THE EFFECT OF A DONOR SUPPORT ON DISTRICT HEALTH SERVICE UTILIZATION IN ENUGU STATE. DISSERTATION SUBMITTED BY EDMUND O. NDIBUAGU DEPT OF COMMUNITY MEDICINE, UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ENUGU TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PART FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FINAL FELLOWSHIP OF THE MEDICAL COLLEGE IN PUBLIC HEALTH NOVEMBER, 2010 1 DECLARATION This work has been done by me under appropriate supervision. It has not been submitted in part or in full for any other examination. EDMUND O. NDIBUAGU 2 DEDICATION This work is dedicated to the poor and downtrodden, who die daily as a result of inability to access basic health care services. 3 CERTIFICATION We testify that this study was done by Dr Edmund O. Ndibuagu, and the dissertation written under our supervision. --------------------------------------- ---------------------------------- Prof C.N. OBIONU DR E.A. NWOBI 4 ACKNOWLEDGEMENTS I immensely thank our Heavenly Father for enabling me, successfully complete this research project. HE most mercifully provided the human and material resources needed for this study. May I thank my very special wife, Ngozi and the children for their love, care and support that guaranteed absolute harmony in the home front which ultimately ensured a conducive environment for this research project. I am most grateful to my supervisors, Prof C.N. Obionu and Dr E.A. Nwobi for their absolute support and guidance which made it possible for the study to be performed with a high level of thoroughness. I am thankful to Dr Chima Onoka, for his tremendous efforts in making sure that the data analysis was professionally done. May I also express my gratitude to all the consultants, residents and the entire staff of the department of Community Medicine, UNTH, Enugu for their support and friendship. I remain grateful to Prof and Dr (Mrs.) Anezi Okoro for their inspiration and encouragement. So many of my friends supported me in one way or another, during my residency training programme. Some of them are; Mr. & Mrs. Fidel Okoye Chira, Mr. Jude Ogota, Mr. Sydney Gbugu, Dr FSA Uzor, Dr Dan Ajawara, Dr Chidi Onuegbulam and Dr (Mrs.) Susan Arinze-Onyia. May I finally thank the Enugu state government for the financial support given through the Health Systems Development Project II programme. 5 GLOSSARY ABBREVIATION MEANING AIDS Acquired Immune Deficiency Syndrome BHSS Basic Health Services Scheme CHEW Community Health Extension Worker CMS Central Medical Store DHS District Health System DFID United Kingdom Department for International Development DHB District Health Board DRF Drug Revolving Fund EOC Emergency/Essential Obstetric Care FMOH Federal Ministry of Health HERFON Health Reform Foundation of Nigeria HIV Human Immunodeficiency Virus HMIS Health Management Information System HSDPII Health Systems Development Project 2 IMR Infant Mortality Rate JCHEW Junior Community Health Extension Worker LGA Local Government Area LHA Local Health Authority MCH Maternal and Child Health MDGs Millennium Development Goals MMR Maternal Mortality Rate NEEDS National Economic Empowerment and Development Strategy NPHCDA National Primary Health Care Development Agency OIC Officer-in-Charge PATHS Partnership for Transforming Health Systems PDPD Policy Development and Planning Directorate PHC Primary Health Care SEEDS State Economic Empowerment and Development Strategy SHB State Health Board TBA Traditional Birth Attendant UN United Nations UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization 6 TABLE OF CONTENTS SUBJECTS PAGE Title page i Declaration ii Dedication iii Certification iv Acknowledgement v Glossary vi Table of contents vii Abstract viii CHAPTER 1: Introduction 1 Objectives 12 CHAPTER 2: Literature Review 13 CHAPTER 3: Materials and Methods 20 Study design 21 Sample size estimation 22 Study population 22 Exclusion criteria 23 Study instrument and data collection 23 Data analysis 23 Difficulties and Limitations 24 CHAPTER 4: Results 26 CHAPTER 5: Discussion 51 Conclusion 54 Recommendations 55 References 57 Annexes 63 - 82 7 ABSTRACT INTRODUCTION: The World Health Organization recommends the District Health System (DHS), (which is a self contained segment of the national health system) as a good means of achieving the aims for which the primary health care approach to health service delivery was set up. Health outcomes are unacceptably poor in most of the developing countries, including Nigeria; hence the need to reform. In 1988 when the National Health Policy was launched, Nigeria adopted the district health system as a means of ensuring self reliant health care delivery to the entire population. In Enugu state, the need to reform arose as a result of the negative health indicators in the state and Nigeria generally. Partnership for Transforming Health Systems (PATHS), which was a United Kingdom Department for International Development (DFID) funded programme, supported the DHS from planning stage in 2004, until the PATHS programme wound up in June, 2008. This research project is aimed at investigating the effect of the PATHS support in respect of the health facilities utilization. The general objective is to evaluate the effect of the DFID support through the PATHS programme, on district health service utilization in Enugu state. LITERATURE REVIEW: The general principle for developing DHS include; equity, accessibility, emphasis on promotion and prevention, intersectoral action, community involvement, decentralization, integration of health programmes, and co-ordination of separate health activities. Donor support has been shown to improve health facility utilization, while lack of drugs decreases health facility utilization. MATERIALS AND METHODS: The 77 primary health care facilities that were supported by PATHS through drug and equipment supply, constituted the study population. An equal number of the primary health facilities that were not supplied with drugs and equipment were selected as control facilities. Retrospective Cohort study was used to extract secondary data from the ministry of health, while structured questionnaire was used to carry out a cross-sectional study designed to assess the knowledge, attitude and practice of the Officers-in- 8 Charge (OICs) of the primary health care facilities in the state, and their Assistants, on the district health system in Enugu state. Data analysis was done using SPSS. RESULTS: The results revealed that the supported facilities were already doing better than the control facilities, prior to the support. The support however resulted in improved health facility utilization, especially in terms of outpatient attendance. The Central Medical Store records revealed that most of the primary health care facilities in Enugu state were not buying drugs from the store. The OICs of the primary health facilities and their Assistants had good knowledge and attitude towards DHS, but their reported practices were inconsistent with observed practices. DISCUSSION: This research project successfully looked at the general and specific objectives for which it was embarked upon. The findings were essentially in keeping with similar findings In Nigeria and elsewhere. There were however some other findings that require further research work. CONCLUSION: District Health System in this study provided the best chance of implementing the primary health care system, and donor support significantly contributed to improved health facility utilization in the supported facilities. RECOMMENDATIONS: These include choosing poorly performing facilities for support in future, strengthening the Central Medical Store by establishing district bulk stores, focusing on personnel issues, and research on the impediments to effective implementation of District Health System in Enugu state. CHAPTER 1 INTRODUCTION The World Health Organization (WHO) Global Programme Committee in 1986 defined the District Health System based on Primary Health Care, as a self 9 contained segment of the national health system. It comprises first and foremost a well defined population (usually 50,000 – 500,000), living within a clearly delineated administrative and geographical area, whether urban or rural. It includes all institutions and individuals providing healthcare in the district, whether governmental, social security, non-governmental, private, or traditional. (1). It was noted that many people in the developing countries do not benefit from modern knowledge and technology that could have protected and restored their health (2). The situation is more difficult in the poorest countries that spend less than US $20 per head per annum. This has necessitated governments to undertake reform of the health sector. In this context health sector reform means sustained purposeful change to improve efficiency, equity and effectiveness of the health sector (2). Health outcomes are unacceptably poor across much of the developing world, and the persistence of deep inequities in health status is a problem from which no country in the world is exempt (3). In the past decades, the decentralization and strengthening of district health systems have been common strategies for structurally changing health services in low income countries especially in Africa (4). In 1985, the African member states of the WHO adopted the three-phased African health development scenario under which the district became the focus for health development (5). WHO strongly recommends integrated