--T
World Health I, 0rganization r @ l-p ,ro,o*,ou,,rro* Africa Ii
o The Delivery of Essential Health Senrices in Southwest Nigeria: Realities and People's Perceptions and Perspectives
\-,/ 29 AUGUST 2011
Oka Obono, PhD Phone: +234 803 3467863 Sociology Department E-nai/: [email protected] (preferred) University of Ibadan ) E -n ai l: oka,. obono@ur. edu.ng I Ibadan, Nigeria ACKNONTLEDGE,MENTS l ( The Southwest Nigeria Team acknowledges the funding and technical support of the African Programme for Onchocerciasis Control (APOC) and the quality assurance supplied by APOC Management and coordination by the African Regional Office of the World Health Organtzaion.
The Team acknowledges the cooperation of the Ministries of Health of Ekiti State and Ogm State and of its personnel and staff who made access to documentation and interyiews possible. In this regard, we record our gratitude to Dr. D.K Aina @ermanent Secretary in the Ekiti State Ministry of Health) and Dr. E.A Ayinde (Head, Department of Planning, Research and Statistics in the Ogun State Ministry of Health). We are grateful for their help in mobilizing health personnel in the districts where we undertook our research in the two states.
Similarly, we appreciate the facilitation provided by Dr. O. Fasina (I\zledical Officer in Charge of Ikere Health District); Dr. T.H Kolawole (I\{edical Officer in Charge of Ilejemeje Health District); Dr. O Akeju (Medical Officer of in Charge of Ado Health District); Dr. Adenusi (I\'Iedical Officer of Health in Obafemi Owode); Dr. Lawal (Ivledical Officer of Health in .l Ikenne LGA); Mrs. Adeleke Q.Jurse at Okessa Health Centre in Ado Ekiti). Our profound gratitude is due to His Royal Highness, King S.A Osatuyi, for his enlightening interviews on community efforts at improving health care delivery in his domain. We owe enoffnous thanks to members of the 24 communities in Ekiti and Ogun States where we undertook the studies. Without their cooperation, out investigation into theit perceptions and perspectives of essential healthcare delivery would not have been possible.
I a SOUTHIrEST TEAM COMPOSITION
Oka M. Obono Dr. Principal S ociology/Anthtopology University of Ibadan Investisator (T)emomaohv) Eme Owoaie Dr. Co-PI Public Health Physician Universiw of Ibadan Ezebunwa E. Dr Principal Sociology (Demography) University of Ibadan Nwokocha Researcher Koblowe Dr. Princlpal Sociology/ Communication Covenant Univetsity, Ota Arikpo Researchet Research Assistants
Joachim Mr. RA Sociology/MBA University of Ibadan .1 Nwachukwu Bayo Adewumi Mr. RA MSc. Sociology University of Ibadan
Sylvanus Mr. RA MSc. Sociology University of Ibadan Otikwu
David Akeju N,ft. RA MSc. Sociology Universiw of Ibadan Charity Ms. RA MSc. Sociology University of Ibadan Umeokoro Opeyemi Ms. RA BSc. Geogtaphy Obaf. Awo. University Balosun Kemi Kalejaiye Ms. RA MSc. African Studies University of Ibadan Abosede Ms. RA MSc. Sociology Univetsity of Ibadan Odunlami
C COMMUNITY PERCEPTIONS OF HEAITH AND HEAITH SERVICE DELIVERY 35 Perceptions of Health Jf Awareness and Knowledge of Health Issues 40 Health Problems and Source of Treatment 43 Perceptions of Health Services and Systems 46
COMMUNITY E,XPERIENCE, OF rMPLEr,{ENrl:to*... OF HEAITH SERVICE DELIVERY 50 Experiences with Health Services 51 Why People Did Not Get AII Prescribed Drugs and Altemative Sources of Medicine59
COMMUNITY EXPECTATIONS ABOUT RESPONSNTE HE,ALTH SE,RVICES 61, Perception of Govemment Contributions 64 Ratings of Government Contributions 65 Community Expectations of Services Govemment Should Provide . .. 66 - READINESS OF COMMUNITY TO PARTICIPATE IN HEALTH SERVICE DELIVERY 68 Community Contributions to the Delivery of Essential Health Services 69 Ways Community Can Contdbute to Essential Health Delivery t3 Individual Conttibutions to Community Health Delivery. 75 Willingness to Conttibute to Health in Future 77 Forms of Future Individual Contributions to Health Care 78 Reasons for No Future Contribution 80 Views about Health Services Provided to Communities 81
E,FFECTIVE COMMUNITY ENGAGEMENT IN HEALTH SERVICE DELN'ERY 82
SUMMARY AND . CONCLUSION 86 RECOMMENDATIONS 87 REFERE,NCES 89 o ANNEXES 90 Annex 1: Survey Instrument 90 Annex 2: Focus Group Discussion Guide 1,04 Annex 3: Indepth Interview Guides 1,07 Annex 4: Guidelines for Case Study Research on Disttict-Level
Delivery of Essential Health Carc . . 71,9
Annex 5: Translated Questionnaire. . . 1.25 List of Tables
Table 1: List of Selected LGAs and Communities in Ekiti State 22
Table 2: List of Selected and Non-Selected LGAs in Ogun State 23
Table 3: DPI3 Covetage by states in the Southwest Zone ... 26
Table 4: Distribution of selected States and LGAs by Locality and DPT3 Covetage... 27
Table 5: Sample Size Calculation ... 27
Table 6: Distribution of Methods and Instruments by Related Research Objectives 30
Table 7: Sociodemographic Characteristics of Respondents in the Health Districts 34
Table 8: Distribution of Respondents by Length of Stay in Communities 35
Table 9: Individuals'Perception of Health... 36
I Table 10: Distribution of Respondents by ftsligious Affiliation 36
Table 11: Distribution of Respondents by Petception of What Constitutes Good Health 38
Table 1.2: DifFrculty with Activities across Distticts ... 39
Table 13: Common Health Problems across Districts 4t
Table 14: Tlpe of Health Problems and Place of Treatment 43
Table 15: Sites for the Management of Health Problems 44
Table 16: Regression of Factors Influencing the rating of Health Care Services in the .. 47
Table 17: Rating of Health Care Services and Occupation of Respondents 48
Table 18: Reasons for Ratings of Health Facilities ... 48
Table 19: Assessment of Community need of Health Services 51
Table 20: Reasons Individuals last needed Health Care Across Districts 53 (-' Table 21: Multiple Regression of Social Factors Influencing Access to Health Cate 56 Table 22: Reasons for not Getting Health Care 57
Table 23: Reasons fot Not Getting All Prescribed Drugs and Altemative Sources 59
Table 24: Cost of Drugs, Reimbusement and Health Insurance 60
Table 25: Perceptions of Govemment Contributions to Health Services 64
Table 26: Community Expectations About on Govemment's Contdbution to Health Carc... 66
Table 27: Individual Opinion on Community Contributions to Health 77
Table 28: Ways Communities Can Contribute to Health 73
Table 29: Individual Contribution across Health Distticts 76
Table 30: Individual Willingness to Contdbute to Health Care 79
Table 31: Reasons for not Contributing to Health Care 80
Table 32: Perception of Health Cate Services Provided in the Community 81 List of Figures
Figure 1: Conceptual Framework ... 16
Figure 2: Analylj.cal Framework.. 18
Figure 3: Sampling of Six Health Health Districts ... 24
Figure 4: Sampling Three Districts 25
25
Figure 6: General Sampling Approach 26
Figure 7: Difficulty with work 40
Figure 8: Difficulty with moving around 40
Figute 9: Perceptions of Health Services 47
Figure 10: People's Feelings About Govemment Involvement on Community Health 49
Figute 11: Entrance to a PHC FaciJity 53
Figute 1.2: Cardboatd Used as a Registration Card 54
Figure 13: Access to Cate by Locality 55
Figue L4: Histogtam Showing Places \Where People Seek Health Care 57
Figure 15: Drug Prescription and AvailabiJity 58
Figue 16: Availability of Prescribed Drugs 58
Figure 17: Empty Drug Stote in a Health FaciJity ... 63
Figure 18: Ratings of Govemment's Contributions to Health. 65
Figure 19: Ratings of Community Contdbutions to Health ... 70
Figure 20: Community Contributions to Matetnal Healthcare Delivery ^) Figute 21: Items Donated by the Community to facilitate the Delivery of Essential Health 72
Figure 22: Community Contribution of a Health Facility 72
Figure 23:Halr.ed Community-Directed Building of Health Centre 74
Figure 24: Individual Contributions to Health 76
Figure 25: Individuals Willingness to Contribute to Community Health in Future 78
1
10 INTRODUCTION
In recent years, the role of communities in the delivery of essential health care services has attracted much recognition from service providers, tesearchers, policy makers and corporate stakeholders. From antiquity, however, that role had always been recognized by communities themselves. It is, therefore, a healthy step in the right ditection for partnets to acknowledge that health service delivery requires multiple inputs that include financing, human resources, inftastructutal support
and, without quesdon, effective community involvement.
That involvement can be developed in conjunction with other health partners if there is a resolution of complex operational questions. How do people's perceptions of health and the health r) system affect their inclination to use services? What expectations and petspectives do they have of "good" health service delivery? How can they be mobilized or effectively involved in the
govemance, management and implementation of essential health care activities?
The answers require the disentanglement of a complicated web of providers, services, financing mechanisms, and institutional arrangements that curendy characterize African healthcare delivery
systems. New research needed to identiS, appropriate prioritizations and relationships in line with
the WHO policy on Primary Health Care (PHC) and the Millennium Development Goals (I\,DG$. In this regard, sttengthening the health service delivery capacity at local level through gteater people's input could faci\tate the scaling up of cost-effective intewentions. At the same time, however, countries and intemational health partners still need solid evidence and messages on the
way in which current results could be improved. They need information on best pracdces, evidence to update policies, and tools to convert the policies into practices, achieve equity, and build consensus through inclusive dialogue with health stakeholdets.
The present study of the essential health care delivery systems of southwest Nigeda ptovides an altemative approach to gathering this evidence and fot strengthening health-systems from the bottom up. Its procedures recognize that while functional institutions and bureaucratic structutes may be indispensable to the effective and sustainable delivery of services, the people remain squarely at the centre of the entire bureaucracy. It identifies gaps in health delivery strategies towards the promotion of gteatet inclusiveness in health systems design, service development and progralnme implementation, monitoring and evaluation.
In this report, the views of community members, which are so frequendy ignored in the health planning and implementation process, form the basis of its ultimate conclusions and recommendations. The solutions do not involve any more financial investment than is ptesendy the
77 t-
case but they do tequire neuz approaches that could optimize cuffent levels of funding. The study shows that solutions to challenges in health delivery are best derived from ideas presented by the people themselves, not from exclusive templates of global thinking is routinely applied to local situations without due regard for their variety. Accordingly, it is fait to say that this teport links global and local approaches in a matrix that improves health outcomes and development at
community levels.
While there lrre marty opinions on what the African region needs to do to make a significant
difference to the health status of communities, the study shows that a well-thought-out strategy that leverages the benefits of multilateral collaboration with community-level petceptions and perspectives is the most appropdate, rights-based and sustainable way of achieving this in southwest Nigeria. The recommendations can inform sftategic policy action by health and related planning authorities in respect of their membership to WHO-AFRO and in terms of their declared commitment to the work of its Regional Committee in promoting community health systems and partnerships within the region.
Policy Significance of Study
Calls for renewing P.i-"ry Health Care (PHC) have repeatedly been made at international, tegional and national foru that have significandy included WHO Regional Committee meetings. The most
recent was Resolution EB124.R8 on health system strengthening, taken at the'I.,246 session of the
WHO Executive Board CWaHO, 2008a). It called for the reaffirmation by Member States of their commitment to values of equity, solidarity and social justice, and the principles of multi-sectoral
acdon, community participation and unconditional enjoyment of health as a human right by all. l Thirty years after the adoption of the Alma-Ata Declaration in 1978, the WHO Regional OfFrce for Africa (IWT{O-AFRO) organized the International Confetence on PHC and Health Systems in
Africa in 2008 CMHO, 2008b). The objectives of the conference were to review past experiences in PHC and redeFrne strategic options and recommendations for scaling up essential interventions to
achieve health related MDGs using the PHC apptoach. The Ouagadougou Declaration focused on nine priority areas of leadership and govemance; health delivery; human tesouces; financing; information systems; technologies; community ownership and participation; and pattnerships for
development and research. Member States tasked to develop a generic framework for implementing the Ouaga Declaration. At the 15th fifteen-ninth session of the WHO Regional Committee for Afica, a framework for implementation of the Ouagadougou Declaration was discussed. Section
seven of the framework deals with community ownership and paticipation (V{HO, 2009).
1.2 _-..r_ T .'
World Health 0rganization I @ rI *o,o*ou,,,ro* Africa
I Ct
o The Delivery of Essential Health Senrices in Southwest Nigeria: Realities and People's Perceptions and Perspectives
ll
29 AUGUST 2011
Oka Obono, PhD Phone: +234 803 3467863 Sociology Department E-nai l: [email protected] University of Ibadan @referred) ) E - n ai I: oka. ob ono@ui. edu. ng Ibadan, i Nigena ACKNOSTLEDGEMENTS
;* The Southwest Nigeria Team acknowledges the funding and technical support of the African f- Programme for Onchocerciasis Control (APOC) and the quality assurance supplied by APOC Management and coordination by the African Regional Office of the World Health Organization. The Team acknowledges the cooperation of the Ministries of Health of Ekiti State and Ogrt State and of its personnel and staff who made access to documentation and interviews possible. In this regard, we record our gratitude to Dr. D.K Aina @ermanent Secretary in the Ekiti State Ministry of Health) and Dr. E.A Ayinde (Head, Department of Pianning, Research and Statistics in the Ogun State Ministry of Health). W.e are gratefi.rl for their heip in mobilizing health personnel in the districts where we undertook our tesearch in the two states.
Similarly, we appreciate the facilitation provided by Dr. O. Fasina (I\dedical Officer in Chatge of Ikere Health District); Dr. T.H Kolawole Pledical Officer in Charge of Ilejemeje Health District); Dr. O Akeju (X4edical Officer of in Charge of Ado Health District); Dr. Adenusi r) (I\tfedical Officer of Health in Obafemi Owode); Dr. Lawal (Ivledical Officer of Health in Ikenne I-GA); Mrs. Adeleke Qrlurse at Okessa Health Centre in Ado Ekiti). Our profound gratitude is due to His Royal Highness, I(ing S.A Osatuyi, for his enlightening interviews on community efforts at improving health care delivery in his domain. We owe enormous thanks to members of the 24 communities in Ekiti and Ogun States where we undertook the studies. Without their coopetation, our investigation into their perceptions and perspectives of essential healthcare delivery would not have been possible.
I SOUTHSTEST TEAM COMPOSITION I
I Oka M. Obono Dr. Principal S ociology/Anthtop ology University of Ibadan Investisator (Demoqraohv) Eme Owoaie Dr. Co-PI Public Health Physician Universitv of Ibadan Ezebunwa E. Dr Princrpal Sociology (Demogaphy) Univetsity of Ibadan Nwokocha Researcher Koblowe Dr. Principal Sociology/ Communicadon Covenant University, Ota Arikpo Reseatcher Research Assistants
Joachim Mr. RA Sociology/MBA University of Ibadan () Nwachukwu Bayo Adewumi Mr. RA MSc. Socioloqy University of Ibadan
Sylvanus Mr. RA MSc. Sociology University of Ibadan Otikwu David Akeju Mr. RA MSc. Sociology University of Ibadan Charity Ms. RA MSc. Sociology University of Ibadan Umeokoro Opeyemi Ms. RA BSc. Geogtaphy Obaf. Awo. University Balozun Kemi Kalelaiye Ms. RA MSc. African Studies University of Ibadan Abosede Ms. RA MSc. Sociology University of Ibadan Odunlami
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I EXECUTIVE SUMMARY
This report presents findings of a multicountry study of the delivery of essential health services in southwest Nigeria, with particular reference to Ekiti and Ogun States. It was commissioned by the Wodd Health Organization Regional Office for Africa (1WTIO-AFRO) and the African Programme for Onchocetciasis Control (APOC) to descdbe the perceptions and perspectives that members of study communities have about the delivery of essential health services in this part of the country. The aim of the study was to document experiences of essential health care services at vadous levels and assess community-level willingness and teadiness to participate in the delivery of those services.
The methodology was centrally developed by the Princtpal Investigators of the study at meetings held at BrazzavTlle and Frnalized at Ouagadougou. It consisted of a triangulation of qualitative and quantitative methods intended to generate robust insights into the perceptual dynamics of healthcare delivery. These methods of dtta collection included in-depth interviews, focus gtoup discussions, observation-guided case studies, and a household survey questionnaire. The qualitative data were analysed using AdasTi software while the quantitative data analysis commenced with electronic entry using EPI-Info of data that were subsequendy uploaded to SPSS for further analysis. The findings followed the main tesearch questions and objectives of study.
These findings show that the population is sedentary, with 53o/o of the respondents living where found for more than 11 years. There is litde variation among the three types of communities studied (rural, urban, and peri-urban) with r^nge of '1.5.4o/o to 18.9oh. This implies on the whole a ^ low propensity to migtate and, in consequence, diminished social mobility and accentuated povetty.
The study shows that people's perceptions of essential health delivery service are changing. This is indicated by a marked shift in use patterns in favour of modern health facilities although as the use of spiritualists and patronage of prayer houses seems also to be on the rise. Explanations for this dual pattern lie in increased levels of spiritual insecurity that is usually identified with low social mobility, together with the the expected effects of aetiology. In the latter regard, perceptions of how a disease comes about will influence health-seeking behaviour. Fluctuations use patterns of health facilities also emanates from fluctuations in offrcial policy that attend electoral change of local council administration. Withdrawn govemment support discourages community initiative or \r involvement in the delivery of essential health services.
Experiences documented at all levels show that people are, therefore, not satisfied with the delivery of essential health services. There is continued perception that the provision of health care services is the obligation of govemment but there is consistent dissatisfaction with health personnel shortages, inadequate drugs and poor health infrastructute. As a result of these expedences, people have come away with poor perception of the health care services and the delivery of essential health care, although they still patonize these services.
The study shows that length of stay 2nd lsligrous afFrliation exert influence on people's perceptions about health care delivery services. More health facilities are located in rural and peri-urban communities than urban communities but there is a concentration of more functional facilities in the urban setting. Because more facilities are found in rual and peri-urban communities, .l respondents feel a more acute need of personnel more than uban residents. To be sure, communities wete disappointed at the level of contributions by govemment to the delivery of I es sential health services.
4 Community members are willing and are ready to panicipate in the delivery of essential health care services at all levels. Areas of participation include the provision of land, maintenance of health centres, supply of provision of accommodation to staff, and the establishment of Community Health Committee. The community Health Committee is a potential vehicle that could enhance the delivery of essential health sewices at the community level. In most communities, however, the committee is made up of opinion leaders and this constitutes it into a viable vehicle for health mobilization and behaviour change.
Willingness and readiness of community to participate could also be hindered by poverty or lack of fi.nances at the community level. Communities could initiate building ptoject through community using self help. However, involvement in the forms of paying salades or fi.nancial allowances or rent on health personnel accommodation is not likely to come from the communities. It is important to enter into a dialogue of equal partners to identifr the potential strengths of each and which elements would define the nature and scope of community participation in the health process.
Across all districts, there is the opportunity to firther change the perception of people and improve the delivery of essential health services if available potentials are explored. The political will to do this needs to be sffengthened and made statutory so that it does not change with changing political dispensations. Policy stability is necessary for stabilising the delivery of essential healthcare services. The study teveals a deep sense of alienation in which community members, especially in rural enclaves, report that "government is far from us." This alienation should be bridged by the adoption of people-centred, proactive, pro-poot policies for sustaining the effective delivery of essential healthcare services.
The recommendations are anchored on the idea that perceptions ate shaped by what People see, hear and experience. It is therefore impetative to upgrade Primary Health Cate facilities (through adequate staffing, stocking of drugs, and infrastructural improvement) in otder to create positive perceptions and influence health-seeking behaviour in southwest Nigeria. An awareness campaign should be intensified at the community level to sensitize people to the need not only to use these seryices but also to participate in theit provision. Since the study shows that communities are capable of tremendous health-related initiative (including the construction of a health facility but are discouraged by fluctuations in the political environment, it is necessary to draw up statutory roles of government and communities in the healthcare delivery process to safeguatd essential healthcare delivery from these political vagaries.
The overall finding is that communities are v/illing and able to make important contribution to the maintenance of health but need an enabling policy environment that protects that willingness from the vagaries of party politics and changes in administration. Govetnment should create that enabling environment. The future forms of individual contributions to the delivery of essential health services are not different ftom their present contributions. This signifres that where improvement is required in these invariant perceptions, there is need for health education and an advocacy campaign that vdll describe to the satisfaction of all the roles different partners *ill plry in support of health care delivery. The study identifies prospects and practices of discrimination in access to health services by rural migtant populations. These rural migrants cover long distances to obtain services and the cost of transportation is usually higher than the cost of health itself. There is need to incorporate this underserved population into the health care management and delivery system. I
COMMUNITY PERCEPTIONS OF HEAITH AND HEALTH SE,RVICE DELIVERY 35 Perceptions of Health 35 Awareness and Knowledge of Health Issues 40 Health Problems and Source of Treatment 43 Perceptions of Health Services and Systems 46
COMMUNITY EXPERIENCE OF IMPLEMENTATION OF HEALTH SERVICE DELI\'ERY 50 Experiences with Health Services 51 Why people Did Not Get All Prescribed Drugs and Altemative Sources of Medicine59
COMMUN ITY EXPECTATIONS AB OUT RESPONSIVE HEALTH SE,RVICES 61, Perception of Government Contributions 64 Ratings of Government Contributions 65 community Expectations of Services Government Should Provide ... 66
READINE,SS OF COMMUNITY TO PARTICIPATE IN HEALTH SERVICE DELIVERY 68 Community Contributions to the Delivery of Essential Health Services 69 Ways Community Can Contribute to Essential Health Delivery 73 Individual Contributions to Community Health Delivery' 75 Willingness to Conttibute to Health in Future 77 Forms of Future Individual Contributions to Health Care 78 Reasons for No Future Contribution 80 Views about Health Services Provided to Communities 81
EFFECTIVE COMMUNITY ENGAGEMENT IN HEALTH SERVICE DELIVERY 82
SUMMARY AND .CONCLUSiON 86 RECOMMENDATIONS 87 REFERE,NCES 89
ANNEXES 90 90 Annex 1: ;;r"., r"rr*-.", 704 Annex 2: Focus Group Discussion Guide 107 Annex 3: Indepth Interview Guides Annex 4: Guidelines for Case Study Research on Disttict-Level Delivery of Essential Health Carc .. 1.t9 r25 Annex 5: Translated Questionnaire. . . These meetings and renewed calls for commitrnent stress the urgency for acceletate progtess in
achieving universal health goals and the MDGs CUIHO, 2006a;2006b). The Social Deterrzinants of Heahh Rcport',,tnderscores the role of communities in health care provisioning and calls for the strengthening of existing structures to ensure health delivery. In this way, it reinforces the need to address the multiple factors responsible for health outcomes especially in resource poot countries
CX/HO 20081. Meantime, community-based activities in health service delivery have tended to be externally-supported ptocesses that do not alurays promote local ownetship. While the overall numbet of community-based organizations (CBOs) has incteased in recent times, thete is litde indication that this resulted ftom/in increased community empowerment or that the otganizations
are being institutionalized as viable mechanisms for community level organDing.
Although the activities of CBOs have without doubt inserted community voices in health care ) delivery, these efforts tend to be fragmented and undocumented. A key challenge to community involvement in this respect is the tendency for health services to use vertical approaches rather than building on what already exists in the communities from other sectors, including local authority
structures and functions; faith-based and community-based initiatives, as well as direct indigenous sociopolitical systems. As a response, new ways of research are deFrning these structutes and supported by WHO's policy on PHC (Bhutta et al., 2008; Lawn et al., 2008; Rohde et a/. 2008;
Rosato et al., 2008; WHO, 2008b; WHO, 2008c). The present study is an expression of these principles. It provides proof of how altemative strategies can generate evidence for strengthening health service delivery from bottom up, which learns ftom local views on current practice and identifying gaps and strategies for effective community participation in health systems design, development, implementation and monitoring.
(_r Problem Statement
Resource poor countries bear the highest butden of communicable and non-communicable
diseases. Motality and morbidity trends show that progress on health indicators and health-related MDGs in Africa is slow and that most African countries will not meet these indicators (AU, 2006;
WHO, 2006a; WHO, 2006b). While it is widely acknowledged that govemments in the region need
to focus on the health systems, which are the backbone of the health services, in order to speed up the attainment of the health indicators, health service delivery remains considerably weak. Investrnents made to strengthen the health systems tend to focus on financing. Limited attention is paid to the communities whose attitudes, perceptions and perspectives lie behind the success or a failue of the entire health process. The tesults have been as unambiguous as they have been predictable. Expected outcomes have not been achieved.
13 Efforts to involve communities in health service delivery remain at pilot stages. They suffer from poor documentation. They seldom influence policy through cogent recommendations or make appreciable impacts on service delivery. Their lessons are lost. Hence the need to assess the status of community involvement in health service delivery, using two states in southwest Nigeria as study sites, in order to document best practices and develop action-oriented sets of options to guide the engagement of communities in health service delivery.
Research Questions
The overall research questions are listed below.
1. How are health and health care perceived by African communities?
2. How is essential health care implemented in urban, peri-urban and rural health districts?
3. To what extent are existing health service delivery systems responsive to community needs? 4. $V'hat is the existing potential and capacity of communities to conttibute to and engage in health service delivery? 5. How can community members and community gtoups be empowered in community health development, and how can their capacity be incteased?
Research Objectives
The main objective of the study was to assess community petceptions and perspectives on essendal health service delivery and to describe the realities of essential health care in Southwest Nigeria as a means of developing more appropriate mechanisms for health service delivery through community participation. The specific objectives are listed below.
1,. To describe community petceptions of health and health service delivery in selected localities ^\ of Ekiti and Ogun States in Southwest Nigeria. 2. To describe and anilyze the implementation of essential health sewice delivery at the level of health distdcts (urban, peri-urban and rural), documenting experiences with community engagement in health in selected localities of Ekiti and Ogun States in Southwest Nigeria.
3. To assess community expectations towards patient- and community-responsive health services in selected localities of Ekiti and Ogun States in Southwest Nigeria.
4. To assess the readiness (abiJity, willingness and capaciry) of communities and theit constraints to participate in health service delivery in selected localities of Ekiti and Ogun States in Southwest Nigeria.
5. To recommend options fot effective community engagement and improved essential health service delivery mechanisms in Southwest Nigeria. 6
14 Conceptual Framework
The conceptual framework used for the study was developed collaboratively at a. meeting of Principal Investigators (PI, that held in Brazzav'tlle, Republic of Congo, 07-10 April 2070. It highlights the preeminence of community perceptions and petspectives as ptedictors of health service delivery outcomes. In that way it foregtouods the terms in which the research ifistruments were developed - to enhance empirical ability to generate information on the links between communities and their respective health service delivery systems, which might inhibit or promote
favourable sustainable outcomes. The framework shows that these perceptions and perspecdves are the mediators of service uptake and are themselves subject to a variety of human and historical expedence with health systems that either facilitate inclusiveness or intensi& th. alienation of
systems. i) resoruce-poor communities from their health
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}{ P iE{ H rt i lr i:. iJ< j .p iiEEi Oiq) U iiE Ii -.4-€i:ei U E i:l J Siiq i* (J t{ =5;I:E ) piE Ei bo o tlr = o ,E EI;gE +a o o oCL oL CL t, tr (E o tr o -,CL E o ! I h (, I i L. {t b TE Tf f o Es I E: t o. E ?il., * €i T E' !l rE i .E+, a Eg ;$ a 52 iiIE ! I I !E I E! TE I = 5l I 3 E 8€ EE E ug :i g r9 oo Definitions of Terms
Attitudes: An expressed way of feeling that people and gtoups have towatds health, health services and the health system. Individual or community attitudes ate feelings that may be influenced by perception, experience, knowledge and awareness. Provider attitudes are feelings, which health workers and other suppliers of health services have towards patients, community members, health selvices and the health system. These feelings may influence individual- and communityJevel perception of health services. Community: A gtoup of people who occupy a defined territory under common leadership, with access to shared local resowces, as the base for carrying out the greatest shate of their daily activities. Such a group may vary by country to include villages, quartets, groups of hamlets, mobile populations, and tempomry settlements.
Community expectations: Prospective opinions that people have about the roles and outcomes of responsive health systems.
Community participation: The process by which people are enabled to become actively and ) genuinely involved in defining the issues of concem to them, in making decisions about factots that affect theit lives, in formulating and implementing polices, developing and delivering services and in taking action to achieve change.
Community perception: The view that individuals and communities have about health services. It can be influenced by outcomes of previous health care expertences.
Community perspectives: The sum of collective knowledge, attitudes, valuadon, awareness, perceptions and experience of the community with respect to health and the delivery of essential health services.
Research to ensure that communities that are usually not part of the process should be involved in the development of policies and systems for theit own health: ownetship - go beyond perception Delivery of essential health services: The system fot making basic cuative, preventive and promotional care available at peripheral levels in a manner acceptable to the community.
Essential Health Services: Basic curative, preventive and prcmotional health services at all levels of the health system.
Health: A state of complete physical, mental, and social wellbeing and not merely the absence of disease.
Health awareness: Consciousness of the value of health and the existence of health opportuniues and tesources, including the right to health, individual and collective responsibility for health, healthy lifestyles, disease prevention and health promotion.
Health care experience: Previous encounters with health services and the related consciousness developed through them.
Health district A deflrned geographical and operational zone for the local implementation of health services. Health districts can have different denominations in different countries, such as Pr6fecture sanitaire (CAR), Local Govemment Area (i.{igeria), Zone de sant6 @RC), District de Sant6 (Cameroon and Senegal) or Service de Sant6 de Cetcle (Ivlali)
Health knowledge: Accurate information about conditions that promote or militate against the achievement of a state of complete physical, mental, and social wellbeing of an individual or community. Health system: "A health system is the sum total of all the organizaaons, institutions and resources whose primaq, purpose is to improve health. A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction. And it needs to provide services that are tesponsive and financially fair while ffeating people decently." 17 (lrttp: / /www.who.int/ fea tares / qa / 28 / en /) Health zone: Unit of a health district offering Pdmary Health Care to deFrned communities through a Front Line Health Facility.
Primary Health Care: "Essential health care base on practical, scientifically sound, and socially acceptable methods and technology made accessible to individual and families in the community through their full paticipation and at a cost that the community and country can afford to maintain in the spirit of self-reliance and self-determination"(.W"HO ,1.978, Alma Ata Declatation) Public health region: A defined geographical zone at the intermediary level for the tegional planning and administration of health care and health services. It encompasses different health districts and can have different denominations in different countries, such as State Qrligeria) and R6gion M6dical (S6negal). Readiness to participate (RTP): The capacity and willingness of individuals and community groups to become actively and genuinely involved in the governance, managemeflt, Ftnancing, and implementation of activities related to Primary Health Care.
Analytical Research Framework
Community perception of health and health care is viewed ftom the perspective of a model that recognizes an interaction among a numbet of variables. These include the environmental and socio-demogtaphic realities of the people as well as their past experiences with the health system. The various socio-demographic and environmental realities of the people constitute the independent variables. On the other hand the model includes past experiences with the PHC to explain the intermediate factors that influence perception and expectation from the PHC system.
These are contained in the analyical framewotk appearing below.
Fig. 2: Analytical Framea)ork
(National and regronal levels)
18 METHODOLOGY
Study Design
This study was designed to allow a description and analysis of community petceptions and expectations of health and health care in the context of district-based health systems in Nigeria. This aimed at determining key factors for community engagement and empowerment in the govemance, management and implementation of Primary Health Cate. The multi-disciplinary
approach combined three analytical designs originating ftom public health and social science r) research, i.e., cross-sectional surveys, qualitative inqulry and case study research. The survey research was based on aD interriewet-administered household survey instrument while the
quditative inqurry was based on in-depth interrriew and focused group discussion methods. These nvo designs contribute to an in-depth, triangulated understanding of community perceptions and perspectives. In addition, the case study design was based on qualitative research methods and enabled in-depth assessments of the realities of essential health care
delivery in two states of the southwest geopolitical zone Nigeria.
Study Sites and Study Population
The study was conducted in two states of the sout}west geo-political zone of Nigeria, a country
with a landmass of 923,768 sq. kilometers that makes it one of the largest teffitories in Africa. With a projected cuffent population of 159,288,426 - calculated at an annual growth of 3.2 percent ftom the 2006 population and housing census (4.2. NPC and ICF Macro, 2009:3), Nigeria is the most
populous country in Africa. Its political structure compdses 36 States and Federal Capital Territory (FCT) distributed into six geopolitical zones (GPZs). Nigeria has some of the worst poverty and
health indicators in Africa, tvlrth 92o/o of the population living on less than U.S. $2 per day. Nigeria has one of the highest infant mortality rates (100 deaths per 1,000 live births) and an adjusted matemal mortality ratio of 800 per 100,000 live births. Approximately 42oh of the country's population is under the age of 15, and another 55oh are between the ages of 15 to 49. Nigeda's
yourig age distribution is due in part to its high fertility (2008 Africa Population Data Sheet; 2008
Nigeia DHS). Poverty, high fertility and mortality rates are main issues influencing the performance
and paftonage of the health care delivery system. These present us with plausible tealities that could influence the use and the effectiveness of health cate delivery system in Nigeda. The focus of this
study is to examine how these tealities are shaped by community perception and perspectives.
19 The SouthwestZone
The Southwest geopolitical zone consists of six states namely; Ekiti, Lagos, Ogun, Ondo, Osun, and Oyo. These states were created fiom the defunct Westem Region and share common cultutal and linguistic atttibutes. It is ancesttal home of the Yoruba, Nigeria's third largest ethnic gtoup and arguably the most urbanized single territory in the federation.
The zone is the site of most of Nigeda's prestigious educational and commercial institutions.
Considered the commercial capital of Nigeria, for instance, Lagos attracts heaq, migation on a continual basis. Oyo State is the home to the University of Ibadan, which was planned as a fully tesidential campus in the tradition of Oxford and Cambddge. With its College of Medicine and 1.4 Faculties; 100 teaching departments and eight cenftes including the Institute of African Studies, the university intensified the westward mobility trends that were entrenched eady in the independent life of the country, from the 1960s.
On the other hand, Ekiti State (one of the trvo states selected for the study) is celebtated for its high educational profile while Ogun State (the other study state) is regarded as "the gateway" state because of its eady contact with Christianity and Western education. Ideally, factors of this nature should enhance the delivery of health care system in the two states.
Between 2005 and 2008, the Community Directed Intervention (CDD Programme was implemented in Oyo State. The programme demonstrated how community delivery of underutilized health interventions can dramatically improve access to vital drugs and preventive fteatments in remote African communides. It underscored the importance of community participation in project implementation especially those related to health cate delivery, and the significance of people's petceptions to the success of health programmes and related initiatives.
)
Using curent DPT3 coverage performance sourced from the Nigerian Demogaphic and Health
Survey Q.JPC and ICF Macro, 2009), the study selected t'wo of the six states that make up the southwest region. These are Ekiti State (88.57o) and Ogun Strte (42.0oh). Ekiti and Ogun are the youngest and oldest states, respectively, and it is of interest that the "younger" state has DPT3 coverage that is more than twice as higher as that of the much "older" state. Holding ethnic factots constant, this difference could point to more fundamental disparities in governance and community involvement in the health care delivery process.
In each state, thtee Local Govemment Areas (LGAs) were selected to reflect rural, urban or peri- urban characteristics in the study. Twelve 12 communities were in tum selected from the LGAs (four pet LGA). Both states have semi-autonomous health systems that independendy develop strategies for attaining health targets in line with the National Health Policy.
20 Ekiti State
Ekiti State with 16 LGAs was created h 7996 out of the old Ondo State. The State has a total population size of faidy over 2.3 million according to the 2006 population census. It is located between latitudes 7"25' ard 80"5'N and between longitudes 4"45' and 5"46 east. It is bounded on the noth by Kwara and Kogi States and on the east, west and south by Edo, Osun and
Ondo States, respectively. As such, Ekiti State is a landlocked state with no coastal boundaries.
With its capital in Ado-Ekiti, Ekiti State covers 6,353 square kilometers. The State is mainly an upland zone, rising above 250 metres above sea level. It has an undulating land surface with a landscape consisting of old plains broken by dome rocks. The State is dotted with rugged hills, notable among which are Ikere-Ekiti Hills in the southern part, Efon-Alaaye Hills in the western boundary and Ado-Ekiti Hills in the central part.
At its creation, Ekiti inherited most of its health and public institutions and facilities from Ondo State. These health institutions are owned and run by the state and LGAs, faith-based
orgarizanorrs, and private/corporate medical interests. Ado Ekiti is the site to the State
Specialist Hospital with nine other LGAs having independent General Hospitals. There are some 250 PHCs located across the LGAs. The govetnment offers free medical seryices to all persons below 18. In the most current DPT3 coverage, Ekiti State recorded 88.5% coverage, making it the most performing state in the implementation of DPT3 health prografirme among states in the southwest. Ado Ekiti is the leading urban centre in the state. Rural Ilejemeje and peri-urban Ikere-Ekiti were the other two LGAs selected for study. The LGAs (Ado, Ikere and Ilemeje) were selected on the basis also of their distance from or proximity to the adminisuative headquarters of the LGA. The accompanying table (Table 1) shows the list of selected LGAs and communities in Ekiti State.
21 Table 1: List of Selected LGAs and communities in Ekiti State
J/^J S e lerted lEAt and Communitiet
ADO (urban) IKERE (peri-urban) ILEJEMEJE (rural)
1, Oke-IIa Okeosun Ijesamodu 2 Basiri Afao Ipere j Ago Aduloju Kajola Iludun 4 Odoado Atiba Iy. 5 Temidire Ijao Ewu 6 Esunmo IIdemo Obada 7 Irona Ugele Ilafon 8 Ureje Are Eda 9 Omisanjana Araromi 1 o Odo Odose (
1 1, Erinfun Ogbonjana 1 2 Ilukuo Okeruku I 3 Opopogboto 1 4 Idolofrn 1 5 Igrgo 1 6 Ekute 1 7 Okesa 1 8 rii
Ogo. State
Ogun State was created out of the defunct Western Region n 1976. With close to 4 million population size, it has a total land arca of 1,6,409.26 square kilometets and is situated between
Latirude 6.2oN and 7.8oN and Longitude 3.00E and 5.0oE. The state consists of 20 LGAs. Three of these were selected for the study. It shares an international boundary with the Republic of Benin to the W'est and interstate boundaries with Oyo State in the north, Lagos State in the south and Ondo
State in the east.
Ifo/Ota and Obafemi Owode LGAs v/ere among the odginal seven LGAs of the state at inception. More than two decades ago, Ifo/Ota was split into Ifo LGA and Ado Odo/Ota LGA. Similarly, Ikenne was created out of the old Ijebu Remo LGA. Thus, Ikenne and Ado Odo/Ota LGAs are contemporaries with respect to date of creation while Obafemi Owode is the oldest of the LGAs selected for this study.
Ogun State recorded 42o/o DPT3 coverage, making it the least pedorming state in the implementation of DPI3 health ptogramme among southwest states. In addition to the DPT3
22 criterion for selection, study sites wete sratified to teflect the need for urban, peri-urban, and rural status. Table 2 shows the number of LGAs in the state. The LGAs selected fot the study are
highlighted in the table.
Table 2: List of Selected and Non-Selected LGAs in
S/N LGAs
1. Abeokuta North a Abeokuta South 3. Ado-Odo/Ota 4. Egbado North 5. Egbado South 6. Ewekoro 7. Ifo 8. Ijebu East ) 9. Ijebu Noth 10. Ijebu Northeast 17. Iiebu Ode 12. Ikenne 73. Imeko-Afon 14. Ipokia 15. Obafemi-Owode 76. Ogun Waterside 77. Odeda 18. Odogbolu 1.9. Remo North 20. Sh
23 Sampling
Owing to variability in PHC development across regional and the district levels, two health regionsl wete randomly selected in two stages. The health regions were grouped into two clusters of "stong2' (well-performing) versus "weak" (less well performing). The most recent (2005-date) NDHS teport on maternal, infant, neonatal mortality, or immunization coverage were used in grouping the regions into the two categories. Intermediate indicators like delivery under skilled personnel or DPT3 coverage were used to buttress the basic data source. One health region was randomly selected ftom each cluster of health regions. The criterion for selecting the health region is the telative success/non-success in implementing the essential health care system as shown in the accompanying two illustrations of the sampling process.
Figure 3: Sampling of Six Health Health Districts
Two stage sampling of 6 health districts in two regiop.=Regionat Capitat CT .-o
The health districts in each of the two selected health regions were classified and gtouped into clusters of rural, urban and peri-urban. One urban District, peri-urban and one rural health district were randomly selected from each sampled health region.
I Please note that terminologcal differences in a multisite multicountry research of essential health care delivery systems are bound to arise from more basic differences in govemance structures. Accordingly, a health "region" may be defined differently in various countries, e.g., "Province", "State", or "Health District." In the present southwest Q.{igeria) context, the applicable term for health region is "state" (see p. 15 for definrtion and operationa\z*iort of terms). 24 Figure 4: Sampling Three Districts
Sampling of three dbtricts in each health region
Rural Hoalih Dlstrlct
3 health districts* in comparison
Urban Hoalth Dlstrlct
r . C, Dffid. S.da (Cm.rmn) PdfdB.-br. (RCA) LEd Gdtrnm.nt Ao. (NrCrr.) zom d. sta (oRc) S.Mc! d. SilS d. C6rd. (MdD
Selection of Communities within Ddistricts
From the list of communities in each district, four wete randomly selected to form clusters from which eligible respondents were drawn. Four communities were randomly sampled ftom each sampled health district. This followed a two-staged apptoach for consistency. The communities (>5k and neat to (<5km) the district and the District PHC were put into clusters of far from ") Centre. Two communities were tandomly selected from each cluster. This yielded a total of 24 communities in six health districts drawn from two health regions in the southwest territory.
Figure 5: Two-Stage Randon Sampling of Four Communities
Two€tage random sampling of four communities in each health district
or\a a Cmmun[Es Front Lrno Hgelth {v^ ) Feclldlca. H..lth a-oo' Posis. ccrlDs dc O1 Sant6, Airo d€ Sana6 etc .itt6GD,to I eacdot tcaton .qyor of lho blJr @muntct ' oo str|plod .ooQ C)o o"o1
25 The following diagram (Frgure 6) summarizes the overall sampling approach and its stages. Figure 6: Ceneral Sanpling ApproachrTl
Sampling in Southwest Nigerian Sites
In line with the multicountry core protocol, a multistage sampling approach was used for selecting the sites for investigating essential health services delivery in southwest Nigeria. The geogaphic and cultural spread promoted contextual understanding of community perceptions and perspectives on essential health service delivery and describes the realities of PHC processes in the area. T'he strategy proved adequate for thtowing light on factors affecting the development of appropriate mechanisms fot health service delivery through strengthened community participation. It commenced with distributing states in the GPZ by DPT3 coverage. As noted eadier, GPZs are the context fot immunization and essential health service delivery in Nigeda. Ekiti State (88.5%) and
Ogun State (42oh) werc selected to teflect highest and lowest coverage, respectively (Table 3).
Table ): DPTS states in tbe Soutbwest Zone Zone DPT3 Cooerage State Cooerage
Ekiti 88.5 Osun 85.6 South West Lagos 73.6 oyo 60.7 Ondo 54.3 Ogun 42.0
National 3t.4 I
26 Table 4 shows the sites selected from the two states. Teritorial residential status (i.e. whether the
selected site is urban, peri-urban or rural) cannot be determined in the Nigerian context at regional
(or state/LGA) levels. Each state or LGA is an admixture of the diffetent ptofiles and it is only at the community level itself that distinctions of this kind can meaningfully be made.
Tabh 4: Distibatiott of tehted Statu and LCAr andDW) Geopolitical Swte (Region) DPT3 LGA (District) Zone Southwest Ekiti 88.5 Ado Ekiti (-f Ikere Ekiti (P)
Ilejemeje @)
42.0 Ota @ Ikenne (P) Obafemi-Owode
Household Sample for Community Survey
Using a 50%o assumed rate of a\/areness of health senices in the communities and a confidence interval of 95oh with an estimated 3.5 percentage error margin, a sample size of 770 + 27 was
computed. The sample size was, howevet, rounded up to 840 households in the southwest to take
account of a 5oh contingency tate, in line with consensus reached atBnzzavTlTe.
Table 5: Sanple Siry Calulation
SAMPLE S IZE CALCUI}ITION ( Sample size = 22 x (p) x (1-p)/c2
Z value for 95o/o confidence level = 7.96
P (7o household heads awareness of the PHC system) = 0.5 or 507o Confidence level
Confidence interval expressed as decimal
Confidence Lower tail confidence interval Higher tail confidence interval Interval 0.035317 0.0353t7
Assumed 507o z2 1-p c2 Lower Sample Upper PHC size Awareness 3.8416 0.5 0.0025 743 770 797
To select the households, a central location in each of the randomly selected communities was
identified. This served as the starting point for data collection in the selected community. Two data collectors (male and female) were assigned to each community. The interviewers 27 moved in opposite ditgqtien5 from the identified starting point and turned right each intersection encountered untjl the desired number of respondents is attained. On occasiolls where the numbet required in any cluster was not obtained, interviewers moved into an adjacent community to complete it.
Research Instruments
Several social science methods of data collection were employed. Each method had implications for aspects of the study. Six different research instruments were employed in the study each tatgeting different sources of information to investigate the research questions.
These distributions are sulrnnartzed in Table 5. These instruments included indepth interviews (IDI$, focus group discussions (FGD, and the household survey questionnaire.
H o u se ho ld S u rue1 pu e stio n nai re
The household survey questionnaire was administeted as a pte-translated intervieur schedule to selected heads of households (HHHs). This form of administration took cogniztnce of differing levels of Iiteracy that would have made uniform self-administration impossible. The instrument was designed to elicit information on the health service experiences, expectations, perceptions, and perspectives of the household. It was administered to 75 heads of households in each of the study communities and obtained information on the demogtaphic and characteristics as well as lifestyles and environmental risk factors of the sampled HHHs.
This instrument generated information into the willingness and capability of the household heads to participate in the delivery of essental health care services in the communities. Ten reseatch I assistants were trained on the objectives and techniques of the study. The research assistants were dtawn from the University of Ibadan (Oyo State), in whose environs the instrument pretests were carried out, and Covenant University (Ogr State). Part of the eligibility criterion for the interviewets was the ability to speak the indigenous Yoruba, pidgt, and English.
28 In-deptb Intertiews
Guides for indepth interviews with community leaders and tepresentatives of Community Based Organizations (CBO$ were developed for the study. They provided qualitative information on the delivery of essential health seryices in the study communities and, more pertinently, their petceptions and expectation from the health service. These instruments ensured the collection of qualitative data on the willingness and capability of the communities to participate in the delivery of essential health care. Interviews wete held with political, opinion, leligious and traditional leaders at
the communiry levels.
Indepth interviews were also held with health workers. These generated important qualitative information on the delivery of essential health services ftom the perspective of providers and ensured the documentation of the health workers' perception of the communities and their tl involvement in the delivery of essential health services. The interviews were conducted with health
workers in charge of health facilities in the selected communities.
Focus Gmtp Discussions
Twelve FGDs with 8-10 persons per session were held in each health region. The groups were
composed in the distribution of three adult females, three males; three adolescent females and three adolescent males. Like the in-depth intewiews, the FGDs elicited information on the people's experiences, perceptions and expectations of the health service as well as the u,illingness and capability of the communities to continue patticipate in the delivery of essential health sewices. The discussions generated insights into invisible and, otherwise, inaudible background factots that
are nonetheless crucial for interpreting evelr the quantitative results.
Case Studies A detailed contextual case study on the delivery of essential health services in the health service
catchments was conducted in the corrse of the investigation. The pri".tprl investigator @I) for was guided by a prepared set of guidelines for obserwations and discussions with health policy makers and opinion leaders at the health district level. Documents were also teviewed to ascertain
funding and othet resource (health commodities, equipment, personnel and technology) base
available to the health facility.
The accompafl),rng table (fable 6) shows the distributions of these reseatch instruments actoss the five study objectives listed previously at page 11. The table shows significant overlaps in the
distribution. These are to be expected when the teseatch process adopts triangulation as a means of
attaining robust and comprehensive understanding of the issues at stake.
29 Tabk 6: Dittrib*ion of Method"s and Infiraments @ Rclated Rcsearch Objectiues
Research Obiectives Data Sources Methods Instruments
1. To describe community perceptions Individuals HH survey HH of healtl and health service delivery Community IDi questionnarre gtoups FGD IDI guide FGD zuide 2. To descnbe and atilyze the Health Unstructuted, Case study implementaton of essential health administratots and informal interviewing guidelines service delivery at the level of health decisron-makers Observations, districts (urban, pen-urban and rural) Health providers unstructured and documenting experiences u/ith Patents structured community engagement in health Documents Document review 3. To assess community expectations of Indrvtduals HH survey HH pauent- and commuruty-responsive Community In-depth interviewing questionnaire health services. $oups Group interviews IDI guide FGD guide 4. To assess the readtness (ability, Individuals and HH survey HH u/illingness and capzciq) of community In-depthinterviewing questionnaire communities and their constrahts to Group interviews IDI gutde participate in health service dehvery. Health FGD guide rmplementers 5. To recommend options for effective Individuals and Case studies FGD gurde community engagement and community Interviews IDI guide improved essential health servlce members Observations Case study guide delivery mechanisms. Document review Providers Decision makers
Data Analysis paantitatiue Data
Collected data were double-checked and edited in the freld by supervisors in line with a built-in quality assurance process. Computer data entry u/as carded out by tained and experienced personnel. All data files were continually re-checked and cleaned by data entry supervisors before it the files were used for the analysis. Multilevel multiple regtession models for data following the
normal, binomial and negative binomial distributions were used. All statistical tests were conducted
at 5% significance level using SPSS software.
pualitatiue Data
Qualitative data were primarily textual and were derived from transcripts of meetings, observadons, and interviews. They data were also audiovisual as the team lqek digital photos and made videotapes of phenomena under review. All textual and audiovisual materials were using ^nalyzed the qualitative softvrare package AdasTi according to agteed ptocedures that would subsequendy
30 faci\tate multisite merger of the results.
Intervievzs wete recorded. Detailed notes were taken simultaneously to take care of nonverbal messages and cues that would not be susceptible to audio capture. Recorded interviews were transcribed accotding to standatd rules and translated into English for onward use in AdasTi.
Detailed minutes and notes wete also taken ftom all stakeholder consultations and these notes were
carefi.rlly transcribed soon afterwards.
I
31 RESULTS
Intmduction
Community perspectives are products of lived expedences produced in encounters vdth the cuffent state of health services. Community readiness and constraints to local participation in health care service delivery require examination in ordet to prescribe acdons that could enhance the delivery of essential health care services at community levels. This section presents findings that describe those perceptions, perspectives and realities in Ekiti and Ogun States, southwest Nigeria. It highlights factors influencing these perspectives and relates them to people's experiences of the strengths, weaknesses, challenges and opportunities of the health cate delivery system. The findings are discussed vith a frm focus on three health districts selected to teflect rural, urban and peri-urban charactedstics in the respecdve states. The presentation generates insights into the tealities across these levels and also identifies vadations in the main botdenecks and ptospects of the delivery system beginning with routine description of the sociodemographic attributes of respondents.
S o ci o de m ogr@ b i c C b ara cte ri $i cs of Re E o n de n ts Sociodemographic characteristics are significant fot understanding and explaining structures and patterns of relationships and the way these can influence r^nge of outcomes. This is because ^ social life is fluxive and variability in social relations and human behaviour it hrgh although it is nonetheless pattemed. Accordingly, sociodemogtaphic characteristics constitute a vital means of disaggregating human behaviour into components that analyze scientific processes and proffer strategies for meaningfirl action-oriented interventions.
Among these attributes, age and sex are the most fundamental. They are not just questions of -) biology. Age is the basis of profound moral and societal expectations. Indeed, the gerontoctacy that is the defining principle behind sociopolitical organizaion in the southwest GPZ- if not the entire country -is also implicated in the age grade system. In addition, age contributes as a strong factor to the maintenance of kinship noffns and ideology in the standatd protocols of Yoruba cosmology. Without rcaliztng age as something more than just a construct of time, ot identi$ring it beyond biology, it is impossible to understand the fabric of Yoruba society. The cosmological ideas underlying the dtbaald, for instance, would not be understood; neither would it be possible to place the veneration of ancestors within a more mortal sphere that demonstrates the continuity and contiguity between the aftedife and this. In this vein also, sex is not just one of two basic divisions into which human beings fall. !7hen data are disaggregated by sex, the procedure gives rise to analysis and interpretation that can utilize gender not only as a sensitizing concept but also as an
32 analytical category for plumbing aspects of social life that would otherwise lie beyond the purview of conventional social or epidemiological explanation.
In this light, the general distdbution in Table L shows that more womeo (51,.4n than men (48.6 %) make up the overall study sample. Although the diffetences are slight, they are consistent udth
normal demogtaphic expectations, which explain the preponderance of men (18%o) over women Q5.4n in the uban sample. The neatly equal proportions of both sexes across the sites increase confidence we have in balanced gender ratios in tlle perceptions and petspectives of the cuffent healthcare delivery in Southwest Nigeria. Table 7 presents this and other sociodemographic
characteristics in Ekiti and Ogun States in southwest Nigeria.
The demogtaphic profile of respondents has implications for the qpe of healthcare services that
should be provided in the community. The profile reveals a population with low income who are I engaged in small scale trading. The majority are in madtal unions and mainly below 44 years old.
This ptovides clues for ateas of possible public intetwention as well as the types of services sorely needed in the study communities. For example, given a distribution of respondents that shows them to be squarely within their teproductive years - before menopause sets in for women - it is teasonable to strengthen matemal health, child health and other teproductive health services. This
would be the beginning of a system that takes cognizance of the age structure and associated health risks and priorities of the communities in which essential healthcare delivery services are provided.
It would be one instance of structuring services and making them affordable and accesslblefmm the
perspectiue of the communiry memberc tbenseluu and, in this sense, building services otganically.
This mode of apprehending the data from the community's point of view is instructive. As Table 8 shows, the study respondents compdse a highly sedentary population. More than half of the tespondents (53oh) have remained in the same place fot a minimum of 11 years. There is litde variation amoflg the three kinds of communities studied, vdth the urban, rual and peri-wban sites
accounting for compatable sedentary rates of 1.5.4o/o, 18.9oh, and l8.6oh, respectively. This implies a low propensity to migrate and, in consequeflce, an ovetall diminished incidence of social mobility. In such a context, health services have to be developed in a manner that tefashions them into
measures of proactive, people-oriented and ptopoor govemance.
2 To dobaale is to lie prostrate before an elder. It is the exptession of deeply held values of filial piety and Ioyalty among among the Yoruba of southwestem Nigeria. 33 Table 7: Sociodcnographic Characteistiu of Reqondents in the Health Di$rict! Sociodemogtaphic Chatacteristics Health District Total
Sex Utban Peri-utban Rutal Male 151 (18.070) 126 (1s.0%) 13r (t5.6oA 408 (48.6n Female t2e (1s.4n 154 (1.ffio4 14e (17.7n 432 (51.404 Total 280 (333%) 280 @34 280 (3r.3%) 840 (100.04 fue <25 43 (5.204 44 (5.3'O st(6.1w 138 (16.6010 25-29 33 (4.004 24 (2.9o/o) 31(3.70., 88 (10.670) 30-34 35 (4.2',4 42 (s.tyo) 37 (5.4oA 114 (13.7o1f) 35-39 s0 (6.070) 44 63n 40 (4.8%) 134 (16.101f) 40-44 34 (4fA 37 (4.501., 36 ($oA 107 (12.90lf) 45-49 21 (2.5o/o) 2s Q.on 30 Q.6oA 76 Q1n 50-54 18 (2.2o/o) 24 Q.eW x Q.8n 65 (7.8010 55-59 B O.6m I0.0n 7 Q.8n 28 (3.401(, 60+ 29 (3.50/(, 31Q.7n 21(2.soA 81(9.701f, Tota/ 276 (33.2%) 27e (il.6%) 276 Q3.24 ul (100.0%) Marital Status Single 60 (7.1W 48 Q.7n 60 (7.1W 168 (20.0%) Married 202 (24.0n 213 (2s.4n 212 (2s.2n 627 Q4.4%) l7idowed rc o.en M $.7n 7 Q.8n 37 (4.404 Divorced 1 QfA s Q.6n 1 QfA 7 Q.804 Separated 1(0.1oo o (o ool0 0 (0 07o) 1Q.1n Total 280 (fi34 280 (7t.i%) 280 (33.3%) 840 (100.0%) Religion Christian 1e3 (23.0%) 217 Q5.8oA 20s Q4.4%) 615 (T.2n Muslim 86 (10.2%) s7 6.8n [email protected] 21s Qs.6n African traditional lsligl on 0 (0.00lo) 6 Q.1n 3 Q.4n 9 (1.1o/o) No relgron lQfA o (o.o7o) 0 (0.070) 7 (0.1o/o) Tota/ 280 (i3.3%) 280 (fi.3%) 280 (33.3U 840 (il34 Evet attended school Yes 236 Q8.1'A 2s0 (2e.8%) 259 (30.8o/o) 74s (88.7%) No 44 (5.2oA 30 (3.60/0) 21(2.50 ., es (1t.3%) Tota/ 280 033%) 280 (fi3A 280 (i).J%) 840 (100.0u Educational level Primary education 63 (8.5"4 s8 Q.8n 62(ffioA 183 Q4.6n Secondary 118 (1s.8%) 112 (1s.0%) 134 (18.001(, 364 (48.904 Higher 46 (6.2n 76 (10.204 58 Q.8'A 180 Q4.2oA Vocational s Q.704 2 Q3n 3 p.4010 rc o3n Religrous/non formal education 3 Q-4n 1Q.tn 2 Q30A 6 (0.870) Other 1Qln 1Q1n 0 (0.0%o) 2Q300 Tota/ 236 (31.7A 250 (y.64 25e (34.8%) 746 (100.0%) Are you engaged in any Income Generating Activity Yes 243 (28.900 24t (28.7W 237 (28.2W 721(8s.8%) No 37 $4n 39 (4.604 43 (51oA lle (14.2%) Tota/ 280 (3t.7y,) 280 (fi.)%) 280 (33J%) 840 (100.0a Occupation Farming/hunting/ fi shing/livest 34 $.7n 13 (1.8o/o) rc Q.201., $ @.7n ock breeding Small scale ftading 65 (9.0o.) 74 (10.3%) 78 (10.8%) 277 Q0.1Yo) Paid employment/ salaried 29 (4.001f) s2 (7.2n 40 (s.soa 121 (16.80/0) Artisans 43 (6.004 41F.7n 48 (6.70 f) 132(1*n Business 68 (9.4o4 51(7.101(, 53 (7.4o4 172 Q3.9oA Other 4 (0.60/0) 10 0.4n 2 (0.301f) rc Q.204 Total 24' (3r.74 241 Q3.4%) 237 (i2.e%) 721 (100.0A
34 Table 8 shows that the high levels of industrial, political, educational, cultural and commercial development recorded in southwest Nigeria is by a kind of social paradox responsible for reduced levels of social mobility. Th. proportions reptesented by a sedentary segment of the parent population are high. It follows that the increasing incidence of interethnic matriages (not shown in the data), reported by independent sources, involves high ptoportions of Yoruba women who contract these unions uithin Yoruba tedtory and not beyond it. The significance is that services need to respond to the poverty ttap in which this type of situation locks many members of southwest society. If the services are always paid fot, they will not always be affordable by all people.
Tabh 8: Distibation of Reqondcntr @ l-ength 0f Stry in Coamsnitiet
Length of stay Utban Peri-utban Rutal Total in community
<1 13 (1.60/0) 77 (7.3o/o) 1.2 (1.4'/o\ 36 (4.3o/o\ 7-4 36 @.3'/"\ 34 (4.7o/o) 34 (4.7o/o\ 104 (12.5%\ 5-10 98 (11.8%) 76 (9.2o/o) 76 (9.2o/o\ 250 (30.1%\ 77-20 74 (8.9o/o\ 63 (7.6o/o\ 69 (8.3o/o\ 206 (24.8o/o\ 27+ 54 (6.50/0\ 92 (11.7n 88 00.60/0\ 234 Q8.2%\ T"t"t ns @.W n6 W'A n, Q3.@
Community Perceptions of Health and Health Service Delivery
Perceptions on Heatb
Perception is the fotmidable process of attaining awareness or understanding with which one can engage environment. It is also the cognitive outcome of that process. Perceptions ate influenced by cultural idiom - filters that enable interpretation of what is seen, heard, and reflected upon. They are the guides of human behaviour. In the context of this study, petception was defined as the view of individuals and communities about health and health services which can be influenced by outcomes of previous health care experiences and other social and cultural factors. It is for this reason that they can be appteciated as formidable modifiers of community involvement in the healthcare delivery process.
Table 9 below displays proportions of respondents in light of their perceptions of their healthcare delivery services and system. It presents individual ranking of current personal health as well as that of the members of the respondents' household. The value of these questions and the impottance of the related responses lie in the expectation that, if people perceiue their health to be sound, even if it is not, then they are not likely to adopt expected measures for improving it. This lends credence to a famt\at social science dictum, which can be paraphrased for contextual emphasis and relevance as
35 follows: If people peraiue thingt to be real orfahe, then thel are real orfalre in their contequencet
Tabk 9: Individuak'Perception of Healtb
Petception Health District
Utban Peri-utban Rutal Total
How will you rate your health today? Good 1e3 (23.0%) 20s (24.4%) 1e6 (23.3%) se4(70.7%) Moderate 82 (9.8o1f) 67 (8.0oO 73 (8.704 222 (26.4%) Bad 5 (0.6010) 8 (1.070) 11(r3oA 24 (2.901f) Total 280 (r.3U 280 (rt.ra 280 (3t.3U 840 (100.0u
Health of membets of yout household? Good 204 (24.3%) 222 (26.4%) 213 Q5.4oA 63e Q6.1%) Moderate 75 (8.9o/o) 58 (6.9o/o) 65 Q.7) 1e8 (23.6%) Bad 1(0.1%) 0 (0.00/") 2Q.201,, 3 (0.4yo) Total 280 03.3%) 280 03.3%) 280 0t.t%) 840 fl00.0%)
Majority of the respondents (70.7o/o) perceived their health as "good". Others perceived their health condition to be "moderate" (26.40/o) and "bad" Q.9Yo). The table shows that more people in rutal communities (1,.3 o/) perceived their health as "bad" relative to tespondents in peri-urban areas (1.0%) and urban arcas (0.6oh). In any case, these rates are low and comparable enough to waffant further reflection. The figures show that there might be a crucial disconnect to health rcahty on the ground and people's perceptions of it.
The Yoruba live in a cosmologically charged moral univetse in which it is believed that the declarations of the spoken word have powet to bring about whatever it is that has been declared. For this reason, is not likely that these reported perceptions of good health are true reflections of the situation on ground. It should be bome in mind that, as the data 6n lsligious affiliation (excerpted below from Table 7) show, the overwhelming majority of respondents are Christians
(73.2'/o).
Table l0: Dioribution of Retpondents b1 Re/igiow -4filiation
Variable Health Disttict
Religion Utban Peri-utban Rutal Total
Chrisnan 1e3 Q3.0%) 217 (25.804 205 Q4.4o/o) 61s (73.2%) Muslim 86 (10.2%) s7 $.8n 72 @.6n 21s Q5.6%) ATR 0 (0 07") 6 Q.7n 3 Q.4n e oln 116 lsligion 1(0.1%) 0 (0.070) 0 (0 0olo) 1 QfA Total 280 033%) 280 (r3%) 280 (33.3%) 840 O3.i%)
This prevalence occurs in a southwest GPZ land that is home or global headquartets of fout of the fastest gtowing Pentecostal churches in the wodd - the Enoch AdeboyeJed Redeemed Christian
36 Church of God, David Oyedepo's Living Faith Ministries (a.k.a. Winners' Chapel), William Kumuyi's ultra-orthodox Deeper Life Bible Church and, to a lesset degtee, Daniel Olukoya's Mountain of Fire and Miracles. Together, these megachurches exett ptofound influence on large congregations for whom admission of poot health may be construed as represendng the absence of faith. It is the norm to listen to statements declaring good health - "I am sttong" - even when the patient is ostensibly ill. Within such an environment, the perceptions that an individual has of his or her health may be immensely coloured or discolouted by the impressions generated by membership to intensive spiritual environments of this kind. Against this backgound, the perceptions teported of good health may not be teflective of medical reality.
According to results shown in Table 11., what people petceived as signs of good health, is defined by the ability to petform physical tasks, which include doing physical work (56.9%); moving around
(60.10/o); aches and pans Q3.6oh); sleeping and waking up without difficulty (16-20/o); performing vigorous or physically demanding activities (25"A; and taking care of oneself O4n. The indication is that popular perceptions of good health are rooted in unambiguous physicality. This may be a carryover from a formet agraLrian economy in which the most important sign of poor health is reduced physical performance on the farms and, to that extent, declining yield. The ftamework does not take cognizance of the psychological and emotional states of individuals. In that respect, it is not sensitive to the definition of health provided at the Alma Ata confetence as a state of complete, physical, social, emotional, and economic wellbeing and not metely the absence of disease. The qualitative data suggest that people's recognition of the psychological dimensions of health revolve around happiness, joy and peace of mind. Respondents stress crying and loss of appetite as signs of poor health in a child as captured in the following statements.
Pt 3: NSIY-| -/ -R-F-IW-FCD-M-A-CM45 Cod.et: [conn-percept-healtfuJ No memos
The wry we ran recognite a ?effln that fu healtlly fu that tbe percon aill not be $ajry du// at a partirular plarc becvuse yhen it down hef the will look happ1, jolfal and cheeful, f tbere * a pkce thy are dix.ussitg he/the aill be able to disrur uery well.
P 1 7 : N S lY- t - 1 -R-N -ILU -FGD -F -A-CM-2 4 Codrt: [conn-perapt-healtfuJ No memot
A healtfui child aould not be ryting all the tine, he would be eating regukrfi and must free _f*, ,r) icknes.
P 5 2 : N S IV-2 -2 -U -N -IKE -FCD -F -A-CM-0 2 Cofut: [conn-percept-healtfuJ No memot
Firct! it hat to with brain when nmeoile brain fu futxioning ffictiue!, tbe percon b healtful rccondg, iomeone brain ma1 be fiactionirg we// but it * pfusica@ challenged that is it ma1 haae diyaset on the 37 bodl or malaia, it na1 be dimble but when there it notbing like ruch we cafl MJ that tbe percon it p@tica@ healtfut and tbe third can be in line witb how {zrlteone * relating to people, 'f someone cannol rekn with peop/e perfect! thel na1 think the person h insane
Tabh 1 l: Distibution of Retpondcn* b1 Perception of lYhat Cor$ituter Good Health
Signs of Good Health Health District Ability to wotk Utban Urban Utban Urban Not mentioned 115 (13.7%) 122 (14.5o/o) 125 (14.90 ., 362 ($.1n Mentioned 16s (le.6%) 1s8 (18.8) 155 (18.5olo) 47s (56.e) Tota/ 280 (r3%) 280 (3r.ta 280 (fi.3%) 840 (100.0a Moving atound Not mentioned 108 (12.e%) 108 (12.e%) 11e (14.2%) 33s Qe.e%) Mentioned 172 (20.s%) 172 (205%) 161(1e.2%) sos (60.1%) Tota/ 280 (il.3%) 280 (3JJ%) 280 OisU 840 (100.0%) Vigorous activities Not mentioned 212 (2s.2%) 214 (zs.sn 204 (24.3) 630 (7s.0%) Mentioned 68 (8.10lo) 66 (7.e%) 76 (9.0o/o) 210 Q5.0%) Total 280 (rJA 280 (t3.3%) 280 (il34 840 (100.0%) Self cate Not mentioned 238 (28.3%) 235 (28.001(, 24e (2e.6) 722 (86.0%) Mentioned 42F.on 45 (5.404 31Q.7n 118 (14.0%) Tota/ 280 (33.ro/' 280 (33.3%) 280 (3J.3%) 840 (100.0%) Concenrating Not mentioned 266 Q1.7%) 262 (31.2%) 265 Ql.sm 7e3 (e4.4%) Mentioned M O.7n 18 (2fA 15 (1.8%o) 47 (5.60/0) Tota/ 280 (fi.3u 280 (33.3%) 280 (fi.3u 840 (100.04 Learning new tasks Not mentioned 271(32.3%) 268 (31.e%) 276 (32.901f, 81s (e7.0%) Mentioned e 0.1n 12 (1.4o (, 4 (05w 2s Q.om Total 280 (33.3%) 280 (33.3%) 280 (i3.3%) 840 (t00.0%) Participating in community Activities Not mentioned 266 Q1.7%) 266 (31.7%) 264 (31.4'A 7e6 (e4.8%) Mentioned 14 (.7n 14 (1.70 f, 16 (1.9o/o) 44 (5.2o4 Total 280 @34 280 (r3%) 280 (31.3%) 840 (100.0w Dealing with conflicts Not mentioned 267 (31.8To) 273 (32.s%) 26e Q2.0) 80e (e6.3%) Mentioned B O.sn 7 Q.801,) 11(1.30/., 31(3.7010 Tota/ 280 (33.3U 280 (fi.ta 280 (33.t%) 840 (100.04 Seeing and tecognizing people Not mentioned 267 Q1.8n 266 (31.7%) 269 (32.004 802 (ess%) Mentioned 13 (1.5o4 14 (1.7o4 n (3n 38 (4.5o/o) Total 280 (313U 280 (y3A 280 (3t.3%) 840 (100.0%) Sleeping and waking up Not mentioned 224 Q6.7o/o) 231 (27.s%) 24e (2e.6n 704(83.8o4 Menfloned s6 (6.7m 49 (5.801.) 31Q.7n 136 (16.2n Total 280 Q).3%) 280 @3A 280 03.3%) 840 (100.0u Sadness and deptession Not mentioned 274 Q2.6Yo) 268 Ql.e%) 277 (v.on 819 (97.5oA Mentioned 6 Q.704 12 (1.4o1f, 3 Q.4010 21(2.soA Tota/ 280 O3.J%) 280 (il34 280 (fi.3%) 840 (100.0u Aches and pain Not mentioned 217 Q5.8o/o) 213 Qs.4%) 210 (25.0o/o) 640 (76.2%) Mentioned 63 (7.5o/o)) 67 (8.004 70 ($oa 200 Q3.6n Total 280 03.3%) 280 (y.3%) 280 (3t.3%) 840 (100.0%) Anxiety and wotrying Not menfloned 271Q3.4o/o) 271(33.4%) 270 (32.1W 812 (e6.7%) Mentioned e (.tn e 0-101., 10 (1.2o4 28 (3.3o/o) Total 280 (33.3%) 280 (33.3%) 280 (3r.3%) 840 (100.0%)
38 Tabh 12: Dfficalry aith actiaities aror Disticts
In the last 30 days, how much Health District difficulty did you have with: Urban Peri-urban Rural Total Vork None 210 Qs.on 215 (76.80/C) 217 ($.8n 642 Q6.4n Moderate 34 (12.1n 49 (17.5o/o) 42 (15.0n 125 (14.904 Severe 32 (11.4W 13 $.6n 21Q5n 66 ?.en Extreme 4 oAn 3 Q10A 0 (0.0olo) 7 Q.8n Total 280 (100.0u 280 (100.0a 280 (100.04 840 (100.04 Moving around None 2220e3n 221(78.en 218 Q7.9oA 661Q8.7o/0 Moderate 24 @.6n 43 (15.4n 47 (16.804 114 (13.60A Severe 31 (111o/(, 14 Q.on 15 QAn 60 Qln Extreme 3 (1n 2p.1n 0 (0.0ol0 5 (0.670) Total 280 (100.0u 280 (100.0u 280 (100.0u 840 (100.0o/E E g"g"g in vigorous activities None 206 (73.60/0) 216 Q7.1oA 207 (73.90i(, 62e Q4.en Moderate 30 (10.7n 44 (1s.7W 52 (18.6n 126 (15.00i(, Severe 32 (11.4o1(, 16 (5.70iC, 17 $ln 6s Q.7n Extreme 12$sn 4 (.4n 4 (.4n 20 Q.4oA Total 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.04 Caring for yourself None 258 (9210i(, 259 (92.504 2s1(8e.6n 768 (91.4o/o) Moderate 11(3.9oA 16 (5.7"4 26 (9304 53 (fioA Severe e Q.2n s (1.870) 3 (ln 17 Q.loA Extreme 2Q.1n 0 (0.070) 0 (0.070) 2Q.20A Total 280 (100.04 280 (100.04 280 (100.0%) 840 (100.0%) Learning None 263 (e3.en 261(93.204 260 (92.90(, 784 (9*oA Moderate e (3.2W 14 (5.0oA 18 (6.40/(, 41$.en Severe 7 Q.sn 4 Q.40/,) 2 (0.70/0 13 0sn Extreme 1Q.4n 1Q.40/,, 0 (0.070) 2Q.2n Total 280 (100.0%) 280 (100.0%) 280 (100.04 840 (100.0%) Personal Relationships None 263 (93.90ic) 262 (93.604 261(93.209) 786 (93.60/(, Moderate 9 Q.20i., 15 (5.4o/0 15 (s.4oA 3e $.6n Severe 7 @.s"4 1Q.40/,, 3 Q.10i.) n (3n Extreme 1(0.40i(D 2Q.701., [email protected] 4 p.5n Total 280 (100.0u 280 (100.04 280 (100.04 840 (100.04 Participate in community activities None 248 (88.6n 2s8 (e21n 243 (86.801c, 749 (89.2n (r Moderate 20 Q.ln 15 (5.40 (, 24 $.6n se Q.on Severe 10 (3.600 6 Q1',A 12($oA 28 (fioA Extreme 2Q.70 .) 1Q.4n 1Q,4n 4p.sn Total 280 (100.0u 280 (100.0u 280 (100.0%) 840 (100.04 Seeing and recogmzrng people/things or recording None 259 (92.5oA 2s7 (e1.8n 249 (88.90/C, 765 (91.1o4 Moderate 12($oA 17 (610/c, 21(7.50iC) 50 (6.070) Severe I Q.9"4 6 (2.10/., e Q.2n n Q.1n Extfeme 1p.40 ., 0 (0.0olo) 1p4n 2 (0.2oa Total 280 (100.0%) 280 (100.0u 280 (100.0u 840 (100.04 Sleeping/waking up None 263 (93.9o ., 257 (91.80/(, 253 (e0.4n 713 (e2.0n Moderate u Q.en le $.8n 23 (8.2W fi $3n Severe 5 Q.8n 3 (ln 4 (1.4W 120.4n Extreme 1Q.40A 1Q.404 0 (0.0"/") 2 (0.2y,) Total 280 (100.0a 280 (100.0u 280 (100.0u 840 (100.0%) Feeding None 268 (e5.7n 25e (e2.5n 260 (92.90/9) 787 (93.7'4 Moderate 10 (3.604 1e (6.8n 15 (5.404 44 $.2o4 Severe 2p.70 ., 2 Q.70/., 5 (1.80/0) 9 (1104 Extreme 0 (0.0%o) 0 (0.070) 0 (0.070) 0 (0.0olo) Total 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%)
39 Figures 7 and 8 display disparities in responses to the question conceming difficulty people with performing work. Diffrculty with work is most severe in urban distticts (1,1..4Y"), while it is lowest in peri-urban district (4.60/0). The same pattern is replicated in difficulty with moving around which was found to be most "severe" in urban districts (11.1o/o) than in peri-urban (5.0%) and rural (5.4%) communities.
Figare 7: Dffirul4t with work Figare 8: Difr*lA with rnouingaroand
90 90 80 80 70 70 60 60 50 50 40 -uft3p 40 -u$3n 30 30 pgli- 20 20 urban urban 10 -pgpi- 10 - 0 0 Rural -
At face value, the pattems rig"ify the severity of health conditions in urban areas but this could result from the type of what French sociolog'ist Emile Durkheim once characteized as organic solidarity and the division of labour that prevails in urban centres. The economy is mote diversified in cities with a definite push away from an agrariar, homogeneity. In consequence, the inability to move about (without the availability of the kind of assistance that rrray have been present from kinsfolk in, say, an tgraian rural setting), this becomes a strong predictot of poor health.
Awareness and Knowledge of Health Issues
Table 13 shows that malana (78.Lo/") and fever (42.a%o) are the most frequendy reported health ptoblems in the study area. These were followed by eye problems (18.5%) and arthritis Q3.0\ and then, hlpertension (8.0%). These health ptoblems ate tlle cause of most deaths to children under five. Respondents are aware of the role mosquitos and environmental santiation play in the transmission of the parasites that cause malaia. Improved sanitary habit delivered through health education will go a long way to reduce the incidence of this disease. It would also cotrect the belief among some respondents that expose to cold weather makes children vulnerabke to malaria. The error may lie in associations between exposure to cold and to the vector of the malaria parasite.
40 P 1 2 : N StY-t -1 -R-F-ILU -IDI-M-A-CL49 Codtt: [Comn-awareJ No menos
Thry wonld rot take care of tbeir child, thry would not wear cloth for their child thy will jurt haue tbem with ordinary pafltr, aear ?ant alone for tbeir child, tbry will rut coaer tbeir bofu, thry will expose the che$ of tbeir child atd ae are in the time of cold and th* ocean make thh pkce coohr that other areat
P 1 2 : N S tY- 1 -1 -R-F -ILU -ID I-M-A-CL4 9 Codes: [Conn-awarc] No meruot
Becauy of cririt, afew dalt agl ae My cbicken pox occur ncent! na1 be becaurc of dry seann.
P 2: NSIY-I -t -U-F-ILU-FGD-M-Y-CM-54
Codct: [Conn-expectJ No memos
ltt the gouemn€l,t tU ar mach as possible to pmuid.e afuquate equipnent for at to serue people better. As )0r can see the envirunment it uery bad, hok at tbe buh arottnd tbe place, thir pkce is aery wall, thgt need to expand thir pkce n things will be eayyfor the people that are working here
P I 5 : N S lY-l -1 -R-F -IYE-IDI -F -A-HO - 30
Cofut: [Conn+xputJ [Dis-burd+on-fadJ No memos
the people in th* area are aery dirt1, n the gouerzment thould train the runitation oficert and make them do their job and empower tbem to go fmn bowe to boarc to percuad.e the people to ue tbe bealth cefier wben thgy are ick and to enforce the uy of treated motqtito ttets aild d{aultert thould be nadr to pa1 nmefnn Tbe nong thould be a toku that will be ffirdable fu the people n that tbry wi// not becaay of tbat ntn awalfrun the tovn
Table 13: Common Heahb Prvbhns ants Diilicts () Common Health Health Disttict Total Problems Urban Ped-utban Rutd Fevet Not mentioned 158 (56.40/0\ t60 (57.1o/o) 166 (59.3o/o\ 484 (57.60/o) Mentioned 122 (43.6W 120 (42.9m r14 (40.7%o) 356 (42.4oo Total 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%) ]il-{elaia Not mentioned 72Qs.7W 54 (19.3'/,) 58 Q0.7%) 184 Q1.9oA Mentioned 208 (74.3"/0) 226 (80.70i.) 222 (79.3'/0) 6s6 Q\.fA Total 280 000.0%) 280 (100.0%) 280 000.0%) 840 (100.0%) Veakness Not mentioned 263 (93.9o/o\ 267 (95.401() 268 (95.7o/o\ 798 (95.0o/o\ Mentioned 17 (6.1%) 13 (4.60/0) 12 (4.3%) 42 (s.0%) Total 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%)
Not mentioned 262 (93.60/0) 253 (90.4Y,) 250 (8930i() 76s (91.tm Mentioned 18 (6.4%\ 27 (9.60/o) 30 (10.7%\ 7s (8.9%\ Total 280 (100.0%t 280 (100.0%t 280 (100.0%t 840 (100.0%t El'. p."bt.- Not mentioned 239 (85.401f) 225 (80.40/C, 221(78.90ic) 685 (81.s7") Mentioned 4714.60/o\ 55 o9.6o/o\ 59 el.l%\ 155 (18.570)
41 280 (100.0%) 280 000.0%) 280 (100.0%) 840 (100.0%) Arthritis Not mentioned 228 (81.4"/") 205 (73.20/") 214 (76.4W 647 07.0"/") Mentioned 52 (78.6%\ 75 (26.8o/o) 66 (23.60/0\ 193 (23.0o/o) 280 (100.0%) 280 000.0%) 280 (100.0%) 840 (100.0%) ResDiratory Droblems Not menuoned 270 (96.40/0) 263 (93.9o/o) 270 (96.40/0) 803 (95.670) Mentioned 10 (3.60/0) 17 (6.10/0) 10 (3.60/ci, 37 (4.4%) 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%) Depression Not mentioned 274 (97.9o/") 275 (98.2o/o) 278 (993oA 827 (98.5"/") 6 (2.1'/o) s (1.8%) 2 (0.7Yo) 13 (1.504 280 (100.0%) 280 000.0%) 280 (100.0%) 840 (100.0%) Diarthea Not mentioned 263 (93.9o/o) 261(93.20/0) 264 (94.3o/o) 788 (e3.8n t7 (6.1%) t9 (6.80/0) 16 (s.7%) s2 (6.2v4 280 (/00.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%) Yomitine in childten Not menfloned 269 (96.10/0\ 266 (95.0o/o) 270 (96.4Yo) 805 (95.870) Mentioned tl (3.e%\ 14 (s.0%\ 10 (3.6%\ 35 (4.2%\ 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (t00.0%) Malnutrition Not mentioned 271 (96.80A 276 (98.60A 280 (100.0n 827 (98.5oA Mentioned 9 (3.2%,) 4 (1.4%\ 0 (0.070) 13 (1.5o/o) Total 280 (100.0%t 280 (100.0%) 280 (100.0%) 840 (100.0%) Di^b.t* Not mentioned 259 (92.5Yo) 261 (93.20/,) 268 (95.7"/A 788 (93.801(, Mentioned 27 (7.5o/o) 19 (6.8'/0) 12 (4.3o/o) 52 (6.2'/A 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (1oo.o%) Hypeftension Not mentioned 257 (97.8o/o\ 258 (92.1o/o) 258 (92.1o/o) 773 (92.0'/o) Mentioned 23 (8.2%) 22 (7.9o/o) 22 (7.9%) 67 (8.0"/") 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.04 Weight loss Not mentioned 277 (98.9o/o) 274 (97.9o/o\ 279 (99.60/0) 830 (98.870) Mentioned 3 (1.1o/o) 6 (2.1%) I Q.4',4 rc 0.2n Total 280 (100.0%t 280 (100.0%) 280 (100.0%) 840 (100.0%t Std" Di...* Not mentioned 266 (95.0o/o) 272 (97.to0 268 (95.7o/o) 806 (96.07o) Mentioned 14 (5.0o/o\ 8 (2.9Yo) 12 (4.3%) 34 (4.0o/o) 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%) None Not mentioned 278 (99.3o/o) 276 (98.601(, 279 (99.60/0) 833 (99.2o4 2 (0.7%\ 4 (1.4"/,) 1 (0.4%) 7 (0.8o/,) 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%) Don't know Not menfloned 273 (97.5oO 276 (98.60A 269 (96.1Yo) 818 (97.40/c) Mentioned 7 (2.5%) 4 (1.4o/o) 11 Q.gYo) 22 (2.60/0) 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%)
Heahh Prublems and Sources of Treatment
Table 14 shows that the health cenffe and the Pdvate Medicine Vendor (PMD are used more frequently by respondents. There is higher use of health centres peri-urban and rural
42 communities than in urban communities. Some health problems are treated spiritually. These
include diffrculty in leaming (77.3%o), difficulty in interacting *ith others (17.3%), and difficulty in
seeing and recognizing people (9.6%).
Tabh l4: Tlpe of Health Prubleru and Place ofTrcatment When people have alny of these Health District problems where do thev eo? Aches and pains 17 (6.10/0) 5 (1.8"/,) 8 0.87") 30 (3.60/0) Health centre 155 65.40/o\ 172 (61.40/o\ 173 (61.80/o\ 500 (59.570) Traditional 15 (5.404 10 Q.6'A I Q..9'A X Q.9) P\N Arl% S8 A1.4. Q2 'O 1(oAm 2 (0.7o/o) '1 0 (0.070) 3 (0.4"/o) Don't know 2 (0.7"/o) 3 (1.1o/"\ 0 (0.0%o) 5 (0.60/0\ 280 (100.0%) 280 000.0%) 280 (100.0%) 840 (100.0%) Difficulw moving around 11 (3.9o/o) 2 (0.7'/o) 6 (2.1'/o) 19 Q.3Yo) Health centre 201 01.80/(i 225 (80.401() 223 (79.601C) 649 (77.30/(i} ) 19 (6.80/0) 15 (5.40ic) 13 (4.60/0) 47 (5.6ob 40 (14.3o/o) 31 (11.1o/o) 36 (12.9o/o) 107 (12.7o/o) 2 (0.7o/") 2 (0.7"/,) 0 (0.07") 4 (0.5v,\ Don't know 7 (2.50/.i) 5 0.870) 2 (0.7o/o) 14 (1.7o 280 (100.0%) 280 000.0%) 280 000.0%) 840 (100.0%) Difficulty engaqing in running 16 (5.7o/o) 14 (5.0o/o) 12 (4.3o/o) 42 (5.0Yo) Health centre 204 02.9o/o) 214 06.40/0) 222 O9.3o/o) 640 06.20/0) Traditional 16 (5.7o/o) 17 (6.10/0) 11 (3.9o/o) 44 (5.2"/o) 29 (10.4%\ 23 (8.2o/o) 30 (10.7o/o\ 82 (9.8o/,) 3 (1.1o/o) I (0.4o/o) 0 (0.070) 4 (0.50i.i, Don't know 12 (4.3o/o) 11 (3.9o/o) 5 (1.8o/o) 28 (3.3o/o) 280 (100.0%) 280 000.0%) 280 (100.0%) 840 (100.0%) Difficulw in caring for vourself 26 (93m 34 02.1o/o) 42 (15.0o/o) 102 (12.1yo) Health centre 182 (65.0n 175 (62.W 180 (6$"A $7 (63.9b
12 (4.3o/o) 14 (5.0o/o) 9 (3.2'/,) 35 (4.2o/o) 7 (2.5o/o) 4 (1.4o/.) 2 (0.7o/o) 13 (1.5o/,\ Don't know 33 (11.8yo) 35 (12.5o/o\ 32 (11.4o/o) 100 (11.9o/o\ 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%) ,') Difficulty in learning Nowhere 40 (1$oA 66 Q3.6"4 70 Q5.0"4 176 Q1.0"4 Health centre 75 Q6.8W 78 Q7.9o/o) 81 Q8.9o/o\ 234 (27.9o/o) 210.5y") 20 (7.1o/o) 21 (7.5o/o) 62 O.4o/o) 3 (1.1"/,) 5 (1.80lo) 5 (1.870) 13 (1.5o/o) Sprntud 47 (16.80/0) 31 (11.1o/o\ 17 (6.1%\ 95 (11.3o/o\ Don't know 94 (33.60/0) 80 Q8.6o/o) 86 (30.7%) 260 (31.0o/o) Total 280 (100.0%) 280 (100.W P".d"tp.d"g t" *--""tty ""d"td* J8 (13.60/0) 68 (24.3o/o) 77 Q7.5o/o) 183 Q1.8o/o) Hedth centre 115 (41.1%\ 116 (41.4o/o) 113 (40.4o/o) 344 (41.0o/o) 13 ((4.60/o) 18 (6.40/0) 15 (5.4o/o\ 46 (5.5o/o) 12 (4.3%) 7 (2.5'/,) 10 (3.60/0\ 29 (3.5o/o) 19 (6.8"/0) 10 (3.60/0) 11 (3.9o/o) 40 (4.8o/o) Don't know 83 Q9.6oA A Qt.go/o) 54 (19.3"/,) 198 Q3.6W 280 (100.0%) 280 (100.0%) 280 000.0%) 840 (100.0%) lnteracting with others 41 (14.60/o) 63 (22.5o/o) 81 (28.9o/o) 185 (22.0% Health centre 83 Q9.6o/o) "l'00 (35.7o/o) 99 (35.4o/o) 282 (33.60/0) Traditional 18 (6.40/0) 19 (6.80/0) 20 0.1,/,) 57 (6.80/0) 8 Q.9o/o) 8 (2.9o/o\ 4 (7.4o/o\ 20 (2.4o/o\ 38 03.60/o) 22 0.9o/o\ 17 6.10/o\ 77 0.2o/o\
43 Don't know 92 (32.9o/o\ 68 Q4.3%) 59 Q1.1o/,) 219 (26.10/0) Total 280 (100.M) 280 (100.0 S*-g t*.g"*t"g p..pLl.hhgt and rennrdino""d Nowhere 10 6.60/o\ 7 QS%\ 74 (5.00/o\ 31r3.7%\ Health centre 190 (67.90/0) 211 O5.4o/o) 215 06.8%\ 616 (73.3%) Traditional 14 (5.00/o\ 16 (5.7%\ 8 Q.9o/o\ 38 4.5%\ 15 (5.4o/"\ 11 (3.9o/") 7 (2.5o/"\ 33 (3.9%\ Spiritual 24 (8.60/o\ 19 (6.80/o\ 11 3.9o/o\ 54 (6.4%\ Don't know 27 0.60/o\ 1,6 (5.7o/o\ 25 (8.9%\ 68 (8.1%\ 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%) Sleeping and waldng up Nowhere 10 (3.60/o\ 12 (4.3o/o\ 11 0.90 \ 33 0.9%\ Health centre 203 (72.5o/o) 214 06.40/0) 228 (81.4o/o) 64s (76.8%) Traditional 12 (4.3o/,) 10 (3.60/o) 4 (1.4%) 26 (3.1o/o) 32 01 4o/o\ 23 (8.2o/"\ 26 9.30 \ 81,9.6%\ 70 G.6o/o\ 6 (2.7o/o\ 4 0.4ok\ 20 QA%\ Don't know 73 (4.60/o\ 15 (5.4o/o\ 7 2.50k\ 35 @.2%\ 280 (100.0%) 280 000.0%) 280 (100.0%) 840 (100.0%) Diffrcult to eat Nowhere 12 (4.3%) 11 (3.9W 13 (4.6%) 36 (4.3%) Health cerue 204 Q2.9oA 215 Q6.8o/o) 231 (82.5o/o) 650 07.4o/o) Tradinonal 12 (4.3%\ 1,0 (3.60/o) 4 (1.4%\ 26 (3.t%) 32 (11.4o/o\ 23 (8.2o/o) 23 $.2%) 78 (9.3%) Spirirual 6 Q.7o/o\ 5 0.8o/o\ 2 0.7%\ 13 0.5%\ Don't know 14 (5.0o/o) 16 (5.1o/o) 7 (2.5%) 37 (4.4%\ 280 (100.0%) 280 (100.04 280 (100.0%) 840 (100.0%)
The health centre was reported to be the place where most health problems are better managed, with the exception of problems related to leaming (11.0o/o) and participati"g i" community activities (6.1%).
The qualitative d^ta are revealing.
P 7: NSIY-| -t -P-N-IKE-IDI-M-A-CL50- 7:1 I
Cofus: [Conn-percept-treat] No memot
Mary people nza g0 to re the dactor and fl,,ffrer at the health centre. Although there are other piuate medical housu arluild, naryl pezph $ill go to the health ceiltre. Ma) be becaase the ynticw thel prouidl are uery afordable clmpar€d to the ones in piuate hotpital. There are other people who go to the mision houses, espedallt for dlliuery. lYonen wbo want to giue birth ue t0 patruni Table 15 describes people's views on where these health problems are better managed. Table l5: Sins for the Mafla4emert of Heahh Problens Where are problems like these better Health District managed Urban Peri-urban Rural Total Aches and pains Nowhere 10 (3.60/0) 3 (11%) 2Q.70/.) 15 (1.870) Health centre 273 06.1.0/o\ 220 08.6%\ 236 (84.3o/o\ 669 09.6o/o\ 44 Traditional 6 Q.ln 10 Q.6n 3 oln le Q3n PMV 46 (16.4n 44 (15.7oA 37 (13.2n 127 (1510i(, Spintual 1Q.4n 0 (0.070) 1p.4n 2Q.2n Don't know 4 0.40/0 3 oln 1(.4n 8(1n Total 280 (100.0a 280 (100.0%) 280 (100.0u 840 (100.0o/o) Difficulty moving around Nowhere 10 Q.6n 1(0.4W 3 (.10/.) M (.7n Health centre 239 (85.40/C) 250 (893oic, 257 (91.80i() 746 (88.804 Tradiuonal 7 Q.5',4 e (3.2W 5 (1.8W 21Q.sn PMV 15 (5.40/C, 13 $.6n 13 $.6n 41(4.eW Spiritual 6 Qln 3 (.1n 1Q.4n 10 0.2n Don't know 3 oln 4 (.4n 1Q.4n 8 (1.00lo) Total 280 (100.0u 280 (100.04 280 (100.04 840 (100.04 Difficulty engaging in vigorous activities Nowhere e Q.2n n Q.en 6 Qln 26 Q.ln Health centre 241(86.10i., 243 (86.804 260 (e2.en 744 (88.6n Traditional 8 Q.eoa 10 (3.6%) 6 Qln 24Q.en PMV 12($oA 10 (3.604 6 @l',i., 28 (330i0 Spiritual 2Q.1n 1Q.40i., 1p.4n 4p50a Don't know 8 (z.en s (.80i9) 1p.4n A 0.7n Total 280 (100.0%) 280 (100.04 280 (100.04 840 (100.04 il Difficulty in caring for yourself Nowhere 24 @.6n 27 (9.60A 17 $.1n 68 (8.170 Health centre les (6e.6w 200 (n.4n 218 (77.en 613 Q3.0o/o) Traditional 10 (3.604 B $.6n 11 (3.904 34 (4.0oA PMV 6 @ln 8Q.en 2Q.7n 16 (1.gvo) Spiritual n Q.en 6 Q.l',.) 4 0.40.) 21QsoA Don't know 34 (121n 26 Q3n 28 (10.0n 88 (10.5% Total 280 (100.04 280 (100.04 280 (1oo.oa 840 (100.04 Difficulty in learning Nowhere 49 (17.504 59 Q11'A 50 (17.en 158 (18.870) Health centre 101Q6.1n 96 (3$oA 120 (42.9o/o) 317 (37.7n Traditional l Q.en 17 (6 1o/o) 13 (4.604 41$.en PMV 3 (1.1W 2Q.7n 0 (0.070) 5 Q.6n Spiritual 41(14.6n 28 (10.0n 23 (8.20i(, 92 (11.001() Don't know 7s Q6.8W 78 (219n 74 (26.40/(, 227 (27.0W Total 280 (100.04 280 (100.04 280 000.04 840 (100.04 Participating in community activities Nowhere 41 (14.604 37 (13.2n 4e (17.5n 127 (1510i(, Health centre 139 (49.60/(, 139 (49.6n 143 (s1.1n 421(s0jn Traditional 7 @.5"4 M Q,1N 13 $.6n 36 @3n PMV 1Q.40i9) 4 0.40/,, 4 (.4n e o1n Spiritud 24 (8.60i(, 15 Q.4n 12 (4.3) 51(6104 {) Don't know 68 (2$oA 6e Q4.6n 5e (211n 196 (2*.4 Total 280 (100.04 280 (/00.04 280 (100.04 840 (100.0%) Interacting with others Nowhere 38 (13.60/0) 4e (17.5n 4e (17.sn 136 (16.204 Health centre 130 (46.4n 123 ($.en 138 (493010 3e1(46.5n Traditional s (1.870) 13 (4.60iC) t Q.90/o 2e Q.sn PMV 1Q.4n 3 (1n 2Q.7n 6 Q.1n Spiritud 21 (9.60q) 21Q.5oA 1,8 (6.40i0 66 (7.goic, Don't know 79 (28.204 71QsAn 62QL1n 212Q5.2n Total 280 (100.04 280 (100.0%0) 280 (t00.oa 840 (100.04 Seeing and recognizing people/things and recordi.g Nowhere 6 Q.ln 3 o10a 1QAn 10 (.2n Health centre 220 Q8.6oA 23s (83.eW 248 (88.60 () 703 ($.7n Traditional 4 Q8.6oA 10 (71.4o/() o (0.070) 14 (1.7oi(, PMV 10 (5s.6oa 6 Q*n 2$11n 18 Q1n Spmtual 16 (5.7o4 e (3.2W 11 (3.e) 36 $3n Don't know 24 (8.6W 17 (6.1W 18 (6.40 .| 5e (7.0n Total 280 (100.0%) 280 (100.0u 280 (100.0%) 840 (100.0%) Sleeping and waking up Nowhere 10 Q.6n 3 (.10/.) 3 oln 16 (1.9o4 Health centre 227 (U1n 2M (8710 () 258 (9210 () 729 (86.80/.) Traditional 5 (1.87") s 0.8n 1(oAW 11(130i., pt\if\/ 16 (\.70/n\ 12 A.io/n\ 9 (1.2o/n\ \7 @.40/"\ 45 Sprntual 12($oA 6 Q.10i., 4 0.4n 22Q.6n Don't know 10 (3.6%) 10 (3.604 5 (1.8%o) 25 (3.0%) Total 280 (100.0%) 280 (100.0u 280 (100.04 840 (100.04 Difficulty to eat Nowhere 10 Q.6n 4 0.4n 3 (1.1o/") 17 Q.on Health centre 232 (82.901() 239 (85.404 2s8 (e21n 729 (86.8n Tradrtional 3 (.10 .) 6 Ql"A 1(0.4%) 10 (1.2.4 PMV 17 (6.10/C) 12 ($oA e Q.2n 38 (4.5oA Spiritud I Q.90i., s (.8n 40.40 .) 17 Q.loA Don't know rc p.6n 14 O.0n 5 Q.8n 2e Q.5n Total 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (1oo.o%) The results also suggest that the influence of traditional doctors is waning as they were mendoned less as a place where most health problems are better managed. However, this does not imply that most people have completely endorsed the use of westem medicine. Rathet, it shows that while perception is changing in favour of modern health care delivery services, spiritual homes and churches are becoming alternative places where people seek medical care. For instance, only 4.9o/o mentioned that difficulty in leaming is better treated by traditional doctor as against 11o/o who mentioned spiritualist. Therefore, it is imperative for Mission Birth Attendants (as they preferred to be called) to be fi,rlly integtated into health care delivery system for the health care systems to experience another level of improvement. The following statement confims the influence of churches/spiritual homes and other altemative sources of cate: P48 : N S lV-2 -/ -R-N -OV/O-IDI-M-A-CL-2 t Codu: [Conn-percept-bfl [Int-nat-gouJ No memot lVe Epeal to the gouemmert t0 clne to onr aid.r. Ma1 be thry thoald bry eqaipnent becaav sone people don't patronise aq thel uisited the herbalists, mistionaies, church and thel euen go far to dcliuer their babiet because a.r)ou are lookingat that health centre, there it no water hewe thrygo to where it will be conaenient to deliuer their babies. Perception of Heahh Services and Slstems Figure 9 shows that, across the districts, people who rated that the services provided by the health facility in their community as good (50.8%0) outnumbered those who perceived such services as bad (42.4Y"), fruther indicating that perceptions of pri-ary health care services wete changing for the better. 46 Figure 9: Peraptiort of Health Seruicu Ratings of Health Services provided in the Community 60.006 52.9o/o 49.60.A s0.8% 50.0o6 40.ooA I Good 30.0% : Bad 20.ool, r Don't know 10.0% O.Oo/o Urban Peri-urban Rural Total Further analysis using the regression (fable 16) shows that occupation, i.e., what people do to earn a living was the main factor influencing the perception or ratings of health services provided in the community. Occupation is a significant determinant of people's socio-economic status. Because level of poverry may be directly linked to occupation, people's ratings may be affected by their inability to afford the cost of health care services. Table /6: fuXrusion of Factorc lafluercittgtbe ratiagof Healtb Care Seruicu in the Commuilty Unstandardized Standardized Sig. Correlations Coefficients Coefficients B Std. Beta Zeto- Partial Part Error order (Constant) 1.934 5.736 .337 Sex 1.783 -.026 -.617 .538 -.045 -.025 1.100 .024 Ase 156 094 1.648 100 Level of education -.040 .220 -.007 -.182 -.008 -.007 .007 Occupation .159 061 104 2.601 010 .111 r04 .103 Marital status -.142 2.295 -.003 -.062 .951 -.002 .oo2 1.317 1.807 .041 Length of stay in -.129 -.080 061 -.075 communitv 1.879 .075 a. Dependent Variable: provides in your community? A cross-tabulation of the above rating with the occupation of respondents (Iable 17) shows that those who rated health service "bad" are predominandy found among small scale traders (57.1%) and farmers (39.7'/0). This tesult taises the question, why do small scale ftadets and fatmers rate health care services as "bad" mofe frequendy than any other occupational groups? The answer might lie in their lower daily incomes relative to rising health costs. The farmer is wotse off because harvest of income for him is mainly a seasonal issue. 47 According to health off,rcials from the two regions: P 1 : N S lY-2 -2 -P -N -OIY/O -IDI -M -A-HO -5 5 Cod.es: [Conn-read1-dff] I\o rzemot Maryt of thorc who patroniTed ils are p00r; tbry are inuolued in farruing and pxry ffading. S o thry don't haue enough nonry to feed themselues adcquatefi not to talk of treatment. P / 5 : N S lY- 1 - 1 -R-F -IYE -IDI -F -A-HO -3 0 Codcs: [Conn-read1J [Conm-read1-dffi No memot The tvmmani4t is rea$t to rce the facilifl but thel haue tome nrctraiu in doing to. The n@or challenge thel haue b poaetE. Mott of the retidentt here are uery p00r and this har nad.e them to run awal frorz ating tbe health centre becaurc of the token the wi// haue to pa1 when thel cone. Thg are afraid of coming because thry belieue thry will be giuen rome prenription ahich thry will not be able to aford Tabh 17: Rating of Health Care Seruir.vs and Oaapation of ReQonfuntt OCCUPATION RATING OF HEALTH SERVICES Good Bad DK Total Farming/ huntrng/ fi shing/ live s tock 31(42.901., 2s (3e.7%) 7 (11.1%) 63 (100.0%0 breedmg Small scale trading 83 Q8.2"4 124 (s71n 10 (4.6%) 217 (100.0W Paid employment/ salaried 77 ($.6n 40 (33.1%) 4 (3.3%) 121(100.0n Artrsans 6s (4e.2n s6 (42.4%) 11($oA 132 (100.0'4 Business es (ss.2%) 66 (38.4%) 11(6.40 f, 172 (100.0,4 Other s (31.3%) 7 $3.8n a Q5.0o/o) 16 (100.0olo) Total 356 (49.4%) 3t8 (44.1%) 47 (6.s%) 727 (100.0%) Table 18 shows that the reasons respondents rated health service as "good" included health petsonnel responsiveness to clients' needs (36.30/0) and adequacy of drugs and equipments (10.4%). Nevertheless, these factors were not sufficient in themselves to produce better healthcare delivery. Tabk 18: Reatow forRatin4r of Healtb Facilities REASONS FOR RATINGS HEALTH DISTRICT Utban Peri-urban Rural Total Attitude of staff to clients is poor 18 (6.8o1(, 29 (1.0.704 \e (7.0%) 66 (8.204 Inadequate drugs and equipment s|(1e3n s4 Q0.0oa s7 Q1.1%) \62 Qj.r%) Very responsive to clients' needs es (36.0n 101937.4W e6 (3s.6%) 2e2 (36.3%) Adequate drugs and equipment 29 (11.004 28 (10.404 27 (10.0%) 84 (10.4%) Friendly environment 8 (3.0%o) 11(4.10 (, 7 Q.6',4 26 (3.20{(, Clean environment 3 0.rn 4 o.sn 4 0.501.) 11. (t.4oA Delays h provision of health care 20 (7.604 ls (s.6w u 6.2m 4e $.1n Lons queue 3 1.7o/o\ 3 fi.7o/o\ 2 (0.7o/o\ 8 (1.0%") 48 Absence of FIW from facility 6 Q3',A 7 Q.6',4 24 @.en 37 $.60A Referral practice in the facility 2 (.0.8%) 6 Q.2',4 6 Q.2n 14 (1.7o/(, Others 2e (11.0%) n $.1n 13 (4.80 f, 53 (6.6"A Don't know 0 (0 07o) 1 (0.4"/o) 1p.40a 2 Q-2n Totat 264 (700.0%) 270 (100.0%) 270 (100.0%) 804 (100.0%) The attitudes of health personnel need to be ad&essed in order to revitalize the health system. Most respondents (64.6%) reported that they were dissatisfred with the way healthcare was ptovided by the government. Across districts, as shown in Figure 10, levels of satisfaction were low and uniform for the wban Q3.6o/o), peri-urban (38.2oA, and rural (34.3o/o) districts. Figare l0: Puplel Fulingt About Couernmefi lrunlaement on Communiry Health Feelllgswlth How Government Prorride Health Care in the (') Community 70.o% 60.00,6 50.0% 40.Oo/o I Satisried 30.o% r Oissatisfied ?o.o% 10.0% o.o% Peri-urban P5 I : NS lY-2 -2 -U-N -ABE-IDI-M-A-HO-5 7 Codrt: [Conn-pan-uiewJ [Conru-read1-difl No memot \J., If the people ve that the politician b wa$ing the monel that fu meant to da the work, thry aill rut be enroaraged to uy tbeir own pertonal mznu to do what the gouemment * supposed to do. Derpbe the fact that it is tbeir own peoph tbat are going to beneftfvn tbe ffin, thg willfeel diuouraged tf thy don't get gouelvmefit il/pport. The statement shows that communal dissatisfaction with senices is linked to official wastefulness. The perception is that much of the tesources that are wasted could be invested to improve the health system. Comrption is cenftal to this wastage. 49 COMMUNITY EXPERIENCE OF IMPLEMENTATION OF HEALTH SERVICE DELIVE,RY Perception is the process of attaining awareness or understanding of the environment. It is rooted in experience. The acquisition of this experience, somedmes taken to mean the same thirig as consciousness, is not possible outside human interaction and its consequences. As a result, perceptions and the consciousness that guide human strategic behaviour ate teductive expressions of complex processes and cultutal tealities. In other words, petceptions are shaped by tusted human expedence, even if that trust is in error or completely misplaced. Accuracy is not what defines perception but its powerful linkage with human social behaviour. For the study, therefore, perception was conceptualtzed as the view held by individuals and communities about health and health services on the basis of experience or contact with the health system. Because perception is historicized in this way, the phenomenon becomes the indicator of what has to be done to improve the healthcare delivery system. P t 7 : N S lY- 1 - / -R-N-ILU-FG D -F -A-CM-24 C o du : [Com m -aware-re l] [Con n -percept- hfl [Corun -percept-treatJ No memot The health facili4t that * in thit toan it good though it depedt on indiuidual expedence, some people dan't /ike patronising the place becauy of the referal practiy ahile some dou not eaen bother heue thry patroilse thert though thel delal peoph too much before thel prouide health yruiws andfor me i alway dcliuer all n1 cbildren in thh health centre and God hat been helping ut. Pl 9: NSIY-| -t -U-N-ADO-FCD-F-Y-CM44 Codcs: [Conn-perceptJ Memot: tME 13/06/11 [9J] The health care tltrtem is not good again because the piaate hoqital ownerc will not be naking income as peopk will not be patroniting them becaay of the free health care senim put in plau b1 the goueruruent, 1oa know the ownerr will not be happlt atd pharcd as people rnry not be patroniting nacb again dae to the free health slstem intrudactior therebjt redacing their curtomert and their proft. Memos: MEMO: ME - t3/06/11 [9] T-y?r, Memo "The health care y.rten is not good again" refert to piuate hoqituh whoy basiner haae been ansettled as a rerult of the fru health poliqt in tbe state P 1 7 : NSIY-| - /-R-IJ-ILU-FC D -F-A-CM-24 Codu: [Conn-perceptJ [Corzn-percept-hf [Conn-percept-treatJ l{o memot 50 lY/e go to piaate clinicfor ddiuery becann of the poor attitudu of the staf in the health cedre and it b not that tberc $af doun't know thejob but-yoa know nmepeople are bom to be k4t ardif cvre b not taken aith tbeir nonchalant attbsd.cs it ma1 caun conplications for tbe people to anJ peffzr that had expeience sach with then will preftr to eai! gou to piaate clinicfor better health care rntices. P 5 t : N S tY-2- / -U-I{-JZN-REP -XX-CM-5 2 Codas: [Conn-percept-treatJ No memot Sone of the people do not accept that itt onll motqnitoet hitet that cauret malaia, thry auribe other tbingt like $ajng too long in the run, na1 be witchcraft and other taboot ahich of cource lzad.t to treatmefi. If yu do notperceiue it has been caased @ enaironment and otherfactor, it afehylr attit/dt to rceking treatruent will of coarce folhw wbat 1oa perceiae as the caute ald tbat * wly naryt of then $ill do not accer thefacilig aaaikble to them beca,,tft of theirperaption of tbe caurcs of malaia P 5 4 : N S lY-2 -2 -U -N -SAN -IDI -F -A-HO -0 9 Codrs: [Conn-percept-treatJ No memot Sone of tbe people go to Traditional Birth Homeq Priuate hotpitak and churcbet bat I dan't kruy wbat ir rerpontible for then going to thote plaas. Itl a perconal dcdtion. Sone of the people $ill come here after going to tberc placu wher thg are rut okay Experience with Health Services Perception and perspecdves are shaped by individual and community experiences. Community perceptions of essential health delivery services therefore, are influenced by people's experiences and encounters with the health delivery system. With regard to the last time respondents needed health services, 26.70/0 tepotted within last 30 day period immediately preceding the interview. Others had needed healthcare between 1 month and less than 1 year (4'1..5o/o); in other wotds, as () many as 68.2%o of the population had needed some form of medical attention withifl the preceding 12 months. This result shows that the need for health is high. Across health district, result shows that rural dwellers (30.4n reported gteater need for healthcare than peri-uban Q2.1oh) and urban Q2.7o/o) dwellers. Table 19 displays results of an assessment of health issues in the study communities distributed by health distticts. Table l9: Atsuwent of Community need of Health Smtices Health Issues Health District Peri-urban Last time flealth was needed In the last 30 days 77 (22.7o/o\ 62 (22.1o/o\ 85 (30.470) 224 (26.70/0) Between 1 month and less than 1 vear 101 (36.10/o\ 131(46.8%\ 717 (41.8o/o 349 (41.5o/o\ Between 1 year and Iess than 2 years 36 (12.1o/o) 27 (9.60/0) 28 (10.0o/o) 91 (10.8o/o) Betweeo 2 years and less than 3 years 17 (6.1%\ 19 (6.80/0) 14 (5.0Yo) 50 (6.00/0) Between 3 vears and less than 4 vears 8 (2.9o/o) 8 (2.9o/o) 7 (2.5o/o) 23 (2.7o/o) More than 4 years 20 (7.1o/o) 22 O.9o/o) 15 (5.4o/o) 57 (6.80/0) Never needed health carc 13 @.60uc) 10 Q.6o/o) 10 (3.90/rD fi Q.9oA Ttrrt 250 000.0%l 51 Number of health facilities available 4 0.50., 0 (0.00/0) 0 (0.070) 4 Q.50/,, 80 (30.0%0) 60 Q2.2n e4 Q4.8n 234 (29.0o4 43 (161n 58 Ql.5o/o) 43 (1s.9n 144 (17.8o4 29 (10.9'A 57 Ql.loA 40 (14.8n 126 (15.6n 16 (6.00c) 24 (8.90i(, 29 (10.7oA 69 (8.60/0) 5 (1.9o/") r0 Q.1n 5 (.en 20 (2.50/(, 2p.1n 0 (0.0%o) 1Q.40i., 3 Q.4019) 2 (0.7'A 0 (0.0%) 1Q.4n 3 Q.4n 0 (0.070) 3 (1.1"/o) 2Q.1n s (0.6%) 0 (0.070) 2Q.70/.) 0 (0.0%o) 2Q.20 .) 0 (0.00/0 3 0100 0 (0.0%0 3 (0.4o/,) 11 0 (0.070) 2 (0.70/C, 0 (0.00/0) 2Q.20/.) 0 (0.0%o) 0 (0.070) 1Q.1n | (02o/o) Don't know 81(3Mn 50 (18.57") 51(18.90/(, 182 (22.60i(D 267 (100.0%) 270 (100.04 270 (100.0%) 807 (100.04 The need for essential health services should be addressed as a priority by health facilities. Results show that rural arid peri-urban communities predictably have fewet health facilities than urban areas. However, ifl general 29o/o of the communities do not have more than t health facility. This Frgure is broken into urban (30.0o/o), peri-urban (22.2o/o), and rural (34.8o/r) sites without adequate facilities. Only 17.8oh 1.5.6oh of all communities had two or three health centres, respectively. ^fld Govemment effots at providing health to the rural population have led to high but nonfunctioning health cenftes in some rural and peri-urban areas where there are reports of 10 and 20 facilities relative to urban communities where the highest number reported was seven. However, in-depth interviews and case study obsewations indicate that migrants in rural areas, especially those who do not speak the same language as the host communities, seldom have facilities located near them. They often spend more on health-related transportation than they do on healthcate itself. Pt 8: NSIV-I -1 -U-F-ACO-IDI-F-A-HO-2 I - 1 8 :/ 5 Codu: [Cap-inpl-difl [Conn-aware-dffi Memos: p'LE - I )/06/l 1 [6]l Those people are not Yoruba (rpeaking pnph) bat thel hear (andcrstand) Englhh, lf thry cone here thq will explain to at in Englith euen if thelt dor't hear English thry will bring another percon that bear (andcrstands) Yoruba, rc that ye wi// expkin to the person and the percon translate to tbem. Memos: MEMOJ bpt Memo These set of non-Yoruba peoph are migrants who dan't $eak the mme langaage tbat boil Lommililiu speak. A sinilar itaation wat discoaered ekewhere, naking it difirult for nigrantt t0 acce$ health care fron hort commuilitier. These comments sig"r& that it may not be enough to have facilities located in communities. They have to be equipped, staffed and maintained. Table 20 displays the distdbution of health condition for which care was needed in their most recent experience. 52 Table 20: Reasons Indiaifuab lag needcd Healtb Care acror Di$ictt Reason Last Needed Care Health District Total Fever 31 (11.60lrD 24 @.9n 26 Q.6n $ 00.00ucD Coueh 10 (3.7oA 15 O.6'A 10 Q,7oA 35 $.3o/o) Vomrtine 5 91.9o/o\ 7 (2.6%\ 4 (1.5'/,) 16 (2.0o/o) Immunization 14 (5.2o/o) 24 (8.e%) 24 (8.9o/o) 62 (7.7o/o) Antenatal consultation 5 (1.9oA 3 01n 4 OSn 12 0.50lrD Family planning 0 (0.070) 1 (0.4o/o) 1 (0.4o/o) 2 (0.2oo 23 (8.60/0) 22 (8.2%) 25 (9.3o/o) 70 (8.7o/o) Dental care 4 (1.5o/o) 1(0.4%) 2 (0.7'/.) 7 (0.9oa 12 (4.5o/o) t3 (4.8"/,\ 10 (3.7o/o\ J5 (4.3o/o) Asthma 6 (2.2'/,\ 2 (0.7'/o\ 2 (0.7o/o\ 10 (1.2o/o\ Heart disease 2 (0.7o/o) 1(0.4%) 1 (0.4o/o\ 4 (0.5o/") Bodily in1ury or pain 31 (11.60/0) 25 (9.3%) 41 (15.2o/o) 97 (12.0o/o) Minor surqery 0 (0.070) 0 (0.0%) 1 (0.4o/o\ 1 (0.1o/o) Sisht problem 2 (0.7o/o) e (3.3%) 12 (4.4o/o) 23 (2.9o/o) Hypertension 4 (1.5o 3 (1.1%\ 5 (1,90/.) 12 (1.50/,) 2 (0.7o/o) 3 (1.1%) 3 (1.1o/o) 8 0.0%o) 47 (17.60/0) 59 Q1.9%) 56 Q0.7o/o) 162 Q0.1o/o) Cough/respiratory problems 1 (0.47o) 3 (1.1%o) 5 (1.97o) 9 (1.170) HIV/AIDS 0 (0.07,) 1 (0.4o/o\ 2 (0.7o/o\ 3 (0.4o/o) Tuberculosis 0 (0.070) 0 (0.0%) 1 (0.4o/o) 1 (0.1o/") Other 44 (16,50/0) 41(15.2%) 25 (930/C) fio 03.60i(, Don't know 12 (4,5o/o) 4 (1.s%\ 4 (1.5o/o) 20 (2.50/q) 267 (100.0oa 269 (100.0n 270 (100.0n 806 (100.0%0) Figure 11 shows the entrance to a structure where PHC service is provided. The photogaph captured it in a state of disrepair and looking semi-abandoned. Figare 11: Efirarce to a PHC Facilig \__ ) 53 Figure 12 shows use of a cardboard for entry of patient information as a mark of inadequate matedals for running the facilities. While this may point to the ingenuity of the personnel, it is not the best u/ay to provide or manage optimal health at the community level. Figare l2: Cardboard Used u a Registration Card P 1 5 : N S W- 1 - t -R-F -LYE -IDI -F -A-HO -3 0 Codct:[Cap-inpl-dffi [Conn-aware-difrJ [Con+onnJ [Con+onn-hfl [Con+onrn-hf-retpJ No memor Sone of the constraints we haue in thh health centre include poor patronage fmm the people equia@ the enlightened ones. Thg are not readl to come becawe there are no batic arnenitiu like toilet to arc ahen the patienfi comaThe enuironmentis uery di@, thereis no secuifii andihpostibleforpeople to $ealfrom the health center the renaining thirugt in tbe hea/th certer eau chi/dren can be rto/en becaure our doors arc spoilt and the nain gate ir bad P47 : N SIV-2 -t -R-N -OV/O -IDI-F -A-HO-08 Codct: [Cap-inpl-dffJ No memos There b nothing encouraging uJ t0 rtal here, there b no lzght, no generator, no toilet and we bauefourpeoph $ajng in a room in the staf quarterc. lYe also haue to take our uacdnu to the general hlQital to keep cool and that is wl4t we haae to cbarge the motherc a tokenfor imrruniqation to rerue at oar transportfare, P5 8 : N SIY-2 -2 -U -N -Ahe-IDI-M-A-HO -5 7 Codu: [Cap-inpl-dffJ ItJo memot lVbere tbe beahh po$ is there and the $af it there, but the facilbiu to do tbe aork are rut tberc, there it not rupportiue superuition and again there h no incefiiue to motiuate hea/th personnel doing the work Figure 13 shows that84.5oh of respondents who sought cor.eat the health faciJitygotit. Across the health districts, respondents in peri-urban (87.5%) and nual (85.7%) communities reported getting health cate. This percentage is higher when compared to the petcentage of urban tespondents who 54 got health carc (80.60/o). Conversely, 1,3.8o/o, 9.2o/o ar,d 10.7o/o of utban, peri-urban and rual respondents respectively, did not receive healthcare. 13: Accex to Caru Did Respondent Get Health Care? 100 90 80 70 50 I Urban 50 r Peri-urban 40 30 r Rural 20 r Total 10 0 Cannot remember We conducted multiple regression analysis to identify the social corelates of healthcate access (fable 27). T\e tesults show that engagement with income generating activity, lsligton and length of stay in the community are determinants factors whether an individual receives health care or not. Individuals with low socio-economic status may not get health care especially when they cannot afford the cost of care. They resort to altematives like the use of ptevious drugs or herbs which they have at home or visit the Pdvate Medicine Vendor. Length of stay ssligion are two "116 elements that could foster communality and belongingness among a people. As stated eadie4 migtant population who most time practice different lsligion and speak different language from their host communities have difficulty in getting health care. This finding opens up a possibility for further research on migtant population and their constaints an access to health care services. Tabh 21: Multiple Re2rettion of Social Factorc InfluercirpAtvess to Healtb Care Unstandardized Standardized Corelations Coefficients Coefficients 55 B Std. Beta T Sig' Zero Partial Part Error order (Constant) -9.789 5.837 -7.677 .094 Sex -r.420 1.543 -.036 -.920 .358 -.046 -.035 .034 Highest level of education -.066 .745 -.077 -.453 .651 -.072 -.077 .017 Income Generating 5.323 2.269 .095 2.346 .019 .055 .088 .087 Activity (IGA)? Marital status 1.860 1.814 .047 1.026 .305 .048 .039 .038 Rehgron? 3.759 1.584 .089 2.373 .018 .095 .089 .088 I*"gth of stay rn -.119 .059 -.081 -2.009 .045 -.048 -.076 Community .015 Ag. .133 .079 .081 1.681 .093 .057 .063 .063 a. Dependent Variable: q4O4last-The last time ... drd you gets health cate Other factors militate against access to c re. A quarter of those who did not get health cate Q5.2oh) said they could not afford the cost of health care, 1,4.0o/o attributed inability to get health care to distance to the health faciJity, 20.6oh said that health provider's drug were inadequate, 8.4% did not get health care because health providers' skills were inadequate. Some tespondents (4.7%) teported that they did not get health care because health workers were not at the facility, while others (2.8n reported that attitudes of health workers were poor. The results show that urban respondents may be facing the challenge of distance to health facitty than those in peri-urban and rural communities as 29.2o/o of them reported this factor relative to none in peri-urban communities and3.1o/o in rural communities, respectively Qable22). Table 22: Reasons for not CettingHealtb Care Reasons fot not getting healtlr Health District Total cate Urban Peri-urban Rural Could not afford the cost of t3 Q7.t%) 8 Q9.6o/A 6 (18.8%) 27 Q5.2'/o) health cate No means of transport I (21%\ 0 (0.0%) 1. (3.1%o) 2 (1..9Yo) Distance to health facility 14 (29.2) 0 (0.0%) 1. (3.1%o\ 1.5 (1.4.0Y,\ The health care provider's drugs 6 (12.s%) 7 Qs.goq 9 (28.10/,) 22 (20.60/0) were inadequate Equipment were inadequate L Q.1%\ 0 (0.0%o) 0 (0.0%") 1(0.9%\ The health ptovider's skills were 1 Q.r%) 4 (1,4.8o/o) 4 (1,2.s%) e @An inadequate Unsatisfactory past experience 1, (2.1%) 0 (0.0%) 1. (3.7%o\ 2 (1..9'/o\ Could not take time off work o (o.o%) 1(3.7%) o 9o.o%) | (0.9%\ Had othet commitrnents | (2.1%\ 0 (0.0%) 0 (0.0%) | (0.9%\ Thought health problem was not I Q.lo/o) 0 (0.07") 0 (0.0olo) | (0.e%) sedous enough Poor attitude of health workers to 1 Q.1'/,) t (3.7%) 1(3.1%) 3 (2.8%) patients No health worker at the facility 0 (0.0%o) o 9o.o%) s (1s.6%) s (4.7%) Other t Q.lYo) 4 (14.8%) 0 (0.0%) s (4.7%) Don't know 7 4.60/"\ 2 fi.4oh\ 4 fi.2.5oh\ 1.3 12.1o/o\ 56 Total 48 (100.0%) 27 (100.0%\ 32 (100.0%\ 107 (1oo.o%) The rural and peri-urban residents sought care more frequently at the government hospital/clinics than urban dwellers. This could be due to the higher number of privately owned facilities in the urban and the pressure of a large urban population on available public tesources, which promotes diversified use. Figure 14 displays this result. Figare 14: Hitngmn SbowingP/acu lYhere Peoph Seek Health Care Placeswhere health care was sought 80 70 60 50 40 I Urban r Peri-urban 30 r Rural 20 5.1 10 *'t __ :sfty* --:--- h -1.80.7 At government At private Faith based hospitaUclinic hospitaUclinic hospital The result on Figures 15 and 16 show that drugs were prescribed, although not in all health centres. More than 80oh of respondents across health districts, claimed that health personnel prescribed drugs for them when they sought health care. A few urban dwellers (7.9%), peri-urban durellets (12.4o/o) and rural dwellers (11,.5o/o) reported that drugs were not prescribed. However, as shown on Figure 6, less than half of respondents to whom drugs were prescribed said that "all of the drugs" were available (a0.0%) genetally. Respondents in urban communities (32.8oh),45.5o/o in peri-urban communities, and 41.9oh in rural communities were able to get all of the drugs prescribed. Figure I 5 : Drug Preuriptior and Auaikbiliry 57 DH H.alth Prrsonn l Pr.!crlb.? 100.096 90.en 80.0[ 70.v/" 60.096 50.0% 40.v/" 30.0/ 20.v/" 10.06 00/ rS tii: IYes Gnnot remember FJ 16: Av ofPrescdbed Auailatrfitv ol Presaibed DrwS across Heahh diskks 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0/6 15.0% 10.0% 5.U 0.0/6 Allofthem SomeofthemNoneofthem Gnnot remember Sirnilarly, other respondents (31.3%o) across all distticts got "some of the drugs", while 22.Ooh dtd not get any of the drugs ptescribed. Utban communities suffered mote from inavailability of drugs (36.9"/0) than peri-urban (14.60/o) and rural (14.1o/o) communities. Pl 7 : NSIV-| -1 -R-N-ILU -FGD-F-A-CM-24 - / 7 35 Codu: [Cornn+xpectJ [Conn+xpu't-nedJ No memot There * no drugs in the centre to cure dffirent ailment or to giae patienfi when rcekt for nedical treatment, although the rurtu there are trying their be$ but tbel lack enougb adcquate *tgs to conpleruent their aork n there * a total need to suppl1 them enough drugt of different nature that cm heal dffirent ailmed n to notiuate people to patronise uerl well Drugs are available more at peri-urban communities than in urban and rural communities. The process and channel of drug distribution needs to be teviewed for adequate distribution of drugs to rural and urban communities. The case study in Sango shows that the Drug Revolving Fund (DRD has helped teduce the burden of nonavailability of drugs in some health centres. Pt 1: NSIY-| -t -R-F-IIE-IDI-M-A-CI-26. Codcs: [Ro/e+onn-oth-act] No memo.r I wat also appointed ar a Percon to be monitoing and inspecting of healtb centre actiaitiw eueil we went to 58 Ado for training I wat appointed to partake ir DRF trainingforfue dals where we lodge at olajora botel in ado Ekiti and thel ako tell u to be going to healtb ceilret rcgularlt to cbeck f tbe bealth perronnel are actaallt doing their work: at tbry rrppote to do it ard if tbere is where thel arv not puforming well. Why People Did Not GetAlI Prescribed Drugs and Altemadve Sources of Medicine Table 23 shows that people did not get all the drugs prescribed because, most of the time, they "could not find all medicine" that was prescribed. In other words, the dnrgs were not available. Actoss the districts, 89.2% of respondents claimed that they could not find drugs prescribed. Only 7.4o/o corld not get drugs because they could not afford it. Medicine shops are the most popular place where drugs which were not found at the health centre were purchased. Urban dwellers use medicine shops (42.4o/o) more than peri-urban (27.Oo/o) and rural (35.0%) dvrellers. Thete ate two reasons for this. First, medicine shops are located very close to the people which make it very easy ,^) for resident to buy prescribed drugs from them. Second, because population of urban settings is mosdy dispersed and there are not enough health ceotres to serve its teeming population, the tendency to tesort to them ir high. Tabh 2i: Reasons for Not GettiryAll Pruribed Drugt and Altervatiue Soarcet Best Reason why People did Health District not get all Prescdbed Dtugs Urban Peri-utban Rural Total Could not affotd the medicine 7 (1,4.e'A 2 Q.4%) 8 (7.8%) 17 (7.4%) Could not find all medicine 38 (8o.e7o) 77 (e3.e%) er (8e.2%) 206 (8e.2%) Did not believe all the 2 $sn o (0.0%) 1(1.0%) 3 (1,.3%) medications wete needed Other 0o/o 3 (3.7%) 2 Q.0%) s Q.2%) Tota/ 47 (100.0u 82 (100.0%) 102 (100%) 231 (100.0%) Alternative sources where drugs ate purchased Patent medicine Not mentioned 132 (e1.7%) 113 (89.7%) 147 (e0.2%) 3e2 (eo.s) Mentioned 12 (8.3%) 13 (10.3%) 16 Q.8n 4t Q.so/o) Total t44 (/00.0%) 126 (100.0%) tfi (100%) 433 (100.0%) Market Not mentioned 132 (e1.7%) 122 (e6.8n 157 (96.3%o) afi Qa.9%o) Mentioned 12 (8.3%) 4 Q.2n 6 (3.7o/o) 22 (5.1o/o) Tota/ 144 (100.0%) 126 (100.0%) 163 (100%) $) 000.0%) Medicine shops Not mentioned 61 (42.4o/o) 34 Q7.0o/o) 57 (35.00/0) 1.52 (35.1%o) Mentioned 83 (57.6%) 92 (73.0o/o) 1,06 (65.00/0) 281. (6a.9%o) Total 144 (100.0%) 126 (100.0w 163 (100%) 433 (/00.0%) Provision shops Not mentioned 118 (81.9%) 723 (97.60/0) 1,60 (98.2o/o) 401 (92.6n Mentioned 2s (17.4n 3 Q.a%o) 3 (,.8n 31].2o/o) Don't know t (0.7%) 0 (0.0ol,) 0 (0ol,) 1(0.2o/o) Total 144 (100.0%) 126 (100.0%) 163 (100%) 4il (100.0%) Cannot femember Not mentioned t42 (98.60/0) 125 (99.2) 16r (98.8o/o) 428 (98.8"/o) Mentioned 2(l.4Yo\ 1(0.8%) 2(l..2To\ 5(l.2oh\ 59 Tota/ 144 000.0%) 126 (100.0%) 1fi (t00%) 43, (/00.0%) Across all districts, the trend is similar except that more urban residents (17.5oh) than peri-utban Q.4n and rural (1.8"/") mentioned that they got their drugs from provision shops. Thus, for utban residents, medicine shops and provision shops are the two dominant places where drugs are purchased, while for rural and ped-urban communities, medicine shops are the ptominent places. As Table 24 shows, many respondents (83.670) reported that they paid for the drugs they got from health centres as against 76.4Yo who said they did not pay. This may imply that only a few segment of the population have access to free health. This segment who got free health c^re are Iikely those seeking matetnal care as most health centres provides free health care services for them. Despite the large numbet of people who paid for their drugs, only 4.4o/o hrd theit money teimbursed compared to 95.6oh who never got reimbursed. Table 24: Cot , Reimhrrsement and Healtb Inrurance Health District Did you pay fot the drugs Utban Peri-utban Rutal Total Yes 110 (84.0olo) 170 (84.2n 178 (82.80 f, 4s8 (83.6%) No 21(16.00/0) 32 (ts.8n 37 (17.2n 90 (16.401(, Total 13t (100.0%) 202 (100.04 215 (100.0%) 548 (100.04 Was the money... Reimbutsed? Yes 10 (8.8olo) 7 (4.0oo 3 (.8n 20 (4.404 No 104 (e1.2n 167 (e6.0%) 167 (98.2o/o) 438 (95.601(, Total 114 (100.0%) 174 (100.0%) 170 (100.0%) 458 (100.0%) Who made the teimbutsement? Employer 3 Q0.0n 2 (28.600 0 (0.070 s (zs.ooa Govemment 0 (0 0%o) 1. (1$n 1(33soq 2 (10.004 Famly members 7 (70.0n 4 (57joq 2 (66.704 13 (6s.0%) Total t 0 (100.0o/o) 7 (100.0%) ) (100.00/,) 20 (100.04 Did you ot family members have health insutance? Yes 6 Q.tn 6 Q.ln 3 Q.fA 15 (1.8o/o) No 234 (83.60r, 247 (88.2%) 22s (80.4%) 706 (84.0%) No idea 40 (1#n 27 (9.600 52 (18.60 (, 1le (14.2%) Total 280 (100.0%) 280 (t00.0a 280 (100.0%) 840 (100.04 Are there othet ways people get subsidies fot health cost? Yes 36 (12.904 4s (16.1%) 60 Q1.4n 141(16.8n No 12s (44.6n 152 (5$oA 120 (42.en 397 (473o1(, No idea 119 (42.5'/0) 83 Q9.600 100 Q5.7oA 302 Q6.0m Total 280 (100.0%) 280 (t00.04 280 (100.0%) 840 (100.04 Othet ways do people get subsidies Community effort 1Q80A 2 (4.4o/,) 2 Q3n s Q.s"a Govemment free health 33 (el.7n 42 (93.3o/o) s3 (\ffin 128 (90.80 (, pfogramme Other 1Q.8n 1(2.8%) 4 Q.8"4 6 (4.3W Don't know 1Q.8n 0 (0.0%) 10.70/., 2 0.401il Total t6 (100. 45 60 141 60 More reimbursements took place at urban (centres 8.87o) than in peri-urban (4%) and rual (1.8%) communities. Sources of reimbursement were family members (65%), employer Q5%) and government (l}oQ. Only 1.8% of the total population had health insurance plans. As many as 84oh did not have such plans and 1.4.2o/o had no what health insutance was. The results indicate that health subsidy is still largely regarded as government business in the suwey communities. It is important to establish local health insurance scheme that will work in patnership with the Community Health Committee (CHC) - a body established and found in most communities to oversee health issues and ptoblems - since many tespondents are either self- employed or unemployed. o COMMUNITY EXPECTATIONS ABOUT RESPONSTVE HEALTH SERVICES The communities expect their govemments to be more involved in the provision of essential health care delivery services at the community level. These expectations mosdy revolve around expansion and upgrading of faciJities. Most health centtes in the urban areas do not have adequate space to operate, because of the population of people accessing health services from such centres. Conversely, in the rural areas, where there is space, there are no facilities or equipment. The availability of cost-effective drugs is anothet leading expectation of rual tesidents given the income profile of most rural residents. There was the stated need also for government to re- t-, introduce community inspection using sanitary officers was emphasized by health personnel. This was viewed as a measure that could curb the practice of neglecting the environment, leaving those who leave on it prone to communicable and infectious diseases. P 2 : N SIY--! -1 -U -F-ILU -FCD -M-Y-CM-54 Cod.a: [Conn+xpectJ No memot L.ct tbe goaernment try at much ar postible to prvuide afuquate equipneil for w t0 ftrue p€zph better. As Jnt/ cat, see the enuimnment h uery bad, look at the butb aruund the place, tbb pkce is aery wall, thry need to expand this pkce so things will be eayfor the peoph that arc working here P 2: NStY--t -t -U-F-ILU-FCD-M-Y-CM-54 Codcs: [Conn+xputJ No memot The expanion of thfu pkce b uery, uerl importart becaase if thel need to do surgery ard other releuant 61 thing the maxet cannot attend to here then thry woald a* then to go to $ate hospital becaute the place is nnduciae then bat instead thel thould nake thefadlifii conpetitiue with the general hotpital and workfor 24 hoars in case of emergeny need.r. P t 0 : N S lV- 1 - 1 -R-F -EIYA -IDI -F -A-CB - 3 8 Coda: [Conn-expect] No memot I will frst requut for the dcuelopment of this nmmuniry in turmt of rccial infra$rurtural arzenitiet (ehcticiu, road, water) this conmani4t had being deueloped u/e! fo communal ffirt, we ba1 trantformer fut oarselues, con$raction of road.t etc. Again i will reque$ for real hotpital and health centre unlike the communi{t clorcd foi beraure the population of the people of tbis commaniry is ouer one million but the hotpital irue is more paranount in our rnind than an1 other thing. P t 3 : N S lY- 1 -/ -R-F -t\E -FGD -M-A-CM4 5 Codcs: [Conn+xpect] [Conrn+xpect+quipJ No memos Pleate what i can sa1 to that b that I will a* the gouernment to prouidc dffirent mediml drugs at afordablepice becaase of the najoriry of people arefarrnert andin sorte caset wherein thel referar t0go andget the drugs elseahere becauv ofit non auaikbiliry in the centre. P / 5 : N S lY- 1 - | -R-F -IYE -IDI -F -A-HO -3 0 Coda: [Conn+xpectJ [Dit-bard-confaaJ No memos The people in th* area are aetl dirry, n the gouerrument thoald train the ranitation oficers and nake tbem d.o theirjob and empower them to gl-frln hoase to hoate to persuadt the ?enph to use the health certer when thry are ick and to enforce the ase of treated mosquito nefi and drfaulters thould be nadc to pajt nmefnel The nonel thould be a token that wi// be afordable @ thepeople so tbat thel wi// not because of that run awal from tbe town P 1 7 : N S lY- 1 -t -R-N -ILU -F CD -F -A-CM-24 Codcs: [Conn+xpectJ [Conn+xpect-rnedJ No memot There * no hagt in the centre to we ffirent ailnefi or to giae patienfi when seektfor medical treatment, ahhough the narses there are trying their but but tbry lack adcquate dragt to coruplement their work n there is a total nead to supp! then enoagh drugs of dffirent natare that can heal diferent ailment n to notiuate peoph to patronise uery well Figure 17: ErpU Drag Store in a Health FaciliE 62 P30: NSIY-2-l-P-F-IPE-FCD-M-Y-CM-03. - )0:32 [wben tbete mosqaitou bin the..J 6616) (Super) Codts: [Conn-expectJ No memot lYhen they morquitou bite the people there will be intwase in nalaia in the sociefl ail wher lor look aroundlou will be reeirg refuw in ruo$ places aronnd the communiry and this can aho haue a drastic ffict on a bealth it tbe commani$, I tbink the be$ thing it to prouifu, the gouernment to prouidt incineratorfor each tovn and a place where thry can be buming all these rcfun and aho gatter, P 1 3 : N S lV- 1 - 1 -R-F -IYE -FCD -M-A-CM4 5 Codcs: [Comm-exped-eqarpJ [Conn+xpect-hrJ No memot The other thirg is that thg thoald inmase the percornel so as to be able to attend to people and nake tbeir job nore eatier, Prvmpt medical dngs tappfi to ease stnx of rcmchingfor drags after prewiptio4 like we that uua@ go to Akiilokfann nmetimu ae mal haae headache, malaia rilal clm€ anltime n yte yafi more *ngs that can be asedfor difereil ailment that h disturbirypeoph,lou krcv ailment b rut ow, a two, atd to zfl, am wn thel klov tbe dragt need.edfor tbev ailmefis that attack mahqfemalet, children and adult so we want more dragt. P t 7 : N S IV- 1 -t -R-N -ILU -FCD -F -A-CM-24 C o fut : [Con n +xpect- k bJ [Conn -expect-n e dJ [Con n +xput-otherJ No memos h naryt occasion wher people comet aroundfor tett, thy can't ffir itfor them and at the vme time when the ickpeople need blood or therc is reed to pax water to their bo@ the health centre cannot prouid.e it then thg will be askirg then to go ail get it at that piaate horpital and this * the nlrv reann wly people will prefer to go that priuate horpital sirce tbgy know thg will get all thry need there. In short, thg thoild prouidcfor u afuqaate eqaipments in thefaciliry so as to handle uaiow med,ical tests. Perception of Government Contributions to Essential Health Service Delivery In Nigeria, govemment is the largest conftibutor to the delivery of essential health services. Through its various agencies, it provides subsidy to the health sector. Over the years, international partners (Global Funds, WHO, APOC, UNICEF, JICA, Canadian and Chinese Governments, DFID, CDC, USAID, PEPFA, GHAIN, UNDP and UNFPA) have collaborated with the govemment to improve the delivery of essential health services in the country. Howevet, govemment's contribution to this sector is still viewed by many as inadequate. The following section deal with the perception of people at various districts on the contributions of govemment to the delivery of essential health services in Ogun and Ekiti states in Southwest Nigeria. 63 Table 25 shows that among the options, ptovision of undet-five immunization (53.1%), provision of health facility (46.70/o), provision of free antenatal care (41..7"h), medicine (13.6W and awareness services were mentioned as areas where govemmeflt contributions are directed. Very few (5.7Yo) reported that provision of essential health services is ftee. This shows that the ptovision of o/o), drugs/medicine (13.6 care for the eldetly (2.6 "/o) and cost recovetT (0.0 %) were scarcely mentioned by respondents. The provision of adequate drugs should be seen as an essential aspect health care delivery. When the centres are left without adequate supply of drugs, patients are not encouraged to paftoniz9 rather to seek alternatives in cheap medicine shops closest to them. In some cases, health personnel employed by the govemment could rum into private consultants to community members when adequate drugs are not found in the centtes. Table 25: Perceptiont of Gouemment Contributions to the Deliaery of Essential Health Servicu Health District Urban Peri-urban Rural Total Facility Not mentroned 174 (62.10i.) 128 (45.70/() ls1(53.904 4s3 ($.en Mentroned 106 (37.9oA 152 (5$oA 129 (46.1'A 387 (461n Total 280 (100.04 280 (100.0u 280 (100.04 840 (100.0a Labour Not mentioned 251(89.60/(, 253 (90.40/0 252 (e0.0n 756 (90.004 Mentioned 29 (10.40i(, 27 (9.6"4 28 (10.00i0 84 (10.070 Total 280 (100.04 280 (100.04 280 (100.04 840 (100.04 Medicine Not mentioned 2s1(8e.6%) 226 (80.70(, 249 (88.90/.) 726 (86.404 Mentioned 29 (10.40 () s4 (1e3n 31(11.10/0 114 (8.6n Total 280 (100.0u 280 (100.04 840 (100.0u 280 (100.0u Training Not menfloned 271(e68n 266 (e5.0n 280 (100.0olo) 817 (9730/C) Mentioned e Q.zn 14 (s.0%) 0 (0.070 n Q.70/.) Total 280 (100.0u 280 (100.0%) 840 (100.04 280 (100.0u Awareness Not mentioned 244 (87.1o4 244 (87 toA 254 (90.70i9) 742(8$n Mentroned 36 (12.904 36 (12.en 26 (9304 98 (11.7o.) Total 280 (100.04 280 000.0u 840 (100.04 280 000.04 Free health services Not mentioned 263 (93.90i(, 269 (96101C, 260 (e2.en 7e2(e$n Mentioned 17 (6.10i0 n Q.en 20 Q1n 48 6.7n Total 280 (100.0%) 280 (100.04 840 (100.04 280 (100.04 Free ante natal cate Not menuoned 174 (62104 167 (se.6n 149 (53.2%) 490 (5$oA Mentioned 106 Q7.9%) 113 (40.4n 131(46.8n 350 (41.7oi9) Total 280 (100.0u 280 (100.0%) 840 (100.0%) 280 (t00.0%) Under five immunization Not menuoned 156 (557o/() 128 (45.1oA 110 (3e3n 3e4 (4o.en Mentroned 124 (4$n 1s2(s$n 170 (60.70/c) 446 ($.1n Total 280 (100.04 280 (100.0u 840 (100.04 280 (100.0u Care for the eldedy Not mentroned 270 (e6.4n 274 (97.9o/(, 277 (98.9yo) 821 (97.7o/(, Mentioned 10 Q.6oA 6 Q.ln 3 (.101., \e Q3n Total 280 (100.0%) 280 (100.0%) 840 (100.04 280 (100.0u cost recovery Not mentioned 280 (100.070) 280 (100.0olo) 840 (100.070) 280 (100.07") Total 280 (100.04 280 (100.0u 840 (100.04 280 (100.0a Other Not mentioned 236 (8$oA 276 (e8.6n 269 (9610/(, 781(e3.0n Mentioned 44 (15.70i(, 40.4n 1,1Q9oA se Q.0n Total 280 (100.0%) 280 (100.0%) 840 (100.0%) 280 (100.0%) Dontt know Not mentioned 2.64 (94 \o/"\ ).70 (96 40/"\ 272 (97.10/"\ 806 99/-00l.\ 64 Mentioned 16 (s.7oA 10 Q.6oA 8 Q.en 34 (4.ooo Total 280 (100.0%) 280 (100.0%) 840 (100.0%) 280 (100.0a Ratings of Govemment Contributions to the Delivery of Essential Health Serwices According to 7o.6oh of the respondents, government contribution to essential healthcare delivery is inadequate (Figue 18). More rural dwellers Q3.9o/) than peri-urban (69.60/o) and wban (68.2%) reported this in a predictable patterfl that follows ovetall govemmeflt investrnent in the three sites. Fip,tre / 8: Ratiryt of Goaemmeat't Contibtiiottt to Heahh. Radngs of Government's Contrlbutlons to the Health of the (J Communfi 80.0% 73.906 70.0% 60.0% so.o% r Adequate 40.o% I lnadequate 30.006 r Oon't know 20.ooa 10.0% o.ooh Peri-urban Total \; Community Expectation of Services Govetnment Should Provide Community expectation on the delivery of essential health services govemment should provide is very high. This is an offshoot of community commitment towatds the delivery of esentail health services. As shall be seen, qualitative data showed that most efforts by the community to make relevant and signiFrcant contdbutions to health servcices are often misconstrue bt govetnment, especially those at the local/rural level. Community activities are viewed by politicians as an attempt by oppositions to derail their government. A such, most communities are expectaing govemment to provide what is currendy lacking in the delivery of esseential health services. Table26 shows that facility Q6.4o/"),labour (39.4o/o), medicine (44.3o/r), free health services (443m, 65 c re for the eldedy (24.8n, and cost recovery (7.5o/o) were the main items mentioned as areas communities woulkd like government to address in addition to the seryices it has been providing. Among all these expectations, provision of drug (44.3o/o), free health care services (44.3oh), and provision of health personnel/labow (39.4'Q rank highest among the list of expectations of comminties towards the government. Table 26: ComnaniU ExPectation on Gouernment't Contribution to Exential Health Care Senticet Health District Utban Peri-utban Rutal Total Facility Not mentoned 186 (66.4%) 204 Q2.9oA 228 (e81.4%) 618 (73.6%) Mentioned e4 (33.6%) 76 Q7.1o/o) s2 (18.6n 222 Q6.4%) Total 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%) Labout Not mentioned t76 (62.en 166 (se.3%) 167 (se.6n s9e (60.6n Mentioned 104 (371n 114 (40.7%) 113 (40.4%) 331Qe.4%) Tota/ 280 (100.0%) 280 (100.04 280 (100.0%) 840 (100.04 Medicine Not mentioned t63 (s8.2%) 161 (s7.soA 144 951.4o4 468 (ss.7%) Mentioned 117 (41.8%) 119 (42.50 (, 136 (48.6n 372 (44.3%) Total 280 (100.0%) 280 (100.0%) 840 (100.0%) 280 (100.0%) Ttaining Not menfloned 246 (87.9o4 2s1(8e.6%) 2ss (e1fa 7s2 (89.soA Mentioned 34 (12.1%) 2e (10.4%) 2s (8.e) 88 (10.s%) Total 280 (100.0%) 280 (100.0a 840 (100.0%) 280 (100.04 Awateness Not mentioned 2s1(8e.6n 2s7 (e1.8%) 274 (e7.en 782 (e3.1n Mentioned 29 (10.4o/o) 23 (8.2'/,) 6 Q.1n 58 (6.eoA Tota/ 280 (100.0%) 280 (100.04 840 000.0%) 280 (100.0u Ftee health seryices Not mentioned 155 (55.4'4 151 (53.9yo) 162 (57.9'A 468 (55.704 Mentioned 12s (44.6n 12e (46.tn 118 (42.1n 372 (4#n Total 280 (100.0%) 280 (100.0%) 840 (100.0%) 280 (100.0%) Free ante natal cate Not mentioned 259 (92.5o/o) 264 (e4.3%) 272 (e7.ln 795 (94.60r, Mentioned 21Q.sn 16 (5.70 f, 8 Q.en 4s F.4n Tota/ 280 (100.0u 280 (100.0%) 840 (100.0a 280 (100.04 Undet five immuniz^tion Not mentioned 266 (95.0oA 275 (98.2oA 272 (97.101r, 8r3 (96.801f, Mentioned M 6.0n 5 (1.80/o) 8ez.e%) 27 (3.20 ., Total 280 (100.0%) 280 (100.0%) 840 (100.0%) 280 (100.0%) Cate fot the eldetly Not mentioned 217 (77.504 211(7s.4%) 204 Q2.9oA 632 ?5.2'A Mentioned $ Qzsn 6e (24.6%) 76 Q7.1n 208 (24.8n Total 280 (100.0%) 280 (100.0%) 840 (100.0%) 280 (100.0u Cost tecovery Not mentioned 2s7 (91.8n 262 (93.604 2s8 (e21n 777 (e2.5n 23 (8.204 18 (6.404 22 (7.9o4 $ Qsn Total 280 (100.0%) 280 (100.04 840 (100.0%) 280 (100.0%) Othet Not mentioned 2s8 (e2.PA 2s6 (e1.4%) 250 989304 764 (e1.0n Meotioned 22Q.en 24 @.6n 30 (10.7n 76 Q.on Total 280 (100.0a 280 (100.0%) 840 (100.0o/o) 280 (100.0%) Don't know Not mentioned 260 (92.904 26t (93.204 160 (ez.e%) 781, (93.0'A Mentioned 20 Q1n 19 (6.8'4 20 (7.f4 5e (7.0n Total 280 (100.0%) 280 (100.0%) 840 (100.0%) 280 (100.0%) 66 (--, 67 READINESS OF COMMUNITIES TO PARTICIPATE IN HEALTH SER\TCE DELIVERY In most communities, there is evidence of readiness to patticipate in health service delivery. Readiness is demonsffably high in most rural communities as they have in place Watd Health Committee or Community Health Committee or Community Development Association which are solely responsible for liaison with health personnel and making joint decisions on health issues affecting the community. In addition, the southwest teritory has a long history of community involvement in traditional self-help projects. The advent of the modern neopattimonial state has been injurious to this aspect of communal voluntadsm as there is the dominant national feeling that the resources of the state ate meant to be distributed and used. This is the principal context of Nigerian politics. Areas of multilateral cooperation should be identified so that the community can be encoutaged to accept tesponsibility, as it has always done, for thos elements of the healthcare delivery system that it lie within its core competence. Communities in the southwest are willing, ready and able to support health projects if that support does not involve recuffent fnancial expenditure. Clearing of weed, maintenance of structure through renovadon, provision of land fot building a centre, and even provision of both land and building structure are among forms of support that community members can make to the delivery of essential healthcare. Most communities are not willing to employ or p^y health personnel. Government insensitivity to community efforts at the local level was implicated by most community members as a discouraging factor for community engagement. Progtess has stalled in places where there were community efforts previously directed at improving essential health care delivery. For instance, a health structure was built to the roof level through community effort, but the govemment failed to complete it. Thtough community mobiliz21i611, a project aimed at providing accommodation for health personnel was stopped by a politically-motivated Council Chairman because he felt it was not appropriate for the community to do so. Thus, politically motivated intentions at the community levels are significant factors discouraging community membets ftom community engagement in tlle provision of essential health care delivery sewices. Factors such as poverty and frequent posting ofhealth personnel are also seen as significant factots that could rmpede community willingness to eflgage in the provision of essential health care delivery services. For instance, a community stopped contribudng money meant for improving the delivery of essential health services when they observed that health personnel, with whom they probably have built and established a system of trust over time were posted away. 68 P 4: NSIYJ -l -P-N-AFA-FCD-F-A-CM48 - 4:22 Codes: [Conn-nad1-difiJ No memos There wu a tine thry informed u abost their needt, tbere wat a tirue when some peoph urc to come around and haae meetitgr with as, but it stryed along tbe lirc. At tbe meeting are wen going to cofiibute N1,000 eacb for the need of the cenhv bat ahng the line, thry stuned po$ing the nanet away So it $opped P 4: NSIY-|-/ -P-N-AFA-FGD-F-A-CM48 - 4:24 [Ye can aho contibrte to deci..J Q3:53) (Super) Coder [Conn-nad1J No memot IYe can aho cofiribute to dccition making in the area of accommodatiot of the health perconnel lYe contibuted monu t0 get a pkce for the Corper Dodor aho thel broryht to th* place, we alto think ve can i) pilt nnnu together to build accommodation to hoase the Corper dactor. The statement expresses the expectation held by communities that government should take the lead role in providing for the delivery of essential health services. It also suggests that communities are ready to play their role by contributing money to meet certain health goals if there is effective collaboration with the govemment. P 2: NSIY--|-t-U-F-ILU-FCD-M-Y-CM-54 - 236) Cod.et: [Conn-nad1J No memos Ma1 be the communi! leadcrc can giue another !ilp?nr't A Sirirq tbem morry to hild anotber facilig because we are aln pan of the gouentnent, the people are the gouerument ro if the goaentrx€fit can giue as j0 raira we car ako add 20 naira. Communi! car participan @ raitingfunhfor then Community Contributions to the Delivery of Essential Health Services The general view of the community is that government's contributions to health is inadequate. For the delivery essential health services to be successful at the community level, community involvement is indispensable. This view is pervasive. Responses that community involvement in health care services is adequate wete higher fot peri-uban Q3.9%) and rural Q21n than for urban 06.1n residents (Figue 19). Conversely,439oh of ruraltesidents,3T.To/o of peri-urbanresidentys, and 40.4oh of urban redisents repotted that community involvement in the delivery of essential health services is inadequate. This shows that community involvement still need to be promoted vigoutously across all districts. 69 Fipare 19: Ratin2s of Comnnnity Contibatiorc to Health Ratintsof Communlry Contributions to the Heahh of Community 50.Oo/o 45.0o/o 4A.Oo/o 35.Ao/o 30.0% t Adequate 25.AoA 20.00a r lnadequate L5.Oo/o I Don't know 10.0% 5.Oo/o 0.0% Urban Peri-urban Rural Total Generally, very few responses featured across key areas where communities are expected to contribute to the delivery of essential health services. Provision of facility (2.9n, selection of volunteers (4.6o/o), taining of volunteers (5%), assist in caring for patients (9.4o/o), and maintenance of facility (93'A were the key areas where communities made their contributions to health. Out of these key areas, assistance in caing fot patient (9.4'O and maintenance of health factltty were the two main areas where community contdbutions were prominent (Ftgure 20). Figure 20: Communiry Contibations to Matemal Healthcare Deliaery Table 27 displays what respondents feel about the nature and purpose of community conftibutions to health care delivery in the study communities. 70 Table 27: Indiuidlal Opinion on Commarity Contibtiions to Healtb Health District Urban Peri-utban Ruml Total Facility Not mentioned 272 (97.1%) 268 (95.7oA 276 998.6"/") 816 (e7.ln Mentioned 8 Q.en 12 (4.3W 4 0.40/., 24 Q.em Total 280 (100.0%) 280 (100.0%) 280 (100.0w 840 (100.0%) Labout Not mentioned 276 998.6n 274 (e7.eW 277 (eg.en 827 (98.5o/o) Mentioned 4 Q.4n 6 Q.1"4 3 Q.ln 13 O.sn Total 280 (100.0u 280 (100.0u 280 (100.0%) 840 (100.04 Health commodities Not mentioned 277 ((eg.en 268 (es.7%) 277 (98.904 822 (e7.e%) Mentioned 3 (.1n 12 (4.3o/o) 3 $.1n 18 Q.ln Total 280 (100.0u 280 (100.0u 280 (100.0u 840 (100.04 Selection of Volunteers Not mentioned 271(e6.8%) 262 (e3.6%) 268 (e5.7%) 801(es.4%) Mentioned e Q.2n 18 (6.4'A t2($oa 3e (4.6W ,) Total 280 (100.0u 280 (100.0a 280 (1qo.ou 840 (100.04 flaining of volunteers Not mentioned 267 (e5.4%) 260 (e2.e%) 271(e6.8%) 7e8 (es.0w Mentioned B $.6n 20 Q.fa e Q.2n 42F.on Total 280 (100.04 280 (100.04 280 (100.04 840 (100.04 Maintenance of facility Not mentioned 261(e3.2%) 241986.1W 260 (92.904 762 (e0.7n Mentioned 19 (6.804 3ee3.en 20 Q.tw 78 psn Total 280 (100.04 280 (100.0w 280 (100.0%) 840 (100.0%) Compensate community volunteerc Not mentioned 276 (98.6'A 279 (99.6'A 277 (eg.en 832 (ee.on Mentioned 4 0.4n 1Q.4n 3 o.1n 8 (1.07") Total 280 (100.0%) 280 (100.0u 280 (100.0%) 840 000.0%) Management of facility Not mentioned 276 (e8.6n 266 (es.on 272 (e7 fA 814 (e6.e%) Mentioned 4 $.4n M Q.on 8 Q.9'A 26 Q.ln Total 280 (100.0u 280 (100.0u 280 (100.0u 840 (100.0a Assist in caring fot patient Not mentioned 24e (88.en 2se (e2.s%) 2s3 (e0.4%) 761 (90.60A Mentioned 31(11.104 21(7.sn 27 Q.6n 7e Q.4W Total 280 (100.0%) 280 (100.04 280 (100.0%) 840 (100.0%) Othet Not mentioned 218 977.goir) 2t4 Q6.4oA 1e8 (70.7%) 630 Q5.on Mentioned 62Q2.1o4 66 Q3.6%) 82 Qe3n 210 Qs.on Total 280 (100.0a 280 (100.0a 280 (100.04 840 (100.0%) Don't know Not mentioned 134 (47.9oA rc7 $9.60A 151 (53.9'/") 452 ($.8n Mentioned 14s (st.8n 13 $0.4n 129 (46.10/0) 387 (46.1n Total 280 (100.0%t 280 (100.0%) 280 (100.0%t 8a0 000.0%t In most rural and peri-urban communities, there are structures meant for promoting community health. The pictures below (Ftgure 21) show some of the ways in which the community get involved in suppoting health cate services at the community level. 71 Figare 2l: Itent Donated bjt the Cornnanifl tofacilitate the Deliuery of Esrential Health Seruicet l The following responses describe community contributions to the delivery of essential health care sewices P 2: NSIY--I-1-U-F-ILU-FGD-M-Y-CM-54 - 2:35 Cod.et: [Conn-rea$tJ No nemot Thank ya some months ago when thry $aned thfu health centre in thh town, the NEPA came and disconnect their ltght, the communifit people in tbis town work or it to reconnect the light, look at tbh gate we learn that the connaniry people are the one that do it. The maternal health structure shown in the picture below (Figure 22) was etected by a community uzith facilitation from a member of the National Youth Service Co1ps. This is aan indication of the survival into th modem en of a resilient communal spirit for self-development that cafl be directed in service of essesntial healthcare delivery at community levels. Figure 22: Cornmaniry Contibution of a Hea/th Faciliry 72 Although more corrununity involvement is required to scale up health services in various distticts, there is need for widespread awareness of all community efforts geared towards health to be created among community members. This will enhance community ownetship and sustainability. Presently, majority of ,the contributions made by the community is decided and implemented by members of Community Health Committee (CHC) or Community Development Associations (CDA{. In most cases, membets of the CHC or CDAs comprise community elders, leaders, ptominent individuals, and CBOs who mobilze funds fot health prcjects. This is why many health- related activities at local levels do not received much publicity, especially in rwal and peri-urban ateas. \7ays Community Can Contribute to Essential Health Delivery According to respondents, the main ways communities can contribute to the maintenance of essential health delivery services are facility maintenance Q3.3o/o), provision of labour/health personnel Q0.0o/o), care for patients (1,6.1%), and support for training of community health volunteers (fable 28). These are the levels and contexts in which govemment should explore opportunities for partnerships that will strength community involvement in these regards. Tabh 28: IYayt Commanitiet Can Contibute to Heahh Ways community could Health District concibute to health Peri-utban Total Facility Not mentioned 226 (80.7o/o) 255 (97.1o/o) 267 (95.4o/o) 748 (89.0o/o) Mentioned 54 (19.3o/o) 25 (8.9o/o) t3 (4.6Yo) e2 (11.0%) Total 280 (100.0%) 280 280 (100.0% 840 n00. Health Not mentioned 242 (86.40/0) 236 (8$oA n6 (8$oA 7M (85.0o/o) Mentioned 38 (13.60/o) 44 (75.7o/o) 44 (15.7%) 126 (15.0o/o) Total 280 (100.0%) 280 (t00.0%) 280 (100.0%) 840 (100.0%) Commodities Not mentioned 247 (88.2o/o) 234 (83.6%,\ 229 (81.8y") 710 (84.5/") Mentioned 33 (11.8o/o) 46 (16.40i(, 51 (18.2%) 130 (1s.5%) Total 280 (100.0%) 280 (t00.0%) 280 (100.0%) 840 (100.0%) Selection of community health volunteets Not mentioned 253 (90.4W 268 (95.7o/o) 257 (91.8%) 778 (92.60/0) Mentioned 27 (9.60/0) 12 (4.3"/o) 23 (8.2'/o) 62 (7.4'/") Total 280 (100.0%) 280 (t00.0%) 280 (100.0%) 840 (100.0%) Support fiaining of community health volunteets Not mentioned 246 (87.9o/o) 244 (87.1%o) 233 (83.2o/o\ 723 (86.1Y") Mentioned 34 (12.1W 36 (12.9'/0) 47 (16.8"/0) 117 (13.9"/0) Total 280 (100.0%) 280 000.0%) 280 (100.0%) 840 (100.0%) Maintenance of health facility Not mentioned 215 (76.80/o) 277 O7.5'/o) 212 (75.7o/o) 644 (76.7%\ Meniorcd 65 (23.2o/o\ 63 (22.5o/o\ 68 (24.3o/o\ 796 Q3.3oh\ 73 280 (100.0%) 280 ft00.0%) 280 ft00.0%) 840 fi00.0%) Compensate community health volunteets Not mentioned 276 (98.6%\ 271(96.8%\ 275 (98.2%\ 822 (97.9"/,\ Mentioned 4 (1.4o/o) 9 (3.2o/o\ 5 (1.87") 18 (2.1o/o) Tota/ 280 (100.0%) 280 (t00.0%) 280 (100.0%) 840 (100.0%) CHC Help Notmetiored 264 (94.3oh) 210 (96.40/o\ 268 (95.7oA 802 (95.5o/o\ Mentioned 16 (5.1o/o) 10 Q.6'/") 12 (4.3"/o) 38 (4.5'/o) Tota/ 280 (100.0%) 280 (100.0%) 280 (100.0%) 840 (100.0%) Assist in carfurg fot patient Not mentioned 246 (87.9o/o) 229 "87.8o/o) 230 (82.1o/o) 705 (83.9%\ Mentioned 34 (12.1o/o) 51 (18.2o/o) 50 (17.9"/,) 135 (16.1%\ Total 280 (100.0%) 280 000.0%) 280 (100.0b 8a0 (t00.0%) Observation and other qualitative data showed that community efforts aimed at improving the delivery of essential health services have been derailed and frustrated by politicians in the past. It is an element of poor govemance that is expressed in the lack of policy option continuity, especially if parq-fifrhated administrations change through regular elections. Figure 23 shows a building that was halted for political reasons. Its construction was an community initiative. According to a community leader: P 7: NSIY-| -1-P-N-IKE-IDI-M-A-CL-50. - 7:4 Codtt: [Conn-rca$t-difi] Itlo ruemos IYe got a land nmetime agl t0 build resid.ential quarterc for the health personnel, n that tbry can work well. In foct we haae sturted noalding the blocks and putting sand there. Then the local gouemnent chairman at that tine and mid that we thould not build tbe ruidcntial qaarterc and that the gouerwment vill baild b. At we tpeak nlw, the quarters haue not been bat, all the blocb and vnd are aafied. Figure 23: Halted Connudg-Directed Building of Health Centre 74 This abandoned project is a soutce of discouagement to community leaders and members who had provided money, time and effort for it. It was stopped by a local govemment Chairman who, according to the community leader, claimed that it was not the responsibility of the community to erect health centres or accorrunodation for health personnel. The health centre in this community is in a state of disrepair and the community has tefused to maintain it because of govemment's attitude. According to another respondent: P5 3 : N SIY-2 -2 -U -N -OTA-IDI-M-A-ST-1 0 - 5 3 : 5 Cofus: [Pat-expedJ No memos Until, when the gouemment lzarns to do their rcrpontibilifl, communi\t efort will nlt be knowr. This view was conftmed by a Medical Officer in Charge of Health: _) Pl 5 : NSIY-I -l -R-F-[YE-IDI-F-A-HO-30 - / 5 :22 C o fus : [Con ru -iruo lue] [Co n m -i nuo lue -ru h] [Conru -readlJ [Coru n -read1-dtfrJ No memot Thry help in dittibrting r€ti, canl out oiertation and contibute nonry before now but tbe commaniry ir not readl to da arythiry again buaute of the attitude of our politidau that enbegh the alhcation that it neaflt to dcuebp the land" Thgt keep uling tbe allorution h not going aroand and this is making the retidrntr of tbe nmmaniry angry. The overall firdirg is that communities are willing and able to make impotant contribution to the maintenance of health but need an enabling policy envitonment that protects that willingness from the vagaries of paty politics and changes in administration. Individual Contributions to Community Health Delivery Some individuals (15%) have made contdbutions to the delivery of essential health care in the community in the past (Fig*. 24). At this level of involvement, the potential of the community for involvement in the delivery of essential health services is not being fully realized. In other words, communities can get more involved in the delivery of essential health services if existing structures established for that purpose ate utilized. 75 24: Indiildaal Contibutions to Heahh Haveyou made contributions to community health ? IYes t No 84.6%0 84.8o/o Urban Peri-urban Rural Among those who mentioned that they had made contributions to healthcare delivery in the community (Iable 29), rhe contributions took the form of support for patient are (24.60/o), maintenance of health faciJity (12.7%), support for training of community health volunteers (11.9 o/o), and selection of community health volunteers (9.5%). The date indicate a need fot training and public support for family-based care providets since that is an area where individual contributions to health is highest (assist in caring for patient). Tabh 29: Indiaidual Contibution arox Health Diticts Ateas of contribution Health District Peri-urban Total Faciliw Not mentioned 43 (100.0%) 47 (700.0o/o\ 42 (100.0o/o\ 126 (100.0%\ Mentioned 0(0.0olo) 0(0.0%) 0(0.0olo) 0(0.0olo) L"b.* Not Mentioned 42 (97.7%\ 47 (700.0'/o) 42 (100.0o/o) 125 (99.2%\ Mentioned 7 (2.3o/o\ 0 (0.07") 0 (0.07") 1 (.87o) Total 4t (100.0%) 41 (t00.0%) 42 (100.0%) 126 (100.0%) Commodities Not Mentioned 43 (100.0%\ 40 (97.6o/o\ 42 (700.0o/o\ 725 (99.2o/o) Mentioned 0 (0.0"/,) 1(2.4%) 0 (0.0"/") 1 (.8"/") S.@ volunteets Not Menfloned 40 03.0%\ 37 00.2o/o\ 37 88.7o/o\ 774 90.5'/o\ Mentioned 3 (7.0Yo\ 4 (9.8o/o\ 5 (11.9o/o) 12 (9.5'/") Total a3 (100.0%) at (100.0% S"pp""t t ."--""tty h..tth volunteets"t"trg "f Not Mentioned 38 (88.4%) 36 (87.7%\ 37 (88.1%) 111 (88.1%) Mentioned 5 fi7.6o/o\ 5 12.2o/o\ 5 /17.9o/o\ 15 ,11.90 \ 76 Total $ (100.0%) 41 000.0%) 42 fl00.0% 126 fl00.0%) Maintenance of health facility Not Mentioned 33 (76.70/o\ 38 (92.7%\ 39 (92.9o/o) 110 (87.3%\ Mentioned l0 (23.3%) 3 0.3"/,\ 3 0.1"/") 16 (12.7%\ Total 43 (100.0%) 41 fi00.0%) 42 fi00.0%) 126 ft00.0%) Compensation of community volunteerc Not Mentioned 43 (100.0%\ 40 (97.60/0) 41 (97.60/0) 124 (98.4m Mentioned 0 (0.07") I (2.4o/o) 1Q.4"6 2 (1.60/0) Total 43 (100.0%) 4t (100.0%) 42 (100.0%) 126 (100.0%) Communitv health committee help Not Mentioned 43 (700.0oh\ 40 (97.60/,\ 42 (7O0.Oo/o\ 725 (99.20/"\ Mentioned 0(0.0olo) 1(2.4old 0(0.0olo) 1(0.8olo) @ Not Mentioned 33 (76.7%) 27 (65.90A 3s $33oA 95 975.4oA Mentioned 10 Q3.3%\ 14 (34.1o/o) 7 (76.70/0) 31 Q4.6yo) Total 43 (100.0%) 4t (100.0%) 42 (100.0%) 126 (100.0%) Othet Not Mentioned 29 (67.4%) 27 (65.90/0) 21 (50.0"/,\ 77 (61.10/0) Mentioned M 42.6%) 14 (341m 21(50.00/() 49 48.9o/o) Total 43 (100.0%) 4t (100.0%) 42 (100.0%) 126 (100.0%) Don't know Not Mentioned 44 (97.8%\ 41 (100.070) 44 (97.8%) 129 (98.5y") Mentioned 7Q.2%o\ 0(0.0o/o\ 7Q.2o/o\ 2(7.5%o\ tVillingness to Contribute to Health in Future Compared to cuffeflt conftibutions of individual to health in the community, willingness to make contributions in the futute is high among wa.L (50o/o), peri-urban (48.8o/o), and urban (44.3o/o) respondents €ig"r. 25). This pattern may reflect realities in which rural communities, who often \-l stand in greatest need of pnmary health cate, are most neglect in govemment planning and distribution of tesources. For this reason, half of the rural population would be willing to make conftibutions to the healthcare system. This could be the proactive result of decades of neglect. In the urban areas, occupational diversity and modemization factors mean increasing institutional responsibility for health care - including the role of the employer in subsidizing health care for workers. This situation is not present in ruml areas and, for this reason, it is impotant for govemment to adopt propoor policies in circumstances of poverty and alienation from the developmental process as can be found in many rural communities. 77 to Contibute to Health in Future lndividual's Willingness to make Contributions in Future 50.o% 47.9% 40.Oo/o I YeS 30.0% INo 20.Oo/o x can't say 10.o% o.o% Peri-urban Total Forms of Future Individual Contribution to Health Care The future forms of individual contributions to the delivery of essential health services are not different from theit present conftibutions as Table 30 shows. This signifres that where improvement is required in these invariant perceptions, thete is need for health education and an advocary campaign that will descdbe to the satisfaction the roles different partnets will play in support health cate delivery. 78 Tabh 30: Indiuidual lYilliunm to Contibute to Health Care Ateas of conribution Health District Utban Peri-utban Rutal Total Facility Not mentioned 119 (93.001r, 1.28 (88.en 129 (93.5oA 376 (91.7oic) Mentioned e ((7.0o/., 16 (11.1n 9 (6.50A 34 @3n Total 128 (100.0%) 144 (100.0%) 138 (100.0%) 410 (t00.04 Labout Not Mentioned 121(e4.sn 136 (94.404 t31(94.9oA 388 (e4.6%) Mentioned 7 F.Sn 8 Q.60.) 7 Qln 22 (5.4oA Total /28 (100.0a 144 (100.0%) 138 (100.0%) 410 (100.0a Commodities Not Mentioned 118 (e2.2%) 128 (88.901(, 118 (85.5olo) 364 (88.8%0) Mentioned n Q.8n 16 (1t.1%) 20 (14.5n 46 (11.2'A Total t28 (100.0a 144 (100.0%) 138 (100.0u 410 (100.0%) Selection of community health vol'nteets ) Not Mentioned 127 (ee.2n 136 (94.404 134 (971o/., 3e7 (e6.8%) Mentioned 1 (0.8%o) 8 Q.6n 4 Q.g',A 13 (3.201., Tota/ 128 (t00.0%) 144 (100.0%) 138 (100.0%) 410 (100.04 Support ttaining of community health volunteets Not Mentioned 113 (88.3olo) 126 (875%) 118 (8s.57o) 357 (87joq Mentioned ls (11.7%) 18 (12.soA 20 (r4.5oa s3 (12.en Total 128 (100.04 144 (100.04 ti8 (100.0%) 410 (100.0%) Maintenance of health facility Not Mentioned 113 (8noA 120 (833oA es (68.8%) 328 (80.0n Mentioned 15 (11.7o4 24 (16.704 43 Q1.2%) 82Q0.0n Total 128 (100.04 144 (100.0%) 138 (100.0%) 410 (100.0%) Compens ation of community volunteerc Not Mentioned 121(e4.sn 142 (98.600 134 (97.1oA 397 (96.804 Mentioned t Q.sn 2 o.4m 4 Q.9"4 13 (3.204 Total 128 (t00.0%) 144 (100.0%) 138 (100.0%) 410 (100.0%) Community health committee help Not Mentioned 127 (99.20/0 142 (98.60 f) 137 (99301., 406 (ee.0n Mentioned 1 (0.8ol0 2 0.404 t Q.7m 4 0.0n Total 128 (100.0u t44 (100.0w t 38 (100.0%) 410 (100.04 Assist in caring fot patients Not Mentioned 103 (80.570) lle (82.6%) 118 (8s.s%) 340 (82.en Mentioned 25 (19.54 2s (17.4W 20 (14.s%) 70 (17.ln Total 128 (100.04 144 (100.0%) 138 (100.04 410 (100.0%) Other Not Mentioned 107 ($.6n 118 879n 116 (8410/(, 341(83.2%) Mentioned 21(16.40/0) 26 (18.f4 22 (ls.en 6e (16.8%) Total 128 (100.0%) 144 (100.0%) t)8 (100.04 410 (100.004 Dontt know Not Mentioned 99 (77 3oA 132 (91.7oA 118 (85.5olo) 34e (8s.r%) Mentioned 29 Q2.7oA 12 (noa 20 (14.sn 61(14.90/0 Total 128 (100.0%) 144 (100.0%) t t8 (t00.0%) 410 (100.0%) Up to 14.5oh of rual residents report that they would like to contribute commodities to the delivery process, compared to 17.7o/o of in peri-urban and 7.8% of urban residents. Similady, 31,.2o/o of rual residents mentioned they would contribute to maintenance of faciJity, compared to 76.70/o and l1.7oh who mentioned so in peri-utban and urban communities respectively. 79 Reasons for No Future Contribution The major reasons some respondents were not willing to contribute to the delivery of essential health services (Iable 31) lie in the perception that this was government's responsibiJity (41.4%). Other reasons include the report that they have no money (1,3.9o/o) or jobs (6.70/r), or that they have have competing obligations (6.40/o). Yet others reported that they could not contributie to health care delivery on account of old age, lack of time, or plainly because they could not work for free. These views strengthen the need for an advocacy campaign because, if people do not feel a connection with the health cate delivery process and do not make any contributions to it, they ate not likely to maintain or sustain it even if support came from elsewhere. Tabh 3/: Reatorc for not Contibuting to Healtb Care Reasons othets are not willing Health District to contribute Utban Peri-utban Rutal Total No iob Not mentioned 13s (e0.0%) 174 (93.504 191(95.5oA 500 (93301., Mentioned 1s (10.0%) 12 (6.sn e $.sn 36 $.7o0 Tota/ 150 (100.04 186 9100.0%) 2oo (1oo.o%) 5)6 (too.oa No money Not mentioned 121(81.2n 1s2 (822n 187 (e3.s%) 460 (86.r%) Mentioned 28 (18.804 33 (t7.8n 13 (6.5Yo) 74 (13.e%) Tota/ 149 (100.0%) 185 9100.04 200 (100.0u 5)4 (/00.0u It is government's tesponsibility Not mentioned 78 (s2.3%) 1t4 (6t.6oA 121 (60.50/0) 313 (58.60(, Mentioned 71 (47.7%) 71Q8.4o6 7e (3e.5%) 221(41.4%) Total /49 (100.0%) /85 9100.0%) 2oo (100.0%) 5t4 (t00.oa I have too many tesponsibilities Not mentoned 140 (94.aYo) 172 (e3.0%) 188 (94.0'A 5oo (93.6"4 Mentioned e $.0"4 13 Q.0n Q $.0n 34 (6.4n Total 149 (t00.0w t 85 9100.0%) 200 (100.0%) 534 (100.0w Othet Not mentioned 14e (100.0n 182 (e84n 1e3 (e65%) s24 (e8.1%) Mentioned 0 (0.0%o) 3 o.6n 7 Q.sn 10 $9oa Tota/ 149 (100.00/0) 185 9100.0%) 200 (100.0%) 5)4 (100.0%) Don't know Not mentioned 148 (ee.3%) 183 (eg.e%) 1e7 (e9.0oa 528 (egfa Mentioned 1Q.7n 2 (l.tYo) 2 $.on s Q.ew Total 149 (100.0%) 185 9100.0%) 200 (100.0%) 534 (100.04 Most of the respondents who thought the responsibility for providing healthcare rested with the govemment were in urban areas (47.7n. This reveals two important elements of community life. First, people in urban areas are often dispersed and lack a sense of solidarity. Th.y do not readily mefilizs themselves for effective community action. Relationships assume the form and quality of an organic solidarity whereby the collective spirit has replaced by individualism. In this environment, community action will be weak and contributions to the delivery of essential health services by the community very low. 80 Views about Health Services Provided to Communities Most respondents (56.87o) tegatded the health services provided in their community as requiring improvement while 16.80/o thought there was need for more conununity involvement (able 32). Tabh )2: Peneptior of Healtb Care Seruicu Pmuided in the Conmanily Health Districts Peri-utban Notmernoned 205 (94.9o/o\ 235 (92.5o/o\ 238 (92.6oh\ 678 (93.3o/o\ 7l (5.70/0\ 19 (7.5o/o\ 19 (7.4) 49 (6.70/o\ 216 000.0%) 254 (100.0%) 257 (100.0%) 727 (100.0%) Need Imptovement Not mentioned 93 @3.70/,\ 109 (42.9%\ 772 (43.60/o) 314 (43.20/d 123 (56.90/0) 145 (57.1%\ 145 (56.4%\ 413 (56.80/0) 216 fi00.0%) 254 (100.0%) 257 (100.0%) 727 (100.0%) Mote community involvement Not mentioned 191 (88.4o/o) 223 (87.8%) 191(74.3%) 605 (83.2oA Mentioned 25 (t1.6o/o\ 31(L2.2%\ 66 (25.7o/o) 122 (1.6.80/0) 216 (100.0%) 254 (100.0%) 257 (100.0%) 727 (100.0%) Support 6aining of community health volunteets Not mentioned 201 (93.7o/o\ 239 (94.1%\ 248 (96.20/0) 688 (94.60/0) 75 6.90/o\ 15 6.90/o\ 9 6.50/o\ 39 6.40/o\ 216 (100.0%) 254 (100.0%) 257 (100.0%) 727 (100.0%) Not mentioned 183 (84.70/0) 240 (94.5%) 249 (96.90/0) 672 (92.4%) Mentioned 33 (15.3o/o\ t4 (5.50/,\ 8 (3.to/o\ 55 (7.60/o\ 216 (100.0%) 254 (100.0%) 257 (100.0%) 727 (100.0%) Don't know Not mentioned 207 (95.4o/o) 249 (98.0%\ 251 (97.7W 707 (97.1o/o) 10 (4.60/0) 5 Q.0"/") 6 (2.3o/o) 2r Q.e) 216 (100.0%) 254 (100.0%) 257 (100.0%) 727 (100.0%) 81 EFFECTTVE COMMUNITY ENGAGEMENT IN HEALTH SERVICE DELIVERY Options recommended for communities involvement in essential health service delivery revolve around the need for govemment to ptovide bettet physical infrastructure and an enabling environment in which its partnership with the communities in the provision of health will be effective and sustainable. The need for expansion and erecting of new buildings was a primary concern for many respondents. Recruitment of personnel was a challenge which community members felt could improve effective community engagement. In particular, medical doctots were in short supply at all levels, a situation that is aggtavated by the medical brain drain. The number of nurses, midwives and health workets was also not adequate. With regard to drug and medicines, they were seldom available and most residents were of the view that the situation needed urgent attention. Many respondents thought community involvement was a significant means of improving the delivery of essential health serwices in the community. But the independent efforts of the communities are sometimes not suppoted by the acdons of government. This discourages further or future effort. Morale is lost. Community members felt that they had a distant government, which was not responsive to their needs. They suggested the need for close collaboration between the govemment and the community. liTithout doubt, this is a serious indictrnent of a democractic system that continually claims that inclusiveness and participatory govemance are among the virtues of cutrent democracy. The need to mobilize the community and engage the Community Ward Health Associations or Community Health Committee in improving the delivery of essential health services was viewed as impetative. This should involve partners and collaborators at the community level for coverage and sustainability as shown in the following responses to the interviews. P 4: NSIV-| -1 -P-N-AFA-FCD-F-A-CM48 - 4:26 Codet: [Pat-expectJ No memot There rhould be a ra@ingpointfor alltbe arociatiot so that when thel want to nobiliry then, it will be aeu eatr to do. lVe haae ro mary attodatiorc in Afao, how manl can thry nobiliqe or inforu at a tirne. l%e need a ralfiingpoint where buming isruet can be ditcared. P 9: NSIV-| -t -P-N-IKE-IDI-M-A-HO47 Codct: [Pat-expectJ I\o memot IVe haue to meet with then and still mntinue to be encouraging theru, b1 letting then rceing the reasou wh1 thel haae to take the healtb yruitvs in tbeir hand.t becaase gouerlment cannot do and euery tine 82 Pt 0: NSIV-| -1 -R-F-EIYII-IDI-F-A-CB-3 8 No memot Proaition of general hlrpital yith nodtn facikry, prouision of enoagh uaccines dning innuilqatiott ?rlgrammq prouition of afuquate eqtipmenfi ir the health fadlig ail inreating of uiitation tine fton once in a month. P2 9 : NSIY-2 -t -P-F-ATA-IDI-M-A-HO-| 1 Cofus: pat-expetJ No memor The communiry tboild be inaolaed in awarener prugram; thry thould go aruttd and tell peoph aboat health progranrues. People likeyu fron IY.H.O thould come regukr! to talk to the people and thfu will etclilrage then that the gouemment liket theru ail it will ercourage theru t0 clrt€, the nirophone ae ase it not for at P 30: NSIY-2 -t -P-F-IPE-FCD-M-Y-CM-0 3 Codtt: [Pat-expectJ No ruemot The avarenex fu not muh fi gnaeflmeflt need,r coutant cvllaboration in a wa1 of hauing rxeetirgt tyith the lead.erc in the ummaill to impruue the health rare nntices. P44 : N S lY-2 -/ -R-N -OIYO -FCD -F -Y-CM-1 5 Codet: [Pat-expectJ No memot yill Thry fuouemnentJ sboild moue clorcr to as ma1 be tf thly ktoa o,.tr mind,r, thry knoa what to do for as. The leadrrc are rot reaSt to dt arytbing thq are rclfsb, there is ru corumailry hadcr that are readl to asi$ P5 ) : NSIV-2 -2 -U -N -OTA-IDI-M-A-ST-1 0 Cofur: [Pat-expetJ ) No memot Until when the gouernment harw to do their respontibilil, rommaniry efut u,ill nnt be knopn. These are shalp statements depicting a feeling of alienation, neglect and abandonment. Although perceptions of health care delivery system are more optirnistic in some quarters, there is an overall consensus that more needs to be done to scale up delivery systems and make them more responsive, user-friendly and sustainable. People's perceptions of health is defined by physical activities and ability to get engaged in rigorous activities. They are influenced by what they see and hear around them; of news about health personnel and sights of dilapidated structues. These form the bedrock of experiences upon which the perception of people are built. For people's perception to be positively influenced, dilapidated structures and lack of equipments across all districts must be address. 83 Observation and results from qualitative data conflrm the finding that inadequate equipment is a major challenge in most of the centres. A few centres do stock and dispense drugs but the reality is that most are short-staffed and facilities are rundown and in a state of decay. In some cases, it was reported that some health personnel go to centres with their personal equipment. Although initiatives from health personnel very good way to motivate self to work, such initiative ^re improvised by using cheap cardboard papet as altemative to registration/clerking card for patients is not the kind of cteativity required to move the health system forward. The Govemment needs to become more involved in the ptovision of vital resources to the health system. In many communities, positive attitudes of health personnel were reported to be responsible for peoples' positive perceptions of the health care system. This was particulady true among the rural poor. It follows that motivated health teams stand a better chance of affecting attitudes and enhancing heaalth performance among ruralites. The results suggest that the influence of traditional doctots is waning as they wete mendoned less as a place where most health problems can be managed. However, the tesults also shows that, while perception is changing in favour of modem health care delivery services, spiritual homes and churches are becoming altemative places where people seek medical care. Therefore, it is impetative for Mission Birth Attendants (as they prefered to be called) to be fulIy integtated into health care delivery system for the health care systems to experience another level of imptovement. Owing to public perceptions of health and health delivery system, peoples' patronage and demand for essential health delivery system tend to differ. Some faith-based organizaions have gowing connection with the health care delivery system. They affect the ideas people have about health, often preferring to treat good health as function of faith and piety. Pruyet houses and Mission houses where Birth Attendants ptovide both spiritual and modern type of cate to clients are common. This shows a need for greater health education for community members as well as increased compteoce among health staff since peoples' petceptions of health are still shaped by metaphysical constructs that lie beyond the puwiew of science. The study identifies prospects and practices of discrimination in access to health services by migant populations, especially in rural communities. V4dle the spread of mote facilities and personnel is good, a population of rural migtants, especially those who do not speak the language of the host community, are depdved of health services. They cover long distances to obtain services and the cost of transportation is usually highet than the cost of health. The need to incoqporate this underseryed population into the health care system cannot be overemphasized. Furthermore, this opens up a possibiJity for frrrther research on migrant population and their constraints an access to health care services. 84 85 SUMMARY AND CONCLUSION People's perceptions of essential health delivery service is changing but remains under the influence of dominant paradigms of the cultural environment. While mote people are now using modem healthcare facilities, the proportion of users of spiritualist and prayer houses appears also to be on the increase. This shows that the perceptions of how a disease comes about influences health- seeking behaviour and may be implicated in its consequences. In othelwords, aetiology is occasionally subsumed by the population within the public discoutse of metaphysics. Experiences documented at all levels show high levels of dissatisfaction with the delivery of essential health services. There is the persistent view that the provision of these services is the responsibility of government but this could be a reflection of the alienation rural tespondents feel from the delivery process and the lack of anarticulated partnership between govenrment and society. This accounts for health petsonnel shortages, inadequate drugs and poor inftastructure used for the delivery of essential health care services. Owing to these experiences, perceptions of the health cate services and the delivery of essential health cate are poor. Communities are willing and ready to participate in the delivery of essential health care services at all levels. Areas of participation include the ptovision of land, maintenance of health cefltres, supply of provision of accommodation to staff, and the establishment of Community Health Committees. These Committees are potential vehicles for enhancing the quality of essential health service delivery at community levels. They have initiated and implemented health projects for their communities but goverflment is not sufficiendy leveraging this potential. It is as thought community and govetnment were working at cross-purposes, nith the community in one instance setting up a structure for health services and the local adminstration discouraging the effot. Willingness and readiness of community to participate could also be hindered by poverty or lack of finances at the community level. Communities could initiate building project thtough community self help initiatives but they are not likely to accept tesponsbility of a fiscal kind - payment of salaries, allowances, or rent on accommodation to health petsonnel. Basic communal poverty makes these unlikely categories of community participation. In all the sites of our investigation, it was abundandy clear that opportunity exists to further change the perceptions of community members and, thereby, improve the delivery of essential health services. It is imperative to develop the political will necessary to do this and bring policy making and community wilingness into greater rapprochement. Advocacy with governmeflt should lead it to the recognition that it has to take the lead in this venture. Community involvement is more likely to proceed from changed governmental perceptions of the minimum standards acceptable as outcomes of its health cate delivery system. 86 RECOMMENDATIONS On the bases of the empfuical results of this investigation, the following ate the tecommendations of this study Since perceptions and perspectives ate influenced by what the people see, hear and experienced,it is imperative to upgrade Primary Health Care facilities (through adequate staffing stocking of dtugs, and inftastuctural improvement) in order to create a positive perception by what the people see. In addition, an awareness campaign should be intensified at the community level to sensitize people to the need not only to use these services but also to participate in theit ptovision. 2. Because perceptions of health are shaped by a pervasive cultural envionment, it is important for Mission Birth Attendants (as they preferred to be called) to be integrated into health care delivery systems especially with regard to maternal health. 3. Sanitary ofFrcers should be re-introduced to scale up and maintain the sanitary conditions of communities. 4. Thete should be offrcial focus on the systematic discrimination against migmnt populations who do not have equal access to health services as indigenous populations especially in the rural areas. 5. The study shows that communities are capable of tremendous health-related initiative (including the construction of a health facility but ate discouraged by fluctuations in the political environment. It is necessary to &aw up statutory toles of govemment and communities in the healthcare delivery process to safeguatd from these political vagaries. 6. Although more community involvement is requked to scale up health services in various districts, there is need for widespread awareness that communities are at the centre of their healthcare delivery system. This awareness needs to be shared by all partners. 7. According to respondents, the main ways communities can contribute to the maintenance of essential health delivery services ate facility maintenance Q3.3"/"), provision of labour/health personnel Q0.0Yr), carc for patients (1.6.10/0), and support for training of community health volunteers. These ate the levels and contexts in which government should explore opporrunities for partnerships that will strength community involvement. 8. The overall finding is that communides are willing and able to make impotant contribution to the maintenance of health but need an enabling policy envitonment that protects that willingness from the vagaries of party politics and changes in administration. Government should create that enabling envitonment. 9. Among those who mentioned that they had made contributions to healthcate delivery in the community, the conftibutions took the form of support for patient care (24.6oh), maintenance of health facility (12.7o/o), support for training of community health volunteers (11.9 o/o), and selection of community health volunteers (9.5%). These data indicate a need for training and public support for family-based care providers since that is an area where individual contributions to health is highest (assist in caring fot patient). 87 10. Compared to current contributions of individual to health in the community, willingness to make contributions in the future is high among rural (50%), peri-urban (48.8%), and urban (44.3"/0) respondents. This pattern may reflect realities in which rural communities, who often stand in gteatest need of primary health cate, are most neglected in govemment planning and distribution of resources. The absence of modemization and social mobility in rural areas makes it important for government to adopt propoor policies that safegtrard health even in the midst of povety and alienation. 11.. The future forms of individual contributions to the delivery of essential health services ate not different from theit ptesent contributions. This signifies that whete improvement is required in these invariant petceptions, thete is need for health education and an advocary campaign that will descdbe to the satisfaction of all the roles different partners will ptay in support of health care delivery. 1,2. Many respondents thought community involvement was a significant means of improving the delivery of essential health services in the community. But the independent efforts of the communities are sometimes not supported by the actions of govemment and this could be discouraging. It is impottant for pa.ttners to forge close collaboradon benveen the government and the community in the design, planning, execudon, monitoring and evaluation ofhealth care delivery in all districts. 1,3. Observation and results from qualitative data conFtrms the finding that inadequate eqr'ipment is a major challenge in most of the centres. A few centres do stock and dispense drugs adequately but most are short-staffed and facilities are rundonw and in a state of decline. It is imetative to strengthen health services by providing needed suport in these areas without which the delivery of essential health services would stagnate and fail. t4. Owing to public perceptions of health and health delivery system, peoples' patronage and demand for essential health delivery system tend to differ across religion. There is need for greater health education for community members as well as increased competeflce among health staff since peoples' petceptions of health are still shaped by metaphysical ideas that lie beyond the purview of science. 15. The study identifies prospects and ptactices of discrimination in access to health services by migtant populations, especially in rural communities. While the spread of mote facilities and personnel is good, a population of rural migtants, especially those who do not speak the language of the host community, are deprived of health services. They cover long distances to obtain services and the cost of ffansportation is usually higher than the cost of health. There is need to incorporate this underserved population into the health care management and delivery system. 88 References African Union, Africa Health Strategy 2007 -2015 (CAMH/MINS(111), Addis Ababa,2006 Bhutta, Z.A.,S. Ali, S. Cousens, T.M. AIi, B.A. Haider, A. Rizvi, et aL 2008. Alma-Ata: Rebirth and Revision 6: Interventions to Addtess Maternal, Newborn, and Child Suwival; What Difference Can Integrated Primary Health Care Strategies Make? Lancet 2008 September, 73;372 Q6a2):972-89. Gyotkos, T.W., S.A. Joseph, and M. Casapia. 2009. Progess Towards the Mllennium Development Goals in a Community of Exueme Poverty: Local vs. National Disparities in Peru. Trupitnl Medicine and Intemational Healtb 2009 June, 1,a$):6a5-52. Lawn JE et.al. 2008. Alma-Ata: Rebirth and Revision 2 - Supporting the Delivery of Cost Effective Interventions in Primary Health Care Systems in Low-Income and Middle-Income Counfties: An Overview of Systemic Reviews. Lancet 2008 372 Q6a2):928-39. Lawn, J.E., J. Rohde, S. Rifkin, M. Were, V.K. Paul, and M. Chopra. 2008. Alma-Ata: Rebirth and !/ Revision 1-Alma-Ata 30 Years On: revolutiotatry, relevant, and Time to Revitalize. Lancet 2008 September, 13; 372 p6a):917-27. Lewin, S.J.N. Lavis, A.D. Oxman, G. Bastias, M. Chopra, A. Ciapponi, et a1.2008. AIma-Ata: Rebirth and Revision 2- Supporting the Delivery of Cost-effective Interventions in Primary Health- Care Systems in Low-Income and Middle-Income Countries: An Overview of Systematic Reviews. l-ancet 2008 September, 13;372 Q6a2):928-39. Rohde,J. S. Cousens, M. Chopta, V. Tangchatoensathien, R. Black, Z.A. Bhutta, et aI. 2008. AIma- Ata: Rebirth and Revision 4-30 Years After Alma-Ata: Has Pri*rry Health-Care Worked in Countries? Lannt 2008 Septembet, 73; 372 p6a2): 950-61. Rosato, M. G. Laverack, L.H. Gtabman, P. Tripathn N. Nair, C. Mwansambo, et al. 2008.Alma- Ata: Rebfuth and Revision 5 - Community Participation: Lessons from Matemal, Newbom and Child Health. l-annt 2008 September, 1.3;372 Q6a2): 962-71.. World Health Organization.2006. Health Financing: A Strategy for the African Region (AFR/RCS 6 / 10), Brazzavr[e, 200 6 World Health Organtzaion 2008. Prinary Heahh Care (I'low Morv Tbm Euer). 2008. World Health Organization 2008. Ouagadougou Declaration on PHC and Health Systems in Africa: Achieving Better Health for Africa in the New Millennium $7orld Health Orgaruzaion.200S.Implementation Framework for Scaling up Essential Health Interventions in the Context of MDGs Q007-201,5) draft,BrazzaviTle, ReSfonal office for Africa,2008 World Health Orgaruzation Resolution EB124.R8: Pri-rry Health Care, Including Health Systems Strengthening World Hedth Organizaion 2008. The World Health Report 2008- Primary Health Cate (I.Iow More Than Ever), 2008. World Health Organization.2009. Framework for the Implementation of the Ouagadougou Declamtion on PHC and Health Systems in Africa: Achieving Better Health for Africa in the New Millennium, 2009. 89 ANNEXE,S Annex 1: Survey instrument (draft) INTERVIEW SCHEDULE FOR HOUSEHOLD HEADS Ouestionnaire No. Household ID No. Time Interview Started: llour: Minute: Time Interview Ended: Hour: Minute: - - Location Information Country Code COUNTRY Region/State Code I I REGION/Province / STATE District Code I I DISTRICT/LGI/#T; Community Code I I Is this urban/rural/peri-urban? l=Urban [ ]; 2=Peri-urban [ ]; 3=Rural [ ] krn Distance of community to the health _ centfe l=Near[ | 2=Fatl LANGUAGE T-ANGUAGE OIT QUESTIONNAIRE: I,ANGUAGE OF INTERVIEIY MOTHER TONGUE OF RESPONDENT \Y/AC A TD ANTqT AT..-rp ITqFT-\) /\.T.'a=1 Nlf) SUPERVISOR FIELD EDITOR OFFICEEDITOR KEYED BY NAMF, NAME 90 *Verbal Consent Form for flousehold Survey Good momingf aftenoonf evening. My name is (Interviewer) I am here on behalf of a research team f We are part of a research pro;ect conducted by ...... (name of research institution) and-supported by the Ministry of Health and the Wodd Health Organization m 72 Afican countries to find out about the opinion of people regarding health and health care. Our Ministry of Health is supporting the study. Your Health Drstrict/LGA has been chosen to be part of this study. We hope that the results of this research wrll be usefrrl for improving health care in the community. Your household has been selected and we would hke to speak to the head of the household or hrs/her representabve. I would hke to ask you some questions if I may, but you can refuse to answer any question I ask. You may end the rnterview at any time. You can also refuse to parucipate m the study entrely. This mtervrew will last approximately 3 0-45 minutes. The rnformauon we collect from you wrll not be shown to anyone outside of thrs pro;ect. Your rdentty ull not be drsclosed to anyone. Ifyou have any question about this study, you can contact the pnncipal rnvestigator: Tel: May I proceed with the interview? Yes [ ] No [ ]) Thank the respondent and leave. Name of Interviewee Date Name of Interviewer Date 91 Section 1: Socio-demographic Information First, I would Lke to ask you some questions about yourself and your household Instruction: circle appropriate options) Head of Household could be assisted by any household member 101 Record sex ofrespondent as observed Male 1 102 How old are you? AGE IN COMPLETED YEARS 103 Have you ever attended school? (Formal and Yes 1. informal) No... 2 )105 104 What is the hrghest level of education you Formal education have attamed? D;-.-, n1 Secondary 02 Higher ...... 03 Vocatronal..... 04 Religious/ non-formal education Islamrc/Koranrcschool...... Other 97 (Specfy) 105 Are you engaged in any Income Generatrng Yes 1. Actrvrty (IGA)? No 2 )107 106 What do you do to eam a living? Farming/hunting/frshing...... 01 Petty trading... 02 Paid employment/salaled..... 03 Artisans...... 04 Rrrsiness Oi Other 97 (Specify) 107. What is your mafltal status now? Single...... 1 Marned/rn union...... 2 Widowed...... J Di-^..",.1 4 Separated 5 1 08. What is your reLgron? ah;cn.- n1 02 ...... 03 (Specify) 1.1o 1gligion.... 04 other 97 (SpeciS) 109. For how long have you Iived m th$ Record actual number (in years) community? - 92 SECTION 2: AWARENESS AND KNOWLEDGE OF HEALTH ISSUES Now I would like to ask you some questions about what you know of health issues in this community. 94 SECTION 3: PERCEPTION OF HEALTH Now I would like to ask you some questions about what you think about health in tlus commututy 95 In the last 30 days, how much difficulty did you have with: Nozr MildModerate Seaen ...... Extreme a) Work o trl pl pl t4l ...... t51 b) Aches and parns q rrl pl pl t41...... ts1 .) Moving around 4 trl t2l pl t41...... pl d) Vigorous activities (e.g. runrung) d) trl t2l pl t41...... t5l .) Selfcare(e.g.washing/bathrng) 4 tll t2l pl [4] t5l f) Concentrating/rememberingthmgs J) trl t2l pl [4] . ....t51 g) Leaming new task/things 9 rrl pl pl t41...... tsl h) Personalrelatronship h) rrl pl H t4l .. tsl i) Parucrpauon rn community acnlrues 4 tll t2l pl t41...... ttl j) Dealing with confucts/tension wrth others ) tll t2l pl t4l ...... t51 k) Seeing and recogmzing people/oblect or reading k) tll t2l pl t4l t5l l) Sleeping and wakrng up 0 trl pl t3l t4l ...... t51 m) Sadness and depression n) [1] t2l pl t4l ...... t51 .r) Anxrety and worryrng pl ...... t51 o trl t2l t41...... l--) When people have any of these problems, where do they go for solutions? No wherc HospitalTraditioul Spmual DK E Aches and parns 4 tll t2l pl t4l...... teE b) Moving around b) tll t2l pl t41...... tesl c) Vrgorous acuvrties (e.g. runrung) d tll t2l pl t4l ...... te81 d) Selfcare (e.g.washing/bathing) d) tll t2l t3l [4] ...... [e8] e) Concentratrng/remembenngttungs 4 trl pl pl t41...... te81 f) I-earning new task/things fl trl pl t)l [4] .. tesl g) Personalrelatronship 9 ttl t2l t1l t41...... teE h) Participation in community activrties a ttl t2l t3l t4l ...... te81 i) Dealing with conflicts/tension wrth , tll t2l H t4l ...te8l others j) Seeing and recognizing people/obiect or j) trl t2l pl t4l. tesl readrng k) Sleeping and walong up k) trl t2l pl t4l...... teE l) Sadness and depression 0 tll t2l pl t4l...... te81 m) Anxiety and worrpng ,") [r] t2l pl t41.,...... te8l In your opinion, where are problems hke these better managed No when HoEitalTraditional Spiitul DK a) Aches and pains 4 ttl t2l pl [4] .... teE b) Moving around b) tll pl ttl [4]. . ..[e8] c) Vrgorous activiues (e.g. running) d tll t2l pl t4l. [e8] d) Self care (e.g. washrng/bathing) d) tll t2l pl t4l. tesl E Concentrating/remembenngthings 4 trl t2l t3l [4]. [e8] f) I-earning new task/tlungs f) ttl t2l pl t4l ...... te81 d Personalrelationship c) trl t2l pl t4l. ..te8l h) Participauon rn communiry activiues a tll t2l pl t41...... te81 r) Dealing with conflicts/tension with i) trl t2l pl t4l...... te81 others i) Seerng and recogmzrng people/object or i tll t2l pl t4l . ... teE readmg k) Sleeping and waking up k) tll t2l pl t4l ...... teE l) Sadness and deptessron q trl t2l pl [4].... [e8] m) Anxrety and worrpng .) [r] t2l t7l [4]. . [e8] 96 Section 4: EXPERIENCE lnTH HEALTH SERVICES Now I would like to ask you some questions about what has been your experience wrth the health servrce in this community. 97 405 Which reason best explains why you or any Could not afford the cost ofhealth care... 01 member of you household drd not get No means of transport...... 02 health care the last time vou needed hea.lth Distance to health fr.,Ir,y.....: . :...... 03 care? Could not afford cost of transport 04 The health care provrder's drugs were tnadequate05 [Circle only one (1) option] Equipment were inadequate... 06 The health provider's skills were inadequate...... 07 Unsatrsfactory past experience 08 Could not take time off work 09 Had other commlEnents...... 10 Drd not know where to go... .. 11 Thought health problem was not serious enoughl2 Tned but was denied health care 13 Poor attitude of health to paflents '14 No health worker at the facfity 15 OTHER 97 (SPECrFY) DONTKNOW...... 98 406 The last time you or any member of your No where.. 01 hnrrcehnld needed health care rwhere rwas tt At home...... 02 sought from? At government ho.prtul/.[rrr..:...... 03 At pnvate hospital/Clinic 04 Farth based hospital...... 05 [Circle only one (1) option] At traditional healer's place ...... 06 At a spiritual home. 07 OTHER 97 (SPECIF9 Cannot remember...... 98 407 The last time vou or anv member of vour n1 L^"".L^l.l .^"-ht h..lth .",. AiA th. h.alth N o) c^- Cannot remember.... 98 health problem? Af +L- rl"^r f^. ll n1 408 --Ii-i--.- "'------..^;I..-,{ ^fd"^- )411 -.-hp. ^f -^,,. h^,,€Fh^t.] h Snme nf them Oi many were available from the health NT^-^ ^frL-- n( facrhties? Cannot remember...... 98 [Circle only one (1) option] 409 Which reason best explains why you or any Could not afford the medicrnes...... 01 member of your household drd not get all Could not find dl the medrcrnes...... 02 the medicines orescribed? Drd not beheve all the medications were needed 03 Started to feel better...... 04 [Circle only one (1) option] Already had some of the medicines at home 05 OTHER 97 (SPECrF9 Cannot remember...... 98 \Y/L^-^ ,{r,l r,^rr ear d.- 410 --,1.-r-^" -,hr-h Mobil patent medrcine vendor 01 or any member of your household could n,) not get from the health facrLty? Medicine shops ...... 03 Provision shops...... 04 OTHER 97 (SPECItr! Cannot remember.. 98 411 Drd you pay for the drugs you or any h^,,eFh^I..I rpfFl,,FA f"^n -.-h.. ^€ -^,,, )s01 the health facilities in the communtty? 412 Was the money, which you or any member Yes ...... , ...... 01 of your household paid for medicine No ...... 02 )s01 reimbursed) 98 !t 99 Section 5: PERCEPTION OF HEALTH SERVICES/SYSTEMS Now, I would like to ask you some questions about what you think or feel about the health service in your commututy? How would you rate the services the health facility Good provides in your communtty? uncertaln 02 Bad Which reason best explains your rating of health Attitude of the staff to chents is poor...... 01 care service in your community? Inadequate drugs and equlpment...... 02 Very responsive to clients' needs...... 03 Adequate drugs and equipment...... 04 Friendly environment...... 05 [Circle only one (1) option] Clean environment...... 06 Delays in provision of health care ...... 07 Absence of health workers from the faci1ity...... 09 Referral practices in the facility OTHER ) How would you rate the way health care in your Good communitv involves vou in decrdins what services Uncertarn rt provrdes and where rt provides them? Bad In general, what is your feeling with the way health Satis6ed care is provided by govemment in your Uncertarn 02 community? Dissatrsfied What can be done to improve the way health care Provide medrcrnes/drugs 01 services are delivered m youl communlty? Involve commututy in the management 02 Provide personnel 03 [Multiple answers allowed] Construct hospital 04 Reduce cost ofsernces 05 Probe [Ask any other?] Select community members to 06 help in delivery ofhealth services 07 Reduce outpatient waiung trme 08 Provide the equipment 09 Replace retired personnel 10 Provide free health care to the poor 11 OTHER-97 (SPECIFY) Don't know.... 98 100 SECTION 6: PERCEPTION OF CONTRIBUTIONS OF GOYERNMENTAND THE COMMUNITY TO THE DELTYERY OF ESSENTIAL HEALTH SERVICES Now, I would like to ask you some questions about what you think or feel should be government contribution to health service in your community. In your opioion, what are government's Provision of health facihty 01 contributions to the health of people in the Provision of health personnel/labour 02 community? Provision of health commodrties 03 Trarning of commututy health volunteers [Multiple answers allowed] Creation of health awareness of prevention 05 Providing free medrcal care for children Probe [Ask any other?] Providing free medical care for mothers Providing free medical care for the elderly 08 Providing free medical care for all 09 Maintenance of health facfity Comoensation of communitv volunteers 1,1 Cost recovery 12 Free services 13 97 (SPECIFY) DON'rKNO\y...... 98 What is your rating of the contnbutrons of adequate 01 government to the health of the Uncertain 03 community? Inadequate 04 In your opiflon, what should be the actual Provrsron ofhealth facility 01 contributions of government to the health Provrsion ofhealth personnel/labour 02 of the commuruty? Provision of health commodities 03 Trairung of commuruty health volunteers 04 [Multiple answers allowed] Creatron ofhealth awareness on prevention 05 Providing free medical care for children 06 Probe [Ask any other?] Providing free medical care for mothers 07 Providing free medical care for the elderly 08 Providing free medical care for all 09 Maintenance of health facility 10 Compensation of community volunteers 1.1 OTHER- 97 (SPECTFY) DONT KNOIY. 98 In your opinion, what are contributions of Provision ofhealth facility 01 your commuilty to the health of people in Provisron ofhealth personnel/labour 02 the community? Provision of health commodiues 03 Selection of community health volunteers 04 [Multiple answers allowed] Support training of commuruty health volunteers 05 Creation of health awareness on prevention Probe [Ask any other?] Provrding free medical care for children 07 Providing free medical care for mothers 08 Providing free medical care for the elderly Providing free medical care for all Maintenance of health facfuty Compensatron of community volunteers Community health committees help with management of the health service OTHER What is your raung of the contributions of Adequate 01 your community to the health of the Uncertain 02 commuruty? Inadequate 101 In your opinion, what should be the actual Provision of health facility 01 contributions of your community to the Provision of health personnel/labour 02 health of the community? Provrsion of health commodiues 03 Training of commuruty health volunteers 04 [Multiple answers allowed] Creation of health awareness on prevention 05 Providing free medrcal care for children 06 Probe [Ask any other?] Providing free medrcal care for mothers 07 Providing free medrcal care for the elderly 08 Providrng free medical care for all 09 Maintenance of health facfuty 10 Compensation of commuruty volunteers 11 OTHER- 97 $PEAFY) DONTKNOW.. 98 As an indrvrdual, have you made any Yes 01 contflbuuons to the health of your No 02 community m the past one year? What contnbutions did you make to the Provision of health facility 01 health of your community m the last one Provision of health personnel/labour 02 year? Provrsron of health commodiues 03 Support training of commuruty health volunteers 04 [Multiple answers allowed] Creation ofhealth awareness 05 Providing free medrcal care for children 06 Probe [Ask any other?l Providing free medical cxe for mothers 07 Providrng free medical care for the eldedy 08 Providrng free medical care for all 09 Marntenance of health facfuty 10 Compensation of community volunteers 11 OTHER- 97 (SPECTFY) DON',T KNOW...... 98 Why did you not make any contributions Poverty 01 to the health care servlce of your It rs not my responsrbilrty 02 commumty in the last one year Government should cater for the people 03 I was no asked to make any contribution 04 [Multiple answers allowed] Everything rs available m the community 05 It belongs the NGOs Probe [Ask any other?] It belongs 16 lsligious orgamzations It belongs to private rndividuals (SPECIFY) DON'TKNOW...... 98 Are you willing to make contributions to Yes 01 the health of your community rn the No 02 future? Cannot say 98 What can you conftlbute to the health of Support the provision of health facrhry your community? Support the provision of health personnel/labour Support the provision of health commodliles [Multiple answers allowed] Support trarning of community health volunteers Creaflon of health awareness Probe [Ask any other?l Provrdrng free medical care fot chrldreo Providing free medrcal care for mothers Providing free medical care for the eldedy Providing free medical care for all Maintenance of health facfuty 10 Compensation of community volunteers 11 OTHER- 97 (SPECIFY) 102 Why are you not willing to contribute I have no job 01 anythng to the health service? I have no money 02 It is the responsrbility of government 03 [Multiple answers allowed] I have too much responstbilitres 04 OTHER- 97 Probe [Ask any other?l (SPECIFY) DON',T KNOW...... 98 Section 7: HEALTH SYSTEM GOALSAND SOCIAL CAPITAL Now, I would like to ask you some questons about what you think are the goals of the health care servrce and how the mimstry of health/government relates with people in your commuilty. How much say do the following categories of Circle only one (1) option for each category people have in gettrng govemment to address issues of interest to them in this commuruty? a) Children Unlimited A lot Some Little None b) Youth a) Ill 121 I3I 4l I5l .) Adults b) I1l l2l I3I 4l IsI d) The eldedy .) tll l2l I3l 4l tsl E Men d) tll 121 t3l 4I I5I f) Women .) H 121 I3l 4l Isl d The educated 0 I1t tzt I3l 4I I5I h) The uneducated d I1l l2l I3I 4t Isl r) Traditionahst h) I1l l2l I3l 4l tsl i) Politicians 1) IU l2l I3l 4l I5l k) Civil Sewants D t1l l2l I3l 4] I5I l) Students k) tlt t2l I3l 4l l5l m) The unemployed r) tll I2l I3l 4l l5I n) CBO m) tU I2l I3l 4l t5l o) Religious groups ., IU l2l l3l p) Community leaders o) Ill Vl l3l How often do you trust the government to do Always 01 what is right? Some of the time 02 Never 03 How much rishts do vou have ln settins the Unlimited govemment to address health issues that interest Some say you? No say at all How free do vou thrnk vou are to exDress Completely 01 yourself on health matters conceming your Moderately free 02 community without fear of government reprisal? Not free at all 03 TI.IANKTHE RESPONDENT 103 Annex 2: Focus Group Discussion Guide APPROPRIATE GREETINGS PRESENTATION OF THE TEAM W'e ate working within a project conducted by ... in cooperation with ..... and .... Your community has been chosen among the ones in the country for this project. We are hold discussions with you on issues related to the delivery of essential health services in your community, yout experiences of health ser',rices, your relation with health seryices providers, involvement on the implementation of health interventions, major concerns about health and health Programmes and how to address them. Your participation to the discussion is very valuable if you are willing to be involved. All information will be used without mentioning your names and held in confidence within the research team and amoflg its collaborators. We seek your conseflt to record the discussion so that we could capture all the ideas expressed. We expect this discussion to last for no more than 60 minutes. INTRODUCTIONS. Country: Type of Group:. Length of Discussion: ..Date: ... Moderator: ..Note-taker: FOCUS GROUP DISCUSSION GUIDE COMMUNITY PERCEPTIONS OF HEALTH 1.. IBREAK ICE]. When you say somebody is "healthy", what do you normally have in mind? PROBE FOR ELEMENTS OR ASPECTS OF HEALTH. ASK: How can you recognize a "healthy person"? 2. Please describe what people in this community regard as the most important elements of health/health serrices. PROBE FOR SATISFACTION S7ITH ESSENTIAL HEALTH SERVICES. 3. If somebody fell i[, what does he/she do/where does he/she go for treatment? PROBE FOR USE OR NON-USE OF DIFFERENT OPPORTUNITIES INCLUDING TRADITIONAL ME,DICINE, AND HEALTH FACILITIES. 104 4. From what you have seen or heatd, or possibly experienced yourself, pPlease describe how people feel about the way the health wotkers treat members of this community when they visit the health facility. Please explain further. COMMUNITIY EXPERIENCES OF DELTYERY OF ESSENTIAL HEALTH CARE 5. Can you now describe how health services help to meet the needs of members of this community? Please tell me more. How do people typically describe their satisfaction with health services? PROBE FOR EQUITY. COMMUNITY PARTICIPATION 6. Please discuss whether membets of IMENTION NAME OF COMMUNITY] are ready to cooperate with the Officer-in-Charge and othet health workers to make health available to \, ../ members of the community. Please explain further. PROBE FOR HOW COMMUNITY CAN PARTICIPATE AND CONSTRAINTS AGAINST ITS DOING SO. 7. Let us talk some more about ways in which the community is involved to ensure health programs in this community work. IPROBE FOR INVOL\IEMENT OF AGE GROUPS, !7OMEN,S GROUPS, CBOs, TRADITIONAL LEADERS, HEADS OF HOUSEHOLDS AND SO ONl. PROBE ALSO FOR THE TNVOLVEMENT OF THE IDENTIFIED GROUPS IN: \Tillingness to participate; decision making/programme implementation; involvement in policy development; ownership of policies; financing and assessing performance; and other forms of participation indicated by discussion gtoup COMMUNITY EXPECTATIONS 8. If you were to suggest improvements to the health services what would you suggest? PROBE FOR: HUMAN RESOURCES. MEDICAL EQUIPMENT. MEDICINES, LABORATORY SERVICES, AND POSSIBLE MECHANISMS. [REITERATE OR HIGHLIGHT MAJOR DISCUSSIONS. THANK PARTICIPANTS FOR THEIR TIME. CLOSE APPROPRIATELY]. 105 RECOMMENDATION The Group (4) proposes 6 FGDs per region. These FGDs should be distributed across the urban, peri-urban or rural districts of each region and organtzed for adult male adults (2), female adults (2), adolescent males (1), and adolescent females (1). 106 Annex 3 Indepth Interview Guides The in-depth interview method vdll be utilized to gather information fiom key informants in the study communities. The multiplicity of tools being used for this study, it is critical for IDIs to be limited to respondents who are knowledgeable on the issues being addressed. The table below presents the distribution of the KII respondents. Ptoposed Distribution and Numbet of IDIs pet Country Category Unit Total DHMT/Regional 1 per district 06 cBo/NGO/FBO 1 per site 06 Community leaders 1 per site t2 Frontline health providers 1 per facility (in-charge) t2 Volunteers/CHW/CDDs 1 per site t2 Total 48 Gendet balance in selection of respondents Data collection Research assistants should be trained to become conversant with the data collection tool should collect the data. It is impotant to note that the IDI guide will be used as just that - a guide. It should not be seen as a questionnaire (this point should be emphasized during training). Data will be tape-recorded (if the materials are available). The collected data will be transcribed, coded and processed using Adas Ti. 107 IN-DEPTH INTERVIEW GUIDE REGIONAL AND DISTR]CT COORDINATORS HEALTH MANAGEMENT TEAM Study Site: Region: Country: Date of the interyiew: Name of the intetviewen Name of respondent: Position/title in community/otganization: Introduction Good morning/afternoon. My name is...... I am here on behalf of the Ministry of Health. We are conducting a study on health issues in this district/local government authority. The information we are collecting will help the ministry to plan better and implement disease prevention and control activities in this area. You have been selected to participate in this interview because we feel your views are important. I therefore, kindly request you to share your honest views on the issues we will be discussing. Your participation in this interr.iew is voiuntary and you are free not to respond to any questions you feel uncomfortable with and this will not affect you in any way. I would like, however, to assure you that the information you provide shall be kept confidential and will only be used for the purposes of this study. This interview will last approximately 45 to 60 minutes. ) Do you have any question or colrunent before we proceed? Interrriewer (f aryt questionf corument, please frst addrus them before proceeding with the interuiew). I also wish to kindly request you to allow me tape-record this interview so that I can capture everything we discuss. Interniewer: In case, the retpondtnts refuses t@e -recording da not use the t@e but proceed aith the interuiew and arrite dawn as much as you cail. 108 NATIONAL, REGIONAL AND DISTRICT COORDINATORSHEALTH MANAGEMENT TEAM ''":"ffi:,::1:Tl,..::x3i;iT:1*"#l'jffi ,-gion/dis,ric,?$,ha,are,he main factors for the mentioned diseases? (Probe on the causes for the various diseases) 'Who are the most affected? 2. Interventions/progtannmes in place r What health prograrnmes ate in place nationally or in the region/district? ' V/hat is the role of the government in addressing these programmes? Is the government responsive to the needs of the people? (Probe on investments in health) Who are yout main partners in health care delivery nationally, in the region/district? e', \' '. 3. Community awareness of health problems W.hat is your view about the community's use of the services available to them? What opportunities exist? What are the difficulties? How is the DHMT /LGA/offrce engaged in mobilizing communities to engage in health care delivery activities? How is health information communicated to communities in this country/ region/ dis trict? What is the relationship between the health providers and community members? 4. Community participation in health service delivery r In what ways are communities involved in health service delivery? o Mobilization and sensitization o Govetnance (decision-maki"g) o Planning (the extent to which the communities views / needs have been taken into account or driven the agenda - probe for concrete examples) o Implementation (service provision) I o Financing and other forms of contribution o Monitoring and evaluation r How are community views channelled to influence or as a response to policies? How is feedback on policies channelled to community members? r How is the community organized? (Probe on whether the community is organized in committees, groups, etc). How is the community voice reptesented at the district, regional and national levels? ! \W'hat types of health financing are accessible to people in this country/region/district? @tobe on community-based insurance, vouchet schemes, waivers). 5. Readiness of community to participate in health care delivery 'What r is the willingness of communities in this to get involved in health seryice delivery? ^te r V/hat training and support activities are in place for enhancing community participation? r What challenges do communities encountet in their involvement in health service delivery? r What is your view regarding the ability of the progtammes to meet the 109 community members' expectations ? 6. How can communities be effectively involved? . \W"hat do you consider key aspects for effective health care delivery at the community Ievel? r What are some of the successful community progtammes in this area? ) 110 LEADERS OF CBO/NGO/FBO AT DIFFERENT LEVELS "i"ffi f !ilt#*:ffi :fr :.','r,::r:a;xuffi::gtng.rsupp.r,ing in this community? Whom are you targeting? How do you reach them? ' i"#:' :"LT #ftx.iJl,;ffi{Hil l:ll..,-; :ffiTx:ni,y (in,e,. sectoral)? . What type of support are the partners providing? ' How does your organtzadotinvolve community membets in health service delivery? How has the communiry responded to your efforts? ( ., 3. C.ommunity awareness of health ptoblems 'lization What is your view regarding the community's u of the available health seryices in place? What are the constmints/challenges facing the community members in terms of utilizing the services? W.hat opportunities exist? How is health information communicated to communities in this country/ region/ dis trict? What is your view regarding the relationship between the health providers and community members? 4. Community participation in health service delivery r How are communities involved in hedth serr.ice delivery? o Governance (decision-mrki"g) o Planning (the extent to which the communities views / needs have been taken into account or driven the agenda - ptobe for conctete examples) o Implementation (service provision) o Monitoring and evaluation o Financing o Mobilization and sensitization r FIow are community views channelled to influence or as a response to health policies? How is feedback on policies channelled to community members? t What is your view about the current level of community participation? t How are the community membets organized in terms of participation in health service delivery? Probe whether they are organized in committees, groups, etc or participate individually and in what ways? r What types of health frnancing are accessible to people in this community? @robe on community-based insurance, voucher schemes, waivers). 5. Readiness (willingness and ability/capacity) of the communities to engage in health service delivery . How willing and ready are the people in this atea to get involved in health service delivery? VThat are the indications? ' What capacity building activities arefhave been implemented for community members to enhance their participation in health activities? 111 r What challenges do community members encounter in their involvement in health service delivery? 6. Engagement of the communities in essential health service delivery r What do you consider key aspects for effective health care delivery at the community level? r W.hat are some of the successful community programmes in this area? (Probe for examples). 112 FRONTLINE HEALTH FACILITY PERSONNEL 1. Disease butden in the region/distrtct/ atea r What are the most common diseases in this area? t Who are the most affected? What factors are responsible fot the disease burden in this area? 2. Intenrentions/ptogtarnmes in place r lVhat health prograrnmes are in this community? r What is the role of the government in the implementation of these programmes? (Is the government responsive to your needs?) r W.hich organrzaions are involved in health care activities in this community? !7hat is your view regarding the effectiveness of these programmes to meet the needs? (.' ') PeoPle's 3. Role of health district in the provision of essential healthcare r What is the role of the district health management team (LGA) in the provision of health care in this area? (Probe on delivery of materials, supervision, reporting, etc) r What challenges do you face in your interaction with the district level? 4. Community awareness of health problems r What is your view of the community's use of the services in place? W.hat opportunities exist? lUhat are the difficulties? r How are the people in this community encouraged to take part in health service delivery? How does yout facility support these activities? r How does your community get information on health? @robe on media, community meetings, etc). r What is your view regarding the community's attitude towatds the services you provide? .l 5. Community participation in health service delivery . How are communities involved in health service delivery? o Mobilization and sensitization o Governance (decision-m^ki"g) o Planning (the extend to which the communities have been involved - probe for examples) o Implementation (service provision) o Financing o Monitoring and evaluation r How are community views channelled to influence or as a response to policies? How is feedback on policies channelled to community members? r How are the commuoity members' organized to participate in health service delivery? @robe whether they ate orgatized in committees, groups, etc). ! What challenges do you encounter in support the community's participation in health care delivery? r \7hat is your view about the level of community participation? r What types of health financing are accessible to people in this community? @robe on 113 .o*rnity-based insurance, voucher schemes, waivers). . 6. Readiness (willingness and abihty / capacity) of the communities to engage in health service delivery r How willing and ready are the people in this community to get involved in health serv"ice delivery? Please, give some examples. ! V/hat uaining has been undertaken for community members to increase their participation in health activities? r V4eat difficulties do people face in their participation in health care activities in this community? 7. How can communities be effectively involved? r V4eat do you consider important in enabling people to participate in health care activities at the community level? r V4rat are some of the successful commuruty prograrnmes in this area? (Ptobe for examples). 114 COMMUNITY HEALTH WORKERS (VOLUNTEERS, CDDS, ETC) 1. Role in the community r What health activities are you engaged in? What other activities are you engaged in? I How long have you been a volunteer/CDD/CFl$fs in this area? r How were you selected to be a volunteer/CDD/CHw? !7hat is your view on this selection process? r How are volunteers/CDDs/CHWs in this atea organized? (Ptobe on whether they ate in gtoups, etc) r What motivates you to keep doing this work? @robe on community support). r Are you receiving any financial or other remunetadon? If yes, please speci$,. t How do you relate with the health workers at the dispensary/health post/health centre? @robe on referrals, superrrision, supplies, tepotting, etc). 2. Capacity to implement health delivery intesentions L) r What training activities have you and other volunteers/CDDs/CHWs received? What were you trained on? !7hat is your view about this training? r lVhat is the relationship berween volunteers/CDDs/CHWs in this community? r What difficulties do you encounter in your work? 3. Community awareness of health problems I What is your view of the community's use of the services in place? W.hat oppottunities exist? What are the constraints? t How are the people in this community encouraged to take part in health service delivery? . How does your community get information on health? @tobe on media, community meetings, etc). 4. Community participation in health service delivery r How are communities involved in health service delivery? o Govetnance (decision-making) o Planning (the extend to which the communities have been involved - ptobe for examples) o Implementation (service provision) o Monitoring and evaluation o Financing o Mobilization and sensitization ! How are community views channelled to influence or as a response to policies? How is feedback on policies channelled to community members? ! How are your community members' organized to paticipate in health service delivery? Probe whether they are organized in committees, groups, etc r $7hat is your view about the level of community participation? r What types of health financing are accessible to people in this community? (Probe on community-based insurance, voucher schemes, waivers). 5. Readiness (willingness and abihty/capaciry) of the communities to engage in health service delivery I How willing and ready are the people in this community to get involved in health service delivery? Please, give some examples. 115 r !7hat training has been undertaken fot community members to increase their participation in health activities? r What difficulties do people face in their participation in health care activities in this community? 6. How can communities be effectively involved? r What do you consider important in enabling people to participate in health care activities at the community level? r What are some of the successful community progralnmes in this area? (Probe fot examples). 116 COMMUNITY LEADERS 1' Role #::;#:ilT ,*, community? (probe on his/her role in heatth service delivery - hold meetings, select volunteers, serve on committees, support to volunteers, etc) ! How does yout community motivate community volunteers? ' How long have you been a leader in this area? What do people do when they are sick? (Probe on what options are avaiiable to people who need health care 2. Interventions/progtammes in place r W'hat are the main health concerns in this area? r W.hat health progralnmes are in this community that addtess these concerns? How are these interventions responding to the needs of the people in this area? ; Which organizaions are involved in health care provision in this community? (Probe ( _, on the availability of alternative health providers - TBA, herbalists, etc). 3. Community awateness of health problems \7hat is your view of the community's utilization of the serr.ices in place? What opportunities exist? What are the difficulties? How are the people in this community encouraged to take part in health service delivery? How does your cofirmunity get information on health? (Probe on media, community meetings, etc). How do you see the relationship benveen the health providets and the community members? 4. Community participation in health service delivery r How is your community involved in health service delivery? o Mobilization and sensitizalon o Governance (decision-muki"g) o Planning (the extend to which the communities have been involved - probe for examples) o Implementation(serviceprovision) o Financing o Monitoring and evaluation r How are community views channelled to influence or as a response to policies? How is feedback on policies channelled to community members? ! How are your community members' organized to participate in health service delivery? Probe whether they are otgantzed in committees, groups, etc r W'hat is your view about the level of community participation? r What types of health financing are accessible to people in this community? @robe on community-based insurance, voucher schemes, waivers). 5. Readiness (willingness and ability/capacity) of the communities to engage in health service delivery r How willing and ready are the people in this community to get involved in health service delivery? Please, give some examples. ! W'hat training has been undertaken for community members to increase theit participation in health activities? 'U7hat r difficulties do people face in their participation in health care activities in this community? 117 6. How can communities be effectively involved? r What do you considet important in enabling people to participate in health care activities at the community level? r What are some of the successful community programmes in this area? 118 Annex 4: Guidelines for Case Study Reseatch on District-Level Delivery of Essential Health Care Methodological Guidelines fot Case Study Research3 on Essential Health Care at Health District Level in Africa 1. Inttoduction Case studies on district-based delivery of essential health care will allow to describe ard analyze in detail and in depth the multiple dimensions of the interface and interactions between communities and the essential health cafe system (including service structures, health personnel and the health administration, information system and insurance mechanisms). t- . Within this multi-country study on community perspectives of health systems in Africa, the f -) case (i.e., contemporary phenomenon) under investigation, arrd area of interest, is the implementation of essential health c re at health district level. Comparative case studies carried out in selected health districts are expected to provide an in-depth understanding of the specific experience with essentiql health care and related community-health service partnerships and the social and technical (dys)functioning of essential health services in time and in the context of regional and state-level health planning. The case studlt is expected to be corducled b1 a tean of a traircd rnior social sciertist (sociologist/ anthropologist urith extensiae expeierce in qualitatiue public health research, ?rrrt*bb PI or Co-PI) and a public health expert.. t A case study is an empirical inquiry that investigates a contemporary phenomenon within its real-life context, especially when the boundaries between the phenomenon and its context are not evident (cf Yin, RK. Case Study Research: Design and Methods. Thousand Oaks, London, New Delhi: Sage Publications 1994. Case study research is appropriate for answering "how" and "why" questions about complex phenomena, questions that need to be answered through a contextual analysis of the phenomenon over time. 119 2.Key questions and data sources Research questions Data sources 1. What are the key public health challenges rn Intenriew with District Medical Officer and the district, e.9., maior public health other public health officials conditions, burden of disease? District Health Reports (unpublished and published) over time Sen ice registers 120 2. How are essential health services Interview with District Medical Officer and organized? other public health officials How do communities perceive access to and the quality of these services? Informal exit interviews with patients How are communities involved in the development of policies and strategies? District Health Reports (unpublished and Are there specific measures for situations of published) over time health insecurity (epidemics, pregnancy) Interviews with community members of co- management committees Administrative and planning documents (' Organigram(s) Structured observations Elements to be included in observational checklist (to be established): 1. AvailabiJity of policy/strategy document 2. Elements of PHC policy strategy 3. Elements of PHC policy strategy implemented Organigram 4. Extemal stakeholders 5. NGOs/CBOs 6. Physical structures (Size, status) 7. Number of health care visits and ho spitalisations by structue 8. Human tesorrces (typ..) by structure 9. Post descriptions 10. Equpment 1 1. Supply and procutement 12. Budget 13. Financing 14. Oversight and stewardship 15. Patient referral and seruces (including paueflt transport, ffansfer and evacuation 16. Social protection including solidarity mechanisms (incl insurance), modes of payment 17. Costs of services and medrcines 121 3. lUhat are the resources (financial, human, Interview with District Medical Officer and other) that are mobilized for essential health other public health officials care? Informal unstructured interviews with k.y 3a. W.hat ^te the potential community community informants fesources for and contributions to the delivery of essential health care? District Health Reports (unpublished and published) over time Administrative documents (budgets and financial reports) Observations 4. V4rat are the different types of intetaction Non participant unstructured observations between different stakeholders (patients, health personnel, administrators, community- based groups, management committees etc)? In formal uns tructured interviews 4a. How are the interactions influenced by people's perceptions of health and health serrices and cultural belief and value systems (including religious beliefs and practices) 3. Methods for data collection A multiple-method approach to data collection will be employed. Data sources may include some or all of the following categories. a. Document review Collect key documents and publications telated to the health district Strategy document(s) Planning documents Minutes of meetings 122 Health service registers Human resources: Numbers by types and distribution Budgets and financial reports b. Archival research Historical analyses c. Open-ended or focused G.y infotmant) interviews District Medical Officer "PHC" Cootdinator Essential health care related key personnel, e.g., health staff at Frondine Health Facilities Selected health staff with longterm work experience in the health district Representatives of CBOs or NGOs with experience in partnering vrith the PHC system lr\--l d. observations S tructured, non-participant Unstructured, non-participant 4. Principles of data collection Principle /.' Use and triangulate multiple sources of evidence A major strength of case study data collection is the opportunity to use many different sources of evidence, e.g., triangulation: tationaie for using multiple sources of evidence Pinciph 2: Crcate a case study data base Field diaryl Notes Photos Film t) Documents Tables Narratives Pinciple -7: Maintain a chain of evidence Allow an external observer to follow derivation from initial research question to ultimate conclusion - and back (court) 5. Data entry Textual data will be entered into Adas Ti, a Qualitative Data Analysis software package. Documents to be collected as W'otd documents ot scanned as pdf fi.les Field notes Interview transcripts or notes 123 6.Data analysis and structure of the case study report Data will be coded according to the categories below and results reported accordingly. Case study research is expected to resultin a short monograph of approximat+ 10 pages (1.5 spaced) covering the following standard sections 1. Basic description of the health district Includes information on the geographical situation, population covered, number and types of health structures and serrices, catchment areas and majot public health problems 2. Organrsation of essential health cate in the district Historf, strategy, organization, governance, financing, human resource situation, and activities carried out. 3. Resource mobilization for essential health care Financial and human tesources mobilized for the delivery of essential health care district ^t level 4. Interactions of different stakeholders in the PHC system Patterns of social interactions between various stakeholders in the essential health care system (including patients and their support networks, health providers, community members etc) 5. Conclusions 6. References 124 Annex 5: Translations ili. Afikun 13.1. Afikunl: ohun idiwon ETO IFORO WANILENT]WO AWON OLORI EBI Nomba Iwe abinilere Nomba idale mo Akoko ibere: wakati: _iseju: _ Akoko : wakati: _ iseju: _ lt Ibi Isoro Ohun ti a fi da orileede ]I ORILE EDE Region/ Ena fun Ipinle I I REGION/Province/IPINLE District Code I I DISTRICT/IJOBA IBILE/Zone Ena fun llu TLU4 Nie ilu nla/igbeiko/Igberiko ti o ti n di l=Ilu nla I l; 2=Igberiko ti o tin di ilu nla[ ]; 3= igberiko[ ] ilu nla? Jijina ilu si ile iwosan 5 -km 1=O sun mo ra[ ] 2=o jina[ EDE EDE TIYE,ABINILERE,: EDE TI A FI IYANI LENU WO F,DF, ARINTRT OT,I IDAHI }N---- SF F T a) a)T I T(IRI TFa)) /RFFNT= 1 RF'F I(O=?\ ,l ALABOJUTO OLLIYEWE\yO ORI PAPA OLUYE\?EWO PELU IFOWOSI NILEISE ORUKO ORUKO + ILU: Awon eniyan ti won gbe ni agbegbe ti o ni adari kan,ti won ni anfani si awon alumoni kan naa, tiwon n lo ni opolopo igba. lru awon eniyan yi le yato ni orile ede kan si omiran bi igberiko, abule,sagodabule, ileto, awon tin lo kakiri, ati awon ti n se atipo. s A o pin awon ilu si isori ti o jina (awon ti o ju ibuso marun) awon ti o sun mo (awon ti ko to ibuso marun) si ile iwosan Uoba ibile. 125 . IwE srsoMPE Mo cBA fun ayewo ile E karo/osan/ale. Oruko mt m (olu beere) Mo wa lati soiu awon oluwadi lati A wa lara awon tr n se rwadr ...... (oruko ile ise oluwadi) tr olu de lse ilera att ajo rlera agbaye nse ni ile adulawo meiila lau mo ero okan awon eniyan nipa rlera ati eto ilera. Olu ile ise ilera ni ode ede yi lowo sL A ti yan ijoba rbile yr lati kopa.A gbagbo wipe ibaiade rwadi yr yio uTrlo fun agbehinde eto ,lera ru ilu yr. A u mu ile ym a si ma fe lati ba olori ile yi soro tabr asoju won. Mo fe lati bere awon ibeere kan ti e ba gba, sugbon e le ko latr dahun ibeere mi , e le da saa yr duro nigbakugba. E le ko lati kopa. Iforowandenuwo yt rna, to iseiu ogbon sl marun dm ni aadota. Oro ti e ba so fun wa a ko ru je ki elomran n yato si awon oluwadr. Ko st ent ti 1'ro mo bi e ti ie. Ti e ba ni ibeere lori iwadi yi, e lo n adari igbrmo oluwadr: oruko- ru Nomba ero ibanisoro Nie mo le te siwa;u ninu iforowanilenuwo yr? Beeni [ ] Beeko [ ]) E se fun idahun o dabo. Oruko oludahun oio Oruko olubeere oio I 126 IPINI: IMO NIPAARAENI Ni rsaiu"rno fe bere ibeere die nipa yin ati ile yin. Itonisona: Fi ami roboto si ey u o to Awon ara ile le ran olori ile lowo 101 Se akosile Isakosabo oludahun bi o ti ri t02 Kini o;o ori re? Koo dun ti o pe kehin 103 Nie o lo ile iwe n? (fr asa oyinbo ati tibile) Rppni 1 )105 104 Bawo ni oti kawe to? Ti asa oyinbo Al.L^h.,. n1 Girama 02 Ile eko giga ...... 03 Ile ikose owo...... 04 f-' Telesi/Tibile Ile kewu...... 05 Omiran- 97 (So pato) 105 N1e iwo nse ise tin mo wo wole? Beeni... ^l Beeko.. 2 )107 110. Kini rse ti ohunse ;ehun? Agbe / olode / apeja/Olohun osin...... 01 Onisowo kekeke...... 02 Onise osu 03 Onise owo...... 04 onis^s,^ o( Omiran 97 (So pato) 111 Ipo rloko laya re rusinsiyr? 1 2 3 A tr yara wa...... 5 Omiran (so pato)- !, 112. Kini esrn re? Onigbagbo.... 01 M,,-,I,,-i o) Adayeba.... 03 97 Emi ko lesrn. Omiran 97 (So pato) 113. Nrgbawo'{/o nl o ti n gbe rlu yi? So pato (ni odun) 127 r IPIN2: IMOATI OYE NIPAOHUNTI O NISE PELU ILERA Mo fe latr beere nipa ohun tr o ru se pelu dera ni ilu yi. 129 IPIN 3: Akiyesi re nipa ilera mo fe bere ohun u o lero nipa ilera ni ilu 130 Kini o lero wipe o ie apeere igbe aye Nigba n nlm ko ni mm ilpa ilera pipe? Okun lati sise [O le mu iu okan lo] Ririn kaakiri Ise agbara( apere ere s$a ) Te si waju [Bere omiran?] Itofu ara (apere wiwe) Ifokansii ati rtonu inkan 05 Krko inkan otun 06 Lilowo si ise ilu 07 Iha ti a ko si ija/lasigbo pelu awon miran Riri ati dida eniyan/ohun kan mo 09 Ssun ati jrjr drde 10 Ibanuie atr tewesr okan Riro a0 didun ara (so Poto) Emi ko m0...... 98 304 Ni ogbon oio seyin bawo ni oti ni isoro t, sl ilpa o) Ise Kos uom rom d* Popo O pogan ni trl t3l t41.... t5l p) Rlrtn ka kiri tll pl t4l ...... tsl q) lse agbara bi ere sisa ttl pl t41...... ttl r) Itoyu ara re bi wrwe tll t1l t41...... t5l s) Kikeko tll pl t4l ...... t51 t) Ibasepo pelu ara tll pl t4l...... t51 Lilowo si ise rlu ") trl pl t41...... t5l Rrn atr drda eniyan mo tabr ") inkan hiha son ttl t l t41...... t51 w) Sru ati irir rrl pl [4] ...... ts1 j) Ohun je i{e trl pl t4l t5l l 131 305 Ti awon eniyan ba ni lara awon isoro woonyi nibo ni won maa n lo fun ono abayo? Ih iuosar lhle Ibi itoogun Ih adura emi komo n) Ara &dun atr lro ,) ttl t2l t4l t5l [e8] Isoro nipa rtin kaa krrr ") p) Isoro an sise agbara bi ere sisa ,) tt I t2l [4] pl teE q) Isoro ati toju ara eni bi wiwe r) Isoro ati keko il tll t2l t4l tsl [e8] s) Isoro atr dasi ise ilu t) Isoro ati ru aiosepo pelu awon miran t4l tsl r) Isoro lre au dtda eniyan tabr ohun kan mo t4l t5l v) Isoro sisun ati pir w) Isoro au jeun t4l tsl t4l ttl t4l t5l t4l t5l t4l ttl Ninu ero okan re nibo m odaraju latr to,u awon rsoro ilera wonyi Kost lle uoun Ibrh Ik ioogan Ihi adsra emi komo a) Ara didun ati ruo b) Isoro nipa nln kaa kiri lfiJ t2l t7l t4l t5l tesl c) Isoro art srse agbara bi ere srsa d) Isoro atr tofu ara eru bi wrwe b tll t2l t3l t4l ttl teE E Isoro ati keko f) Isoro ati dasi ise ilu ,fiJ t2l t|l t4l t5l teE g) Isoro ati ni ajosepo pelu awon miran h) Isoro rre ati dida emyan tabr dtll ohun kan mo Isoro sisun ati 11i efil Isoro atr ieun "ft| l 8t1l htll , [1] itll 132 Ipin 4: TRIRI RE NIPA ETO ILERA Bayi mo fe bere awon ibeere nipa iriri ti e ni nipa eto ilera ni ilu yi. Nigba wo ni iwo tabi enikan ninu ile yi nilo Ogbon ojo seyin eto ilera kehin? Larin osu kan si odun kan seyrn Laann odun kan si mefi seyrn [Mase mu iu okan soso lol Larin odun meii si meta sehrn Larin odun meta si merin seyin O ju odun merin lo A o nilo eto ilera ri Emr ko mo Nigbatr rwo tabi ara ile re nilo twosan keyin, Ile iwosan melo ni o wa ni arowoto re lati yan okan ninu won? (-/ [So iye igba] 403 Kini di tr o sapejuwe iulo ti iwo tabr ara de Igbona ara 01 re fi nrlo iwosan keyrn? Igbe gburu 02 Iko 03 [Mu okan ninu wo] Eebr 04 Abere ajesara 05 Itoju oyun 06 Aisan awo ara tabi. an yiytn 07 Ifetosomobibi 08 Omo bibi 09 Itoju eyrn 10 Orike ara didu 11 Iko Asma 12 Okan didunni 13 Ego ara tabi ara didun 14 Ise abe ranpe 15 Isoro iriran 16 Ifunpa giga/eye riru 17 Ito sugar 18 Iba 19 Iko au rsoro nipa mimi 20 Arun eedi 21 Iko ife 22 97 (so ?ao) Emr ko mo..... 98 Nrgbati iwo tabi ara ile rc nilo iwosan keyrn, 01 Nieeniwosangba? 02 98 133 405 Kini o fa ti iwo tabi ara ile re ko fi ri itoju A ko ru owo ti o to fun itoiu 01 gba nigbati e lo si ile iwosan keyin? Ko si bi a tl le de ibe ...... 02 Ibi jrna si ile iwosan...... 03 [Mu okan soso] A ko le san wo oko...... 04 Oogun ile iwosan ko to 05 Ohun elo ti won ni ko to ...... 06 Awon eleto iwosan ko tu oye ti o to ...... 07 Iriri ti mo ni keyrn ko te mi 1orun...... 08 Emi ko le fi ise mi sile 09 Mo ni ohun miran lati se...... 10 Emr ko mo ibr u mo le 1o...... 11 Molero wipe isoro ilera naa ko po to lati lo 12 Mo gbryanju sugbon won ko toiu mi 13 Iwuwasi awon olutoju buru jai 14 Ko si olutolu ni rle iwosan...., 15 Omiran 97 (So pato) Emr ko mo..... 98 406 Nigbati iwo tabi enikan ruu de re ruIo Ile iwosan iloba 01 iwosan mbo ni e ti ri iwosan gba? lle iwosan adam...... 02 Ile iwosan rjo/ile agbebr /ile adura...... 03 Omiran 97 [Mu okan soso] )414 407 Nrgbati 1wo tabl entkan mu de re nilo Beeni...... 01 iwosan? 02 98 408 Ninu awon oogun ti a ko fun o rugbati rwo Gbo gbo won 01 >411 tabi ata de re lo si ile iwosan keyin melo Die mnu won ...... 03 ninu won nr won ni nr ile rwosan? Won ko it tita ...... 05 [Mu okan soso] Emi ko ranti...... 98 409 Kiru o fa ti iwo tabr ile re ko fr ri A ko ni owo lati ra won.. 01 ^won ^ta oogun gba? A ko ri gbogb oogun naa... 02 Emi ko gba pe gbogbo oogu" rr^ni -o.r,fo 03 [Mu okan sosol Ara mi bere si n ya. ... 04 Mo ni awon oogun die sile tele 05 Omiran 97 (So pato) 98 410 Awon tr nl 411 Se o san owo fun oogun u iwo tabi ara ile R..-i 01 re gbe ni ile iwosan? R..L^ o') )501 412 Owo ti rwo tabr ara ile re san se a da pada 01 fun o? 02 )501 134 I l 135 IPIN 5: AKTYESI NIPA ETO ILERA Ni bayr m fe bere nip aero okan re si eto ilera inu ilu yr? I 136 l I I IPIN 6: Alciyesi ipa iioba ati ilu si ipese iwosan alabode Bayi, mo fe beere nipa ohun ti o lero wipe o ye ki o je oiuse iioba ninu eto iwosan ni ilu yi. Eto ilera wo ni iloba n pese ni ilu yi? Ipese ile iwosan 01 [O le mu ju okan lo] Ipese awon osise 02 Ipese oogun ati awon ohun elo mtan 03 Te siwaiu [bere omiran?] Idanileko awon ti won nse iranwo fun eto ilera nilu 04 Tita awon eniyan ;i nipa idena aisan 05 Ipese ilera ofe 06 Ipese itolu fun awon abolun 07 Ipese abeere ajesara fun awon omo u ko pe odun marun 08 Itoiu awon agbalagba Eto owo dida pada I Kint osuwo tr o fun ilowosr rjoba nipa eto O kun oju isuwon ilera ilu yi? Ko kun oju isuwon 02 Emr ko mo Ise/ohun flrran wo ru o ye ki iioba pese? Ipese ile rwosan 01 Ipese awon osise 02 [O le mu ju okan lo] Ipese oogun afl awon ohun elo mran 03 Idanrleko awon tl won nse iranwo fun eto ilera nilu 04 Te si waju [Bere omiran?] Tita awon emyan jr nipa idena arsan 05 Ipese ilera ofe 06 Ipese itoju fun awon aboyun 07 Ipese abeere aiesara fun awon omo u ko pe odun marun 08 Itoju awon agbalagba 09 Eto owo drda pada 10 omiran 97 (So pan) Emi ko m0...... 98 604 Kim ipa u awon ara ilu n sa lati lowo si Ipese ile iwosan ilera awon eniyan du yi? Ipese awon osise Ipese awon ohun elo [O le mu ju okan lot Yiyan awon amugbalegbe fun iranwo eto ilera 04 Atileyrn fun kiko awon amugbalegb eleto ilera 05 Te si waju [Bere omiran?] Si si iranwo lati rip e ile iwosan n lo deedee Fifun awon amugbalegbe ni owotabi eto miran 07 Awon igbimo ti a ko 1o ninu ilu yi n se iranwo lati rip e ohun gbogbo nlo deedee ni ile iwosan 08 Iranlowo lati toju alaisan omiran - 97 (So Pato) Emr ko mo...... Kini osu won ti o le fun ilowosi ilu o KUN OJU rSUI0TON 01 ilera awon olugbe re? Ko kun oiu isuwo 02 Emr ko mo- 98 137 I Nr erongba okan re kini o ye ki won se? Ipese ile rwosan 01 Ipese awon osse 02 a [o le mu ju okan lo] Ipese awon ohun elo 03 U Yryan awon amugbalegbe fun iranwo eto dera 04 Te si waju [bere omiran] Atileyrn fun kiko awon amugbalegb eleto ilera 05 Si sr iranwo lati np e ile iwosan n lo deedee 06 Frfun awon amugbalegbe tu owotabr eto mran 07 Awon igbimo u a ko jo runu ilu yt n se iranwo lati rip e ohun gbogbo nlo deedee ni ile iwosan 08 Iranlowo lati toju alaisan 09 omiran 97 (So pato) Emr ko mo...... 98 Gegebr olodonni, nie o u sa lpa kan pato si Beem 01 rlera ilu yr m odun kan seyin? Beeko 02 Kinr ilowosr/ipa ti o ti sa? Ipese ile iwosan 01 Ipese awon osise 02 [o le mu lu okan lo] Ipese awon ohun elo 03 Yiyan awon amugbalegbe fun iranrvo eto ilera 04 Te si waiu [bere omiran] Atileyin fun krko awon amugbalegb eleto ilera 05 Sr si iranwo lau rip e ile iwosan n lo deedee 06 Fifun awon amugbalegbe ni owotabi eto miran 07 Awon igbimo ti a ko 1o ninu rlu yr n se ranwo lati np e ohun gbogbo nlo- deedee ni ile iwosan 08 Iranlowo lati tolu alaisan (So Pan) Emr ko mo..... Ni oio waju se wa fe lati sa rpa tte si {era Beeni 01 ilu re? Beeko ...... 02 Emr ko le so 98 Ipa wo gan ru o fe sa? Ipese ile iwosan 01 Ipese awon ostse 02 Ipese awon ohun elo 03 Yiyan awon amugbalegbe fun tanwo eto dera 04 Atileyio fun kiko awon amugbalegb eleto dera 05 St si iranwo lati rip e ile iwosan n lo deedee 06 Frfun awon amugbalegbe ni owotabt eto mi.ran 07 Awon igbrmo ti a ko 1o ninu ilu yi n se ranwo lati rip e ohun gbogbo nlo deedee ni ile iwosan 08 lranlowo latr toiu alaisan (So pan) Emr ko mo...... Krni ofa t1 1wo ko fi fe lowo sr? Emi ko nise 01 Emi ko lowo 02 [O le mu ju okan lo] O;use rioba ru 03 Ojuse mi ko /ko saye fun mr Te siwaiu [Bere omiran?] 138 Kini o fe Iati so fun oga. awon eleto Ise won dara 01 iwosan nipa ipese eto iwosan fun ilu yi? O ye ki won tun gbe yewo lo won se atunse 02 Ise won ko dara 03 Ilu nilo lati tunbo lowo si 04 Ilowo si awo oluranlowo /amugbalegbe eto ilera 05 Ipin 7: AWON ILEPA ETO ILERAATI ANFANI TI AWON ENTYAN PESE mo fe bere nipa ohun ti e ro wipe o ie ilepa eto ilera ati bi iioba tin baa won eniyan Io ni ilu 701 Bawo m lioba ti n gbo ohun awon eniyan rvonyi Mu okan ninu isori kankan si nipa ohun ti o kan won ni du yr? O po die ni o kere kosi Emi ko mo q) Won omode p) Ill 121 I3l I4l I5l r) Awon odo q) Ill 121 I3l I4l I5l $ Agba o lll 12t I3l t4l IsI t) Awon Okunrin s) I1l 121 I3l l4l IsI ") Awon Obinrin 0 I1l 121 I3l I4l tsl v) Awon ti won kawe u) Ill a2l I3l l4l I5I w) Awon ti won ko kawe v) Ill l2l I3l I4l I5l .) Awon tibrle w) I1l l2l I3l I4l I5l y) Awon oloselu x) I1l 421 I3l t4l Isl 4 Awon osrse Iloba y) Ill a2l t3l I4l I5I Awon Omo ile iwe z) I5l ^ ) I1l 121 t3l t4l bb) Awon ti ko nise lowo n) I1l 121 I3l I4l I5I cc) Awon Elegbe je gbe bb) [1] 121 l3l l4l I5I dd) Awon elesin cc) Ill 121 t3l t4l tsl ee) Awo adari ilu dd) I1l l2l I3l I4l IsI 702 Bawo ni o se gbekele rjoba si lau se ohun tr o to? Gbogbo igba 01 E kan kan 02 Kamari 03 Emr ko nt idahun 00 703 Se o ro wipe o ru eto lau n wipe ijoba da si ohun Beeni 01 to ni se pelu ilera ti o kan o? Beeko 02 )70s 704 Bawo m anfaru ti o ru tioo to latr ie ki iioba da si Ko lopin/o po 01 eto ilera tr o kan o? Die 02 Ko si rara 03 Emi ko ni idahun 00 705 Bawo ni aye ti gba o to lati sotenure lati 1e ki Patapata 01 iioba da si eto ilera tr o kan ilu re lai si iberu pe a Aya gba mi die 02 le fr iya je o? Emi ko to bee/ aye ko gba mi rara 03 DUPE LOWO OLUDA}IUN. 139 a v Figure 72: Cordboord Used os o Registrotion Cord Figure l7: E*Pg Drug Storu in a Health Faciliry Figure 20: Connuniry Contributiont to MaternalHealthcare Deliuerl ('i Figare 2/: Items Donated fut the Connariry nfacilitate the Deliuery of Exential Health Senticu ,.-) Figure 22: Communiry Contibution of a Health Facilig Figure 2i: Hahed Comnunifl-Diretted Bailding of Health Centre ANNEXES Annex 1: Survey insttument (dtaft) INTERVIEW SCHEDULE FOR HOUSEHOLD HEADS Questionnaire No. Household ID No. Time Interview Started: [Iour: Minute: Time Inteniew Ended: Hour: Minute: - - Location lnformation II COUNTRY Region/State Code I I REGION/Province/STATE _District Code I I orsrrucrfl.cf;/frry Community Code t I Is this urban/rural/peri-urban? l=Urban [ ]; 2=Peri-urban [ ]; 3=Rural [ ] Distance of community to the health centre -lon l=Near[ | 2=Fatl I LANGUAGE I-ANGUAGE OF QUESTIONNAIRE,: I-ANGUAGE OF INTERVIEW MOTHER TONGUE OF RESPONDENT WAS A TRANSI-ATOR USED? (llES=1, NO=2)... SUPERVISOR FIELD EDITOR I OFFICE EDITOR KEYED BY NAME NAME _\ Section 1: Socio-demographic Information First, I would like to ask you some quesdons about yourself and your household. Instructron: ctcle appropriate options) Head of Household could be assisted by any household member 101 Record sex of respondent as observed Male...... 1 Female.. .2 t02 How old are you? AGE, IN COMPLE,TED YEARS 103 Have you ever attended school? @ormal and rnformal) )10s 104 What rs the highest level of educatron you Formal education have attained? Pnmary...... 01 Secondary 02 ,, l Hgher ...... 03 Vocational..... 04 ReLgious/non-formal education Islamic/Korarucschool...... 05 othet 97 (SPeofi') 105 Are you engaged in any Income Generaung Acuvrty (IGA)? )107 106. What do you do to eam a livrng? Farming/hunting/fishing...... 01 Petty trading... 02 Paid employment/salaried... .. 03 A *icanc nl Business.....- 05 Other 97 (Speci$) 107. What is your marital status now? c:--l- \Y/'id^-,p.1 T)ivorccd 4 ( 108. lVhat rs your reLgion? Chnstran...... 01 Mrrslim O, 03 (SpeciS) No relig,ion.... 04 other 97 (SPeci$) 109. For hour long have you lived in this Record actual number (in years) commuruty? ------t In the last 30 days, how much difficulty did you have with: None Mild Modcrate Seun ...... Extnme 4 Work 4 tll t2l t3l t41...... tsl b) Aches and pains a trl t2l pl t41...... t51 .) Moving around 4 trl t2l pl t41...... p1 d) Vigorous activities (e.g. running) d) tll pl pl t4l...... t51 E Self care (e.g. washing/bathing) 4 trl t2l pl t4l. .. t,l f) Concentrating/remembenngthmgs "0 tll t2l pl t4l. tsl g) I-eaming new task/things s) tll t2l pl t41... t5l h) Personalrelationsllp a tll t2l pl t4l t,l i) Participation in community activities 4 ftl t2l tll t41...... t5l i) DeaLng with confucts/tension with others ) trl t2l t3l t4l ...... ts1 k) Seeing and recognizing people/object or reading k) tll t2l pl t41...... tt1 l) Sleeping and wakrng up 0 [1] t2l pl t41...... ts1 m) Sadness and depression n) fil t2l pl t41...... tsl (, n) Anxiety and worrying 4 tll t2l pl t41...... t,l When people have any of these problems, where do they go for solutions? No uhcn HospitalTraditional Spitaal DK a) Aches and pains 4 tll t2l pl [4]...... [e8] b) Movmg around a tll pl til [4] . . .te8l c) Vigorous activities (e.g. running) 4 trl t2l pl [4]...... [e8] d) Self care (e.g. washing,/bathing) d) tll t2l pl [4]...... [e8] E Concentraung/rememberingthings 4 tll pl t3l [4]...... [e8] I kaming new task/thrngs 1) tll pl t7l t41...... te81 g) Personalrelationship 9 trl pl pl t4l ...... te81 h) Parucrpatron rn commuruty activities a tll pl t1l t4l .....te81 i) Dealing with confucts/tensron with , tll t2l t7l t4l . ..tegl others i) Seeing and tecognzing people/ob;ect or j tll pl t7l t41...... te81 reading k) Sleeping and waking up k) tll pl t3l t41...... te81 ) Sadness and depression 0 trl t2l pl t4l ...... te81 m) Anxiety and worrying D,) fil t2l ttl t41...... te81 In your opinion, where are problems like these befter managed No when HoEitalTradirtonal Spiitml DK E Aches and pains 4 trl t2l pl t41...... te81 b) Moving around a tll pl tll t41...... [e8] .) Vrgorous acurrties (e.g. running) E tll t2l H t4l ...... te81 d) Self care (e.g. washrng/bathrng) d) ttl pl tll t4l ...... tesl .) Concentrating/rememberingthings ,) ttl t2l pl t4l ...... teE I Leamrng new task/things I ttl t?l t3l t41...... teE d Personalrelationship s) ttl t2l H t41...... teE h) Participation in communiry activrties h) trl t2l pl [4]...... [e8] i) Dealing with conflicts/tension with 4 ttl tzl pl t41...... te81 others j) Seeing and recogmzing people/obiect or ) tll t2l pl t41...... teE reading k) Sleeping and waking up k) trl t2l pl [4]...... tesl l) Sadness and depression q trl t2l pl t41... teE m) Anxiety and worrying r") fil t2l pl [4]...... [e8] 405 \Y/L:-L --^.-^- !.-.r --^l^i-. .,,1"- Could not afford the cost of hedth care...... 01 member of you household did not get No means of transport.... 02 health care the last time vou needed health Distance to health facility...... 03 care2 Could not afford cost of transport..... 04 The health care provider's drugs were inadequateO5 [Circle only one (1) option] Equrpment were rnadequate.. 06 The health provider's skills were inadequate...... 07 Unsatisfactory past experience. 08 Could not take time off work 09 Had other commitrnents.. 10 Did not know where to go ...... 17 Thought health problem was not serious enoughl2 Tried but was denied health care...... 13 Poor attitude ofhealth to patients ... 14 No health worker at the faohty...... 15 OTHER 97 (SPECIFY) (-, DON'TKNOW...... 98 406 The last time vou or anv member of vour No where 01 L^"".h^l.l -...1..1 h..lth .".. -.hc.e -,ac.it At home 02 sought from? At government hospital/clinic.... 03 At pnvate hospital/CLnic ...... 04 Faith based hospital...... 05 [Circle only one (1) option] At ttadrtional healer's place ...... 06 At a spiritual home 07 OTHER 97 (SPECrF9 Cannot remember...... 98 407 The last dme vou or anv member of vour Yes 01 hn,rc"hnl.l .n'roht hcalth rare Airl the hcalth No 02 -.^":r-. n.-".ik- .-- -..li.i-. f^' rl.. Cannot remember.. 98 health problem? 1-\f tL'- rlr^r ."-.- f^' 408 --,li-inac -.-"-;L-.1 All of them...... 01 )411 mpnhef h^,,cch^l/] h^u, ^f -^,r" Some of them. 03 many were available from the health None of them. 05 facilities? Cannot remember...... 98 [Circle only one (1) option] 409 Which reason best explains why you or any Could not afford the medicrnes...... 01 member of your household did not get all Could not frnd all the medicmes...... 02 the medrcines orescribed? Did not believe all the medrcations were needed 03 Started to feel better...... 04 [Circle only one (1) optionl Already had some of the medrcrnes at home 05 OTHER 97 (SPECIFTO Cannot remember...... \Y/L-.- ,L.1 r,^rr ftar tl"^ 410 --.1,-.--" -,}'i.l' Mobil patent medicme vendor.. 01 or any member of your household could Market...... 02 not get from the health facility? Medicine shop s ...... 03 Provrsron shops...... 04 OTHER 97 (SPECrFY) Cannot remember...... 411 Did you pay for the drugs you or any -.-h., ^f ,,^,,. t ^,,".L^1,{ ....i.,.4 f.^ )501 the health facilities in the community? 412 Was the money, which you or any member n of your household paid for medicine No 02 )501 reimbursed? Section 5: PERCEPTION OF HEALTH SERVICES/SYSTEMS Now, I would like to ask you some quesuons about what you think or feel about the health service in your community? How would you rate the services the health facility Good provides in your community? uncertain 02 Bad lWluch reason best explains your rating of health Atntude of the staff to chents is poor...... 01 care servlce in your community? Inadequate drugs and equipment...... 02 Very responsive to clients' needs...... 03 Adequate drugs and equipment...... 04 Friendly environment...... 05 [Circle only one (1) optionl Clean environmeot...... 06 Delays in provision of health care ...... 07 Absence of health workers from the Referral pracuces in the facrlrty...... , t) How would you rate the way health care in your Good communitv mvolves vou in decidins what services Uncertain 02 it provides and where it provides them? Bad In general, what is your feeling with the way health Satisfied care is provided by government ln your Uncertarn 02 community? Dissatisfied What can be done to improve the way health care Provide medrcrnes/drugs services are delivered in your community? Involve community m the managemelt 02 Provide personnel 03 [Multiple answers allowed] Construct hosprtal 04 Reduce cost of services 05 Probe [Ask any other?] Select community members to 06 help rn delivery of health servrces 07 Reduce outpatient waiting time 08 Provide the equpment 09 Replace retired personnel 10 Provide free health care to the poor 11 (SPECTFY) Don't know.... 98 11 In your opinion, what should be the actual Provision of hedth facility 01 contnbutions of your community to the Provision ofhealth personnel/labour 02 health of the community? Provision of health commodities 03 Training of community health volunteers 04 [Multiple answers allowed] Creation ofhealth awareness on prevention 05 Providing free medrcal care for chddren 06 Probe [Ask any other?] Providing free medical care for mothers 07 Providing free medrcal care for the eldedy 08 Providing free medrcal care for all 09 Maintenance of health facihty 10 Compensation of community volunteers 1.1 OTHER- 97 $PEAFY) DONTKNOW...... 98 As an individual, have you made any Yes 01 contnbutions to the health of your No 02 community in the past one year? a, What contributions did you make to the Provision of health facdity 01 health of your community in the last one Provision of health personnel/labour 02 year? Provision of health commodrties 03 Support training of community health volunteers 04 [Multiple answers allowed] Creation of health awareness 05 Providrng free medical care for children 06 Probe [Ask any other?] Providrng free medrcal care for mothers 07 Providrng free medrcal care for the elderly 08 Providing free medical care for all 09 Maintenance of health facfity 10 Compensation of community volunteers 11 OTHER- 97 (SPECTFY) DONT KNOW...... Why drd you not make any contributions Poverty 01 to the health care servrce of your It is not my responsrbihty 02 community in the last one year Govemment should cater for the people 03 I was no asked to make any contribution 04 [Multiple answers allowed] Everything is available in the commuruty 05 It belongs the NGOs Probe [Ask any other?] It belongs to reLgious organizations It belongs to pflvate rndividuals (SPECTFY) DONT KNOW...... 98 Are you wilLng to make contributons to Yes 01 the health of your commuruty in the No 02 future? Cannot say 98 What can you contribute to the health of Support the provision ofhealth facilrty your commuruty? Support the provision of health personnel/labour Support the provision of health commodities [Multiple answers allowed] Support trarning of community health volunteers Creation of health awareness Probe [Ask any other?] Providing free medical care for children Providing free medical care for mothers Providing free medical care for the eldedy Providing free me&cal care for all Marntenance of health facil-rty 10 Compensation of community volunteers 11 OTHER- 97 (SPECIFY) DONT KNO\q...... 13 Annex 2: Focus Group Discussion Guide APPROPRIATE GREETINGS PRESENTATION OF THE TEAM W'e are working within a project conducted by ... in cooperation with ..... and .... Your community has been chosen amoflg the ones in the country for this project. !7e are hold discussions with you on issues related to the delivery of essential hedth services in your community, yout experiences of health services, your relation with health seryices providers, involvement on the implementation of health interventions, major concerns about health and health progratnmes and how to address them. Your participation to the discussion is very valuable if you are willing to be involved. A1l information vdll be used vrithout mentioning your names and held in confrdence within the tesearch team and among its collaborators. We seek your consent to record the discussion so that we could captue all the ideas expressed. We expect this discussion to last for no more than 60 minutes. (_t INTRODUCTIONS. Country: Region/provnce / Departrnent/District: Community: Number of paticipants: . . . Type of Group:.. Length of Discussion: ..Date: ... Moderator: ..Note-taker: FOCUS GROUP DISCUSSION GUIDE COMMUNITY PERCEPTIONS OF HEALTH 7. IBREAK ICE]. When you say somebody is "healthy'', what do you normally have in mind? PROBE FOR ELEMENTS OR ASPECTS OF HEALTH. ASK: How can you recognize a "healthy person"? 2. Please describe what people in this community regard as the most important elements of health/health services. PROBE FOR SATISFACTION !fITH ESSENTIAL HEALTH SERVICES. 3. If somebody fell ill, what does he/she do/where does he/she go for treatment? PROBE FOR USE OR NON-USE OF DIFFERENT OPPORTUNITIES INCLUDING TRADITIONAL MEDICINE AND HEALTH FACILITIES. 4. Ftom what you have seen or heard, or possibly experienced yourself, pPlease describe how people feel about the way the health wotkets treat members of this community when they visit the health facility. Please explain further. 15 RECOMMENDATION The Group (4) proposes 6 FGDs per region. These FGDs should be distributed actoss the urban, peri-urban or rural districts of each region and orgarized fot adult male adults (2), female adults (2), adolescent males (1), and adolescent females (1). 17 IN.DEPTH INTERVIEW GUIDE REGIONAL AND DISTRICT COORDINATORS HEALTH MANAGEMENT TEAM Study Site: District: Region: Country: Date of the interview: Name of the interviewet: Name of respondent: ', ,) Position/title in community/organization: Inttoduction Good morning/afternoon. My name is...... I am here on behalf of the Ministry of Health. We are conducting a study on health issues in this district /local governmeflt authority. The information we are collecting will help the ministry to plan better and implement disease prevention and control activities in this area. You have been selected to participate in this interview because we feel your views are important. I therefore, kindly request you to share your honest views on the issues we will be discussing. Your participation in this interview is voluntary and you ate free not to respond to any questions you feel uncomfortable with and this will not affect you in any way. I would like, however, to assure you that the information you provide shall be kept confidential and will only be used for the pulposes of this study. This interriew vrill last apptoximately 45 to 60 minutes. Do you have any question or cofirment before we proceed? Interviewer (/ an1 questionf comment, please frst addryss then before procuding with the ifieruiew) I also wish to kindly request you to allow me tape-record this interview so that I can capture everything we discuss. Interviewer:Ia case, the respondents refuses t@e -recordirg do rot use the t@e bil proaed with the interuiew and nrite daar as mttch as you cail. 19 6. How can communities be effectively involved? r What do you consider key aspects for effective health care delivery at the community level? r What are some of the successful community programmes in this area? l/ 21 r What challenges do community members encounter in their involvement in health service delivery? 6. Engagement of the communities in essential health senrice delivery r W.hat do you consider key aspects for effective health care delivery at the community level? r What are some of the successful community programmes in this atea? @tobe for examples). 23 O. n"raio.ss (willingness and ability/capacity) of the communities to engage in health senrice delivery r How willing and ready are the people in this community to get involved in health service delivery? Please, grive some examples. r What training has been undertaken for community membets to increase their participation in health activities? r What difficulties do people face in their participation in health care activities in this community? 7. How can communities be effectively involved? I \7hat do you consider important in enabling people to participate in health care activities at the community level? ! What are some of the successful community programmes in this area? (Probe for examples). l) 25 r What training has been undertaken for community members to inctease their participation in health activities ? r What difficulties do people face in their participation in health care activities in this community? 6. How can communities be effectively involved? r What do you consider important in enabling people to participate in health care activities at the community level? ! W.hat afe some of the successful community programmes in this atea? Probe for examples). i) 27 6. How can communities be effectively involved? ! What do you considet impotant in enabling people to paticipate in health care activities at the community level? ! W.hat are some of the successfrrl community programmes in this area? 29 2. Key questions and data sources Research questions Data soutces 1. !7hat are the key public hedth challenges in Interview with District Medical Officer and the district, e.g., major public health other public health officials conditions, burden of disease? District Health Reports (unpublished and published) over time Service registers 2. How are essential health services Interview with District Medical Officer and organized? other public health officials How do communities perceive access to and the quality of these services? Informal exit interviews with patients How are communities involved in the development of policies and strategies? District Health Reports (unpublished and Are there specific measures for situations of published) over time health insecurity (epidemics, pregnancy) Interviews with community membets of maoagement committees Administrative and planning documents Organigam(s) Structured observations Elements to be included in observational checklist (to be established): 1. Availability of policy/sttategy document 2. Elements of PHC policy strategy 3. Elements of PHC policy strategy implemented Organigram 4. Extemal stakeholders 5. NGOs/CBOs 6. Physical structures (Size, status) 7. Number of health c re visrts and hospitalisations by structwe 8. Human resources (typ"r) by structure 9. Post descriptions 10. Equipment 11. Supply and procutement 12. Budget 13. Financing 14. Oversight and stewardship 15. Patient rcfetal and services (including patient ftansport. ftansfer and evacuation 31 Health service registers Human resources: Numbers by types and distribution Budgets and financial reports b. Archival research Historical analyses c. Open-ended or focused G.y informant) interr.iews District Medical Officer "PHC" Coordinator Essential health care telated key personnel, e.g., health staff at Frondine Health Facilities Selected health staff with longterm work experience in the health district Representatives of CBOs or NGOs with experience in partnering with the PHC system d. Observations C' l -/ Structuted, non-pamicipant IJnstructured, non-participant 4. Ptinciples of data collection Pincipk /.' Use and triangulate multiple sources of evidence A major sftength of case study data collection is the opportunity to use many different sources of evidence, e.g., triangulation: rationale for using multiple sources of evidence Pinciph 2: Crcate a case study data base Field diaryl Notes Photos Film Documents Tables Narratives Pinciple 3: Malntal.n a chain of evidence Allow an external obseryer to follow derivation from initial tesearch question to ultimate conclusion - and back (court) 5. Data entry Textual data will be entered into Atlas Ti, a Qualitative Data Analysis software package. Documents to be collected as Wotd documents ot scanned as pdf files Field notes Interview transcripts or notes 6. Data analysis and structure of the case study report Data will be coded according to the categories below and results repoted accordingly. 33 Annex 5: Translations ili. Afrkun tt.l. Afikunl: ohun idiwon ETO IFORO WANILENI.IWO AWON OLORI EBI Nomba Iwe abinilere Nomba idale mo Akoko ibere: wakati: _iseiu: _ Akoko : wakati: _ iseiu: _ lbi Isoro Ohun ti a fi da orileede ]I ORILE EDE Region/ Ena fun lpinle I I a REGION/Province,/tPINLE District Code t I DI ST RI CT / IJ OB A IBILE, / Z one Ena fun Ilu TLIY Nie ilu da/igberiko/Igberiko ti o ti n di l=Ilu nla I l; 2=Igberiko ti o tin di ilu nla[ ]; 3= igberiko[ ] ilu nla? Jijina ilu si ile iwosan 3 -km 1=O sun mo ra[ | 2=o jina[ I EDE EDE IWE,ABINILE,RE: EDE TI A FI !rANI LENU WO F,DF, ARINIBI OT,I IDAHI IN_-.- qli F T C] all II(IRIIF'C)) /RF'FNIT=1 RFFI{f)=2\ ATABOJUTO OLUYE\?EWO ORI PAPA OLLTYEWEWO PELU IFOWOSI NILEISE ORUKO ORUKO z ILU: Awon eniyan tiwon gbe ni agbegbe ti o ni adari kan,tiwon ni anfani si awon alumoni kan naa, tiwon n lo ni opolopo igba. lru awon eniyan yi le yato ni orile ede kan si omiran bi igberiko, abule,sagodabule, ileto, awon tin lo kakiri, atiawon ti n se atipo. 3 A o pin awon ilu si isori ti o jina (awon ti o ju ibuso marun) awon ti o sun mo (awon ti ko to ibuso marun) si ile iwosan ijoba ibile. 35 IPINI: IMO NIPAARA ENI Ni isalu,mo fe bere ibeere die nipa pn ati ile yrn. Itonisona: Fi ami roboto si ef u o to Awon ara ile le ran olori ile lowo 101 Se akosile Isakosabo oludahun br o ti n 102 Kini oio on re? Koo dun ti o pe kehin 103 Nje o lo ile rwe ri? (fr asa oyinbo ati tibile) )105 104 Bawo ni oti kawe to? Ti asa oyinbo Alakobere...... 01 Girama 02 Ile eko giga 03 Ile ikose owo...... 04 f; TeIesr/Tibile Ile keurr...... 05 Omiran- 97 (So pato) 105 Nje iwo nse ise tin mo wo wole? Beeru 1 Beek< 2 )107 1 10. Kiru ise ti ohunse jehun? Agbe/olode/apejalOlohun osin...... 01 Onisowo kekeke...... 02 Onicc nc'. 01 a-)-ic. ^-,^ nA f)-icn.r,n 06 Omiran 97 (So pato) 111 Ipo iloko laya re nisinsiyi? 1 ) f)lrn tahi ava ti L,, 1 A ti yara wa...... 5 Omiran (so oato) 112. Kiru esrn re? Adayeba..... (so pato) Emi ko lesin .04 Omiran (So pato) 113. Nigbawo wo tu o ti n gbe ilu yr? So oato (ni odun) 37 39 Kini o lero wipe o je apeere igbe aye Nrgba ti enlar ko ni inm ilpa ilera pipe? Okun lati sise 01 [O le mu ju okan lo] Ririn kaakin 02 Ise agbara( apere ere sisa ) 03 Te si waiu [Bere omiran?] Itoju ara (apere wiwe) 04 Ifokansii ati rironu nkan 05 Kiko inkan otun 06 Lilowo sr rse ilu 07 Iha u a ko si ija/laqgbo pelu awon miran 08 Riri ati drda eniyan/ohun kan mo 09 Sisun ati /yi dide 10 Ibanuje au rewesr okan Riro ati didun ara (to Poto) Emi ko m0...... 98 () 304 Ni ogbon ojo seyin bawo ni oti ni isoro sr nipa ") Ise Koi isom isom die Pnpo O po gar ni tll pl [4] ...... t5l p) Rrin ka krn tl I t7l t4l ...... t5l O Ise agbara bi ere sisa trl pl [4] ...... pl r) Itoiu ara re br wiwe ftl pl t41...... t5l s) Krkeko , ttl t3l t41...... t5l t) Ibasepo pelu ara al r<7 t) trl pl L' J...... -.--..---. r'J Lilowo si ise ilu ") a7 r<1 ,) tll pl L' t -...... ---"--- L- l v) Riri ati dida eniyan mo tabi inkan hiha sori ,) tll t1l t41...... t51 w) Sisu ati jiji w) tll pl t41...... t5l i) Ohun le jije ttl t3l t4l t5l t) 41 Ipin 4: IRIRI RE NIPA ETO ILERA Bayi mo fe bere awon ibeere nipa iriri ti e ni nipa eto ilera ni ilu yi. Nigba wo ni iwo tabi enikan ninu ile yi nilo Ogbon ojo seyin eto ilera kehin? Larin osu kan si odun kan seyin Laarin odun kan si mefi seyin Mase mu iu okan soso lol Larin odun meji si meta sehin Lann odun meta sr menn seyin O 1u odun merin lo A o nilo eto dera ri Emr ko mo Nigbati irvo tabi ara ile re nilo lvosan keyin, Ile iwosan melo ni o wa ni arowoto re lati yan okan mnu won? ko poto/ Emi ko m0...... 98 (t [So iye igba] 403 Krni idi u o sapeiuwe julo ti rwo tabr ara de Igbona ara 01 re fr nilo iwosan keyrn? Igbe gburu 02 Iko 03 [Mu okan ninu wo] Eebi 04 Abere aiesara 05 Itoiu oyun 06 Aisan awo arr-tabi ara F),un 07 Ifetosomobibi 08 Omo bibi 09 Itoiu eyin 10 Orike ara didu 11 Iko Asma 12 Okan drdunni 13 Ego an tabr ara didun 14 Ise abe ranpe 15 Isoro iriran 16 Ifunpa grga/eie riru Ito sugar Iba Iko atr rsoro nipa mimi Arun eedi t',.-) Iko rfe (to ?oto) Emi ko mo..... Nigbati iwo tabi ara ile re nilo rwosan keym, Nie e ri iwosan gba? 43 () ) 45 IPIN 6: Akiyesi ipa iioba ati ilu si ipese iwosan alabode Baf, mo fe beere nipa ohun ti o lero wipe o ye ki o ie oiuse iioba ninu eto iwosan ni ilu yi. Eto ilera wo ru rjoba n pese m du yi? Ipese de nvosan 01 [O le mu fu okan lo] Ipese awon osise 02 Ipese oogun ati awon ohun elo miran 03 Te siwaiu pere omiran?] Idanileko awon d won nse ranwo fun eto ilera nilu 04 Tita awon eniyan ii nipa idena aisan 05 Ipese dera ofe 06 Ipese rtoiu fun awon aboJrrn 07 Ipese abeere ajesara fun awon omo ti ko pe odun marun 08 Ito;u awon agbalagba Eto owo dida pada (So Pato) o Emi ko mo..... 98 Kini osuwo ti o fun ilowosi ijoba nipa eto O kun o;u isuwon ilera ilu yi? Ko kun oju isuwon 02 Emr ko mo Ise/ohun miran wo ni o ye ki iyoba pese? Ipese ile iwosan 01 Ipese awon osise 02 [O le mu ju okan lo] Ipese oogun ati awon ohun elo mran 03 IdaruIeko awon ti won nse iranwo fun eto ilera nilu 04 Te si waiu [Bere omiran?] Tita awon eniyan ji nipa idena aisan 05 Ipese ilera ofe 06 Ipese rtoju fun awon aboyun 07 Ipese abeere aiesara fun awon omo u ko pe odun marun 08 Itoju awon agbalagba 09 Eto owo drda pada 10 omiran 97 (So pato) Emi ko m0...... 98 604 Krni ipa tI awon ara ilu n sa lau lowo si Ipese ile iwosan ilera awon eniyan ilu yi? Ipese awon osise Ipese awon ohun elo [O le mu iu okan lo] Yiyan awon amugbalegbe fun iranwo eto ilera Atileyin fun kiko awon amugbalegb eleto ilera Te si waiu [Bere omiran?] Si si iranwo lati rip e ile iwosan n lo deedee Fifun awon amugbalegbe ru owotabi eto mtran Awon igbimo ti a ko jo ninu ilu yi n se iranwo lati rip e ohun gbogbo nlo deedee nide iwosan 08 Iranlowo lati toju alaisan - (So pato) Emr ko mo..... Kini osu won ti o le fun ilowosi ilu yi si o KUN OJU TSUWON 01 ilera awon olugbe re? Ko kun oiu isuwo 02 Emi ko mo 98 47 Kini o fe lati so fun oga awon eleto Ise won dara 01 iwosan nipa ipese eto iwosan fun rlu p? O ye ki won tun gbe yewo kr won se atunse 02 Ise won ko dara 03 Ilu nilo lati tunbo lowo si 04 Ilowo si awo oluranlowo /amugbalegbe eto ilera 05 a (So pan) Emr ko mo..... 98 IPin 7: AIVON ILEPA ETO TLERA ATT ANFANI TI AWON ENIYAN PESE mo fe bere ruoa ohun tl e ro wlDe o ie ileoa eto ilera atl br rioba trr baa won enivan lo ni ilu 701 Bawo ni Ijoba ti n gbo ohun awon eniyan wonyi Mu okan ninu isori kankan si nipa ohun ti o kan won ni ilu yi? O po die ni o kere kosi Emi ko mo q) Won omode P) IU pt I3t I4l I5l r) Awon odo o tll 121 I3l I4t I5I s) Agba 0 tll l2l I3l t4l l5I t) Awon Okunrin 0 t1l 121 I3l t4l t5l Awon Obinrin q ") [ll l2l I3l I4l I5I 9 Awon tr won kawe ") tll l2l I3l I4l IsI w) Awon bwon ko kawe v) t1l 121 t3l t4l I5I , Awon tibile w) t1l 121 t3l t4l t5I y) Awon oloselu .) El l2l I3l I4l ts] z) Awon osise Ijoba y) Ill 121 I3l I4l I5l n) Awon Omo ile rwe 4 [ll l2l I3l t4l I5I bb) Awon ti ko nise lowo ^ ) tll l2l I3l I4l l5I (-, cc) Awon Elegbe ie gbe bb) El 121 I3l t4l I5I dd) Awon elesrn cc) I1l 121 I3l t4l I5I ee) Awo adari ilu dd) EI 121 I3t I4t I5I 702 Bawo ni o se gbekele rjoba si lau se ohun ti o to? Gbogbo rgba 01 E kan kan 02 Kamari 03 Emi ko ni idahun 00 703 Se o to wipe o tu eto lau n wipe iioba da si ohun Beeni 01 to m se pelu dera u o kan o? Beeko 02 )705 704 Bawo ni anfani ti o ni tioo to lati re ki iioba da si Ko lopin/o po 01 eto ilera tr o kan o? Die 02 Ko si rara 03 Emi ko ni idahun 00 705 Bawo ru aye u gba o to Iatr sotenure lau je ki Pzttpata 01 ijoba da si eto dera ti o kan ilu re lar sr iberu pe a Aya gba ml dre 02 le 6 iya 1e o? Emi ko tobeef aye ko gba mi rara 03 DUPE LOWO OLUDAHUN. 49