Public Perception on the Effectiveness of Indigenous Healthcare Delivery System in Enugu State
CHAPTER ONE
Objectives of the Study
Overall Objective
To examine factors which impede Indigenous Health care delivery in Enugu.
Specific Objectives
- To identify Indigenous Health care facilities and services provided in Enugu State.
- To identify constraints faced by Indigenous Health care facilities in Enugu State.
- To investigate barriers which people face in accessing health services in Enugu State.
- To examine community participation in Indigenous Health care in Enugu State.
- To propose the way forward for improving Indigenous Health care delivery in Enugu State.
CHAPTER TWO
LITERATURE REVIEW
The World Bank (2009) conducted a survey entitled Indigenous Health Care Delivery in Nigeria. The study found out that (i) services provided by Indigenous Health care facilities varied significantly depending on the size of the facility and (ii) most health facilities had decaying infrastructure, did not offer basic services, lacked equipment, personnel, pharmaceutical and medical supplies. The study concluded that these factors made it difficult for the health facilities to offer a range of services which they were supposed to provide at Indigenous Health care level. The study also found that factors such as low personnel qualifications, low job satisfaction and poor remuneration undermined the efficiency of Indigenous Health care services in Nigeria.
The study by the World Bank (2009) was important to this research because it identified problems faced by Indigenous Health care facilities such as lack of drugs, equipment, pharmaceuticals and staff. The literature by the World Bank was beneficial to this research because the research sought to find out how the identified problems impact on service delivery by Indigenous Health care facilities in Enugu State. However, this literature did not provide information on the supply chain of the identified medical supplies to health facilities and how often stock outs of essential supplies occur. For example, there was need to know how long it took health facilities to get replacement whenever essential supplies run out. This research also found out what category of health personnel which is in short supply going by the required staff establishment for Indigenous Health care facilities and how frequently stock outs of essential supplies occur. This research therefore sought to fill the identified gaps.
Das Gupta and Rani (2003) in Strengthening Indigenous Health Care in India, found out that strengthening Indigenous Health care was an effective means of reducing communicable and non communicable diseases like HIV/AIDS, tuberculosis and malaria. In combating HIV/AIDS, the strategies used were prevention, care and surveillance. For sexually transmitted diseases, awareness raising and condom provision were part of the prevention programme which was used. Knowledge of HIV/AIDS grew and the programme managed to reduce HIV/AIDS infections by 10% within a year although in rural areas, the prevalence rate remained high due to low level of knowledge about the diseases. Similary, a malaria prevention and control programme managed to reduce malaria cases from 1,650, 000 in 2003 to 945,000 in 2005. Strategies which were used are early diagnosis, prompt treatment, promotion of mosquito nets, in – door residual spraying, Information, Education and Communication (IEC) materials and community conversations. Furthermore, the study found out that by training community members in Direct Observation Treatment (DOTS) 85% of tuberculosis patients were being cared for by community members. The programme had promoted early detection and effective treatment of the diseases.
Although the survey observed that the majority of public health clinics were found to be clean and functioning, there were some suggestions of poor quality services, as some of the conditions that were reported to be the main causes of morbidity and mortality in children namely diarrhea, lack of vaccines and preventable diseases could not be handled by the clinic. Simple treatments for conditions such as childhood diarrhea were not available in 70% of the health facilities surveyed.
CHAPTER THREE
RESEARCH METHODOLOGY
Research design
Five (5) out of 20 identified health facilities organised events in the communities such as soccer tournaments, drama, traditional dances and popular theater. These events were aimed at mobilizing people who came to attend such activities to access health services. On the sides of these events, VCT and family planning services were provided. These health facilities also made use of local and national events being commemorated in their communities such as the Independence Day, World AIDS Day, local sports tournaments and traditional ceremonies to provide health services and health education at such gatherings.
Three (3) out of 20 identified health facilities conducted household visits to inspect sanitary facilities. Four (4) out of 20 health facilities had trained malaria agents who were providing indoor residual spraying to households in their community.
Sensitisation on hygiene and malaria were also done during household visits.
The study found out that 9 out of 20 identified health facilities carried out inspections in the communities to ensure compliance with environmental health practices. Food and water samples from these trading places were also taken for testing. Samples of water from wells and boreholes were also taken in order to assess the quality of the water which people were using in the communities.
CHAPTER FOUR
COMMUNITY PARTICIPATION IN INDIGENOUS HEALTH CARE
Scope of Community Participation in Indigenous Health Care
Planning and Management
The study found out that there are decentralised structures of heath care management in Enugu State known as Neighborhood Health Committees (NHCs). All the identified health facilities serviced specific catchment areas and within a catchment area there were several Neighborhood Health Committees (NHCs) which worked hand in hand with health facilities. At the health facility level, each health center or health post has a Health Center Committee (HCC) which is made up of all the Chairpersons of NHCs in the catchment area serviced by the health facility. During the annual planning process for the district, NHCs, who are representatives of the community, meet with members of the community to review experiences, determine priorities and to agree on community actions. Community representatives thereafter meet with staff at the health facility to draft community action plans. The community action plans are then submitted to DHMT for inclusion into the district action plan which is later submitted to the Ministry of Health through the Provincial Health Office, Government of the Republic of Nigeria (2010). Communities in Enugu State participated in the day to day management of health facilities through their elected representatives who are Chairpersons of the Neighborhood Health Committees (NHCs). Chairpersons of NHCs are members of the Health Center Committees (HCCs).
The HCCs were responsible for managing the operations of health facilities.
Budgeting
Community members in Enugu State participate in budgeting for health care activities in the district. Every year Neighborhood Health Committees (NHCs) identify activities which they want to undertake and these are submitted to Enugu State Health Management Team (CDHMT). After the community action plans have been submitted to CDHMT, NHCs are then given budget ceiling for their action plans which they use as a guide in budgeting for community health activities. At the health facility level, community representatives (Chairpersons of NHCs) also take part in formulating the budget for the health center or health post as members of the Health Center Committees, (Ibid).
CHAPTER FIVE
CONCLUSIONS AND RECOMMENDATIONS
Conclusions
The study has concluded that although health facilities exist in Enugu State, they are inadequate to meet the needs of people in the communities. As discussed on page 46, lack of expansion in existing health facilities and construction of new ones in light of population increase has rendered the available health facilities to be inadequate. This had led to overcrowding in most health facilities.
The study has concluded that the infrastructure and equipment in most Indigenous Health care facilities in Enugu State is poorly maintained based on the number of health facilities with non – functioning equipment and those in need of repair, maintenance or renovations. As discussed on page 48, some health facilities could not provide immunisation services on daily basis because refrigerators were not functioning and hence failed to sustain vaccine stocks. Breakdowns in the radio communication system and solar power affected effective delivery of Indigenous Health care in most health facilities.
The study has concluded that most health facilities in Enugu State provide the Basic Health Care Package which is supposed to be provided at Indigenous Health care level. However, there was no integration in the provision of health services. As discussed on page 54, all services provided by health facilities have been allocated specific days on which they can be accessed and all the identified health facilities did not operate for 24 hours a day.
The study concluded that the number of households dissatisfied with service provided by health facilities in Enugu State is high. As discussed on page 61, the major causes for these were long period of waiting time, lack of personnel and lack of respect or attention.
The study has concluded that shortages of personnel in Indigenous Health care facilities impede delivery of health services. As discussed on page 64, 13 out of 20 identified health facilities had shortages of personnel, this made it difficult for the available staff to operate effectively due to high workloads and some health facilities were also using cleaners to attend to patients.
The study has concluded that shortages of equipment in health facilities compromise the delivery of health services in Enugu State. As discussed on page 73, shortages of equipment made it difficult for health facilities to provide health services on a continuous basis because certain services could not be performed in the absence of required equipment.
The study has concluded that stock out of drugs in health facilities hinders effective delivery Indigenous Health care in Enugu State. As discussed on page 67, it took about 3 weeks for some health facilities to get supplementary drugs when they ran out of stock, this led to disruption in provision of health services.
The study has concluded that inadequate funding prevents many health facilities from effectively sustaining their operations. As discussed on page 72, many health facilities could not perform their core functions such as providing environmental services as well as community outreach programmes because their budgetary allocation could not meet the costs of conducting these activities on a regular basis.
The study has concluded that access to health services by people in Enugu State is hindered by physical, social, economic, cultural, quality of services provided and information barriers. As discussed on page 76, 78 and 81, distance to the health facilities coupled with poor state of roads acts as a disincentive in accessing health services. Although the government adopted a policy of free health care, there are still indirect costs to accessing health services which people incur hence lack of income is still an obstacle to accessing health care.
The study has concluded that there is poor community participation in Indigenous Health care delivery in Enugu State. As discussed on page 93 and 98, community participation in Indigenous Health care in Enugu State is hindered by limited training of community health workers, lack of motivation, lack of interest, personal commitments, ignorance and inadequate support to community health workers.
Recommendations
The study recommends that the number of health facilities should be increased in order to increase health service delivery capacity in Enugu State. Expansion of existing health facilities should also be done to enable them cope with the increase in demand for health services due to population growth.
The study further recommends that a programme should be put in place to focus on regular maintenance of health facilities in order to enable them function effectively. Regular assessments of health facilities should also be conducted in order to appraise the infrastructure in health facilities.
The study recommends that there should be integration in the provision of health services in health facilities so that people should be able to access all the services they need whenever they visit a health facility. Furthermore, all health facilities should operate for 24 hours in a day and should be open on public holidays in order to enhance access to health care.
The study recommends that more health personnel be recruited and should be equitably distributed in all health facilities based on the existing staff establishments. There is also need to strengthen managerial and administrative procedures to ensure that staff shortages which occur as a result of health personnel going on leave, transfer and retirement are expeditiously taken care of to avoid disruptions in the delivery of health services.
The study recommends that availability of equipment in health facilities should be improved by: (i) establishing and maintaining an equipment database system which will provide information on the status and adequacy of equipment in Indigenous Health care facilities; (ii) developing and implementing appropriate equipment development plans so as to ensure a planned and coordinated approach to equipment management, (iii) ensuring compliance with the established maintenance policy and guidelines at all levels and (iv) improving capacities for management and maintenance of equipment at all levels.
The study recommends that the distribution of drugs to health facilities should be strengthened to make it more effective by; (i) ensuring adequate supply of drugs to health facilities by giving them more than the average quarterly allocation they get and; (ii) developing and implementing a contingency or emergency plan to sustain the supply of drugs in an event of stock outs.
The study recommends an increase in the amount of funding to health facilities in Enugu State to enable them meet the costs of their operations and funding to health facilities should also be consistent with their monthly action plans.
The study recommends that the following should be done to increase access to health services including ART by people in Enugu State: (i) constructing of more health facilities to cope with increased demand for health services due to population growth. (ii) sufficiently stocking health facilities with needed supplies to avoid passing the costs of these supplies to patients; (iii) health facilities should also stop charging all forms of penalty fees; (iv) improving the quality of services provided by health facilities through increasing availability of trained personnel to reduce waiting time by patients.
The study recommends that the following be done to improve community participation in Indigenous Health care in Enugu State: (i) train more community health workers; (ii) Scale up of behaviour change communication to enable people assume responsibilities for their health at individual, household and community level; (iii) provide adequate support to community health workers through regular provision of drug kits and empowering them with income generating activities.
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