The Delivery of Essential Health Services in Africa Realities and People's Perceptions and Perspectives
REPORT SUBMITTED FOR THE NORTH WEST SITE IN NIGERIA
Patients being attended to at the Health Facility in Gwagwada. Kaduna State Nigeria List of authors Dr Elizabeth O Elhassan - Sightsavers (Principal Investigator) Mr Oluwatosin Adekeye - Department of Psychiatry ABIJ Zaria (Co-investigator) Mr Sunday Isiyaku - Sightsavers Nigeria Dr Felicia NC Enwezor - Nigerian Institute for Trypanosomiasis and Onchocerciasis Research, Kaduna Dr Felicia Anumah - Department of Medicine, College of Health Sciences, University of Abuja Mrs Hafsat L Kontagora - Department of Social Development, Kaduna Polytechnic Ms Folake Ibrahim - Sightsavers Nigeria Mrs Tinuola A Olumeyan - Department of Cooperative Economics and Management Kaduna Polytechnic Mrs Eunice O Ohidah - Department of Education Technical, Kaduna Polytechnic
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2 Foreword
It is hoped that the results of this study will strengthen the health system. Issues relating to the health system building blocks (leadership and governance, information, finance, technology, medicines and supplies, workforce and service delivery) highlighted by the study as well as the attributes (quality, access, coverage and safety) when addressed will lead to the desired outcomes of improved health, efficiency, responsiveness and social and financial risk protection of the population. Acknowledgements
WHO/AFRO The Nigeria NorthWest team acknowledges the WHO/AFRO for technical and financial support for the study. Sightsavers, Nigerina Institute for Trypanosomiasis Research, Kaduna Ahmadu Bello University and Kaduna Polytechnic for releasing staff to participate
APOC For coordinating and providing technical assistance for the study
The Governments of Kaduna and Jigawa States For cooperation during the study at the states and local government levels
Federal Ministry of Health For their cooperation and support at the national level
Members of the study communities For their enthusiasm and active participation in the study
Community members For their time and invaluable contributions to the discussions
4 Executive summarT
There is an urgent need to efficiently improve the delivery of health services to communities who are the end users of health care. This has led to a global movement aimed at renewing primary health care, a call that has been echoed at international, regional and national conferences, including WHO regional committee meetings. However lack of resources and practical implementation strategies has created a need to accelerate progress in achieving universal health goals and the MDGs. Community involvement is currently considered key to the success of health care delivery especially given the successes recorded in previous control programmes such as eradication of the guinea wonn and control of river blindness. The community directed interventions for major health problems in Africa has been demonstrated to be an effective strategy for malaria TB, and child nutrition (vitamin A supplementation). This study therefore intends to bridge the gap between health service delivery and communities as a means to improving the delivery of PHC by documenting the perceptions of health and experiences within essential health care services.
Process and methods The study was carried out in 24 communities in two states (Kaduna and Jigawa) in North West Nigeria. The communities were randomly selected from six districts covering urban, peri-urban and rural. The multi-disciplinary study combined three analytical designs originating from public health and social science research, i.e. cross-sectional surveys, qualitative inquiry and case study research. This allowed for a description and analysis of community perceptions, experiences and expectations of health and health care services within the context of district-based health systems in Nigeria. The cross sectional household survey was based on an interviewer administered instrument while the qualitative inquiry focussed in-depth interviews and focus group discussions. The case study design was based on document reviews and in-depth interviews with principal officers at the state and district levels (health, budget and planning).
Results Health was perceived mainly as a state of physical well being as indicated by the ability to move around (92.9% urban, 85% peri-urban & 89.3% rural) and work (96J% urban, 87.9% peri-urban & 94.6% rural). Feeding, hygiene and sanitation were considered important in staying healthy across the districts. Essential health care services provided at the districts were the treatment of ailments, prescription and dispensing of drugs, antenatal care, immunisation services, childbirth, counselling of patients and malaria treatment and prevention. There was a general dissatisfaction(64.6%o urban & 66.1% rural) with the provision of health care based on the perceived high cost of services, unavailability of drugs, unavailability of health personnel or a health facility and distance to the facility. There was a moderate satisfaction (58.2%) in the peri-urban area because of special district health initiatives especially in Jigawa state. While there was a general dissatisfaction with service delivery the respondents perceived the facility (44.6% urban, 59.3% peri-urban & 52.5% rural) as good. Community members to some extent were involved in health service delivery such as planning, collection of drugs, mobilisation of the community for certain health activities and awareness creation. This had been facilitated by previous experience with other health activities leading to a willingness to continue to participate in health activities. Participation in health care had been in the area of assisting in caring for patients (20.4% peri-urban), sanitation (1 1.S% urban),Umanagement of the facility (14.3% peri-urban) and in some cases the selection of community volunteerc (3.2%o).
Conclusions The general perception of health care delivery in the study area was poor based on the experiences and involvement with the health service. This was despite the fact that there were some health initiatives going on within some of the districts. The community members' expectations of the health service delivery system were not adequately met. There was however an overwhelming willingness and readiness to engage with the health service based on previous experiences with other health programmes and the availability of social capital within the community. There are no structured systems of reimbursements for procured drugs except in a few instances where this is done by community associations. Govemment was the major financier of health in the study site; alternative mechanisms such as social health insurance were non existent and thus there was no social and financial risk protection. Based on the outcome of the study, there is a need for improvement of health service delivery in the areas of coverage, service delivery, policy and leadership inline with the PHC reforms. Also the performance of the health systems should be assessed using the WHO health system framework with due attention paid to planning and M&E. This would change the perception and perspectives of community members and also strengthen community engagement.
6 List of acronyms
Acronym Description AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care APOC African Programme for Onchocerciasis Control CBO Community Based Organisation CHEWs Community Health Extension Workers CHOs Community Health Officers DFID Department for International Development EHA Environmental Health Attendants EHO Environmental Health Officer EPI Expanded Programme on Immuni zation EU European Union FCT Federal Capital Territory FGDs Focus Group Discussion FLHFs Frontline Health Facilities IEC Information, Education and Communication IDIs In-depth Interviews ITNs Insecticide Treated Nets JCHEWS Junior Community Health Workers KII Key Informant Interview LGAs Local Government Areas (LGAs) M&E Monitoring and Evaluation MCH Maternal and Child Health NGOs Non-Governmental Organization NHMIS National Health Management Information System NPHCDA National Primary Health Care Development Agency NPI National Programme for Immuni zation SCHEW Senior Community Health Workers TB Tuberculosis (TB) UN United Nations LINDP United Nation Development Programme LINICEF United Nations children Emergency Fund USAID United State Agency for International Development wHo World Health Organization
7 List of authors...... 1 Foreword...... 2 Acknowledgement...... 4 Executive summary...... 5 List of Acronyms...... 7
6. Table of contents ...... 8
7. Introduction...... 9
7.l.Literubtre review...... 10
7.2. Rationale...... 1 1 7.3. Background...... 9 8. Purpose and Objectives...... _...... 144 4.1. Overall research questions ...... I44 4.2. Overall research objective...... 14 4.2.1. Specific research objectives ...... 14q 4.3. Conceptual framework...... 155 9. Methodology...... 16
9. 1 . Study design ...... 1 6 9.2. Study sites and study population...... 16 9.3. Samp1ing...... 18 9.3.1. Selection of health regions and districts...... 19 9.3.2. Selection of communities within districts ...... 200 9.3.2.1Actual Sampling inNorthwest Site...... 21 9.3.3. Household sample for survey research at community level...... 222 9.4. Research instruments ...... 23 9.5.Data analysis ....255 9.5.1. Quantitative data ...... 255 9.5.2. Qualitative data...... 25 9.5.3. Data analysis meeting ...... 25 10. Results .....26
I l. Discussion...... 56 12. Conclusion...... 58 13. Recommendations...... 61 14. References...... 62 15. Annexes...... 63
8 1. Introduction There is an increasing recognition of the role of communities in the delivery of health care, particularly in developing countries. This is mainly due to the recognition that health service delivery requires multiple inputs including finance, human resources, community involvement and infrastructural support. To ensure healthy lives of individuals in Africa, the provision of essential health care is critical. However, effective involvement of communities in health service delivery raises several complex questions, amongst them: o What are the people's perceptions of health and of the existing health system? o What are their expectations and perspectives of "good" health service delivery? o What are the essential elements of community-based health service delivery? o How can corlmunities be effectively involved in the governance, management and ]. implementation of essential health care activities?
Finding answers requires untangling the complicated web of providers, services, financing mechanisms, and institutional arrangements that characterise healthcare delivery which have levels of heterogeneity far exceeding those of the health-care provision of the Western world. New avenues of research are starting to delineate these structures and encouraged by WHO's policy in regards to Primary Health Care (PHC) (1-6) and its role in strengthening health systems towards accelerated efforts in achieving the Millennium Development Goals (MDGs)(7). Strengthening the health service delivery capacity at local level with greater people's input could facilitate the scaling up of the already proven and cost-effective interventions towards sustainable health care and responding to priority health needs. We know that countries and international health partners need solid evidence and messages on the way the current disease-oriented efforts and resources can yield better and faster results in improving the current health status of people. They also need information on the best practices, evidence to update policies and tools to convert the policies into practices, tools to make health systems equitable, and also tools for dialogue and consensus building among health stakeholders. This study posits an alternative approach of gathering evidence for strengthening health-systems from the bottom up. The institutions and bureaucratic structures may be the skeleton of the health service, but the people are its heart beat. Community views are persistently missing from so-called "people centred" health systems discussions. The study outlined in the present protocol focuses on listening to the people. It will provide learning about current health delivery practices and identifu gaps and strategies for more effective community participation in health systems design or development. This study sought the views of community members who are so frequently ignored. And by doing so, it identified a set of immediate-impact solutions, which take into account the limitations of the existing organizational weaknesses and financial gaps in health systems strengthening. Such solutions need not require substantial extra investment but rather new approaches that could optimize the current level of funding. But the important point is that the outcome of the study will provide suggestions originating from the people themselves and not from global thinking trying to find solutions for the local level. It will be an opportunity to link global and local approaches to improve health outcomes and development at local/community level.
7. Literature review
Nigeria is a federal country of 36 federating States that have considerable economic and political authority. Some States in Nigeria have resources above the annual budgets of some countries in the I sub region. Yet in many States, the health system is in a state of near collapse despite the substantial resources allocated to this tier of goverrunent (Oloriegbe,2009). On the international scene, the introduction of the MDGs, health systems framework and challenges of globalisation, brought to the forefront the disadvantages of a selective view of PHC and separation of health from development. This resulted in a review of the PHC approach with four interdependent reforms recommended in universal coverage (equity); service delivery (people centred health systems); public policy (to promote and protect the health of communities) and leadership (expand stakeholders' base and hold leaders accountable). The National Health Policy and Strategy to achieve health for all Nigerians was promulgated in 1988 and revised in2004. The policy document is a result of several consultative processes, incorporating views from stakeholders and reflecting new realities and trends in the National Health Situation including regional and global initiatives such as NEPAD and the MDGs. The main policy thrust focuses on National Health System and its Management; National Health Cares Resources; National Health Interventions and Services delivery; National Health Information Systems; Partnership for Health Development; Health Research and Health Care Laws.
Primary Health Care continues to be the cornerstone of health development in Nigeria. A working document has been developed for the revitalization of the implementation of primary health care as part of government stewardship role to reach the MDGs. Health service management is decentralized at the three tier levels. In addition, some States have Health Management Boards which is responsible for direct service delivery while the Ministry focuses on policy formulation, standard setting and monitoring and evaluation. The WHO provided a health systems framework with six defined building blocks of leadership and governance; services delivery. human resources, financing, information systems and health technologies which aim at attributes of people centeredness, quality, access, coverage, and safety with outcomes of improved health and efficiency, responsiveness and social and financial risk (WHO, 2000). This was followed by a framework for action by everyone to improve outcomes (WHO 2002). The framework provides M&E and performance assessment tools (WHO, 2009; wwu,'.who.int/health-slustems-perfbrmance). The Ouagadougou Declaration on Primary Health Care and Health Systems in Africa focused on nine major priority areas adding community ownership and participation, partnerships for health development, and research to the six building blocks of the framework. This framework was proposed for the necessary activities in each of the priority areas, and proposed recommendations for consideration by Member States in the development of their own country frameworks. In addition, the framework for implementing activities related to health information and research for health which have been taken into account in the Algiers Framework (wHo,2008). Challenges to Primary health care: The key social determinants of ill health in Nigeria still include hunger, poverty, and illiteracy, lack of clean water, poor sanitation, poor housing, gender disparity and unemployment. Apart from its inability to provide basic health care services for majority of the population, it lacks the ability for disease surveillance, prevention and management. For example, only l8% of Nigerian children age 12 - 23 months can be considered fully immunized (NICS,2006). No health system can function effectively without all components of the framework. Unfortunately however, several challenges impede the smooth functioning and effectiveness of our systems. Prominent among these challenges are the paucity of accurate data on the health workforce situation at the PHC level, inadequacy in numbers of the PHC workforce, inequitable distribution, low morale, poor job-satisfaction, inter-cadre conflicts, disparities in remuneration packages and continuing migration, etc. The results of all these are poorly performing and ineffective health personnel providing ineffective primary health services. (Manuwa-Olumide; 2009). Nigeria's overall health system,,Operformance was ranked 187th among the 191 members states by the World Health Organization (WHO, 2000). This assessment is confirmed by Nigeria Health indicators, the nation has one of worst human development indicators in Sub- Satraran Africa and the world at large especially as regards to women and children. The situation of maternal and child health in Nigeria is among the worst in Africa and has not improved significantly over the past decade. In fact the situation has worsened in most states.
Community Perspectives and Participation: From a community perspective, participation in health services evolve because people from different sectors in a community come together to pursue tasks or solve problems which they perceive to be in the interest of the community. According to Taylor (2004), community participation in health prograrnmes and services is firndamental to effective and accessible primary health care. Collins (2001) in Taylor (2004) noted that many rural communities have by necessity become involved in supporting their health care services. The communities spend time, money, and provide in-kind support to their hospitals, aged care facilities and health services. Community Participation is strengthened through the Village Health Committees (VHC).The establishment of VHC is emphasized in the current Health Sector Reforms. The private sector provides 65.7% of health care delivery in Nigeria. Efforts are on for increased public private participation in health care delivery but there is yet to be a framework for collaboration. However, the need for collaboration between public and private sectors was addressed by the Health Sector Reform document and a framework is being developed to operationalise it. While there are contractual agreement in the areas of security, laundry, equipment supply and maintenance, there is none in direct service provision. Conclusion Our current national health indicesl indicate clearly that the performance of our health system is abysmally poor. Unless there is a drastic change in the performance of our health system at all levels, and particularly at the primary health care (PHC) level, these national health indices will most certainly remain poor for several decades and it is most unlikely that we will achieve the health millennium development targets within the stipulated time.
7.2. Rationale The rationale for this approach is simple. The people - the heart beat of the health systems - want to improve their own health and health care. And they can, if governments and other agencies recognize that this motivational force can be harnessed and used. But it is important to understand that it can also be damaged. The importance of a well-thought-out strategy, involving all partners, health initiatives, funding agencies, to make sure the inherent motivation of individuals and communities to help themselves can really make a difference for health care in Africa. The study will be listening to people to make health service delivery "people centered" and people sensitive so as to respond to their needs and expectations. While there are many opinions on what the African region needs to do to make a significant difference to the health status of communities, the voice of communities that are most affected by ill-health and inadequate access to healthcare has not always been heard. A few examples exist of highly successful programmes which adopted an approach where formal health systems established partnerships with local communities to design and jointly implement progralnmes that significantly and effectively turned around the health status and even the social conditions of those communities. The study is an action-oriented multi-country study carried out with a view to bridge the gap between health service delivery and communities as a means to improving the delivery of PHC. Clearly, a fresh and innovative approach to,,.,engaging communities in leveraging significant and effective changes is urgently required. This approach would result in a better understanding of what needs to be done and to alternatives in terms of conceptualizing the delivery of PHC. New insights into the way in which communities both participate in and benefit from the PHC system would be the key to unpacking essential actions required for this programme.
7.3. Background
There is a global movement to renew Primary Health Care (PHC), a call that has been echoed at international, regional and national conferences, including WHO Regional Committee meetings. The most recent call was the resolutionl on Primary Health Care, including health system strengthening, taken at the one hundred-and twenty-fourth session of the WHO Executive Board. The calls for a renewal of the PHC reaffirm the commitment of Member States to the values of equity, solidarity and social justice, and the principles of multi-sectoral action, community participation and unconditional enjoyment of health as a human right by all. The calls represent the ambition to try to deal effectively with current and future challenges to health, mobilizing health professionals and lay people, govemment institutions and civil society around an agenda of transformation of health system inequalities, service delivery organization, public policies and health development. As part of this global movement, thirty years after the adoption of the Alma-Ata Declaration in 1978, the WHO Regional Office for Africa organized the International Conference on Primary Health Care and Health Systems in Africa in 2008. The objectives of the conference were to review the past experiences in PHC and redefine strategic recommendations for scaling up essential interventions to achieve the health related MDGs using the PHC approach for strengthening health systems, through the renewed commitment of all countries in the African Region. The Ouagadougou Declaration (WHO, 2008) focuses on nine major priority areas of leadership and governance, health delivery, human resources, financing, information systems, technologies, community ownership and participation, partnerships for development and research. To facilitate real actions, Member States asked for the development of a generic framework for implementing the Ouagadougou Declaration. At the 59th session of the WHO Regional Committee for Africa, a framework for implementation of the Ouagadougou Declaration was discussed. Section seven of the framework deals with community ownership and participation3. There has been a long history of PHC efforts in the continent. Since the Alma -Ata and Bamako Declarations, progress has been made in some countries in the eradication of small pox and control of measles, good progress in eradication of poliomyelitis, guinea worrn disease and elimination of river blindness. However, there is a lack of resources and practical implementation strategies and some countries need to accelerate progress in achieving universal health goals and the MDGs 2,4,5. The Social Determinants of Health report reinforces the need to address the multiple factors that are responsible for health outcomes especially in resource poor countries (WHO, 2008). The report underscores the role of communities in health care provisioning and calls for the strengthening of existing structures to ensure health delivery. Community-based activities in health service delivery have tended to be extemally-supported processes that do not always promote community ownership. It is notable that community-based organizations have increased in the recent past as a mechanism for community level organizing. Through CBOs, community voice in health care delivery has increased although the efforts tend to be fragmented and not documented. One of the key challenges to community involvement is the tendency for health services to use vertical approaches rather than building on what already exists in the communities from other sectors,,,rincluding local authority structures and functions; and community-based initiatives. New ways of research are defining these structures faith-based -ll and supported by WHO's policy on PHC.6 Therefore, strengthening health systems capacity at the local level with greater community input could facilitate the scaling-up of already proven cost- effective interventions towards sustainable health care and responding to community priority needs. This study therefore seeks to use an alternative approach to identify ways to generate evidence for strenglhening health service delivery from bottoh up, providing learning from community views on cunent practice and identiffing gaps and strategies for effective community participation in health systems design and development to improve the health care of the people.
Nigeria has a population of 149 million (extrapolation from 2006 Census) 70% of whom are poor rural dwellers that live on less than a dollar a day. Under five mortality and maternal mortality are 19411000 live births and 1100/100,000 births respectively (UNDP Human Development Report, 200712008 and Africapedia 2005). These indicators are among the highest in the World. Given these indicators the need for a strong primary health care cannot be under estimated. Health care provision in Nigeria is a concurrent responsibility of the three tiers of govemment in the country. However, because Nigeria operates a mixed economy, private providers of health care have a visible role to play in health care delivery. The federal government's role is mostly limited to coordinating the affairs of the university teaching hospitals, Federal Medical Centres (tertiary health care) while the state government manages the various general hospitals (secondary health care) and the local government focus on dispensaries (primary health care), (which are regulated by the federal govemment through NPHCDA). The total expenditure on health care as % of GDP is 4.6, while the percentage of federal govemment expenditure on health care is about 1.5%. Service provision is charactenzed by poor infrastructure, weak leadership, lack of equipment and drugs, poor maintenance culture, urskilled staff, long distance from communities and inadequate community participation. As a result of these most people have no access to health services.
Kaduna state was created in1976 with an estimated population of 6.1 million (2006) and an annual increase rate of 3Yo. lts population comprises of Hausa, Gbagyi, Adara, Ham, Atyap, Bajju and Agworok ethnic communities. The state has 23 local government areas with 255 political wards. Health wise, Kaduna state has unacceptably high mortality rates and disease burden profile. Leading causes of ill health and death are communicable diseases. Malaria, diarrhoeal diseases, respiratory tract infections and vaccine preventable diseases top the list (PATHS2; 2011).
Jigawa state in north eastern Nigeria is undergoing a comprehensive health process of health reforms. It is currently adopting a new structure called the "Gunduma" health system, the states own version of the district health system recommended by WHO. The integrated system brings primary and secondary care services together under one management structure. Inaugurated September 2007, aimed at promoting the health status of the people through an improved integrated health care service. The current health system is not achieving the required results based on indicators such as the number of deaths of children less than five years, number of deaths of women from pregnancy related conditions being very high. Also the non-availability of basic drugs, facility infrastructure and ownership of health progrzunmes. Many of the health institutions (27 LGAs, SMOH, PHCA, SMOLG) work vertically thus duplicating resources. Support and supervisory systems for health facilities is weak such that communities have lost confidence in the health system and quality of service. The Federal Government in the state is responsible for tertiary care, the state for secondary care and27 Local Government Authorities (LGAs) for primary health care in their areas. Added to this, 13 the State Ministry of Health (SMOH) is responsible for coordinating and monitoring hospitals, the State Ministry of Local Government (SMOLG) is responsible for LGA health departments, and a parastatal, the Primary Health Care Agency, is responsible for providing technical support to the LGAs.
8. Purpose, Research questions and objectives
8.1. Overall research questions 1. How is health and health care perceived by African communities? 2. How is essential health care implemented in selected urban, peri-urban and rural health districts? 3. To what extent are existing health service delivery systems responsive to community needs? 4. What is the existing potential and capacity of communities to contribute to and engage in health service delivery? 5. How can community members and community groups be empowered in community health development, and how can their capacity be increased?
8.2. Overall research objective To assess community perceptions and perspectives on essential health service delivery and to describe the realities of essential health care in Africa in order to develop more appropriate mechanisms for health service delivery through community participation.
8.2.1. Specific research objectives 1. To describe community perceptions of health and health service delivery 2. To describe and analyze the implementation of essential health service delivery at the level of health districts (urban, peri-urban and rural) documenting experiences with community engagement in health 3. To assess community expectations towards patient- and community-responsive health services. 4. To assess the readiness (ability, willingness and capacity) of communities and their constraints to participate in health service delivery. 5. To recommend options for effective community engagement and improved essential health service delivery mechanisms.
14 CD .= ootr 'EOotr a trrE a oo==-L C'lF>o o-ot, Ers Eo -
o o fi*iEr (E rts L +,o E o .9t ao slii* =(E o I IfE[E I sEi eE .= 'rrIi!t- tr g;i{ $ J E E o o o o Eg$EE (, o oCL o CL !, c .ll o tr o t, L CL o ? o E ? }E o (D aE t L Ir €t I ' EE , lt t o cl Ril i iEtc :E CL l- 2d a lE i .E ri i iE9E iI G :s I I lr t ?E I f3 a ;l i! E () ! TE I (.) E€ E c9 :E { o o EE = U o ?n 6 9. Methodology 9.1. Study design This multi-country study is designed to allow a description and analysis of community perceptions and expectations of health and health care in the context of district-based health systems in Nigeria in order to determine key factors for community engagement and empowerrnent in the governance, management and implementation of Primary Health Care. The multi-disciplinary study combines three analytical designs originating from public health and social science research, i.e., cross-sectional surveys, qualitative inquiry and case study research. The survey research was based on an interviewer-administered household survey instrument. The qualitative inquiry was based on in-depth interview and focused group discussion methods. These two designs contribute to an in-depth, triangulated understanding of community perceptions and perspectives. The case study design was based on qualitative research methods and allow for an in-depth analysis of the realities of essential health care delivery in selected Local Government Areas in Nigeria.
9.2. Study sites and study population The study was carried out In the North West Zone, Nigeria on the basis of the core protocol developed in Brazzaville Republic of Congo between 7-10 April 2010. Nigeria was chosen as one of the countries to participate in the study. Its selection resulted from a multi stage sampling process. First, the countries were clustered into three sub-regions according to WHO/AFRO membership structure. Within each sub-region, four countries were selected on the basis of PHC system/performance, linguistic groupings and size. The 12 countries in the study selected with a wide variety of PHC scenarios representing the WHO region for Africa (AFRO) and constitute 260/o of the total member states (46) of AFRO Region. These countries are also reflective of the different regions of WHO/AFRO and also the major linguistic groupings. Nigeria was chosen as one of the countries to be studied in the West African sub region because of its cultural diversity, heterogeneous health systems and the varying performance in the delivery of essential health services. Nigeria also has a track record of having participated in many WHO/TDR and APOC multi country studies in the past. NIGERIA With a landmass of 923,768 sq. kilometers, Nigeria is one of the largest territories in Africa and in WHO/AFRO. However, with a projected current population of 159,288,426 -- calculated at an annual groMh of 3.2 percent from the 2006 population and housing census (q.v. NPC and ICF Macro, 2009:3), Nigeria is the most populous country in Africa.
Nigeria, especially the Northern cm.!oo.r part, has some of the worse health Southwest 1 Gtfl ol Guaw Southeastzone 16 o 1m ax) aOO tglornaia.r indicators in the world, in spite of its enormous human and natural resources for health care promotion. The human development index (HDD for Nigeria is 0.511 (UNDP, 2009), which makes 158th out of 182 countries reported. The UNDP Human Development Index Report for 2009 also put life expectancy for Nigeria at 47.7 and 767th out of 182 countries. Children underweight here is29%o and I I lfr of the 182 countries.
In terms of health equity in the health sector, the Yazbeck (2009), reporting for the World Bank, noted that compares very poorly with other medium and low income countries of the world. The report showed that percentage of women with three or more antenatal visits varied widely among the different quintiles. It gave a population average of 57.4 and a difference of 57.9 between the poorest and wealthiest quintiles. The population average for Nigeria is below the sub-Saharan average of 58.9. On the other hand, the variation between the poorest and wealthiest quintile is much wider that what obtains in the sub-Saharan Africa (35.8). Other key indicators show weak perfornance of the Nigerian health system. The record of children fully immunized show a population average of 13.0 compared to all African countries average of 48.2. The variation between the poorest and the wealthiest quintiles is 36.8 compared to the all country average of 31.3. These are very serious concerns and strong points for studying the Nigeria health system, its delivery of essential health services and the people's and perceptions and perspectives on health service delivery in Nigeria.
The Nigerian health care system is divided into the primary, secondary and tertiary levels of care, which are under the three tiers of government though with some overlapping of responsibilities. The lowest is the PHC level and service delivery is through PHC centres, which is the responsibility of the local government levels. However, the Federal Ministry of Health through the National PHC Development Agency fashions policies, develops PHC physical structures and supervises the operations of PHC centres. The state and Federal govemments are responsible for secondary tertiary care in general hospital and teaching and federal medical centres respectively. However, some state govemments also provide tertiary care through state-owned Teaching hospitals. These tertiary institutions also provide some PHC services through their general outpatient departments. Other providers include private, mission and various private and public employee-owned health facilities. They provide a mixture of services ranging from primary to tertiary care. The Federal Ministry of Health provides the overall policy environment that the health-care system operates in.
Nigerian political structure comprises 36 States and Federal Capital Territory (FCT) distributed into six geopolitical zones (GPZs). These GPZs are made of States with semi- autonomous health systems that independently develop strategies for attaining health targets in line with the National Health Policy. The GPZs represent broad clusters of political, cultural and linguistic realities in Nigeria. They are the fundamental context for understanding Nigeria ethnic diversity. The realities represented by this spread go a long way to influence the health services and health behaviour of the people. In other words, without taking these diversities into account, the empirical results of this study cannot be generalized and the political chances of their acceptance and ownership become negligible. It is for this reason that previous WHO/TDR and APOC multi-country studies gave multiple sites to Nigeria, to cater for the cultural heterogeneity. This report is for the Northwest Zone
17 Table 1: PARTICIPATING INSTITUTION AND PROPOSED RESEARCH SITE
{FRO 3ountry Research )I [Iealth Regions Health Districts iub- tnstitution(s) F well performing J:Urban Region 'less well JU:Peri-urban rcrforming 3.:Rural
Iema'a, Kagarko, lhikun (Kaduna) [Vest \igeria Sightsavers )r. Elizabeth rlorth West rnd Dutse, Malam {,frica llhassan Kaduna* and Madori, Roni tigawa- States) iJigawa)
Using current DPT3 coverage performance as contained in the Nigerian Demographic and Health Survey (NPC and ICF Macro, 2009), the study will be undertaken in one of three of the country's six geopolitical zones (GPZs). The Northwest is the lowest (9.11%), Southwest (66.50/o) and Southeast (66.90/o) of the geopolitical zones. It corresponds to one of three major linguistic and cultural zones in Nigeria; the Hausa/Fulani. It is noted that ethno- linguistics and cultural realities are fundamental in understanding health-seeking behaviour of a people. This earlier informed the inclusion of countries in the core protocol. While the Northwest provides data from the Hausa/Fulani dominated Northern block made up of Northeast and North central, it also provides data as on the GPZ with very weak DPT3 record. It gives the study the opportunity to learn from a weak system and its environment. This selected GPZ also corresponds to the lowest performing zone in the country with respect to DPT3 coverage. This will provide a basis for comparability of operational environments that inform the different performance rates in Nigeria.
9.3. Sampling
9.3.1. Selection of health regions and districts Because of existing of variability of the PHC development at regional and the district levels, two health regionsl were randomly selected in two stages. The health regions were grouped into two clusters of "strong" (well-performing) versus "weak" (less well performing). The most recent (2005-today) DHS report (or in its absence, alternative data sets) per country on maternal, infant, neonatal mortality, or immunization coverage should be used in grouping
1 A health "region" may be defined differently in various countries, e.g., "Province", "State", or "Health District"
18 the regions into the two categories. Where data on these are unavailable, intermediate indicators like delivery under skilled personnel or DPT3 coverage and/or other sources should be used. One health region was randomly selected from each cluster of health regions. Effectively the criterion for selecting the Health region was the relative success in implementing the essential health care system. Two stage sampling of 6 health disflqts in two t€'oHc=Regional capital -o \Vi (.'
The health districts in each of the two selected health regions was further classified and grouped into clusters of rural, urban and peri-urban. One urban District, peri-urban and one rural health district was randomly selected from each of the sampled health region.
Two-stage random sampling of four communities in each health district
o Communities Front Line Health a) Facilities, Health Posts, Centres de Sant6, Aire de Sant6 etc o ' 6istric\^o o Potential location 'taeq/ of the four ' . comm unities ao o sampled
19 9.3.2. Selection of communities within districts From the list of the communities in each district, four communities were randomly selected to form the sampling clusters from which eligible respondents were drawn. Four communities were randomly sampled from each sampled health district. Again, this followed a two-stage sampling process. The communities were put into clusters of communities far (>5km) from the district and others near (<5km) to the District PHC Center. Two communities were then randomly selected from each cluster. This gave a total of 24 communities in 6 health districts drawn from2 health regions in the north western site.
Sampling of three districts in each health region
Rural Health District
3 health districts* in comparison
Regional Urban Health District Capital
* e.g., District de Sant6 (Cameroon) P€fecture sanitaire (RCA) Local Government Area (NEeria) Zone de sant6 (DRC) Service de Sante de Cercle (Mali)
Health region Peri-urban District
20 The following diagramme summarizes the overall sampling approach and its stages.
9.3.2.1Actual Sampling in the North Western Site In line with the multi country core protocol a multi stage sampling approach was the means of site selection for investigating essential health services delivery in Nigeria. The geographic and cultural spread will promote contextual understanding of community perceptions and perspectives on essential health service delivery and describe the realities of Primary Health Care in Nigeria. In this way, the multi-stage sampling strategy proved indispensable to the aim of developing appropriate mechanisms for health service delivery throu gh stren gthened community participation.
Sampling commenced with the clustering of states into an existing framework of six GPZs established by government for development and health planning purposes. As noted earlier these GPZs are the context for immunization and essential health service delivery. These GPZs were stratified by latest DPT3 coverage, as shown in Table 2. On this basis, the North West (9.11) GPZ, was selected to represent low coverage. The comprehensive figures are shown in the second column of Table 2.
able2z Distribution of Geo-Political Zones (GPZs) and States bv DPT3 C Zone Zonal Coverase States/Resion DPT3 North West 9.11 Zamfara 8.8 Kano 7.6 Kebbi 7.2 Sokoto 2.0 Katsina 1.7
21 The next stage of sampling involved the distribution of states within each GPZ, also in accordance with DPT3 coverage. Table 2 also shows the comprehensive figures for the 36 states and FCT. In the North West GPZ, the highest and lowest performing states were purposively selected. Thus Kaduna and Jigawa States were selected. Table 3 shows this distribution.
Table 3: Distribution of selected States, LGAs and Communities by Locality and DPT3 Geopolitical State DPT3 LGA (District) Communities Zone (Resion) North West Kaduna 32.7 Jema'a (U) Gindin Dutse, Kagom Tsakiva. Kwasiri. Tsintsiva Kagarko (P) Janjala, Gidan Makeri, Katugal, Koso Chikun (R) Gwagwada, Dutse, Kashebo Unguwan Kurumbu
Jigawa 0.0 Dutse (U) Jaudi, Mangala, Ruru, Sararai
Malam Madori Zitan, Gororai, Maiso (P) Jalawa
Roni (R) Kagadama, Fiafaiko, Jikin Kaini Mamudawa
9.3.3. Household sample for survey research at community level Using a 50 percent assumed rate of awareness of health services in the communities and a confidence interval of 95Yo with an estimated 3.5 percentage eror margin, a sample size of 770 + 27 was computed. The sample size was however, rounded up to 810 households per country, taking into account a 5Yo contingency rate.
able 4: Sam Size Calculation
,]t-o\lcz Samole size=22 * (o) * Z value for 95Yo confidence level :1.96 p (70 household heads awareness of the PHC system) : 0.5 or 50% Confidence level = 95oh Confidence interval expressed as decimal Confidence Lower tail confidence interval Hisher tail confidence interval Interval 0.03s317 0.03s317 Assumed Lowe Sample z2 P 50% PHC l-p c2 r size Uooer
22 Awareness 3.8416 l0.s lo.s lo.oo2s 743 lttO ltst
The research team worked in two regions, six districts and24 communities, a sample size of 840 households resulted in 35 households interviewed in each of the 24 communities.
To select the households, a central location in each of the randomly selected communities was identified and this served as the starting point for data collection in the selected community. Two data collectors were assigned to cover each community cluster. The interviewers moved in opposite directions from the identified starting point in each community, continuing to turn right at any junction until the desired number of respondents was attained. On occasions where the number required in any cluster was not reached, interviewers moved into an adjacent community to complete the number.
9.4. Research instruments A number of social science methods of data collection were employed in data collection identified to ensure data on the study objectives and research questions. Each method had implications for different aspects of the study unit of analysis and specific information needs of the research questions. These are summarized in the table below. Six different research instruments were employed in the study each targeting different sources of information to investigate the research questions. These instruments include:
Household survey instrument: This provides information on the health service experiences, perceptions and expectation from the perspectives of the household. This was administered on the 35 heads of households in each of the study communities. It also ensured information on the demographic and characteristics as well as the lifestyle and environmental risk factors of the households head selected for the study. This instrument also investigated the willingness and capability of the household heads to participate in the delivery of essential health care services in the communities. The household survey instrument was interviewer-administered on the selected household heads for uniformity on the interpretation of concepts and recording of responses. Ten research assistants were trained on the objectives and techniques of the study. The research assistants drawn from the Universities and research institutions in the selected health regions were required to speak the local language which was employed in the administration of the household survey.
Guides for In-depth Interviews o (IDD guides to interview community leaders and representatives of Community Based Organizations (CBO|. This provided qualitative information on the delivery of essential health services in the study communities. It will also provide information on the experiences of the communities with the health services as well as the perceptions and expectation from the health service. This also ensured qualitative data in the willingness and capability of the communities to participate in the delivery of
23 essential health care. Essentially, it provided information, from the point of view of these critical stakeholders. This instrument was administered on the community political, opinion, religious and traditional leaders. o In-depth Interview (IDI) guides to interview community health volunteers. This ensured information on the experiences of the community volunteers in the delivery of essential health services in the communities. It also ensured data on the perceptions of the health service as well as the expectations from the perspective of the community volunteer health workers. Their willingness to continue to participate in the delivery of essential health service was also ascertained. o In-depth Interview (IDI) guides to interview health workers. This provided qualitative information on the delivery of essential health services from the perspective of the health workers. It also ensured the documentation of the health workers' perception of the communities', their involvement in the delivery of essential health services among other issues. This was administered on the health workers in charge of health facilities in the selected communities. Focus Group Discussion (FGD) Guide for group interviews with community groups: Twelve FGDs (3 adult females and 3 males; 3 adolescent females and 3 adolescent males) with 8-10 persons in each session held in each health region. This resulted in 24 FGDs by the study site and 288 FGDs in all 12 countries. Like the in-depth interviews, the FGDs elicited information on the people's experiences, perceptions and expectations of the health service as well as the willingness and capability of the communities to continue to participate in the delivery of essential health services, among others. Social scientists, vast in skills for moderating FGD sessions and note- taking were engaged for the study. Guidelines for Case Study Reseqrch on District-based Essential Health Services: This provided a detailed contextual case study on the delivery of essential health services in the health service catchments. The principal investigator for each country site was guided by this instrument on the health policy makers in the health district as well as opinion leaders in the health district. There was also a review of documents to ascertain funding and other resource (health commodities, equipment, personnel and technology) base available for the health facility. Essentially it provided data for the description of the delivery of essential health care in the health service catchment. Traditional health workers were also interviewed here.
Table 5: Data Collection Tem atelGuide
Regional, national, district
Communitv level
24 Level HHS Case F'GD In-denth interviews Studies Communi CBO/I\ Regional, CHW Health ty leaders GO national, s providers district CI 35 I I I C2 35 1 C3 35 I I c4 35 I C5 35 I I I C6 35 I C7 35 I
C8 35 1 C9 3s I I I c10 35 1 cll 35 I I ct2 35 1 cl3 35 I I 1 ct4 35 I cl5 35 I I cl6 35 I I ct7 35 I 1 I cl8 35 I cl9 35 I 1 c20 35 1 c21 35 I 1 I c22 35 I c24 35 I I Total 840 6 t2 12 6 l3 12 t2
9.5. Data analysis
9.5.1. Quantitative data All gathered data was double checked by field supervisors before entering into the computer. Double entry was done for quality assurance. Data entry was done by trained data entry personnel. All data file was continuously checked and cleaned by data entry supervisors before being used for analysis. Multilevel multiple regression models for data following the normal, binomial and negative binomial distributions were used. The two levels were the individual households as first level and clusters as second level. All statistical tests used a significance level of 5Yo and conducted using SPSS, SAS and STATA softwares.
9.5.2. Qualitative data
All qualitative data was word processed and analysed using Atlas Ti
9.5.3. Data analysis meeting A joint data analysis workshop was held in WHO AFRO Brazzaville to analyse data from all study sites
25 10. RESULTS
The main objective of the study was to assess community perceptions and perspectives on essential health service delivery and to describe the realities of essential health care in Kaduna and Jigawa states in order to develop more appropriate mechanisms for health service delivery through community participation.
l0.l. Socio-demographic characteristics of respondents
The socio-demographic distribution of respondents who provided their perceptions and perspectives on essential health service delivery is presented by age, profession, marital status, religion, length of stay in the community, and educational level. Respondents consent was sought before the interviews and they willingly provided information on the various health issues.
Table 6: Socio-demographic distribution of respondents
Sex of % Peri % Rural Yo Average respondent Urban Male 196 70 187 66.8 220 78.6 71.8 Female 84 30 93 33.2 60 21.4 28.2 Profession Farming 180 64.3 180 64.3 180 64.3 64.3 Smallscale 32 11.4 35 12.5 35 12.5 12.1 trading Paid employment 20 7.1 16 5.7 20 7.1 6.7 Artisans 15 5.4 10 3.6 19 6.8 5.2 Business 10 3.6 13 4.6 11 3.9 4.0 No occupation 19 6.8 24 8.6 12 4.3 6.5 Maritalstatus Single 8 2.9 11 3.9 11 3.9 3.6 Married 263 93.9 255 91.1 261 93.2 92.7 Divorced 7 2.5 13 4.6 7 2.5 3.2 Separated 0 0.0 1 0.4 1 o.4 0.2 Religion Christian 136 48.6 101 36.1 88 31.4 38.7 Muslim 143 51.1 178 63.6 192 68.6 61.1 African traditional 1 0.4 I 0.4 0 0.0 0.2
In the study area, most of the respondents were males (71.8%), with farming being the main occupation. Most (64.3%) of the respondents were married (92.7%) and Moslems accounted for 6l.lo/o.
26 Figure 1: Level of education in the study area. The respondents had different levels of education. The highest levels of education in the peri- urban and rural areas were primary, and Islamic/ Koranic while the urban areas had a
r ufban % mixture of primary and secondary education (Fig. l). t Peri-urban %
! Rural %
roe --- *C ,.d.{..C dd
Figure 2: distribution Respondents
The majority of the respondents interviewed in all areas were within the age of 25 - 54 years (Figure I Urban% 2). I Peri-Udan %
I Rural %
27 -
Figure 3.'Length of Respondents stay in the ,"] Community Almost 80% of respondents 160 in the urban, peri-urban and rural areas had lived in the communities for more than
20 years. 40
30
20
10
0 <1 Year l-4Year5 5-l0years 11-20Years Morethan 20 years
10.2. National Health care policy
The goal of the National Health policy is to establish a comprehensive health system based on primary health care that is promotive, preventive, restorative and rehabilitative to every citizen of the country, within the available resources, so that individuals and communities are assured of productivity, social well being and enjoyment of living.
The health system based on primary health care (PHC) among others includes Matemal and Child Health (MCH), including family planning. Maternal and Child Health services are provided at all levels of health care in Nigeria. However it is at the PHC facilities that basic elements of essential services are provided.
10.2.1. State and local government based delivery of essential health care services.
Information collected were from documentation provided by the health services and in-depth interviews describing in detail the multiple dimensions of the interface and interactions between communities and the essential health care systems (including service structures, health personnel and the health administration, information system and insurance mechanisms). There were however limitations which included poor record keeping and unavai labil ity of documentation.
10.2.2. Availability of PHC policy, Elements of PHC and elements implemented
There is a national primary health care policy which covers eight (8) elements which operates. These are health education on prevailing health conditions, routine immunisation
28 against childhood diseases and pregnant women, environmental and personal health, provision of essential drugs and equipments, maternal and child health and family planning, treatment of minor health conditions minor surgery and emergencies, prevention and control of endemic diseases and water and sanitation. Delivery of essential health services at both state and local government levels are based on these policies with modifications. For instance in Jigawa state, the minimum package for essential health covers six areas - communicable diseases, child survival, safe motherhood, nutrition, non communicable diseases and health education and community mobilisation. The state plans to review these to eight. There was no additional element implemented outside the ones provided by the National Primary Health Care Development Agency.
10.2.3. Physical structure, technology and supplies
10.2.3.1. Kaduna State:
Infrastructure-has five tertiary hospitals, 28 secondary hospitals, over 1,000 local government facilities and an estimated 656 private sector facilities. ln 2006, several state government hospitals benefitted from major rehabilitation work and this has been ongoing since then. However, available resources are not adequate for the number of facilities in the state. This has resulted in inadequate staffing of most facilities, poor maintenance of infrastructure, inadequate services such as electricity, water supply and sewage, and inadequate supplies of equipment, drugs, and consumables.
The secondary health care facilities were reported to have just enough equipment to carry out emergency activities especially obstetric care while the PHC were being equipped and rehabilitated, 96 PHCs had been rehabilitated so far out of 990 health facilities.
Technology: At the national and University Teaching Hospitals, The VAMED project has transformed the tertiary institutions in urban and peri-urban areas. However there were none of such in the study areas. Also there is no such transformation at the primary and secondary level.
10.2.3.2. Jigawa state: health service delivery was currently improving, though only about half of the population has access to health services - general access is hindered due to, among others, decay in infrastructure, shortage of skills and quality of staff, poor attitude of health care providers, lack and poorly maintained equipment, low outreach services, poor preparedness for emergencies as well as poor private sector participation. Currently there are 603 state owned public health facilities and none has the full contingent of staff and only eight (8) are offering services as provided for in the minimum service package. Although the nine (9) Gunduma councils are offering outreach services to their catchment areas, the coverage is ineffective due to severe logistics problems coupled with inadequate funding as well as inability to properly identify many of the underserved populations.
Infrastructure: was described as functional, though the quality was reported as not conforming to standards due to lack of equipment such as forceps and dressing materials. All equipment was reported to be purchased at the state, while the LGA did not handle such
29 things. This was done to ensure quality assurance and uniformity of equipments provided. Model health care centres are available and the National Primary Health Care Development Agency ensures that the state and local governments provide appropriate equipment.
10.2.4. Human Resource
Various categories of staff employed by the state governments were deployed to the local governments and were providing health services at the various health facilities. Training and retraining is ongoing for the different cadres of staff in a cascaded manner. The community health extension workers are to train community health workers and provide health education on all major diseases. The availability of staff by cadre varies at different levels such that some facilities have doctors on national service corps and some do not. The impact of staff cadre availability is such that deploying sanitation officers for environmental hygiene is challenging due to state responsibility for recruitment for the secondary level. This has in part led to inadequate female health workforce, concentration in urban areas resulting in inequitable distribution.
Staff training is a key issue in health care delivery especially at the PHC level, there are attempts at continuous maintenance and upgrading of technical skills and expertise as well as supervisory and managerial skills to be carried out in an integrated and holistic way across the state.
10.2.5. Post Descriptions
Job descriptions are available for all cadre of workforce. These state the duties, purpose, responsibilities, scope and outcomes needed from a position (Annex 3).
10.2.6. Financing
The key sources of funding are the state ministry of health (SMOH) and the local governments. Other sources of funding are UN Agencies-WHO (providing technical assistance), and UNICEF; Bilateral and Multilateral-World Bank, DFID, USAID, ECPRIME PATHS, GLOBAL FUND, NGOs-CBM, and Society for Family Health within the study site. Others are the Yakubu Gowon entre, ICAP and several national, Faith Based organisations. It is important however to note that communities were also involved in some form of financing where they were maintaining the facility by replacing broken furniture (Annex 1). There are budget lines for health care delivery at the state and local government levels. A very high percentage of the allocation was released and expended over the last three years (Table 8a). It various policies which affect the cost of services; there is the free maternal care package which involves antenatal care, norrnal delivery care, emergency obstetric care and overheads such as stationery. There is also the free child health care package which includes management of common childhood illnesses (drugs for malaria, drugs for respiratory tract infection, diarrhoea drugs and ORS, drugs for worrns and drugs for meningitis).
30 Table 8a: Analysis of State Budget and Expenditure for 2008 to 2010
State State/ Budget US$ Expenditure US$ LGA 2008 2009 2010 2008 2009 2010 Kaduna State 32,439,676 78,466,074 139,682,30 33,473,274 41,504,741 33,251,418 9 Chikun r.345.587 935,674 768,986 1,234,678 r,467,395 1,489,678 Kasarko 1,672,583 1,529,601 t.267.492 1.053.087 1.322.186 r.293.667 Jema'a 721.444 634.219 576,808 599.760 650.833 632.819 Jigawa State 2,372,760 1,387,626 NA 1,264,702 NA NA Roni NA 1,077,489 939,904 NA 527,879 NA Dutse NA 603,367 721,048 NA NA NA IVTMaid NA NA NA NA 274,248 NA ori
NA-Not available
The estimated cost of implementing the policy in the first three years was $120,000,000. The budget was used for community information and mobilisation, provision of free drugs, improvements in staffing and infrastructure, and strengthening management systems to enable the delivery of quality services. The key sources of funding were the SMoH and LGAs. The free MCH programme is being run in all the public hospitals in the state and in over 300 PHC facilities.
10.2.7 . Service delivery
Uptake of services and admissions increased from 2008 to 2010 except for the decrease in Jigawa state in 2010 (Table 8b)
Table 8b: Service delivery data showing Number of Hospital visits and Admissions
State LGA Visitations Admissions 2008 2009 2010 2008 2009 2010 Kaduna Chikun Kasarko Jemaa *Total 629.198 633,370 1.010.311 62,242 83,646 82.217 Jigawa Roni 2.143 50.552 81.030 0 3.944 1.925 Dutse 161,880 272,261 183,982 3,838 8,052 8,596 MlMaidori 35.881 s9.397 52.448 1.81 I 2.815 2.106 Total 199,904 382,210 317,460 5,649 14,811 12,627
*Data were not segregated
31 10.2.7.1. Referral Systems
Fig.6c: Local means of transportation in communities
In the study site, the primary health care facilities were carrying out referrals and these occurred in situations where there were no laboratory equipments to carry out tests, the health workers also had a community health worker standing order which stipulates conditions that would necessitate referrals. These referrals were written in referral notes and in some cases recorded. Reasons for referrals were explained to patients, the referral facility described and in cases where the client was a mother, she was asked to liaise with the household head. Community members had some form of arrangements with road transport associations, community means and other volunteers in the community to assist in taking their family members to the referral centres (Fig. 6c).
10.2.8. Social protection To maintain a responsive and co-coordinated health system that is capable of promoting health status, the following measures were introduced to strengthen and address the health insecurity: Sustainable Drug Supply System (SDSS) and Drug Revolving Fund (DRF) are strategies for procurement and distribution of drugs from the central medical store at the state level to the hospital and primary health care (PHC) facility. The schemes ensure that drugs are procured by patients at subsidised rates. Meanwhile the government has a maternal and child health care initiative which provides free drugs to pregnant women and children under five. However, the implementation of SDSS and DRF alongside free maternal and child health care has created problems among other clients who failed to understand why they have to pay for drugs and at the same time these drugs are said to be free as part of the free maternal and child health care. This has implications in the delivery of essential health services and negates the principles of social protection.
The health facilities provide routine immunisation services in addition immunisation campaigns that seeks to reduce the burden of vaccine preventable diseases (VPDS) e.g. tuberculosis, diphtheria polio, tetanus, Hepatitis B, Measles and Yellow fever.
32 10.3. Community perceptions of health and health service delivery
The perception of the respondents on the different health programmes was based on their experiences with the health service. Government facilities where available, were the most frequently visited by community members.
Table 7: Services provided at the health facilities S/1,{o Services provided at the health facilities Urban 96 Peri-urban 96 Rural % I Treat Ailments 82.9 85.5 73.8
2 Prescribe drugs 69.2 59
J Dispense drugs 45.4 s3.3 50.2
4 Antenatal care 37.2 34.5
5 Immunisation 36.0 33.2
6 Delivery 15.8 19.8 20.1
7 Counsel Patients 24.6 2t.s 18.3
8 Malaria treatment and prevention 15.3 8.3
As shown in Table 7, services provided at the health facilities included curative (treatment, prescription, dispensing, diagnosis), preventive (immunisation, antenatal and counselling) and promotional (health education). "VWten we visit the government health facility, some of the staffs are friendly as they take their time to attend to us, giving us drugs, and also advising us on how to take better care of our health." FGD Youth Females, Tsinsiya Community, Jemaa LGA, Kaduna State. "V[hen we are sick we go to the LGA- Roni hospital for treatment where we are given drugs, also our women also go there for checks during pregnoncy" FGD Adult Males, Faifaiku Communily, Roni LGA, Jigawa State.
Figure 4: Perception of health facility Just over half of the respondents in the peri-urban and rural areas and 44.6%o in the urban area rated the health care service provided by the facilities as good.
33 50
45
40
35
30 Urban % 25 r I Peri-urban % 20 r Rural % 15
10
5
o Very NoHealth lnadequate Adeguate Attitudeof Absenceof responsive facility or far drugs drug,s health Health to Clients workers worker
A newly constructed good health facility Poorly maintained health facility Figure 5.'Reasons for rating the health facility
The major reasons for these ratings were responsiveness to client needs in all areas. In addition to these, were presence or absence of health facility in urban, and adequacy or inadequacy of drugs in rural areas. "The attitude oJ the Health Provider was good, I met her and my time was not wasted." Exit Interview with Adult Female, Madaki communifit, Kaduna Stale "We must tell you that we are not satisfied at all, because we don't have the health focility here and most of us go to the private clinics for treatment, so all government health interventions do not reach us. For exomple tf some one is very sick or a woman is in labour,
34 we hqve to carry her on a local bed to the river bank where a conoe will cross over with her, or for bilre to carry to the private clinics at Jagindi Tasha which is easier for us" FGD Adult Females, Tsinlsiya Community, Jema'A LGA, Kaduna Stale. "Due to the distance between this community and heolth facility, sometimes people loose their life before getting any medical attention" FGD Adult Males, Kurumbu Community Chikun LGA, Kaduna State.
Fig ure 6.' Satisfaction 70 of respondents with provision of health 60 care 50 More respondents in the urban and rural 40 r Satisfied areas were dissatisfied t Dissatisfied with provision of 30 health services at 20 facilities while a moderate number in 10 peri-urban areas were satisfied with the 0 Peri-urban % services. "I om not satisfied with the services I received from the health facility, the drugs are not too expensive and most of us are poor such that we cannot afford even the cheap drugs." Exit Interview with Adult Female, Busawa communily Dutse LGA, Jigawa State.
Table 8: Number of respondents who made payments for drugs and possible reimbursements
Variables Response Urban % Peri-urban % Rural % Payments made Yes 94.8 87.4 for drugs No 5.2 12.3 10.9
Reimbursements Yes 0.3 2.1 made No 98.8 96.6 97.9
Who made the Family JJ.J 75 60 reimbursements members
Community 33.3 0 0 associations
Government 0 0 20
35 Most of the respondents paid for drugs received from health facilities. Only in few cases were reimbursements made to indigent patients by either family members in peri-urban and rural areas or community associations in urban areas. "We have funds from the self help group for the poor, when there are no funds in our account we approach our political leaders who always help. One of such support was N55, 000 ($367) from the local government chairman when we needed to take a patient to a private hospital in Kano State" In-depth Interview with CBO Leader, Mamudawa Communily, Roni LGA, Jigawa State. In the peri-urban and the rural areas, some reimbursements had been made by government and the NGOs.
Drugs for treatment Patients waiting to be cared for in HF
10.3. Community perceptions of health Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO, 1946).ln North West Nigeria (Kaduna and Jigawa states) the community perception of health was based mainly on the state of physical well being.
Table 9: Common health problems in the community
Common health problems Urban % Peri-urban % Rural 94 Malaria 77.1 76.4
36 Fever 59.3 s9.6 s9.3
Measles 13.9 6.t 5.7 Abdominal Pain 20.0 19.6 20.4 Eye problem 23.2 23.2
Arthritis l6.l 14.3 14.3 Respiratory Problem t7.t 27.1 28.6 Hypertension 29.6 t9.6 12.9
The common health problems across the study communities were malaria, fever, eye problems, respiratory tract infections, hypertension and abdominal pain (Table 9 above). "The main health concerns are malaria and fever" In-depth Interview with community leader Chikinkaini, Roni LGA, Jigawa State. "The main diseases are hypertension and sometimes fever and malaria, others are Liver problem and respiratory problems" In-depth Interview with community leader Kwagiri, Jemaa LGA, Kaduna State. Respondents believed that the diseases especially malaria were caused by mosquitoes bites and that all age groups were affected. "Fever, headaches, abdominal pain and malaria are caused by mosquitoes and affict all people." In-depth ffierview with community leaderRuru, Dutse LGA, Jigawa State. "Malaria is caused by mosquitoes from several breeding sites." In-depth Interview with community leader Katugal, Kagarko LGA, Kaduna State.
Table 10: Signs of good health Variables Urban % Peri-urban 96 Rural94 Ability to work 96.1 87.9 94.6
Moving around 92.9 85.0 89.3 Vigorous Activity 39.3 32,1 Self care 2t.t Sleeping 20.4 25.4
Participation in community activities 15.0 16.4
Seeing and recognition 9.3 5.7 8.9
Respondents in all areas based the signs of good health on the ability to work and being able to move around (Table 10 above).
37 70
60
50
40 r Urban% 30 r peri-urban % 20 a rutaloh
10
0 Healthy Hy8,iene& Regular Avoid risky Promptly Engaging in feeding Sanitation checkup behaviour seekinghelp exercise in health facility
Figure 7: Respondents view of slaying healthy l The respondents' view of staying healthy was healthy feeding, practicing hygiene and sanitation and regular health check up (Fig. 7). "I will recognise a healthy person by his or her ability to take care of him-self and keep his surroundings clean". FGD Adull Females Tsintsiya communily, Jema'a LGA, Kaduna State.
Figure 8z Ailments of women of child bearing age In women of child bearing age the major ailments in all districts irrespective of I Urban% classification I Peri-urban % were fever, r Rural % malaria, I Rural % abdominal pain followed by hypertension (Fig 8).
.o( .o8 (d s' --C C."-.-"-.' "c
38 20
15
10
5
o *."s "-""t """" Figure 9: Common ailments of children Major ailments in children were m malaria and fever. Other common ailments were, respiratory problems, 10 vomiting and diarrhoea, and measles, although vomiting and diarrhoea were lower in urban areas 0 than in peri-uban and rural while ttlalada Fever Respiratory Vomiting Dianhea Measles pmblems measles was higher in urban areas (Fig. 9).
39 Figure 10: Common ailments in the elderly In the elderly the major ailments across the districts were eye problems and arthritis. Other common ailments were malaria, fever and severe weakness. Hypertension was higher in urban than peri-urban and rural districts (Fig.l0).
100 90 80 70 60 50 40 I Urban % 30 r Peri-urban oi6 20 r Rural 96 10 0 .,o9' .o.,-""- at'.ro\ .,Qo Gdr ^"tC
Figure 11: Where community membersv sought solution for health The majority of respondents in all areas with health problems sought solution from the government health centres. Other places were private clinics, informal drug sellers and traditional healers (Fig. 1l). "When somebody is ill we toke him or her to the government heolth facility for treatment." FGD Youth Females Tsintsiya community, Jemaa LGA, Kaduna State. "Apart from the hospital we also go to the traditional healers to cure our illnesses."FcD Adult Males Faifaiku community, Roni LGA, ligowa State. "V[hen someone is ill, the person goes to the chemist for treatment" FGD Youth Males, Gogon Tsakiya community,Iemaa LGA, Kaduna State.
40 16 Figure 12: .4ilments not t4
taken to the 12 hospital l0 The major ailment 8 r Urban % not taken to the r Peri-urban % hospital in urban 6 r Rural % areas was 4
convulsion, others 7 were athritis, 0 depression, fracture, snake bite sr""-" .".- ,'.t"o and mental illness. "."" .-C ,oo""'""n.""4-t"" In peri-urban areas, major ailments were mental iilness, depression and snake bite while in rural areas, major ailments not taken to the health facilities were mental illness, depression, fracture and atrthritis (Fig 12.)
Figure 1-1.' Where solution for other ailments were sought Traditional healers were the major place where people across the district classification sought solution for other ailments. Few people from rural areas also 15.9 consulted spiritual and patent medicine vendors while fewer people from urban than Spiritual Patent Herb! nowhere peri-urban areas sought Medicine solutions from them (Fig. vendor l3). *We go for Traditional treatment in our community and even outside the community when people suffer from spiritual attacks and mental illness" FGD Youth Males, Gogon Tsokiya, Jema'a LGA, Kaduna State "V[/hen people are sick in our community, most of them visit the hospitol while some visit the traditional healers and traditional birth attendants" In-depth Interview with community leader Kagadama, Roni LGA, Jigawa State "Wen someone is sick.we take the person to the traditional healer who gives us herbs" FGD Adult Males, Kurunbu community Chikun LGA, Kaduna State.
41 Reasons for poor awareness and mobilisation were discussed with the state and national levels. At the national level, awareness and mobilisation were carried out through the engagement of different audiences such as opinion leaders, religious leaders, trickling down the line. Associations such as FOMWAN and care givers were known to drive the mobilisation leading to an increase in service utilisation however where such awareness and mobilisation is poor, this has been traced to the lack of interpersonal communication skills by health workers, a need which has given rise to trainings so as to address these "Quite a number of associations are involved in qwareness creation such os FOMWAN, the issue however is the poor interpersonal communication skill of the health worker which afficts mobilisation of the community but we are carrying out trainings to address these." In-depth interview with Director FMOH Abuja. Other hindrances identified nationally include lack of education on the part of the community, health programmes upsetting community routines, lack of functional ward development committees and inability of communities to adequately communicate their needs "Poor literacy in the community, functional ward development committees and health programmes which upset community activities hove affected participation in health programmes" In-depth interview with Director NPHCDA Abuja.
At the state level, poor awareness and mobilisation was said to be due to non involvement of community members in mobilisation, sensitisation and in decision making "The non involvement of community members in mobilisation, sensitisation and decision making has given rise to low participation of these community members in health programmes" In-depth interview with Director PHC SMOH figawa state. There is also a perception at the state level that monetisation has also affected mobilisation as communities expect to be paid for participation which is not sustainable "These community people do not participate because they expect to be poidfor something that is beneficial to them qnd this is not sustainable." In-depth interview with Director PHC SMOH Koduna state. The local government authorities identified a need for more education as presently, some communities believed that their time was being wasted and also wanted compensation for involvement in health activities "This people in the villages need to be more educated as they think we are wasting their time whenever we come to discuss health issues, also they want to be paid for every thing. " In-depth interview with Head of health Dutse, Jigawa state. ln some cases, poverty which makes people go to their farms instead of participating in health is also an issue "Due to poverty, sometimes when we go to talk to the community about health matters they prefer to go to their farms than to stay and listen to us" In-depth interview with Head of health Jema'a LGA Koduna state.
42 Fig ure ly': .Responsibility for ensuring good health in the community Across the districts, responsibility for ensuring good health was said to be with heads of household and community leaders (Fig l ).
o o0 -./ --d .r"'-,f-'..C
Figure I5: The health service that government provides Across all the areas, a urban 0,6 community r peri-urban % perception ! Rural % of the major
nu." n.r'" -ruo*
"tt-."
contributions of government to health service delivery was in immunisation. Other areas of contribution were provision of health facility, antenatal care, medicines and personnel/labour (Fig l5). However this was lower in rural areas. The distribution of ITN was mentioned as a moderate contribution only in peri-urban areas. "The health focility provides immunization
43 which prevents our children from diseases, and we are also given medicines when we are sick" FGD Adult Females Kogo Community, Kogarko LGA, Kaduna State. "The health programmes that take place in the health facility are Mectizan distribution, Albendazole, polio immunisation and malaria control." In-depth Interview with community leader, Jaude, Dutse LGA, Jigawa State.
Figure 16.' Satisfaction with services provided by government Dissatisfaction was higher in urban and rural LGAs. However, only half of the respondents in peri-urban areas were satisfied with service provided by government (Fig l6).
Figure 17: Adequacy of 80 government's 70 contribution 60 Most of the respondents in the 50 study area (Urban 40 72.5oh, Peri-urban 59.6% &. rural 30 75.4%) rated the 20 contribution of 10 government to the the o health of hadequate Don't know community as inadequate (Fig. 17). "Sometimes the health workers do not come out, you have to go and lookfor them from house to house to get them to attend to you. Sometimes you may not even see them at all." FGD Adult Males Kogo Community, Kagarko LGA, Kaduna Stale.
44 Figure /8.'The degree of freedom in expressing opinion on health matters
r urban % In all the districts, just over half of the I Peri-urban % community r Rural % members were completely able to express their views 10 on health issues in 0 the community. Completely Moderately Not free at all These community views were channelled to influence or as response to policies through the community leaders who were sometimes members of the hospital board, to the ward heads and onto the secretary of the local government. "I qm the chairman of the hospitol board. With the other members we sit for meetings and make our contributions" In-depth Interview with community leader Gwagwada, Chikun LGA, Kaduna State.'oOur views are cltannelled through me and the ward heads to the secretary Local Goyernment Authority/ Chairman" In-depth Interview with communily leader Jaude, Dutse LGA, Jigawa State.
10.4 Community experiences and involvement in the delivery of essential health services Engagement of community members with the health system was primarily based on experiences and sources of information available to them, their involvement in decision making, perception of who had a greater say in health issues, and respondents trust in getting government to do what is right.
Figure 19: The major sources of information on health In all the LGAs, the major source of information which enabled community members to engage with the health system was through community announcement. Radio announcement was another source of information. o'We sensitise and mobilise the community by using town criers then we go from house to house while also holding meetings with community members" In- Health facility/LGA Health Dept
45 deplh Inlerview with CBO Leader, Mamudawa Community, Roni LGA, Jigawa State. "I encourage people in the community to participate in health activities through the village crier, and ward heads that ensure heads of households are owore of the dffirent health programs." In-depth Interview guide with community leader, Jaudi, Dutse LGA, Jigawa State.
Figure 20: The participation of community members in health service delivery The major form of participation of community members in urban and peri-urban LGAs was to assist in caring for patients; other forms were sanitation and maintenance of health facility, and management of facility for peri-urban. The major participation in rural LGAs was to o'Our assist in caring for patients (Fig 20). community Participates in sanitation and cleaning
25
20
l5
to a Urbtno/o r Pari-urban',Z, 5 t RuraloX
^-"-"."'o t'"*d ^.""* ^od ond *'++ "::i:."t$:s surrounding, clearing the bush, burning the grass" In-depth Interview with community leader, Ungwar Kurumbu, Chikun LGA, Kaduna State. However, constraints identified in getting involved in health service delivery were long patient waiting time, health workers not coming to work on time, and lack of health facilities in some cases. Communities also felt that health workers perceived themselves as superior to them. "Our ideas dffir because they see themselves as superior to us, but we hwe to cooperate because it is compulsory in order to move forward" FGD Adult Males, Fadaiku Community, Roni LGA figawa State.
46 60
Figure 21.' Rating of 50 tn involvement 40 decision making . GOOO r BAD Community members 30 r Don't Know in all areas rated their 20 involvement in deciding on services 10 and locations as good 0 although higher in peri- peri-urban % urban than rural areas (Fig.2l). They were involved in planning, collection of drugs, mobilising the community for health programmes such as immunisations, sensitisation and awareness creation. "The community participation in health care is good because sometimes we are involved in how services qre delivered and this leads to a greot turn out and uptake of services" In-depth Interview with Ruru Community leader, Dutse LGA, Jigawa State. "We are involved in health service delivery by setting up a committee to go to the LGA to collect drugs and the community raises the money for their tronsport." In-depth Interview with community leader, Kwagiri, femaa LGA, Koduna State. "We decide on the mode of Mectizan@ tablets distribution, time and announce to the community so they can be available." In-depth Interview with Community Based Organisation Leader, Tsintsiyo, Jemaa LGA, Koduna Stote.
Table 11: Perception of members of the community who had greater say in health issues
Variables Urban %o Peri-urban 96 Rural96
Community leaders 67.5 67.5 44.6
Religious groups 61.4 62.5
CBOs 42.9 48.2 34.6
Civil servants 40.4 53.2 39.3
48.6 60 46.1
33.9 49.3 34.6
In the urban, peri-urban areas and rural areas, community leaders, religious groups and politicians were perceived to have a greater say in getting government to address issues of interest to them (Table I l).
47 Figure 22: Respondents trust in government to do what is right In both the urban and peri-urban areas, respondents always trusted government to do what is right while in rural areas, they trusted NoAnswer government some of the time to do what is right (Fig22).
Tablel2: Respondent's affirmation in getting government to address issues
Variable Response Urban % Peri-urban 96 Rural %
Having rights Yes 83.2 88.2 80
No 16.8 l 1.8 20 How much rights Unlimited 63.5 63.2 5r.8
Some say 28.3 36.6
No say at all 5.2 5.7 4.9
The majority of respondents in all the LGAs affirmed their rights in getting government to address issues that interest them. Over half of these respondents expressed having unlimited rights and freedom of expression without fear of reprisal (Tablel2).
10.5 Community expectations towards patient- and community-responsive heallh services Community members who visited the health facilities expected service providers to be responsive and provide medicines. Further visits to these facilities were usually based on the quality of services received.
Figure 23: Last 60 54.3 time of visiting the facility 50 The majority of 40 I Urban % people in all areas 30 either visited the I Peri-urban % 20 r Rural % 10
Last3odays Between I Between lyr Between 2yrs & month & less and less than less than 3yrs than I year 2yrs facility in the last 30 days or between I month and less than 1 year (Fig 23). "Wen we are ill, we go to the hospitol in Hadejia, and Garin Gabas for treatment or the private chemist" FGD Adult Female,Ialawa Community, Dutse LGA, Jigawa State.
Figure 2y': Reasons for Visiting the Health Facility The main reason for visiting the facilities in all study areas was fever while another main reason was malaria (Fig.
24). Other reasons r Urban% urban for visiting in I Pera-urban % areas were typhoid r Rural % and hypertension.
Hypertensaon
Table,I3.'.Respondents who received care and prescriptions when they visited the facility Urban Peri-urban Rural Variable Yes % Yes % Yes % Received care 270 96.4 274 97.9 270 96.4 Got a prescription 267 96.4 269 97.5 267 95.4
49 In all LGAs, the majority of those that visited the health facilities received care and got a *We prescription (Table l3). go to the hospitals in Dutse and Jigawa or Sakwaya for ante- natal, post- natal care and delivery. The services are sometime free ond some we pay a token .fo, drug" FGD Adult Females Mangala, Dutse LGA,Iigawa State.
Figure 25.'Available sources of medicines for respondents The majority of respondents in all LGAs who had received care and got a prescription sourced the drugs mostly from medicine Provision Medicine mobil market cannot Shops shoos remember shops (Fig 25). There was a general perception at the national and state levels that supplies were inadequate in the past but that this was changing as the health sector enjoys grants from several organisations "1n the past, there were issues with supplies but with the current level of NGO involvement we have adequote supplies" In-depth Interview with Director NPHCDA. There was also introduction of the SDSS and DRF to boost supply and this was yet to go round all health facilities in the state The recent introduction of DRF has served as a boost to drug supply in Jigawa state" In-depth interview with Director SMOII Jigawa state. Also the NPHCDA's response to lack of drugs was that basic drugs had been provided but that shortage may be an issue of accountability as the agency had provided seed money from the drug revolving scheme "Most PHCs should have the basic drugs. The shortage of drugs mcty be an issue of accountability as the agency has provided seed money from the drug revolvingfund scheme." In-depth Interview with Director NPHCDA Abuja. The national government is responsible for tertiary services while the states are responsible for secondary health service delivery while the local government is responsible for primary health care delivery "The states are responsible for secondary level service delivery while the Local Governments are responsible for the primary levels". In-depth Interview with Director FMOH Abuja. According to the state officers shortage of drugs at health facility was a distribution problem from the local government as drugs had been dropped with them. "We have provided the LGAs with drugs and this has even been dropped but they simply refuse to distribute them". In-deplh Interview with Director SMOH Kaduna State The local government were aware of the state of shortage of drugs and had made requisition but were *We told by the state to be patient are owore of the insfficient drugs and have written to the state. We were asked to be patient". In-depth interview with Head of Health Chikun LGA, Kaduna State.
50 . urban %
r Peri-urban %
E Rural %
couldnot Distance Nohealth Nohealth poor ThouB,ht afford the to health workerat facility attitudeof health cost of facility the facility health problem health care worker was not serious enough
Figure 26: Reasons why health care was not received The main reason why members of the community in the study districts did not receive health care was cost of health care. Other reasons were distance to health facility, unavailability of health facility and health workers in urban LGAs while in rural LGAs, these were poor attitude of health worker and lack of awareness on seriousness of aliment (Fig. 26). "Another problem we hwe when we go to the clinic is the cost of the drugs. We were told that there are free drugs but we are still chargedfor the drugs and where we connot afford them we go to the local healers" FGD Adult Moles, Kogo Community, Kagarko LGA, Kaduna State. "Due to the distance we have to travel; people do not go to government health facility frequently." FGD Adult Females Dutse CommuniE, Chikun LGA, Kaduna State.
The national and state levels were surprised that drugs were expensive at the community level. Their perceptions were that certain measures such as SDSS and DRF had been put in place to address the issue of cost and therefore believed that the drugs were cheaper compared to the patent medicine stores. Community members expected the drugs to be given free as there were other programmes in the community with free drugs "We have just started the SDSS and DRF system in the state and it needs time to spread so that it will take care of the current cost of the drugs that make community members go to the chemist to purchase". In-depth interview with Director SMOH figawa state. The perception at the local govemment level was similar to the state and they felt the revolving scheme was necessary to keep the stock going. There was an identified need for sustained education of the community to help change the perception and the need for government to engage the community to assess their views on costing, not assuming that the community cannot contribute lo this "the community needs to be involved in determining the cost of the drugs after all they are the ones who will buy them". In-depth interview with Heod of health Molammadori LGA Iigawa state.
51 Figure 27: Availability of ro0 93 medicines 90 80 Most of the 70 60 respondents in all r Urban% 50 LGAs in the study r Peri-urban% 40 area could not find r Rural % all the prescribed 30 medicines Fig 27). 20 "At the government 10 0 heolth facility, could not afford could not find Already had Cannot drugs are not all someat home Remember always available so that when we are given a prescription, we sometimes have to go to the private chemist to buy them." FGD Youth Females Tsinlsiya Jemaa LGA, Kaduna Stale. "Sometimes you may go to the facility and not meet any health worker, where they are there; you mqy not get the drugs prescribed". FGD Adult Males, Faifaiku, Roni LGA, Jigawa State.
10.6 Readiness (ability, willingness and capacity) of communities and their constraints to participate in health service delivery
10.6.1. Ability Figure 28: Contributions made by community members to their health The major contributions of community I Urban % members in r Peri-urban % urban areas t Rural % were assisting in caring for patients, sanitation, and maintenance of health facility. ;:.:}w In addition to $c"'"" these, peri- urban areas also contributed to facility and their management. Major contributions of rural areas were in assisting in patient care which had been rated inadequate by the community
52 members themselves. "We have self help systems where onyone who needs tronsportation to the hospital is taken free of charge by vehicle owners; people also contribute money to meet medical bills." In-depth Interview with CommuniE Leoder Ruru, Dutse LGA, Jigawa State. "The service from the clinic is not good enough, we still need more of the nets and other services, we also need more awareness on health issues that we are ignorant qbout" FGD Adult Males Faifaiku community, Roni LGA, figawa State. "We task ourselves to take care of the health facility; we also pay stipends to those that are looking after the place" In-depth Interview with community leader, Gwagwada community, Chikun LGA Kaduna Stote. Poverty, old age and too many responsibilities were the major reasons for unwillingness to contribute by the respondents aged 55 to 75 years. "The major dfficulties members' of this community face are transportation to the health centers and finance for paying medical bills since majority of us are poor" In-depth Interview with Community Leader, Kwagiri Jemaa LGA, Kaduna State.
Figure 29: Contributions of community members in the past year
In the past one year, the contributions of community members in urban areas were mainly in sanitation and assisting in caring. In additional to these, peri- urban areas supported maintenance while the major contribution of rural areas was assisting in caring. Only l3Yo of respondents in urban areas provided financial support (Fig. 29). "We mobilize our youths and sensitize our women to participate in healthcare activities, contribute .financially to help in taking care of problems in the facility, we also give financial assistance to people wlto are indigent and cannot pay for drugs when they are sick. Sometimes we are involved in governance, for example, I am the chairman of the hospital board. With the other members we sit for meetings and make our contributions." In-depth Interview with community leader, Gwagwada, Chikun LGA, Kaduna State. "Tltere is no health financing in our community, but to assisl patients, members of our organization contribute NI00 ($0.67) weekly to support the community healthcare." In-depth interview with CBO Leader Tsararai community Dutse LGA, Jigawa State.
53 Table 13: Readiness of community members to make contributions to their health in future
Variable Response Urbon % Peri-urban % Rural %
Willingness to contribute Yes 88.6 86.8 86.6
No 6.8 6.1 8.6
10.6.1. Willingness:
Eighty seven percent of community members expressed their willingness to cooperate with health workers working in their community. "Yes, we are ready to cooperate with health personnel in Garin Gabas becouse we have a cordial relationship with them" FGD Youth Females, Jalawo, Malammaidori LGA, Jigawa Stote. "Yes we are willing to cooperate with the health worker in the facility" FGD Adult Males Kogo Community, Kogarko LGA, Kaduna State. They also were willing to participate in health service delivery as a result of previous experiences with other health programmes such as distribution of Mectizan@ and Albendazole tablets and polio immunization. Community engagement has also been fostered by training received by the community "The people are willing and ready to get involved in health delivery because they have the experience of Mectizan, ITN and Albendazole distribution" fn- depth Interview with community leader, Jaude, Dutse LGA, Jigawa State. "My people are willing and ready to be involved in Health Service delivery ie contributed funds for surgery (amputation of a man in Kaduna, surgical fees for a female)" In-depth Interview with community leader, Gindin Dutse, Jemoa LGA, Kaduno State. Organised groups in the community such as religious organisations, youth groups and gender related groups facilitated their participating in health service delivery. "We organize members through Church Associations, i.e. Youth groups, CWO, Zumutan Mata, Zumutan Maza, Choristers, Charismatic Renewal, Zumunta Yarmata, Church Council, Hamlets are organized by Heads." In-depth fnturview with community volunteers Kogum Tsakiya, Jemaa LGA, Kaduna State. "Community members are organised to take part in health core delivery through the church elders, youth, women and political groups." In-depth Interview with FLHF Kwagiri, Jemao LGA, Koduna State.
The areas of cooperation identified by the community members were cultivating a good relationship with the health worker, respecting them.
At the state level, there was an awareness of the willingness of communities as expressed by their construction of facilities. However, govemment had not taken advantage of this to man and provide equipment due to budgetary limitatiots "Some communities have constructed facilities fro themselves and are only waiting for us to come and take them over and provide staff and equipments" In-depth interview with Director SMOH Kaduna stale. The dire need for health staff is being addressed as approval has been given for the recruitment of staff.
54 However political interest in the recruitment exercise has been a hindrance "The present governor is very passionote about health and has given approval for recruitment but so many party people are bringing the names of their people so that the employment has not been carried out" fn-depth interview with director SMOH Kaduna State. At the local govemment level, the challenge was in the area of community perception of some of the programmes and this was being tackled by education of the community "We have some problems with the woy the community sees some of the health programmes and we hwe been involved in education to solve these problems" In-depth interview with Head of health Roni LGA, Jigawa state.
10.6.2. Capacity: They made small financial contributions and could organise fund raising events. "We will also organize a fund raising so that we have enough funds to erect our own structure which could be used as a heolth facility" FGD Adull Males Kogo Community, KagarkolGA, Kaduna State. "Our relationship with the health worker is good, we cultivate a good relationship with them since they live with us in this community" In-depth fnterview with community leader Guromari, Malammaidori LGA, Jigawa Slale. "The community attitude to us the health worlrpr is good but they want free drugs. They also respect us and we have a good relationship" In-depth Interview with FLHF worker Malom Maidori LGA, Jigawo State.
Lack of health facilities in some of the communities, shortage of commodities, access especially during the rainy season and lack of basic amenities in the community such as potable water were identified by the respondents as impediments to their participation in delivery of health services. "The dfficulties people foced in their participation is pipe-borne woter which is a burden and takes most of their time" In-depth Interview with communig leader, Ruru, Dutse LGA, Jigawa State. "The dfficulties we face with the participation in health care activities are shortage of ITNs and Mectizan@ tablets" In-depth Interview with community leader, Jaude Community, Dutse, Jigawo State. "The dfficulties the people face are occess (rainy season to Jagindi, bod roads to Kwagiri, shortage of drugs and attitudes of Health Workers" In-depth Interview with community health volunteer, Tsintsiya Community, femaa LGA, Kaduna State. "The community members are willing to participate in health service delivery, only that we don't have the focilities and personnel" In-depth Interview with community leader, Gindin Dutse, Jemaa LGA, Kaduna State.
10.7. Roles of communities in health care delivery Communities identified as support of government initiatives, awareness creation, compliance to treatments, and volunteering. "The community roles should be awareness creation at community gathering, by heads of households, and ward heads. If there was a need to pay volunteers to motivate them, then members can agree an amount and olso waivers as applicable i.e. elderly, and poor" In-depth Interview with community leader, Tsintsiya, Jemaa LGA, Kaduna State.
55 "Tlte roles of communities ore to support government's effirts, uptake of services provided in hospitals, compliance to treatment and community based treatments, self help in medical financing" In-depth Interview with Community leader Ruru, Dutse LGA, Jigawa State.
Respondents felt they could play these roles, if educated and adequately mobilised through community meetings on benefit of the interventions. "The level of participation in health care is good because we educate the community on the benefit of immunization, and we reach the whole community through community meetings which has led to fewer polio refusals" In-depth Interview with community leader, Maiso, Dutse LGA, figawo State "We can cooperate with the health facility by educating other members of the community about the health programs and asking other women to bring out their children for immunizotion when the need arises" FGD Adult Females Kogo Community Kagarko LGA, Kaduna Slate.
In Jigawa state, the health service was had put measures in place to improve the relationship between the health providers and the communities whenever there was a strain such as radio phone in programmes and suggestion boxes. "There is a strain in the relationship that we have inherited but we have our ears open for complaint radio phone in programmes in Kangama and Hadejia FM radio programmes counselling on relationship, to check this situations, we also hove suggestion box. The situation is such that health workers are fighting patients and vice-verso. Now, with all these efforts in place things are chonging" In-depth Interview with Director PHC Gunduma Health Council, Hadejia, Jigawa State.
11. Discussion The respondents in the study area were mainly males (71.80 ), this is mainly because the household instrument was addressed to heads of households. They were mostly farmers (64.3%), married (92.7%) and majority Moslems (61.1%).ln the rural area, primary education was the highest level of education acquired (37.9%), while in the peri-urban area it was koranic/Islamic education (32.5%o). In the urban area the highest level of education acquired was primary and secondary education, with only a few acquiring higher education. The age range of the respondents was between 25 to 54 years, implying that they were old enough to provide adequate and accurate information on the state of individual health, health seeking behaviour and health care delivery in their communities. The implication of this socio- demographic pattern could be responsible for the perceptions of health service delivery in areas relating to cost of services provided, transportation to distant health facilities amongst others as outlined in the results. Information provided by the respondents is deemed reliable as most of them (79.7o/o urban, 68.7% peri-urban & 77S% rural) had lived in the community for over 20 years and (70.8% urban, 94.20 peri-urban & 81.7% rural) had sought health services from the facilities and thus had experience with the health systems. Their length of stay and usage of the health facilities allows for conclusions to be drawn from the information provided on essential health care delivery. Different health programmes implemented at the health districts were the treatment of ailments, prescription and dispensing of drugs, antenatal care, immunisation services, taking delivery, counselling patients and malaria treatment and prevention. These services are not unexpected as they are within the components of the PHC (National Health Policy, 2004).
56 However these government's contributions were rated inadequate as they did not meet community expectations vis a vis the PHC minimum health package. The PHC reforms (WHO) which should have allowed for universal coverage for improved equity; service delivery to make health systems people centred; public policy to promote and protect the health of communities and leadership to expand stakeholder base and hold leaders accountable is yet to be fully felt. The general perception of the respondents was that the health facility was good across all the study areas (urban, peri-urban and rural). This perception could be attributed to limited health facilities available for comparison. There was however a general dissatisfaction with the provision of health care based on the cost of services which were considered high in the rural and urban areas while the peri-urban area reported satisfaction with the provision of services. This is not surprising as the health initiatives in Malammadori and good leadership in Kagarko (both peri-urban) could have accounted for the rating. Common health problems in all the study districts were malaria and fever. The high frequency of malaria is a reflection of the disease burden in Africa including Nigeria (Roll Back Malaria, 2002). The signs of good health were based on physical activities such as ability to work and move around. This poor understanding of definition of health which includes social and mental fitness could be attributed to their level of education and exposure. The respondents viewed staying healthy as arising from healthy feeding followed by hygiene; sanitation and regular check ups and these are in line with standards of best health practices. Solutions to these health problems were sought mainly from government and private hospitals mostly outside the study districts. There were however ailments such as mental illness and convulsions that were not taken to the hospitals. These were mostly taken to the traditional healers and spiritual healers based on cultural beliefs of the respondents. The household heads were mainly responsible for ensuring good health in the community irrespective of classification of districts. This is not unusual in the African setting where men play significant roles in decision making. Experiences of community engagement with the health system were facilitated by the avenues through which information was available to them and this was mainly because there was no barrier to information on health and health service delivery, suggesting good awareness on health issues. This was also confirmed by community involvement and participation in health issues irrespective of the districts. The communities were able to express their opinions freely on health issues through their community leaders. This being the major channel of communication between the community and the government which government recognises and responds to. For example government has put in place a drug revolving scheme in response to the community needs. There are other initiatives as found in the study (free maternal and child care) which contradict certain aspects of the DRF thus disrupting the uptake of drugs under the system. On the other hand, most of the respondents who received care and got prescriptions sourced for drugs from medicine stores. This is inline with the findings of Nishtar (2007) who reported that in developing and underserved areas, a mixed health system in which out-of-pocket payments and market provisions of services predominate as a means of financing and services in an environment where publicly financed govemment health delivery co-exists with privately owned market delivery is the norm.
57 There are no structured systems of reimbursements for procured drugs except in a few instances where this is done by community associations. Alternative forms of health financing which was non existent in the study site would go a long way in assisting indigent members of the community and prevent the sick people from missing out on treatment and social and financial risk protection. It was evident from the study that community members were ready and willing to participate in health service delivery (Taylor, 2004) based on their contributions in areas such as maintenance of the health facility, assisting in caring for patients, sanitation, management of the health facility and in some cases selection of volunteers and provision of health commodities. This was not surprising considering the communities previous experiences with other health programmes such as guinea worrn eradication, Onchocerciasis control and polio immunisation. In addition, community members perceived their roles as that of providing support to government initiatives through awareness creation, compliance to treatments and volunteering. Effectiveness in playing these roles was enhanced by health promotion on the benefit of the interventions. Identified impediments to effective participation in health care activities were attributed to shortage of commodities, access to the health facilities, affordability and lack of basic amenities.
12. Conclusions Based on the evidence gathered during the study, the research team arrived at the following conclusions irrespective of the district classification:
l. Communities had a poor perception of health as this was essentially based on physical well being. Most of the health facilities were rated as good but the service delivery was perceived to be inadequate. 2. Implementation of essential health care services was for basic and curative, preventive and promotional health but these did not fully meet the requirements of the PHC policy. The system for essential health care delivery experienced difficulties with affordable of drugs, shortage of drugs linked to supplies and distribution. A mixed health system with no alternative forms of health financing was non existent. J. Community expectations and responsiveness on health service delivery were met to some extent. Further visits to these facilities were usually based on the quality of services received. They could play the role of support to government initiatives, awareness creation, compliance to treatments, and volunteering if educated and adequately mobilised through community and radio announcements. 4. Communities were willing and making contributions to health service delivery mainly by assisting in caring for patients. Other forms such as sanitation and maintenance of health facility were rated inadequate. The lack of health facilities in some communities, shortage of commodities, inaccessibility especially during the rainy
58 season and lack of basic amenities in the community such as potable water were identified as impediments to participation. 5. There is a huge potential to explore for community engagement based on experience and evidence with previous community based health initiatives. Community and radio announcements were the most common means of information sharing for effective engagement of communities. 6. Government, community members and community groups have a crucial role to play in empowering and developing the capacity of communities towards effective health development.
There were however issues peculiar to each district. These are as follows:
Urban LGAs: . Highest workforce . Highest population with hypertension . Highest financial contribution to health
Peri-urban LGAs: . Highest attendance at government health facility . Highest rate of involvement in decision making . Highest rate of sourcing ofprescribed drugs from medicine shops
Rural LGAs: r Least workforce r Least awareness on the contribution of government to antenatal care and this has implications for uptake of Maternal and Child Health services. . Least trust in government to do what is right.
13. Recommendations In order to foster improved health service delivery, the recommendations emanating from the study as they affect government and the community are as follows:
At the level of government, there is a need for an improvement in health service delivery: o Leadership and Governance o Scale up the use of the WHO health systems framework and sub system assessment tools o Embed health within the wider development sector to facilitate construction of roads and provision of water to improve access, awareness creation,
59 communication for management of medicines and supplies, and improvement of sanitation to improve PHC for essential health care delivery. o Explore UN resolution on water and sanitation as a basic human right to improve community participation and scale up these components of PHC o Develop a policy on people centeredness to improve responsiveness e.g. reduction in out patient waiting time and improve uptake of services o Take advantage of community structures and religious groups; use community leaders and radio announcements to improve awareness. o Involve communities in management of health services o Agree a joint funding platform with donors to streamline activities o Develop partnerships with other health providers with a view to improving health seeking behaviour of community members on convulsion, depression, mental health, fracture and anhritis for which they do not seek support from the health facility o Health workforce: o Improve workforce especially of the technical cadre o Provide incentives for rural posting to promote equitable distribution o Information: o Identify gaps in health information system o Identify gaps in health promotion to improve community understanding of health o Utilise major community and radio announcements to promote community ownership o Medical products, vaccines and technology: o Rehabilitate/upgrade infrastructure and technology to improve attributes of access, coverage, quality and security o Use the sub system assessment to identiff bottle necks in drug procurement, supply and distribution to address shortages o Health Financing: o Improve funding for technology, infrastructure, medicines and supplies, and logistics to improve care and delivery o Engage communities in determining cost of medicines to improve access and affordability. o Introduce community health insurance to ensure social and financial risk protection. o Service delivery: o Improve access and quality of service delivery
At the level of the community: o Leadership and Governance: o Improve patient care/support
60 o Harness willingness and involvement of community health committees in the improvement of health service delivery o Medical products, vaccines and technology: o Contribute to development and maintenance of infrastructure o Contribute to essential health commodities o Health financing: o Harness financial contributions
61 13. References
l. Abouzahr C, Wardlaw T. (2001); Maternal Mortality in 200: Estimates developed by WHO, L|NICEF, and LJNFPA 2. Health and human rights publication series (2008) Issue No.5. 3. Ladipo, O .A. (2009); Delivery of An Effective Maternal and Child Health Services in Nigeria. 4. Manuwa-Olumide, A. (2009); Addressing the Human Resource Challenges in Primary Health Care in Nigeria 5. Monitoring and Evaluation of Health Systems Strengthening- an operational framework WHO Geneva November 2009 6. Nishtar S. (2007); Politics of health systems: WHO's new frontier. Lancet 370:935-6 7. Oloriegbe, I. (2009); Challenges of Health Care in Federal System - The Nigeria Situation. A Paper presented at the National Health Conference 2009, Uyo, 8. Taylor, J. (200a); Community participation in the organization of rural general medical practice: three case studies in South Australia, PHD thesis, department of Health Sciences University of SA, Adelaide 9. WHO (1978) Declaration of Alma Ata 10. WHO, UNICEF, L|NFPA (2007); Advocacy Brief: In Family Planning/Child _Birth Spacing for Health and national Development Action Points for Policymaker. Federal Ministry of Health with support from ENHANCE projecVUSAID I l. Preamble to the Constitution of the World Health Organization as adopted by the International 12. Web.worldbank.org-health systems funding platform
I 3. wwu'. wh o. i nt/h eal th -slzstem s-perfo rm ance 14. www.rvho.int/topics/primary_health care 15. wr*ry.rvho.int/health financing/pb l.pdf 16. www.the lancet.com Vol 373 page2162 17. WHO (2000): The World Health report: Health Systems: Improving performance. Geneva: World Health organisation, 2000. 18. WHO (2008): Commission on Social Determinants of Health. Geneva, World Health Organization, 19. WHO (2009): Monitoring and Evaluation of health systems strengthening-an open operational framework. WHO Geneva 20. WHO (2007): Everybody's business: Strengthening Health Systems to improve health outcomes: WHO's Framework for Action. 21. WHO (2008): The Ouagadougou Declaration on Primary Health Care and Health Systems in Africa: Achieving Better Health for Africa in the New Millennium was adopted during the International Conference on Primary Health Care and Health Systems in Africa, held in Ouagadougou, Burkina Faso Z2.Yazbeck A.S. (2009): Attacking inequality in the health sector: A synthesis of evidence and tools. The World Bank Publication.
62 13. Annexes
Annex 1: Stakeholders, NGOs, FBOs and CBOs and the activities they support at state and local government levels
S/l\[o. Name of stakeholders, Programme supported at LeveUkind of support NGOs and CBOs state and LGA (financial. cash etc) I Partnership for Involved in strengthening Support in the provision of Transforming Health good governance of PHC. logistics, drug supply, Systems (PATHS) Human resource and Funds MCH and infrastructural HIV/AIDS programmes development. and immunization. Dig boreholes and pit latrines and also involved in community sensitization. It is also involved in support supervision. 2 European Commission Strengthening primary Provision of infrastructure, Assisted Partnership to health care routine immunisation Reinforce lmmunisation service delivery, Efficiency (EC PRIME) management capacity buildins. and coordination. J lnternational Centre for HIV/AIDS control Provision of retroviral Aids Programme programme drugs, testing, awareness (ICAP) raising, training and monitorins and evaluation. 4 Medecins Sans Disease out break such as Supply of drugs for control Frontieres (MSF) cholera and meningitis ofdisease out break.
5 United States Agency HIV/AIDS, TB, Malaria, Increased access to quality for International MCH, Family Planning family planning and Development (USAID) and Reproductive Health, reproductive health Water supply and services. MCH efforts Sanitation, Nutrition focus on routine immunization, polio eradication, birth preparedness, maternity services, and obstetric fistula repairs. Increasing access ITNs, net re- treatment kits, and malaria treatment for children and pregnant women. Reduction of death and disability, especially in the vulnerable co-infected
63 HIViAIDS population, double case detection rate and halve incidence of TB. 6 UNICEF Policy development, Supply of ITNs, malaria, Immunisation, procurement of vaccines maternal and child health, and provision of logistics water and sanitation and for immunisation, nutrition. construction of boreholes, provision of micronutrients, social mobilisation, production of IEC materials, training, coordination, monitoring and evaluation 7 World Health Control of locally endemic Provision of drugs and Organisation (WHO) diseases, Strengthening logistics, provision of health systems, vaccines, and provision of Strengthening National IEC materials. Health Information System, Immunization, environmental health promotion, promoting reproductive health, nutrition and food safety, and occuoational health. 8 National Primary Health Supports national policy on Provision of guidelines for care Development implementation of PHC implementation of PHC, Agency (NPHCDA) and demonstrate replicable builds model primary models in the states. health care centres for replication by local governments, provision of solar panels to power PHC centres, and funds logistics for immunization. 9 Yakubu Gowon Centre Malaria Control, Advocacy Provision of insecticide (YGC) treated nets and Coartem for pregnant women and children less than five years ofage. l0 Civil Society for HIV/AIDS Support to awareness HIV/AIDS in Nigeria creation, IEC, capacity (CISHAN) buildins of health workers t1 Partnership for DFID supported Support to awareness Promoting Routine programme for routine creation, IEC, capacity Immunisation in immunisation of mothers building of health workers Northern Niseria and children. Thev are in in immunisation
64 OPRINN) Jisawa State. t2 CBM Vision 2020 Primary eye care and Support to blindness Oncho control in Jigawa prevention, capacity state building of health care workers, MIS, mass distribution of Mectizan@ tablets. 13 Netherlands Leprosy Leprosy control, state wide Drugs, capacity building, Relief fNLR) M&E. 14 TB Network TB control, State wide Support to HIV/AIDS and TB control l5 ACOMIN - Malaria AIDS , TB, Malaria, Support to CBOsIFBOs network Kaduna and Jigawa states working on the three diseases, provide effective programme management and administration, as well as the monitoring and reporting on the activities of CBOsffBOs and WHDCs l6 Rotary Chikun LGA Suoport to immunisation t7 Hope for the Village Water, HIV/AIDS, Rickets, HE, Immunisation, Child child Immunisation, MCH, growth monitoring, care of Capacity building common ailments, capacity Chikun LGA, Kaduna building of TBAs, VHWs, State nutrition, deworming, water, hygiene and sanitation l8 Sightsavers Eye care in the state and Human resource Oncho control in Kaduna development, Equipment State and Logistics, Drugs and Consumables,IEC material, and Community Mobilisation. t9 Nigeria Urban Family Planning Training, social Reproductive Health mobilisation service at Initiative (NURHD community level, IEC material, jiggles and drama, advocacy to traditional and religious leaders, ensure flow of contraceotive. 20 Christian Association of Health service delivery, Capacity building of health Niseria (CAN) state wide staff. HIV/AIDS. TB 2t Jamaatu Nasril Islam Health care delivery, state Awareness creation, HE (JND wide
65 22 Women Development Gender, health Empowerment of women, Associations (WDAs) community participation 23 Community Community development Empowerment, community Development participation Associations 24 Association for Reproductive health, Awareness creation, HE, Reproductive and HIV/AIDS Capacity building Family Health (ARFH)
Annex 2: Category of Health Workforce Providing Health Services
Kaduna state Jisawa state S/ Category of State Chikun Kagarko Jemaa State Roni Dutse M/ No Staff Dori I Doctors 240 r23 2 None None ) Pharmacists 104 5 5 61 I 3 Nurses/mid 5l l0 19 s64 4 wife 4 Community 20 20 J 5 88 I Health Officer 5 Community 5l t02 t20 62 1,944 6t 35 Health Extension Workers 6 Laboratory 266 25 ll t4 7 I staff 7 Environment 27 l2 il t3 98 49 al Health Workers 8 Management NA l8 team 9 Pharmacy 140 l0 4 tt tech/asst l0 Dental 114 0 0 0 tech/assl
Annex 3: Post descriptions of Health workforce
Director/Co-ordinator PHC: Each local govemment has a director PHC who is the head of the primary health care department of the local government and is responsible to coordinate all primary health care activities in the local government area. The director also supervises all areas involved in the provisions of primary health care at the local government, is the chief health adviser to the local government and ensures that primary health care activities as laid down in the plan are complied with. He also publishes monthly and annual health statements of the local government.
Medical OfficerlRegistrar: carrying out general medical and health duties in a local government area to include: taking charge of defined local government medical/health departmental units, and practicing his specialty.
Nurses: they should have undergone training of three years duration in the theory and practice of nursing in accordance with the regulations of the Nursing Council of Nigeria. Their duties include: undertaking nursing care of patients, assisting doctors in the operating theatres, feeding patients and undertaking laundry care, assisting in group therapy and social activities, ensuring cleanliness, and taking charge of the maternity ward.
Midwife: under the 2009 Appropriation Act, the Federal Govemment of Nigeria assigned the responsibility of establishing the Midwives Service Scheme to the National Primary Health Care Development Agency. The scheme mobilised unemployed and retired midwives for deployment to selected primary health care (PHC) facilities in rural communities to facilitate increase in skilled attendance at birth and the reduction of maternal, newborn and child mortality in Nigeria. They are required to have undergone training in an institution recognised for training midwives for three years and on successful completion should lead to registration by the Nursing and Midwifery council of Nigeria.
Their duties include taking charge of a maternity home/ward of the local government hospital, matemity or health centre, performing midwifery duties in maternity wards, undertaking home visits, and undertaking domiciliary midfiery services and taking care of mothers and babies. Other duties allocated to the senior midwifery officer include teaching and supervision of trainees, taking charge of family activities in the communities and also in the clinics. Immunization at the ante-natal clinics and post-natal clinics, detection of early complications, referral and circumcision of male children at birth are other duties performed by the senior midwife.
Community health Officer: coordinating and supervising the activities of the community health extension workers and other various members of the primary health care team, giving intensive care both in the clinic and the community, taking charge of all activities in the PHC including delivery of normal pregnancies and family planning, organising and supervising community health education programmes, conducting laboratory tests and compiling and analysing data on PHC.
Pharmacist: controlling and supervising the pharmacy technicians in a small hospital, dispensing prescriptions to in-and-out patients and keeping the prescription records as required by the law, preparing simple pharmaceuticals such as mixtures, lotions, syrups etc, maintaining stores and keeping relevant store records and controlling and issuing drugs.
Pharmacy Technician: training is for three years at the state school of health technology and their duties include dispensing prescribed drugs under the supervision of a senior,
67 maintaining and cleaning the pharmacy and pharmacy equipment while those at senior level cadres are involved in taking charge of the primary health care dispensaries.
At the local government level, the nursing cadre and community health worker were observed to be high with adequate arrangements being made for effective supervision down the lines, to senior level, principal assistant chief and chiefs being overall responsible for the lower levels. The organogram in the local government with respect to health (PHC) is indicated below:
Local govern ment organogram
Executive Chairman
Supervisor councillor for Health
LGA PHC Coordinator
Asst Asst Asst PHC Asst PHC Asst PHC Asst PHC Coordinato Coordinato Coordinator Coordinato Coordinato Coordinator r Medical r M&E r r Social Monitoring Immunization Maternal Essential Environmental mobilisation and , disease child health drug , water and office staff evaluation control and family supplies and food sanitation welfare and control of planning and equipment, training diarrhoea nutrition treatment of diseases and minor health ailment education
68