Chapter 3: The Hospital Without Drugs

Chapter 3: The Hospital Without Drugs

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Mrs. Adebola is sixty years old, a retired primary school teacher in Osun State. She has high blood pressure managed — poorly — at the state general hospital. Her husband, a retired civil servant of sixty-eight, has a tumour. It is growing. It is painful. It needs surgery.

The General Hospital in their town has no surgeon. The State Specialist Hospital has no anaesthesia. The Teaching Hospital has a six-month waiting list for surgeries that may never happen, because the operating theatre has no running water and the surgical equipment was last serviced in 2017. "Go to a private hospital," they tell her. The cost: N2.5 million. Her life savings, accumulated over thirty-five years of teaching: N800,000.

For four months, Mrs. Adebola watches her husband suffer. She feeds him painkillers bought from a patent medicine store — N500 per strip, three strips a week — that do nothing for the tumour but dull the screaming. She prays. She asks relatives for money. She considers selling her only plot of land. She watches her husband shrink into himself, losing weight, losing hope, losing the ability to walk without assistance. Four months of agony. Four months of waiting for a miracle that should have come from a functioning healthcare system.

The miracle comes from Canada. A nephew in Toronto sends $3,000. The surgery happens at a private hospital in Ibadan. The tumour is removed. Her husband survives.

But the four months of pain — the sleepless nights, the borrowed transport money for hospital visits that yielded nothing, the humiliation of begging — that was the cost of one vote in 2019. The vote that elected the governor who oversees hospitals with no drugs. The same governor who, three months into his first term, flew to Germany for a "routine check-up."

"His cough gets a German doctor," Mrs. Adebola says, her voice flat with the particular fury of the betrayed. "My husband's tumour gets a prayer."

This is Nigeria's healthcare system. It is not underfunded. It is dismantled — deliberately, systematically, generationally — by the same electoral choices that send governors to London for headaches while sending citizens to early graves. The numbers are not abstract. They are Mrs. Adebola's husband. They are 58,000 women who die in childbirth every year. They are 768,000 children under five who do not survive to blow out their birthday candles. They are the N29.3 billion that fled this country in search of medical care that should exist here, in hospitals that should work, staffed by doctors who should stay.

This chapter is an autopsy of a healthcare system killed by bad votes. The body on the table is yours.

3.1 The Healthcare Collapse

3.1.1 The $29.3 Billion Exodus: Medical Tourism as Governance Failure

Between 2015 and 2023, Nigerians spent $29.3 billion on foreign medical treatment. That is not a typo. That is not a projection. That is Central Bank of Nigeria data, corroborated by the Federal Ministry of Health, tracking the hard currency that fled Nigeria's shores in search of what Nigerian hospitals should have provided — cardiac surgery, cancer treatment, kidney transplants, neurosurgery, uncomplicated childbirth.

$29.3 billion — an average of $1.2 to $2 billion annually depending on the year and exchange rate. To comprehend the scale: it exceeds Nigeria's annual federal budget for 2024. It is enough to build 200 world-class tertiary hospitals at $150 million each. It is enough to equip every primary healthcare centre in Nigeria with drugs, diagnostic equipment, and solar power — five times over. It is enough to train 50,000 specialist doctors and pay them competitive salaries for a decade. Instead, it bought German check-ups for governors, Indian heart surgeries for ministers, and London cancer treatments for senators.

The destinations tell the story of Nigeria's healthcare failure in geographic form. India captures 40% of Nigerian medical tourists — approximately $11.7 billion over eight years — because Indian hospitals offer cardiac bypass surgery for $15,000–$25,000 that is simply unavailable in most Nigerian public hospitals. The United Kingdom takes 20% — $5.9 billion — for oncology and complex paediatric cases that Nigerian facilities cannot handle. The UAE attracts 15% — $4.4 billion — for cosmetic and wellness procedures that Nigeria's elite prefer to have administered in Dubai's gleaming clinics rather than in Lagos's decaying wards.

Table 3.1: Medical Tourism Expenditure — Destination Breakdown (2009–2023)

The procedures that drive this exodus are not exotic. Cardiac bypass surgery — available in every Indian city with a population over one million — is performable in fewer than five Nigerian public hospitals. Kidney transplants, routine in South Africa and Egypt, are unavailable in any Nigerian public hospital. Chemotherapy cycles that cost $200–$500 in Nigerian public facilities are often impossible because the drugs are out of stock; patients who can afford it travel to India for $1,500–$3,000 per cycle rather than wait for a pharmacy that may never restock.

Table 3.2: Medical Tourism — Cost Abroad vs. Public Hospital Availability

The currency cost alone is catastrophic. $29.3 billion in foreign exchange, spent on healthcare that should be available domestically, represents one of the largest capital flights in Nigerian economic history. It competes with oil theft for destructive economic impact. But unlike oil theft, which enriches criminals, medical tourism impoverishes the nation while enriching foreign hospitals.

The governance indictment is absolute. Every political office holder who travels abroad for medical treatment has made a confession — not in words, but in the most consequential choice a person makes about their health. They have declared, through their actions and their spending, that the system they oversee is unfit for their own family. If it is not good enough for the governor with his German check-up, why is it good enough for Mrs. Adebola's husband with his tumour?

The poster line writes itself: The hospital your grandmother trusted now has no paracetamol. But the Governor who oversees it has a private jet for medical flights abroad. That is not healthcare. That is betrayal.

Table 3.3: Healthcare Indicators by State — The Geographic Lottery of Survival

The geographic lottery is stark. A child born in Ogun State has a life expectancy of 61.4 years — fifteen years longer than one born in Kebbi, where life expectancy of 48.4 years rivals war-torn nations. The infant mortality gap is equally brutal: 16 deaths per 1,000 in Ogun versus 90 in Kebbi. These are not natural disparities. They are the direct, measurable consequences of governance choices — of health budgets allocated or stolen, of PHCs equipped or abandoned, of doctors retained or driven away.

3.1.2 70% Out-of-Pocket: When Healthcare Is a Luxury Good

Nigeria's health financing structure is an inverted pyramid. Instead of the government bearing the largest share of healthcare costs — as it does in every developed nation and most developing ones — Nigerian citizens pay directly from their own pockets for more than 70% of all health expenditure. The government's contribution, at 3.6% of GDP, falls so far below the 15% target set by the Abuja Declaration of 2001 that it constitutes not underfunding but abandonment.

Compare this with global benchmarks. In the United Kingdom, out-of-pocket health spending is 18% of total health expenditure — the NHS covers the rest. In France, it is 11%. In Germany, 14%. Even India, with its vast population and comparable development challenges, has reduced out-of-pocket spending to 33%. Nigeria's 70% is among the highest rates in the world, exceeded only by a handful of failed states where government has collapsed entirely.

This 70% figure translates into daily arithmetic of impossible choices. At a per capita health expenditure of N33 — approximately $0.02 per day — the Nigerian government's contribution to each citizen's health is the price of a single tablet of paracetamol, if bought in bulk, if the hospital has stock, if the supply chain has not broken down. The citizen must find the remaining 70% from an income already consumed by food inflation, generator fuel, transport costs, and school fees.

The catastrophic expenditure threshold — defined by the World Health Organization as health spending exceeding 10% of annual household income — is crossed by approximately 40% of Nigerian households every single year. A single serious illness does not merely deplete savings. It destroys families. The breadwinner who misses work for treatment loses income. The treatment that requires payment upfront depletes reserves. The debt incurred to pay hospital bills compounds at informal interest rates. The next illness — and there is always a next illness — pushes the family from survival into destitution.

The National Health Insurance Scheme (NHIS) covers fewer than 5% of Nigeria's population. The remaining 95% — approximately 210 million people — have no risk pooling, no catastrophic coverage, no safety net. The informal sector, which employs 80% of Nigerian workers, is almost entirely excluded. A market woman with malaria pays cash for diagnosis, cash for drugs, cash for transport to the clinic. A farmer with a hernia saves for years for surgery that may never become affordable, or travels to a traditional healer who makes the condition worse.

The COVID-19 pandemic exposed this fragility in its most lethal form. When the virus arrived, Nigeria had fewer than 500 ventilators for 200 million people. Healthcare workers died for lack of personal protective equipment. Oxygen shortages killed patients who could have survived. The official death count of 4,000+ is almost certainly an undercount — excess mortality studies suggest the true figure may be ten times higher. The pandemic did not create Nigeria's healthcare weakness. It simply revealed what was already known to every family that had buried a relative who should have lived.

The fundamental injustice is this: healthcare in Nigeria is treated as a market commodity, not a public good. Those with money live. Those without die. The senator who chairs the health committee and has never used a Nigerian public hospital enjoys health insurance worth N30 million annually, funded by taxpayers who cannot buy malaria drugs. The minister of health who flies to London for a headache oversees hospitals where headaches are treated with prayers because there is no paracetamol.

This is not a health system. It is a death panel administered by the wealthy for the poor.

3.1.3 1,050 Per 100,000: The Maternal Mortality Disgrace

Nigeria's maternal mortality ratio — 1,050 deaths per 100,000 live births — is not merely a statistic. It is a verdict. A verdict on governance, on prioritization, on the value that Nigerian political leadership places on women's lives.

Translate that number to human scale. Approximately 58,000 Nigerian women die annually from pregnancy and childbirth-related causes. That is 158 deaths per day. Six deaths per hour. Every ten minutes, a Nigerian woman bleeds out, seizes from eclampsia, or succumbs to infection in a childbirth that should have been safe. The causes are not mysterious: hemorrhage (25%), infection (15%), eclampsia (12%), obstructed labour (10%), unsafe abortion (8%). Most are preventable with basic obstetric care that Nigeria's PHCs should provide but cannot.

Table 3.4: Maternal Mortality Ratio — Nigeria vs. Comparator Countries

The global comparison is devastating. Nigeria accounts for approximately 20% of global maternal deaths despite having only 2.8% of global births. This disparity is staggering — it means Nigerian women die in childbirth at rates that have no parallel in any nation not currently at war. India, with nearly seven times Nigeria's population, has reduced its MMR to 103 through targeted investment in skilled birth attendance, emergency obstetric care, and midwifery training. Nigeria's MMR has barely moved in two decades.

The infrastructure gap explains why. Only 20% of Nigerian health facilities provide emergency obstetric care. Skilled birth attendance stands at 43% nationally — 80% in urban Lagos, 20% in rural Jigawa. The geographic lottery is lethal: a woman in Lagos has five times better survival odds than a woman in Sokoto. A woman delivering in a private hospital has ten times better odds than one delivering in a primary health centre.

The adolescent dimension compounds the crisis. One in four Nigerian girls has given birth by age 18. Adolescent pregnancy carries twice the maternal mortality risk of adult pregnancy. Child marriage — still prevalent in northern states, where the family planning budget was cut by 97% in recent years — amplifies the death toll. Girls who should be in school are in labour wards without blood supplies, without oxygen, without doctors.

Nigeria's family planning budget cut of 97% is not fiscal prudence. It is femicide by spreadsheet. When women cannot access contraception, they have more pregnancies, closer together, at younger ages, with worse outcomes. The Kebbi infant mortality rate of 90 per 1,000 live births — compared to Ogun's 16 — is not a medical mystery. It is the predictable consequence of a state that does not invest in maternal health, does not educate its girls, and does not provide family planning services.

Maternal mortality is not a medical problem. It is a governance priority problem. States that invested in PHC functionality, midwifery training, and emergency transport — Lagos, Oyo, Kaduna under reform-minded leadership — saw their MMR decline. States that treated maternal health as an afterthought watched their women die in numbers that constitute a silent genocide.

3.2 The System That Kills

3.2.1 The Primary Healthcare Death: From PHC to No-C

Primary Health Care — PHC — is supposed to be the foundation. The first point of contact. The clinic in your community where you take your child for immunization, where the midwife assists your delivery, where malaria is diagnosed and treated, where hypertension is monitored, where basic antibiotics and analgesics are dispensed. In Nigeria, PHC is not a foundation. It is a graveyard.

Nigeria has more than 30,000 PHC facilities nationwide. Fewer than 5,000 are functional. The remaining 25,000 exist on paper, on signboards, in budget documents — but not in reality. A visit to a typical rural PHC reveals a building with peeling paint, a locked pharmacy, an empty laboratory, and a single community health extension worker who has not been paid in three months. The doctor was transferred — or never posted. The drugs were "in transit" — or sold on the black market. The equipment was donated by an NGO — and sits unused because there is no technician to operate it, no power to run it, no consumables to make it work.

Table 3.5: PHC Facility Status — National Assessment (2023)

The 75% stockout rate for essential drugs is not a supply problem. It is a corruption problem. The National Primary Health Care Development Agency (NPHCDA) has a centralized procurement system. Drugs are purchased. They enter the supply chain. And somewhere between the federal warehouse and the clinic shelf, they disappear — diverted to private pharmacies, sold to NGO projects, or simply lost to documentation fraud. A mother who walks five kilometres to a PHC with a feverish child finds the antimalarial out of stock. The child gets sicker. The mother pays twice — once in transport, once in private drug costs she cannot afford.

The power deficit is equally lethal. Ninety percent of PHCs have no reliable electricity. Vaccines that require refrigeration spoil. Laboratory equipment that needs power sits idle. Night deliveries happen by candlelight — if they happen at all. The PHC with no light is a PHC that cannot perform emergency surgery, cannot run a blood test, cannot even charge the phone that might summon help.

The infrastructure deficit compounds the human resource crisis. Nigeria has just 0.25 hospital beds per 1,000 people — one-quarter of the WHO minimum standard of 1.0 bed per 1,000. Some analyses put the figure as high as 0.50, but even the optimistic estimate represents a catastrophic shortage. Nigeria needs 386,000 additional beds and $82 billion in healthcare real estate investment merely to reach the global average of 2.7 beds per 1,000 people.

The personnel desert is equally devastating. Nigeria has approximately 35,000 doctors for 220 million people — a ratio of roughly 1:6,300, compared to the WHO minimum of 1:600. The shortfall is catastrophic: Nigeria needs 237,000 doctors to meet basic standards, and has fewer than 15% of that number. Of the doctors who exist, 50% practice in Lagos and Abuja alone, leaving the remaining 36 states to share the other half.

The state-level divergence is extreme. Lagos State, with its relatively better health insurance system and higher budget allocation, has functional PHCs in most wards — not perfect, not British-NHS-standard, but functional. Ekiti State, under reform-minded leadership, invested in an innovative PHC programme that reached communities other states ignored. Oyo has built healthcare infrastructure with political will that neighbouring states lacked.

But in Zamfara, Yobe, Sokoto, and Borno pre-Zulum, PHC is fiction. The facility exists as a building, sometimes. The staff exist on payroll, occasionally. The drugs exist in procurement documents, never. The patient exists in pain, always.

3.2.2 The Brain Drain Pipeline: How Bad Governance Exports Healers

Between 2019 and 2024, more than 6,000 doctors left Nigeria. Twelve thousand nurses followed them. Thousands of pharmacists, laboratory scientists, physiotherapists, and radiographers joined the exodus. They did not leave because they hate Nigeria. They left because Nigeria made it impossible to practice medicine.

The brain drain pipeline is institutionalized. The United Kingdom, through its Health and Care Worker visa, absorbed approximately 50% of emigrating Nigerian doctors — 1,500 to 2,000 annually. The United States, through the USMLE and residency matching system, took 25%. Canada, through Express Entry, took 10%. The Middle East — Saudi Arabia and the UAE — recruited directly with tax-free salaries that no Nigerian hospital could match.

The push factors are economic and existential. A house officer in a Nigerian teaching hospital earns approximately N150,000 per month — about $100 at current exchange rates. The same doctor in the UK starts at £3,500 per month — approximately $4,400, or forty-four times the Nigerian salary. But it is not only money. It is equipment: the Nigerian doctor who has never operated an MRI machine because the hospital has none. It is security: the doctor kidnapped on the way to work in northern states, the doctor assaulted by relatives of a patient who died for lack of drugs. It is burnout: 100-hour weeks, no leave, no research opportunities, no career progression, and the grinding hopelessness of watching patients die from conditions that should be treatable.

Table 3.6: Medical Brain Drain — Destination and Volume (2019–2024)

The economic calculation of brain drain is devastating for Nigeria. Training one doctor costs the Nigerian government approximately N3–5 million in public subsidy — medical school infrastructure, teaching hospital attachments, licensing examinations. When that doctor emigrates, that investment is transferred, free of charge, to the British or American healthcare system. It is educational colonialism in reverse: Nigeria trains, the West gains, and the patient in Sokoto dies for lack of a doctor who now works in Manchester.

The ethical dimension is complex. A doctor swears an oath to serve humanity. Can that oath be fulfilled in a system that denies the doctor equipment, drugs, security, and a living wage? The doctor who stays may be a hero. The doctor who leaves may be a realist. But the system that forces the choice is the villain.

States that invested in doctor welfare retained more of their workforce. Lagos, with its health insurance mandate and relatively competitive salaries, kept doctors that Sokoto lost. Delta and Rivers, with their teaching hospital investments, retained specialists that Yobe never had. The pattern is clear: better governance produces better retention. Worse governance exports healers while importing corpses.

The brain drain accelerates. Each doctor who leaves makes the remaining doctors' workload heavier, the burnout deeper, the incentive to leave stronger. It is a death spiral — fewer doctors, worse care, more deaths, more emigration, even fewer doctors. The only way to break it is at the source: governance that values healthcare enough to fund it, protect it, and staff it.

3.3 The Health Voter

3.3.1 The State Health Scorecard: Where Your Governor Ranks

Your governor controls your health. Not metaphorically — literally. State governments manage primary healthcare, employ most healthcare workers, fund state teaching hospitals, and determine whether the PHC in your ward has drugs or dust. The federal government sets policy and provides guidelines, but the state government determines whether those guidelines become clinics or remain paper.

A composite state health scorecard — combining maternal mortality ratio, infant mortality, health worker density, PHC functionality, health budget allocation, and health insurance coverage — produces a stark ranking that correlates almost perfectly with governance quality.

Table 3.7: State Health Budget vs. Abuja Declaration Target

The top performers are not mysterious. Lagos leads because it combines the highest health budget with mandatory health insurance registration covering more than 5 million residents, functional PHCs in most wards, and the political will to retain health workers through competitive salaries. Ekiti's innovative PHC programme reached communities that other states abandoned. Oyo invested in healthcare infrastructure with measurable outcomes. Kaduna, under reform-minded leadership, implemented the Basic Health Care Provision Fund effectively and prioritized health worker retention.

The bottom performers are equally predictable. Zamfara has the highest maternal mortality, the lowest health spend, and near-total absence of specialist care. Yobe's PHCs are non-existent in many LGAs. Sokoto combines child marriage prevalence with low health investment to produce maternal death rates that belong in the nineteenth century. Borno, devastated by conflict, is improving under Zulum but started from near-zero after years of insurgency and neglect.

The budget indicator is the most powerful predictor. States allocating 8% or more of their budget to health — Lagos, Ekiti, Ondo — produce better outcomes than states allocating less than 5% — Zamfara, Jigawa, Yobe, Sokoto. The gap between Lagos's 8.4% and Zamfara's 3.1% is not merely fiscal. It is the difference between life and death for thousands of citizens.

Lagos State's health insurance mandate — requiring every resident to register — is the most significant state-level health reform in Nigeria. It covers more than 5 million people, funds facility upgrades, and provides a revenue base that other states lack. Zamfara's health insurance coverage is zero. Not low. Zero. No risk pooling, no catastrophic coverage, no safety net. A Zamfara resident with cancer has two options: pray, or travel to Kaduna — if they can afford the transport and the private hospital bills.

Voters in healthy states should reward governors who invested in healthcare. Voters in sick states should punish governors who treated health as an afterthought. The scorecard is public. The data is available. The only missing element is the voter's will to hold governors accountable for the bodies that pile up in their underfunded hospitals.

3.3.2 The ROI of Health Investment: Why Healthcare Is Economic Policy

Healthcare is not consumption. It is investment. This is not a moral argument, though the moral case is overwhelming. It is an economic argument, backed by data that every voter should understand before casting a ballot.

The World Health Organization estimates that every $1 invested in primary healthcare returns $10 in economic productivity. Healthy children attend school more regularly and learn more effectively — critical in a nation where 89% of 10-year-olds suffer learning poverty. Healthy adults work more days, earn more income, and pay more tax. Healthy populations require less welfare spending and generate more economic growth. Healthcare investment is not a cost to be minimized. It is a growth engine to be maximized.

Malaria alone costs Nigeria approximately N480 billion annually in lost productivity — treatment costs, work days missed, premature deaths, and diminished educational outcomes. A worker with untreated malaria loses 5–10 working days per year. At an average productivity value of N5,000 per day, that is N25,000–N50,000 per worker per year across millions of workers. A single disease, mostly preventable with bed nets and basic treatment, drains the economy of hundreds of billions.

The demographic dividend amplifies the case. Nigeria's median age is 18. Maximizing the productivity of this youth bulge requires healthy youth. A stunted child — 33.8% of Nigerian children under five suffer chronic malnutrition — will never reach cognitive or physical potential. A sick adolescent misses the schooling that would enable economic participation. A young adult disabled by preventable disease becomes a dependent rather than a contributor. Nigeria cannot afford a sick generation if it hopes to develop.

The World Bank Human Capital Index ranks Nigeria 152nd out of 157 countries — below war-torn nations, above only Chad, South Sudan, Mali, and Niger. Health is the primary driver of this ranking. A country that cannot keep its children alive, its mothers safe in childbirth, and its workers healthy cannot build human capital. And a country without human capital cannot build anything else.

The catastrophic cost of healthcare failure extends across generations. When a breadwinner dies from a preventable condition — hypertension unmanaged because the PHC has no drugs, diabetes untreated because insulin is unaffordable, appendicitis fatal because the surgical theatre has no light — the family loses income permanently. Children drop out of school. The intergenerational poverty trap snaps shut. The N85,000 annual out-of-pocket health expenditure, multiplied across millions of families, represents not just a household cost but a national productivity hemorrhage.

The political economy of health is clear: politicians who understand health as economic policy invest in it. Politicians who see it as consumption cut it. The governor who funds PHCs, retains doctors, and stocks pharmacies is not being generous. He is being smart — investing in the human capital that generates the tax revenue that funds every other state function. The governor who cuts health budgets, lets PHCs decay, and watches doctors emigrate is not being fiscally prudent. He is being economically suicidal — destroying the productive base that his state needs to grow.

The voter's choice is therefore an investment choice. Voting for healthcare is voting for your family's economic future. The hospital without drugs is not merely a health crisis. It is a factory for poverty — producing stunted children, disabled adults, orphaned families, and diminished futures.

The poster line should be engraved on every ballot paper: The hospital your grandmother trusted now has no paracetamol. But the Governor who oversees it has a private jet for medical flights abroad. That is not healthcare. That is betrayal.

Source Notes — Chapter 3

Primary Statistical Sources
- Federal Ministry of Health and Social Welfare: National health accounts, medical tourism expenditure estimates, health facility inventory, and workforce statistics.
- National Primary Health Care Development Agency (NPHCDA): PHC facility assessments, immunization coverage data, and community health program reports.
- National Bureau of Statistics (NBS) Health Sector Reports: Health expenditure data, disease burden statistics, and health workforce surveys.
- Central Bank of Nigeria (CBN) Medical Tourism Forex Data: Estimated foreign exchange expenditure on overseas medical treatment (2009–2023).

International Health Data
- UNICEF Nigeria Maternal Mortality Dashboard: Real-time and historical MMR data, causes of maternal death, and intervention coverage rates.
- WHO Nigeria Country Cooperation Strategy: Healthcare system assessment, workforce density data, and health infrastructure benchmarking.
- World Bank Human Capital Index 2023: Nigeria's HCI ranking, decomposition by health and education components, and comparator country analysis.
- IHME (Institute for Health Metrics and Evaluation) Global Burden of Disease — Nigeria: Disease burden, risk factors, and health outcome trends.

Medical Brain Drain Sources
- Medical and Dental Council of Nigeria (MDCN) Workforce Registry: Registered physician data, emigration tracking, and training output statistics.
- GMC (UK General Medical Council) Registration Data: Nigerian-trained doctors registered to practice in the UK (2019–2024).
- ECFMG (Educational Commission for Foreign Medical Graduates) US Data: Nigerian physicians certified for US residency programs.
- Nigerian Medical Association (NMA) "Physician Migration Survey" (2023): Survey of 2,000+ doctors on emigration intentions, drivers, and deterrents.

State-Level Health Sources
- State Health Accounts (BudgIT Compilation): State-by-state health budget allocation, PHC expenditure, and health insurance coverage data.
- Lagos State Health Management Agency (LASHMA) Reports: Health insurance enrollment, facility upgrades, and maternal health outcomes.
- PATHS2 (Partnership for Transforming Health Systems) State Assessments: PHC functionality, health worker presence, and drug availability surveys across 12 states.
- Society for Family Health (SFH) "PHC Diagnostic": National assessment of 1,200+ PHC facilities on infrastructure, staffing, and service readiness.