The dusty roads of Wushishi in Niger State carry with them a burden that weigh heavily on women like Asmau Musa. As a mother of four children, each of her pregnancies has been accompanied by the same routine visits to the Primary Healthcare Centre (PHC) in Wushishi town, with her husband by her side.

These trips are not simply a matter of choice or a show of the deep love and care that the husband has for the wife, but rather they are of compulsion and dictated by cultural and religious norms. Musa, like many women in her community, understands the unspoken rules that govern her life.

“Anytime I try to visit without his knowledge, it means I am disobeying him, and he might divorce me,” she said. The stakes are high; her health and the well-being of her children, are delicately balanced as she runs the risk of losing her marriage as voiced by her earlier.

“Even if there is free or subsidised healthcare service, my husband will not permit me to go alone,” Musa continues. Similarly, Hajiya Salamatu Musa Dauda, a resident of Gwarjiko, also in Wushishi faces the same challenge.

Though she is aware of the free healthcare services offered at Wushishi PHC, she has never taken advantage of these services. “The reason I do not go to the PHC is because my husband is mostly not around,” Dauda explained.

“My religion does not permit me to go on my own. It forbids us from attending gatherings with men without our husbands’ consent. Living among my husband’s relatives and friends means I need their permission to attend hospital.”

In Niger State, the challenges highlighted by Musa and Dauda are pervasive. Despite free healthcare services, certain cultural and religious pressures often prevent women from accessing care independently.

Findings by the New Telegraph revealed that the presence of male healthcare providers further complicates matters, as some husbands insist on accompanying their wives to ensure adherence to these aged-long religious and cultural norms.

How gender gaps, religious and cultural norms impact BHCPF implementation in Niger. For many women in rural communities of Niger State, the journey to health facilities is not just ordinary or physical, but a complex negotiation of cultural expectations.

These cultural pressures often compromise their health or cause delays in receiving timely medical attention. Despite progress made through government programmes, societal constraints frequently overshadow their benefits.

Findings reveal that women, particularly those in rural areas, face immense pressure from their communities and families, which limits their ability to independently seek medical care.

This issue is particularly evident in the implementation of the Basic Healthcare Provision Fund (BHCPF), a federal initiative designed to improve maternal and child healthcare.

Supported by annual grants from the Federal Government’s Consolidated Revenue Fund and contributions from international donors, the BHCPF seeks to ensure that vulnerable citizens can access essential health services.

It operates through three main channels: the National Primary Health Care Development Agency (NPHCDA), which provides funding and personnel for Primary Health Centres (PHCs); the National Health Insurance Scheme (NHIS), which insures vulnerable citizens; and the National Emergency Medical Treatment (NEMT) component, which ensures prompt emergency responses.

Together, these gateways aim to improve access to healthcare for women in Niger State. However, despite these efforts, societal norms rooted in religion and aged-long gender stereotypes continue to hinder progress.

Religious leaders and women’s associations expressed concerns regarding the barriers women face in accessing healthcare. Hajia Hauwa Kulu, Amira of the Federation of Muslim Women Associations of Nigeria (FOMWAN) and Evangelist Ladi Nuhu, Chairperson of the Women Wing of the Christian Association of Nigeria (WOWICAN) in Niger State, both decried how religion and culture prevent women from accessing free healthcare services, including those provided through the BHCPF.

According to Kulu, while men might not care about the gender of the healthcare professional in their own medical emergencies, they often hesitate or disapprove when it comes to their wives, even in critical situations.

“I call on men in our society to understand that unless their wives are healthy, they will not be comfortable living with them. If they do not allow their wives to access health facilities independently, they are doing injustice to their families,” Kulu notes.

She emphasises the critical need for men to support their wives’ health needs, adding, “Trust your wife; it is when she is well and healthy that you want to interact with her. If she is unhealthy, the marriage won’t be comfortable.”

Evangelist Nuhu shared these concerns, pointing out the harmful consequences of preventing women from accessing healthcare in rural areas like Gwarjiko. “The deprivation of women by their husbands from seeking medical care shows that their lives are not valued, regardless the illness.

Our women and children urgently need these services, especially the free healthcare provided under BHCPF,” says Nuhu. She adds, “I appeal to our men, who sometimes insist on accompanying their wives to health centres or otherwise prevent them from going alone.

As the chairperson of Christian women in the state, I raise my voice on behalf of our women, urging our men to allow them to seek medical care. Our women and children need these services, especially the free healthcare offered by the BHCPF.”

BHCPF making strides

While the Basic Healthcare Provision Fund (BHCPF) has made significant strides in improving healthcare access across Niger State, deep-rooted gender, cultural, and societal constraints continue to hamper its full implementation.

These inequalities manifest in various forms, from limited accessibility to disparities in service utilisation and health outcomes. As these challenges persist, the effectiveness of the BHCPF, particularly in rural areas, remains limited, raising concerns about the sustainability and inclusivity of the initiative.

Across the state’s rural communities, where the impact of the BHCPF is most needed, the voices of those affected reveal the extent of the impact of these persistent inequalities.

A local community leader and the Ward Development Committee (WDC) Chairman in Edokota community, Gbako Local Government Area, Abubakar Zubairu, shares his frustrations. “The BHCPF has brought a lot of changes to our PHC, but the reality is that many women in our community still face difficulties accessing these services.

The health centre is too far for some, and without proper transportation, many women and children are left without the care they need.” Another resident, Abdullahi Kassimu, says: “Even with the improvements, we still see many women unable to make it to the health centre, especially those living in more remote areas.

The distance and lack of roads make it almost impossible.” Service utilisation is another area where the impact of cultural and religious norms is keenly felt.

In Edokota, 41-year-old Salamatu Mohammadu describes her experience, saying, “for me and my children, I do not mind going to the hospital anytime the need arises, but because of cultural and religious reasons, I cannot do so until I get permission from my husband.

If he is not around, sometimes he will ask me to wait for him so we can go together, or he will ask me to hold on till the next day.” She adds that the distance from their home to the facility often discourages her, especially when her children need urgent medical attention.

Musa, the mother of four in Wushishi recounts how she almost lost her life due to her husband’s reluctance to allow her to visit a health facility alone, blaming the situation on religion and cultural practices. “There was an incident when I was pregnant; I would have died if not for God because he took me to the facility late,” she recalls.

Recent data on the implementation of the BHCPF in Niger State highlights both progress and persistent challenges. While all 274 wards and focal facilities received N300, 750 each for the first quarter of this year, funds for the second quarter are yet to be disbursed.

Mallam Isah Umar, the Monitoring and Evaluation Officer for FOMWAN in Niger State, points out that a March 2024 survey by his organisation revealed disparities in fund distribution. Although each facility received N300, 750, concerns were raised about the unequal distribution of funds, particularly given the varying needs of facilities in rural and hard-to-reach areas.

He discloses, “For instance, at the Gwarjiko PHC in Wushishi LGA and Lemu PHC in Gbako LGA, the BHCPF allocation was barely sufficient to cover the budget in their business plans for the first quarter. The funds were used for various purposes, including purchasing furniture, repairing facilities, and buying drugs.

“In Gwarjiko PHC, insufficient funding has left the facility without essential equipment such as delivery beds, children’s weighing scales, ultrasound machines, and partographs.

“Additionally, compared to Lemu PHC, Gwarjiko health facility lacks a functional borehole yet they received the same amount despite differing challenges and infrastructural advantages.”

Staffing shortages also plague the system, worsening the inequality. While Lemu PHC benefits from a larger staff base, including Community Health Extension Workers (CHEWs), pharmacists, and midwives, Gwarjiko PHC suffers from an acute lack of midwives, Junior Community Health Extension Workers (JCHEWs), security personnel, and cleaners.

“Lemu PHC is staffed with several midwives under the Midwives Service Scheme (MSS), whereas Gwarjiko only has one midwife,” Umar discloses. The gender imbalance within the Ward Development Committees (WDCs), which is crucial to BHCPF implementation at the grassroots level, also mirrors these disparities.

These committees, essential to the PHC Facility Quality Improvement Committee, are tasked with ensuring community involvement, transparency, and inclusive decision-making in managing the BHCPF.

Yet, societal norms continue to limit women’s participation, undermining the effectiveness of the program at the local level. In Gwarjiko PHC, religious and cultural norms were cited by residents, including FOMWAN’s Kulu, as key barriers to women’s participation in WDCs.

Similarly, in Lemu PHC, men consistently outnumber women in the committee due to community leadership norms that limit women’s participation. According to Amina Binta, a member of the Ward Development Committee (WDC) in Wushishi, frustrations among women in rural communities are mounting.

“We raise critical issues, such as the urgent need for better healthcare facilities and infrastructure, but our concerns are often dismissed,” Binta says. “Despite our efforts, there is little follow-up and concrete actions are rarely taken.

The delays in funding and lack of resources severely limit our ability to address the pressing needs of our community. For instance, our calls for clinic repairs or improved maternal health support often go unanswered.

We need a more inclusive approach where our voices are genuinely considered, and resources are allocated to make a real difference. “At the WDC meetings, our influence feels minimal. We advocate for crucial improvements in healthcare services and infrastructure, but our input often falls on deaf ears.

“The gap between our recommendations and what actually gets implemented is frustratingly wide.” Despite these challenges, the BHCPF remains a critical component of Niger State’s healthcare system, Aisha Mohammed, the Desk Officer for BHCPF in the Ministry of Primary Health reiterates.

She reaffirmed that the BHCPF operates in the state through three gateways, with 45 per cent of funds allocated to the State Primary Health Care Development Agency, covering maintenance, drug purchases, and outreach services.

She said 274 focal health facilities in the state collectively received the total sum of N82, 405, 500 in the first quarter of the year. Specifically, Gbako LGA, with its 10 wards, was allocated N3, 007, 500, while Wushishi, with 11 wards, received N3, 308, 250.

This funding is crucial for sustaining operations, but persistent cultural barriers continue to undermine the BHCPF’s potential impact, Hajia Habiba Umar, an official of the Niger State Contributory Health Agency (NiCARE), stresses.

She notes that the success of the BHCPF’s multiple gateways in the state depends not only on financial allocations but also on tackling the deep-rooted inequalities that hinder women and children from accessing essential healthcare services.

Experts view

While women in WDCs voice their concerns, experts highlight the broader implications of these issues on healthcare access and equity in the state. Kulu emphasises the importance of ensuring equitable access to healthcare, including initiatives like the BHCPF for women and vulnerable groups.

“In recognition of these facts, we are collaborating with the International Budget Partnership (IBP) under the Strengthening Public Accountability for Results and Knowledge (SPARK) II initiative to implement a campaign aimed at improving the quality of maternal health care services offered at Primary Healthcare Centres (PHCs),” Kulu explains.

The SPARK initiative, active in six local government areas (LGAs) of Niger State, aims to improve public sector accountability and enhance service delivery to marginalised communities. Dr. Amina Yusuf, a public health expert in Minna, also comments on the situation, noting, “While the BHCPF has made significant strides in improving maternal and child health services, gender disparities regarding access still remains a critical issue.

Women in remote areas still struggle with poor facilities, poor sensitisation and education, and inadequate resources, which undermines the program’s goals.”

Similarly, Mr. Matthew Oladele, Executive Director, Initiative for Social Development in Africa (ISODAF), a non-governmental organization, with a focus on enhancing processes towards the provision of quality developmental and sustainable social service’s needs, emphasises the need for stronger feedback mechanisms and accountability in the implementation of BHCPF and delivery of healthcare services especially in the rural areas.

“What I will advise in the area of transparency and accountability is to strengthen the capacity of the Ward Development Committee (WDC) so they can monitor the implementation of the project without encumbrances across the facilities,” Oladele says.

He further suggests that a feedback platform for citizens could help address inefficiencies in healthcare services. “BHCPF has increased health service delivery, but there are still gaps, particularly for women, that need to be addressed through better monitoring and community involvement,” he adds.

Although BHCPF mandates universal access to healthcare services, experts stress that targeted interventions are crucial to effectively address these disparities. Umar points out significant challenges in funding and enrolment under BHCPF.

She explains that the fund is specifically aimed at vulnerable populations, which make up about 30 percent of Niger State’s population, roughly 3 million people. However, the current funding levels cover less than 100,000 individuals.

“The funding barely covers up to 100,000 people. Despite the existence of funding, many are still left out,” Umar states. She adds that those not enrolled in BHCPF must pay for services, which often discourages them from seeking medical care.

“Some people avoid going to the hospital because they cannot afford the medical bills, but those enrolled know that healthcare is free for them, so they utilize the services more frequently,” Umar discloses.

Umar of NiCARE also stresses the importance of continuous collaboration with Ward Development Committees (WDCs) and Officers-in-Charge (OiCs) to ensure that enrolled individuals present their cards when accessing healthcare services.

“We also continue to collaborate with the WDCs and OiCs to ensure that these people receive the best possible care whenever they visit the facilities,” she says.

Govt reacts

Reacting to the challenges posed by social and cultural practices in the implementation of the Basic Healthcare Provision Fund (BHCPF), Dr. Bello Tukur, the Commissioner for Secondary and Tertiary Health, emphasises the urgent need to address these barriers.

He acknowledges the significant obstacles created by religious and traditional beliefs, particularly in rural areas, and stressed the importance of community education. “Our people in the rural areas do not understand that sickness does not wait,” Dr. Tukur says.

This is as he emphasises that certain health issues require immediate attention, warning that delays could lead to severe consequences, including loss of life or permanent disability.

Tukur also notes the need for timely healthcare intervention, adding that “it is crucial that we educate our people to understand that seeking healthcare at the appropriate time is as important as seeking health itself.

If you seek help too late, there may be nothing else that can be done to salvage the situation, and irreversible damage may have already occurred.” He further urges residents of the state to recognise that every investment made in the health sector by the current administration is intended for their benefit.

“I want to call on the people to know that every investment made in the health sector by the current administration is for their use and for them to benefit and have the best quality of health for themselves and their immediate families,” he adds.

Tukur further urges traditional and religious leaders to take an active role in educating and sensitising their communities. “We need our traditional and religious leaders to talk to our people, especially the men, during sermons and at various gatherings, so that families, women, and children can access healthcare facilities whenever they need it, even if the men are not around,” he says.

He further discloses that he has directed the departments and agencies under his supervision to involve trained professionals in planning health programs to ensure the better utilization of resources and maximise the value of state government investments in the health sector.

Meanwhile, the Director of Planning, Research, and Statistics at the Niger State Contributory Health Agency (NiCARE), Pharmacist Abdul Musa, acknowledges that although the BHCPF aim to improve healthcare access, entrenched traditional practices continue to shape how communities perceive and use health services across the state.

He emphasises the state government’s commitment to advocacy and sensitisation, particularly within Emirate councils and among key stakeholders.

“The government is doing everything it can to mitigate the impact of these practices by prioritising advocacy and community education,” Musa says.

This report was done with the support of the International Centre for Investigative Reporting.