ASSESSMENT OF BARRIERS TO THE UTILIZATION OF PRIMARY HEALTH CARE SERVICES ( A CASE STUDY OF BATSARI LOCAL GOVERNMENT AREA OF KATSINA STATE)

CHAPTER ONE

INTRODUCTION

A PHC-based health system is an overarching approach to the organization of health systems designed to improve population health and maximize equity. Such an approach makes the right to health a guiding principle of the health system, with the health system structures and functions oriented towards achieving equity in health and social solidarity, based on a core set of principles and elements. Primary health care can also act as the basis of the healthcare system by establishing fundamental policies, programs and priorities that respond to the population health needs. In Nigeria, a notion of primary health care is seen as a defined set of services, which are in accordance with local needs, and it is an entry point into the health care system.¹ the services at that level alone are not sufficient to adequately cater for the more complex health needs of the populace. Thus health care systems should work in an integrated manner through the development of mechanisms that coordinate care across the entire spectrum of services, including referral systems.

With this background in mind we can conveniently say the history and development of health systems in Nigeria can be classified in accordance with the historical evolution of the nation into; Pre colonial period, Colonial and post colonial era. The health care system in the pre colonial period was both a combination of the orthodox and the modern which was tailored towards serving the need of the missionaries and the slave traders , the modern system was able to serve them with basic services comparable to their level of development , in the colonial period the first national development plan called the 10 years national development plan and social welfare (1946-1956) was a modest ,realistic, practicable and adequate plan considering the era in which it was proposed , it provided a plan for the provision of more hospitals , more personnel ,especially doctors and perhaps it is this its therapeutic and infrastructure based orientation and disposition that has persisted up till today leading to neglect of preventive services by our policy makers

The third national development plan 1975-1980 highlighted serious concerns for rural development with a need to reduce disparities between regions and localities and a fall out of this process is the basic health service scheme, whose major strengths are, ⁴

Delegation of responsibilities to non physicians in order to augment the deficiencies of doctors.

Location of training centres in environments similar to where trainees will serve. Use of home based care records to increase patient’s participation in health care.

The Basic health service scheme failed at the end due to the neglect of more important principles of PHC like community participation and intersectoral collaboration.^4,74

It is supposed to be the first level of care for individuals and families with the national health systems and it should at least be able to provide the following components.⁸⁰

1. Immunization against the major communicable diseases

2. Prevention and control of locally endemic diseases and epidemics

3. Maternal and child health including family planning

4. Environmental sanitation including adequate water supply and hygiene

5. Health education on the prevailing health problems and the methods of controlling them

6. Adequate nutrition through promotion of food supply and proper nutrition

7. Provision of essential drugs

8. Appropriate treatment of common diseases and injuries

Recently mental and dental care as well as primary eye care has been included as other components of primary health care. The basic principles of the PHC system are essential health care, community participation, equity, appropriate technology and intersectoral collaboration.

Due to the palpable demand for a grass root based health care system , the WHO in conjunction with UNICEF organized the Alma Ata conference in Kazakhastan (USSR) in 1978, The conference was a scientific movement of professionals, institutions, governments, civil society organizations, researchers and grass roots organizations that undertook to tackle the politically, socially and economically unacceptable health inequalities in all countries, the declaration was clear about the values of social justice, right to health for all, community participation and solidarity, with the overall aim of the attainment of a level of health that will ensure a socially and economically productive life for all by the year 2000.⁵

A part from the basic health service scheme which failed due to the circumstances enunciated above, a second attempt at implementing PHC was done in 1980 and 1985 , during this period the government began the implementation of the various programmes of PHC in pieces without any attempt to integrate them and without any clearly mapped out plan and objectives, this led to the fragmentation of services with both the states and federal governments pursuing different objectives agreeable to them and to donor agencies interested in some of the programmes.

A deliberate attempt to adapt and nationalize the entire components of the PHC system started in 1986 in 52 pilot LGAS, which culminated in the adaption of the national health policy by the armed forces ruling council in 1987 and launched in 1988.^6,7 The goal of the national health policy is the attainment of a level of health care that will enable Nigerians live and achieve socially and economically productive lives, through the emergence and institutionalization of a comprehensive primary health care system ,that is promotive, protective ,restorative and rehabilitative.⁷ By 1990 the federal government has extended the PHC system coverage to all the LGAs of the country.⁸

1.1 Statement of the Problem

The fundamental problems of PHC as outlined at the Alma Ata conference have been recognized and respected by all nations and yet there are divergences and ambiguities in interpretation across countries worldwide, a recent report by WHO African region puts the level of PHC utilization at 5-7%,⁹ this translates to about 95% underutilization of the services , despite the monumental budgetary expenditure on PHC through mass construction of clinics, staffs recruitment ,continuous training and series of collaborations across all sectors

The 2009 world development report released by UNDP and the national demographic health survey 2008 portrays the extent of poor utilization of primary health care system in the nation in general and the northern states in particular, as the level of utilization of individual components of PHC is very poor, for example the overall national immunization coverage is 29% and state like Katsina recorded less than 1% coverage for all antigens, national contraceptive prevalence rate was 15% and 1% in Katsina, the state had antenatal coverage of 14.4% and only 4.7% of women delivering in the hospital.^10,11

In view of the fact that so much investment has been done and is still being done by all sectors of the government towards strengthening the system, yet patients still by pass the it and go to other secondary and tertiary centres , therefore over stretching the existing secondary and tertiary health facilities, there is therefore a need to for a study to analyse the various barriers to effective PHC utilization as well as explore all the broad issues affecting health at the primary health care level.

1.2 The Research Question

Based on the Alma Ata declaration, primary health care is supposed to function on the principles of equity and social justice which will serve as a vehicle for the attainment of the legendary health for all by the year 2000, ¹² the essential components of primary health care have been outlined, but numerous factors serve as barriers to the utilization of these essential services, it is imperative therefore that a research is carried out to highlight these factors, hoping that this findings will enrich academic discussions and affect policy making towards finding a realistic solution to the problem of health care at PHC level.

1.3 Justification for the Study

In line with the global commitment for health for all by the year 2000 and in consonance with the declaration of Alma Ata, Nigeria adapted primary health care as the first level of care to provide a comprehensive preventive, curative and restorative care for its citizens., The demand for primary health care services are daily dwindling and the expenditure on the part of the government and other stakeholders is on the rise, yet there is a decline in the rate of utilization.^13,14,15 Thirty two years after the Alma Ata conference the services at the primary health care level are deteriorating and the care been offered is either inverse or fragmented, and in most cases impoverishing in nature, this justifies the need to ascertain why despite the monumental investment the services are not improving, and despite the increase in the number of primary health care centres and primary health services in the state in particular and the nation in general, the indices for morbidity and mortality are on the rise.^16,17

As an additional measure of commitment on the part of the Government, the nation has also invested heavily on the primary health care in policies, infrastructures and institutions, in terms of policies for instance the national health policy 1988 had primary health care as its fulcrum and the revised 2004 national policy also retained PHC as its major fulcrum too, the establishment of the national primary health care development agency NPHCDA to provide technical guidance as well as source and mobilize resources for PHC in Nigeria is also an added another measure of commitment, likewise the huge expenditure on PHC by the nation in terms of man power and material resources , despite all these the people still by pass the PHC system leading to congestion and over stretching of the nations secondary and tertiary health centres.

Some other achievements in the nations attempt to institutionalize primary health care include the rolling out and the entrenchment of the Bamako Initiative in 1988, the complete demarcation of the roles and responsibilities of the three tiers of government , the introduction of the referral system as well as the establishment of schools of health technologies to provide available and affordable critical manpower gaps in the sectors, the institutionalization of the concept of ward and village development committees as well as some degree of intersectoral collaboration.