Prospect And Challenges Of Primary Healthcare Programme In Rural Community

Project and Seminar Material for Public Health

Abstract

This study examined the prospect and challenges of primary healthcare programme in Offa LGA of Kwara State. A crosssectional survey research was conducted to generate data to answer the research questions as well as test the hypothesis. Both quantitative and qualitative research approaches were combined in the study. A sample of six hundred (600) women aged 15-49 years, who had at least one child or had been child-caregivers was given a set of questionnaire administered by trained research assistants. Qualitative data were generated by Focus Group Discussion (FGD) with community members as well as in-depth interviews (IDI) with health workers. The analysis of study data showed that the situation of PHCs in the LGA was generally poor. Results from multiple regression analysis showed that cost of services and personnel problems which included attitude of health workers, waiting time and appointment time were the major challenges the people encountered in accessing PHC services in the LGA. These were statistically significant at P≤0.001 level. Mothers were often reluctant to visit PHCs because of the shabby manner in which they were treated by the health workers. Another major problem the people encountered in accessing PHC services was distance and cost of transportation to the facilities. The study recommended more Government presence in the rural areas in form of provision of adequate health facilities, medical consumables and adequate sensitization to improved rural participation. Training and retraining of health workers was also recommended.

Table of Content

Chapter One

Introduction

1.1 Background to the Study
1.2 Statement of the Problem
1.3 Research Questions
1.4 Objectives of the Study
1.5 Significance of the Study
1.6 Definition of Concepts

Chapter Two

Literature Review

2.1 Review of Empirical Literature
2.1.1 Global Trends in Child Mortality
2.1.2 Child Mortality in Nigeria
2.1.3 Factors Associated With Child Mortality in Nigeria
2.1.3.1 Poor Maternal Health
2.1.3.2 Nutritional Status
2.1.3.3 Demographic Factors
2.1.3.4 Environmental Factors
2.1.4 Access to Primary Healthcare Programs in Nigeria
2.1.5 Factors Affecting Access to Healthcare Programs in Nigeria
2.1.5.1 Political Factors
2.1.5.2 Organizational Factors
2.1.5.3 Location/geographic Factors
2.1.5.4 Educational Factors
2.1.5.5 Cost of Services
2.1.5.6 Cultural Barriers
2.1.5.7 Presence of Patent Medicine Vendors
2.1.6 Efforts to Improve Access to Healthcare Programs in Nigeria
2.2 Review of Relevant Theories
2.2.1 Individual or Intrapersonal Health Behavior Models/theories
2.2.1.1 Health Belief Model
2.2.1.2 Theory of Planned Behaviour
2.2.2 Interpersonal Health Behavior Model/theories
2.2.2.1 Social Network Theory
2.2.2.2 Structural Basis for Action Theory
2.2.3 Community Level Model/theory
2.2.3.1 Culture-bound Theory of Disease
2.3 Theoretical Framework
2.4 Study Hypothesis

Chapter Three

Research Methodology

3.1 Research Design
3.2 Area of Study
3.3 Study Population
3.4 Sample Size
3.5 Sampling Procedure
3.6 Instrument for Data Collection
3.7 Methods of Data Collection
3.8 Methods of Data Analysis
3.9 Limitations of the Study

Chapter Four

Analysis and Presentation of Data

4.1.1 Age Distribution
4.1.2 Marital Status
4.1.3 Occupational Distribution
4.1.4 Level of Education
4.1.5 Religious Affiliation
4.1.6 Number of Years Lived in the Community
4.2 Issues on Child Health: Common Health Problems Among Children
4.2.1 Common Health Problems in Children and Their Managements
4.2.2 Options Taken by Respondents for Childs Healthcare
4.2.3 Options Taken for Child Health and the Level of Education of Respondents.
4.2.4 Options Taken for Child Health and Marital Status
4.2.5 Reasons for Taking Various Options
4.3 Situation of Primary Healthcare Programs
4.3.2 Decisions-making on Health and Education in the Households.
4.3.3 Respondents Perception of Cost of Services at PHC
4.3.4 Use of PHC in the Communities
4.3.5 Distribution of Respondents on How Often They Visited the PHC
4.3.6 Respondents’ Experiences at the PHC
4.3.7 Major Problems in Accessing Healthcare Programs
4.4 Issues on Immunization and Use of Insecticide Treated Nets
4.4.1 Knowledge About Immunization.
4.4.2 Bringing Out Children for Immunization.
4.4.3 Immunization of Children and Level of Education of Respondents
4.4.4 Effectiveness of the Immunization Exercise
4.4.5 Reasons for Bringing Out Children for Immunization
4.4.6 Ever Heard About ITNS
4.4.7 Reasons for Not Using ITNS.
4.4.8 Common Statements About ITNS and Immunization.
4.5 Multiple Regression Analysis
4.6 Test of Hypotheses
4.6.1 Hypothesis One
4.6.2 Hypothesis Two
4.6.3 Hypothesis Three
4.6.4 Hypothesis Four
4.6.5: Hypothesis Five
4.7 Summary of Findings

Chapter Five

Discussions, Conclusion and Recommendations

5.1 Discussions
5.1.1 Options Taken in Child Healthcare
5.1.2 Problems in Accessing PHC Services
5.1.3 Common Health Problems Among Children in the LGA
5.1.4 Awareness of Health Interventions Like Immunization and ITNS
5.2 Conclusions
5.3 Recommendations
References
Appendix
Questionnaire

Chapter One

Introduction

1.1 Background to the Study

At the assemblage of world leaders in 2000 to define global development goals for the millennium, child mortality was identified as one key indicator of development. It was thus identified to be monitored as an indicator of social, economic and health development for different countries and zones in the world. Targets were set for attaining the millennium development goals (MDGs). For instance, it was expected that by 2015, global child mortality rate would be reduced to 45/1000.

To achieve this target, global efforts were galvanized to produce technologies that would ensure child health the world over. The production and distribution of effective vaccines and technology that protect children against the known childhood killer diseases were promoted. The primary healthcare (PHC) system in every country of the world was identified as the main driver for successful struggle against childhood deaths. The PHC centres were expected to provide the platform for the delivery of ante-natal and post-natal care for women, during which the babies would also be immunized against childhood killer diseases. Consequently, one primary function of the health centers was to promote access to health interventions and thus reduce childhood mortality.

In 2004, the United Nations established the Inter-Agency Group for Child Mortality Estimation (IGME) to advance the work of monitoring the progress towards MDG4 which targets the reduction of under-five mortality rate by two-thirds between 1990- 2015 as global momentum and investment for accelerating child survival and growth (UNICEF, 2010). This has prompted a renewed focus on the issue of access to health interventions. Thus while addressing the World Health Assembly in 2005, Bill Gate (2005) called on world players in global health to devote more thinking and funding to promoting access to interventions that exist for good health. The study proposed here is intended to examine the issue of access to PHC services in Nigerian rural communities, employing data from Offa Local Government Area (LGA) ofKwara State.

1.2 Statement of the Problem

Commonly defined as one’s ability to obtain and appropriately use good quality health technologies and commodities as and when needed for good health (Ensor & Cooper, 2004), effective access to healthcare programs by women and children remains limited and problematic in Nigeria. For instance, the 2008 Nigerian Demographic and Health Survey (NDHS) revealed that only 23 % of children aged 12-23 months, the age by which they should have received all vaccinations, were fully vaccinated. Fifty percent received vaccinations for BCG and 41% for measles. Fewer children received DPT 3 (35 %) and polio 3 (39 %), compared with those who received DPT 1 (52 %) and polio 1 (68 %). Only 19 % of children are fully immunized by 12 months of age.

Overall, 29 % of children in Nigeria have not received any vaccinations.

Similarly, the ownership and use of insecticide treated nets (ITNS) leaves much to be desired. Only 8% of households covered in the 2008 NDHS had at least one ITN, while only 3% owned more than one ITN. The average number of ITNS per household was less than one. This is worrisome considering the large sizes of households in Nigeria.
The vigorous distribution and promotion of the use of insecticide-treated nets (ITN) among pregnant women and children under-5 years of age has not yielded the expected result of controlling malaria, especially among these groups of people. Only 8 % of households own more than one mosquito net. Worse still, only 3 % own more than one ITN. The average number of ITNS per household is less than one. This falls short of the target of at least two ITNS per household, despite the tremendous progress in net production and availability in Nigeria.

Access to these life saving technologies differ among people in different demographic clusters. The 2008 NDHS shows that while more children (<5 years) in the rural areas (12.6%) than those in the urban areas slept under any net, only 5 % of the children (<5 years) in the rural areas compared to their counterparts (6.5%) in the urban areas slept under ITNS. Fewer children in the lowest quintile (2.5%) compared to 8.0% in the highest quintile slept under ITN. The picture is not different with access to immunization.

According to Frost and Reich (2008) the prevailing child mortality rate in developing countries is because many people do not have access to healthcare programs especially the rural dwellers. The low child health status and poor uptake of interventions designed to promote child health in Nigeria are largely attributable to poor antenatal care (ANC) practices, lack of access to and weak health systems. The situation is further aggravated by poverty and ignorance, which account for women’s inability to access critical ANC services and counseling on important safety measures, drugs and other interventions like ITN use (Onokerhoraye, 2000). In many cases, medical facilities are few and thinly spread. In the hard to reach rural areas, with difficult terrain and poor road network, modern health facilities are luxuries the dwellers can hardly afford, even when they wish (Okonofua, 2010). Attendance at ante natal clinics (ANC) is very poor for a number of personal and logistic issues confronting mothers especially with respect to distance, means of transport and sometimes attitude of health staff.

Nigeria is signatory to several agreements reached at international conferences in 1993 to solve the problem of poverty, hunger, malnutrition and child survival in the world. But it is a sad commentary to note that 18 years after this historic movement began, several millions of children have been left behind (Ogundipe, 2008). Ojanuga (2009) opined that child mortality rate is still on the increase and is buoyed by sociocultural factors which negatively impinge upon physical well being and accessibility to appropriate healthcare programs.

There is also the problem of low education especially health education among the rural dwellers. This has limited the abilities of community members to make rational choices (Federal Ministry of Health and Social Services, 1998). According to Ugwueje (2008), education acts as a very important variable because it alters other features of household living conditions such as knowledge of proper health facilities, perception of illness and disease etiology and personal illness control measures.

Furthermore, World Bank (2002) observed that economic hardship is one of the major causes of the increased child mortality rates in Africa. Resources to buy adequate and high quality foods have declined in most families and this has affected the feeding practice of the children (Rokx& Brown, 2002). In her study, Onyeneho (2005) argued that failure to access child health programmes in developing countries depends upon bridging gaps in delivery and community utilization of services.

The foregoing problems and issues tend to suggest that increased child mortality in the country is related to poor access to Primary Healthcare programs. While the problem may be the same in most Nigerian communities, the actual manifestation and explanatory factors may differ from one locality to another even among social groups within the same society. This agrees with the view of Frost and Reich (2008:xi) when they concluded that “just because a good health technology exists, does not mean that it will be delivered, used or achieve its potential to bring good health”. It is therefore, the major challenge of this study, to identify the factors that affect access to primary healthcare programs and their effects on child mortality in Offa Local Government Area of Kwara State.

1.3 Research Questions

Based on the foregoing, the following research questions are formulated to guide this study:

What is the situation of infant and child health in Offa Local Government Area of Kwara State?
What is the level of uptake of technologies for child survival in Offa Local Government Area?
What are the cultural factors affecting access to Primary Healthcare programs in Offa Local Government Area?
Is the cost of healthcare programs an impediment to access to healthcare programs in the Local Government Area?
What are the implications of the mother’s level of education on accessing healthcare services in the Local Government Area?
Are there spatial differences in access to Primary Healthcare programs by communities in Offa Local Government Area?
What are the consequences of poor access to Primary Healthcare programs on the child health in the Local Government Area?

1.4 Objectives of the Study

The main objective of the study is to examine the prospect and challenges of primary healthcare programme in rural communityin Offa Local Government of Kwara State.

The specific Objectives of the study are:

To ascertain the health situation of children in Offa Local Government
To find out the level of uptake of technologies for child survival in the Local Government Area.
To ascertain the cultural factors affecting access to Primary Healthcare programs in Offa LGA.
To find out how the cost of healthcare programs impedes access to healthcare programs in the LGA.
To identify the implications of mothers level of education on accessing healthcare programs in the LGA.
To find out the effects of distance in accessing Primary Healthcare programs in Offa LGA.
To ascertain the consequences of poor access to Primary Healthcare programs on child survival.

1.5 Significance of the Study

The population situation in Nigeria shows that the level of mortality, especially infant and child mortality is still high. To this effect, this study has both theoretical and practical relevance.

Theoretically, this study stands to provide additional knowledge to the body of existing literature on child health in Nigeria and other developing countries with particular reference to rural areas. The result of this study will serve as good base or guide for future reference and it will also encourage further research on the health of the children in the rural areas since currently, it demands for proper attention. Furthermore, this study will provide relevant information on the factors that affects childhood mortality and poor utilization of primary Healthcare programs especially in developing countries. The study will provide empirical data to test the relevance of some of the existing theories on child health in rural Nigeria.

Practically, the findings of this study will reveal the factors that militate against proper utilization of primary healthcare programs and its effects on child mortality. The result from this research will also help planners design relevant, persuasive health messages that will help change the people’s attitude on the utilization of primary healthcare programs and create more awareness on the situation of child mortality in the country. More important, the process of interviewing and supply of responses to the questions will afford the people in the study communities the opportunity to review their child health practices for the better.

1.6 Definition of Concepts

Access to Healthcare Programs:

Access to healthcare programs is defined as one’sability to obtain and appropriately use good quality health technologies and commodities when needed for good health (Frost & Reich, 2008).

Childhood Mortality:

“Mortality refers to decrement process by which living members of a population gradually die out” (Preston, Heuveline, & Guillot, 2001:92). Childhood mortality refers to death of persons under-5 years (WHO, 2020). It is measure by the number of deaths occurring between the first year of birth and the fifth birthday in a given population.

Infant Mortality:

This is the death occurring during the first year of life (UNICEF, 2010). In this study it will refer to the death of person aged 12 months or less.

Mortality Rate:

This is a measure of the number of deaths(in general, or due to a specific cause) in some population, scaled to the size of that population, per unit time. It is typically expressed in units of deaths per 1000 individuals per year (http://en.wikipedia.org/wiki/Mortality_rate, accessed 06/05/2020). Kpedekpo (1982) defines mortality rate as the number of deaths per 1000 people in a particular population in a given point in time.

Neo-natal Mortality:

The neonatal period commences at birth and ends 28 completed days after birth. Neonatal mortality thus refers to deaths during the first 28 completed days of life (WHO, 2020). In this study, it will be seen as the phenomenon of death among children within the first 28 days of life.

Primary Healthcare:

According to WHO (1978), Primary healthcare is defined as essential healthcare based on practical, scientifically sound, and socially acceptable methods and technology made accessible to individual and families in the community through their full participation and at a cost that the community and country can afford to maintain in the spirit of self-reliance and self-determination.

Primary Healthcare Programs:

This refers to the provision of primary healthcare, including preventive healthcare programs and education (Texas Department of Health Services, 2007). In this study, it will include provision of the first course of health management, especially education and preventive services. It entails basic curative, preventive and promotional healthcare programs. In this study focus will be on the provision of basic curative, preventive and promotional healthcare programs in government established health care centres.

Rural Communities:

According to Mendelson and Bollman (1998), rural communities are populations living outside the commuting zones of larger urban centres. Plessis, Beshiri, Ballman and Clemenson (2002) defined it as population living in towns and villages outside the commuting zone of larger urban centres with population of 10,000 or more. They however suggested that the appropriate definition should be determined by the question being addressed. Thus in this study, rural communities will refer to areas that are outside the urban areas or cities. They have health facilities that provide primary healthcare while people with serious health problems are usually referred to secondary and tertiary health facilities in large urban centres.

Socio-Economic Factors:

Smith (2000) defined socioeconomic factors to include income, ethnicity, sense of community and other such factors. In this study socioeconomic factors will refer to education, gender, occupational, income and legal factors that influence the ability of mothers to access primary healthcare programs.Under-five Mortality Rate: WHO (2006) defined it as the probability of a child born in a specific year or period dying before reaching the age of five expressed per 1000 live births. In this study, it will be taken as a measure of the proportion of children dying between birth and age five per thousand births.

Utilization of Primary Healthcare Programs:

Nteta, Mokgatte and Oguntibeju (2010) conceptualized this as the practice of visiting and receiving primary healthcare programs from primary healthcarecentres in the communities. In this study it will refer to the manner in which the study subjects use primary healthcare programs in their communities for the prevention of health problems in their children under five years old.

Chapter Five

Discussions, Conclusion and Recommendations

5.1 Discussions

The discussion of the findings will be presented under four major topics of interest in this study.

5.1.1 Options Taken in Child Healthcare

Result from the study revealed that the first place the people visited for their children’s healthcare was the Primary Health care centres (66.3%) in the respective communities. This is in spite of the inadequacies found in the PHCs. The second place the respondents visited for children’s healthcare was the hospitals located in the neighbouring towns such as Awka, Oko, Ekwulobia. Medicine stores were the third option taken by the people. The study also showed that the location of the respondents affected their health seeking behaviuor as those who lived close to the PHC centres accessed it more than those who lived far away from the centres. Another major factor that influenced the people’s option was the level of education of the respondents. Our findings here agreed with the findings of Grossman &Kaester (2000). In that study it was observed that education of the care-givers was a major determinant of demand for healthcare. They found education to be the most important correlate of good health. They further stated that education of the parents, particularly the mother, was also important in determining child health status. This is further corroborated by Umoh’s (1994) assertion that lack of education or ignorance is a major constraint in accessing healthcare programs in Nigeria.

Findings from this study are in agreement with the above literature as it showed that those with no formal education and those with only primary education patronized the traditional and spiritual healers more than those with secondary and higher levels of education.

5.1.2 Problems in Accessing PHC Services

This particular section of the research finding covers most of the research questions that sought to expose the problems the people encountered in accessing PHC services in the area.

The major problem the people faced in accessing PHC services was the cost of services at the centre. The second major problem was absence of medical personnel especially medical doctors and qualified nurses at the PHCs. The third problem was logistics and the fourth was lack of facilities. Brown et.al (1993) noted that these factors were very crucial as they determine the extent to which services are conveniently organized for prospective client and this encompasses such issues as clinic hours and appointment system, waiting time and mode of service delivery, attitude of health workers and buying of drugs outside the facility. The qualitative data confirmed these problems as some of the participants complained bitterly about these issues.

Generally these findings agree with the empirical findings of Ensor and Copper (2004) on the role of demand-side barriers in impeding access and use of healthcare programs. Further, the findings also agree with Frost & Reich (2008) as they identified bottlenecks to access as major problem in the use of healthcare programs in developing countries.

The findings also agree with the structural basis for action theory which formed the theoretical framework for this study. It specifically states that the condition of the health facility will influence the people’s decision to visit or not to visit the facility.

Although a number of socioeconomic factors negatively affected access to PHC services, it is interesting to note that the PHCs in the LGA were the first port of call despite their inadequacies.

5.1.3 Common Health Problems among Children in the LGA

The findings from the study show that the health problems among children in the LGA were similar. The most commonly mentioned health problem among children in the communities under study was malaria which was mentioned by 83.0 percent of the respondents. Fever was the second most common health problem among children mentioned by 62.2 percent of the respondents in all the communities studied. About a third (33.3%) of the respondents mentioned spiritual attack (ntutu). It was observed from the study that while children with illnesses like malaria and fever were easily taken to the PHC, children who suffered from spiritual attack (ntutu) were taken to traditional or spiritual healers since it was believed that taking them to the hospital may worsen the illness. This is in line with the theoretical basis of this study (Culture Bound Theory of Disease) which argues that the people’s cultural interpretation of an illness will determine whether they will access modern healthcare programs or not.

5.1.4 Awareness of Health Interventions like Immunization and ITNS

The result from the study suggests that there is a positive disposition towards ITN and immunization in the communities. The respondents tended to disagree with the statements that portray negative opinions while agreeing with those that were positive in nature. For instance 69.0 percent of the respondents disagreed with the statement which holds that ITN is harmful to children. On the other hand, 69.3 percent agreed with the statement, which suggests that immunization is effective in protecting children against diseases. This positive disposition to health issues and interventions suggests an appreciable level of knowledge of health interventions in the communities. This is contrary to the general view that rural dwellers do not appreciate these health interventions.

5.2 Conclusions

Results from the study show poor access to primary healthcare programs in Offa LGA. This is blamed, in part, on Government negligence which is manifested in lack of training and re-training of health workers; inadequate supervision of health workers; lack of medical supplies and consumables as well as maintenance of the existing health facilities. Further the result also shows that the people’s poor access to primary healthcare programs is influenced by the people’s lack of knowledge about the services available at the primary healthcarecentres. For instance, even though the people were aware of immunization and insecticide treated nets, they still fail to utilize these services.

Information from the interview sessions held with community members in the Local Government Area shows that some challenges encountered in accessing PHC services in their various communities included high cost of healthcare programs, transportation to the health centres, bad and inadequatde of health workers towards community members and inadequate medical facilities.

Access to PHC services implies that the facilities exist; that the people have the information they need to properly utilize the facilities; that they can be reached by the people who need them; and that the cost of healthcare programs is affordable. In the case of Offa LGA, these have not been achieved. Healthcare programs are perceived and are indeed out of reach of the people. The services are either unavailable as and when needed or the health workers are unfriendly and poorly motivated to provide the needed services.

5.3 Recommendations

According to Bill Gates (2005), the state of Primary Healthcarecentre is a major indicator of the society’s level of development. Access to PHC and Child Mortality Rate (CMR) are both a development as well as justice variable. The development studies and social justice orientation of any government are measured against its efforts at enhancing access to PHC services, enhancing child’s health and reducing Child Mortality Rate (CMR) in its area of jurisdiction. This is in line with global benchmarks. To achieve greater access to PHC services in Offa LGA of Kwara state, the following recommendation are therefore put forward:

Kwara State Government should, as a matter of urgency, develop a comprehensive policy on access to PHC services. The policy should include an annual work plan and budget, and a mandatory requirement for each LGA in the state to contribute to increasing access to the PHCs in their area.
Offa LG authorities should involve the community members in disseminating information that concern health in the LGA as they are emotionally connected to their own people.
The LG authorities should be willing and ready to employ and pay medical doctors to boost the people’s confidence in accessing PHCs as that was the major problem faced by the people in the LGA.
The State Healthcare programs as well as the Local Government Service Commission should employ more health workers with at least one midwife to ensure safe delivery and reduce infant mortality.
Efforts should be made by Kwara State Government to link the PHCs to secondary and tertiary hospitals, where complicated cases can be referred to.
The cost of services should be made affordable through a drug revolving fund. This will increase access to PHC services.
Offa LG authorities should make plans to construct good road networks to increase access to PHC services.

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