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1
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
TO
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
2
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
3
DEDICATION
This work is dedicated to the poor and downtrodden, who die
daily as a result of inability to access basic health care services.
4
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
5
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.
6
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
7
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
1 12
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
8
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-
9
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
10
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.
(1).
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
(7).
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
11
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).
12
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
13
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
14
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
15
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
(26);
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
16
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.
17
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
18
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).
19
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).
20
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
21
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
22
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
23
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).
24
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
25
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
26
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
27
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
28
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
29
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
(62).
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
30
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
31
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
32
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.
33
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:
34
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
35
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.
36
Table 2: Socio-demographic characteristics of the OICs and their Assistants in both the study and control facilities.
VARIABLE CONTROL n(%)
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).
37
Month Study
(Outpatient
attendance)
Control
(Outpatient attendance)
Chi square (p value)
January
February
March
April
May
June
2333
2537
2648
2208
2485
2841
1387
1336
1361
1239
1513
1380
35.22
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)
Chi square (p value)
January
February
March
April
May
June
12922
10566
10172
12917
13106
13653
4984
4825
5069
7422
7377
5449
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.
38
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.
39
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.
0
2000
4000
6000
8000
10000
12000
14000
16000
January February March April May June
Year 2004
Year 2008
40
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)
0
1000
2000
3000
4000
5000
6000
7000
8000
January February March April May June
Year 2004
Year 2008
41
(Deliveries) (Deliveries)
January
February
March
April
May
June
102
118
135
96
106
90
30
43
51
78
105
63
46.80
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)
Chi square (p value)
January
February
March
April
May
June
126
145
161
192
212
216
35
47
84
95
110
70
18.30
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.
42
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.
0
50
100
150
200
250
January February March April May June
Year 2004
Year 2008
43
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.
0
20
40
60
80
100
120
January February March April May June
Year 2004
Year 2008
44
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
March
April
May
June
1607712
948195
2356193
555741
2052325
3767794
0
6465
9032
418666
33902
75742
3.8
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
2004.
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
45
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%)
46
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
VARIABLE CONTROL n(%)
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
VARIABLE CONTROL n(%)
STUDY n(%)
TOTAL n(%)
BEST DECRIPTION OF THE ENUGU DHS
47
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.
90
91
92
93
94
95
CONTROL STUDY
DHS MAKING POSITIVE IMPACT ON THE STATE HEALTH DELIVERY SYSTEM
DHS MAKING POSITIVEIMPACT ON THE STATEHEALTH DELIVERYSYSTEM
48
Table 13: REASONS GIVEN BY RESPONDENTS ON WHY DHS IS NOT MAKING POSITIVE IMPACT
VARIABLE CONTROL n(%)
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.
49
Table 14: OPINION ON THE EFFECT OF DHS ON THE NUMBER OF DELIVERIES
RECORDED
VARIABLE CONTROL n(%)
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.
50
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.
0
5
10
15
20
25
30
35
40
45
50
Has improvedmoderately
Has improvedtremendously
Has improvedslightly
No change Has declinedUnable toestimate
Controln(%)
Studyn(%)
51
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.
0
10
20
30
40
50
60
70
80
90
100
Existence of healthfacility committe
Regular Meeting ofHealth Facility
Committee
Regular scheduledmonitoring
/supervisory visits bymembers of the Lha
Control(%)
Study (%)
52
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.
0
10
20
30
40
50
60
70
80
Monthly Bimonthly Quarterly 6 monthly Annually
Control(%)
Study(%)
53
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.
48.3
0
10
20
30
40
50
60
Staffrecruitment
Staff posting Staffdiscipline
StaffPromoting
Qualityrecognition
CONTROL
STUDY
54
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.
77.3
93.7
0
10
20
30
40
50
60
70
80
90
100
CONTROL STUDY
55
Table 15: REASONS GIVEN FOR NOT DISPENSING DRUGS TO PATIENTS
VARIABLE CONTROL n(%)
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
56
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.
57
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.
58
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
HMIS.
59
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
60
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.
61
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
62
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
63
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.
64
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.
65
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72
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
73
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
74
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
75
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
76
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
77
ANNEX D
THE EFFECT OF A DONOR SUPPORT ON DISTRICT HEALTH SERVICE UTILIZATION IN ENUGU STATE
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)
JAN FEB MARCH APRIL MAY JUNE REMARKS
78
ANNEX E
THE EFFECT OF A DONOR SUPPORT ON DISTRICT HEALTH SERVICE UTILIZATION IN ENUGU STATE
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)
JAN FEB MARCH APRIL MAY JUNE REMARKS
79
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
to.
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? -----------
80
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)
81
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
82
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
2006
others
2. How many Health Districts are there in Enugu state? (Tick as appropriate)
YES NO 4
7 17
56
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
9
17 56
65 others
83
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
17 39
7 56
65 others
84
7. Which of these are Health Districts in Enugu state? (Tick as appropriate)
YES NO
Enugu Metropolitan Aninri
Awgu
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)
85
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
Poor
Others (Specify)
86
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)
87
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)
88
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
89
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)
90
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?
91
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