INVESTIGATION: How Bandit Attacks, Government Negligence Undermine Healthcare Access In Niger State

Since 2016, bandits have attacked several communities in Niger state, kidnapping and killing scores of health workers and destroying healthcare facilities. In this report, Arinze Chijioke looks at how the attacks have worsened access to healthcare and government’s lack of commitment to reviving the sector.

In June 2021, the tranquillity of Salka village, Magama Local Government Area (LGA) in Niger State was shattered when five masked bandits stormed a hospital, kidnapping Dr. Precious Emeka, a dedicated young medical doctor. Despite establishing the only healthcare facility in Salka and providing essential services, Dr. Precious became the sole target of the attackers. Tragically, a day later, a local vigilante group discovered his lifeless body in the bush, marking the end of a promising healthcare service in the community.

Dr. Emeka ran the only private hospital in Salka village till he was killed.

Following Dr. Precious’s brutal demise, the once-bustling hospital closed its doors, leaving the community without essential healthcare. Traumatized employees left the community, and residents found themselves without medical assistance.

This grim episode is just ofne in a series of attacks that have plagued Niger State for seven years. Bandits, responsible for countless deaths and the destruction of livelihoods, have driven residents from their ancestral homes, turning farmlands into burial grounds across 18 out of the state’s 25 local government areas.

Among the sectors that has severely been impacted by the incessant attacks is the health sector, with several health facilities destroyed, health workers kidnapped and killed in some instances.

In December 2020, head of the Primary Healthcare Centre (PHC), Garin-Gabas, Rafi Local Government Area, Hajiya Halima Isah, was kidnapped alongside her two children. They were kept for six days and only released when a N3 million ransom was paid.

In Shiroro Local Government, primary healthcare centres in eight wards out of the 15 in the LGA have been closed. By December 2022, more than 3,000 of the personnel, some of them medical doctors, pharmacists and midwives had left their jobs in the state health sector to seek greener pastures elsewhere due to the attacks.

Former National Association of Nigerian Nurses and Midwives, NANNM, Niger State Council, Mrs. Anna Simon said that between 2015 to 2023, more than 400 nurses had left Niger State.

This local crisis mirrors a national epidemic, with data from the Nursing and Midwifery Council revealing that, in just one year (March 2021 to March 2022), a staggering 7,256 trained nurses left Nigeria for the UK. Over the five-year period from 2017 to 2022, a staggering 57,000 trained nurses sought opportunities abroad, drawn by the prospect of better pay and improved working conditions.

Dr. Mathew Oladele, the Program Director at the Initiative for Social Development in Africa, painted a grim picture of the challenges faced by healthcare workers in Niger State. Kidnappings have left some workers in captivity for over three years, while ongoing bandit attacks in Munya, Shiroro, Magama, Mashegu, Paikoro, and Wushishi have created an environment where providing healthcare services becomes increasingly difficult. Despite having more than 3,000 Primary Health Care Centers (PHCs) in Niger State, including dispensaries and basic health clinics, the grim reality is that over half of the purportedly functional 1,300 PHCs rely on a lone staff member to cater to the health needs of entire communities, often without the presence of doctors.
The Gulu experience

In October 2022, Zubairu Hassan, Chief Imam of Gulu in Niger State, woke to a nightmare as over 100 bandits descended on his community, sending families into a panicked frenzy. Fleeing to the safety of a nearby bush, Hassan returned later to discover the ruthless attack on Abdulsalam Abubakar General Hospital in Gulu. The bandits left a trail of devastation, claiming two lives and abducting over 20 healthcare workers.

The bandits did not carry out any physical destruction on the facilities but sources disclosed they carted away some medical equipment prompting the state government to shut down the facility temporarily. It was reopened through the intervention of the House of Assembly Member representing Gulu, Idris and the Lapai local government chairman.

Inside Gulu General Hospital

However, Hassan laments that post-attack, access to healthcare in Gulu has been a shadow of its former self. Health workers lived inside the hospital and so, it was easy for them to attend to the health needs of the people. Once a bustling hub of medical activity, Gulu General Hospital welcomed residents from neighboring communities. The attack disrupted this lifeline, leaving healthcare workers scattered and inaccessible.

“We had doctors, there were several nurses and other health workers, our people did not have to travel long distances to access medical care,” said Saidu Umar, son of one of those who were killed during the attack.

The aftermath of the October 2022 attack has drastically altered the healthcare landscape in Gulu. Zubairu Hassan, once accustomed to seeking medical care within his community, now faces a 45-kilometer journey to Lapai whenever his children fall ill.

This predicament echoes throughout Gulu as other residents grapple with the same reality.

The absence of healthcare workers compounds the challenge. The sole doctor, who occasionally visits during emergencies, quickly retreats to Lapai after attending to patients, leaving the community underserved. The burden on the remaining healthcare providers intensifies as they attempt to fill the void.

“If there is emergency at night, the patient resigns to fate or waits till the next morning to travel, “Hassan said. “We have had women go through complications during pregnancy because they could not immediately be attended to.”

Apart from his father who was killed, Umar said that the bandits also kidnapped nine of his family members who were only released after a ransom was paid.

“Since then, the government has not even come to share in our pain, “he said. “What is most worrying is that they have refused to look into bringing in doctors who will attend to our health needs.”

Niger’s healthcare system still awaits promised reinforcements
Following the migration of health workers across the state, commissioner for Health and Hospital Services under the administration of former governor, Sani Bello, Dr. Makun Sidi Sidi said the recruitment of 400 health workers and 850 midwives under different partnership programmes by state has been adequately catered for.

In a notice of vacancy in June 2022, the former Executive Director, Niger State Primary Health Care, Ahmed Bello, said that it was “In line with the blueprint of the former governor, Abubakar Bello in revitalizing and transforming the healthcare Sector.

“Applications are hereby invited from suitably qualified Midwives, Nurses and other Healthcare Cadre Staff essential to delivering Routine Immunization (RI), Maternal and Child Health and other Primary Health Care (PHC)services in Selected Primary Health Care Centers (PHCCs) across the 25 LGAs in Niger,” the notice read raising the hopes of residents across concerned communities.

Regrettably, investigations reveal a disheartening reality despite the administration of computer-based exams in November 2022 and the subsequent shortlisting of applicants, there has been no tangible progress in the actual employment of health workers across various communities, failing to fulfill the commitments made.

Mohammed Hassan applied for the position of a health scientist. Despite receiving a notification that he was shortlisted for an interview; the process seemingly reached an abrupt halt after the interview in February 2023. Subsequently, he received no communication regarding whether he had passed the interview or any updates on the recruitment process.

“The forfmer administration was not serious with the process, I think they commenced the process to score political points because the governor would have completed everything even before leaving office,” he alleged.

In contrast to Hassan’s experience, Nuhu Aliyu faced complete silence after the examination, and he said none of his friends who applied for the same role have commenced work. Aliyu points out that the previous administration should have initiated the recruitment process promptly, considering the exodus of healthcare workers and the relocations spurred by attacks.

This September, the current administration made a similar announcement, declaring its intention to recruit over 1,000 doctors, nurses, and other essential health workers to address the manpower shortage in the health sector. Despite the governor’s assurance and commitment to prioritizing healthcare, nearly four months later, reports from various communities indicate a lack of visible recruitment or presence of health workers. The disparity between promises and outcomes raises concerns among communities eagerly awaiting improvements in their healthcare services.

Gogala health centre still not functional after attack

In March 2022, Shehu Garba, a resident of Gogala in Shiroro local government, urgently needed blood due to illness.

Dilapidated Gogala PHC

Unfortunately, upon reaching the Gogala Primary Healthcare Centre, they found no one available to attend to them. The family rushed to Erena town, but before they could reach a hospital, Shehu became weak and passed away. The family had to bring him back home for burial.

Six months prior, in September 2021, bandits had attacked the hospital, vandalizing drugs, hospital beds, and other essentials, while also stealing some equipment. Health workers had to flee for their safety. Musa Usman, an employee at the hospital, recounted, “It was in the middle of the night; we were still working when we heard gunshots, immediately we ran away.”

Since the attack, there has been no government effort to restore the functionality of the health center. The door remains unfixed, and the drugs and equipment taken have not been replaced, leaving the community without crucial healthcare services.

Musa Usman

Concerns about safety have led health workers to stop coming to the community, leaving residents to face the consequences. They now seek healthcare outside the village, often at private health centers, which can be expensive. Those unable to afford it resort to local remedies. Zaharia Musa, a resident, highlighted the challenges faced by pregnant women in Dakpala, who must be driven on precarious roads to other locations for care.

The door was destroyed by bandits in Gogala

“The hospital has been under lock and key ever since the attack more than two years ago,” Zaharia said. “Workers hardly come around because of fear of attacks, and there are also no equipment, leaving residents without access to healthcare.”

Auta Dada, another resident, noted that even before the attack, the Primary Health Center (PHC) serving Gogala was in poor condition, with parts of the structure dilapidated and leaky roofs. Promises to renovate the facility were unfulfilled.

Auta Dada

“With the attack, the situation is worse, and with no attention, some parts of the hospital are falling already,” Auta Dada emphasized. “We need the government to help us because we risk losing lives due to lack of access to healthcare.”

Like Gogola, bandits attacked the Dnakpala Primary Health Care Centre- also in Shiroro- and carted away drugs and other medical equipment in September 2022.

Before that attack, the PHC had medical equipment that were used to treat sick patients. Secretary of the Dakpala traditional council, Shagari Bawa said that health workers were always on ground.

However, after the attack, the PHC has remained deserted. Drugs and equipment have not been replaced. Healthcare workers have stopped coming to the hospital, except the doctor who comes ones in a while.

Traditional head of Dakpala, Mr. Abdullahi said that the state government came to Dakpala and promised to help revive the health centre after the attack.

Abdullahi Sarkin Dakpala says that the community has lost lives because there is no access to healthcare

“Sadly, we have not heard from the government since then and the dilapidated state of the road leading to our community contributes to delay in getting to locations with functional hospitals on time.”

No commitment to healthcare delivery
The immediate past administration in Niger State claims that it revitalized and transformed the healthcare sector in the state. In an article titled Niger: How Governor Sani-Bello recorded achievements amidst ridiculous criticisms, the Chief Press Secretary to the former governor Bello, Noel-Berje claimed that the administration tackled the infrastructure deficit in the health sector through the construction, rejuvenation and upgrading of ailing Primary Health Care (PHCs) facilities across the 274 wards in the state.

However, investigations reveal that Primary Health Centers (PHCs) in many wards were not upgraded as claimed, resulting in a significant challenge in accessing healthcare. In areas where health facilities exist, they are dilapidated, lacking personnel to attend to the health needs of the people.

“The former administration did not show commitment to dealing with the challenge of access to healthcare, even the current administration is not doing enough in that regard,” Oladele said.

Analysis of budget implementation reports also shows a lack of clear commitment to primary healthcare delivery even in the face of bandit attacks by successive administrations.

For instance, out of N340m budgeted for construction, provision of hospitals and health centres in 2022, only N32.9m which is less than 10 per cent was released. Also, out of N4.9bn (N4,923, 934,472,19) earmarked for Primary Healthcare Development Agency, only N230m, representing 4.7 per cent was released.

In the same year, a budget of N4.1 billion was allocated for the rehabilitation and repairs of hospitals and health centres. Despite a revision to N5bn, only N1.3bn, representing 27.5 per cent was released.

An analysis of the 2023 shows a similar trend of lack of commitment to primary healthcare delivery, with no specific budgetary provisions for affected communities. Out of N7.25bn earmarked for the primary healthcare development agency, N140.48m was released in the first quarter while N2.4bn was released in the second quarter.

Also, out of N8.2bn for the rehabilitation and repairs of hospitals and health centres budgeted in 2023, only N37m representing 0.4 per cent was released in the first quarter while N102m representing 1.7 per cent was released in the second quarter. No amount was released in both quarters for the construction, provision of hospitals and health centres out of the N150m earmarked.

In September 2023, incumbent governor, Umaru Bago approved the release of N170 million for the revitalisation of primary healthcare facilities across the three political zones as part of repositioning the health sector. He also approved another release of N250 million to all the focal primary healthcare centres in 274 wards to address issues of dilapidated facilities and lack of commodities. Observers keenly await the translation of these releases into tangible improvements in healthcare.
How about funds from development partners?

Available reports show that massive resources have been deployed by development partners over the years to improve healthcare quality at the primary level in Niger state.

In 2018 for instance, the Bill and Melinda Gates Foundation deployed $1.84m to be spent in four years on catalysing primary healthcare. In 2022, the state announced the launch of its contributory health scheme which will see it expend one per cent of her consolidated revenue as equity fund to widen universal health coverage for its residents.

Unfortunately, health indices persistently reflect poor outcomes, and significant strides in reproductive, maternal, and child health remain elusive. According to the 2023 state of states report by Budgit, just 1.6 per cent of women population in the state are covered by any health insurance plan.

The report indicates that a mere 38% of deliveries in Niger State occurred in healthcare facilities, representing the lowest utilization rate in the North-Central region. Traditional birth attendants handled 5.4 per cent of deliveries, while 38 per cent were conducted by relatives or friends. Nurses and medical doctors accounted for 30 per cent and 6.5 per cent, respectively.

There is a way out

Oladele recommends incorporating security measures into the planning and construction of Primary Healthcare Centers (PHCs). He emphasizes the necessity of features like perimeter fencing, burglary-proofing, and reinforced walls to enhance security. Furthermore, he suggests ad-hoc training for community members in attack-prone areas, accompanied by adequate logistics, incentives such as welfare allowances, health insurance, and hazard wages for health workers.

Addressing security concerns, Oladele proposes establishing military camps in vulnerable locations, ensuring the safety of health workers and residents. Collaboration with local youths for quick response and intelligence is also recommended

“The government must put primary healthcare funding on the first line charge so that as it comes, it goes to them to be used in providing access to healthcare, “he said. “This will help deal with poor budget performance as it relates to health”.

On his part, public health physician, Dr Laz Ude said that there is also the need to establish fund for scholarships for dependants of health workers who get incapacitated or lose their lives in the course of their duty.

We are dealing with the situation

In his reaction, Commissioner for Primary Healthcare, Niger State, Ibrahim Dangana said that the current administration was strengthening healthcare service provision across areas that have not been affected by insecurity to enable residents of communities impacted access care close to them.

“For security challenged areas, we work closely with security outfits who let us know when it is safe to move into communities and conduct outreach programs, including immunisation for children, anti-natal services for women, providing them with essential drugs needed during pregnancy. We also give nutrition supplements for malnourished children. It is known as hit-and-run.”

He explained that when bandits attack, their primary target are kidnapping workers for ransom, carting away motorcycles which are used for outreaches in hard-to-reach communities and drugs.
“Now, we no longer keep our motorcycles in vulnerable facilities but local government headquarters, we are also working closely with local vigilante groups in areas where we provide services to ensure that we do not put our workers in harm’s way,” he said.

He claimed that since June, the government has recruited over 300 health workers- majorly nurses and midwives-under an MOU with Global Alliance for Vaccine Initiative (GAVI), adding that majority of them are being posted to rural areas that are understaffed.

“We also have approval to recruit over 400 health workers to replace those who are retired or those who are away on study leave. It will come on stream in the first quarter of 2024,” he said.

On security, he said that the current administration has established the homeland security and pastoral and nomadic affairs ministries to revamp the security architecture of the state and the grievance of pastoralists who are perceived to constitute majority of the bandits respectively.

“The ministries are working with the Military, Navy, Airforce, Police and other outfits across the state, “he said. “They have been reaching out to both farmers and herders to broker peace and understanding and increase the coordination of security related issues.”