Keywords: Primary health care, participation, ranking, health behaviour, services
Part of the fundamental principle underlying the national health policy in Nigeria to achieve health for all Nigerians is based on the national philosophy of social justice and equity (FMH, 1988). The international conference on Primary Health Care defines primary health care as:
essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and their families in the community through their full participation and at a cost that community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination (WHO, 1989)
PHC, according to the Alma-Ata declaration cited above, was aimed at addressing the main health problems in the community, providing promotive, curative, and rehabilitative services. Eight services were identified as the main focus of PHC as follows:
It is evident from the foregoing therefore, that PHC embodies the basic needs approach, and the approach of the 60s was a development away from hospitals towards health centres and sub-centres using auxiliary personnel. PHC however, is a shift towards the front-line of day-to-day activities carried out within the community.
Evolution of primary health care in Nigeria
Primary Health Care Service became a dream come true for the first time in Nigeria in 1975, when Yakubu Gowon, Nigeria’s leader announced the Basic Health Service Scheme (BHSS) as part of the Third National Development Plan (1975-80). The objectives of the scheme were to increase the proportion of the population receiving health care from 25 to 60 percent, correct the imbalances in the location and distribution of health institutions and provide the infrastructures for all preventive health programmes such as control of communicable diseases, family health, environmental health, nutrition and others and establish a health care system best adapted to the local conditions and to the level of health technology (Sorungbe, 1989).
build in each local government area a comprehensive health institution that would serve as the headquarters of the services, four primary health centres and 20 health clinics. This was called a basic health unit designed for a population of 150,000. The health clinics were to be the most peripheral health facilities, each serving a population of 2,000. The aim was that a primary health centre would serve as a referral centre for four health clinics and serve a population of 20,000, while the comprehensive health centres, and the four health clinics would serve a population of 50,000, with mobile clinics from the primary health centres.
Nineteen (19) schools of health technology in each state were established to train three categories of community health workers (the supervisors, assistants and aides). The community health officers were to be trained in the teaching hospitals. In 1978, a decision was taken to build a basic health centre in a local government in each state so that a model health service could be set up that would later be copied by other local governments (Oyegbite, 1989).
Several factors have been adduced by critical observers and stakeholders for the poor
This paper therefore, is an attempt to highlight what PHC services are within the context of Nigeria’s health policy and to know how the people in rural communities prioritize these services when health care providers come their way. It is strongly believed in this analysis that an in-road into the ranking
Materials and methods
by the use of questionnaire administered to 275 respondents randomly selected from seven communities in Ijumu Local Government Area (LGA), in Kogi state, Nigeria. 235 respondents (or 85 per cent )turned in their completed
questionnaires, which is statistically significant enough to proceed with this study.
Preference Based Analysis (PBA) is used in this study for prioritizing the eight PHC services identified, since expectations provide a problem of choice (preference) for people to act or not to act. The eight PHC services under review in this study were ranked by each community. The mean preference score of each service by each community was used as the criteria for ranking. The individual preference score of each service was summed up and averaged at each community level to obtain the mean preference score. The ranking order of each PHC service gives identification for the independent variables (X1-X7) in each community. Each community was asked to give a score between the ranges of 1-10
to each of the PHC services (ascending order of priority).
Table 1: Respondent’s perception of the most relevant PHC service to their community
Source:Field survey, 2008
Table 2: Mean Preference Scores (MPS) of PHC services by communities
Source: Field survey, 2008
Table 1 above shows respondent’s perception of the most relevant PHC service in the seven communities that were surveyed. The responses of the subjects are shown in the simple frequency distribution as indicated in Table 1 above. A close examination of the table reveals that the three most recognized PHC services according to
the 235 respondents randomly selected from the study areas, in descending order of priority are: supply of safe water and basic sanitation, maternal and child health and family planning and immunization against major infections and diseases with 20.4%, 17% and 16.2% respectively. It is likely that no other thing than
personal, utilitarian factor that most informed the preference choice of the respondents in Table 1 above. For instance, only 4.3 and 7.2 per cent of the respondents saw the relevance of treatment of common diseases and injuries as well as health education as far as the PHC is concerned. Individuals within the various communities studied seemed to have perception of PHC services in accordance with the perceived benefits that could accrued to them.
Table 2 above shows the mean preference score of each PHC service by the community members. In this analysis only the first 3 mean preference scores (MPS) for the PHC services for each of the 7 community are stated in descending order. Each community ranked the difference PHC services on a scale of value between 1 and 10 in ascending order of priority. The analysis revealed that:
Community A identified the following as its priorities in descending order
preference scores (MPS=5.49, 5.04 and 4.85 respectively as its priorities in descending order.)
Community B identified the following as its priorities in descending order
and 5.10 respectively)
Community C identified the following as its priorities in descending order
Community D identified the following as its priorities in descending order
and 2.22 respectively)
Community E identified the following as its priorities in descending order
Community F identified the following as its priorities in descending order
Community G identified the following as its priorities in descending order
General observation and inference
services of PHC that are of priority to the communities. There is variation in the priority of PHC services by the different communities. This agrees with Rifkin’s (1986) findings that community participation is specific, dynamic and grows out of specific situation. The preference scores of the respondents in Table 2 above to each of the PHC service shows to a large extent
the level of participation that the respondents would be involved if they had choice(s).
However, it can be observed in Table 2 that the supply of safe water and basic sanitation as a PHC service appears to be the most preferred by almost all the communities. This is an area of primary health care in which community participation in likely to be more effective in the communities under review. As in Table 1 where the supply of safe water and basic sanitation claimed 20.4 %, same is observed in Table 2 where the same PHC service became the most preferred by almost all the communities. The utilitarian value of portable water and environmental sanitation to human productivity could have informed such ranking of this PHC service by the different communities.
It was only community C that did not identify supply of safe water and basic sanitation as one of its 3 top most priorities. The findings again revealed that community participation in primary health care services is based on nothing else than rational considerations. The PHC service preferred in one community may not be relevant or desirable in another community.
Implications for national health care development
Any plan for beneficiary participation in health matters, and in the primary health care scheme in particular that has become Nigeria’s health policy corner stone, should take into cognizance the unique socio-cultural context in which health actions are being taken. Besides, health care development in Nigeria can only attain the Millennium Development Goals (MDGs) of 2015, if the target population for whom most primary health care services are supposedly designed, are not only treated as rational beings but are also sufficiently involved in the critical
stages of project planning, evaluation and decision making.
Summary and conclusions
Findings from this study have revealed that there is no uniformity in the ranking of PHC services in most rural communities. The pattern is likely to be the same in the urban centres because most of our cities have become receiving ends of ceaseless migrants from the rural areas. One major inference that has been drawn from this analysis is that every community will want to opt for a PHC service whose end they are able to see more clearly and utilize more to advantage, among several alternatives.
It is against this background that this paper strongly recommends to government and all stakeholders in the health industry to endeavour to first clearly understand the needs and
aspirations of their target population before delivering any health service to them. This is because this study has abundantly shown that every community has its unique health needs and preference. Both health providers and consumers should work together as partners in progress and treat one another as rational beings.
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