CPED Policy Brief Series 2015, No. 3
KEY FINDINGS OF THE PRIMARY HEALTH CARE STUDY IN DELTA STATE, NIGERIA
Policy Brief by
Centre for Population and Environmental Development, CPED
This Policy Brief is supported by Governance for Equity in Health Systems Program of the International Development and Research (IDRC) and the West African Health Organisation (WAHO) as well as the Think Tank Initiative also of IDRC.
(C) Centre for Population and Environmental Development (CPED)
BS-1 and SM-2, Ugbowo Shopping Complex,
Ugbowo Housing Estate,
P.O. Box 10085, Ugbowo Post Office,
Benin City, Nigeria.
All rights reserved. This Policy Brief is copyright and so no part of it may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, electrostatic, magnetic tape, photocopying, recording or otherwise without the express written permission of the publisher, and author who is the copyright owner.
First produced in 2015
Professor Andrew G. Onokerhoraye
Executive Director, CPED, Benin City
This policy brief is the fourth in the series of communication to policy and decision makers on the on-going research project of the Centre for Population and Environmental Development (CPED) titled “Strengthening the health system in Nigeria through improved equitable access to Primary Health Care (PHC): The Case of Delta State, Niger Delta region” funded by IDRC and WAHO.
The policy brief series is designed to draw attention to key findings and their associated policy implications as the project is being executed. This series number presents a summary of the key findings of the research project as outlined in the interim report for the attention of policy makers.
We are particularly grateful to IDRC and WAHO as well as the Think Tank Initiative for the support to CPED which has enabled the Centre to carry out the study and the publication of this policy brief. We also appreciate the corporation of the Delta State Government and other stakeholders within and outside Delta State in collaborating with CPED in the execution of the on-going research project so far.
Andrew G. Onokerhoraye
Key Findings of the Primary Health Care Study in Delta State, Nigeria
The Primary Health Care (PHC) study in Delta State collected data from public and private PHC facilities in nine Local Government Areas (LGAs) selected from the three senatorial zones in the state. The LGAs are: Aniocha North, Bomadi, Ika South, Isoko North, Ndokwa East, Okpe, Udu, Ughelli South and Warri North. It was designed to provide information on the general performance and utilization of PHCs that offer primary health care services including maternal, child, and reproductive health services as well as services for specific infectious diseases, such as sexually transmitted infections (STIs), HIV/AIDS, tuberculosis (TB), and malaria. Information was collected, using facility audit questionnaires, interviews with health service providers, observations of client-provider consultations, household surveys and exit interviews with clients, to assess the capacity of facilities to provide good quality services and also to assess the existence and the strengths and weaknesses of infrastructure and systems to support these services. The survey also sought to assess adherence to standards in the delivery of curative care for sick children, family planning, antenatal care (ANC), normal and complicated deliveries. Community health workers, community stakeholders and mothers of children were interviewed in a sample of communities in the nine LGAs where these PHC facilities were surveyed. Focus group discussions and key informant interviews were held with various stakeholders on their assessment of PHC services in their respective communities. Feedback from respondents and other stakeholders on the findings of the study was also carried out in the target LGAs.
The project is funded by Canada’s International Development Research Centre (IDRC), Ottawa and the West African Health Organization (WAHO). The general objective of the project is to contribute to a body of evidence on the strengthening of the health system in Nigeria that can influence the development, modification and implementation of policies on equitable access to health care with specific focus on the primary health care services. This section presents a summary of the key findings of the study based on the major components of the study. A more detailed presentation of the findings is in Part B of this report.
2. Demographic Characteristics of the Population served by PHCs
· The study shows that households sizes of between 3 and 6 members account for almost three-quarters of all the households in the study areas. This large household size that dominates the study areas has implications for access and utilisation of PHC services as the financial burden of health care is high among the vast majority of the population. Often this results in selective health care in which some members of the household are given priority attention when they are sick because of their perceived importance in the household.
· Over 45 per cent of the members of the households are less than 29 years most of whom are not in employment while about 5 per cent are beyond the age of 60 years which indicates that they may not be in employment any longer. This pattern has considerable implications for primary health care demand and use. While the demand for PHC services is obviously high among the people who are dependent on the working population, the ability to pay for primary health care services is low considering the fact that they depend on the less than 50 per cent of the household members that are probably working.
· Heads of households constitute just about 21 per cent of all household members in the study areas. Since the household head often carries out the main financial burden of care for the needs of the other members, this implies that about 80 per cent of the household members depend, in one way or the other, on the 21 per cent that constitute the household head. Furthermore over 41 percent of the household members are children who are not only dependants but require special health attention. These two characteristics of the household composition in the study areas have implications for primary health care demand and utilisation.
· The high proportion of the married within the households which on the average for the study areas, is higher than 45 per cent indicates that there is a high demand and need for maternal and child health care. This requires an appropriate response by primary health care centres. Children of less than 10 years constitute about 15 per cent of the population and this again has implications for the demand for PHC services. It was also found in the study that the dominant users of PHC services are women and children.
· The fact that about 80 per cent of the members of the households attained at least primary education level has implications for the demand and use of primary health care services as most of them are knowledgeable on health care issues. This pattern is also reflected in the educational level of users of PHCs. Key informant interviews and focus group discussions show that the vast majority of the people are aware of the challenges facing PHC services delivery in their communities and did indeed propose strategies for improving the situation.
3. Primary Health Care Level- Health Facilities and Equipment
· A full package of guidelines for the management of various key basic ailments —which includes management of malaria, integrated management of child illness, treatment and care of people with HIV/AIDS, PMTCT of HIV and family planning is available in about 60 per cent of the PHCs and more significantly in private owned PHCs.
· A full package of general purpose health management equipment including blood pressure machine, stethoscopes, microscopes, weighing scale for adults, weighing equipment for under-five, hand gloves, syringes and needles, and refrigerator is available in about 50 per cent of the PHCs and more significantly in private owned PHCs.
· A full package of different types of drugs and supplies including injectable antibiotics, oral antibiotics, oral contraceptive pills, IUCD, injectable contraceptives, vitamin A capsules, vaccines and first-line anti-malarial drugs is available in about 65 per cent of the PHCs and more significantly in private owned PHCs.
· A full package of different types of laboratory test facilities including urinary test, pregnancy test, ova parasite test, blood count, malaria parasite, PCV, and sugar test is available in about 20 per cent of the PHCs and more significantly in private owned PHCs.
· A large proportion of the PHCs do not have beds for the admission of patients when the need arises. In those PHCs which have admission bed facilities about 70 per cent are actually functioning.
· Less than 30 per cent of the PHC facilities have regular water supply, i.e., year-round water is supplied by a tap in the facility from a protected or unknown source, or water is supplied from a protected well or pump, and water outlet is available within 500 meters of the facility. One of every four PHC facilities has regular electricity or generator with fuel. Overall, only one of every ten facilities have regular supplies of water and electricity as well as client comfort amenities such as a functioning client latrine, a protected waiting area and a basic level of cleanliness.
· In terms of communication, it was found that the commonest means of communication is the cellular phone (GSM), but found in only 24.33 per cent of the PHC centres. This is followed by computer facilities (found in only 5.67 per cent of the centres), landline phone (2.22 per cent of the facilities) and shortwave radio facilities (1.89 per cent).
4. Primary Health Care Services
· The commonest illness reported in the study areas is malaria, which accounts for 42.67 per cent of all reported cases. The second most prevalent type is diarrhoea, which accounts for 17.11 per cent of all the cases reported. Since these illnesses can be handled by primary health care centres, it shows the need for them to be prepared to handle such cases in their localities. Of course most of the patients handled are women and children. The PHC staff interviewed reported that malaria constitutes about 62 per cent of the cases which people bring to their PHC centres.
· The survey shows that 30.44 per cent of sick and injured household members visited ‘public’ PHCs while 23.56 per cent of such persons visited ‘private’ PHCs. Furthermore, 14 per cent of household members visited pharmacist/chemists, while 13.78 per cent visited traditional healers. Community-owned health centres were visited by 12.67 per cent of all sick and injured household members. The findings show that about 67 per cent of household members that were sick in the last four weeks preceding the survey visited public primary health centres with about 23 per cent using private primary health centres. It shows further that about 28 per cent still visit traditional healers or private chemists. This is a challenge to primary health care services in the study areas as there is need to encourage such household members to use public or private primary health centres.
· A full package of primary health services including immunization and mother-child care, child delivery, family planning, ante-natal/post-natal care, treatment of minor ailments, HIV Testing and Counselling, Health Education Talk, and dental care services is available in less than 10 per cent of the PHCs and most of these are private PHCs.
· Geographic proximity is a major determinant of the utilization of PHC centres. On the average, 27 per cent of the respondents live within 14 minutes of the nearest PHC centre while about 29 per cent live within 15-30 minutes and 21.78 per cent of all respondents live within 31-45 minutes of the nearest centre. The most disadvantaged group, (living more than 60 minutes of the nearest centre), constitute 10.56 per cent of the respondents. Although some localities are indeed very far from the available PHCs, the general pattern is that PHCs are fairly accessible geographically to the people of the study areas.
5. Maternal and Child Health Care
· An average of about 45 per cent of the female members had live births in the twelve months preceding the survey. In terms of health care high birth rates imply increased demand for maternal and child health care in the study areas.
· The finding that about 70 per cent of the female members that were pregnant received prenatal health care shows that a considerable proportion about 30 per cent do not use prenatal health care services which is a major challenge for maternal health care in the study areas.
· ANC services are available in 70 per cent of PHC facilities and close to 60 per cent of them offer postnatal care (PNC), and tetanus toxoid (TT) vaccine. Overall, only a little over 50 per cent of ANC facilities have visual aids, ANC guidelines, and individual client cards —items considered important for provision of quality ANC counselling.
· Less than 50 per cent of ANC facilities in PHCs have all five essential supplies for basic ANC services (blood pressure apparatus, foetoscope, iron and folic acid tablets, and TT vaccine) for basic ANC. All infection control items (soap and running water or else hand disinfectant, latex gloves, disinfecting solution, and sharps box) are available in less than 40 per cent PHC ANC facilities. About 40 per cent of the facilities that offer normal delivery services have all infection control items (soap and running water or else hand disinfectant, sharps box, disinfecting solution, and clean latex gloves) at the service site.
· Less than 25 per cent of the PHC ANC facilities have all medicines for managing common complications of pregnancy (a broad spectrum antibiotic, an antihelminthic, a first-line antimalarial, an antihypertensive, and at least one medicine for treating each of the following reproductive tract infections: trichomoniasis, gonorrhoea, chlamydia, syphilis and candidiasis).
· All basic equipment and supplies for conducting normal deliveries (scissors or a blade, cord clamps or ties, a suction apparatus, antibiotic eye ointment for the newborn, and a disinfectant for cleaning the perineum) are available in the delivery area in about 30 per cent of PHC facilities offering delivery services. The availability of each of these items individually ranges from 75 percent of facilities having antibiotic eye ointment to 97 percent having scissors or a blade at the service site.
· Approximately 50 per cent of PHC facilities offer all three basic child health services— outpatient curative care for sick children, childhood immunisations, and growth monitoring. Practically all facilities offer outpatient curative care for sick children. Out of the facilities offering outpatient curative care for sick children, about 70 per cent have treatment guidelines for sick child services.
· Complete evaluation of sick children for general danger signs (the sick child’s inability to eat or drink, vomiting everything, and febrile convulsions) during sick child visits are not routinely done in most of the PHC facilities largely because of the lack of adequate staff.
6. Primary Health Care Personnel
· Female employees dominate the employment structure of the PHCs as over 90 per cent of the PHC staff interviewed are females, except in PHCs located near urban centres where males are quite significant. It appears women are pushed to rural PHCs in the study areas.
· About 9 per cent of the staff of the PHCs are medical doctors but most of these are in Private PHCs. Midwives and nurses are the largest category of PHC staff followed by auxiliary nurses and community health personnel.
· Less than 50 per cent of the staff in the PHCs are professionally trained in basic PHC health care delivery skills such as IMCI, Maternal and child health, life saving skills, adolescent sexual and reproductive health, HIV/AIDS opportunistic infection treatment, PMTCT of HIV, Family Planning and STI diagnosis and treatment.
· Less than 50 per cent of the PHC staff are involved in outreach PHC services such as home visitation and follow up, immunization, home service and mobilization of community people on PHC activities. Nearly all staff interviewed reported that they need assistance with transportation to better visit households and to facilitate the travel of the sick to secondary health facilities during referral.
· Only about 30 per cent of the staff reported that they received regular supervision from the Ministry of Health and its agencies.
7. Primary Health Care Governance
· PHC providers, especially in the public sector identified a number of constraints affecting the effective management and delivery of PHC services including inadequate equipment and personnel, poor management structure, poor housing and sanitary environmental condition and lack of drugs and laboratory services.
· Less than 40 per cent of the PHCs promote the participation of the community members in PHC activities such as planning and design, environmental sanitation, building public toilets and monitoring project implementation.
· Approximately 54 per cent of the PHCs reported that they have functioning Health Management Committees embracing community members. However over 30 per cent of the committees did not meet in the year 2013 preceding the surveys in 2014.
· The factors identified by PHC staff as responsible for the poor performance of Health Management Committees include lack of financial motivation for their participation and lack of knowledge of the part of community members on the importance of the Health management Committees.
PHC is a key foundation of effective health systems in Nigeria as in other parts of the country and indeed developing countries. Despite evidence documenting the benefits, Delta State has not achieved a universal access to PHC services as reflected in the findings of this study. Provision of PHC requires political will, intersectoral collaboration, sufficient human, physical and financial resources, and community participation.