. And then we have our parent organization, the National Primary Healthcare Development Agency. We work hand-in-hand. A lot of programmes have been carried out working in collaboration. For instance there is the basic healthcare development fund where NPHCDA is the gateway. We have the health insurance, the emergency and the NCDC, the centre for disease control for different programmes.
How o you manage your cold chain facilities? They were installed in a lot of the model primary health centres and they need power supply. But a lot of the centres do not have power supply. The vaccines could go bad in such situations.
Here at the board we understand the importance of the cold chain system in proper health management system. It is not just at looking at cold storage, we are also looking at logistics. How do you move them maintaining a certain temperature to a certain station. And how is it also preserved in that location until a client, a baby or mother accesses it or given that immunization or vaccination as it were? So, here at the board we have a state cold chain store. We have walk-in freezers. I am telling that 24/7 light does not go off in that place. We even have a separate generator for the cold chain, outside the one for the offices. We have a separate generator for the cold chain.
At the level of the facilities, how do they get these vaccines to them. We do what we call a PUSH system. You take the vaccines to them so it’s easier for them in terms of logistics to get these vaccines. We push it to the local government and the heads of those facilities come to collect them according to their needs and they take them to their facilities.
It is worth mentioning that all our healthcare centres that provide these services, we have cold chain freezers in all of them except those health posts where they come and then they go. Even in some of our health posts we have them. But all our health centres we have solar-powered freezers. So, those freezers are always working 24/7.
Are you worried that people are not taking advantage of what you have put in place?
If you look at our figures, people are actually accessing our services. They are accessing immunization services. I can tell you for free. I will take you round and you will see what is happening in our facilities. Like I told you we have isolated cases. But most of our facilities, mothers are taking advantage of them.
People running tertiary institutions are complaining that people that should be going to the primary and secondary health institutions are coming direct to the tertiary institutions.
Just to tell you, it was really really bad previously when we had a lot of people going to the tertiary institutions because they hnd confidence that when they go to those facilities they will receive expert care. But right now I can tell you for free that the dynamics have changed. A lot of people are now accessing our primary healthcare centres. That is why if you go to the tertiary health centres now, they will tell you that they have sent some of their doctors to our facilities because this normal delivery, they don’t take them like that again. You can go to our tertiary institutions, you can go to BMH, the normal delivery, that is the vaginal delivery, the number that they take in those facility has really reduced to the extent they will now send to so our busy facilities very, saying, nurses, doctors, go and see how they are taking normal vaginal delivery in those facilities. So, like I said, it’s a process. It’s changing. We are strengthening our system. And the more w strengthen our system, the more people become aware that they can access those services in our health centres, the less people you would find in those tertiary and secondary facilities.
There is this primary health centre, Obio Cottage Hospital. It has been commended because they said Shell is behind it. Does it have a relationship with you?
It’s in partnership with Shell. It’s not that Shell is behind it. It’s Rivers State Government facility.
It’s in partnership. It is Obio Community Health Insurance Scheme at that Obio facility. And it’s a tripartite arrangement. The community is involved, the government is involved, SPDC, a partner is also involved. It’s a fantastic scheme. The facility is doing well. And one of the key reasons is because of the insurance scheme. That is why the government in its wisdom has decided that we are going to implement the Rivers State Health Insurance Scheme. The training has been ongoing. The process has been activated. The training has been ongoing. Stakeholders have been called to discuss the implementation. And I am sure in a few months you would hear that the health insurance scheme has been activated and you will see that facility will start being busy just like Obio Cottage Hospital.
How much did it cost to put up one of these model primary health centres?
That was one in 2010, 2011. We don’t have access to that information. It was done at the level of the ministry of health. So, we don’t have access. We don’t build per se.
