Lack of Ambulance, Emergency Services Hamper Universal Health Coverage in Rural Borno Communities
By Zainab Yetunde Adam
Maryam Umar is seen fidgeting continuously in the waiting area of Zabarmari Health Clinic, Jere Local Government Area (LGA), Borno State. When this reporter walked up to her for an interview, the reasons behind Maryam’s restlessness became obvious.
In her arms is a 5-month old baby desperately in need of immediate treatment for Severe Acute Malnutrition (SAM). For the second time in her life, she is in need of emergency attention.
The first time, she lacked emergency obstetric care that made her anaemic and unable to produce breast milk to feed her baby. Maryam still wriggles in pain as she walks back home with a sachet of Oral Rehydration Therapy (ORT) and 5 tablets of paracetamol following a nurse examination to treat her malnourished baby’s diarrhoea and vomiting issue.
Outside the clinic was Yusuf Mohammed, a volunteer worker at Zabarmari Clinic and also a resident of the same community exchanging pleasantries with patients visiting the clinic. Mohammed hopes that the rate of maternal deaths in the community will reduce soon.
For over 30 years, Mr. Mohammed has witnessed several instances where patients referred to other hospitals by the clinic for complicated and emergency care die while their relatives are still looking for means to transport them or search for transport fare due to lack of emergency ambulance services.
“There was a woman named Maryam from Lagawa settlement under Zabarmari community, who was rushed into this facility for an emergency removal of placenta. Her situation was complicated and we could not handle it. She was referred to the state capital immediately but there was no means of transportation. The family had no car nor money to transport her. The facility staffers had to contribute money to pay for the transport fare. Unfortunately, she died on her way to the state capital because of the delay in sorting out her transportation.”
Mohammed decried the difficulty patients encounter whenever they are referred to a higher level of care. According to him, commercial vehicles are impeded by road closures and delays at checkpoints which might not have been the case with an ambulance considering the effects of Boko Haram crises in Borno.
The Boko Haram crises is a huge humanitarian problem that has displaced millions of people in Northeast Nigeria with terrorists attacking government institutions and civilians in busy markets and villages. To this end, security checkpoints are mounted on the roads within and outside the state capital as part of a counter insurgency operation.
“An hour before Zabarmari attack of Saturday, 28th November 2020, a woman was brought into Zabarmari facility in need of urgent attention but the clinic didn’t have an ambulance to transport her.
“Her husband had to use a bicycle after the attack to transport her out of the facility. We don’t know what means of transportation he later used to convey her to the state capital, but she died on arrival at Sunni hospital, Maiduguri,” Mohammed said.
“We might continue experiencing more complications, if we don’t have standard pre-hospital services during emergencies,” said Fatima Yusuf, another resident of Zabarmari community.
Throughout her stay in Zabarmari community, she noted that hardly did a patient in need of emergency care ply the 25km untarred Zabarmari road in a commercial car, lacking the assistance of a trained personnel without dying or develop complications.
Another resident of the community, Zainab Mohammed said she usually give birth at home because her delivery mostly occurs during weekend. Although, she has been lucky, she said that lack of emergency services including a conducive mode of transportation has worsened the situation of many pregnant women who developed eclampsia and other birth complications in her community.
“At times after home delivery, one still need to go to a secondary health centre to treat anaemia, agalactia or other post-natal sicknesses,” she said.
Despite millions of naira spent on ambulance and emergency services, patients still rely on private and commercial vehicles in rural communities
Despite, about N612m budgeted for the purchase of ambulances from 2018 to 2022 by the Borno State Government, residents are still left stranded whenever they require the services of an ambulance during medical and healthcare emergencies. The National Primary Health Care Development Agency (NPHCDA), under its minimum standard of PHCs identified ambulance services as mandatory for PHCs to function properly.
Despite the need for efficient and quality ambulance and emergency services due to the peculiar insecurity situation of Borno state, findings reveal that most rural communities outside of the state capital are left stranded with patients seeking healthcare resorting to unsafe means of transportation.
For instance, patients with haemorrhage and chronic eclampsia after birth who are referred from Dalaram Primary Health Care Centre, to the State Specialist Hospital in Maiduguri Metropolitan Council (MMC), which is about 5km, resort to using Keke Napep (tricycles).
“Many women have lost their pregnancies on the road to the hospital or even gave birth half way over the night at Zabarmari. We often struggle hard to save the baby and the mother once there is delay and complications already developed.
“We are in need of ambulance for urgent referral because you hardly get a Keke Napep to convey a person in need of emergency on time,” said Mrs. Abu Isa, the Deputy-in-Charge of Dalaram PHC.
According to Isa, Dalaram PHC was given a Keke Napep ambulance in 2020, but the facility only used it for 5 months before it broke down. The ICIR gathered that the said ambulance which is currently under repair, since April 2022 is one of the 10 medicalized mini ambulances which were procured by the United Nations Population Fund and the Korean International Cooperation Agency (UNFPA-KOICA) and distributed across 3 LGAs of Konduga, MMC and Jere to prevent post-partum haemorrhage among other maternal complications that need life-saving emergency care between six and 12 hours after a woman has given birth. Additionally, Action Health Incorporated (AHI), in collaboration with the UNFPA donated five fully-equipped IVM-1100 tricycle ambulances to the Borno State Ministry of Health in 2020. Sadly, residents, particularly rural women and children, are yet to feel the impact of the donations and monies spent on ambulance and emergency services in the state.
Residents lament how poor emergency services is worsening access to healthcare
Attahire Kachalla resides in Lambu Filin Ball Internally Displaced Persons (IDPs) camp in Jere LGA. An event happened this year and it has stuck with her since then. She and some women fell ill and had to be conveyed to a hospital in an open truck while she was unconscious during an emergency child birth in April, this year.
“At this IDPs camp, if your illness is severe we contribute money amongst ourselves and get the person to the hospital at all cost and trucks come in handy,” said Kachalla.
She, however, noted that entering such trucks should not be the norm but patients and residents seeking healthcare especially during emergencies are left with no choice. Another resident who live close to Dalaram PHC, Abba Kaka, stressed that chances of community members surviving any medical emergency situation at night is very low since there are no vehicles to convey them to the hospitals or to a higher level of care when referred.
“If patient’s relatives are around during emergency, we will ask them to lift the patient up and take her/him to the truck,” Kaka said.
Kaka disclosed that the Dalaram PHC is rarely patronized by persons from the camp during emergencies adding that the PHC’s ambulance and emergency services is in comatose since the departure of a non-governmental organisation, Alliance for International Medical Action (ALIMA) who were jointly operating the facility early this year. The ICIR discovered that ALIMA spent 10 months at Dalaram PHC in 2021 and 3 months in 2022.
Disturbing stories that makes people avoid PHCs at their immediate disposal is not only common to Abba Kaka.
At Gongulong community also in the same LGA, 30-year-old Fanna Modu said that she doesn’t use the PHC in her community because of poor service delivery despite living adjacent the facility.
“There are no emergency services here. Most of the time, I travel to the state capital for proper care or beg the Civilian Joint Task Force (CJTF) to help transport us in their trucks during emergencies.”
Usman Bukar, a community leader corroborates Modu’s statement. Bukar said that whenever residents have emergencies, the CJTF will be summoned to help with their Hilux vehicles to transport them to the hospital. The CJTF is a loose group of young people that was formed in Maiduguri to help oust Boko Haram Islamist fighters from the city.
“Gongulong PHC closes by 4pm everyday so we have to use other alternatives when they close for the day.”
Mr Bukar noted that getting an ambulance with more trained personnel to attend to patients during emergencies will reduce the health risks.
Endless wait at community PHCs jeopardise emergency response
“I have witnessed many women in need of obstetric care, deliver at the gate of Fori PHC while waiting for the staff to come,” says Bulama Modu a resident of Fori in same LGA.
According to him, Fori PHC, in Jere LGA has a partly equipped ambulance but lack of fuelling and maintenance services has hampered their use.
“How can an ambulance operate without fuel in an emergency?” he enquired calmly.
Another resident, Zainab Mohammed explained that she started experiencing labour complications overnight but had to wait till the following morning before going to the clinic.
“The baby had already started coming out of me when the facility opened at 7:00am. I was later referred to the Nursing Home and was conveyed in my husband’s car. There was no urgency on the part of the staffers, neither did any emergency services came to our aid,” she said.
Ambulance: For show or use?
When Fori PHC was visited by this reporter, two ambulances were parked in the premises. The PHC is said to render all integrated PHC services. A staff of the facility who preferred to be anonymous said that the bus ambulance belongs to their facility while the Keke Napep ambulance belongs to another facility, Jiddari Polo PHC. The staff added that the Keke Napep ambulance was parked at their premises due to security concerns.
When asked about the functionality of their ambulance, the staff said they rarely use it due to lack of funds for fuelling and maintenance. A cursory look into the Borno State Primary Health Care Development Agency (BSPHCDA) allocation, indicated that N31,400,000.00 was budgeted for fuelling and general maintenance from 2019 – 2022.
“In an ideal situation, every emergency obstetric case, convulsion or other emergency cases are to be transported in an ambulance, accompanied by an expert,” the staff outlined.
Approximately, Fori PHC requires about 300 litres of fuel and 10litres of engine oil quarterly to effectively use their ambulances, a staff who does not want to be mentioned said. The staff hopes that the introduction of the Basic Health Care Provision Fund will cater for the facility’s need when it becomes operational.
Ambulance sharing amongst health clinics
Like other PHCs, the use of commercial or staffers vehicles to transport emergencies to a secondary facility is not new at Jiddari Polo Primary Health Centre, in Jere LGA.
The last emergency referral made at the facility of an anaemic patient was carried out with one of the staff’s vehicle in May 2022. According to Hajja-Gana Habib who is the officer-in-charge of Jiddari PHC, the facility has an ambulance which serves more than one PHCs in Galtimari ward.
“The ambulance at Fori clinic is not frequently used unless someone volunteers to fuel it when there is an emergency. We often share ambulance between ourselves to cater for emergency transportation of patients.”
Binta Abdullahi, a resident of Galtimari ward for over 30 years said she has never seen an ambulance in the facility.
“I once took my mother-in-law, suffering from chronic hypertension to the hospital around 2am but nobody was there to attend to us. Thank God she didn’t die,” she said.
Similarly, local sources at Zabarmari disclosed that there has been no ambulance and emergency services in the PHC since 1990. The community health officer of Zabarmari PHC, Abubakar Jidda affirmed that they only issue referral forms whenever the need for urgent intervention and evacuation arises.
“If referring a patient is the last solution, we just have to fill the referral form and give the patients or patients’ relatives to sort themselves out because we don’t have an ambulance for that.”
Jidda said transportation from Zabarmari to Maiduguri, cost up to N1,500 which is sometimes not affordable for most patients who are mostly peasant farmers.
The story is slightly different at Gongulong community. Ms. Maimuna Abba, who is the officer-in-charge of Gongulong Comprehensive Health Centre, said that late night emergencies, pregnancy and birth complications is their greatest problem. She stressed that availability of a well-equipped ambulance will aid quick intervention, on-road assessment, management and transportation of patients in a more coordinated way.
“A patient might come here bleeding with either haemorrhage or eclampsia. We will have to control it on the spot before looking for a commercial tricycle to transport the person to a secondary healthcare facility,” she reiterated.
At Gongulong and Zabarmari facilities, the fear of the health workers hinges on reducing mortality and morbidity rate in the community because their facilities serve as first point of call for more than 30 settlements prior and during current insurgency. As IDPs are relocated back to their ancestral homes or safe abodes, there is no doubt there will be need for emergency services especially during referrals to secondary or tertiary facilities.
In 2017, the National States’ Health Investment Project (NSHIP) and Performance Based Financing (PBF) scheme brought much relief to patients who couldn’t afford the cost of transportation from one facility to another. The NSHIP fund was used for maintenance services at targeted health centres and patients’ transportation (on referrals) for three years before it stopped.
According to WHO, about 930 million people worldwide are at risk of falling into poverty due to out-of-pocket health spending of 10% or more of their household budget. Borno, being a conflict-ridden state, a huge chunk of these expenses is spent on conveying patients in private cars, motorcycles and sometimes wheelbarrows to and from hospitals during emergencies.
Spiral of silence by Borno State Government
The Ward Health System as contained in the Minimum Standards for Primary Health Care in Nigeria recognises three facility types namely; health post, primary health clinic and primary health care centres, as crucial in strengthening healthcare delivery at the grassroots. However, emergency services at such facilities are rarely available because referrals are made with commercial vehicles instead of safe and comfortable transport systems like ambulances.
Sources within Borno State Primary Health Care Development Agency (BSPHCDA), saddled with the management and supervision of PHCs in the state, revealed that the Agency is financially hampered and cannot carry out its responsibilities as it should. The agency had no take-off grant when it started in 2013, the source added.
The agency only gets funding through partnership agreements between the state government and development partners via counterpart funding and other Basket funds. Findings showed that the funds realised are mostly used for routine immunization and training of health practitioners in the state.
Efforts to speak with Borno state government officials proved abortive. As at the time of filing this report, FOI letters sent to Borno state finance, budget and planning ministry, health and human services ministry, and the Borno State Primary Health Care Development Agency (BSPHCDA) specifically requesting for budgetary allocation, amount appropriated and capital releases on primary healthcare and emergency services from 2019 to 2022 got no response from any of the organisations.
Text and WhatsApp messages sent to the known contact of the Executive Director, BSPHCDA, Dr Goni Abba was also not replied. Several attempts to speak with Dr. Abba in an interview was futile. Visits paid by this reporter to the Agency between 1 to 4 August, 2022, yielded no fruitful outcome.
*This report is supported by the John D. and Catherine T. MacArthur Foundation and the International Centre for Investigative Reporting, ICIR