Sociodemographic characteristic of respondents
A total of 16 people participated in the IDIs (see table 1 and 2). They include OICs, HFCCs, Midwives, HODs, and CHEWs. Participants' ages range from 25-61years. All the HFCCs and HODs are males, except the HOD of Ibagwani Dev. Centre. In addition, four FGDs were conducted (see table 1 and 2), comprising of two women and two men groups. There were 8 participants for each FGD.
(Table 1)
(Table 2)
Participants discussed a wide range of issues that captured politics and the role of influential persons in daily functioning of PHCs. Analyses of their responses nevertheless revealed four themes: 1) Individual’s interest in the siting and building of health facilities; 2) relationship with influential persons and the recruitment of staff; 3) political interference in the sanctioning of defaulting health workers and 4) interventions to politicking in PHCs.
Individuals’ Interests in the Siting and Building of Primary Health Centres
We found that community members are actively involved in the siting and building of PHCs. Those in need of health centres are often required to provide lands and equally participate in the building process by the local government health authorities. Typically, communities map out communal lands for the project or formally request for the land belonging to private individuals. One of the participants, a HOD in one of the local governments, recounted the procedure:
Some report their need…, they would say they want a health centre in their area, we would ask them if they have a land to spare and if they have then we would ask them to choose a place where the facility would be built (19).
Most times, communal lands are not available leading to the formal request for lands belonging to private individuals. In some cases, clash of interest occur as land owners engage in local politics to donate lands for the health centre and this often lead to poor location and other challenges that mar access. Illustrative quotes from one of the health committee chairmen and an OIC recounted this ordeal:
Yes, I think that is what happened here, there was some form of competition… because as you can see this facility is not sited along the road even though the structure here is wonderful. So, I think they placed it here so it would benefit some persons (17)
Like I said before, assuming we have land or we are united then the health centre would have been built around the town but as you can see it was taken almost to the boundary between us and Obimo, sometimes they are attacked by thieves (10).
Participants revealed that politicking to influence the siting of PHCs is sometimes driven by the desire to ensure that the facility is situated closer to landowner’s homes. Also, participants reported that some individuals not only donate lands but fund the building process. This gesture reportedly has political undertone as it would later be used for campaign to earn votes, loyalty and allegiance. These were captured in the following quotes made by one of the OICs and HFCCs.
When they wanted to build the facility, the godfathers would be saying it must be at a particular location where it is close to his place not considering the road and the people” (1).
They do that so that later on they could use it for campaign saying that they did this and this, so it is just to boost their ego and not a centralized opinion (10).
Thirdly, we found that part of the reason people politick in the siting of PHCs is to position themselves for employment opportunities. Participants reported that those who donate lands do so in the hope that such gesture would be exchanged for employment opportunities upon completion of the facility. This does not have any legal backing as landowners are sometimes disappointed by the government authority. One of the participants in the FGD session pointed to another participant as the one who donated the land for the building of the community health centre and claimed that he was duly compensated:
It is one of us that gave the land and not the government. He (pointing to one of the participants) is the one that gave out the land so the facility can be built. So government compensated him by asking him to bring in people that would work there, like security man (18)
But the participant who donated the land revealed that he was promised employment opportunity and that the promise is yet to be fulfilled:
I am the person that gave them my land…, even, the things they promised me for the land, they are yet to fulfil it. They promised me that I would be given opportunity to bring in workers but I am yet to get such opportunity. In fact, government neglected us in that place so it not worth talking about (18)
Politicking was found to delay the siting and building of PHCs as powerful landowners clash over whose land will be used. In the end, it could lead to the siting of the facility in isolated and hard to reach areas that are without electricity, water and security. Also, disagreements in the process of siting health centres discourage community members from utilizing the facilities as oppositions reportedly spread fake news and plant traditional birth attendants very close to the facility. These lead to poor motivation to work and encourages absenteeism among health workers, and on the part of community members, it reduces access to health centres. An illustrative quote from two participants in the IDI, a HOD and an HFCC, captured it this way:
When I told the villagers to give me a site to build the health centre, do you know that in my village they delayed for two years without raising a site? And what makes you think that after those arguments and fights the health centre would function well when it is located in an isolated place? There is a cottage hospital in Obimo, it was closed down because of politics, yes, because of politics!... finally, they built the hospital in a location that is inaccessible and isolated and you expect a health worker to stay in a place without fence, security, electricity or water to live there and those same people who fought against getting a site would want to bring the hospital down by planting some Traditional Birth Centres (TBCs) very close to the health centre and even tell people not to go to the health centres but to go to some TBC just to make sure that no one uses the health centre (7)
It makes the health centre not to function as it should because those people whose voices are not heard during the siting of the primary health centre live close but they prefer seeking health care farther away from here in places that even require transportation. It happens! (17)
Relationship with Influential Persons and the Recruitment of Health Workers
Health workers reported some form of relationship with people in (political) authority. Health workers may be friends, relatives, or god-children to people in authority and these people influenced their recruitment in the PHCs. One of the health workers, a CHEW recounted how she was employed:
what happened was that there is this brother of ours that works there then so from time to time I kept on telling him that I need a job and he kept assuring me that whenever there is an opportunity he will let me know. Eventually, he helped me secure this job (17).
There were suggestions that political influence in recruitment is more widespread in recent times as health workers identified to be recruited with political influence were said to be dominantly junior workers and newly employed staff:
Almost all these junior workers were given jobs by politicians (15).
The politically powerful do not stop at assisting their relations to gain employment, they also assist them with other opportunities at their workplace in terms of scheduling them for attractive training opportunities. Illustrative quotes from one of the HFCCs captured it this way:
Yesterday I experienced it… so you find out that those that are the highly ranked people would like their relations to participate, so they would come to the training and ensure that their (relations) names are there (10).
Furthermore, the study found that one of the dangers of allowing influential persons to influence the recruitment of staff is the employment of unqualified persons in the place of qualified ones. Thus, the basis for employment into primary health centres is tilted towards the connection a health worker has rather than the qualification, thereby leading to the recruitment of unqualified persons. Health workers recruited on the grounds of political connections feel less obliged to report to work:
The recent graduates we have are very intelligent but they don’t get the job because they have no one to connect them. Everything is about politics because most of the people you see there are related to one politician or the other (18)
the implication is that they would employ the wrong people, like in health, when I came on seat, I raised an alarm because I met some unqualified staffs and it became a case and I told them when I question a staff I would know if she knows what she is doing or not (5).
Let me say you are one of the stakeholders at the local government… you have every right to get workers from your place because you are a politician even though those who you brought might still be studying and wouldn’t come to work, yet they get paid. (10)
Service users who participated in the study complained of the low quality of health workers stationed at the primary health centres. This affects their trust in health workers at PHCs and consequently leads to low utilisation. Two of the participants in the FGD session indicated that:
As for me, for those coming from Oji, they know nothing about nursing except only one of them. The rest are only qualified to be cleaners. I can’t even allow them to inject my son (18).
If you get a doctor to interview them, you would be shocked that they would not be able to say anything because they are not qualified. You can even go ahead and interview them now and push out those ones that know nothing (laughter from the background) (18)
Political Interference in the Sanctioning of Defaulting Health Workers
The primary health centres, as an organization, needs sanction to deter health workers from defaulting organisational rules. However, the study found that interferences from persons in powerful positions prevent this from taking place and equally affect the performance of the facility. Difficulties experienced in sanctioning staff could be traced to the fact that many health workers were employed through the help of people in corridors of power. As one of the HODs observed, there is always a tendency for them to protect who they helped to gain employment. Therefore, when they default and are about to be punished, they plead with the person who influenced their employment to intervene.
When you employ someone you would try to give her security so when the person has a problem she would try to link up to their brother, uncle, in-law or anybody called their Godfather” (19).
Sometimes the OIC feels like reporting people (hissed) in short I don't know how they see it… but most of us are afraid … I don't know about others just myself” (15).
Some would call politicians and they would question you on why you had to remove a staff. I did a transfer when I started my job and since last year I have been fighting the war because of it (7)
yes. I told you about when I had a clash with them about this case and the next day I was given a letter to vacate my position as the health committee chairman, the letter is still in my house (3).
Similarly, we found protection of health workers may not always be from politicians or influential persons in the community but from their senior colleagues. In some cases, health workers who are in good relationship with a senior health worker often have some form of protection when they default. But, other workers without such privilege would often be disciplined when they commit the same offence. Such relationship may be with the OIC of the facility or the HOD. As noted, if there is pressure to discipline the staff, they are instead transferred to another facility where they enjoy greater liberty. One of the health committee chairmen narrated it this way;
When there is clash and a superior person like OIC or NIO has a quarrel with the junior staff who misbehaves or goes against the ethics of health…, if she is persistent and get reported to the HOD, he influences the sanctioning of the junior staff then the best thing the HOD does is to change the unit of that worker or get her transferred to a place where she can easily influence the authority of other workers to the benefit of the junior worker probably who is related to her (laughs) (10)
Our findings also show that interference from persons in authority positions in the sanctioning of staff often leads to insubordination and lack of proper decorum in the health facility. This is because protected staff know that sanctioning them has consequences. One of the participants, a head of department captured it this way;
It makes some of them arrogant. They would tell you to do anything you like because they have “Abraham” as a father and when you follow it civilly, you would find out that the person has someone that would make you lose your job (19)
I invited him, gave him the query and when he was done reading it he threw it and walked away…the committee found out that the OIC was behaving in that manner because he has someone, I wouldn’t call names, to protect him (19).
Under normal circumstances, the junior workers are meant to be accountable to the superior in their unit but because of the interference, things go wrong (10).
Interventions to politicking in PHCs
Our study also revealed strategies that could help reduce eminent politicking during the siting of health centres. One strategy that was prominent in the data was a clear orientation of the priorities and focus of the primary health centre which could help reduce scuffles for supremacy that inhibits the proper location of health facilities. An illustrative quote has it that stakeholders and community members should be consulted and sensitized on the importance of locating health centres in strategic places:
Before siting the facility, the people through the traditional ruler should be consulted and sensitized of the importance of health centres and then advised to present land that is at the centre of the community. If the facility is sited at the centre, people would utilize it better (17)
Another suggested strategy that could help reduce political interference in the recruitment and sanctioning of staff in the health sector is the synergy between government authorities and community stakeholders. Individuals alone cannot stop political influence and interference because they do not have the power to, but synergy with stakeholders, health workers, and government at the local and state level would go a long way. Such synergy can enable a higher tier of authority (e.g. the state government) to directly implement sanctions when political influence at the local government level is protecting and errant staff. According to a health committee chairman,
If the person cannot be punished at the local government level, then it can be taken to the state level where such staff might not have those in their favour (20).
Achieving these would however mean getting powerful community members like the traditional ruler or chairman of the community to partner with health workers, their managers, and government at both the local and state level to support the anticorruption efforts. As the study found, traditional rulers could petition errant health workers and follow it up to ensure it is enforced. Similarly, when the chairman of the local government is fully involved in the petitioning, staff compliance is high. An instance of commitment displayed by the chairman of the local government in an attempt to discipline staff with political connection was captured by one of the HODs, he opined that,
Well, the one I experienced was the intervention of the former chairman of the local government of Oji River, I issued a query and he followed it up to make sure that the staff obeyed… and the staff realized her mistakes (19).