It was not the first time this particular patient would be referred to go do a test at a private hospital or lab. Sometime in November 2018, he was referred by a female doctor at the same Primary Health Care Centre (PHC).
While at this private hospital, the patient told this reporter that he observed that almost half of the patients at the front desk were from the same PHC as he. Clearly, they too had been referred to do various medical tests there.
The Lagos State government in 2016 reiterated its commitment to improving the quality of service delivery at all its Primary Healthcare Centres, after the establishment of the Health Sector Reform Law in 2006. It promised to look into the areas of infrastructural upgrade, data management, operational cost, power supply, water supply, and drug supply.
Also, in December 2017 the Lagos State government signed the 2018 Appropriation Bill into law. The N1.4 trillion budget was said to be the second-largest in the country and the first budget of the state to cross N1 trillion. Based on sectoral allocation, N92.67 billion was earmarked for running the health sector in the state, which the Lagos State Primary Health Care Board (PHC) is part of.
But despite the commitment and efforts of the state government to raise the standard of the PHCs, and budgetary allocations to the health sector, some PHCs still cannot conduct basic tests either due to lack of equipment, lack of staff, or unforeseen circumstances like the absence of a lab scientist. This was the finding of an investigation carried out by this reporter over a period of few weeks across some PHCs in Lagos State.
Araromi Primary Healthcare Centre
Somewhere in the boisterous community of Obalende, Lagos Island, just after Moloney Street, quietly sits a brown one-storey building. One would find it hard to know it’s a Primary Healthcare Centre (PHC), except for the faded notice, ‘Araromi Primary Healthcare Centre’, printed on a flex banner and nailed to the wall.
When this reporter entered Araromi PHC at 10:02 am, there were five people inside – four women and a man. A pregnant woman (the cleaner) was sitting behind a table by the door segueing with another woman closely beside her. They seemed to be doing nothing as two of the other women were sleeping on the patients’ waiting seats. The man, identified as the security man, stood and left quickly, leaving this reporter with the four women.
“What do you want?” one the women, the nurse, asked. This reporter said he wanted to see a doctor for some health complaints. The nurse’s face lit up a little as if a real patient had finally come.
“Help me get a card,” she said in Yoruba language, addressing the cleaner who acted as the card issuer in the interim.
A white form was brought out and this reporter’s details were collected and documented. Once done, the nurse charged N100 ($0.27) for the green card. Then, she asked, “Ehen, so what’s wrong with you?”
This reporter explained the resistant malaria he had been experiencing, the treatment he had received, and asked to do a test.
After writing the symptoms, the nurse offered to give this reporter something stronger for malaria.
“No,” she said when this reporter insisted on a test. “Why not try something stronger, like an injection? Let me give you an injection.”
This led to an argument between this reporter and the nurse. Under normal circumstances, PHCs are supposed to check and note a patient’s vitals – blood pressure, temperature, and so on – before the patient sees a doctor for consultation. But here was a nurse insisting on injecting a patient immediately after taking down the complaints, bypassing due procedure.
“See, here we don’t have the kits and equipment to do malaria test,” the nurse said when this reporter insisted on a test. “We have a lab; there is a lab but no one to run it too. I can take you to the lab if you want. If you can’t go to Sura, there is nothing I can do.”
Sura is the clinic the nurse referred this reporter to. When this reporter requested a referral slip, the nurse said there was no need for one.
“Go to Sura, tell them you’re from Araromi health centre,” she said. “Go to their lab, they have the kits. You don’t need a referral slip, just go there. We are the same.”
The referral slip is a document that details the type of tests that a patient needs to conduct outside a hospital. The slip was denied this reporter. Rather, a piece of paper was given to him with the name of a woman he was to meet with at Sura’s lab.
“Let me just help you,” the nurse said. “Take this paper, go there and ask for this woman [name withheld]. She used to be here, but because the pregnant women prefer going to Sura, that’s why she’s there now. Go to her.”
Clearly, Araromi PHC does not have the facilities to conduct basic tests. There is also the issue of shortage of staff. Patients who come to this clinic are referred to Sura. That is, unless they agree to take injections from the nurse without a proper lab test.
Sura Primary Health Centre
Locating a place in Lagos Island is not usually a walk in the park, especially when you are not conversant with the area. So, after being tossed about by ‘direction givers’ for almost another hour, this reporter finally arrived at a yellow and green bungalow of a health centre, not as a referred patient but as a first-timer. It was exactly 11:59 am.
Unlike Araromi which was empty of patients and bland due to the lack of activities, Sura Primary Healthcare Centre was quite busy and things moved pretty fast. More than 20 people had already taken up the seats. This reporter later found that on this particular Friday, these people were not seeking any medical attention. They were not patients; they were health workers getting ready for training on Yellow Fever.
There was no young person among them, apart from the young man at the front desk and this reporter, the only ‘patient’ at that time, who just walked in looking confused, wondering who to talk to.
“Over there,” a voice by the door said. It was the young man at the front desk, clad in black. “Go to that place and get your card,” he said, pointing in the direction of the records cubicle when this reporter said he wanted to see a doctor.
At the registration department, this reporter was told that there were no single cards for issuance. Only family cards were available.
“Oga, we don’t have a single card. We only have the family card,” a plump, dark-complexioned man said through an opening, after taking his eyes off his phone.
A family card is a bigger folder which an entire family can use. Once a patient gets one of them, a tiny slip is given, which the patient is expected to bring whenever he/she wants to visit the clinic for consultation. A family card goes for N300 ($0.82), this reporter was told, while the single card goes for a standard price of N100.
This reporter further learnt that the single card finished a day before the visit (November 29). When this reporter asked what would happen if one could not afford the family card at the moment, the card issuer said there was nothing he could do.
“There is nothing I can do. The single cards have finished. They got finished yesterday. I’d give you a single card if there was one,” he said.
Given the circumstance, this reporter had no choice but to settle for a family card. From there, he was shown a room beside the registration cubicle, just by the left, where his vitals (blood pressure and temperature) were checked. He was further directed to the consulting room. By then, the Yellow Fever training had begun.
At the consulting room, the doctor did not talk much. He just listened and kept writing. When this reporter said he wanted to run a test, the doctor looked at him as if something was wrong with the request. He, however, recommended malaria parasite (MP) and full blood count (FBC) and gave directions to the lab.
Entering the lab, it was obvious that Sura Primary Healthcare Centre has the required equipment to do all most basic tests. An electronic microscope and other equipment were present. The tests cost N1,500 ($4.12), but this reporter could only afford one. This reporter’s blood sample was collected and within 25 minutes, the result was out, and drugs were prescribed.
Iponri Primary Healthcare Centre
The all-green painted bungalow seemed devoid of patients when this reported arrived. Apart from the workers at the main hall and three nursing mothers present at the time of visit, it was either the centre was newly built and as such gets a low patronage or this reporter was too early. It was about 9:58 am.
“What do you want?” a lady asked as this reporter stepped in. You can tell she was the card issuer as she sat behind a desk by the door with a shelf of files behind her. These card issuers are usually the first point of contact at any primary healthcare centre in Lagos. So, it is common to always hear that question on entry.
“I want to see a doctor,” this reporter replied, adding that he was a first-timer.
The card issuer began processing the card immediately, inserting the details this reporter supplied in the PHC’s daily attendance register. It was really fast, and in a few minutes, this reporter was talking to the doctor, and again, insisting on doing a test before any medication. The fair-complexioned doctor then recommended MP and Widal tests, amounting to N1,000 ($2.74), and directed this reporter to the lab where a young man was fiddling with some things. He was the lab scientist.
“The tests are N1,000. If you are ready let me know so I can take your blood sample,” the lab scientist said while retrieving the doctor’s note from this reporter.
After taking the blood sample, he politely asked for payment. “You can bring the money, and wait outside,” he said, adding that the result would be ready in 25 minutes.
The lab result was ready in 25 minutes as promised. But while everything seemed to be done right at this PHC, one thing was missing – they failed to check the vitals of this reporter as is the custom. When this reporter asked the card issuer why his vitals were not checked, she said it would be done by another nurse who would interpret the results of the test and prescribe drugs.
“They will do it. She will do it,” the card issuer said, pointing at the nurse. “Just take the result to her.”
The nurse interpreted the result, and the drugs were prescribed, but the vitals were never checked.
Besides the fact that this PHC has the equipment to do basic tests, this reporter learnt that it can also do other types of tests.
“We do all kinds of tests here,” said the lab scientist, who by then was out in the main hall, joining in the small talks.
Perhaps as a proof of this, while this reporter was being processed for the green card earlier, a woman from a hospital in Randle, a community in Surulere, walked in and made a request to conduct a Packed Cell Volume (PCV) test.
Iponri PHC has been in existence for six years. This reporter walked out of the facility at 11:30 am with the test results.
Oba Salami Primary Healthcare Centre
The weather was already hot when this reporter arrived at Oba Salami PHC, Fadeyi, at noon, 30 minutes after leaving Iponri PHC. The yellow and brown painted bungalow looked newly built, and this reporter learnt it is just a year old. However, it looked lonely and devoid of patients, as most health centres are usually crowded by that time of the day. There were only two patients at the PHC – this reporter and a woman. A few staff were present.
As this reporter entered the facility, two voices asked, simultaneously, “What do you want?” One of the voices came from a small room close to the gate, while the other was from a room in the main building.
While this reporter was in a dilemma, pondering whose question to respond to, the question came again, “What do you want?” This time, a nurse in a pair of white trousers and a spaghetti top stepped out of her office. She looked experienced.
After this reporter explained what his ‘mission’ was and opted for a test before treatment, the nurse processed a card for him. A family card was given to this reporter at N100 (as against N300 at Sura). This reporter’s vitals were not checked.
“I initially wanted to place you on malaria and typhoid treatment (injections), but since you want to do tests, then we’ll do both malaria and typhoid tests,” the nurse said. “Your money is N1,000.”
But given the limited resources available at the time, this reporter opted for only Widal test. His blood sample was immediately collected and within a few minutes, the results for both malaria and typhoid were out. Then another argument started.
“You have to pay extra,” said the lab scientist, a female, to this reporter, handing the result to the nurse. “I mistakenly did for malaria and typhoid, since we run it together.”
As the lab scientist made her point, she was backed by the nurse. But this reporter politely made his stance known, explaining to them that paying extra would be inconvenient. With that settled, the result was handed to this reporter who then took his leave.
This PHC, this reporter learnt, has the facilities to conduct all kinds of tests as well.
“Yes, we do all kinds of tests,” the nurse said. “People don’t usually come here much. They don’t know about this place because it’s new. It’s, maybe, one year old. So, people don’t really know about it. It’s now they are beginning to be aware of this place. But we believe with much awareness, they will begin to access this place.”
Ogudu Primary Health Centre
Visiting Ogudu PHCis usually done very early in the morning to enable one to get attended to early. The meticulous nurses here will never break the first-come, first-served rule. Patients know this, so at 6:00 am, the place is always crowded, with patients taking numbers in the order of arrival.
But on Monday, December 3, 2018, this reporter intentionally visited the facility late, at about 8:36 am. The pews were filled. But luckily, this reporter was placed on the 25th spot in the waiting list.
The crowd was much, and attending to patients was slightly slow, but gradually, in this slow pace, the crowd began to reduce as the nurses kept yelling out names. Sitting in the back, this reporter observed that as patients went into the consulting room, they came out with a slip in their hands, each looking for which direction to take. Curious, this reporter approached one of the patients, a dark, slim girl, and asked what the slip was for.
“I was given this slip and was asked to go and do the tests written here in Ojota because they can’t do it here. When you go in, they will give you yours,” she said.
The distance between this PHC and Ojota is quite much, but that did not seem to bother this female patient, just like many of the people who visit Ogudu PHC.
Shortly after, another woman stepped out, with her toddler son in front of her, holding her own slip in search of where to do the recommended tests.
At 12:15 pm, this reporter sat with a young female doctor in one of the cubicles with ‘Consulting Room’ crested on a plaque hanging on the brown wooden door. After this reporter explained the ‘symptoms’ he was experiencing and insisted he would not take any medication until he knew the exact ‘illness’, the doctor instantly tore out a referral form, wrote Malaria Parasite, Full Blood Count, and Widal on it and said, “Go and do these tests.”
This reporter asked why he was being referred elsewhere for tests that should be easily done at the PHC, the doctors said, “Because we don’t have the facilities. This is a primary health centre and not a general hospital.” This is despite the existence of a lab room at the centre.
“We do MP using the strip, The Rapid Diagnostic Testing. It means that you just put a pinch of blood on a strip and add a buffer on it and then it brings out two lines when it’s positive, and one line when it’s negative,” she explained.
“But it is not reliable. Most times, it tells you negative, and the patient presents clinical symptoms that you will obviously know that it’s probably malaria or something. It is simple, effective but non-specific because it can give you a false positive and a false negative if there is any viral infection in the blood – a viral infection in the blood that clears out after three/four days without use of drugs. The test can give you positive that it is malaria; meanwhile it’s not malaria.
“We would prefer the proper facilities and equipment for malaria testing. But it is expensive. A rapid diagnostic test is just N500. But if you want to do a blood smear for malaria, a real one, you’d have to do it outside,” she said.
Alapere PHC, Ketu
At 09:06 am when this reporter stepped into Alapere PHC, the place was already busy. It was noisy, with nursing mothers whose babies’ cries filled everywhere, a sign that it was Wednesday, a day for immunisation.
Balikis, whose job it is to issue cards to first-timers, asked the usual question, eager to know what this reporter wanted.
“We don’t have doctors here. But we have nurses who will attend to you,” Balikis told this reporter when he asked to see a doctor.
With that, she began registering this reporter. As she handed the blue card to this reporter, she said the health centre is equipped to carry out all kinds of tests.
“Yes, we do tests here. We have a lab,” she said, smiling as if she had hit the answer right, and offered this reporter a seat.
The nurse was not around at this time, and this reporter was asked to wait. The babies cried louder, and their mothers did their best to know why. The nurse arrived at 10:00 am, but it took a while for this reporter to get attended to because there were babies who needed prompt attention.
“What is wrong with you?” the nurse asked, after injecting a few of the babies.
As this reporter spoke, narrating the symptoms and saying he would prefer to do a test first before anything else, the nurse kept writing in a book. Once she was done, she got up and said, “Follow me.”
No one was in the lab when the nurse and I got there. Balikis confirmed the lab scientist’s absence. It was noon and the number of patients had doubled.
Back at the nurse’s office, she asked if this reporter would do the malaria and Widal tests outside.
“Will you go and do the tests outside? Our lab scientist is not around,” she said. She said they would have done the tests if the lab scientist was around, and offered to issue this reporter a referral slip to enable him do it at a private lab she recommended.
This reporter gathered that prior to this time, Alapere PHC never had a lab. It was also learnt that the lab was recently established, precisely two weeks before this reporter visited the facility.
“We have the equipment to do all the tests. I’m only referring you [to a private lab] because the person [lab scientist] is not around. This is not supposed to be so,” she said compassionately as she tried to give directions to the private lab she had referred this reporter to.
“We didn’t have a lab here before. This lab is just two weeks old, and a lot of people don’t know it exists. So we’re still trying to tell them that we now have a lab,” she said.
Apparently, this PHC has an equipped lab to handle basic medical tests, but the patients who were at the clinic the same day this reporter was there would have been referred to a private lab if the need arose because the lab scientist was absent. Also, the vitals of this reporter was partially checked.
Agawaru PHC, Lagos Island
Located in a heavily-clustered environment, a renovated, creamy-white and green one-storey building houses Agawaru Primary Healthcare Centre in Adeniji, Lagos Island. Walking through the gate, this reporter met three men whom he told the reason for his visit.
“Go inside,” said the bearded one among them.
Five people were inside the PHC, three women and a man, a patient. Already familiar with the drill, this reporter went straight to the card issuer, a dark petite-statured woman, and repeated his reason for visiting.
Although she found it difficult to spell this reporter’s name, despite several attempts at helping her with the correct spelling, the card issuer eventually spelt ‘George’ as ‘Jeoge’. “I can remember it [the correct spelling],” she said with a smile.
Soon after, an exchange of N50 ($0.14) for the blue card was made, and this reporter went to see the nurse. After explaining the state of his health to the nurse, the nurse handed this reporter a piece of paper on which was written ‘MP, Widal test’.
“Go and do these tests upstairs,” she said, pointing to the direction. At first, the lab technician, Akinyo Adeola, wasn’t around, but he reappeared holding a black nylon amidst efforts to figure out where he went. From there, we went upstairs.
“You’re running MP and Widal, so we use kits, the Rapid Diagnostic Test (RDT),” he said. “Yes, we do other types of test, but presently there is no light [electricity). Once there is no light, we just collect the sample and when there is light, we run the test. Also, when there is no light, we also allow the blood to settle down so we can make use of the serum for tests like hepatitis, and others. We make use of this RDT because presently the microscope is not on so we use RDT. We are precise in our results.”
Adeola then took the blood sample of this reporter and asked him to wait downstairs for the result which, he said, would be ready in approximately 30 minutes.
Downstairs, this reporter observed that the temperature of another patient was checked using the digital temperature gun, but the patient’s blood pressure was not checked. None of these checks was done on this reporter.
When Adeola brought the results, this reporter went back to the nurse hoping she would recall she had not done the vitals. Instead, she started making drug prescriptions and asked this reporter to wait for the pharmacist. “She’ll soon be here,” she said.
After a brief talk with the pharmacist, this reporter left with the result. On the door of the lab is pasted a list of a range of tests conducted by this PHC, indicating that this PHC can conduct basic tests and more, but may have to resort to using RDT for tests like malaria parasite when there is no power supply. The RDT is said to be non-specific and hence, could be unreliable.
Patients spend more to conduct tests at private hospitals or private laboratories. They also have to travel long distances to the locations of these labs sometimes.
Should PHCs conduct tests?
The question of whether PHCs should conduct tests is worth considering. The Primary Health Care system of Lagos State is regulated by the Lagos State Primary Health Care Board (PHCB) which was established through the Lagos State Health Sector Reform Law 2006 to develop Primary Health Care to a level where services will be accessible, acceptable and affordable to the people of the state.
Section 79 (1) of the Lagos State Health Sector Reform Law 2006 states: “There is established the Lagos State Primary Health Care Board (referred to in this part as ‘the Board’) which shall have the overall responsibility for Primary Health Care Management.”
Although the Lagos State Health Sector Reform Law of 2006 does not explicitly state whether or not health centres should carry out preliminary or basic tests, it, however, created a laboratory unit in the Lagos State Primary Health Care Board (PHCB) as indicated on the Lagos State website.
The board spearheads the objectives of the state for establishing the Primary Health Care System, and given the creation of a laboratory unit within the board, this then implies that PHCs should be able to conduct at least the basic tests.
“They are supposed to conduct basic test for all those small illnesses,” a source at the Lagos University Teaching Hospital (LUTH) confirmed to this reporter. “Some Primary Healthcare Centres have laboratories attached to them. So, if they have the facilities, they are supposed to conduct tests. But if the government (local or state) establishing them doesn’t provide them with facilities, then they can refer them (patients) to a General Hospital.”
Bypassing examination of patients’ vitals
BDSUNDAY’s investigation found that almost all the PHCs visited bypassed doing the vitals of this reporter, who posed as a patient. Those who did only did it partially, checking either of blood pressure or temperature. PHCs like Araromi, Iponri and Oba Salami did not examine the vitals of this reporter. Alapere PHC only checked the blood pressure of this reporter, while Agawaru PHC neglected this process completely during consultation with the nurse, but it checked only the temperature of another patient using the digital temperature gun.
Vitals or vital signs are a group of four to six most important signs that tell the status of the body’s life-sustaining functions whose measurements are taken to help assess the general physical health of a person, give clues to possible disease, and show progress towards recovery.
Although there are four primary vital signs – body temperature, blood pressures, pulse, breathing rate – PHC nurses find it difficult being faithful to examining just two: body temperature and blood pressure. This indicates a poor understanding of the importance of checking a patient’s vitals or a clear case of lack of professionalism.
Recounting an experience relating to vitals, a patient told this reporter that when he went to a hospital and his temperature was checked, it happened that it was very high. So, the nurse had to, with the doctor’s consent, administer an injection to bring down the patient’s temperature before sending him to the doctor. But assuming that was not done, perhaps it could have been a different story.
Speaking to BDSUNDAY, a public health specialist, Doyin Odubanjo, said checking the vitals of patients when they visit hospitals, especially primary health centres, is an opportunity to prevent any catastrophic event that could happen.
“If it is not done, especially for high-risk patients, the chances are that you could have catastrophic events right after that, even if the patient has been in the hospital recently. If he does not come to the hospital or doesn’t visit any health centre, you may not know. Perhaps the only time you will see him is when he has complications of the high blood pressure, maybe with a stroke,” Odubanjo said.
“But if for whatever reason he happened to come to the primary healthcare centre before then, and you did the vitals, you measured the blood pressure and you saw it was high, then you have the chance to intervene before there is any catastrophic event. So that is the problem you are trying to avoid (by measuring the vitals). You don’t want people to suffer kidney damage or any heart damage or damage to the brain which results in stroke as we call it.
“You don’t want any of those things to happen before you find out there is something wrong with this person. So any contact with the PHC should be looked at as an opportunity to screen people, and that’s why you do some of those vitals. Those vitals will serve as your screening test. And if you do find anything, you are already at the PHC, you can advise; if it can’t be managed there, you can at least advise the person to seek medical care,” he further said.
Odubanjo said poor attitude to work and the inability to replace damaged equipment could be a reason healthcare workers ignore checking the vitals of patients.
“There are different things that can cause it, top among which, perhaps, is attitude. People have a poor attitude to their work. Also sometimes, it could be equipment. In which case, people want to do these things, but over time, the equipment they had, got spoilt, was never replaced despite pleas. It might get into a pattern whereby they really stop doing it. So even if you provide it later, they may not really use it because they’ve got into a pattern. So, it’s either the attitude or the fact that you have an unconducive environment,” he said.
Government officials respond
Although the government officials contacted to give more insight as to the reason some PHCs are equipped to handle tests while are others lack the same equipment claimed that all PHCs in Lagos State are well equipped to do tests, the reality seems to be the opposite as some of them (PHCs) lack equipment.
A top government official (name withheld) operating within the health ministry, Lagos State, sounded shocked on phone when this reporter contacted him to explain why some PHCs are equipped to run tests while others are not.
“All of them should be able to conduct basic test so long as they are functioning. They should be able to conduct tests. It depends on what you people consider as basic test. But basic test can be conducted at the primary care level. All of them should be able to,” the official said.
When he was told that some of the PHCs that were visited said they do not have the facilities to run tests, he said, “Well, I’ll ask the Primary Healthcare Board. That should not be totally true because there is a tendency for them to be equipped with equipment that is far beyond what they should have at the primary healthcare centre.”
“Basic test, they must be able to do with high valued equipment. As long as they are operating, whether for 8 hours or 12 hours, they must be able to perform those tests,” he added.
On the amount of money released out of the health budget, the official said he could not give figures.
“The budget is different from how much has been released. I can’t give you figures as to what has been disbursed because the account department keeps all the records,” he said, and referred this reporter to the special adviser on primary health care.
When contacted, Femi Onanuga, special adviser to the governor on PHCs, said in a phone conversation that all the PHCs can do basic tests.
“There is nowhere we cannot conduct simple, basic ancillary tests. I doubt that your statement because no matter what, we will be able to do simple, simple ancillary test since it’s a basic primary health care. We can do malaria, we can do typhoid, we can do PCV. All primary healthcare centres can do that,” Onanuga said.
“So, what you are saying that some can do some test, all of them can do some basic tests. We are not expecting to do highfalutin test, but simple tests like malaria parasite, PCV, or Haemoglobin and small, small tests. That is why we are there. If we need to do those highfalutin tests, then we go to general hospitals,” he said.
Desmond Okon
