The Delivery of Essential Health Services in Africa Realities and People's Perceptions and Perspectives REPORT SUBMITTED FOR THE NORTH WEST SITE IN NIGERIA Patients being attended to at the Health Facility in Gwagwada. Kaduna State Nigeria List of authors Dr Elizabeth O Elhassan - Sightsavers (Principal Investigator) Mr Oluwatosin Adekeye - Department of Psychiatry ABIJ Zaria (Co-investigator) Mr Sunday Isiyaku - Sightsavers Nigeria Dr Felicia NC Enwezor - Nigerian Institute for Trypanosomiasis and Onchocerciasis Research, Kaduna Dr Felicia Anumah - Department of Medicine, College of Health Sciences, University of Abuja Mrs Hafsat L Kontagora - Department of Social Development, Kaduna Polytechnic Ms Folake Ibrahim - Sightsavers Nigeria Mrs Tinuola A Olumeyan - Department of Cooperative Economics and Management Kaduna Polytechnic Mrs Eunice O Ohidah - Department of Education Technical, Kaduna Polytechnic f 2 Foreword It is hoped that the results of this study will strengthen the health system. Issues relating to the health system building blocks (leadership and governance, information, finance, technology, medicines and supplies, workforce and service delivery) highlighted by the study as well as the attributes (quality, access, coverage and safety) when addressed will lead to the desired outcomes of improved health, efficiency, responsiveness and social and financial risk protection of the population. Acknowledgements WHO/AFRO The Nigeria NorthWest team acknowledges the WHO/AFRO for technical and financial support for the study. Sightsavers, Nigerina Institute for Trypanosomiasis Research, Kaduna Ahmadu Bello University and Kaduna Polytechnic for releasing staff to participate APOC For coordinating and providing technical assistance for the study The Governments of Kaduna and Jigawa States For cooperation during the study at the states and local government levels Federal Ministry of Health For their cooperation and support at the national level Members of the study communities For their enthusiasm and active participation in the study Community members For their time and invaluable contributions to the discussions 4 Executive summarT There is an urgent need to efficiently improve the delivery of health services to communities who are the end users of health care. This has led to a global movement aimed at renewing primary health care, a call that has been echoed at international, regional and national conferences, including WHO regional committee meetings. However lack of resources and practical implementation strategies has created a need to accelerate progress in achieving universal health goals and the MDGs. Community involvement is currently considered key to the success of health care delivery especially given the successes recorded in previous control programmes such as eradication of the guinea wonn and control of river blindness. The community directed interventions for major health problems in Africa has been demonstrated to be an effective strategy for malaria TB, and child nutrition (vitamin A supplementation). This study therefore intends to bridge the gap between health service delivery and communities as a means to improving the delivery of PHC by documenting the perceptions of health and experiences within essential health care services. Process and methods The study was carried out in 24 communities in two states (Kaduna and Jigawa) in North West Nigeria. The communities were randomly selected from six districts covering urban, peri-urban and rural. The multi-disciplinary study combined three analytical designs originating from public health and social science research, i.e. cross-sectional surveys, qualitative inquiry and case study research. This allowed for a description and analysis of community perceptions, experiences and expectations of health and health care services within the context of district-based health systems in Nigeria. The cross sectional household survey was based on an interviewer administered instrument while the qualitative inquiry focussed in-depth interviews and focus group discussions. The case study design was based on document reviews and in-depth interviews with principal officers at the state and district levels (health, budget and planning). Results Health was perceived mainly as a state of physical well being as indicated by the ability to move around (92.9% urban, 85% peri-urban & 89.3% rural) and work (96J% urban, 87.9% peri-urban & 94.6% rural). Feeding, hygiene and sanitation were considered important in staying healthy across the districts. Essential health care services provided at the districts were the treatment of ailments, prescription and dispensing of drugs, antenatal care, immunisation services, childbirth, counselling of patients and malaria treatment and prevention. There was a general dissatisfaction(64.6%o urban & 66.1% rural) with the provision of health care based on the perceived high cost of services, unavailability of drugs, unavailability of health personnel or a health facility and distance to the facility. There was a moderate satisfaction (58.2%) in the peri-urban area because of special district health initiatives especially in Jigawa state. While there was a general dissatisfaction with service delivery the respondents perceived the facility (44.6% urban, 59.3% peri-urban & 52.5% rural) as good. Community members to some extent were involved in health service delivery such as planning, collection of drugs, mobilisation of the community for certain health activities and awareness creation. This had been facilitated by previous experience with other health activities leading to a willingness to continue to participate in health activities. Participation in health care had been in the area of assisting in caring for patients (20.4% peri-urban), sanitation (1 1.S% urban),Umanagement of the facility (14.3% peri-urban) and in some cases the selection of community volunteerc (3.2%o). Conclusions The general perception of health care delivery in the study area was poor based on the experiences and involvement with the health service. This was despite the fact that there were some health initiatives going on within some of the districts. The community members' expectations of the health service delivery system were not adequately met. There was however an overwhelming willingness and readiness to engage with the health service based on previous experiences with other health programmes and the availability of social capital within the community. There are no structured systems of reimbursements for procured drugs except in a few instances where this is done by community associations. Govemment was the major financier of health in the study site; alternative mechanisms such as social health insurance were non existent and thus there was no social and financial risk protection. Based on the outcome of the study, there is a need for improvement of health service delivery in the areas of coverage, service delivery, policy and leadership inline with the PHC reforms. Also the performance of the health systems should be assessed using the WHO health system framework with due attention paid to planning and M&E. This would change the perception and perspectives of community members and also strengthen community engagement. 6 List of acronyms Acronym Description AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care APOC African Programme for Onchocerciasis Control CBO Community Based Organisation CHEWs Community Health Extension Workers CHOs Community Health Officers DFID Department for International Development EHA Environmental Health Attendants EHO Environmental Health Officer EPI Expanded Programme on Immuni zation EU European Union FCT Federal Capital Territory FGDs Focus Group Discussion FLHFs Frontline Health Facilities IEC Information, Education and Communication IDIs In-depth Interviews ITNs Insecticide Treated Nets JCHEWS Junior Community Health Workers KII Key Informant Interview LGAs Local Government Areas (LGAs) M&E Monitoring and Evaluation MCH Maternal and Child Health NGOs Non-Governmental Organization NHMIS National Health Management Information System NPHCDA National Primary Health Care Development Agency NPI National Programme for Immuni zation SCHEW Senior Community Health Workers TB Tuberculosis (TB) UN United Nations LINDP United Nation Development Programme LINICEF United Nations children Emergency Fund USAID United State Agency for International Development wHo World Health Organization 7 List of authors.... ..... ... ...1 Foreword. ............2 Acknowledgement. ..........4 Executive summary. ........5 List of Acronyms. ...........7 6. Table of contents ..........8 7. Introduction.. ............9 7.l.Literubtre review. ......10 7.2. Rationale.... ..... ......1 1 7.3. Background........ .......................9 8. Purpose and Objectives........... .........._........144 4.1. Overall research questions ..................I44 4.2. Overall research objective... ..................14 4.2.1. Specific research objectives .........14q 4.3. Conceptual framework......... ...................155 9. Methodology.......... ....................16 9. 1 . Study design ....... ................. 1 6 9.2. Study sites and study population........ .....................16 9.3. Samp1ing............ .................18 9.3.1. Selection of health regions and districts................ .............19 9.3.2. Selection of communities within districts ......200 9.3.2.1Actual Sampling inNorthwest Site........ ........21 9.3.3. Household sample for survey research at