the effect of a donor support on district health service ...

THE EFFECT OF A DONOR SUPPORT ON

DISTRICT HEALTH SERVICE UTILIZATION IN

ENUGU STATE.

DISSERTATION SUBMITTED BY

EDMUND O. NDIBUAGU

DEPT OF COMMUNITY MEDICINE, UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ENUGU

THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF

NIGERIA

IN PART FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF

THE FINAL FELLOWSHIP OF THE MEDICAL COLLEGE IN PUBLIC HEALTH

NOVEMBER, 2010

DECLARATION

This work has been done by me under appropriate supervision.

It has not been submitted in part or in full for any other

examination.

EDMUND O. NDIBUAGU

DEDICATION

This work is dedicated to the poor and downtrodden, who die

daily as a result of inability to access basic health care services.

CERTIFICATION

We testify that this study was done by Dr Edmund O. Ndibuagu,

and the dissertation written under our supervision.

--------------------------------------- ----------------------------------

Prof C.N. OBIONU DR E.A. NWOBI

ACKNOWLEDGEMENTS

I immensely thank our Heavenly Father for enabling me, successfully

complete this research project. HE most mercifully provided the human

and material resources needed for this study.

May I thank my very special wife, Ngozi and the children for their love,

care and support that guaranteed absolute harmony in the home front

which ultimately ensured a conducive environment for this research

project.

I am most grateful to my supervisors, Prof C.N. Obionu and Dr E.A.

Nwobi for their absolute support and guidance which made it possible

for the study to be performed with a high level of thoroughness. I am

thankful to Dr Chima Onoka, for his tremendous efforts in making sure

that the data analysis was professionally done. May I also express my

gratitude to all the consultants, residents and the entire staff of the

department of Community Medicine, UNTH, Enugu for their support

and friendship. I remain grateful to Prof and Dr (Mrs.) Anezi Okoro for

their inspiration and encouragement.

So many of my friends supported me in one way or another, during my

residency training programme. Some of them are; Mr. & Mrs. Fidel

Okoye Chira, Mr. Jude Ogota, Mr. Sydney Gbugu, Dr FSA Uzor, Dr Dan

Ajawara, Dr Chidi Onuegbulam and Dr (Mrs.) Susan Arinze-Onyia.

May I finally thank the Enugu state government for the financial

support given through the Health Systems Development Project II

programme.

GLOSSARY

ABBREVIATION MEANING

AIDS Acquired Immune Deficiency Syndrome

BHSS Basic Health Services Scheme

CHEW Community Health Extension Worker

CMS Central Medical Store

DHS District Health System

DFID United Kingdom Department for International Development

DHB District Health Board

DRF Drug Revolving Fund

EOC Emergency/Essential Obstetric Care

FMOH Federal Ministry of Health

HERFON Health Reform Foundation of Nigeria

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

HSDPII Health Systems Development Project 2

IMR Infant Mortality Rate

JCHEW Junior Community Health Extension Worker

LGA Local Government Area

LHA Local Health Authority

MCH Maternal and Child Health

MDGs Millennium Development Goals

MMR Maternal Mortality Rate

NEEDS National Economic Empowerment and Development Strategy

NPHCDA National Primary Health Care Development Agency

OIC Officer-in-Charge

PATHS Partnership for Transforming Health Systems

PDPD Policy Development and Planning Directorate

PHC Primary Health Care

SEEDS State Economic Empowerment and Development Strategy

SHB State Health Board

TBA Traditional Birth Attendant

UN United Nations

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WHO World Health Organization

TABLE OF CONTENTS

SUBJECTS PAGE

Title page i

Declaration ii Dedication iii

Certification iv Acknowledgement v

Glossary vi

Table of contents vii Abstract viii

CHAPTER 1: Introduction Objectives

CHAPTER 2: Literature Review 13 CHAPTER 3: Materials and Methods Study design Sample size estimation Study population Exclusion criteria Study instrument and data collection Data analysis Difficulties and Limitations

20 21 22 22 23 23 23 24

CHAPTER 4: Results 26 CHAPTER 5: Discussion Conclusion Recommendations

51 54 55

References 57 Annexes 63 - 82

ABSTRACT

INTRODUCTION: The World Health Organization recommends the District Health

System (DHS), (which is a self contained segment of the national health system) as

a good means of achieving the aims for which the primary health care approach

to health service delivery was set up. Health outcomes are unacceptably poor in

most of the developing countries, including Nigeria; hence the need to reform. In

1988 when the National Health Policy was launched, Nigeria adopted the district

health system as a means of ensuring self reliant health care delivery to the entire

population.

In Enugu state, the need to reform arose as a result of the negative health

indicators in the state and Nigeria generally. Partnership for Transforming Health

Systems (PATHS), which was a United Kingdom Department for International

Development (DFID) funded programme, supported the DHS from planning stage

in 2004, until the PATHS programme wound up in June, 2008. This research

project is aimed at investigating the effect of the PATHS support in respect of the

health facilities utilization. The general objective is to evaluate the effect of the

DFID support through the PATHS programme, on district health service utilization

in Enugu state.

LITERATURE REVIEW: The general principle for developing DHS include; equity,

accessibility, emphasis on promotion and prevention, intersectoral action,

community involvement, decentralization, integration of health programmes, and

co-ordination of separate health activities. Donor support has been shown to

improve health facility utilization, while lack of drugs decreases health facility

utilization.

MATERIALS AND METHODS: The 77 primary health care facilities that were

supported by PATHS through drug and equipment supply, constituted the study

population. An equal number of the primary health facilities that were not

supplied with drugs and equipment were selected as control facilities.

Retrospective Cohort study was used to extract secondary data from the ministry

of health, while structured questionnaire was used to carry out a cross-sectional

study designed to assess the knowledge, attitude and practice of the Officers-in-

Charge (OICs) of the primary health care facilities in the state, and their

Assistants, on the district health system in Enugu state. Data analysis was done

using SPSS.

RESULTS: The results revealed that the supported facilities were already doing

better than the control facilities, prior to the support. The support however

resulted in improved health facility utilization, especially in terms of outpatient

attendance. The Central Medical Store records revealed that most of the primary

health care facilities in Enugu state were not buying drugs from the store. The

OICs of the primary health facilities and their Assistants had good knowledge and

attitude towards DHS, but their reported practices were inconsistent with

observed practices.

DISCUSSION: This research project successfully looked at the general and specific

objectives for which it was embarked upon. The findings were essentially in

keeping with similar findings In Nigeria and elsewhere. There were however some

other findings that require further research work.

CONCLUSION: District Health System in this study provided the best chance of

implementing the primary health care system, and donor support significantly

contributed to improved health facility utilization in the supported facilities.

RECOMMENDATIONS: These include choosing poorly performing facilities for

support in future, strengthening the Central Medical Store by establishing district

bulk stores, focusing on personnel issues, and research on the impediments to

effective implementation of District Health System in Enugu state.

CHAPTER 1

INTRODUCTION

The World Health Organization (WHO) Global Programme Committee in 1986

defined the District Health System based on Primary Health Care, as a self

contained segment of the national health system. It comprises first and foremost

a well defined population (usually 50,000 – 500,000), living within a clearly

delineated administrative and geographical area, whether urban or rural. It

includes all institutions and individuals providing healthcare in the district,

whether governmental, social security, non-governmental, private, or traditional.

It was noted that many people in the developing countries do not benefit from

modern knowledge and technology that could have protected and restored their

health (2). The situation is more difficult in the poorest countries that spend less

than US $20 per head per annum. This has necessitated governments to

undertake reform of the health sector. In this context health sector reform means

sustained purposeful change to improve efficiency, equity and effectiveness of

the health sector (2).

Health outcomes are unacceptably poor across much of the developing world,

and the persistence of deep inequities in health status is a problem from which no

country in the world is exempt (3). In the past decades, the decentralization and

strengthening of district health systems have been common strategies for

structurally changing health services in low income countries especially in Africa

(4). In 1985, the African member states of the WHO adopted the three-phased

African health development scenario under which the district became the focus

for health development (5).

WHO strongly recommends integrated healthcare at the district level, involving all

healthcare providers, both public and private, and all health system – modern and

traditional, orthodox and non-orthodox (2). Integrated District Health System is

the means by which specific health programmes can best be delivered in the

context of overall healthcare needs (6). Strong health systems must have district

health systems and community health services that are functional and effective

The District Health System provides the best chances of implementing Primary

Health care as laid down in the declaration of Alma-Ata in 1978 (8,9). This finding

was incorporated in the 1987 Harare declaration, signed by Representatives of 22

African countries (9). Primary health Care, as articulated in the Alma Ata

Declaration of 1978, was a first attempt to unify thinking about health within a

single policy framework (3).

The first serious attempt at implementing the Primary Healthcare in Nigeria as

laid down in the Alma-Ata declaration was the introduction of the Basic Health

Services Scheme (BHSS) (1975 – 1980) (10). The BHSS failed at the end of the

planned period to accomplish much or make any remarkable impact because the

more important areas of community participation and intersectoral co-operation

in planning and implementation were not addressed (11).

The second attempt at implementing PHC in Nigeria was between 1980 and 1985,

during which period the government began the implementation of the various

programme components of PHC without any attempt at integrating the services,

and without any clearly mapped out plans and objectives (11).

With the launching of the National Health Policy in 1988, a National PHC system

was adopted in Nigeria using the District Health System approach to ensure a self

reliant healthcare delivery to the entire population (11). In her state health policy

published in December, 2003, it was stated that the state healthcare system will

operate a District Health System with a unitarised healthcare delivery structure

based on 17 LGAs, and39 LGA Development Centers (12).

In September, 2004, the Enugu state Ministry of Health organized a conference

tagged “Turning Point in Health Practice”. The conference held over a period of

three days, September 23rd to 25th, 2004 with some 300 delegates from the

different stakeholders in health, attending each day. Among other objectives, the

conference was aimed at appraising the standards and ethical practices in the

health sector. The conference concluded with all the stakeholders signing up to a

communiqué, which among other items, praised and congratulated His Excellency

the Governor on his vision to adopt and embark on the implementation of the

District Health System, given its pro-poor client focus, as the veritable instrument

for driving the reform of the Health Sector in Enugu state (13).

However, the National Primary Healthcare Development Agency (NPHCDA) in

2001 introduced the “Ward Health System” to revitalize the Primary Healthcare in

Nigeria (14). The Ward Health System entails the adoption of the political wards

as the operational units for the implementation of the PHC programmes. Since

the introduction of Ward Health System model, PHC centers have been built by

the Federal government. These centers are to serve as apex health facilities and

referral centers within the ward (15).

Very recently, June 8th to 10th, 2009, the Nigeria National Health Conference held

at Uyo, Akwa Ibom State, with a total of 650 participants comprising of core

stakeholders in health observed that in spite of decades of implementation of

PHC and short time left before 2015 for the attainment of MDGs, the progress

made so far is very poor, coverage with key high impact cost-effective

interventions remain very limited and health status indicators have remained

unacceptable (16).

Nigeria’s health indicators are among the worst in the world; life expectancy has

declined to 43years (2006) from 47 years. The National Health conference held in

Abuja in 2006 which was facilitated by Health Reform Foundation of Nigeria

(HERFON), concluded that the Nigerian Health system remained in a deplorable

state, being dysfunctional and grossly under funded with public per capita health

expenditure of US $9.44 on health (World Bank,2005) compared with the

expected US $34 (17).

Prior to the HERFON National Health Conference of 2006, a national Health

summit organized in 1995 made recommendations that necessitated a critical

look at the national health policy, with a view to making changes that would

accelerate health development in Nigeria (18).

In May 2008, however, the Senate of the Federal Republic of Nigeria passed a

new Health Bill that seeks to chart a new and productive course that will improve

tremendously healthcare delivery system in Nigeria. The National Health Bill,

having been passed and harmonized by the Senate and the House of

Representatives, is awaiting Presidential ascent in order to become law (16). It is

important to note that the federal Government had tried in the past to improve

the health status of Nigerians through a Health Sector Reform programme

embarked upon in 2004. This was located within the country’s overall macro-

economic framework called National Economic Empowerment and Development

Strategy (NEEDS) (19). This Health Sector Reform programme establishes a

framework, including goals, targets and priorities that should guide the action and

work of the Federal Ministry of Health and to some extent State Ministries of

health and our health development partners from 2004 to 2007 (20).

Since 1993; there has been a downward trend in health development. A very high

proportion of PHC facilities serve only about 5 – 10% of their potential patient

load, due to consumers’ loss of confidence in them, among other causes (18). Our

secondary healthcare facilities are in a prostate condition. The referral system

between various types of health facilities is either non-functional or ineffective. It

was also observed that erratic supply and non-availability of essential drugs and

related materials is a common feature (18).

Nigeria was ranked 187th among the 191 UN member states of the WHO in 2000

(21). The infant and maternal mortality rates remained one of the highest in

Africa; Infant Mortality Rate was 115/1,000, Under-5 Mortality Rate was

205/1,000, while Maternal Mortality Ratio was put at 948/100,000 (22).

Very noteworthy is that under the current 1999 constitution only vague reference

is made to the responsibility of the Local Governments for health. The

constitution falls short of specifying what roles the LGAs, State and Federal

Governments must play in the National healthcare delivery system (23). Full

decentralization of responsibility for health services to local authorities has often

been seen as an ideal for district health systems - to establish strong local

accountability and bring health closer to the people. Experience across Africa has

not been encouraging, however. In Nigeria for instance, delivery of primary level

care was fully decentralized to Local Government Authorities more than two

decades ago, with hardly any accountability for service delivery to higher levels

and weak support and oversight. This appears to have contributed significantly to

the dramatic decline in primary health care services in Nigeria – and to the

difficulty in resurrecting them. Health services are technically complex and local

authorities find them very difficult to manage on their own (4).

There is no sense of cohesion between State and Federal Ministry of Health. State

authorities perceive National Health council which meets once a year for a week

as a waste of time, a ‘talk- shop’ where it is alleged that the FMOH tries to get the

states to merely rubber stamp decisions already taken (20).

Availability and usage of drugs has been challenging to healthcare delivery system

in Nigeria. Nigeria started implementing the Bamako Initiative in 1989 in only 53

LGAs. Later the Petroleum Trust Fund supported the programme, and by 1999 all

the LGAs were reported to have been supplied with drugs, worth three billion

Naira. As at 2004, there was no tangible result of the PTF’s financial investment in

the Bamako Initiative in the country (24).

In Enugu state, the need to reform arose as a result of the negative health

indicators in the state and Nigeria generally. Core welfare indicators in the state

(2002) revealed as follows: 37% of households in the urban areas and 27% in the

rural areas had reasonable access to health facilities (20). Some identified

negative issues around the healthcare delivery system in the state that militate

against quality healthcare delivery system include (25):

I. Fragmented services and poor referral mechanisms between the health

centers and the hospitals.

II. Lack of joint health planning and delivery of service by the local and State

Governments.

III. Lack of drugs and hospital equipment

IV. Dilapidated state of the public health facilities.

V. Poor management of available resources.

VI. Patients kept away from the public heath facilities, resulting in patronage

falling to well below 20% where patients sought for treatment.

VII. High cost of healthcare.

In October 2003, the State Council on Health recommended the District Health

System framework as the new approach to healthcare delivery in the state; and

this was adopted by the state Government in January 2004 (25). This DHS became

the foundation for Enugu state major health sector reform.

The Enugu state health model specifically provided for (25);

I. A pro–poor focused healthcare service.

II. Integration of primary and secondary healthcare.

III. A strong partnership between public and private care providers

IV. A devolved management structure down to the point of service delivery.

The Partnership for Transforming Health Systems (PATHS), which is a programme

of the United Kingdom Department for International Development (DFID), has

been supporting some health projects in Enugu state since 2002 (26). However,

after the adoption of the DHS by the state Government in 2004, as the new

approach to healthcare, PATHS effectively provided the necessary technical

assistance and expertise for the development of the DHS (25). By July 2004, the

draft legal framework of the DHS was developed.

In August 2004, the State Governor approved the governance structure and the

composition of the constituent bodies. At that stage, the constituent bodies were

a. The Policy Development and Planning Directorate (PDPD).

b. The State Health Board (SHB)

c. Seven District Health Boards (DHBs).

These bodies were formally inaugurated by the state Governor on September 21,

2004 (26).

In addition to the initially inaugurated nine constituent bodies, fifty six Local

Health Authorities (LHAs) were inaugurated in September 2005. The number was

based on the 56 local councils created by the State Government out of the

Federal Government recognized 17 Local Government Areas.

In her poverty reduction strategy, Enugu State Economic Empowerment and

Development Strategy (SEEDS), the Enugu state government identified “Public

sector Reform to enhance the capability of the public sector to deliver basic

services” as one of the four strategic themes to achieve the goals of Poverty

Reduction Strategy/SEEDS (22). As it concerns health, the strategic objectives of

improving delivery of basic social services include;(20)

I. Reduce Under-5 mortality to 30/1,000 live births by 2009.

II. Reduce infant mortality rate by 10% between 2004 – 2007.

III. Reduce maternal mortality to 100/100,000 by 2009.

IV. Reverse rise in prevalence of HIV/AIDS by 2007.

V. Reduce incidence of priority diseases by 2007.

VI. Reduce incidence of malnutrition among children; reduce incidence of

stunting, wasting and underweight to 5%, 1% and 3% respectively.

VII. Increase access to medical services.

VIII. Improve satisfaction levels for the quality of medical care at all levels.

Some identified key strategies by government to achieve the above objectives in

health sector include:(25)

a) Improving health infrastructure at all levels and

b) Integrating primary and secondary healthcare services.

The vision of DHS in Enugu state was that it would allow primary and secondary

health services to be integrated, marking an end to fragmented and inefficient

service delivery. The devolution of management under the DHS was also expected

to create new opportunities to revitalize poorly functioning primary healthcare

facilities. DHS implementation in Enugu state required a fundamental shift in the

roles, responsibilities and approaches of all constituent bodies. PATHS facilitated

these changes and provided support in the following specific areas;(26)

I. The framing of the DHS legislation.

II. Establishment of the constituent bodies.

III. Establishment of District headquarters.

IV. Extensive capacity building trainings for the seven hundred, and seventy six

(776) constituent body members to acquaint them of their revised roles

and responsibilities.

V. Designing, development and implementation of the underpinning systems

for financial management, human resources management, health

management information system (HMIS), and drug revolving fund (DRF), all

adapted to reflect the new structure.

VI. Development of business plans and budgets for each of the constituent

bodies and the working interfaces between them.

VII. Engagement and Advocacy, aimed at local governments to improve their

knowledge and understanding of the new system.

VIII. Strengthening the new management lines of accountability to support the

shift away from local government control of primary care.

IX. Encouragement of reporting channels with, and between the constituent

bodies.

X. A study tour to learn from the Ghana DHS.

The Enugu state District Health System law was legislated upon, and passed in

July, 2005; while it was signed into law by the Executive Governor in August of the

same year. Essential parts of that law specify the constituent bodies of the Enugu

state model, their membership, as well as their roles and responsibilities (27).

The Policy Development and Planning Directorate, reports directly to the Hon.

Commissioner for Health, and is headed by the Permanent Secretary in the state

ministry of health. The other seven members of the body in the state Ministry of

Health include; Director of Medical services, Director of Nursing Services, Director

of Finance, Director of Planning, Research and Statistics, Director of

Pharmaceutical services, Director of Public Health Services, Director of

Administration and Supply. The body is generally responsible for developing

major strategic health policies and plans for the state, and adapting national

Health policies into state policies.

The State Health Board is also based in the state ministry of health and is made up

of the following fifteen members; The chairman, The Health Administrator, Head

of Medical services, Head of Public Health services, Head of Pharmaceutical

services, Head of Nursing services, Head of Finance services, Head of Health

Management Information System, Head of Human Resources Management, Head

of Works and Maintenance, A representative from the Local Government service

Commission, A representative from the Community Development Coordinating

Committee, Three other members to be appointed from the private sector, who

in the opinion of the Governor posses the requisite competence and integrity. The

SHB generally oversees the service delivery bodies which are the DHBs, and the

LHAs indirectly. SHB is in charge of the implementing arms of the DHS. The SHB

also reports to the Hon. Commissioner for Health.

The District Health Boards are seven in number. Each health district has a District

Health Board. These are (27):

a) Agbani District Health Board

b) Awgu District Health Board

c) Enugu Metropolitan DHB

d) Enugu Ezike DHB

e) Isi- Uzo DHB

f) Nsukka DHB

g) Udi DHB

Each DHB is made up of the following eleven members; Chairman, District Health

Officer, Medical Officer, Nursing Officer, Pharmacy Officer, Community

Mobilization Officer, Finance Officer, Human Resource and Logistic Officer, who

shall be the secretary to the Board, Public Health Officer, A Health Supervisor for

a local Government Area in the District, and a Private sector Representative to be

appointed by the Commissioner from among the Health Institutions. The main

function of the Board is to Implement approved polices for healthcare delivery in

the state and increase access to improved health services.

Each of the fifty six Local Health Authorities is made up of the twelve members,

and is headed by a Chairman; who shall be a medical doctor of not less than three

years post registration. The Secretary, who is the executive head of the LHA; is the

head of the health department of the LGA or local Development Council. The

LHAs increase access to improved health services, and implement approved

policies for healthcare delivery in LGA / LGDC (27).

Enugu state has articulated a radical vision to transform its inefficient health

services and base it on the WHO District Health System model. International and

National Consultants were recruited to assist in increasing the awareness and

understanding of the impact of reforming the health sector in Enugu state by

introducing the DHS. At the onset of the introduction of the DHS in Enugu state,

some of these Consultants noted that the quality of services delivered in the

health facilities is judged to be poor. Demotivated staff, shortage of equipment,

supplies and drugs, irregular services and advanced state of physical disrepair is

the rule rather than the exception. Inevitably, utilization in public sector facilities

is very low. There is no organized referral system in place (28).

The health services were judged to be unsatisfactory and inadequate in meeting

the needs and demands of the public, as reflected by the low state of health of

the population. The state health services as previously organized showed major

defects such as inadequate coverage. It was estimated that only about 66% of the

population had access to modern healthcare services. The health data indicating

the general state of health of the population include IMR of 72/1,000 and MMR of

700/100,000 (12).

From the onset of the implementation of the DHS in Enugu state, till June 30

2008, when PATHS programme terminated in the state; significant progress was

made in delivering quality healthcare to the people of the state. The healthcare

system in the state however continues to suffer from substantial problems. It

remains under funded, lacking in sufficient qualified staff, has a poor

infrastructure base, and lacks some supplies of basic drugs and other

consumables. These inadequacies continue to influence the quality of the health

services being provided to the public. The exact status of health outcomes in the

state is however difficult to know, as data, whilst improving, is generally lacking or

of poor quality (29).

Despite the fact that the public sector had 436 facilities at the start of the PATHS

programme, due to the very poor state of these facilities, much of the healthcare

delivery before the DHS was introduced was provided by the private and faith

based sectors (26).

By the end of its programme in Enugu state (June 2008), PATHS had facilitated

the supply of medical equipment and drugs by DFID to eighty one (81) public

health facilities and fifteen (15) private/faith based health facilities. Among these

public health facilities are seventy seven (77) Primary Healthcare Centers, and

four (4) Secondary Healthcare facilities. Health workers of these facilities were

trained on the use of the medical equipment, Drug Revolving Fund (DRF)

implementation, Interpersonal Communication Skills, Life saving skills, Packages

of care, Essential obstetrics Care, and Financial management (26).

The Enugu district health system, delivers healthcare services to a defined

population within a geographical area (varying in size from 160,000 – 600,000)

and through various categories of health facilities (30).

JUSTIFICATION: An evaluation of the first phase of PATHS supported health

facilities is imperative, as phase 2 of the PATHS programme has just started.

Findings from this study will shed light on the changes occasioned by PATHS

support, and serve as a baseline for phase 2 of the PATHS programme; and the

current on-going health sector reform in the state and Nigeria generally.

OBJECTIVES

GENERAL OBJECTIVE: To evaluate the effect of the DFID support through the

PATHS programme, on the District Health service utilization in Enugu state.

SPECIFIC OBJECTIVES:

1. To assess and compare patients’ attendance in the study and control sites

from January to June, 2008.

2. To ascertain and compare the Drug Revolving Fund turnover in the study

and control sites from January to June, 2008.

3. To determine and compare the number of deliveries in the study and

control sites from January to June, 2008.

4. To assess the knowledge, Attitude and Practice of the Officers-in-Charge of

the Primary Health Centers in the state, and their Assistants on the District

Health System in the state.

CHAPTER 2

LITERATURE REVIEW

The PHC approach is the means of achieving Health for all. This approach which

presupposes the full participation of communities ensures that essential

healthcare is accessible to all individuals and families at an affordable cost. It is

based on the principle of self-reliance and self-determination and is most

efficiently implemented at the district level. The health district is the smallest

clearly defined administrative and operational unit where qualified personnel

with different competences would work together with the community and other

agencies to provide essential healthcare, by ensuring that the elements of PHC

are properly addressed (31).

This DHS is a vehicle for the delivery of integrated healthcare (26). A District

Health system includes the inter-related elements in the district that contribute to

health in homes, educational institutions, workplaces, public places and

communities, as well as in the physical and psychological environment (32). The

component elements need to be well coordinated by an officer assigned to this

function in order to draw together all these elements and institutions into a fully

comprehensive range of promotive, preventive, curative and rehabilitative health

activities (1). At the apex of the DHS, is the health office managed by a multi-

disciplinary district health management team (1). The District health management

team should always be headed by a doctor with Public Health qualifications (8).

The general principle for developing DHS includes equity, accessibility, emphasis

on health promotion and disease prevention, Intersectoral action, Community

Involvement, Decentralization, Integration of health programmes, and Co-

ordination of separate health activities (1).

Decentralization is a very important aspect of District Health System. Generally,

the concept implies the shift of power, authority and functions away from the

center. It is seen as a mechanism to achieve the following: greater equity and

efficiency; greater involvement of and responsiveness to communities; the

reduction in the size of bureaucracy far removed from the communities being

served; and greater coordination between social sectors. The World Bank views

the decentralization of public health services as potentially the most important

force for improving efficiency and responding to local health conditions and

demands. Decentralization can take many forms. One set of typologies is the

following (33):

Deconcentration;

Devolution;

Delegation; and

Privatization.

The district is the most appropriate level for coordinating top-down and bottom-

up planning, for organizing community involvement in planning and

implementation and for improving the co-ordination of government and private

healthcare (1). It is a manageable unit of the health system which can integrate

health programmes by adopting top-down and bottom-up planning (34).

Strengthening the DHS is an essential step in making health services accessible

and affordable for the population groups who would otherwise be unable to reap

the benefits of healthcare and access to essential drugs. The fact remains that in

the current socio economic circumstances there is simply no realistic alternative if

the whole population is to be provided with the basic healthcare, especially in the

rural area (8). Strengthening the district level continues to be a complementary

strategy for reinforcing primary healthcare, thereby improving access of the poor

to services (35).

PHC calls for services to cover the entire spectrum of preventive and curative

medicine. This can only be provided within the framework of an integrated

healthcare system, an objective that can not be achieved overnight but offers far

more sustainability than any fast-track programme (8). In September 2000,

following a historic Millenium Summit in New York, USA, the Millennium

Development Goals were adopted globally to enhance improvement in the health

status of mankind (36). Analysis of these goals, point out that they are fully in line

with the concepts of PHC (8). On present trends, the health-related MDGs are the

least likely to be met, despite the availability of powerful drugs, vaccines and

other tools to support their attainment. A failing or inadequate health system is

one of the main obstacles to scaling–up interventions to make achievement of

internationally agreed goals such as MDGs a realistic prospect (3).

PHC was revisited at Riga, ten years after Alma-Ata Declaration, and it was clear

that the consensus was the same. What is urgently needed is a frame work that

would facilitate implementation, especially in developing countries (36).

Elaborating a framework for national health development would involve, among

others, establishing health districts as the operational units for planning,

organizing and financing community health activities (36). Ideally, the DHS would

bring together community leaders, health team members and other community

based workers to work for health and development. A district is small enough for

its major problems and constraints to be readily understood, but large enough to

have professionally qualified staff (36). Also, a district health system is large

enough to justify the costs involved for investment in the management of health

services, and small enough to know and take account of the demographic and

socio-economic situation. Top-down and bottom-up planning approaches can

easily be coordinated because of direct contact at all levels (5).

Some specific advantages of DHS include (8);

Large enough to justify the investment and management cost, especially in

hospitals.

Small enough to be familiar with the relevant demographic and socio-

economic factors.

Participatory planning and organization are more feasible.

Communication with target groups is easier because of the geographical

proximity.

Management is less complex.

Easier to coordinate various programmes and services at different levels.

Intersectoral cooperation is easier.

However, there must be some degree of centralization in resource allocation and

planning for PHC (37).

Introduction of DHS, and decentralization of the health system does not always

ensure improved utilization rate of the health facilities. A study of the

performance of health system decentralization in Zambia, revealed that there has

been relatively little impact of decentralization on the utilization rate for

outpatient services (38).

However in some other countries such as South Africa, and Rwanda; introduction

of DHS played a significant role in improving the health conditions of the people.

In South Africa, a significant departure from the past was the decision to create a

unified but decentralized national health system based on DHS model. Full

implementation of DHS in South Africa commenced after the adoption of the

government White Paper for the Transformation of the Health Sector in that

country, which was released in April 1997 (32).

Donor support has been shown to play a role in Primary Health Care Facilities

utilization. A demonstration project started in 1997 in two large rural Tanzanian

districts (Tanzania Essential Health Interventions Project, TEHIP); had within five

years improved the mix and quality of primary health care services, increased the

coverage and use of these services, and reduced infant and under-5 mortality rate

by over 40%. Significantly this was accomplished by using a donor-provided extra-

budgetary increment of about US$1 per capita per year (39).

There is heavy reliance on donor funding by African countries exceeding about a

quarter of health care funding in 35% of countries. The PHC programmes are

grossly under-funded leading to low performance of PHC delivery facilities.

Equipment is an essential element of any health care service delivery. To deliver

efficient services, basic equipment must be available in a facility (40).

Donor support certainly plays a very significant role in the health care delivery

system of some countries such as Cambodia, where in 1999 donor support

contributed about 77% of the total public sector health expenditure (41). In the

1999 USAID Congressional presentation, US$2.5 million was requested to increase

the utilization of quality primary health care and basic social services (42).

Through the Manas Taalimi National Health Care Reform programme in

Kyrgyzstan (2006 – 2010), being supported by various donor agencies such as

DFID, USAID, WHO, UNICEF, etc; significant achievements has been recorded in

certain vital areas such as increased utilization of PHC services, and improved

availability of the additional drug package benefit in rural areas (43).

In the year 2000, a project was designed to investigate the impact of a health

systems development in Utta Pradesh, India; on utilization of health services, and

patient satisfaction for the poor and lower caste members. The project

introduced a range of reforms including provision of essential drugs, repair of

equipment and facilities, and management training. The study revealed that there

was consistent increase in monthly outpatient visits at all levels of project sites

compared to controls, indicating that the project has improved overall utilization

levels (44).

Some earlier studies in parts of Nigeria showed wide variations in utilization and

coverage levels among facilities within different local government areas. While

some showed an increase in antenatal care utilization and supervised delivery

coverage, others recorded low levels of utilization and coverage of these MCH

services (45,46,47). All the LGAs that showed increased coverage and utilization

were donor agency supported and it is doubtful the same can be said about

government supported LGAs (48).

Availability of essential drugs at all levels of the health care delivery system

enhances quality of care and promotes the utilization of health services by the

community. The effectiveness of health services in Nigeria is severely hampered

by the shortages of essential drugs, the most serious constraints occurring at the

PHC level. The shortage of drugs has caused a major decline in the utilization of

health services (40).

Lack of drugs has been identified as one of the barriers to PHC facility utilization

(49). Nigeria adopted the Bamako Initiative in 1988 with financial and technical

support from WHO, UNICEF and DFID (50). The necessity for Bamako Initiative

was the situation in the 1980s, when there was severe problem in financing

health services in sub-Saharan Africa, including Nigeria (48). In recognition of this

dismal and most unacceptable situation, the World Health organization African

Region, in collaboration with UNICEF in September 1987, proposed measures at

its annual meeting of African Ministers of Health in Bamako, Mali; for providing

the necessary resources and dealing decisively with the problems of health care

delivery in many parts of sub-Saharan Africa. These measures form the basis of

what is now known as “Bamako Initiative” (51).

Bamako Initiative aims to ensure a steady supply of the most basic essential

drugs, prescribed under generic names, at affordable prices and at the same time

improving prescribing practices. The availability of drugs is one of the most visible

symbols of quality care to consumers. More essential drugs were available in the

Bamako Initiative health centers compared with the non-Bamako Initiative health

centers (50). In Nigeria, patients visits dropped by 50 – 75% when health facilities

ran out of commonly used drugs (52).

In a study done to verify if Bamako Initiative improved the utilization of maternal

and child health care services in Nigeria, it was found that utilization of

immunization, antenatal and delivery services improved, but curative service

utilization worsened. Major factors affecting the use of these facilities include;

potential exclusion of some socioeconomic groups due to financial reasons,

distance and non-availability of medical doctors (48).

The DRF scheme adopted by Khartoum, Sudan made essential medicines available

at its health facilities and increased health services utilization compared to those

without DRF scheme. Sustained availability of low cost medicines near where

people live, that benefit previously disadvantaged poor population, particularly

the vulnerable rural group, is achieved through DRF (53). There is evidence which

suggests that patients welcome the availability of medicines at health facilities,

and often interpret this as quality indicator of available health care services and

this perception enhances utilization rates in health facilities (54,55). The primary

aim of DRF was, and is still to improve the utilization of primary health care

services through the establishment of a reliable and self-financing supply of

essential medicines of acceptable quality at low cost, which the community can

afford with full area coverage and total cost recovery within each PHC facility (56).

The availability of a wide range of medicines is one of the most visible symbols

that distinguish health facilities operating DRF. The overall utilization rates of

public health facilities operating DRF steadily increased with DRF introduction in

Khartoum, in 1997, but never returned to the pre-DRF level. This increase of

about 260% in the utilization of public health facilities was observed (53).

World Bank support for expanding district infrastructure and staff training in

Zimbabwe has improved service quality and contributed to increased facility

deliveries, inpatient attendance, and contraceptive prevalence; but has no

measurable impact on outpatient attendance or disease patterns. Outpatient

attendance actually declined following facility completion in 1991; coinciding with

drought, increased fee enforcement and drug shortages, suggesting that

improved infrastructure and training alone are inadequate to improve outpatient

utilization (57).

Some selected multilateral and bilateral organizations already assist the Nigerian

Health Sector with funds that equal or even supersede the federal expenditure on

health. What has been conspicuously lacking is an appropriate coordination

mechanism to make the most of donor assistance. Factors that can also be said to

contribute to the gross underutilization of health facilities include; lack of physical

access, functionality and appropriateness of managerial structures, funding, the

technical and managerial competences of health workers, the mobilization and

involvement of communities in health management, and the political will and

commitments of governments (58).

Today it is clear that left to their own devices, health systems do not gravitate

naturally towards the goals of health for all through PHC as articulated in the

Declaration of Alma – Ata. Health systems are developing in directions that

contribute little to equity and social justice, and fail to get the best health

outcomes for their money (59).

CHAPTER 3

MATERIALS AND METHODS

STUDY AREA

Enugu state is located in the South Eastern part of Nigeria, and is one of the thirty

six states that make up the Nigerian Federation. The state is made up of 17 Local

Government Areas, from which were carved out 39 Development Centers (60).

The state shares boundaries with six other states namely, Imo and Abia States on

the South, Benue and Kogi States on the North, Anambra State on the West and

Ebonyi State towards the East. People of Igbo extraction are the natives of Enugu

state. Some people from other tribes and nationalities also reside in Enugu State

(59). Based on the Nigerian population Census of 2006, the state is inhabited by

about 3.26 million people (61).

Majority of the people in the urban areas are civil servants while those living in

the rural areas are predominantly farmers and palm wine tappers. There are also

traders, artisans and industrialists in the urban areas. English and Igbo Languages

are commonly spoken by the people. There are generally two seasons of the year,

namely rainy (April to October) and dry (November to March) seasons (60).

The Public Health facilities in the state are 436 (26), comprising 4 tertiary

hospitals, one of which is owned by the state Government, and other 3 by Federal

Government; 55 secondary healthcare facilities while the rest (377) are primary

healthcare facilities. There are also about 485 private and faith based health

facilities in the state, providing different levels of healthcare services in the state

Donor support to healthcare delivery in the state is provided mainly through the

PATHS (DFID) programme, and the World Bank assisted Health Systems

Development Project (HSDP2). UNICEF and WHO also play significant roles in

supporting healthcare delivery, especially in the areas of immunization, disease

surveillance, maternal and child health issues.

The United Kingdom Department for International Department, through the

Health Commodities Project (HCP), working with PATHS, supplied significant

quantities of drugs and medical equipment to eighty one Public health facilities,

by December, the 31st 2007. Seventy-seven of these facilities are primary health

care facilities. Various forms of capacity-building trainings were given to the

health workers in the health facilities.

FORMATION OF HEALTH RESEARCH TEAM

Health research team was formed to carry out the study. The team was

made up of the following;

I. The Researcher

II. Eighteen research assistants (The Officer in charge of health department of the

state Local Government Service Commission, and the Local Immunization

Officers of the seventeen Local Government Areas)

STUDY DESIGN: Observational epidemiological study design, employing

Retrospective cohort and Cross-sectional study techniques:

a) Retrospective Intervention Cohort study: Relevant Health Management

Information System data in both the control and study health facilities

were extracted; from the Planning, Research and Statistics (DPRS) unit of

the State Ministry of Health, and the Central Medical Store (CMS). The data

were collected for a period of six month (January – June, 2008). Data on

outpatient attendance and delivery were collected from the DPRS, while

data for drug purchases were collected from the CMS. 2004 data for the

same six months period were collected and used as baseline. DFID (PATHS)

support to health facilities commenced in 2005.

b) A second part of this study was a Cross-sectional study that assessed the

knowledge, attitude and practice of the Enugu District Health System, of

the Officers-in-charge and their Assistants in the study and control

facilities.

The study focused on the last six months of PATHS programme in Enugu state;

that is from January 1, 2008 to June 30, 2008.

SAMPLE SIZE ESTIMATION: Sample size estimation, was done using the

following formula: nf = n/1+(n)/(N) (63). Where;

nf = the desired sample size when population is less than 10,000

n = the desired sample size when population is more than 10,000

N =the population size.

n can be calculated using the following formula; n = z squared x p x q / d squared.

Where;

z = The standard normal deviate, usually set at 1.96 ( or more simply at 2.0),

which corresponds to the 95% confidence level.

p = the proportion in the target population estimated to have a particular

characteristic. If there is no reasonable estimate, 50% (i.e.; 0.50) is used.

q = 1.0 – p.

d = degree of accuracy desired, usually set at 0.05 or occasionally at 0.02.

Using the above formula, and taking z to be 1.96, p 0.50 and d to be 0.05; n = 384

The study population in this case is the 77 supported health facilities. Applying the

first formula then will give a sample size of; 384/ 1+ (384)/(77) = 64. Sixty-four,

therefore is the minimum required sample size for the study.

STUDY POPULATION: The total population (77) of the supported public primary

health care facilities (ANNEX A) constituted the study population, with the aim of

obtaining an optimum level of accuracy and validity, during the analysis of data.

Similarly 77 non-supported public PHC facilities constituted the control

population. Two respondents from each of the facilities participated in the Cross-

sectional study, so as to optimize the accuracy and validity of the results. This

gave a total of 154 respondents for the cross-sectional study in the study

population. An equivalent number of respondents from unsupported public

primary health care facilities, were randomly selected as control. Out of the

remaining 300 public primary healthcare facilities in the state that were not

supported by DFID, 129 are either Health Posts or Health Clinics; while 83 had

been supported by the PATHS2 programme that commenced in 2009. The control

health facilities were then selected from a sampling frame of 88 public primary

health centers that were not supported by the PATHS programme. Table of

random numbers was used to select the control health facilities (64). Only Primary

health Care Centers were supported. No Health Clinic or Health Post was

supported by the PATHS programme.

EXCLUSION CRITERIA:

Secondary and Tertiary health facilities

Private health facilities

Health Posts and Health Clinics

Facilities supported by PATHS2 programme

STUDY INSTRUMENTS AND DATA COLLECTION: Secondary data were collected

from records domiciled in the department of planning, research and statistics

(DPRS); and the state central medical store (CMS). Both departments are in the

state ministry of health. A proforma was used to collect each set of data.

Information were collected on monthly outpatient attendance, monthly deliveries

and DRF purchases. These set of data were collected by the researcher.

A self-administered, structured questionnaire was used to elicit information from

the respondents in the study and control groups for the cross-sectional study. The

information elicited was on facility service utilization by patients, drug revolving

fund turnover, obstetrics services, and the knowledge, attitude and practice

towards the Enugu state District Health System by health facility workers. Data

collection, collation, analysis and interpretation, were commenced in mid-March,

2010; and was completed by the end of July, 2010.

DATA ANALYSIS: The information generated were analyzed, using statistical

package for social sciences (SPSS) 11.0 for windows. The analysis was done

quantitatively only and presented in the form of tables, and charts. Mean and

standard deviation were calculated where necessary. Chi –Square test and

student t–test at p< 0.05 level of significance and 95% confidence interval were

used to compare variables.

OUTCOME MEASURES: The Health Management Information System data were

analyzed in terms of out-patient attendance, number of deliveries and the DRF

turnover (Drug purchases). Information on drug sales was not available. Data

from the health facilities survey were measured in terms of proportion of health

workers with the correct knowledge of district health system; and the right

attitude and practice of the Enugu state district health system. Scores were

assigned to the response, and scores above 50% were considered adequate.

ETHICAL CONSIDERATION: The Ethical committee of the University of Nigeria

Teaching Hospital gave formal approval prior to the commencement of the study.

Consent was obtained from the Hon. Commissioner for Health Enugu State, the

Health Administrator (HA) of the state and the health workers that participated in

the study. The scope of the study and level of participation of respondents were

explained to them. They were assured of confidentiality and the participation was

voluntary.

LIMITATIONS: Some limitations of this study are:

1. Getting the respondents from facilities located at hard-to-reach areas of

the state to complete the questionnaire. These facilities are predominantly

located at Nkanu East, Uzo-Uwani and Igboeze North Local Government

Areas. These areas also do not have telephone services. Repeated visits to

these facilities, using motorbike helped overcome this difficulty.

2. Getting the questionnaires completed at first visit to the facilities. Some

respondents were frequently absent from the facilities. We kept re-

scheduling appointments with them, and kept re-visiting until we got the

questionnaire completed.

3. It is noted that utilization of health services is a complex behavioural

phenomenon, related to the availability of services, quality and cost of

services, social structure, health beliefs, and characteristics of the users.

Some other factors influencing the use of health services include:

Sociodemographic characteristics such as education, place of work,

marital status and number of children.

Location and distance of health services facilities.

Type of services available/received.

Perceived quality (by the users).

Reasons for choice (for the facility).

Source(s) of alternative/supplementary health care services.

Perceived satisfaction (by the users).

Perceived severity of the illness.

Previous/Peer – group experience.

Attitude of health workers/user friendliness.

4. There was no record of pre-PATHS support DRF data at the Central Medical

Store.

5. Record of drug purchases from the Central Medical Store post-PATHS

support was very scanty.

CHAPTER 4

RESULTS

This study assessed the effect of a donor (DFID) support through the PATHS

programme on district health service utilization in Enugu state, with the aim of

providing a credible guide to the Partnership for transforming Health Systems 2

(PATHS2) programme, towards making a better impact on the health status of the

people of Enugu state. Three hundred and eight questionnaires were given to the

OICs and Assistants in both study and control facilities; but two hundred and

ninety four (95.5%) were returned for analysis.

Table 1: General Characteristics of Health Facilities in both the study and control groups

VARIABLE CONTROL n(%)

STUDY n(%)

TOTAL n(%)

FACILITY TYPE URBAN RURAL

11 (7.6%) 134 (92.4%)

8 (5.4%) 141 (94.6%)

19 (6.5%) 275 (93.5%)

SUPPORT FROM OTHER DONOR ORGANIZATIONS 50 (34.5%) 55 (37.2%) 105 (35.8%)

TYPE OF SUPPORT RECEIVED INFRASTRUCTURE HOSPITAL EQUIPMENT DRUGS AND MEDICAL/SURGICAL SUPPLIES

8 (16.0%) 18 (36.0%) 32 (64.0%)

13 (23.3%) 31 (56.4%) 24 (43.6%)

21 (20.0%) 49 (46.7%) 56 (53.3%)

The facilities in both the study and control groups are predominantly rural. 64.0% of the respondents from the control group claim to have received drugs and medical/surgical supplies from other donors such as HSDP II (World Bank assisted), while 43.6% from the study group also said they received same from the same donor.

Table 2: Socio-demographic characteristics of the OICs and their Assistants in both the study and control facilities.

STUDY n(%) TOTAL n(%)

SEX MALE FEMALE

17(11.7%) 128(88.3%)

20(13.4%) 129(86.6%)

37(12.6%) 257(87.4%)

QUALIFICATION PUBLIC HEALTH NURSE COMM HEALTH OFFICER NURSE/MIDWIFE COMM HEALTH EXT WORKER JUNIOR COMM HEALTH EXT WORKER ENVIRONMENTAL HEALTH OFFICER PHARMACY TECHNICIAN OTHERS(ALL MEDICAL DOCTORS)

4(2.8%) 14(9.9%) 13(9.2%) 94(66.2%) 14(9.9%) 1(.7%) 1(.7%) 1(.7%)

4(2.7%) 21(14.3%) 14(.5%) 95(64.6%) 5(3.4%) 0(.0%) 2(1.4%) 6(4.1%)

8(2.8%) 35(12.1%) 27(9.3%) 189(65.4%) 19(6.6%) 1(.3%) 3(1.0%) 7(2.4%)

Majority of the OICs and their Assistants in the facilities are females (88.3% in the

control facilities and 86.6% in the study facilities). The respondents were

predominantly of the rank of CHEW or below.

Table 3: Out-patient attendance in the study and control facilities pre-

intervention (2004 baseline data).

Month Study

(Outpatient

attendance)

Control

(Outpatient attendance)

Chi square (p value)

January

February

P < 0.0001

Total 15052 8216

Out-patient attendance was significantly higher in the supported facilities prior to

the support (P < 0.0001).

Table 4: Out-patient attendance in the study and control facilities post

intervention (2008 data)

Month Study

(Outpatient

attendance)

Control

(Outpatient

attendance)

January

February

592.02

P < 0.0001

Total 73336 35126

The difference between the study and control facilities became wider after the

intervention. The out-patient attendance increased tremendously after the

intervention.

Table 5: Percentage increase in out-patient attendance in the study group and

control group.

Year Out-patient

Attendance

Increase (%) Chi square (p

value)

Study group 2004 15052 58284

(387.22%)

74.23 (p =

0.000) 2008 73336

Control group 2004 8216 26910

(327.53%) 2008 35126

Difference between

% increase

59.69%

The percentage increase in out-patient attendance from 2004 pre-PATHS

intervention to 2008 post-PATHS intervention in both the study and control

groups, revealed that it is statistically significant.

Fig 1: Bar chart showing outpatient attendance in the study facilities pre and post intervention.

For study facilities, pre-intervention (2004) versus post intervention (2008):

Chi square = 279.11, P < 0.0001. The intervention led to a very significant increase

in the outpatient attendance in the study facilities, as shown by the red bars.

January February March April May June

Year 2004

Year 2008

Fig 2: Bar chart showing the outpatient attendance in the control facilities

pre and post PATHS intervention.

For control facilities, 2004 baseline data versus 2008 data: Chi square = 233.76,

P < 0.0001. There was no direct support from PATHS by way of drug and

equipment support to these facilities, yet they recorded significant increase in the

outpatient attendance after the intervention was made in the study facilities. The

red bars represent the very high increase that was recorded after the intervention in

the study facilities.

Table 6: Monthly records of child deliveries in the study and control facilities

pre-PATHS intervention (January to June, 2004).

Month Study Control Chi square (p value)

Year 2004

Year 2008

(Deliveries) (Deliveries)

January

February

P<0.0001

Total 647 370

The study facilities were already recording significantly higher levels of deliveries

than the control facilities, prior to the PATHS support.

Table 7: Monthly records of child deliveries in the study and control facilities

post PATHS intervention (January to June, 2008).

Month Study

(Deliveries)

Control

(Deliveries)

January

February

P = 0.0025

Total 1052 441

Surprisingly, the level of significance as shown by the Chi square test narrowed

after the support was given. One expected a more significant increase in the

number of deliveries recorded in the supported facilities when compared to the

control facilities, as observed in the outpatient attendance record.

Fig 3: Bar chart comparing the record of child deliveries in the study facilities pre

and post PATHS intervention.

For study facilities’ pre-intervention deliveries (January to June, 2004) versus post

intervention deliveries (January to June 2008): Chi square = 32.08, P < 0.0001. The

intervention clearly resulted in a statistically significant increase in the number of

deliveries recorded in these facilities.

Year 2004

Year 2008

Fig 4: Bar chart comparing the record of child deliveries in the control facilities’

pre and post PATHS intervention.

For control facilities pre-intervention child deliveries (January to June 2004)

versus post intervention child deliveries (January to June 2008): Chi square = 4.60,

P < 0.47. There is no significant increase in the number of deliveries recorded in

the control facilities from their baseline data before PATHS intervention in the

study facilities, to their record in 2008 after PATHS had intervened in the study

facilities.

Year 2004

Year 2008

Table 8: Record of drug purchases by the study and control health from the

Central Medical Store post PATHS support (January to June, 2008).

Month Study

(Purchases in

Naira)

Control

(Purchases in Naira)

T test

January

February

1607712

948195

2356193

555741

2052325

3767794

418666

P=0.003

Total 11,287,960 543,807

The record of drug purchases from the Central Medical Store by both the study

and control facilities were very scanty after the intervention (January to June,

2008). Only 12.6% of the required data was available in the study group, while

0.02% was available in the control group.

No record of drug purchases was found in the Central Medical Store for the year

KNOWLEDGE, ATTITUDE AND PRACTICE OF DISTRICT HEALTH SYSTEM BY THE FACILITY OFFICERS-IN-CHARGE AND THEIR ASSISTANTS.

Table 9: PROPORTION OF OICs AND ASSISTANTS WITH CORRECT KNOWLEDGE OF DISTRICT HEALTH SYSTEM GENERALLY

VARIABLES CONTROL

n(%) STUDY n(%)

TOTAL n(%)

The DHS providing the best chances of implementing Primary Health Care

125 (86.2%) 133 (89.3%) 258 (87.8%)

Integration of Primary and Secondary Health Care as an important aspect of DHS

125 (86.2%) 134 (89.9%) 259 (88.1%)

Ideal DHS also providing for integration of the private health facilities, orthodox and non-orthodox methods of health care services.

72 (49.7%) 78 (52.3%) 150 (51.0%)

Integrated DHS as means by which specific health programmes can best be delivered in the context of overall health needs.

68 (46.9%) 83 (55.7%) 151 (51.4%)

Population being an important issue in a good DHS. 93 (64.1%) 99 (66.4%) 192 (65.3%)

Good referral system being essential for the proper functioning of the DHS.

131 (90.3%) 142 (95.3%) 273 (92.9%)

Deconcentration being an aspect of decentralization in DHS

42 (29.0%) 37 (24.8%) 79 (26.9%)

Devolution being an aspect of decentralization in DHS

15 (10.3%) 16 (10.7%) 31 (10.5%)

Demonstration not being an aspect of decentralization in DHS

15 (10.3%) 6 (4.0%)

21 (7.1%)

Delegation being an aspect of decentralization in DHS

77 (53.1%) 89 (59.7%) 166 (56.5%)

DHS being recommended by WHO as a means of properly implementing primary health care, as envisaged in the Alma-Ata declaration.

112 (77.2%) 118 (79.2%) 230 (78.2%)

Over 50% of respondents from the study group had good knowledge of the different characteristics of DHS stated in the variables above except the various aspects of decentralization, while over 50% from the control group had good knowledge except different aspects of decentralization, and the integration aspect of DHS. Table 10: PROPORTION OF OICs AND ASSISTANTS WITH THE CORRECT KNOWLEDGE OF SOME SPECIFIC ASPECTS OF ENUGU STATE DISTRICT HEALTH SYSTEM

VARIABLES CONTROL STUDY TOTAL

The Enugu State DHS law being enacted in 2005 25 (17.2%) 17 (11.4%) 42 (14.3%)

Enugu state DHS comprising seven Health Districts 133 (91.7%) 128 (85.9%)

261 (88.8%)

The DHS in Enugu state being made up of nine constituent bodies, outside the Local Health Authorities

17 (11.7%) 12 (8.1%) 29 (9.9%)

The Policy Development and Planning Directorate (PDPD) being headed by the Perm. Sec. MOH

14 (9.7%) 11 (7.4%) 25 (8.5%)

The State Health Board (SHB) being headed by the Health Administrator

42 (29.0%) 64 (43%) 104 (35.3%)

The Enugu state model of DHS providing for fifty six Local Health Authorities

53 (36.6%) 69 (46.3%) 122 (41.5%)

The Executive head of a Local Health Authority being the LHA Secretary

70 (48.3%) 75 (50.3%%

145 (49.3%)

With the introduction of DHS in Enugu state, the HOD Health in the LGA, is now known as the LHA Secretary

124 (85.5%) 128 (85.9%)

252 (85.7%)

The respondents exhibited poor knowledge of many aspects of Enugu state DHS as stated in the variables above. More than 50% of them did not know the number of constituent bodies that make up Enugu state DHS, headship of the PDPD and SHB, the number of Local Health Authorities.

Table 11: IDENTIFICATION OF THE CORRECT NAMES OF THE HEALTH DISTRICTS IN ENUGU STATE

STUDY n(%)

TOTAL n(%)

Enugu Metropolitan being a health district 97 (66.9%) 87 (58.5%) 184 (62.6%)

Aninri not being a health district 121 (83.4%) 138 (92.6%)

259 (88.1%)

Awgu being a health district 102 (70.3%) 119 (79.9%)

221 (75.2%)

Enugu-Ezike being a health district 104 (71.4%) 119 (79.9%)

223 (75.9%)

Udi being a health district 117 (80.7%) 122 (81.9%)

239 (81.3%)

Ezeagu not being a health district 117 (80.7%) 134 (89.9%)

251 (85.4%)

Over 50% of respondents from both the study and control facilities had correct knowledge of

the names of the health districts in Enugu state.

Table 12: ATTITUDE OF OICs AND ASSISTANTS IN RESPECT OF THE ENUGU STATE DHS

STUDY n(%)

TOTAL n(%)

BEST DECRIPTION OF THE ENUGU DHS

Excellent health sector reform Good health sector reform Very good health sector reform Unnecessary health sector reform Bad health sector reform

60(42.3%) 43(30.3%) 30(21.1%) 9(6.3%) 0(.0%)

56(38.9%) 40(27.9%) 46(31.9%) 1(.7%) 1(.%)

116(40.6%) 83(29.0%) 76(26.6%) 10(3.5%) 1(.3%)

DHS MAKING POSITIVE IMPACT ON THE STATE HEALTH DELIVERY SYSTEM

133(91.7%) 141(94.6%) 279(93.2%)

POSITIVE IMPACT RATING High Average Very high Poor Below average

38(28.6%) 47(35.3%) 46(43.6%) 1(.8%) 1(.8%)

66(46.8%) 44(31.2%) 30(21.3%) 1(.7%) 0.(.0%)

104(38.0%) 91(33.2%) 76(27.7%) 2(.7%) 1(.4%)

40.6% of all respondents described Enugu DHS as an excellent health sector reform, while 38.0% gave it a high positive impact rating. Only 3.5% of respondents thought that DHS was an unnecessary health sector reform, while only 0.7% rated the positive impact made as being poor.

Fig 5: Bar chart showing the percentage of respondents in both the study and control groups that agreed that DHS has made any positive impact on the state health delivery system.

94.6% of respondents from the study group agreed that DHS made positive impact on the state health delivery system, while 91.7% from the control health facilities held the same view.

CONTROL STUDY

DHS MAKING POSITIVE IMPACT ON THE STATE HEALTH DELIVERY SYSTEM

DHS MAKING POSITIVEIMPACT ON THE STATEHEALTH DELIVERYSYSTEM

Table 13: REASONS GIVEN BY RESPONDENTS ON WHY DHS IS NOT MAKING POSITIVE IMPACT

STUDY n(%)

TOTAL n(%)

Poor implementation of the reform programme 3 (25.0%) 5 (62.5%) 8 (40.0%)

Lack of commitment of the constituent bodies’ members

4 (33.3%) 3 (37.5%) 7 (35.0%)

Poor attitude to work by the health facility workers 2 (16.7%) 3 (37.5%) 5 (25.0%)

Poor funding by the state government 4 (33.3%) 1 (12.5%) 5 (25.0%)

Poor funding by DFID (PATHS) 3 (25.0%) 1 (12.5%) 4 (20.0%)

Poor motivation of the Civil Servants working in health

4 (57.1%) 3 (37.5%) 7 (35.0%)

Defective planning of the system 7 (58.3%) 2 (25.0%) 9 (45.0%)

A total of 5.4% of respondents said that the DHS did not make any positive impact on the state health delivery system. 35.0% of this proportion believed that poor motivation of the civil servants working in health is the reason why no positive impact was made. 40.0% said that poor implementation of the reform programme was the reason for not making positive impact.

Table 14: OPINION ON THE EFFECT OF DHS ON THE NUMBER OF DELIVERIES

RECORDED

STUDY n(%)

TOTAL n(%)

Has improved moderately Has improved slightly Has improved tremendously No change Has declined Unable to estimate

40(27.6%) 44(30.3%) 15(10.3%) 33(22.8%) 9(6.2%) 4(2.8%)

51(34.2%) 36(24.2%) 44(29.5%) 11(7.4%) 4(2.7%) 3(2.0%)

91(31.0%) 80(27.2%) 59(20.1%) 44(15.0%) 13(4.4%) 7(2.4%)

TOTAL 145(100.0%) 149(100.0%) 294(100.0%)

Most of the respondents from the study facilities were of the opinion that child

deliveries recorded in the facilities improved moderately, while most of the

respondents from the control facilities believed that the improvement was only

slight. A total of 4.4% of the respondents were of the opinion that the number of

deliveries declined.

Fig 6: A BAR CHART SHOWING THE OPINION OF THE RESPONDENTS ON THE

EFFECT OF DHS, ON THE OUTPATIENT ATTENDANCE RECORDED

Most of the respondents from the study facilities were of the opinion that the

number of outpatient attendance improved tremendously as a result of the

introduction of the DHS, while most from the control group believe that the

improvement was only moderate. Only 1.6% of all the respondents were of the

opinion that the outpatient attendance has declined.

Has improvedmoderately

Has improvedtremendously

Has improvedslightly

No change Has declinedUnable toestimate

Controln(%)

Studyn(%)

Fig 7: BAR CHART SHOWING THE PRACTICE OF SOME DISTRICT HEALTH SYSTEM

GUIDELINES BY THE OICs AND THEIR ASSISTANTS

Over 60% of the respondents said that they comply with some specific DHS

guidelines such as existence of health facility committee, regular meeting of

health facility committee, and regular scheduled monitoring/supervisory visits by

members of the local health authority.

Existence of healthfacility committe

Regular Meeting ofHealth Facility

Committee

Regular scheduledmonitoring

/supervisory visits bymembers of the Lha

Control(%)

Study (%)

Fig 8: BAR CHART SHOWING THE REGULARITY OF MONITORING/SUPERVISORY

VISITS AS REPORTED BY THE RESPONDENTS

Most of the respondents (74.2% in the study group and 60.7% in the control

group) reported that monitoring/supervisory monitoring team visits them

monthly. 3.1% of respondents from the study facilities said that a team visits

them annually, while none of the respondents from the control facilities agreed to

annual being monitored annually.

Monthly Bimonthly Quarterly 6 monthly Annually

Control(%)

Study(%)

Fig 9: BAR CHART REPRESNTING THE PERSONNEL ISSUES ADRESSED BY THE

LOCAL HEALTH AUTHORITIES, IN RESPECT OF THE HEALTH FACILITIES.

Staff discipline is reported by both the study and control facilities to be the most

frequent health facility personnel issue addressed by the Local Health Authority.

This was followed by staff posting.

Staffrecruitment

Staff posting Staffdiscipline

StaffPromoting

Qualityrecognition

CONTROL

Fig 10: BAR CHART SHOWING THE PERCENTAGE OF RESPONDENTS WHO

AFFIRMED THAT, DRUGS WERE DISPENSED TO PATIENTS IN THEIR FACILITIES.

More respondents from the study group (93.7%) affirmed that drugs were

dispensed in their health facilities. 77.3% of respondents from the control group

also affirmed that drugs were dispensed in their facilities.

CONTROL STUDY

Table 15: REASONS GIVEN FOR NOT DISPENSING DRUGS TO PATIENTS

STUDY n(%)

TOTAL n(%)

Drugs not available now 19 (59.4%) 6 (66.7%) 25 (61.0%)

Drug has never been available 14 (43.8%) 3 (33.3%) 17 (41.5%)

Health facility workers not allowed to sell private drugs

14 (43.8%) 3 (33.3%) 17 (41.5%)

Usually very difficult to replenish used drugs 10 (31.2%) 4 (44.4%) 14 (34.1%)

Patient usually not willing to purchase drugs from the facility

5 (15.6%) 0 (.0%) 5 (12.2%)

Prices of CMS accessed drugs, usually very high 1 (3.1%) 1 (11.1%) 2 (4.9%)

6.3% of respondents from the study group and 27.7% of those from the control

group said that drugs were not dispensed in their health facilities. 66.7% of this

proportion from the study group, and 59.4% of the proportion from the control

group believe that drugs were not dispensed because of none availability of drug

during the time of completing the questionnaire, while 33.3% and 43.8%

respectively said that drugs have never been available in the facilities. 33.3% and

43.8% respectively submitted that drugs are not dispensed because health facility

workers are not allowed to sell private drugs. Only 11.1% and 3.1% said that the

prices of Central Medical Store accessed drugs are very high.

Table 16: DRUG REVOLVING FUND PRACTICE

VARIABLES CONTROL STUDY TOTAL

n(%) n(%) n(%)

Sources of drugs dispensed Supplied through the district health system approved channel (DRF) Supplied privately by the LHA Secretary Supplied by the community Privately provided by the health facility workers Supplied privately by the LHA chairman Supplied by a private drug vendor

90 (84.1%) 8 (7.3%) 5 (4.6%) 0 (0.0%) 1 (0.9%) 3 (2.8%)

130 (97.7%) 0 (0.0%) 0 (0.0%) 3 (2.3%) 2 (1.5%) 0 (0.0%)

220 (91.7%) 8 (3.3%) 5 (2.1%) 3 (1.2%) 3 (1.2%) 3 (1.2%)

Drug revolving fund roll out and training 0 (.0%) 149 (100.0%)

149 (50.7%)

LHA Secretary ensuring prompt replenishment of drug through the CMS

57 (49.6%) 72 (55.0) 129 (52.4)

Use of government approved drug price list 101 (69.7%) 137 (91.9%) 238 (81.0%)

Conspicuous display of price list 85 (84.2%) 112 (81.8%) 197 (82.8%)

Keeping good records of drug usage and purchases

86 (59.3%) 111 (74.5%) 197 (67.0%)

Operation of separate DRF Account 75 (51.7%) 105 (70.5%) 180 (61.2%)

Facility Health Committee approval of DRF transactions

101 (69.7%) 114 (76.5%) 215 (73.1%)

Community member being a signatory to DRF Account

80 (55.2%) 118 (79.2%) 198 (67.3%)

Keeping of separate cash and receipt books for DRF transactions

85 (58.6%) 117 (78.5%) 202 (68.7%)

Stacking of DRF items on shelves or pallets 85 (58.6%) 130 (87.2%) 215 (73.1%)

Monthly stock count and valuation of DRF items 76 (52.4%) 88 (59.1%) 164 (55.8%)

HANDLING OF EXPIRED DRUGS Repackaged Given away to health facility workers Dispensed to patients if it is not more than 3 months expired Given to poor community members who might not be able to afford quality drugs Returned to the Central Medical Store Thrown away or destroyed by health facility workers

14 (28.6%) 1 (2.3%) 18 (31.6%) 1 (2.2%) 65 (81.2%) 1 (2.2%)

10 (40.0%) 0 (0.0%) 10 (43.5%) 2 (10.5%) 103 (97.2%) 0 (0.0%)

24 (32.4%) 1 (1.6%) 28 (35.0%) 3 (4.6%) 168 (90.3%) 1 (1.6%)

Most of the respondents from both the study and control groups (91.7%) submitted that they

sourced their drugs through the DHS approved channel, which is the Central Medical Store.

90.3% also, said that they returned the expired drugs to the Central Medical Store.

Table 17: OBSTETRICS SERVICES PROVIDED IN THE FACILITIES

VARIABLES CONTROL n(%)

STUDY n(%)

TOTAL n(%)

Antenatal care 118 (81.4%) 130 (87.2%) 248 (84.4%)

Delivery 111 (76.6%) 128 (85.9%) 239 (81.3%)

Post natal care 96 (66.2%) 117 (78.5%) 213 (72.4%)

Induction of labour with Pitocin 30 (20.7%) 38 (25.5%) 68 (23.1%)

Episiotomy and repair 78 (53.8%) 102 (68.5%) 180 (61.2%)

Management of Pre-eclampsia 27 (18.1%) 33 (22.1%) 60 (20.4%)

Manual removal of placenta 34 (23.4%) 47 (31.5%) 81 (27.6%)

Blood transfusion 3 (2.1%) 6 (4.0%) 9 (3.1%)

Emergency/Essential obstetrics care

49 (33.8%) 74 (49.7%) 123(41.8)

Records of deliveries kept 99 (68.3%) 133 (89.3%) 232(78.9)

89.3% of respondents from the study facilities said that records of deliveries are

kept in the facilities, while 68.3% from the control group gave the same response.

Most of the respondents from both the study and control facilities submitted that

antenatal care, delivery, postnatal care, and episiotomy repair are provided in

their facilities.

Table 18: TRAININGS RECEIVED FROM PATHS

VARIABLE CONTROL STUDY TOTAL

Life Saving Skills (LSS) 3 (2.5%) 2 (1.5%) 5 (2.0%)

Medical Packages of Care 35 (29.4%)

17 (12.7%

52 (20.6%)

Surgical Packages of Care 53 (44.5%)

55 (41.0%)

108 (42.7%)

Financial Management 26 (21.8%)

58 (43.2%)

84 (33.2%)

Health management Information System 2 (1.7%) 2 (1.5%) 4 (1.6%) Interpersonal communication 56

(46.3%) 95 (69.3%)

151 (58.5%)

Emergency/ Essential obstetrics care 30 (27.0%)

48 (32.2%)

78(30.0)

Interpersonal communication skill was the area on which most of the respondents

were trained (69.3% from the study group and 46.3% from the control group).

More respondents from the control group were trained on medical and surgical

packages of care, than those from the study group. More respondents from the

study group however received the financial management training. Only two

persons from each group, making a total percentage of 1.6% received training on

RECORDS OF OUTPATIENT ATTENDANCE KEPT IN FACILITIES

Up to 99.1% of respondents from the study and 95.8% from the control facilities,

submitted that records of outpatient attendance are kept in their health facilities.

In summary, the results of this study revealed as follows;

Out-patient attendance improved significantly in the PATHS supported

health facilities.

The outpatient attendance in the control facilities also increased after the

PATHS intervention in the state.

The number of deliveries in the supported health facilities also increased

significantly.

The supported health facilities significantly purchased more drugs from

the Central Medical Store, than the facilities that were not supported.

The supported health facilities were already doing better than the

facilities that were not supported, prior to the support. This is a

confounding factor.

The Officers-In-Charge of the primary health facilities and their Assistants

had good knowledge and attitude towards DHS, but their reported

practices was not in consonance with observed practices.

CHAPTER 5

DISCUSSION

The general characteristics of the studied facilities in both the urban and rural

areas, and support from other donor organizations were not significantly

different. Most of the facilities were rural based while the socio-demographic

characteristics of the Officers-In-Charge and their Assistants in both the study and

control groups are similar. The six facilities in the study group that have medical

doctors as the Officers-In-Charge, co-existed with secondary health care facilities

which the doctors were heading. The primary health care and the secondary

health care facilities were merged when the primary health care arm was supplied

with drugs and equipment by PATHS. This ensured that the host community

benefited maximally from the PATHS support, since the secondary care arm

usually had more competent and qualified personnel. Moreover, the DHS

advocate the integration of Primary and Secondary care services.

The percentage increase in out-patient attendance in the study facilities after the intervention is statistically significant. This increase in out-patient attendance is consistent with findings in Tanzania (39) and Cambodia (41), where donor support has been shown to contribute to improved primary health facilities utilization. The same finding was made in studies carried out in Kyrgyzstan where support from agencies such as DFID, USAID, WHO, and UNICEF led to significant improvement in the utilization of primary health care services(43). In Utta Pradesh, India also there was consistent increase in monthly out-patient attendance as a result of donor support (44). Some earlier studies in Nigeria revealed that all Local Government Areas that showed increased coverage and health facility utilization were donor agency supported (48). This current study is in agreement with this finding. It was observed that out-patient attendance in the control health facilities also

increased significantly after the PATHS intervention. Although the PATHS

programme did not offer direct support by way of drug or equipment supply to

the control facilities, the formal introduction of the district health system in

Enugu state and the attendant reforms may have contributed to improved health

care delivery across the state. The increase in the out-patient attendance in the

control facilities was however not as significant as the increase in the supported

facilities after the support. This suggests that the PATHS support possibly played a

role in the improved out-patient attendance noted in the supported facilities.

This study revealed that the supported facilities recorded significantly more out-

patient attendance than the control facilities prior to the PATHS support.

However it is on record that baseline survey was conducted to select the most

functional facilities for support, in line with PATHS leadership belief that

supporting facilities that already showed clear signs of viability will ensure good

returns on their investment (65). The difference between the percentage increase

in the study population and the Control group is statistically significant (p value of

0.000). This again is consistent with the view that PATHS intervention contributed

significantly to improved out-patient attendance in the supported facilities.

It is noted that other factors that can affect health facility utilization include socio-

economic issues, distance from the facility, none availability of properly trained

health personnel, type of services available, attitude of health workers, perceived

quality of care, none mobilization and involvement of communities in health

management and the political will of governments (40,48,49,54,55,58). It is

however assumed that these factors did not significantly affect the positive

outcome of the donor support on district health service utilization in this study,

since both control and study facilities were located in rural areas, and the facilities

being randomly selected will have similar exposure to the stated factors.

The number of deliveries in the supported health facilities increased significantly

after the support. This finding agrees with a study carried out in Zimbabwe to

assess the impact of World Bank support. It was discovered that the support

improved service quality and contributed to increased facility deliveries (57).

Significantly more deliveries were recorded in the supported health facilities than

in the control facilities prior to the support (p<0.0001). This also could be as a

result of the bias noted above in selecting the facilities for support. Though the

supported facilities performed better in the area of deliveries than the control

facilities; the difference was not as significant as recorded prior to the support

(p=0.00025). Some of the suggested reasons for this include the observation that

more deliveries are occurring outside the public health facilities, issues such as

security concern, poor work environment and poor health worker/client

relationship undermine 24-hour service in the facilities (66). More deliveries

occurring outside the public health facilities could be as a result of PATHS support

to the private health care providers by way of training of traditional birth

attendants (TBAs) and partnering with four Faith based secondary care facilities in

the area of Emergency Obstetrics care (EOC). Fifteen private health care facilities

were also supplied with drugs and equipment by PATHS (26). These measures

taken by the PATHS programme towards improving the services of the private

sector health providers appear to have made the services of the private sector

attractive in the area of child delivery.

The supported health facilities significantly purchased more drugs from the

Central Medical Store, than the facilities that were not supported. The Enugu

state guideline on procurement and sale of drugs clearly states that the health

facilities shall procure drugs from the state Central medical Store (CMS) (67). This

study revealed that although the supported facilities significantly purchased more

drugs from the CMS, there was paucity of records of drug transactions in the CMS

and the health facilities. It appears that most of the drugs being used in the

facilities are not procured through the CMS as required.

Some earlier studies noted that majority of health facilities surveyed in the south

eastern part of Nigeria do not provide all services required of them because they

are poorly maintained and do not have enough skilled health workers (68). Poor

work ethics among health workers, leading to marked staff indiscipline, and poor

staff motivation and reward system were also identified as reasons why health

facilities performed poorly (66). The DFID support however resulted in

significantly increased out-patient attendance, deliveries and drug revolving fund

turnover in the supported facilities.

Less than 50% of respondents in both the study and control groups think that DHS

has made any positive impact on both the number of deliveries and outpatient

attendance recorded. This is in spite of the earlier finding in this research project

that there has been very significant improvement in the number of outpatient

attendance, and deliveries recorded in the primary health care facilities, since the

implementation of DHS in Enugu state. The unfavourable view expressed about

not making positive impact, could be as a result of some other factors such as

poor staff motivation and reward system, leading to disenchantment among the

health facility workers. Poor work ethics among the health facility workers,

leading to marked staff indiscipline, could also be a factor (66). This view requires

more research effort for its authentication.

The claim by majority of the respondents that their work in the health facilities is

guided by the DHS guidelines is doubtful, since no reliable data on out-patient

attendance, deliveries, and DRF turnover was found in most of the facilities. The

Enugu state district health system guidelines state that the health facilities should

keep proper records of their out-patient attendance, child deliveries and drug

revolving fund turnover. Training on Health Management Information System was

targeted only on HMIS and M&E Officers, to the exclusion of the Officers-in-

Charge of the facilities and their Assistants. (26). This lack of training on HMIS for

the Officers-in-Charge and their Assistants, may have contributed to the poor

record keeping observed in the facilities. Only two persons from the study

facilities and two from the control facilities received the HMIS training. These

persons could have been former M&E officers who were deployed to work in a

facility as Officer-in –charge or Assistant

CONCLUSION: The results of this study specifically revealed that outpatient

attendance improved tremendously in the PATHS supported health facilities, and

also in the control facilities to a significant extent. Significant increase in the

number of child deliveries was also recorded in the supported, and control health

facilities. The supported health facilities significantly purchased more drugs from

the Central Medical Store, than the facilities that were not supported. The study

also revealed that the supported facilities were already doing significantly better

than the non-supported facilities, in the areas of outpatient attendance, child

deliveries and drug revolving fund practices. The Officers-in-Charge of the health

facilities in both the study and control health facilities, and their Assistants had

good knowledge and attitude towards district health system, but their reported

practices were not in consonance with observed practices, such as is seen in their

claim to keeping records of out-patient attendance/deliveries and buying drugs

from the Central Medical Store. These records were not available in the facilities

and there were no records in the Central Medical Store showing regular purchase

of drugs by them.

RECOMMENDATIONS: It is believed that the following recommendations will

further improve health facility utilization in Enugu state.

Preference ought to be given to poorly performing health facilities in

selecting those that will be donor supported. This will ensure that better

services are extended to communities that previously had poor access to

quality care.

The state Central Medical Store needs to be expanded and made more

functional. This could be achieved through the creation of drug bulk

stores as CMS outlets in the different health districts. This will enhance

access to quality drugs, by the health facilities.

Stepping up monitoring/supervisory activities to ensure that health

facilities operate within stipulated guidelines.

Recruiting more qualified staff to man and provide service in the health

facilities. Over 73% of the primary health care facilities are headed by

Community health Extension Workers and less qualified personnel. The

key to effective and efficient delivery of health care is to ensure sufficient

numbers of adequately paid and well trained health professionals (3).

Organizing regular trainings on HMIS and M&E, and providing adequate

logistical support for these activities; to ensure improvement on data

collection, collation, transmission, storage and usage.

Paying attention to staff motivation and welfare, by ensuring that their

remunerations are commensurate with those of the other health workers

in Nigeria. Improvement in the working and living conditions of health

workers is a pre-condition for the effective delivery of public health

services (6). Poor staff motivation was one of the reasons identified in this

study, on why DHS is not making positive impact on the state health

delivery system.

Embarking on a research project designed to identify the factors that

militate against proper implementation of DHS in Enugu state; with the

aim of taking steps to ensure proper and effective implementation.

Research into attitude of health staff (work ethics/staff indiscipline) is

required to investigate the effect on health facility utilization.

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ANNEX A

TITLE: THE EFFECT OF A DONOR SUPPORT ON DISTRICT HEALTH SERVICE

UTILIZATION IN ENUGU STATE

DFID SUPPORTED PRIMARY HEALTH CARE FACILITIES – INTERVENTION (STUDY)

HEALTH FACILITIES

NOTE: HC means Health Center

1. Oduma Achara HC 27. Emudo HC 53. Mgbagbu Owa HC

2. Agbani HC 28. Ezere HC 54. Umabi HC

3. Achi Uno HC 29. Mmaku HC 55. Ogwofia Owa HC

4. Amafor Ugbawka HC 30. Mpu HC 56. Iji-Nike HC

5. Ozalla HC 31. Ugwuoba HC 57. Umuaga HC

6. Obune Inyi HC 32. Abakpa HC 58. Aguobu Umumba HC

7. Ihe HC 33. Amokpo Uno HC 59. Obuofia HC

8. Akpoga Nike HC 34. Ngwo Hill Top HC 60. Mbu Akpoti HC

9. Amalla Orba HC 35. Ugwogo Nike HC 61. Mbu Agudene HC

10. Ovoko HC 36. Uwani HC 62. Neke HC

11. Akwuke HC 37. Aguibeje HC 63. Eha-Amufu HC

12. Ogbede HC 38. Ette HC 64. Ebe HC

13. Mgbuji HC 39. Imilike Uno HC 65. Obollo Afor HC

14. Nsukka HC 40. Obollo Eke HC 66. Ibagwa-Aka HC

15. Opi HC 41. Uhunowerre HC 67. Amalla Ogazi HC

16. Oyofo Oghe HC 42. Unadu HC 68. Igogoro HC

17. Awha Imezi HC 43. Mbu Amonu HC 69. Okpuje HC

18. Ukpabi-Nimbo HC 44. Umualor HC 70. Ohebe Dim HC

19. Olido HC 45. Adani HC 71. Umunko HC

20. Obinofia Ndiuno HC 46. Aku HC 72. Ummunna HC

21. Akegbe Ugwu HC 47. Ezi Ukehe HC 73. Ozalla HC

22. Akpugo Ihunekwa HC 48. Ibagwa Ani HC 74. Awlaw HC

23. Mburubu HC 49. Nkpologwu HC 75. Isu Awa HC

24. Okeani HC 50. Umulokpa HC 76. Nomeh HC

25. Ubahu HC 51. Abor HC 77. Nkwe HC

26. Amoli HC 52. Ikedimkpa HC

ANNEX B TITLE: THE EFFECT OF A DONOR SUPPORT ON DISTRICT HEALTH SERVICE

UTILIZATION IN ENUGU STATE RE: CONTROL HEALTH FACILITIES

S/N FACILITY LGA

1 Obollo-Etiti Basic Health Center Udenu 2 Uwelle Ukehe Health Center Igbo-Etiti

3 Unonagu Health Center Udenu

4 Ibagwa Nike Community Health center Enugu East 5 Eziokwe Health Center Amuri I Nkanu West

6 Maternal and Child Health (MCH) Center Awgu) Awgu 7 Akpugoeze Health Center Oji River

8 Agbogazi Health Center Enugu east 9 Umudioha (Imezi Owa) Health Center Ezeagu

10 Basic Health Center, Mile Two Oji River

11 Umana Ndiuno Health Center Ezeagu 12 UDA Health Center Igbo Eze North

13 O’eji Ndiagu Health Center Nkanu west 14 Alulu health Center Enugu East

15 Iva Pottery Health Center Enugu North

16 Inyi (Umuokoro) Health Center Igbo Eze North 17 Ibagwa Ezimo Health Center Udenu

18 Amansiodo Ndiagu (Ihuonyia) Health Center Ezeagu 19 Umuitodo (Obollo Nkwo) Health Center Udenu

20 Adaba Health Center Uzo-Uwani 21 Ahani/Ametiti Health Center Oji River

22 Ohodo health Center Igbo-Etiti

23 Ezimo Uno Health Center Udenu 24 Ugwuleshi Health Center Awgu

25 Okpudo Health Center Ezeagu 26 Isikwe Health Center Oji River

27 Mgbowo Health Center Awgu

28 Agbudu Health Center Udi 29 Ugbo-Odogwu Health Center Enugu East

30 Ezimo Agu Health Center Udenu

31 Umudim (Imezi Owa) Health Center Ezeagu

32 Obinagu Amokpo Health Center Enugu East 33 Ndiagu Obuno Akpugo Health Center Nkanu West

34 Amodu/Okpebe Health Center Nkanu West 35 Amechi Health Center Enugu South

36 Agbogugu Health Center Awgu

37 Nchatancha Health Center Enugu East 38 Obeagu Health Center Enugu South

39 Achi Agu I Health Center Oji River 40 Onu-Ato Health Center Enugu North

41 Ijo Health Center Igbo-Etiti

42 Ogbaku Health Center Awgu 43 Achi Agu II Health Center Oji River

44 Ekoli Health Center Aninri 45 Udi Health Center Udi

46 Nachi Health Center Udi 47 Ugbeke (Dr Chimaroke Nnamani) Health Center Igbo Eze North

48 Ugbo Health Center Awgu

49 Ede-Oballa Health Center Nsukka 50 Ihuokpara Health Center Nkanu East

51 Amaja Community Basic Health Center Igbo Eze North 52 Mgbidi Health Center Awgu

53 Obe Health Center Nkanu West

54 Ette-uno health Center Igbo Eze North 55 Nenwe Health Center Aninri

56 Iheaka Basic Health Center Igbo Eze South 57 Nenwenta Health Center Awgu

58 Obeagu Health Center Aninri 59 Igugu (Ebeano) Health center Udenu

60 Nsude Health Center Udi

61 Isi-Enu Health Center Nsukka 62 Iwollo Health Center Ezeagu

63 Inyi Health Center Oji River 64 Agu-Amede Health Center Isi-uzo

65 Coal camp Health Center Enugu North

66 Amuri II Health Center Nkanu West

67 Umundu Health Center Udenu

68 Ugwuaji Health Center Enugu South 69 Eha-Ndiagu Health Center Nsukka

70 Obodo Nike Health Center Enugu East 71 Amokwe Health Center Udi

72 Owelli Health Center Awgu

73 Umunze Health Center Nkanu West 74 Eke Health Center Udi

75 Ugbawka Health Center Nkanu East 76 Nkerefi Health Center Nkanu East

77 Obinagu Uwani Health Center Nkanu West

ANNEX C

THE EFFECT OF A DONOR SUPPORT ON DISTRICT HEALTH SERVICE UTILIZATION IN ENUGU STATE

PROFORMA FOR COLLECTING DATA ON OUTPATIENT ATTENDANCE, FROM THE DEPT. OF PLANNING, RESEARCH AND STATISTICS, STATE MINISTRY OF HEALTH

S/N HEALTH

FACILITY OUTPATIENT ATTENDANCE IN 2008 (JANUARY – JUNE)

JAN FEB MARCH APRIL MAY JUNE REMARKS

ANNEX D

PROFORMA FOR COLLECTING DATA ON DELIVERIES, FROM THE DEPT. OF

PLANNING, RESEARCH AND STATISTICS, STATE MINISTRY OF HEALTH

S/N HEALTH FACILITY

DELIVERIES IN 2008 (JANUARY – JUNE)

ANNEX E

PROFORMA FOR COLLECTING DATA ON DRUG PURCHASES IN NAIRA, FROM THE

CENTRAL MEDICAL STORE, STATE MINISTRY OF HEALTH

S/N HEALTH FACILITY

TOTAL AMOUNT OF DRUGS PURCHASED (Naira) (JANUARY – JUNE 2008)

ANNEX F

THE EFFECT OF A DONOR SUPPORT ON DISTRICT HEALTH SERVICE UTILIZATION

IN ENUGU STATE.

QUESTIONNAIRE

No.---------

INFORMED CONSENT: We are conducting a study on the District Health System,

being implemented in Enugu state. The major aim of the study is to assess the

effect of the DFID support, given through the PATHS programme that ended in

June, 2008. The assessment shall be on the utilization of our Primary Health Care

facilities. We would like you to answer questions which will assess the Knowledge,

Attitude and Practice of the Enugu State model of District Health System. Your

participation is voluntary. You may not answer questions which you do not wish

Please note that your answers will be treated with utmost confidentiality. Thank

you for participating in this study.

CONSENT GIVEN Yes No

GENERAL INFORMATION

Name of Primary Health Care facility -------------------------------------------------------

Type of facility URBAN RURAL

Was the facility supplied with drugs/Equipment by PATHS? Yes No

If yes, when was the supply made? ------------------------------------------------------

What was the value, in Naira of the first supply made to your facility? -----------

Did your facility receive any kind of support from any other donor organization,

between 2006 and 2008; except PATHS? Yes No

If yes, what is the name of the organization? --------------------------------------------

Which type of support was given?

YES NO NOT SURE

infrastructure

Hospital equipment

Drugs and Medical/Surgical supplies

How long have you worked in this facility? ----------------------------------------------

Name of Officer-in-Charge/Assistant (Optional) -----------------------------------------

Sex ----------------

Age ----------------

Qualification(s) (Tick as appropriate).

Public Health Nurse

Community Health Officer Nurse/Midwife

Community Health Extension Worker

Junior Community Health Extension Worker Environmental Health Officer

Pharmacy Technician Others (Specify)

GENERAL KNOWLEDGE OF DISTRICT HEALTH SYSTEM

1. The District Health System provides the best chances of implementing

Primary Health Care. True False Not sure

2. Integration of Primary and Secondary healthcare is an important aspect of

District Health System True False Not sure

3. Ideal District Health System also provides for integration of the private

health facilities, orthodox and non-orthodox methods of health care

services. True False Not sure

4. Integrated District Health System is not the means by which specific health

programmes can best be delivered in the context of overall health care

needs. True False Not sure

5. Population is usually not an important issue in a good District Health

System. True False Not sure

6. Good referral system is essential for the proper functioning of the District

Health System. True False Not sure

7. In District Health System, decentralization involves the follow; (Tick as

appropriate)

YES NO NOT SURE

Deconcentration Devolution

Demonstration Delegation

8. District Health System is recommended by World Health Organization as a

means of properly implementing Primary Health Care, as envisaged in the

Alma-Ata declaration. True False Not sure

KNOWLEDGE OF THE ENUGU STATE MODEL OF DISTRICT HEALTH SYSTEM

1. In which year was the Enugu state District Health System law enacted; (Tick

as appropriate).

YES NO

2002 2003

2004 2005

others

2. How many Health Districts are there in Enugu state? (Tick as appropriate)

YES NO 4

65 others

3. How many constituent bodies, outside the Local health Authorities, make

up the District Health System in Enugu State? (Tick as appropriate)

YES NO 3

65 others

4. The Policy Development and Planning Directorate (PDPD) is headed

YES NO

Hon. Commissioner, MOH Perm. Sec. MOH

Health Administrator

Director, Admin. & Supply MOH Director, Medical Services

others

5. The State Health Board (SHB) is headed by; (Tick as appropriate)

YES NO Hon. Commissioner, MOH

Perm. Sec. MOH Health Administrator

Director, Admin. & Supply MOH

Chairman, SHB others

6. The Enugu state model of the District Health System provides for how many

Local Health Authorities? (Tick as appropriate).

YES NO

65 others

7. Which of these are Health Districts in Enugu state? (Tick as appropriate)

YES NO

Enugu Metropolitan Aninri

Enugu-Ezike Udi

Ezeagu

8. The Executive head of a Local Health Authority is (Tick as appropriate)

YES NO Chairman

Medical Officer LHA Secretary

Traditional Ruler

Religious leader Others (Specify)

9. With the introduction of District Health System in Enugu state, the HOD

Health in the LGA, is now known as, (Tick as appropriate)

YES NO

HOD, Health matters LHA Secretary

OIC, LGA Health Health Chief

CHO Health

Others (Specify)

ATTITUDE OF OICs AND ASSITANTS

1. Which of these, in your opinion best describes; the District Health System

introduced in Enugu state.

YES NO

Excellent health sector reform Very good health sector reform

Good health sector reform Bad health sector reform

Unnecessary health sector reform

Others (Specify)

2. Do you think the District Health System has made any positive impact on

the state health delivery system? Yes No Not sure

3. If yes, how would you rate the positive impact?

YES NO

Very high High

Average Below average

Others (Specify)

4. If no, which of these best describes the reason; for District Health System

not making any positive impact?

Yes NO

Poor implementation of the reform programme Lack of commitment of the constituent bodies’ members

Poor attitude to work by the health facility workers

Poor funding by the state government Poor funding by DFID (PATHS)

Poor motivation of the Civil Servants working in health Defective planning of the system

Others (Specify)

PRACTICE OF SOME DISTRICT HEALTH SYSTEM GUIDELINES BY THE OICs AND

THEIR ASSISTANTS

1. Do you have health facility committee in place? Yes No Not sure

2. Does the committee meet regularly? Yes No Not sure

3. Do members of your Local Health Authority pay regular scheduled

monitoring/supervisory visits to your facility? Yes No Not sure

4. If yes, how regular are the visits? (Tick as appropriate)

YES NO Monthly

Bimonthly Quarterly

6 monthly

Annually Others (Specify)

5. When was the last monitoring/supervisory visit held? --------------------

6. Which personnel issue(s) has the LHA addressed? (Tick as appropriate).

YES NO

Staff recruitment Staff posting

Staff discipline Staff promotion

Quality Recognition initiative

Others (Specify)

7. Are drugs dispensed to patients in your facility? Yes No Not sure

8. If no, why? (Tick as appropriate)

Yes No

Drug has never been available Health facility workers not allowed to sell private drugs

Patient usually not willing to purchase drugs from the facility

Prices of CMS accessed drugs, usually very high Usually very difficult to replenish used drugs

Drugs not available now Others (Specify)

9. If yes, what is the source of the drugs?

Yes No

Privately provided by the health facility workers

Supplied through the district health system approved channel (DRF) Supplied by the community

Supplied by a private drug vendor Supplied privately by the LHA Secretary

Supplied privately by the LHA Chairman Others (Specify)

10. Was there a Drug Revolving Fund roll out, and training by PATHS in your

facility? Yes No

11. If yes, how long ago was this? ------------------------------------------

12. If you source your drugs through the Central Medical Store, does your LHA

Secretary ensure prompt replenishment of your drugs, when your stock is

getting exhausted? Yes No Not sure

13. Are you using the government approved price list to sell to your patients?

Yes No Not sure

14. If yes, is the price list conspicuously displayed? Yes No

15. Do you keep good records of drug usage, and purchases in your facility?

Yes No Not sure

16. If yes, kindly give us the total amount spent on purchasing drugs, and sales

made in the following months;

PURCHASES SALES January 2008

February 2008 March 2008

April 2008

May 2008 June 2008

17. Do you operate a separate DRF account? Yes No Not Sure

18. Does the facility health committee approve your DRF transactions?

Yes No Not sure

19. Is a community member a signatory to your DRF account?

Yes No Not sure

20. What do you do with your expired drugs?

Yes No Not sure

Repackage them Give them away to health facility workers

Dispense them to the patients if it is not more than 3 months expired.

Give them to poor community members, who might not be able to afford quality drugs.

Return them to the Central Medical Store

Throw them away, or destroy them by yourself Others (Specify)

21. Do you have separate cash books and receipt books for DRF transactions?

Yes No Not sure

22. Do you stack your DRF items on shelves or pallets?

Yes No Not sure

23. Do you carry out monthly stock count and valuation of the DRF items?

Yes No Not sure

24. Do you provide Emergency(Essential) Obstetrics Care (EOC)?

Yes No Not sure

25. Were you trained by PATHS on Emergency Obstetric Care (Essential

Obstetric Care)? Yes No

26. What obstetrics services do you provide in your facility?

Yes No Not sure Antenatal care

Delivery Post natal care

Induction of labour with Pitocin

Episiotomy and repair Management of Pre-eclampsia

Manual removal of placenta Blood transfusion

Others (Specify)

27. Since the introduction of District Health System, what would you say about

the number of deliveries now recorded in your facility?

Yes No Not sure

No change Has improved slightly

Has improved moderately Has improved tremendously

Has declined

Unable to estimate

28. Do you keep records of deliveries in your facility?

Yes No Not sure

29. If yes, kindly supply the number of deliveries taken in the months listed

below.

DELIVERIES January 2008

February 2008 March 2008

April 2008

May 2008 June 2008

30. Were you trained by PATHS on Interpersonal Communication Skills (IPC)?

Yes No

31. Since the introduction of District Health System, what would you say about

the number of patients that now present at your facility on outpatient

bases?

Yes No Not sure

No change Has improved slightly

Has improved moderately Has improved tremendously

Has declined

Unable to estimate 32. Do you keep record of your out patient attendance? Yes No

33. If yes, kindly supply the number of patients that attended your facility in

the months listed below, excluding children that came for immunization;

OUTPATIENTS

January 2008 February 2008

March 2008 April 2008

May 2008

June 2008 34. What other trainings did you receive from PATHS, before the programme

came to an end in June, 2008?

Yes No

Life Saving Skills (LSS) Medical Packages of Care

Surgical Packages of Care

Financial Management Health management Information System

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