University of Ghana http://ugspace.ug.edu.gh RA552. G5 M52 bite C.l G379400 University of Ghana http://ugspace.ug.edu.gh ACCESSIBILITY TO AND UTILIZATION OF PRIMARY HEALTH CARE IN THE GA, DANGME EAST AND DANGME WEST DISTRICTS OF THE GREATER ACCRA REGION BY CHARLOTTE MONICA MENSAH THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF PH.D DEGREE IN GEOGRAPHY AND RESOURCE DEVELOPMENT NOVEMBER, 2003 University of Ghana http://ugspace.ug.edu.gh GOD MOVES IN A MYSTERIOUS WAY HIS WONDERS TO PERFORM; HE PLANTS HIS FOOTSTEPS IN THE SEA, AND RIDGES UPON THE STORM. WILLIAM COWPER (1731-1800) University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that, except for„references to other people’s work which have been duly acknowledged this work is the result of my own research and that it has neither in part nor in whole been presented elsewhere for another degree. CHARLOTTE MONICA MENSAH (Candidate) NAA PROF. JOHN S. NABILA (PRINCIPAL SUPERVISOR) ..........' t M i A * ................ PROF. ELIZABETH ARDAYFIO-SCHANDORF (SUPERVISOR) DR.MARIAMA AWUMBILA (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh DEDICATION Dedicated to the glory of the Father, the Son and the Holy Spirit, and to my parents, the late Mr. John K. Abakali and Mrs. Joana Abakah; and to my darling husband, Mr. Eric Nii Yarbcfi Mensah. University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS To God alone be all the glory and honor for the great things He does daily in our lives. I am particularly grateful to God Almighty, my Heavenly Father and the Holy Spirit, my Senior Partner, for their full sponsorship of my studies. Without their help, I could not have done it. I appreciate their love and support so much. I am also grateful to the Government of Ghana for a 3-year Bursary sponsorship package. To my darling husband, Nii Yarboi, T say thank you for your financial and moral support. I wish to express my gratitude to my supervisors, Naa Prof. J.S. Nabila, Prof. (Mrs). Elizabeth Ardayfio-Schandorf, Dr. (Mrs) Mariama Awumbila and Dr. Samuel Agyei-Mensah, all of the Department of Geography and Resource Development, University of Ghana, Legon, for their immense constructive criticisms and suggestions which have been instrumental in shaping this thesis and bringing it to its present form. I am truly grateful to Prof. P.W.K. Yankson, Prof. George Benneh, Prof. Jacob Songsore, Prof. Alex B. Asiedu and all the lecturers in the Department for their encouragement and help throughout this study. I say a big thank you to the NUFU programme of the Norwegian Ministry of Foreign Affairs for availing me of the opportunity to spend a semester at the Geografisk Institutt of the Norwegian University of Science and Technology (NTNU) Trondheim, where I updated my literature review, participated in some lectures and seminars on Health Development issues, as well as processed some of my research data with the help of Kyrre Svarva*(IT Consultant). I appreciate the support and encouragement of both the staff and University of Ghana http://ugspace.ug.edu.gh the students. Special mention is made of Prof. Aase, Prof. Lund, Stig. Bodil, Nina, Chamila, Jyoti and George Owoisu for their special attention and care throughout my wonderful stay in Trondheim. I am thankful to Emelia Agyen, Angela and Israel Aflu, David and Joseph Kukula, Charles Agyemang, Maku Martey, Naki Odonkor, Naa Atsoi Sowah and Vida Adjei for their great help as Research Assistants in the Ga, Dangme East and Dangme West Districts. I am grateful to Dr. Yao Yarbani, Dr. Irene Agyepong and Dr. Emestina Mensah-Quainoo of the Ada, Dodowa and Amasaman Health Centres, as. well as the medical assistants, nurses and other medical personnel for their immense support and help in my field survey. To my darling husband, Nii Yarboi and his family, my sweet mother, Joana, and my daughters, Emelia and Doris, my brothers John and Alfred, and sister, Joe-Star and their families, I say a big Thank you. God bless you. To all my friends, especially Florence Simpson, Fauslie and Willie Tengey, Osei and Dinah Osei-Tutu, Sister Mabel Sey, Sister Laudy Kankam, Sandra Cofie, Joana and Peter Acquah, Sarah Ankrah, Dr. Eric Kra and the late Nora Taylor (who died before she could complete her Ph.D), I say Thank You for your love and encouragement. To my seniors and colleagues, especially Prof. Daniel Buor, Dr. Dr. Richard Kofie, Osman Alhassan, Dr. Morgan Attuah, Mr. Albert Allotey, Mr. Opoku Pabi and Mr Fiah, I express appreciation for their suggestions anytime it became necessary to confer with them. I am really grateful to Mr D.J. Drah (Senior Technician) for the excellent maps and diagrams he produced for me. 1 say a big thank you to Mr Richard Asamoah for his University of Ghana http://ugspace.ug.edu.gh untiring efforts in typing the manuscript also to Mrs Jemima Anderson, English Department, for helping with the editing and proof reading. I am grateful to Mr Jude Hama, Mr Yaw Abaidoo, Mr Awuku Kwasi and all my colleagues at the Scripture Union for their encouragement and support. I cannot forget the House of Zion Ministries Int. • (Pokuase), especially Mama Esther Amoaku, Mama Ramona Kwami, Sister Mona, Apostle De Love, Bro. Michael, Pastor Norbert Marfo and Sister Doris Amaka for their enthusiastic prayer support for me throughout my studies. I am most grateful to the men and women in the study areas for allowing my field assistants and I to experience this first hand. They gave permission to my team and I to enter into their homes and lives and gave up precious amounts of free time to answer our never-ending questions. To all my loved ones, my sons and daughters from St. Monica’s Secondary School, Mampong-Ashanti and Accra High School and all Scripture Union Groups in Ghana, I say God bless you and grant you the grace lo excel in all your endeavours. While I sincerely share the credit for this work with all the people mentioned above, the responsibility for any short-coming is solely mine. Charlotte Monica Mensah v University of Ghana http://ugspace.ug.edu.gh ABSTRACT The study examined the accessibility and other socio-economic forces that influence the utilization of primary health care services in the rural parts of the Greater Accra Region of Ghana. Three administrative districts, Ga, Dangme West and Dangme East, were selected for study. Both qualitative and quantitative data were used. Questionnaire and interview schedules reinforced by focus group discussions and observations, were the main research instruments. Descriptive and multivariate techniques are the analytical tools. The main factors that influenced utilization as established by the empirical research, have been income, distance, transport and service costs, waiting and travel times, educational status in the analysis. The researcher establishes that, the main factors that influence utilization of primary health care services in the rural parts of Greater Accra Region are income and distance. The other factors are service costs, transport cost and waiting time. Income shows a positive relationship with utilization, whilst service cost exhibits a negative relationship to validate the hypotheses. Income makes a stronger impact than distance, service cost and waiting time. The impact of education, though statistically significant, is weak. There were differences by place of residence, and also by health status (patient and non­ patient). With regard to income, the impact at the Ga District is stronger than that of the Dangme West and Dangme East Districts, whilst non-patients are more affected than patients. With regard to distance and utilization, the Dangme East and Dangme West Districts show a stronger negative impact than the Ga District, whilst the impact of patients is stronger than non-patients. Waiting time and service costs have a greater impact in the Ga District than in the Dangme West and Dangme East Districts. For health status, patients are more affected by distance than non-patients. Several recommendations have been made to enhance utilization and the quality of health and health care. These include among others the strengthening and upgrading of primary health care facilities in the rural districts, improvement of the quantity and quality of medical and paramedical staff and the introduction of a National Health Insurance Scheme. University of Ghana http://ugspace.ug.edu.gh ACRONYMS AMA Accra Metropolitan Assembly BCG Bacillus Calvette Guverin CDR Committee for the Defence of the Revolution CHNs Community Health Nurses CWC Child Welfare Clinic DHA District Health Administration DHMT District Health Management Team DHT District Health Team DPCU District Planning Coordinating Unit DPT Diphtheria, Pertussis, Tetanus EPI Expanded Programme on Immunization GAR Greater Accra Region GDHS Ghana Demographic Health Survey GLSS Ghana Living Standards Survey HIV Human Immuno-deficiency Virus IUD Inlra-uterine Device MCH/FP Maternal and Child Health and Family Planning MOH Ministry ofHealth NDC National Democratic Congress NID National Immunisation Days OPD Outpatient Department University of Ghana http://ugspace.ug.edu.gh OPV Oral Poliomyelitis Vaccine PDC People’s Defence Committee PHC Primary Health Care SAP Structural Adjustment Programme SRN State Registered Nurse TBA Traditional Birth Attendant UNESCO United Nations Eduacational, Scientific and Cultural Organization UNICEF United Nations Children Fund WHO World Health Organization University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Declaration ... i Dedication ... ii Acknowledgements ... iii Abstract ... vi Acronyms ... vii Table of Contents ... viii List of Tables ... xviii List of Figures ... xiv CHAPTER ONE: INTRODUCTION 1.1 Tntroduclion ... 1 1.2 Statement of problem ... 4 1.3 Objectives ... 9 1.4 Literature Review .... 9 1.4.1 Definition of Health and Primary Health Care ..