Are we building PHCs or delivering healthcare?
A comparative review of Primary Healthcare Centre (PHC) and Human Resources for Health (HRH) data from Abia, Anambra, Ebonyi, Enugu and Imo reveals a fundamental health-system problem: the Southeast does not merely have a shortage of facilities or health workers. It has a conversion problem, converting infrastructure, personnel and public investment into consistently functional health services.
The numbers matter, but what do they actually tell us? Are we measuring facilities, or services? Are we counting health workers, or measuring whether the right worker is available when a patient needs care? Are we measuring revitalisation, or sustained functionality?
A PHC is not functional simply because a building exists, just as a health worker is not effective simply because the worker has been recruited. Functionality requires infrastructure, personnel, equipment, medicines, utilities, management, referral systems and sustained financing to work together.
The real test is therefore not how many PHCs exist, but how many can reliably deliver the right care, with the right personnel and resources, when citizens need it.
Abia: Strongest evidence of integrated conversion
Abia currently presents the strongest evidence of movement from investment to operational capacity. Of its 761 PHCs, 536, or 70.4 percent, are operational, the highest rate among the five states. It also has 55 Level 2 functional facilities, or 7.2 percent, and 68 revitalised facilities, or 8.9 percent, again the highest number and rate of revitalisation.
But the more important story lies beyond the facility statistics. Abia’s HRH assessment covered 749 facilities and identified a 65 percent workforce deficit, particularly among doctors, pharmacists and nurses. The state responded by recruiting 771 health professionals, including 77 medical officers, 40 pharmacists, 50 medical laboratory scientists and 500 nurses. More than 450 nurses were subsequently deployed across the 17 local government areas (LGAs), with deliberate emphasis on rural and underserved PHCs.
This creates a stronger reform sequence than simply building or rehabilitating facilities: assessment, recruitment, deployment and rural targeting. The critical question now is different: Of the 536 facilities classified as operational, how many are adequately staffed, equipped, supplied and capable of delivering the services expected of an operational PHC?
Abia has therefore moved beyond the question of whether facilities can be activated. Its next challenge is sustained functionality, quality and utilisation.
Anambra: Strong infrastructure, significant conversion gap
Anambra has the largest PHC network, with 667 facilities, but only 332, or 49.8 percent, are operational. It has 64 Level 2 Functional facilities, or 9.6 percent, and 53 revitalised facilities, or 7.9 percent.
The tension is obvious. Anambra has substantial infrastructure and revitalisation activity, yet roughly half of its PHCs remain outside the operational category. Why? Is the constraint infrastructure, staffing, equipment, medicines, utilities, management, financing or referral capacity?
The aggregate data cannot answer that question, but they make facility-level diagnosis unavoidable.
A revitalised building is an input, not an outcome. What happens after revitalisation? Does the facility receive the health workers, medicines, equipment, utilities and supervision required to sustain service delivery?
Anambra’s next challenge is therefore to improve the conversion of revitalisation into operational and sustained service capacity.
Ebonyi: High operationality; severe HRH vulnerability
Ebonyi has 512 PHCs, of which 337, or 65.8 percent, are operational. Its 59 Level 2 Functional facilities represent 11.5 percent, the highest functional rate among the five states. Yet only two facilities, or 0.4 percent, are reported revitalised.
The HRH picture is more concerning. The HOPE-GOV planning tool identifies 12,312 workers required against only 1,270 available. The gap field is reported as #REF!, and the tool itself indicates that its gap-analysis formulas require review.
The recruitment plan proposes 1,016 recruits in 2026, 1,085 in 2027 and 1,063 in 2028.
This creates perhaps the sharpest contradiction in the dataset: How can 65.8 percent of facilities be operational when only 1,270 workers are reportedly available against a requirement of 12,312?
More fundamentally, what does “operational” mean if the human resources required to sustain those facilities are not available?
If the recruitment programme is implemented effectively, Ebonyi could unlock substantial capacity within its existing PHC network. But recruitment must be based on reliable data, appropriate cadre requirements and realistic deployment and retention arrangements.
The unresolved formula errors therefore matter. How can a state make major long-term workforce commitments if the underlying gap calculation still requires validation?
Ebonyi’s challenge is to convert relatively strong facility operationality into sustainable service functionality.
Enugu: Strong diagnosis; workforce binding constraint
Enugu has 563 PHCs, of which 284, or 50.4 percent, are operational. It has 57 Level 2 Functional facilities, or 10.1 percent, and 30 revitalised facilities, or 5.3 percent.
Its greatest strength is the quality of its HRH diagnosis. The 2026 projection identifies 8,274 workers required against only 1,810 available, producing a gap of 6,464, or 78.1 percent. Phase 1 recruitment added 450 workers, but about 93 percent of the original gap remains.
The problem is therefore no longer diagnosis.
How quickly can implementation close a gap that is already clearly quantified?
Enugu appears to have developed its physical PHC platform faster than it has expanded the workforce required to operate it fully. This is a sequencing challenge rather than necessarily a policy failure.
But the policy implication is clear: additional infrastructure will have diminishing value if the workforce required to operate it remains unavailable. Conversely, recruitment will have limited impact if workers are not deployed equitably, retained in underserved areas and supported by functional facilities.
Enugu’s priority is therefore to move from diagnosis to accelerated recruitment, deployment and retention.
Imo: Hardest combination of operational and HRH constraints
Imo faces the most difficult combined challenge. Of its 615 PHCs, only 271, or 44.1 percent, are operational, the lowest rate among the five. It has 44 Level 2 Functional facilities, or 7.2 percent, and 26 revitalised facilities, or 4.2 percent.
Its HRH assessment reports 2,513 workers across 327 assessed PHCs and identifies significant shortages among doctors, nurses and midwives, CHEWs, CHOs and other cadres.
But the most important finding is attrition.
Rural LGAs reportedly experience significant health-worker attrition associated with inadequate infrastructure and weak incentives. This creates a reinforcing cycle: difficult working conditions encourage attrition; attrition produces understaffing; understaffing weakens service delivery; and weak service environments make rural facilities even less attractive.
So the question is not simply: How many workers can Imo recruit? It is: How many can it retain where they are most needed?
Recruitment alone will not break this cycle. Imo requires an integrated strategy linking facility revitalisation, staffing, rural incentives, accommodation, supervision, career progression and retention.
What the five states tell us
The comparative picture is clear, but it should not be mistaken for an absolute health-system league table.
Abia currently provides the strongest evidence of integrated conversion from HRH assessment and recruitment to deployment and PHC operationality. Ebonyi has strong reported operationality and the highest Level 2 functional rate, but severe HRH vulnerability. Enugu has strong diagnostic and planning capacity but an enormous workforce gap. Anambra has the largest PHC network and substantial revitalisation activity but weak conversion into operational facilities. Imo has the lowest operational rate and faces the additional burden of HRH shortages and rural attrition.
The analytical ranking is therefore Abia, Ebonyi, Enugu, Anambra and Imo. But the datasets are not fully harmonised. Abia’s HRH assessment covers 749 facilities against 761 in the current PHC dataset. Imo’s HRH assessment covers 327 facilities against 615 in the current PHC dataset. Ebonyi’s HRH planning tool uses a specific HOPE-PHC configuration, while the Enugu HRH projection and PHC functionality data may relate to different reporting periods and definitions.
Operational, Level 2 Functional and revitalised facilities may also overlap and should not automatically be treated as mutually exclusive categories. The ranking should therefore be read as a comparative analytical assessment of the available evidence, not a definitive league table of overall health-system performance.
Are we measuring investment or functionality?
The Southeast should now move beyond counting facilities and personnel. The real performance chain is facility readiness, operationality, staffing, retention, medicines and equipment, utilities, management, referral capacity, utilisation and ultimately health outcomes.
But how much of that chain is currently being measured? Are governments measuring buildings when they should be measuring services? Are they counting health workers when they should be measuring workforce availability at the point of care? Are they celebrating recruitment when they should be measuring deployment and retention? Are they measuring revitalisation when they should be measuring sustained functionality?
And perhaps most importantly: Are governments investing in PHCs, or are they building a functional primary healthcare system?
The fiscal implications are equally important. Is it more valuable to construct another PHC or to make an existing non-operational PHC fully functional? What is the marginal health return from another building compared with putting a nurse, medicines, equipment, water and electricity into an existing facility? How much of every naira invested in PHC infrastructure is actually converted into additional service capacity? These questions should increasingly determine budgeting, recruitment, deployment, revitalisation and accountability.
Abia needs to consolidate its gains and ensure that operationality translates into sustained service quality. Anambra needs to identify why substantial infrastructure and revitalisation have not produced higher operational coverage. Ebonyi needs to reconcile high operationality with its severe HRH deficit and strengthen its planning data. Enugu needs to accelerate workforce expansion and deployment. Imo needs to break the cycle of poor infrastructure, attrition and low operationality.
The final test is the citizen
Ultimately, the citizen should be the unit of analysis. If a woman, child, elderly person or other citizen walks into a PHC at 2 p.m. on an ordinary Tuesday, what exactly will they find?
Will the right health worker be there? Will essential medicines be available? Will the equipment work? Will there be water and electricity? Will the facility provide the service required? If the case is beyond its capacity, will the referral pathway work? And will the same service still be available tomorrow, next week and six months from now?
That is the difference between a facility being administratively operational and a health system being genuinely functional. The Southeast’s PHC challenge is therefore no longer adequately described as simply a shortage of facilities or health workers. It is a problem of converting infrastructure, human resources and public investment into consistently functional, adequately staffed, geographically equitable and patient-responsive health services.
The ultimate question is therefore not how many PHCs can the governments point to? It is: How many citizens can point to a PHC and say, “When I needed care, it was there”?
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Chiwuike Uba, Ph.D., CPA, FCMA, a professor of economics with a keen focus on public financial management and public sector reforms, serves as chairman of the board of the ACUF Initiative for Policy and Governance Ltd/Gte. He can be reached at chiwuike@gmail.com and via (SMS) at + 234 803 309 5266
Southeast: Between building PHCs and delivering healthcare