WASH takes a back seat as Kwara govt embarks on PHCs renovation
Although Kwara state government has embarked on the revitalization of its Primary Health Care system, an unhealthy pattern that may scuttle the intended benefits has been unraveled. A fact-finding visit to rural communities in Asa and Moro local government areas (LGAs) by Solacebase correspondent , JUSTINA ASISHANA revealed a disregard for WASH infrastructure in the majority of the PHCs.
By Justina Asishana
Despite the rehabilitation of Primary Health Centers (PHCs) by the state government, several facilities still lack Water, Sanitation and Hygiene (WASH) infrastructure. Visitors to the Tepatan Health Center in Moro local government area of Kwara state have no access to toilet facilities whenever they want to excrete or ease themselves while in the health facility.
“Whenever I and other workers or patients want to excrete or are pressed, we go into the bush o! There is no toilet. We are currently constructing a toilet but it is not ready yet, so it is the bush that we do our business with,” said Fumilayo Audu, the officer-in-charge of Tepatan Health Center in Moro local government area (LGA), Kwara state, told Solacebase.
Although Tepatan Health Centre was recently renovated and painted by the National Youth Service Corps (NYSC) Batch A, B and C set of 2021, a closer look at the facility paints a different story entirely. The centre which looks new to passersby lacks adequate space, facilities, and essential medical equipment.
The health centre also lacks access to potable and quality water as staffers have to take a 10 minutes’ walk to the middle of the community to fetch water from a borehole. Although, the centre is currently constructing its toilets it has been halted due to the unavailability of funds, according to Audu. The soak-away has already been dug but not connected to the building. The toilet is also yet to be fixed.
“The toilet is under construction but we have dug a soak-away pit outside but it hasn’t been connected to the toilet because the money has finished. Maybe when we get the next tranche, we will be able to complete the toilet. We only have room for one toilet for now,” Audu said.
She also explained that the health facility which serves over 10,000 residents of Tepatan community is having serious setbacks regarding access to Water, Sanitation and Hygiene (WASH) infrastructure adding that it has made it difficult for the health centre to deliver quality services to its patients.
Among the services rendered by the health centre include treatment for diseases and ailments like malaria, fever, diarrhoea, headaches, immunization, maternal and child health, take deliveries, ante and postnatal, HIV counselling and testing and nutrition.
“Despite offering these services, we do not have enough space, as you can see, there is no table, no chair, and not enough benches. It is still under construction because the money we received was not enough to complete the reconstruction but even after the construction, the space is still not enough.
On a tour of the facility, Audu noted that for anyone who wants to use the toilet, the bush is there to carry out their business.
The water, sanitation and hygiene challenges faced by Tepatan Health Center are faced by most of the primary health centres across rural communities in Kwara state, as the majority of these facilities lack potable water and a good toilet system.
In particular, water supply and toilet facilities in the majority of the PHCs visited do not meet the minimum requirements stipulated by the National Primary Health Care Development Agency (NPHCDA) in 2017 for a basic health centre. The NPHCDA specifies that a primary health centre should have water and toilets facilities within its vicinity.
In the few PHCs that have toilet facilities, the staffers rarely make use of them due to lack of water. Patients and officials disclosed that they prefer to defecate in the bush.
Kwara health sector expenditure and its slow-paced PHCs renovation drive
Analysis of Kwara state government budget for capital expenditure in the health sector showed that in 2020 and 2021, the state government budgeted N17.94bn and N13.35bn respectively for capital expenditure. However, in 2022, the amount budgeted was reduced to N12.3bn.
In 2020, the Kwara state government expressed its plans to begin the renovation of 193 Primary Health Care (PHC) centres across the 16 Local Government Areas of the state in its bid to create a sustainable healthcare delivery system.
The government said that the renovated PHCs would be equipped with state-of-art equipment to meet the needs of the people at the grassroots and the reconstruction would be done in batches, where about 40 health centres would be the first beneficiaries. However, the plan is being executed haphazardly, with critical elements including water, sanitation and hygiene (WASH), necessary for effective and quality healthcare delivery not well prioritized.
According to UNICEF, hundreds of millions of people face an increased risk of infection by seeking care in health facilities that lack basic necessities, including water, sanitation, hygiene (WASH) and health care waste services.
UNICEF further stated that health facilities without proper toilets and waste disposal can spread diseases instead of preventing them. The organization noted that sanitary management of excreta in health care is particularly important to ensure faecal pathogens do not contaminate the health care facility environment or surrounding areas.
The Kwara State government in its 2021 Fourth Quarter Budget Implementation Performance Report claimed to have expended N2.279 billion (13.98%) on the health sector with the total amount of N196.16 million spent on unidentified selected basic health centres across the state.
In its 2022 first quarter implementation performance report, the state government said it spent N973.67 million on the health sector which makes up 5.9% of the approved budgeted amount. Sadly, no amount was expended on capital expenditure as a huge percentage of the funds released was for personnel and overheads.
A cursory look at the N12.3 billion budgeted for the entire health sector in 2022, showed that the state government budgeted N1 billion for the construction/provision of hospital/health centres while N500 million was proposed for the rehabilitation/repairs of hospital/health centres.
Visits to PHCs across rural communities in Asa and Moro LGAs paint an appalling scenario. Many of the facilities are without toilets and the few with toilet facilities, are not utilised by staff due to their uncleanliness and lack of water.
Majority of the staff in the PHCs visited said they prefer defecating in the bush than using the facilities’ toilets. Findings also showed that there is gross negligence on the part of the government and the contractors handling the ongoing rehabilitation projects across the state. They tend to leave out key issues including those related to the provision of water supply and toilet facilities in the PHCs. Most of these facilities also do not have a good waste disposal system.
For instance, the Community Health Post in Ajia Bako Afenifere, Moro LGA looks welcoming and pleasing to the eye, but it lacks water and a good toilet. Sources in the community told Solacebase that the health post was built by the Ajia Bako community after requests made to the government for a health centre fell on deaf ears.
When a visit was paid to the clinic, it was under lock. Residents said that the health worker who is the only staff had gone out to administer the COVID-19 vaccine to community members yet to receive the vaccine. However, a tour around the centre’s vicinity showed that it lacked a soak-away which meant that the facility has no toilets.
Habibat Ibrahim, who lives close to Ajia Bako PHC informed Solacebase that the poor sanitation infrastructure at the hospital has been a major challenge to officials and patients patronizing the facility.
“One time at the PHC, I had to go to the bush in front of my house when I was pressed. When I returned, I had to stay in the queue behind four people even though I was next in line before I left. The hospital is good and it is helping us a lot, but the lack of water supply and toilet facilities is a major problem affecting us.
“We have other issues too. There are times without drugs and testing kits. We sometimes have to pay for malaria drugs when people in other places are getting it free of charge,” she said.
The health official at Ajia Bako PHC, Mrs Risikat Alaba later disclosed that there are no free malaria drugs in the PHC because it is a new facility and yet to be officially captured under the program.
In Budo Egba PHC, Asa LGA, one of the nurses, Abdulkadir Sherifat claimed that the toilet was functional. However, a visit proved otherwise. Dead insects were seen on the floor while the water system had no water in it. The bowl of the toilet was stained with grime and dirt. It showed that there was no regular cleaning of the toilet.
Lingering equipment and personnel problems
According to the guidelines for the creation of PHCs, it was stated that the Primary Healthcare Centers are expected to run 24 hours’ services except for health posts which should run for eight hours or as determined by the community hosting it. However, none of the PHCs visited run a 24-hour service as they are all short-staffed.
Ajia Bako PHC is facing the same challenges other rural health centres are facing which include inadequate beddings, no drugs, no test equipment and lack of staff. Although, the Basic Health Center in Otte-Oja, Asa LGA, has all the facilities often found in a standard PHC, however, the facility which caters for over 14,000 residents in the area, is also grossly understaffed. The centre is manned by four staff.
The officer-in-charge, Nurat Ibrahim, explains that she acts as the nurse, matron, and midwife to take deliveries of babies, conduct malaria testing, carry out family planning, do consultations, administer and sell drugs, do record keeping and any other tasks needed by patients who visit the PHC.
“No health worker wants to work in the rural area. I think the government should make it mandatory for the student nurses and health workers to be posted to the health centres in the rural areas for their practical period. Although the Community Health Workers try to post their students here but when they come, they are not ready to do anything.
“All our equipment and tools are just wasting away. We have sophisticated equipment for testing, we have standard wards with beds and standard delivery rooms but these are rarely used. We do not admit people overnight, just for the daytime and they leave,” she said.
Data on the state of WASH in Kwara state
The lack of WASH facilities in PHCs is one of the major contributory factors to improper hygiene practices, thereby increasing the risk of hospital-acquired infections.
According to UNICEF and the National Bureau of Statistics (NBS) report, the north-central region ranks lowest of all geopolitical zones in the number of people using basic water supply, and sanitation services.
Out of the 36 states and the federal capital territory (FCT), Kwara ranks 36th, just a step above Ebonyi which sits at the bottom of the table.
The report also showed that Kwara ranks highest amongst states where open defecation is rampant in the country. Also, data from the 2021 WASH National Outcome Routine Mapping (NORM), showed that 50 per cent of the state population engages in open defecation while only 12 per cent of residents have access to basic hygiene services.
Adequate WASH facilities allow patients to keep their dignity and invariably prevent epidemics. Poor access to WASH in health care facilities, especially in delivery settings, negatively affects maternal and newborn health through multiple direct and indirect mechanisms and increases the risks of hospital-acquired infections for other patients and visitors.
UNICEF supported the National Primary Healthcare Development Agency (NPHCDA) to develop technical guidelines for WASH facilities in PHCs across the country. The aim of the guidelines is to provide a framework and standards for the construction of PHC WASH facilities in the country.
According to the specifications, it was recommended that a PHC should have one of the three types of excreta disposal systems which could be the Ventilated Improved Pit (VIP) latrine, Pour-Flush Toilet, or the Water Closet Toilet in rural, peri-urban and urban areas.
The guide also recommended that provisions be made for two separate units of empty-able, lined ventilated improved pit latrine; urinal and hand washing, one unit each for males and females. Sadly, most of the PHCs in rural communities in the state do not meet these recommendations. According to World Health Organisation, the recommended standard toilet to patient ratio is 1 to 20. This implies that one latrine or toilet to 20 users at in-patient centres.
The poor WASH statistics have found their way into primary health centres, thereby reducing the capacity of the PHCs, which is often the first port of call for rural populations, to respond to diseases as the majority of the healthcare facilities visited in Asa and Moro LGAs stated that malaria and diarrhoea are the top ailments treated in the health facilities.
Experts admonish government on WASH mainstreaming in health facilities
The Executive Director of Media Advocacy and Technology Center in Ilorin, Musa Aliyu, while speaking with Solacebase, said that the 774 PHCs in Kwara state are grossly underdeveloped when it comes to the issue of WASH.
According to him, a recent survey conducted by his organization, in collaboration with other partners showed that the majority of PHCs, particularly in the rural area, lacked basic facilities for hygiene particularly water supply and toilet facilities adding that the rehabilitation of some PHCs has done no justice to this development.
“Most of these facilities tend to engage in open defecation. Unfortunately, the rehabilitation ongoing in some PHCs equally shows gross neglect on the part of the government and the contractors handling these projects. They tend to leave out key issues of water supply, waste disposal and sanitation in the PHCs. Most of these facilities do not have toilets and soak-aways.
“It is quite unfortunate that a budget of N2.2 billion has been expended in the renovation of PHCs in Kwara state and unfortunately, a key component of the sustainability in these PHCs is missing, which is water and sanitation. It is quite unfortunate that the impact of the funds appropriated for the health sector has not been felt especially in PHCs in the rural areas,” Aliyu said.
Aliyu recommends a more robust engagement of policymakers and other stakeholders on how to ensure the sustainable administration of PHCs in the state. He added that a thorough system for monitoring and evaluation must be entrenched specifically to meet WASH needs in the health facilities.
“This is the time for the government to be more transparent and accountable to the stakeholders in the sector especially when it comes to healthcare financing.”
Aliyu also advocated the allocation of funds to the construction of toilet facilities, employment of more health workers, and equipping of PHCs across the state.
The Executive Director of Gem Hub Initiative, Pitan Oyeyemi noted that the Basic Healthcare Provision Fund (BHCPF) which is sent directly to the health facilities to attend to priority needs can be maximized in meeting the WASH needs of the facilities that have none.
“The Basic Health Care Provision Fund is a catalytic intervention by the Federal Government of Nigeria to improve health care services and subsequently health outcomes at the subnational level.”
She expressed dismay that a primary health facility would be allowed to operate without toilet and sanitation facilities adding that this practice encourages people to indulge in open defecation.
“It is disheartening that some primary health care facilities have no toilets! The PHCs are the closest to the people. Aside from being the first contact for health care, they are to uphold the principle and practice of top-notch hygiene. A health care facility without a toilet automatically promotes open defecation, which contributes significantly to public health issues and emergencies. If it is not corruption, then it is incompetency. It is just like building a mansion without a toilet, it’s a matter of time, the mansion will become an eyesore,” Oyeyemi stated.
Oyeyemi appealed to the state government to take ownership of sustainable financing of the health system in the state through various innovative funding stating that the government can involve private sector and development partners.
“CSOs and youth should always call government to action in ensuring health care centres have proper WASH facilities. I will like to use this opportunity to ask people at the helm of affairs, decisions and policymakers to be genuine and full of compassion for the people they lead.”
Meanwhile, a common theme of requests by residents across various communities visited showed that the provision of water and toilet facilities will greatly reduce the susceptibility of residents to malaria and diarrheal diseases.
Solacebase efforts to speak with the Executive Director of the Kwara state Primary Healthcare Development Agency (KPHCDA), Dr Nusirat Elelu proved abortive. This newspaper placed several calls to her official lines but it was not answered. Several messages also sent were not replied to.
Subsequently, Solacebase contacted the Commissioner of Health, Dr Raji Rasaq , he instructed that the Director of PHCs in the Ministry of Health, Dr Micheal Oguntoye be contacted. When Oguntoye was contacted to provide information on the poor state of WASH in PHCs and react to other findings of this report, he declined comments stating that he has not been directed to speak on the matter by the commissioner.
This information was related to the commissioner, who then provided another contact, Bukola Fabiyi, who he said was in charge of WASH in the Ministry. When Fabiyi was contacted, she became evasive. She said she was in a meeting and would get back to the newspaper but she didn’t. A day after, another call was placed to her phone and she promised to respond to the questions but she failed to do so. Subsequent messages and calls placed to her lines were not answered nor replied.
This publication is produced with support from the Wole Soyinka Centre for Investigative Journalism (WSCIJ) under the Collaborative Media Engagement for Development, Inclusion and Accountability project (CMEDIA) funded by the MacArthur Foundation.