Alone in the Ward: The Staffing Crisis Plaguing Ebonyi Primary Health Care Centres

By Ugonma Ogbu, Abakaliki

In a quiet corner of Izzi Local Government Area in Ebonyi State, Nurse Gloria is jolted awake by a loud bang in the door. It was just a few minutes before 3am. Peering through the window, she saw Mr Nwali, a local resident of the community, shaking the door more frantically while calling out her name. Nurse Gloria could see his pregnant wife slowly making her way to the entrance, assisted by her sister in-law. His wife had gone into labour.

Her mind races desperately on what to do with the situation. She had recommended Mrs Nwali to Nwophoke General Hospital for a Caesarean section two days earlier. Although it was quite some distance from the community, but her own facility could barely mange a C-section with its equipment. Here, Gloria was alone. No doctor, no cleaner, no second nurse. Just her. To pull off the delivery, she would have to rely on Mr. Nwali and his sister-in-law for assistance. Taking a deep breath, Nurse Gloria prepared for an unpredictable and potentially dangerous delivery Alone.

Unfortunately, Gloria's story is not unique. Her story mirrors that of many healthcare workers across Ebonyi State, where severe staffing shortages in Primary Health Centres (PHCs) have turned what should be community lifelines into sites of chronic struggle.

When Caregivers Are Overwhelmed* PHCs are meant to be the first port of call for Nigeria’s healthcare system, especially for pregnant women, children, and the elderly in rural communities. But in Ebonyi, several PHCs visited across Afikpo, Onicha, and Ohaukwu LGAs, facilities operate with just one or two staff members, sometimes none at all. “There are days I have to turn patients away because I can’t do everything alone,” says another health worker who requested anonymity. “They get angry, and I understand. But what can I do?” Over time, this pressure builds into resentment, both on the side of the healthcare provider and the patient.

The Disappearing Trust In Ohaukwu Local Government Area, when a community resident, Amarachi Nwibo, had her come down with a fever, she didn’t think of the PHC. She went straight to a patent medicine store. “I’ve waited for hours at the PHC only to be told the nurse was in Abakaliki to buy drugs,” she recounts. “Other times she’s just too tired to see everyone. I don’t blame them, but I can’t risk my child’s health.” Photo3 In Azuituma Health Centre, Umuezoka (Ezza North LGA), Officer-in-Charge Nnenna Itumo says past neglect still haunts the facility. “Most of the immunization drugs had expired before I resumed duty,” she explains. “Now I go door-to-door administering vaccines and informing residents that the facility is functional again.” Photo4

_Image: Azuituma Health Center, Umuezoka, Ezza North LGA left desolate with just one Health worker on site_ In Ndukwe Akpoha, Afikpo, Officer-in-Charge Patience Nworie says community members often see the PHC as her personal clinic. “They call it ‘Patty’s Clinic’ and refuse to pay for medications not covered under the free program,” she says. “They don’t understand that I’m here because the government placed me here, not because I own it.” This erosion of trust is one of the most damaging outcomes of the staffing crisis. Without personnel, facilities fall into disuse. And when patients stop coming, public health indicators, such as immunization coverage, antenatal care, and disease prevention begin to collapse. Bureaucracy and Bottlenecks: Who Should Hire and Who Actually Does? At the heart of the staffing crisis in Ebonyi’s primary health care (PHC) system lies a tangled web of responsibilities shared by several government agencies, each playing a critical yet sometimes overlapping responsibilities. The National Primary Health Care Development Agency (NPHCDA) sets federal standards and offers technical support through programs like the Basic Health Care Provision Fund (BHCPF), but does not directly hire staff at the state level. That responsibility falls to the Ebonyi State Primary Health Care Development Agency (EBPHCDA), which was created to unify and manage PHC operations under the "Primary Health Care Under One Roof" (PHCUOR) policy, with the aim of streamlining services and improving accountability. The policy empowers state agencies to hire, pay, and oversee staff independently. However, in Ebonyi, the policy remains largely unimplemented as some key functions are still controlled by the State Ministry of Health and the different Local governments. “PHC staff are still paid by Local Governments, but managed by the agency,” explains Dr. Philip Emeka Ovuoba, Executive Secretary of the EBPHCDA. “We monitor staff performance, know when they retire, and identify where new staff are needed. But we don’t control their salaries. If you don’t pay a worker, how can you discipline or motivate them?” An Age Long Crisis The staffing shortages in Ebonyi PHCs are not new at all, as it has spanned through several administrations of government without any attention from government until now. “The last recruitment was over 16 years ago,” says Dr. Ovuoba. “Previous administrations did not prioritize primary healthcare. This crisis has festered for more than a decade. Currently, we even have the association of Local Government Nurses in Ebonyi state. They are just 28, but we still hope to make it up through an appeal to the Governor”. A Glimpse of Hope Recent developments under the administration of Governor Francis Ogbonna Nwifuru suggest a turning point. The government has launched revitalization projects in 25 PHCs across different LGAs, aiming to upgrade them to Level 2 facilities. These upgrades include full staffing, better equipment, and on-site staff quarters. Photo 5

_On-going Revitalization of Umuome Health Center, Oriuzor in Ezza North and building of Staff Quaters_ The agency also received its first independent budget, separate from the Ministry of Health, helping to cut through bureaucratic delays. “For the first time in years the agency was able to present its own budget independent from that of the Health Ministry”, says Dr. Ovuoba. “To all our amazement, the Governor not only exceeded the roof, but also doubled the figure for approval after considering the scope of the challenges of healthcare at the primary level in the state”. To improve monitoring and staff welfare, the agency is partnering with local government chairmen, ward development committees, and community leaders. Donor-backed programs are also stepping in. The World Bank-assisted IMPACT project (Immunization Plus and Malaria Progress by Accelerating Coverage and Transforming Services) has deployed two ad-hoc workers to PHCs in each of the 171 wards in Ebonyi. “We identified staffing shortages as a limitation to our objective and the welfare of the healthcare system in general", says Mr. Patrick Ogbodo Njoku, the Program Manager, IMPACT, Ebonyi state. "This is why we started the project by engaging ad hoc staff that will subsequently be integrated as full staff when the program is over ”. The National CHIPS program (Community Health Influencers, Promoters and Services), led by NPHCDA, is placing trained agents in communities to deliver basic healthcare and refer residents to PHCs and rebuilding confidence in the system. A Better Future for Frontline Workers Despite these efforts, experts agree that structural reforms are critical. Ebonyi must implement PHCUOR fully, centralizing payroll under the agency to improve oversight and planning. The Executive Secretary of Ebonyi Primary Healthcare Development Agency, Dr Emeka Philip Ovuoba, also recommends decisive actions to be taken towards the implement the PHCUOR policy in the state, while eradicating all forms of interferences and bureaucratic bottlenecks. “States that have succeeded in implementing the PHCUOR, pull all the allocation for health workers into one central purse under their state agency so that payments of all PHC workers are being funded from there", he says. "This way, we can monitor retirements, fill vacancies promptly, and track staff performance.” He also suggests relocating the agency’s offices away from the State Ministry of Health to assert its autonomy and reduce interference. Health professionals further advocate for structured training programs, consistent incentives, and a platform for staff to voice concerns and be rewarded for excellence. CONCLUSION Behind every under-resourced Primary Health Centre in Ebonyi is a health worker stretched to their limit, and a community caught in the crossfire of system failure. Until meaningful action follows these promising policies and press releases, residents like Mr. and Mrs. Nwali and frontline workers like Nurse Gloria will continue to bear the brunt of a broken system.