ry Health Care E OF THE ART Edited by ' E.A. Oke B.E. OwumF UNIVERSITY OF IBADAN LIBRARY Primary Health Care In Nigeria: The State Of The Art UNIVERSITY OF IBADAN LIBRARY Primary Health Care In Nigeria: The State Of The Art mred by E. Adewde Oke Bernard E, Owumi Pubhhed by the Deparfment of Sociology University of Iba dan h d a n Nigeria UNIVERSITY OF IBADAN LIBRARY Published by @Department of Sociology, . Faculty of Social Science, University of Ibad an, I badan. Nigerian. All rights resewed. - No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form, or by any means, electronic, mechanical, photocgpying, recording, or o t h d , without prior permission of the copyight. ~ wiler , First Published 2993 ISBN: 978-32524-1-0 Production by Cadalad ~ i ~ e r iLaim' ited P. 0. Box 20133, U. I.., Ibadan UNIVERSITY OF IBADAN LIBRARY Contents Ut of contributors . . . . . . . . . . . . . . . . . . . . . .ix -Mace . . . * . . . . . . . . . ., m . . . . . . . . . . . . . . . x Introduction : . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi i 1. I h e -Theory & evolution of Primary Health. Carc in Ni&e_ri-a Lay'ErinaStro . . . . . . . . . . . . . .. 1 2. Thc qf PWC in developing society: Tbt Nigerian uprience - A d e d e Oke . . . . . . . . . . . 5 . 3. The appkation of the fundamental principles d PHC at the local governme& level in Nigeria - A W d & u m . . . . . . . . . . . . . . . . . . . . . .1 4 4. Primary mlth Care: The gramoot means of minimal H d t h ~ . & w Hh O~W re alistic - A. O. Olutayo . . . 22 .. 5. Stra~forCOmun-i typdpationin-phary healthcare programmp:. The partidpatory rural ap@d z t p w 0.X O p e y e . , . . . . . . . . .. 37 6. The place of tmdifi#nd m6dtcinc in PHC . . . . . . . . . . . . . . . . . . . . . . . .4 8 7. Voluntary HeaI'thcarc workers and the sueceaofPHC-B. E -*. . . . . . . . . . . . . . .- 5 6 8. Culture, man and utilization pattern of PHC and its implications for developing societies - 4 A . m . . . . . . . . . . . . . . . .. m . . m m . , m m 6 1 9. Psychodynamics of PHC Consummation in Nigeria . -- S K. Bslogru . . . . . . . . . . . . . . . . . . . . ;. . 7 0. 10. p1.0bkms and ~o~utiontos the PHC executidn in ~igeria - A . . I . . ; .................... 78 3 - UNIVERSITY OF IBADAN LIBRARY 11. PHC a beautiful concept fraught with constraints: The Nigerian experience: - F. I. 'Agbodahor . . . . . . .8 3 12. The 'roIe of local governfnent & the ~mXnhnityi n the attainment of PHC god: The Nigerian experience - a. A. okll~~r.a. . . . . . . . . . . . . . . . . . . . . .9 3 13. Strategia of deveIoping tho human resources at Community level - A, N. I-& . . . . . . . . . . . . . . . .1 04 14. Primary Healthcare & Independent Source of funding in Nigeria - DmJe gede . . . . . . . . . . . . . . . . . . .11 3 List of participants . . . . . . . . . . . . . . . . . . . . . . . 125 UNIVERSITY OF IBADAN LIBRARY Thanks to Dr. E. A,' Oke, Inrmediabe past He& W n t of Sociology dB.A. N. Isamah, the m n tH ead ofthe Deparbmnt and Dr. B. E. Owumi, the Coordinator for thetheir suppon in making this a reality and hal lYt o our wives ~ r sL.o la 0ke and Mrs. A. E. Owumi far their moral support and mdersmding. We hope that this kmk will stimulate further wabhops and discus- sions and eventually enhance pruticipation in and utilidon of PHC senrice& Dr. E. Akwale Oke Dr. BanardOwumi UNIVERSITY OF IBADAN LIBRARY Introduction Primary Healthcare has become the cornerstone of the Nigerian Healhue system since the Alma Ata declaration of 1978 and the in- ception of Prof. OIiioye Ranso~lleKutia s the helms man of the health ministry during the Babmgida's administration (FMOH 1988). The Alma Ata declaration actually drew the attention of the world to the madequacieg of the western healthcare structures and facilities in the maintcnanct of the health needs of the people of the world and tbc third world societies in particuhr. For instance research (Rifkh & Walt, 1986) and f ~ ? edxp erien~e(I tyavyar 1987) have shown that tec4- nical, curative interventions were expensive and limited in coverage and impact and that preventive measures. might improve more lives at a lower cost. Again the ever r i h g c ost of technical care was made avail- able for mainly the rich and the middle income, urban people laving those with low incoma mainly .in the nual areas without any access to healtb services. These drawbacks gave the impetus for the evolution ~f the PHC strategy as a better approach for the extension of the fmn- brs of healthcare. It should be noted however, that the concept (primmy healthcare) is not actually new in the Nigerian context except in terms of phrax~ l - ogy. Nigeria had earlier established the basic healthcare services scheme (BHSS) as a strategy for healthcare development which has a primary orientation (Third Mationat Dev. Plan 1975-80; Oyeneye, 1985), but for financial, manpower, political, pIanning and implemen - tation pitfalls among others the programme did not see the Iight of the day (Oyeneye, 1985; Ityavyar, 1987). The "popuf&tion" of the PHC strategy by the A h a Ata dedamtion sort of rejuvenated the interest of the Nigerian government to this approach of healthcare delivery which emphasizes p~ventive,n on technical and people oriented. Up till the moment, a huge amount of resources have been expended on the implementation of the scheme in the face of a number of problems mitigating the realization of the noble efforts of the govem- ment at extending the rrontiers of healthcare delivery. Given this back- UNIVERSITY OF IBADAN LIBRARY ground, the department of Sociology, U n i v d y of Ibadm thought it worthwhile to m u t e a training programme to keep the executors and implementors of the programme abreast *th the concepts, .principles and problems of implementing the PHC programme and how to nsolve the health problems of the majohty of the population. The papers which have been presented here are thmfore meant to highlight the activities of the executors of the prugramme as hell as the poky makers and suggest possible strategies for making it more effective. It also attempt to rekindle and awaken, and inform the Nigerian pubIic of the primacy of the programpe in our heaItb quest, - '$e basic theme that runs through or forms the bedrock of analyds is the primacy of the PHC. Consequendy, this piece is considered a major handbook for every Nigerian concerned with health nBtters. The first two papers (Chapters one and two) give a vivid account of the evolution and essence of PHC in Nigeria pointing out the pitfalls of the western heaftheare modd. This is closely followed by chapter three which examinesI the principles of PHC to faditate bpi-ta- tion of the programme at the local level. Chapter four critically anaIysh the Nigerian healthcare system from the c o l o d tirpes and questions the western approach of hdthcare devdopmt. Given the existing pattern the author doubts the suitability of lhe programme for the poor except indigenous methods are galvanized.. Chapter five discusses.t he strategies .for community participation in PHC from the participatory rural appraisal model; TXs'modeI stresses the utiIity of the "locale" in programme development and management for optimal benefit: Chapter six examink the place of traditional medicine in PHC. The paper tries to establish the prence of tradi- tional medicine within every culture and the primacy of traditional medicine within the stmcture of PHC that strases awbibility, '@I- dabifity and acceptability which are the hallmark of traditional medicine: Closely followed by this, is voluntary '&a1 thcare workers and the success of PHC which is the theme of chapter seven. This piece examines VHW and attempts to suggest how it can enhance the success of PHC within the Nigerian economy that is market oriented. HeaIth services utilization form the basis of the next two chapters (chapters eight and nine). While chapter eight examines the influence of man and culture on PHC and by exteniion Health behaviour chap- ter nine discusses psychological determinants of health patronage in Nigeria. Arising from the above patterns, the problems of PHC management I UNIVERSITY OF IBADAN LIBRARY in Nigeria were thus examined critically; chapter tm attmnpb a analysis of problems associated with PBC..i n Nigeria whilc a elevenemninestheconsmimsofPHC rdyingh&+vilyonanev~3ono component of the PHC programme as a basis for assesriag the art. The roE of the Iocd government and a o r b made & ~l'I%€I realize the target of health for all by the year 2ooo is d e d in chap ter twelve. Chapter thirteen examin= the importance of W o p h g th human resources of a community by governments and how dtemative s o h o ff und for development can bc sourced through proposal Wrip iag techniques, while the last chapter ex&- rbm independent sour- ces of financing PHC. References Federal Ministry of Economic Planning: Tbird National Devhpment PIan 1975-1980 Lagos Vol 1. Federal Ministry of H ~ l t hT. he Natiod Health Foky and a#mw to achieve Health for d1 Nigerian. Lagos. October, 1988, Ityavyar, D.A. (1987)T'he State &d Health S e e in Nigeria Adils Smtntm VoI 3. .-, . . . Oyeneye, 0.Y .( 1'985) Mobising indigenous reso-, for PHC - Nigerix A note on the place o f traditional medicine &M&jn'aeVo120Nol:-' ' : . . , Rifldn, S. B. & Walt Gill (1986) Whg H&@ kProveiD: efining tly issues concerhing compkhhnsive PHC' & selective PHC Social Wenm & ~ e d i c h eVo I 23 No 6. WorId Health, Organisation (WHO) Report of the international conL ference on Primary Healthcan A h a Ata USSR 6 - 12 September, 1978. xiv UNIVERSITY F IBADAN LIBRARY TheTheory and Evolution owfirnary Healthcarein Nigeria Layi Erinosho Department of Sociology Ogun State University Ago-Iwoye Nigeria's health sector has been hndeqgoing:a momentous and remark- able ohange in the past six years largely becaw' of ihe vision .of the incumbent Honourable Minister of HegIth and ~ b a Snery ices, Professor Olikoye Ransome-Kuti. The years have witnee6 a dramatic and perceptive shift in the orientation bf hcaltb pr~grammcsf rom cutative to preventive care. Ia order to bring ,?bout this shift, the Nig,&n authohties for the first t h e i n the history of the country, conceived, adopted and 'are dog- gedly implementing a national hedth policy; l"he god of .the1p olicy is to en!ble "all Nigtians to achieve- sociafly and. mno@ically produc- tive lives, while the c6rnerstone of this poIicy i s piimary health care. The implementation of .this has equally been_xpade*possible through an unprecedented.f inancial, . technical, .logistical and other forms of support from international ,organisatioris. Second, several h d i h personnel needed to provide service at the pdmary h d t h care level have been trained at the Schools ,of Health Techadbgy built for this purpose in the country. Third; &ps are being tiken to sustain, on a longer-term basis, the primary health programmes, TO this end, the responsibility for providing primary health 'care is now vested- in the LucaI Government Authorities .whileLas pecial ag$nCy is being estab- lished by the Federal Government to help sustain ' the monkntum which it had built up for this apprbach oyer the! pist six years. The poIicy and programmes initiatives on'p rimary health care have attracted both praise and condemnation in vario& quarters. Then are, on the one hand, those who commend tha p m t a dminisrntion for 1 UNIVERSITY OF IBADAN LIBRARY addressing the priority.needs of a vast proportion of Nigerians for the first time since the attainment of nationhood. Yet others are wont to criticize these new initiatives for a variety of reasons. In my view, these divergent viewpoints on the ebr t s of the present administration pro- vide the basis for d deeper understanding of the evolution and theory of primary health care. This is because they represent the two cornpet- ing theoretical approaches toward the promotion of health care in the context of a developing country, Let us for a moment explore the standpoints of these approaches. Critics of the current emphasis on primary health care are usually drawn from among those who strongry subscribe to the orthodox ap- proach toward the provision of health care in the context of developing country. The orthodox orientation is anchored on the belief that the development and promotion of health care could readily be achieved if formally trained physicians and other high Ievel health personnel as- sume a pivotal role, and secondary and tertiary health facilities are opened in sufficient number to provide total coverage for the popula- tion. This was the dominant perspective since the attainment 'of politi- cal independence and it remained in £ o m until the last six years. To wit, the Fourth NationaI DeveIopment Plan, 1980- 1985 which was the last to be proposed before the onset of this administration intones: critical shortages exist in the essential categories of health manpower, including personnel in 'the development and maintenance of medical, paramedical and services. As shortage of doctors continues . t .~be a major problem. Whilst, the target set by the WHO for this part of the world is a doctor/population 1: 22,0~),.rec'orded in 1972. To achieve the WHO target, we need more than double the .present number of doctors by 1980. The document rurther states: IN REC~GNITIQNO F THE HIGHLY -STRATEGIC ROLE OF DOCTORS EN THE HEALTH CARE DELIVERY-SYSTEM and the current critical shortages of this personnel in most parts. of the country, steps will be taken in the plan period to undertake accelerated expansion of medical colleges and associated facilities for clinical train- ing. This exercise will be arried out within the,framework of the expansion programmes of universities and will SEEK TO ESTABLISH appropriate ratios -in the enrolment be 2 UNIVERSITY OF IBADAN LIBRARY tween the faculties of medicing , y d o ther fabulb, adequate account king taken d the era1 rn-s needs of'the countfy . The objective a£! & cy will, however, seek to ensure substantial . increases i n annuai bdmissibn level of 3;000 for the whole system by 1980. The orthodox orientation, therefore, prompted a huge investment in the training of physicians, the establishment and' rapid expansion oE secondary and tertiary health care facilities in the couhfry, all of which underscored the strong emphasis in the curative as opposed tb tht preventive approach. For many in this school, the emphasis on the curative approach was synonymous with DEVELOPPENT h d h r adequate provision of hedth care for the populatioa. &spite the huge idvestment in the'tr-g of high Ievel hedth man- power such as physicians and in ,the establishment. as well as expansion of secondary and tertiary health care faciliti~w, ell- informed observers were wont to demonstfate that the promotion of the physical, social and mental well-being of a vast proportion of Nigerhs remaid .an illusion for a variety of reasons. First, it bec~tmss elf-evident that the sophisticated health facilitiw on which so much had been in-d ranabed in-sible to rural dwellers where the majority of *$hep eople Iive. Besides, the inv-ent could not be justifled as several facilities were usually not in full operational state =.the kuipment were often in the state of disrepair for a variety of reasons. Second; the hi@ level health manpower on which so much hope was p l a d were &o often not accessible to thc majority in the population &use of the@ preference for practice in urban centres. nird, there was evidence to suggest an inverse relationship between the epid&ological reality and .investment in health care programmes. While the population s&md mainly from parasitic and infectious dkases which could be prevented, the pattern of investment in health ceue progrsrmmes was attuned to curative programmes, demonstrated by the emphasis on the 'estab b e n t a nd expansion of secondary and tertisry health care facilities and high level hedth manpower. In realization of tJje failure of health care programmes to ad* the needs of the people at the grassroot kvel led other obwers to cafl for a decisive shift from a system of m e w hich is anch~redo n the orthodox approach to one which emphisizes primary health care. Primary health care is essentially health care based on prac- tical, scien~cdlys ound and sucialIy acceptable methods 3 UNIVERSITY OF IBADAN LIBRARY and technology made univcdally accessible to individuals and families in the community and 'through their fd1 par- ticipation and at a cost that the community and country can afford to maintain at every .state of their development in the spirit of self-reliance and self-determination.'it forms an in- tegral part both of the cowtry's health system, of which it is 'the central f;nctional and main .focus, and of the overall m5al and economic development of the community. It is the f i t level of contact of individuals, the famiIy and com- munity with the national health system bringing health cart as close as possible to where people live and work, and con- stitutes, the lint element of a continuing health care process. In tssence, the raison d'etre for the theory of primary health care in the country is 'informed by the foregoing. It's origin can, however, be traced back to tht introdudbn of the Basic Health Services Scheme in thc early seventie. The Scheme did' not have the necwssry politid and material support f ir take-off and soon became moribuad: Con&- quently, W d v e a dministrations continued to pay l i s~em b to tb promotion d the Scheme. It is the p m t a dmh&kation that has at- tungtedto adtun b d i nstitutiopali the &- of the Scheme in the context ef primary health progrimme. Whether the Scheme or primary health programme will be sustained may well depyd ' on the orientation of the next administration. My hunch at this 'pornt is that primary health care will face serious challenges in the years ahead if we are to judge by past eiperience with bovative prog&ynes which implanted in our society. Whatever' be the case, Z hope that my hunch turns out to be an illusion. References Fourth Natidnal ~eveloimentP lan, 1980-'1985, Federal Ministry of Economic Plannin~,L agos. Federal Ministry of Health, The National Health Policy, 1988 ' WHO, The Alma Ata kclaration UNIVERSITY OF IBADAN LIBRARY The '~ssenceo f Primary Health Care (PHC) in Developing Society:T he Nigerian Experience Adewale Oke Department Of Sociology University of Ibadan Ibadan, Nigeria. Certain suggestive relationships kt ween socio-cultural, environmental and personal factors which relate to and' influence the. utiIization of health and medical services by various individuals and groups have been identified by a number of students of social professions (Rosenst ock, 19 66; . KasI and Cobb, 1966; Lernkr andT'*der, 1963; Kegies et al, 1965; H e w , 1 974.) . The& students .have also stressed the fact .that those having closest a m s s to health and medical services are actually ;thedse gment of the society who have the least need for health education and public hesld services from the standpoint of dative socio-ecobodc position. The segment who have the greatest need have the least a w k t o the% ser- xices - these are the ruralists and the iIIiterats'who fotin the butk of a developing society, perhaps, more than 80% of 'such' society pa- titularly, our own society. This paper focuses. on Nigerian Society specifically the essence of the PHC in Nigeria. In order to reach the vast majority of the population, there was a need to adapt the philosophy, the style and actual practices of health and medicaI services to suit the need of our people so as to provide maximum health services and achieve health for a11 Nigehns by the end of this century, hen& a reformulation of 'Thk National Pedth Policy and Strategy" otherwise refared to as' "The ~undamentalP riu- ciples underlying the National Health Policy" (Itansome-Kuti, 1988) it states: UNIVERSITY OF IBADAN LIBRARY The National Health Policy is based on the National Philoso'phy of social justice and equity. A health system based on Primary Heath Care .... shall be the key to 'the development of the Natiod Health Policy. Emphasii &all be plaoed on the preventive and promotive measuies.which shall be integrated with treatment and rehabifitation in a multidisciplinary and multi- sectord approach involviag efi - fective community pHipation. That Primary Health Carc shall be scientificalIy sound implies that all Mtb practiceg rand technologies both orthodox and traditional shall be evduated to determine their efficacy, safety and appropriate- ness, The goal of the National Health Poky in tbis iPense is to establish a comprehensive healthcare system which is promotive, preventive, ns- torative and nliabilitative to all Nigerians within the available r e m 4 ces so as to achieve socially and economically productive lives. The Need And The Implementation Of Primary Health Care Ia Nigeria The introduction of the PXC wris informed in part by the realization that the western orthodox medical 'caie did not serve adequately d of the citizens. .Thisd oes not mean that the orthodox medic9in , has not achieved much, in fact; it has a si-t; impact 'ont hc health status d Nigerians. However, it is obiow that .the were ac- tually ddgned for only a dl segment of the so&@. . The history of the orthodbx medicine in Nigeria weals that initially' it was designed to serve the interest of tbe church &,ionarb and their converts and later the intereqt of the colonial.govemment, tar-. geted at Europwmpopdation, and later extended to' the Nigerians working for the colonial governmeat (Adetoro, 1989). Adetoro reported that even today, only 35% of Nigerians are: served by westero orthodox medicine. i t is not surprising therefqre;that the swvicesTwerem ostly located in . the urban centres where the Europeans and the Nigerians worldng for them often mided. The Federal Min is t ry of Health (FMOfl) is well aware of .this fact, in the formulation of the ~at idnalH ealth Policy (1 988) it noted: The public health services in.N igeria originated from the 6 UNIVERSITY OF IBADAN LIBRARY British Army Medical Services Government during'the colonial era. Government offered to treat the Iacd civil wr- van& and their relatives and eventually, the Id population living close by Government Stations. Thi pattern persisted even after the independence. Hospitals were .built in urban centres throughout the country mostly to cure or treat dis- ms& and little or no concern on preventive medicine and preventive InaUUTeS. This sys tern came under severe attack, scholars (Mojekwu, 1978; Aghayere, 1986; h i , 1978; Onadeko, 1978; Peam, 1980; Olmide, 1982 etc.) revealed that most of the deaths in our country wepprcvent- able, they are caused by preventable diseases, the origin of 'filch ~ould be traced directly or indirectI y to do-cultural and environmental fa- tors (Oke and Yoder, 1989). .This position is summkized by the FMOH (1988) as follows: The health services of Nigeria have evolved through a series of historical deveiopments including a sucassion~ofp olicies and plans which had been introduced by previous ad- ministrations. The health semias 'are judged to be unsatis- factory and inadequate in meeting the needs and d m & O P the public as reflected by the low state of health of the 1 population. It is apparent from the above that the orthodox medical 8ervice was far away removed from the needs of the bulk d d e ' population, it is also obvious that it was not intended for thk g m d ,p opulation, ar' such, there was a need to evolve a system that would cater for all the, citizens - the PHC. n e in ception of the PHC can be w d ba ck k 1985 when the Federal Government . established52 model PHC, ihc selected Local Government Areas (LGAs) throughout the country. By 1987; the num- ber has increased by 31 (Adetoro, 1989). The model project was designed as a protot* from which sub- sequent projects .would'bed eveloped or improved upon. Although it was obvious that the Federal Government has decided to embark or implement fully the PHC programmg, the sufcess of 'the prototype has stimulated the governmen! and have giveh the Ministries.of H d t h (Federal and States) and all participati~ga gencido-tions' much confident to pursue the programme vigorously. Today, PHC is household word in Nigeria and its impact is felt throughout . - a UNIVERSITY OF IBADAN LIBRARY country. Let us discma a few of the projects which hdp to stmgtW~ ComponenB of the PHC. T h e indude: (I) EPI (Expanded Propamme on Immunization) (2) Control of Diarrhd Diseases (3) Control of Malaria and (4) Continuing Education Perhaps the most component of the PHC that has the greatest im- pact on Nigerians is the EPI. The Programmes Is targeted at-children between 0 to 2 years of a@ and women of child-bearing age (15 - 49 yean of age). EPI prevents the six most deadly childhood d h s e s , namely, Tuberculosis, Diptheria, Whopping Cough, Tetanus, Polio and Measlw. AII the LGAs provide immunization servica. The number of im+ munization administered h a generally risen each year since 1988 (CCCD, 1991) which results $ U e r proportions of imrnunhd in. dividuak (target groups) against the six diseases. The CCCD reportedd for ample , that 700,000 doses .of meal& vaccine were given in 1988 compared to 2.5 million doses in 1P90,2;6 million doses of Dm wcm given in 1986 canpared to 72 million in 1990. It is 'the ambition of the Government to eradicate all thesc.distases within a reasonable time, The target c o v w f or 1m was 80% bf the population which the Government claimad it has ach'hed although a- f ~ l d=p ort actually shows 76.6% eovcrrrge. (See able 1). The country was divided into .five zones (see the table referred t& above). It is interesting to note thAt Zone C which is made up OE Abuja, Katsina, Kwara, Nig" E and Sokoto has exceeded the target .kith 84.7% coverage while Zone which is made of Bauchi, Bofno, Goa- gola, Kano, Plateau has the h t co verage '(68:l%). The regsan for the disparity is not clear but we noted that Zone C might have d v e d . more attention. We obseive'that aside from the active involvemept of the UNICEF and the Minist* of Health, other agencies and or; gmbtions, such as the CCCD, the HEALTHCOM, ADDR, IDRC - have worked extensively ip the zone by way of formative and baseline studies semhm, workshops and internention programmes. UNIVERSITY OF IBADAN LIBRARY Table 1I Immunization Covemge By Antigen 12-23 Month Cohort On Crude Data Up to 2 Years of Age, by State, Febmary 199 1 State Beg Beg Dptll M- 'Full d scar opv 1 la3 Va0c &ten= tion Akm b r n 97.6 90.0 97.4 93,8. 88.5 93.8 Anambra 99.5 93.2 99.8 93.7 89.8 99.0 Benut 95.7 90.0 93.6 78.5: 67.0 86.1 Crm Rim 99-0 96.2 97,6 86.1 80.4 93.3 Imo 90.1 79,7 ,88,1 76.2 .' 69.8 76.7 Rivers . 96,7 91,4 94.5 86.1 79.4 . 90.0 h e B - 95.2 82.1 93.7 82.5 . 81.9 76.9 83,9 Abuja 100.0 97.7 100.0 100.0 100.0 100.0 99.6 Kaduna 100.0 97.5 100.0 94.1 94.1 .. 91.6 97.5 HCatsina 89.6 83.4 88.4 65.4 75.8. 61.6 74.4 KA 100.0 .W.6 100.0 100.0 100.0 100.0. 99.9 Niger 99.0 85.6 97.4 83.0 92.3 827 86.7 Soko to 99.0 86.5 98.4 91.1 92.3- . a 8 8 . 9 89.4 Zone C 97.3 90.2 96.7 86.8 90-3 84.7 .91.3 Bwchi 99.0 93.2 97.6 83.5 89.8 80.1 89.8 Borno 98,l 91:s 98.3 87.4 95.1 85.9 . 97.1 Gongola 97. I 91.3 96.2 83,7 87.5 80.3 . 86.5 Kaoo 89.9 79,7 89.4 58.0 73.9 51.7 .79.7 PIattau 89.7 81.4 85.8 63.7 73.0 58.3 '76.5 Hipia 95.5 87.5 94.4 81.1. 84.7 '76.6. 87.7 Criteria: MeasBes > 36 wmb DFTIfOPVl> 6 &, Intetvals between repeat dam > 21 day& - UNIVERSITY OF IBADAN LIBRARY Control ofDimhoeal. Dismw Diarrhoea, pz&ul&y childhood diarrhoui poses the great& thrqt to the wwival of children under the age of five in our society (0 and Yodcr, 1989). In 1989 alone,' there were 213,638 cases of repo3 diarrhoea resulting in 855 deaths (Nigeria Bulletin of Epidemiology, 1991). And yet this disease can easily be managed or pmmtd. TfBt p h t herefore is to reduce diarrhoea inudence by improving water and sanitation, pmcnt dehydration' wnd dnutrition through home trcai- m a t that f o c m on tarlj. use of home fluids such as sugar-ssrIt-~~l~- tion, proper feeding and by treatment of dehydration at hdth faditis with ORS (CCCD, 1991). Home fluid-treatment is fairly accepted throughout Nigeria. The CCCD reported that since 1987, 349 professionals have feceivkd t r ab - ing in the clinical management of diarrhoea. The clinical trainin prograriune has been reviewed and updated *and agreemmt has bee f reached with the WHO on a cooperative activity with regard to h c prove pm-service training materials for our mdical students. The responsibility of control or management d malaria rests tidly with the National Malaria and Vector Control Division. The technical committee meeta d-annuaIly and reviews malaria therapy eficacy, studies and other mearch data. The monitoring of d d a resistance is 'carried out by the .National Malaria S W i a n c e Netyork which consists of multi disciplinary teams from our dvtrsities. In ad; dition, the CCCD has helped in developing a new malaria traai module for mid-level and peripheral health' workers which wag pretested in Niger State and h i b een approved for use throughout thd country. . . The HEALTHCOM: has also introduced a .s eries of interventiod programs in Niger State to improve the.hoalth of schoql pupils and the genpral community by the provision of potable water ahd improve4 personal hygiene. Parents were persuaded' through mu1 tipIe corn-; mltnication channels to take a child with fever to' the riearest health facility within 24 hours for diagnosis and treatment. The importank ' of compIeting the three-day medication even though the fever may disappear in two days was stressed. Parents were taught. that a-fever UNIVERSITY OF IBADAN LIBRARY caused by mosquitoa is very dangerous but it be treated with chlbroquine. The use d chloroquinc for treatment of malaria fever was recommended by th@ ., Federal Ministty of Health and promoted by the HEALTHCOM. The impact of the intmention was monitored through a re!porting form distributed to health centre stair (Yoder and Oke,.. I 991). Al- though it is dinicult to quantify thehpact of the inmention at present, it is obvious that the& is a 'significant improvement in the management of malaria - this' will.b e more appuent in the nem fu- ture if the programme can ,ks ustained. Continuing Eduattbn A major but often overlooked aspect of the BHC is the continuing edudation. The only well o r g a n a programme b w n t o me is the Niger State Continuing Education Prograinme established .in 1989 at the Mitina Schod of H d t h Technology. The CCCD reparted that nine modules for trai@g LGA Managers in priority child survival and managerial topics were adapted to Niieria 'circumstances. Already, LGA Managers from the State have been trained in the Programme and positive impact has been d&omtmtcd. More of such programme sh~uldb e established to accelerate the achievement of the PHC objectives. There are other components of the PHC that are not discussed here due to lack of spa= and time - they include; water'and sanitation, personal hygiene, school health, guinea worm prevention, nutrition and home accidents. These are also declared pkority of fhe Federal Ministry of Health with regard to PHC. Conclusion . . The Federal and State Ministries of -~ealtahn d 811 the collaborating organizationdagencies are actively engaged in PHC intervention. The basic strategy of the intervention is to involve communities in 'the plan- ning, implementation and evaluation of .the progiammes. ?%in=ter - ventions are based on community perceived and-e xpressed 'needs as identified through formative research, informal and formal baseline studies and a series of consdtative meetings with appropriate agencies and authorities. The PHC has been an exciting experience in this country. Nigerians UNIVERSITY OF IBADAN LIBRARY have been able to identify with it, they are involved in the and execution of the intemention programmes and o improved their hedth status although in some of the p r o p m m ~ , is very dimcult to quantify. For example, the impact of PHC ~roje& on immunization coverage in Niger State by the HEALTHCOM w itlitidly mcult to assess with the data available partly.b ecause of d stxategy of the Federal Ministry of Health to plan a n n d special hi- munhtion days. This did not allow aocurate measurement of the fcwl of slcoeptaaa and internalization of the programme. There ismalsot he problem of accuracy of the hailable data. Nonetheless, the assemlent of the project by personnel from the Ministries of Health was remarkably consistent with regard to the achievement of its objectivq, W& have similar information from dserent parts of the country. It is apparent that much has been achieved but there is much to be done to sustain the present achievement, improve upon it a d g o for- ward. Much improvement is needed in the provision of h d t h and so+ cial facilities, there is also a need for povisiqn, of more faditits for contiauing education for h d t h workers and intensification of basia health education for all Nigerians. Adetoro, A.A. (1989) "An Evaluation d a Model Primary Health Ciwe Project: The Case of Owo". Ile-Ife Unpublished M.Sc, Thais, Obaferni Awolowo University. Aghayere, V.Q., (I 986) "Making Human and Financial Resources for Health for all in Nigeria by the Year 2000". Paper prmmtcd at the National Conferen= on PHC at the UNIBEN. Combating Childhood -&cable Dhase (CCCD) (1991). "An- a d R eport 1990 & Workplan fox f99f '. Lagos Nigeria CCCD Project. Federal &istry of Health (1988). "The National Health Policy and Strategy to Achieve Health for All Nigerians". Lagos, Federal Ministry of Health. Hartman, A.A. (1974) "Delay in Detection of Cancer: A Review of the Literature". Hdrh Educ, Mwnogr. .' 2: 98-128 Kasl, S.V. and Cobb, S . (1966) "Health Behwiour, 11lness Behaviour and Sick Role Behaviour", Archives of Envimtw-tal He& UNIVERSITY OF IBADAN LIBRARY Reports 80 12 kb.; 246-250. Kegelu, S., Stephen et sl8(1965). "Survey of ~eliefsA bout Cancer Detection and Taking Papnicoloau Tests". W M cH dHeallr R e p a 80: 815-824. Lcrner, M and Anderson, O.W. (1963) Health Progress in the Unitd States, *1900-1960. A Report of ihe Health Information Founda- + tion. Chicago. University of Chicago Press. Lesi, F.E.A. (1978) "Infant Mortality, Diet and Diseases". A&aa MW J O ~ &V. O ~1.8 . NQ.- 2: 1 1411 8, Mojekwu, V.I:(1978) "Role of the N m in the BHSS" in &k &g&e VoI. 2 No. 14:14-2i. Nigeria .Bulletin of -Epidemiology (1991): " D hN otifllcation Reports from S-, January - -berg 1990". N o s i F e d M inis- try 0.f Health. Oke, E, Adewale and 'Yoder, P. Stanley (1 989). "Knowledge and Rac- ties Related to Diarrhoea and Oral Rehydration in Niger Statc, Nigeria". 3nd Mdcrta C o d m m oa Dimhmal . D k u a ( AF- CODD )&- P 4 18-2i. . Olumide, E.A. (1982) "The Control of Communichle Diseases a d th e Federal Republic of Nigeria Third National IhvqIopmco! Plan 1975 - 1980: A Critical Analysis". N w a a M edadJ OW@ Voi. 12 No* 1: 105111? Onadeko, M.O. (19%) ' !'Public Healtb and thc Nigerian Populafion Pmmre",N @*m ~ c d h Jdou rnal Vol. 8 NO.3 : 220-224. Pearce, T.O. (1980) "Political and Econodb Chapges Nqgeriq and the Organization of - d i d Qk" Soc. &.,~ c dV:ol . 148 No. 2: 91-98. Ransome-Kuti, Olilcoye (1988) "Health' and Social Poky in NigerW. Keynote Address Delivered &the Opening m o n y d f t h eS eminu on 334th and Social Policy in Nigria. Ue-Ife, Qbafemi Awolowo Uaiversit y. Roseastock, I.M. (1966) Why ~ e o ~Ul see Health M c e . Millbank MmnoNRund Qwm&X U V - 3: 94-127. . . Y d e r P. Stanley and Oke, Adewale (199 1) HEALTHCOM' iq Final Case Evaluation Report. Washington D.C. The Academy for Edbcational M o p r h t p f . I3 UNIVERSITY OF IBADAN LIBRARY The Application of the Fundamental Principles of Primary HealthCareatt heLocal Government Levels in Nigeria Ademola J. Ajuwon, African Regional Health Education Centrc Department of Preventive and Social Medicine University of Ibadan Introduction Since the A h a Ata declaration in 1978, Primary -Health Cart.(PH has been adopted in many countrim of the world as the key to th development of hdlth care progr-es, it has also been .widdy ac ctpted as the means of attaining health for all by 2000 (WHO, 1978) PHC is defmed as an essential health care that meets the needs of t1h majority of the people in any community at a cost that is affordable to them. It includes not only the serviwi provided at health centres, I c h h a nd dispensaries but also what individuals and familks can do to promote and maintain their health: W O ,19 78). In Nigeria, the fmt serious attempt to implancnt PHC even pm' dates the Alma Ata daclaratio~I~n 1975, the Basic Hedth &.ice Scheme was launched by the then government of ~eAra~l akubu Gowon as part of the Third National Devdogment Plan (1 975-80). The programme was aimed at increasing the proportion of the population d v i n g health care from 25 to 60%. However, the programme failed to tach this target mainly h a u s e the principle of PHC were not adopted during the implemcnthtion. For example, the &-unity did npt participate; in the planning and implementation of the programme. In addition, large quantities of sophisticated equipment were purchased arrd imported into the country contrary to the principles of self-reliance and use of appropriate -technology (Ransome-Ruti, 1988; Alakija, 19 8% *., 14 UNIVERSITY OF IBADAN LIBRARY . A second attempt was ma& to impkment PHC i a . hm untty in 1986 when the then Minister bf Health, Prof-r Olikoye W a a o m b Kuti launched the progr&n~eA. lthoufh some problem wm en- countered, at the initial--&a&, a lot has been achkvd since the - inctption of the programme in the country. For example, the s m for implembnt ing the programme h~ changed. 'Local'G overnment Areas (LGAs) an w w the foci ofimost PHC activih. For this' pur- pose, 52 LGAs were selected and dkigaated models for PHC p r o m - mes. - Component of FHC Ideally, the contents, or components of the PHC.s hould be dew- mined by the main health problems: common ia.the comn~u*nityH. ow- ever, .the -World H d t h Orpnization (WHO) (1978) ftcommends that PHC dwuld helude at least the folIowiag components: . (a) Education concerning prevailing health in the corn- munity; @) Promotion of food and adequate nutritson; (c) Supply of adequate potable water and- basic sanittahn; (d) Provision of+maternala nd child care including family p ladng (c) Provision of Wunization s d c e s against major infectious dic- -; ( f ) Treatment of common diseases and injurie - (g) Promotion of mental health; 0) Provision of essentiaI .drugs; @ Control of Id end.e mi.c disease. Fundamental Principles Guiding Implementation 01 PHC P r o m e . . As mentioned earlier, PHC seeks to meet the.h ealth care nesds of as many people as possible at the lowest pose cost. IQ order to m h th is goal, the impIementation of P. HC. must b gdded by q e f ol- lowing p~ciples: 1. Involvement and participation 2 Use of appropriate technology UNIVERSITY OF IBADAN LIBRARY 4, Use of Id raowta,. These p ~ c i p l at e fundamental ia the s e tha~t th ey &- the outcome of the PHC programme, By participktion, we.me& that the person, growp or community for whom the PHC programme is k g pla nned actively works with ihe health worker in planning and implementation of the p r o p m w ~Pa r- ticipation of 'the beneficiari~o f a PHC programme is crucial for four main reasons. . The first is based on the principle of civil nsponsiW~ty.h d h g to the WHO (1978) people have a right,a nd duty to participate e i k individually or coI1ectively in the planning and implementation of their bealtb cart. Secondly, if people m i p a t e , they are M y to lx htm- ested in helping t h d v e s a nd feel committed to take neccsmy utim to improve their health. Thirdly, participation aunu*l that the PHC mias meet the rest1 and not the perceived needs of the people. Fin& ' ly, it facilitates sdf-reliance of the -ting group or cummunith, Having d'kwsed the importslnce of participation, the next logid issue is how to entiwe that bdiciaris of PHC progame8 at the LGA levels participate in planning and implementation of the P = ~ t P n n = S - The following suggestions are practical ways af facilitating c m munity participation. 1. Keep people iafomed about the progr& Wig planned. This can be .done by meeting and discussing .with community and opinion leaders. 2 Encourage suggeshbns to be made, either directly or tbrough rep- resentatives, e.g. a planning committee. 3. MutuaIIy set out specific tasks and mpa~'b1itiesfu r all those involved. 4. A&.O w1dge and pr& all those involved in the programme. Use of AppropriateTechnology Technology is simply.t he means by which people utilisa %hee nviron- ment to safisfy their needs and wants. It involves amo~g.hhers: 1. The production of tools or materials and, UNIVERSITY OF IBADAN LIBRARY Z Thc creative a@ty to improve the materials. The technology or method used in PHC delivery should mesh with the cllltutd and resource patterns of a w~~ in order to mrrximisc beaefit and m h h b ~ p t i o n sI.n PHC,r rgood cmnple of appropriate technology is the local proddon of sugar-salt-solution as an dal rehydration drink instead of 'mprtatidn of cxpnsiv~in ix- hue from pharmaceutical. companies. For a tachnplogy to be a p propdate, it must k 1, ScientilicaIly sound; 2 Adapted to local n d s o f the population; and . 3. Simp16 and can be easily maintained by the people. . As shown in the components, PHC seeks to provide comprehensvc or hotistic care to people. In order to reach this goal, all 8eckrs or depwhnents must 'co-oprate, therefor&,d l hands must be Qn deck for health, I For example, at the LGA levels, there are many people .drawn frum various departments who make signiflc~ntc ontributions to the pronio- tion of PHC services. Sucb persons include agricultural. extension workers, social welfare officers, community development officers, school kchers etc. AII persons whose work contribute to the health of the people should, therefore, be involved in as much as possible in planniog the ,p rogrammes. Ways of ensuring co-opration of all SectodDepartmpnts ofplan. ning PHC programmes at the LG. A. b e 1 - ' I. Formation of a committee involving representatives of afl the key sectors. Meetings should bc held regui ly and rqles and respon- sibilities of each sector mutdly agreed upon shpdd b sfit out. 2.' Good interpersonal relationship and effective communication skills a= also cmciat Use of Local Resources In planning PHC programmes at the LGA level, emphasis must be placed on*u se of locally available .m- in the com~unity.E m- ' 17 -- . UNIVERSITY OF IBADAN LIBRARY p b i s should be on use of local resources becaw: 1. It saves money. 2 It promotes self-reliance of the community. 3. It facilitates use of appropriate technology, 4, It fosters pride in people who are able to hdp fimm~lwT*h is pride will further encourage them to try to solve m6ie p r o b b zlsiag aeir own florts. However, although ii is best tp implement PHC .programma uskg resources from within.benefting cuqmunib, S O M ~ Wresa~ur ces needed may not be available in a community because tht'progrmmc may be too big for the resources adable, AIso the problem may bc dmcult to solve. Under this condition, it is necessary to look gutside for: such resour- ces, Most time the comgmnity m b e r s are not aware about the pIace to obtain the resources. They need to be linked-up with such external resowws. Resource + W i n gis the process of bringing together-wn ex- ternal .resource to a community in need of reso- (Briegm, 1978). Ways of effectively linking up communities with external 1. Provide b a c k g o d information about - Names of the agencies, organizations or individuals that ' have the resouroes - Description and type of r.aourcesp rovided by the agencies - Location of the resource agency - Special requiremenb if' .any, the .agency danand before giving RSOU~O~(SW HO, 1988);. 2. Encourage community members 'to visit the agency. This will enable them lerun the skiU of mouroe; linking. 3. Encouagetheco-mitytomakethed&isionwhetherton~t or reject the resources, i.e. the corhmwiity sh@d be encouraged to make informed decision. Hating discussed the principles guiding PHC programmw at the LGA level, it is necessary to highlight the procases invoIved in plan- ning and impIementing and evaluating tho progiaums. UNIVERSITY OF IBADAN LIBRARY Outline d Planning and implemcptation of programmes at the Locll Government h a Le vel Usidg a PHC ~ ~ p k a c b There are three components of the propmmm, namely planning, implementation and evaluation, (a) En@ into the Community Meet the leaders of the community to inform them about the programme and enlist their support and co-operation. (b) Identify n d s Sometimes the felt needs ofthe people do ,notc oincide with those of the LGA, government or fujndini.agqwies, Yet, we must be sensitive to the needs of .the *pie otherwise they may not be motivated to acti~dy.participatien the programxnes been p r o m . (c) Prioriri'ks the d Rarely do commdties have only one' felt need. More often that not their aeeds'are numerous. Given the fact that Community resom.arel imited t h.me~& p lust .be prioritised. The community should be encouraged.to start with their most important felt need.' (d) Set goddobykcrives or t q & .O bjectives need to be set to keep tpe progran~Wo n .track and to help in evaluation. Look inwards to determine locally av.ailaablr esources and if .reed be, Shk-tap the 'cbhtrni'ty* & e ~ t e r d mm. (a) Co-nce work on the programme as planned. (b) Monitor progress in order to ensure that p r o m is implemented as planned+A lso, identify problems imped- ing Prngras* (c) Feedback outcome of monitoring into on-going prognun- mes. UNIVERSITY OF IBADAN LIBRARY (a) Review p r o p m e after completion to determine: - the extent to which set objectives have bed accomplished - m n sl e q e d in order to avoid &venting the wheel. I The commllnity memben must be encowaged to actively p&rticipate+ in all these phases of the programme. Primary Heal* Care is 'the bedrock of the health cam systm in Nigeria. PHC is rooted in the philosophy of equitable accea to health care since it& main goal is to meet the essential health cam nee& of hm ajority of the population at a cmt they can afford, TI& godean . be attained only-if the f&dsmcntal principles guiding Pr'rmaty W t h .ba re put into consideration during the phdng and imphents- tion of the programme. U * r r i ' kefexe~cea I Alakija, W. (1986):. Primmy health can lecfm'n o- for,, CI. ornunity hcalth &den.ta- Medisu- Publhtio_n. , &. n.h P . . Brieger, W.R. (1 978): The resource lhX. Int&rtalronirl J u m d af Heal~~du1tion,Vol.XXI'16%167.. . . Ransome-Kut i, Oi (1 988): Introduction ' In Stredgthening primary health care at the local governmed Level - .The Nigeriaa ex- perienoe. (Eds) Ransome-Kuti, Sorungbe, Oyegbits; and?, B d s a i y e , Academy Press, Lagos. X-XVI. World Health Organisation, (1 988): Education for health - A manual on health education in primary h d t h m e . Qeneva. , . . W.H.O. (1978): Alma Ata ,1978: R h a k y h d t h c&. 'Health' for AN Series, No. 1. Geneva. . . I UNIVERSITY OF IBADAN LIBRARY . - Prhaxy Health Care: the Graasroot Means of Mini - maI HeaIthcareSemices: How Realistic? OIutayo, A.Q Department of Socjology University of Ibadan Ibadan, Nigeria introduction It is of great intern, but also of gresrt .concern, that ufltil.more than three decades .of Nigeria3 independence, hedtkis ~ n l ky i ng ,pruhed as 'primary' to the citizens of the natiod It .is of f l , ~ i n m e sbcto,a use it requires a need to study why the sitdon.$ .whatzit is. ,It is a h o f great con& because the Merent g o v ~ ~ - ~ . bonalyy bteb ed m actions that could make Nigeria 'catch up' with the a$twbile colonial government and other developed nations. Such +.have been tan- tamount to chasing shaddm ' These actions might,b e .conwcWI with the fact that planners and policymahrs ='not gmuioely in the welfare of the majority of the people. . Anyway, the Babangida's regime has declared -its intention' to democratize both the political ..and the .health iastitubm, Tbe.l atter i qua1 to the agreement with the h a At a declaration of 1978 , w,h.ic h states that: ' (i) health is a fundamental human ri&t and . that health involves (a &te .of wmplete physical, m t a l +d d wellbeh g....' , (ii) health would be made available to & basedon the PMC$~~S ~f equity md S W d j e , . (&) the planning and i m p b t a t i ~ n.o f hehlthare would involve the participation ofdl the people, individually and collectiv-e ly;. . 1 UNIVERSITY OF IBADAN LIBRARY (iv) there is political wmrnitment and wil l to ensure health for ip by the: year 2000, I (v) 'health& wealth' impIying that health is dated to all espCctJ of national and community -development such ss promotion of food supply and proper nutrition; adequate supply of water an9 basic sanitation; industry; education; homing; Flnimd bus- bandry and so on; I (vi) cheap, socidly acceptable methods and technology which an scientifically sound would be d M e to individuals 4 families in the community. Our task in this paper is to exarie the podli ity of dising these laudable ideas,, To achieve this task, .we have to fm the &uct ld context within which Primary HeaItb Care ( h e r d l a &erred b as PHC), stated above wodd exist. Interestingly, PHC -to struGturally trans- form &is existing social structure as the objectiva~im ply. -mt-' ly, the most important point to o-e k that the M c te nets of the - .PHC have a lot in common with that of the 3-w Adjus-t Programme (SAP)'. These basic tenets include: - equity and social justice - p o l i ~ dm mmltment and will - community and involverpent . intersectoral action and; - the use of appropriate technoloa through s e l f - reh~ , , . SAP and PHC .. I t is very important to state that the Structural Adjustment; Progrm'e implied above: is'f at above.t he economic acfjushent being attempted by the Babangida ngime? The political, economic, ediwa- tional and other institutions are m n a s .a stnrc'turd whob dl of which 1 have to change from the2 d i g or ientation. This & 'what become8 fundamental to PHC. A total transformation of the socads trwbm requhd since it cuts across the entire social fabric. Par-pb 18 of the Alma Ata-declaration states, in part, that: '... Health activities should be undertaken concurrently with measures such as those for the'improvement of nutrition,.,, increase in production and employment, and a mok equi- UNIVERSITY OF IBADAN LIBRARY I table distributioh .of pemonal in- anti-poverty 7, ; and protection dnd improvemmt of the mvbmmt.' The wim,.thtrefore, is to dose the gap between the "ham". and "have oots", and "achieve more,. equitable diibution of ... ~ ~ . ! ' 5 The idea of closing the gap between the rich and tb poor, especirrlly within nations, qms the building of a new eocish :amagemat. This is to be achieved through the partkipation of majority of the people in the affairs of the nations, inclvdhg health. This is the original MI- tion d demgacy which most Third World nations should asphe to achieve.' Building new social arrangement also reg* the need to draw closer to the exploitation of the physical environment. It implies that the principle of self-reliance and self-determination? Like democracy both SAP and PHC agree that the ds'tin g type of develop- ment orientation is undahble. The argument that devcl~pingn a- tions have not managed their zesouraq well - a d t a i t d Feet of the inequalities perptrated by the ruling elita. This has led to tbe d t h g debt-burden which-t hese nations now &ouldcx.8 - To reduce this-debt-burden,d eveloping na l jms muk be d h t ; reduce inequalities between the "haves" and the "have now both in the urban and mql mas; enwurap &a1 j e bvd w most pea* in governance and so on. In short, the conditiom that .led to SAP &O informed PHC. These are, indeed, good ideals that nation3 should aspire to achieve. But how can these be rralised ycith 'the co~tinud existence of the old social structue? In other words, to realist the i d m and ideals of PHC 'as the grassroot means of,minimal h@th HS- vices, the transformation of the &id st&ctG:is bitable. But who would embark pn this t a ~ MT he succ&. of whwmr attanpts to carry out this task is dewdent on the-extent to which tho= who ~ C U W the present position' aie ready to relinquish their position and priviledges.'4%nsequentryJ an 'analysis of the social structun as it affects the health institution becomes important. This would expos , the need for PHC and the extent to which it is p.osible for the syston ' to come to reality. Nigeria's Health Institution in Pmpctive Prior to the establishment of Western medicipe, Wtioqal medic'ie defined by the World Health Orgwhtion .as 'thee total' conibition ~f knowledge and practices, whether applicable or noi used d i q ~ nosing, preventing or eliminating a physical, mental, or social dlneur, 23, UNIVERSITY OF IBADAN LIBRARY and which may rely exclusively on past ex- and o constituted the means by which thc daerent cma~unitiwto ok can a their health and hkdth-related problems. The colonial inkmention wy with the aim of 'modemising' these practices. The modernisation process involves the importation of the highly technological and did- ferentiated medicaI system in Western Europe, mpcklly Britain, into Nigeria. Missioaary groups were the first to encourage 'modern'- medicine in W s t Africa, followed by the colonial govcrnmnt (with * application undir the military Generally, emphasis was laid on the construction of teachin4 general, and specialist hospitals located in major tom. The training of medical d~ctorsw as also preferred to a d b r y training school which graduates students as medical assistants. The students have started realising the new status which they would acquire at the h p e a n s . Medical Schools were "modelled on hstitutiws in h countries of the colonid govtmmmt(8) and their i n t d e d d with very Little adaptation to African smi~cultural*is.'" students, when they graduate, preferred to work in the urban cm than in the rtuaJ areas. At independem, these practices .continlied and the go elites did not give due consideration to 'the manag miuhtrativt capacity of the country. Thcy created an stitutions with loans borrowed abroad from both private and commercial sources. Since the Europeans ( c o ~ o d~id )no t under- stand the indigenous traditional d i e , t hey'f ound .non ecd for' it. l2 The new medical doctors, realising the impoitana of this to their new statuses, found it irrelevant. This is because they. wodd hyc had to be competing with the 'unlearded'.medical pmditionm -%who ironi- cally nurtured, brought them up with traditional medicine. Their newly, a acquircd position have 'to be enhanced. Especially Wause they wenl few in number, foreign experts were employed in the hospitds. &phis-' ticat& quipments inc~udingd rugs were i m p ~ . ' 3 A H t & i ~L ed to the debt-burden already mentioned above. ~ n f 0 ~ th8e $~tuaytion , till today, has not essentially changed. Obafemi Awolowq University Teaching wo J d soon launch its multi-million haira fund. In spite of a 1 the debt aimed. at improving the health status of Nigerians, health facilities are stilI very inadequate; only a. few people can aord the available &ices; there is ao inbalance in the distdbu- tion' of mxsomel and facilities to the u r b a nd d artas; the em-' UNIVERSITY OF IBADAN LIBRARY #asis of European modiciae baa no bearing with the indigenous strut- toncurative r&er tdan preventive health systrm is encouraged and m on.". lt- is not therefore surprisine that health-statw of Nigerians is vcry poor. There are still no enough h e d i d pmo~e1T.h ere are 6,200 N i a n s per doctor in 1986; 99,000 people per dentist; 24,300 per pharmacist; 1,950 per nurse; 2,340 per mid-wife and there am 1,100 people per hospital bed.'' M e e xpectancy at birth is still one -of the lowest in world at 51. Infant mortality rate is 100 per 1000 and maternal mortality is around 'the same range as at 1980 (a'situation that has not changed sipifrcantly today).16A il of thw resulted because of the type of health care system in Nigeria. Most important is the nature and content of medical education which hal; continued to sect the statw of hedth in Nigeria. Brew-Graves summibed these to in- . dude. l7 (a) absence of national health manpowq which has led Ju the disparity between proadures and ihe qployers of health c q ; @) ,m . any doctors trained '.fui years ' at pu. b.li .c expeaGave .left for ' ; ., , . non-Ajkka.n. c.. o.. untries; . .. . ,, .;... . .. '' ' (c) d u l u p a re wentially foreign-based and highly- strwtund; (d) t rainhi has becn 'hospital-based.a nd; cssenwy, dinical-orientcd ' and ign~rcdc ulture and sucio-ccanomiic background; (e) the training is dkipline-oriente+da nd depaxtmcntally organid rather than -competmcylbased, problem-oriented and inter-dt- eiplinary; . r . . ' (9 teaching rather than student responsibility for learning . is h- ph&e& , - .' . (g) there is no team ap-p roakh; . . , . * . l . . : . . .; ... ,:. . -, , y + -.,. t - ! 8 .: ' . I ' (6) the products 'of't he:m ,e . did institutions unint&ested in 'rural , . ar&;,and - . . (i) the products are unsympathetic, gains-oriented and .lacked leader- ship. . .. All of these have existed since 1948' whbn the first College of a Wcineytas~tabIisMa nd even, in some cases, before then. They all continue to exist today. A practice - more or less 3 way of life - is e3t-d to change within 14 years (from 1986) through the Primary H d t h Care System 15 is, bfact, supposed to be a reVoIutionary tians- formzition. Attitudes of nwjical doctors, nurses, mid-wives as well as rutai dwelfers have to change within '&is period. The content of medi- UNIVERSITY OF IBADAN LIBRARY cal education and its prwtia; q d a U y private medicel must change $&fEaatly. Primary Health-C art -. building a new bdth institution o i l new foundation. It implies a.recomeptulisatio~o f -what health is; 14 1 has to be seen, in the word3 nf Limbo, 'as a whole, as part axid 4 of a culture, ib bound& and its phmiplai king studied more than its incidentals'.19 Health is no more to be &riaived as distasc for which preventive ind curative m t h d o f care arc being fod:It now implies the standard and style of iiving of pcople.bwc: The rcal capd&dmcam of the inBiv?ual, his s t a d d of education, and aecegs food and potable watm con- tribute more to. (his) health than the numbr of h4spital M, doctors, and nurses.. . Hcalth is therefore a a - to which ,all national sociodcon& activifp, including ths. prevention arid care of disease, contribute. Hence, it is not only the hsaltb indtution fhat q q e a chaogc. in 1 orientation nor is the ministry or miunittee @ whafevg f- that should implement PHC. Au the s d d h s t i w r n ihv~lwd must be transformed. The prmmt ' d h i i o n ' of '4idr as in the rural and urban arem has to chap h favour of the form#. Those 'who have' must be ready tahmqmt of what they have-tot be 'have nots'. Indeed, a new era of gowmmm is required -- a new aad 'truly revolutionary national .idtoibgy firwn which W m t i o n and motivation for true and socially relevant development codd be dAW' 21 FWC involves the 'use of indigenous natural and human -~e80urce. This can only be achieved through the decenwation of porithl, responsibility and obligation to allow fbr fd'$nticipation of all man- bers d the community. The-i mplication of 'this is not only the hvo1- vement of people but dso the ~ ( ~ soef traditional herbs and doctors which .and who are socially aweptable. Unfortunately, PHC expects that 'traditional workers and traditional birth attendants' should be 'trained for and attuned to PHC', anly !wb= ap-&i@ 24 (my emphasis), In this wise, one can allm:that PHC.i9 only a W- step taken in the right direction but not a full-step. "Scientifically' sound and socially acceptable me'fhods of technology ....." as well 'the spirit of self-reliance and sd f- determination! become contradictory. PHC, as it is, e n m u r 8 ~th e persistm&-ef the. top-bottom develop- ment strategy. The-grassroot( bottom) ate not b l y .t o t a b active par- 26 . - UNIVERSITY OF IBADAN LIBRARY tkipation - a eituatiq which n e g m the cmence of PHC, We hall elucidate on thig law, LEt US k y b riefly examine how the stmbm of PHC is a t a b W i d Nigeria. It baa been variously srgucd that thk fmt attempt at establidin~ PHC in Nigeria was b 1975, during Wed Gowon's govenmint. Though this might bc assumed. as ti6 foundatidn on which presmbef- forts are being b a d , ?He was not the national policy nor was it the cbmnt~neo f healthcan delivery -2Jt was not uqii! 1986 when an aeuiated national policy bakd' on PHC as its mmrstonc was promulgated." In fict, the ittempt during Gowon's regime vsrlidatm the fact +that SAP and 'PHCh ave a lot itl oommon. It was during the later part of Oowonf~re gime that the debt burdm ac- tualiy started getting out of hand, Howem, the regime-was, probably, not bold enough to implement the SAP as dt ought to, Tlda ~ Q arC- gument g= for the governments after this, until dUrirtg. Babaqida's r&ne, At least for thii this regime has ta be commended. It is the k t ti me in the nation's history that a government.w ould prof- such a radical idea. It is radical in the sense that it is a departure from the existing nom and also because it cares (or attempts.to care) for the majority of the people. Like the transition to grassroot democracy however, the implementation, or rather genuineness, b m e s ques- tionable. -Theze is already an inconsistenq in the hgphtatiiqn of €he PHC which resulted from the lack -of consistency. in the transition p z o g r a ~ ~Fto.r example, the plan once .&&bed by: pr. Ogundeji, the B Health Zone coordinator, in a . p a h pmmtcd in 1987 wd. another paper which gave the same plan as Ogunhji's by Kgode Oycgbiitt, specid assistant to >he Wster of Health has changed. The change resulted from .the creation d more local g ~ b e p t sin. + 1991. Formerly the n u m b of health Co "1%"' ttee was b 6 n 10 andI2D,000. The upper limit .now changed to 50 due to the e s f a b l S k t *f.&n wards. This problrm appears trivial, at lqs t on paper. Mom important is h e f a ~ th at the implementati011 proaso h o l ~ the local governments which would t>e strengthened to take -of sueh health matters. The Ministry of Health plans (and alnady in thi process) to set up Villi@ IDtVetopment Conm@ees (VDCs) with em- ' .. 27 UNIVERSITY OF IBADAN LIBRARY @ash -.health. T h c C ~ w ~ oinr ds-t wards am to hdp a d h h g thil aim. Tbe committee should not be nore than 4 ~ t h e o d t h s y w o u l p a e l c c t t h e i r o w n v o ~ ~ ~ u l t h w o r k y -0 who would k traioed in simple ways of 8oIving idmtilbd p b b s m ' - the gospd of PHC, supportive referral system being put in place at both the state and local goverament Other activitis in process M u & the training of PHC p m d , t he -dad hgnmmc on hmunktion; iratment of bco-n minor ailments, control of c o m m ~ t aend endemic diseases, family plan- nutrition progmunm and cnvironmentd, ii So far, it could be o w that the MkkktsyofHealth is still thc only dcparfmcnt iav~lvcdi n't hc Primaty HcaItb Cart System. h r d - ing to Dr. OgunJde inter-sectoral colla~ratiohis still very, d-t. When meetings to be heid with other ministries, .the people -.who rcptw#nt t h v~ar ious minhtdes ak not the m.m .s tm and not w&l the -r-Gienerrrls if they send any rr:pmenta$ive at all. E4is conclusion k that each depsrtment still guards its power jealously?7 Hma lhe 1 rn-t of PHC is bound to have major p r o b b since pmmtt .situation goa contrary to its focus. Wth activitk amor 'be undertaken conairren'tly .with , m ha s those for the improvamt of nutrition, parhdarIy of children ' and mothers, inwasc in production and employment, and. a mo= equitable dWwion,of pmd incume, anti-poverty measurq a3! is bing seen m Nigeria now is not a&, Hence, its xole as a -tram- forming institution .becow impossible: In so far as. health-. is not TCCO- as ~o-e h p m t .in ~ndition.sa nd quality dlite,beal#hfordlbythcycar2000isunrralisticl. * . Onc can tbcnfom assert for M e as S amba did ,fni.Gambiit hat: * . -*Asa slogaa (sic), I 'think H d t h for All, by the ~ ~ 2 0 is0 0 '&&y -5 It has &anis& local and intematiod opiha; But whether or noi the objdve it'cxPr&k -"be achieved & w d s on the dcgnc of local and: i n ~ s i d d t m t n t . whid~,fornow,i s Wto zero. Fmkmpre,t he attinides gf traditional healers are only to be.modified ir onder to discourage ~ a d i t i & ~i m k gp ractices.. for ex- . ' . - UNIVERSITY OF IBADAN LIBRARY ample, Dr. Ogwdeji pointed out that4t raditional. wodd be en- ~oukgcdt o replaw a i r equally dbtive drugs' with W E S ~ ~ OW.T his is in line With PHC feconuncgdation but, which negam the idea of W-reliance aad self-determinatioa In so far as this is the case, Wth for all by the year 2000 is only a mirage. I#& is Wm:'thc mmpt of h d t h cannot 'bc based on tbin or eIaborae abstract@& irretevant to the ov&d needs of the society and divoxced from the natural objects of its interests..... Wth must spring from t& peo - a truly dialectic purpose, it must draw from its tradition.,., 4 situation when the ideology, planning, and imp1ementation -canes . from abdve is -also a major problem. Consequently, there is the naed to give important consideratiom to tbe study of the existing traditional health cart system. Wbat'this ze- q b is that mGdical doctom, numa, midwives, students in medical and-p 5uamcdica.l profession as well .as the ruling elites should. come down from their' ' 'hi& pedestal' to learn and]. identify ,with the .trardil tional healers. These are to be re- evaluated for .implementation. Though this may take a long time and.h ardwork, we should learn from Wmde Abimbola's obsemation that the Chinese continued to use their traditional medicine but also intenszed research to exph2n their mode of actioli ?' The choice of V W th rough couucillon is dso a probIem. Money politics has continued to be the .basis of elections in NwA. In this situation, coundors are more interested in their 'pockets' than what they can do for the people (&e people have been bribed before, any way), Therefore, one c~mnot-~budot ubt- the 'success ofjPHC in their hands. In addition,' the hct that politicians are apt to. choose who voted for them as lVHW wuld, .affect the'iuwa of PHC. Thc prows of choosing the VHW is very - d a l . t ot he s u m o f PHC. Where the person (or people) the comoauai8 prefer(s). is .not taken, ir; may Iead to the failure of the p s ~ g m q e . . . , Closely related to tws problem is the fact that-,it1.3n ot ,easy to change people's attitudes. Yet medic4 doctbrs snd.stude~tia nd mn the community members have to change their attitudes. To ,date, the norms and values in relation to txpectations from goliticiwns;. to the divergent perceptioa d life among the rural' and urbz$ dweUers; and even the traiped V H W has to change. In case of the latter, for exkPle, it has been found out that most health workers mbit have been taught some,t hings but their belief might hinder the impiernentad~n.~~, Finally, as a matter of emphasis, the politicitl trahsition which : : I 'C I I &, 29 I a UNIVERSITY OF IBADAN LIBRARY Nigeria is undergoing d w n ot &ow that them zm principled de - cad, visionary and innovation kaders. Whst most of thtm-art94~- ested in i s how b recoup the money they in- in e k b s , anp more. Consequently,-o ne ~ obut-tbe pd mhfic h u t the success t of tht PHC which devolves on the councillors at the ward M. Tfrt @sation of health for aIl by the year 2000 is dependent on,& rcaktion of npnsentative gnssroot d m not bas ed on m o d poritics. Unfortuaately thc lam is the case, Wbat hop is left for thk PHC? Poor people in slums and villages cannot do it by themelm. This would only amount to tdling thcm "to liR t h d v t s by their own bootstraps and forgetting that most of them are barefoot ~ n y w a ~po' l'it~ic~ian s an, in most cascs, out of the point; influential, elites are wwy at doing srich things; educated elites think mom of t h ~ v t s w;h ither P m Heal * -7 mere is however, a ray of hope. Tbe Cbr is th W t h . h d a t i o might hdp out but dcfmitely ndt tradition@h eaith.pkctitionaq oth non-governmental organisations may also help but &t in so fardrag i threatens their existence-profit. The Nigeria social structure d, l i needs a shake-up. But by \khoq - + 1. We have u d t hb in theconrextof.fhe-Alma,AtaDed7ar - -19 7.8 '... bringing health care as -closea. s pom'ble to ,where peopl live and pork .... I.a nd involving all as- d humao activities, See Alma Ata 1978: Primary -HC~IW#CI are( World Hedth'.Or-' pisation,General, 1978). - ' . . , 2. It-is important to point out that-SAPp redates 1986.The la*' years of General'G, owon's .g~v~ment;.~Murtala-Clb;'$siLsjo's @me, Shagari, k d B uhari-Idia&on regima; all attempted to implement the propramme. It is bnly'th@ they are in-ted implemmfing pLt of the programme. See, am* othem;.Be'n9 , Turok (ed.) B b t a nd Dtm-bj (London: - Institute for A f d d Alternatives, (1991j . , 3. . ~ c eb nimodc, B. 'me P o l i t i ~cogomyo f w d t i o i in a! Depressed' Economy' in Prr'whiation oE.~?rbEha t- L N J ~, (NB.i ger ian Econom. ic S. ocicw, 1988). ! 4. Op. Cit. 5, ' Bid. Paragraph 17. . - -' UNIVERSITY OF IBADAN LIBRARY this s o ~ ~ ~ beelser mo d er Olutayo, AX). 'b acy: The Case of Local Govanmcnt in Niria' at a Conference on Democracy Orgmiscd by the Pepart- m a t of Classics, University of Ibadan and the Classical ment Association d NigeFia. June, 1992; @. is M y to w- out in a publishad form under anotha .topic)... 7 Our idea d the principle of df-reliance setmu a littic bit dapcr than what is implied ia the definition of PHC approach ( A h Ata Up. Cit. Para: 1). We do bekve,.bow&r, that thc words 'scientifically sound' means a long-term proa~sof WOW indigenous med'ie. This ought to st- bmdhtely. In o k words, 'scicotiLic' undentand'mg of 'Mtbnal hGalth can' &odd start now and bc encouraged. 8. We should mention here that the proass actually bcpn a- the colonid ped&. This and the people to whom g o - ' ~ ~ handed over to ied to the. existing situation. See Ekch, P.P. Cofonialh~a nd SmY S~nrctun(I.n augural Laturr, Univdty of Ibadan, 1980);-s ee also. (llutayo, A.O. The Dcve10pment d Underdevelopment: Rural Economy .of CoIoU.S outh Wmkm Nigeria'. An Unpublished Ph.D. Thesis, October, 1991; Jplius Ihonvbere (ed.) The Polilicd Economy of Cn'sis and 'Und~- dedopent h Mi:M ey:ted Warks of CIau& Akc (NI& -..>, JAD Publishers Ltd . 3989). el,, r , . :4.a~;= -,F.'~> b$ d -,l - 9. World Health Organisation: "African Traditbsd Medicine". AFRO Technical Report Series, No. 1, 1976. , 10. Tola Olu Pearce 'social Change -and t6s Modemisation d the M,e!&al Sector: in Simi Afonja and Tda Qlu Pezulce (~3.)- Skid sage in N@wiw (England:' hngman Group Ltd. 1984). 11. S. H. Brew-Graves, 'Medical Education, Health' Care and Development, in A f h ' Paper kaented .at the Co11qp M, College of. Medicine; Ufiiversity of Ibadan, 26, 1990 (Dr. Brew-Graves is 'the WHO ~cpresctna tivcs and Resident , Programme Coordinator in Nigeria). 12, Also 'important is the fact that colonies were seen as am- for trade. See, among others, Waltet Rodney, Hdw E k p U ndr- devdopd Africa (London: Publishing House, 1972):. ' - 13. Aiubo, S.O. 'Debt Crisis, Health and Health Stnriw in Afrkd. Social Science Med. Vol. 31, NO;6 pp:639448, 1990, P w ,Op . Ci t.; also in 1982, Fcderd Governmeni' Officials pkfw to go 31 UNIVERSITY OF IBADAN LIBRARY h a d fo r Medical Can,S eptrmk 6, . m yT h a b i d . See ah Oguadeji, M.O. 'Primary Health Care in N I Achiev'tment h c e Inception and P r o w f or tht Future', Paper presented st 'a SeminarlWorkshop oh\ Comrnuni~M obilizatim and Training for Primary Health Gaze Workers,. 14th Sept. 1987. kegbeyen, J.B.O.' 'me Imperatives of Preventive Health Care in Nieria" in P m d i n g s of the National Cod-ce of the badan Suci~E&omic Grpup in ~eveluphentS. mtegk in 2191 Century N i a J uly, 1991. World h e l o p e n t Report 1991: Ihe Chsllengc of Development @Wished for the World Bank by Word University Ress, 1991). Op. Cit. 'See for example Roemer, M.1. 'Private Medical Practice: Obstacle to Health for AU' in .WoddH kkJtb F-, Vol. 5,1984. Lambo; T.A. '~olitib,id eology, and health', 'World Health F o e V ol. 1 (1, 2) 1980 p: 6. Samba, E.M. "Primary Health Care: unknown,' pitfalls, and ' hazards', World Xed& F o m , Yol. 2 (3) p. 359, 1981. b b o , O p: Cit. p. 6; ' ~ l m a - ~Otpa. Cit. para: 22. Op. Cit. (Ogundeji, M.U. and pear^$.' See the :~breword't o the Federal, Ministry of Health: The Na- tional Health Policy and Strategy to Achieve.Health Tor dl N i g h s , Lagos, 1980 by ]Prof. Olikdye Raawmq-Kuti. Ogundeji, M.O. (Op. Cit.) and Oyegbite, K.S, 'Overview of Primary. Health Care in Nrgeria', n.d, Our source :of information is ,Dr.. Martins 10. Ogundeji,. Zond &ordinator of B .kealth Zone (cmprishg:of Delta, *&lo, Lago$. O p , Ondo, Osunna nd Oyo) i n a n in@* held with him on the 17th of A&&, 1992. All the information with. regards' to the establishment of PHC in Nigeria emanated frdm him. The critique is o m . This is. one of - the ..pitfaIls Gambia. experienced,.P HC SWin 1978 at the Gambia:%e Samba, EM.O p. Cit.'p p. 358- 363. On page 361 he stam: 'In my owri opinion, .management was the most critical factor in the success or.faih& of PHC. A$ the mtral lev91 we had an interministerid, c o ~ i t mw,h ose meetings were UNIVERSITY OF IBADAN LIBRARY - - - initially well at&ded. As thc hcymwn'camc to an a d , dif- ferent, often ccd~icting,p riorities emerged. Am.dance at tbe meetings b c a e M orer as t h e w ent on. Other mm. tm. becsme less cooperative; some w&-down Wright obstmtivc. ...' Sa also, on the problem &management espedally at the political level, Muriel Skeet, 'Community Health work-: promoters 'or in- hibitors of Primary Health Care? W o r . . H d t bF orum, Vol S, , 19M pp. 291-295,. 28. Samba, E.M. 0p.Cit. p. 362. 29. h b o , O p. Cit. p. 6. 30. Wande A b i i l a !Traditional Medicine in Nie The Journey so Far', Paper Pmented at the b F a i r Seminar Organkkd by the NTA Channel 7, Lagos. Feb. 26, 1988. 31, Skeet, M. Op, Cit; and also Ratnaike, R.N. O'NeiI, P. apd, Ch yno weth, R-. ' 'Village Health W,orkers and Malnu.t ri.t .ion. :' A Project that failed'; 32. 'Dialogue on Diarrhoea', No. 49, June 1992 .(AHRTAG, . don). , . 33. Quoted from M,'A, Farid, The ~ a l & P rogramme - .from euphoria to anarchy' World Hid& F-, VoL *-I -(1 ;2) 1980 p. 20. -6): -5% ,,I? L'r '.' lRcf#exllces , . . - . A?.' 4bimbola Wande (1988) Traditional Mcdicinc:in N@X 'mJ:~ so Far', pa r Presented at the Fr~FairS a n k O rganis.e d .b y the N-T A &gel i,.+gos. Feb. . , 2 6. * ,-, - - , , . ,. , AHRTAG, (1992) 'Dialogue on Diarrhoea',?No. 49, Jwe . . A l b , S.0.- (1 990) 'Debt Crisis, Health and Health Se&s -. in '" . ., . . e. W dS ci'mce Mdeiae, Vol. 31, No. 6. . . kegbeyen, J.B.O. (1991) "The Imperatives d Preventive Health 'Can in Nigeria" in Proceedings of the National ~onferedceb, f the badan Socio-Economic Group in Development Strategies h 2M Centwy Nigeria. July. Brew-Graves, S.H. (1 9 9 0 ) 'Medical Education,. Health Csn end Developnent .in Afb ' Papr Pmmtcd at tb College hcturc, UNIVER ITY OF IBADAN LIBRARY College of Medi%e, University of Wan, July 26, 1990. Ebb, Pa P*( 1980) C ~ I ~ a i mddh S WTYS ~ C - ( h u m L bol - . ture). University of Ibadan, Farid, hl. A. (1980) 'The Malaria Prognume - from mphoria anarchy' World H d t h F-, VO~f. , (1, 2). Federal Ministry of Health, (1980) 'The National Health Policy a d Strategy of A c h w Health for all Migerians,' Lagos. Ihonvbere, J. (ed. 1989) me Politid l%traamy of W and Un&- &&opmat Ib Alrica: Selmttid Works of Uaude Akc (Nw , J A D Publishers ,L td. I Lamb, T.A, (1980) 'P,olitics, ideojogy, and health', WaPld H d f h Forum, Vol. 1 (1, 2). Ogbd,eji, M.0. (1487) '~rimaryH edth Care in Nigeria: Acbitvcm' It since Inception and F9ospects. for the F u t d , P a p p rosentad I a ~ ~ o r k s h oon Cpom munity hddhtion and T h i n k for'P riimary H d t b Carc Workers, (14th Sept. 1987J.' . + Oiutayo, A.O. (1991) 'The Developmeat of Und&wIopmcnt: R Economy of Cobaid South Watem Ni- An Ph.D, Thcsis; (October, 1991). Olutayo, A.O. (1992) 'Surviving Within De3naxaq: The Clrse of loc$l Government in Nigeria,' Paper ' Presented at a Conference df DePlmcy Organiscd by the Department of Cl&q, Uni d Ibadaa and thi Cl&id AssociatiDn of N-. (Junc E1 jr." a Onbode; B.. (1988) 'The hli tical .Economy of PrjvatiEation in D Depressed Economy: in Pn.mtiiation of PubIr'c E h e h N&a N+an &an. on.& , S*&" . . . I ~t&, ?6h 01; (1984) 'Social Change and-the ~ & m i k t i u n4 f Medical Sector', in Simi Afonja and Tola Olu Pemc (ad.) Sd' mange h i n w a ( England: h n b Gr oup Ltd. ? Rodney, W. (I 972) How Eumrpe Underdeveloped Afrim ondog: Bogle +'Overture and Darees Ss lam: ~ a n z a n hP ublishing H o w . Rocmr, M.I. (1984) 'Private M d i d Practice: O M t to Health 4,' Wudd H d t h F m ,. b l . 5. UNIVE SITY OF IBADAN LIBRARY Samba, E.M. (1981) "Phary Health w:unk nowns, pitfdh, and hazards'. World; H d ~Fo.rum Vol. 2 (3). Skeet., M. (1991) '~o&unity Health workers: promoters or inhibitors of Primary Health Care? WoM hi^ F o m , Vol. 5. 'lbrok, Ben Twok (&aDebt )& ~ u c . m c y (London: Institute for African Altem&es. World Development Report (1991): me a d m .of 13edopmt (Published for the World ~dlbry Word University Press. UNIVERSITY OF IBADAN LIBRARY Strategies-ForC ommunity Participation in Primary Health Care Programme: The Participatory Rural AppraisalAppr-h O.Y. Oyeneye Dqmrtmmt of Sociology F d t y o f S o d and Management Scien- -0- State ~ n i v e n i t ~ Aprwoye. "Fre~-&fly, benafrciary knowledge of the local situation wilt ' . p m t w asteful and inappropriate schemes d-ed by ig- norant outsiders". Cow and Mom (1988) ' Introduction So much has been Mitten already on Nigerian local governmmt since the reform of 1976. The reform attempted to make local gove~nmtnt the most important organ of the Nigerian dmhistrative $Mm. The xefom defmd, in clear terms, the structure and functions of the local government. Adequate constitutiond guarantees were dm put in place to protect the local governments. Of course, statutory allocations both horn the Federal and State governments, were ma& avdble to thwn. Staff training a?so received a boost through s p W grants. Tksc enabled bcal governen t oficials to attend workhbps snd & on different areas of the local government functions. In spite of all these, development at the grassroot has r a n a i d rather low. There are, in fact, some who argue that local govmments have failed to live up to expectation. Thw critics have suggated fur- ther reforms to make local government more =levant at the gmsmok To some extent, these critics are right. But what is required to make locd government more reIeva_nt is not another wholesale reform, 36 . UNIVERSITY OF IBADAN LIBRARY . ? Rather, local governmat functionah should be enw- and a- +d to more tmilling opprtupitiw to *t han mon innovative ca@g out the responsibiitb assigned than to make life more man- h#ul for the majority of people living in their constituencies. This short paper addresses the iwue of Community Rdcipation in hject Planing and- ImpImentsztion at the Id level. 2ke idtention is to introduce participants to Participatory Rurrtl' Appraisd (fRA) which I consider a very good strategy for promoting pmtkipation in the$anning and'implwnentation of Rimary Health Care Programma at the local level: This approach is mnsidered useful because-most of the lM government areas in Nieria are rural. A very h r p propor- tion of Nigerians live in these nrrd areas wbere the need for d e c k health care senices is felt most. Primrsry Health Care Primary Health'C are i s now f d y e stabihhed in.N igh-;o s the strategy for providing health can for the entin population'. According to the 1978 klmation of Alma Ata, Prhaq+HealthC art is d e w ' thus: Primary Health Care is ssenthl health carc based on pqc- ' tical, scientifically sound and social acceptable h o d s , technology made universally accessible to individuals and families in ' thc 'community, thmuglt th& f u u : ~ @ i t i q andit a wst that the community and the'whtry &'aDlM ' to maintain at every stage of their develo-t in the spirit of self-reliance .and .seWdetermhation. ' '1t forms an integral part both of the country's health sys- tun, of which it 'is the central function .an3 main proms, and of the overall social and economic development of the community. - . It is the first level of' contvt of individuals, .the family and t$e community with the .national health system, bringing healthare as dose. as possible to where the people live and work, and. wnstitum health can process.2 Five main u n i ~ pdrin ciples underhe the P b m y Hdth M strate-gy. These arti: , eqhtablt distribution UNIVERSITY OF IBADAN LIBRARY - -community pmicipation . - a prevtntivdpromotive approach - appropriate technolggy; and - a muitisectoral approach. Since 1985 when the present military administration came hito power, a lot resources has been committed to the health sector. ?I%e Federal Government allocated huge sums of money to the States to rehabilitate general hospitJ s which form an important component of the 1P;H.C. The teaching hospitals under the control of the Fed@ Ctovemment dso received special grants to improve their se&m The training of the different cadres of health workers atso r e v d a b ~ @ , as d n a m a nd workshops are organised to provide them.w ith q u i - site sk*dIsi necessary for the operation of the P.H.C. system. All ME show the commitment of the government to the P.H.C. Attempts at ensuring community participation in the F.H.C. bas m ceeded .in some areas. But t0.a large extent, community participation remains problematic because of the attitudes of health professionah Often, health professionals assume that they are in position to w!m the health problems, needs and priorities of the p p 1 e in the can- munity. They b l ~ tehe . peopIe for theit poor -heaIth and fofmula~ policies and strategies without the input or partidpatihdi: the peopls. This- not.o ily negates one d the basic pfinciplk. of -P.H.C.; it also un- dermines the pragresg of the programme ai the &munib levdml b present state of aairs need to be r&&'& to ehcdure community participation in PHC. Community Participation and Planning Process at the Local , I , level : Contributing to a workshop organiscd for local government OMS by the Faculty of Social and Management Sciences, Ogun State 'University in 1985, .I wrote inter alia:. . The anal ysh, of the present situ'at@n ai the.loc@l evel is basi- cally that the bureaucrats and pr6fkionds inonopolisc the planning process and daision-making'siructuitt hereby alienating the citizens. The planning strategy be'mgga ddpted is simply one in which the planners plan for the pedple and not with the people. This strategy not ,only negates democratic political prms&s, it also makes the c i t W hos- UNIVERSITY OF IBADAN LIBRARY tile to government projects desigped to 6 them and en- hance their living cundiiioas. (Oyeiieye) 1985). Tbis situatiun has remained very much the same till today. Whik it ir true that many local governments across the country have atreP@ened their public relations machinery to enhance public en- ~ ~ to suppnort their ptrogramm es and bavd always extended thdr hands of goodwill to the people, c o m m d j participation has &ambed low. The failure sf these effurts suggest the need to further search for approaches thatcould be lised to enhance conrmunity par- *tion m project training and imple~entationa t tbe Id l e d in N&a. It is in this context that I find Participatory Rural Ap@d relevant as a toof that may be wed to promote combunity par- thipation in PHC at the local level, Participatory Rural Appraisal Approach (PRA): What is PRA? When, where and how did it o&iaite? Wbat is the importance of PRA to 1 0 4 government fuctio'nzuh? When and where is the approach? Participatory rural appraisal originated in the hte 1970s' in Chang Mai and Kohn Kean Universities in Thailand. It emerged as an alttr; native to the conventional 'top-down' approach to rural' devdopnent. The idea of PRA arose due to the disillusion of 'development experts regarding the Ioag delays and huge expem&mumd in cpndwthg for- mal surveys to generate data for policy formiation. NO$ bply do these format surveys mult in the cotlection of 100 much data, it has been found that quite often, the data cobte&'& h d k t .i h pub- h i o n d the results are usually late ind inappro@ate.*th :tgo or no participation by the local peopIe.'~hi the need f~r+moqnu afitr- the, in$epth information and insiets from the Id people rottfier ' than mere quantitative daia that gave birth to PRA, As m approach, -it enables go~emmmto ff*, professipnds and ~onsdtantst o l a m from and with rural--peg& directly and fm to face. It also enhances their understanding 6F the perception, priori-b md needs of the rural people.5 Thus, PRA challenges the prevalent nhtion among professionals and development administrators that the rural people are ignorant. Secondly, it enmaram participation and empowerment of the people in the andysis of probhs and the fofi mulation of possible solutions. This, indeed,. is an essential re~uiFemept for succwsful development within @e c,ontext of gr-otrdeveloprneDt UNIVERSITY OF IBADAN LIBRARY which is the cornerstone af the present a d d h a t i o n . Participatory Rural Appraisal is used mostly in the developin$ countries. Usually, it is used in solving problems at the local i d , some development ddministrators have used it to fma w l u t b to llri gent urban probIems. PRA has been wed .mostly in .the n&dW field. It has also been used for salving prohlam in hdth, nuWn,1 economics, energy and forestry. I This approach has been found very useful when exploring an I - to learn about the key' problems or when pluming for r-h or; development projects (Explanatory PRA). The approach is equally use-; ful when dealing wifh conflicting diDFerenca between different group\ (Conflict ResoIution Pa). 1 Practitioners of PRA used several techniques which mclude the fol- lowing: - direct observation - participant observation including being taught and .part@st- ing in village activities - secondary data review - informal interviews - group intewiews - wealth ranking . - stories and case histork - workshops and braimtohing - groupwdks - participatory pupping and modelliag - time 1hes and .treads. - rapidreportwitioghthefidd. , This list is by no means exhaustive as then $ a b w t o f Merent: techniques. The techniques or a comb'iation 'ofa ny of these teem 1 - used by practitioners depend on the problem at hand. Let me elaborate I on each technique. Direct Observation: involve looking kt-hand at the.mndl- tions, the agricultural, heal& hutrition, economic practices, .the people, their xelationships, -asp roblems etc. - ParticipadtObservation:: This req- the actad. hvolvmeat qf the professionals in.t he different activitikities. of t6e people in the aun- UNIVERSITY OF IBADAN LIBRARY milnity under consideration, Secondary Data Review: This involves learning from existing om- hl records, maps, photographs, s u w y documents and census repork InformalInterviews: This is usually conducted among key infonu- ants in the community such as village heads, opinion leaders, religious W m ,sch ool teachers, retired civil servants and dl those directly af- fected by the problems being examined. GroupInterviewar: This may be focus group for the investigation of ht-t groups or speddist attituh. It may also be open gro~~ps workshops for general discuision and/or feedback. This is useful for collecting vitd infomation. WealthRanking: This is the proass of discdon with Momants about the nature of poverty and w d t h in theit area as 8em by h. This is usually followed by a process of ranki& households in that area based on the criteria provided by these informants (who actually do the ranking ekrcise). The greatest adk~tsgeo f wealth ranking is that it genera- useful insights into local perceptions of weal& and ppverty rather than an imposition and applhh%no f criteria developed by outsiders. It is also very useful in identifying target groups attention. Above all, wealth ranking can promote s&&iab T need ~deve1opmeots ince the - programmes and/or projects emanating from it (wealth ranking) will be m i v e d as just aqd equitable,h'#be yas Of the in the community concerned. Stories a dC ase ~istodes: This relam to the report of the PRA exercise. It concerns the record of in&fing' stories told d m g i nter- views and the description of househoids with un- usual or intensting . &uations. ' Workshopsan'P2fBralnstoming: This b normally conducted to &- cuss problem and to analyse the ppssible options for s. olving the iden- tE~edp-r oblems. - Group Walk: This simply refers to the @up walk round the cdm- muniw for direct observation of the conditions of the peapleqaxldt he mrmnunity in general. Participatory Mapping and Modelling: This refers to maps made by the people on paper, the floor or the grqund. It could be used for showing numbers and locations of people, natural resourcts an+,>d dtocisrl attributes etc. as indicated below: People - tend type information on all the peoplehthe comm&ty. - compilitiofi d community register - sacial p u p s ( clan,e thnic etc'.) . .. UNIVERSITY OF IBADAN LIBRARY - keyinformuts - Health speeialis$ mAa cp3 - handicapped - children who do or do not attend school - pregnant women - the sick by t y p o f d h , by location and social p u p . - household chmcteMh. N a t d R e s o m : - landusepattern - location of the diaretent community r#~,mes. Social attributes: - ownership of aswts, wealWwelI-being st9to8. Facilities -- watersupplies community facilities - school, churches, mosques, M e se tc. - Post Ofice, Chemists, health posts, Family Planning Centmi; - Path roads etc. Hazards: - pollution - flood - prohibited areas - accident spots I . G L L * ? -.- - pestsetc. Participatory mapping and modefling is useful ia several .ways<.- start- ing point of entry with community thus establishjng rapport, ooll&n of demographic data, ideritiF1cation oP ,vdnerab!e. a m m a and danning by the community and participatory location of fadiht. Time Lines and Trends: These relate to major &an& -in+th e pagt such as incidence of d i m , trends in epidemics, changesin the en- vironment and changes in access to services. This technique help people to analyse and make sense of what has d.It & ,hdps in conflict resolution and in building on pmviow ~ f f l u r c s . . I Planning aqd Implementing a,PIRA: . , , Having examined, albeit brieflys1s ome of the dnferent -teshniqug used in PRA, an attempt is made i n this section to &ow -how a PRA is planned and implemented. For the purpose of Yytration,; we sbrll famu attention ona health problem - widespread orguinea-worn in ad aria of a local government. It is this health problem that-has ncas- UNIVERSITY OF IBADAN LIBRARY dated the p h h g o f the PRA. Tbie following steps will be taken: @ C o r n p o s \ i o n o f ~ P R A ~ (i) Initial preparation -- lia'mn with the Iocd ,goy-t head- ~ a n d t h e C h i e f s i n t h e a m a ( s ) a i & e d b y h . ~ (.I Consideration of type? of information nquirrd; @) Cumidemtion of people to be d d e a t i b d f or dmant hfomra- tion; Composition of a PRAT-: A PRA team should hot be too larp if it .is to be & d y e . Mem- M i p s hould not exceed ten; and the& must+bep wpte.who d- iic'lently knowledg&blc about the problan up& considemtion. In the ' of the guinea-worm, a PRA team of seven members is ~ n s h e d mjequate. The membership will include a doctor with special 'hienst in community medicine, a PHC Officex,P dtulogist, Laboratory Technologist, Community Development Officer, Budget. and. P h d n g Officer and an Administra$ive Offar who will coordina@t he -. of the team. Key infohnants from the area.und6r'considdnw ill also be included. The administrative officer is expected 'to gather xeleyapt'ddcutvmts for the other m e m b o f the team ahd $ISO zii& p d h h qm tacts with relevant bodies informing .them about fie composition of the team, its purpose and the need for their cdo-tioi h ie x&ting the ' team's task. The appropriate village heads should also ' be infofmed about the-formation of the team and its pmp& o&mr is PL90 expected to fix the date and place of the fmt mcet&~gI.t is nomd to haw the meeting in the arealviI1age that is plagued. ,d; t.h.. the' disease* 2 Types of Information Required: For a PRA to achieve the desired results, & team..meplh r m y t consider and carefully identify the various typ& of information atEy need from the .arealvillage .under cobsideration. This should be done befdn the first 'meeting. With particular reference to 'tlk guinea-wonn 43 UNIVERSITY OF IBADAN LIBRARY probl-em , the underlisted basebe informati011 are consided dcvmt: secondary source of data f& the past history and the swioal-! tural, economic and political devebpment of the meq - the prevalence of the disease in the area; - the type-and number of household &&, - the =d istribution of those aEected including chif-, - level .ofe ducation, type of occupation and income lev& of those Gected; - so - of drinking water and nutii&nat.b&aviour of the : people; - location and number of modern Wthf sc*ties a\ianablc in the I area including .the number of persowel, equipment in use and supply of drugs; - other sources of health w e d elivey such as c h d t s hop aad - traditional medical pactitioners; when the disease was fust noticed in the aria; . - what the people consider to be the mhr-major causrs of the disease and ?he- possible@ mediates olutions, ' Tbe People to be seen: ' The fmt people to be seen by the PR'A team ak the heads of the villages micted by the disease, Others include: shoo1 teachers, retired c iv i l sewants, nlidous leaders, opinion leaders and those by the dkase:as wet1 as ahndful b.f .th ose not+airested' in.t he ' d o u s ag-group and oocupations. P1RA Techniques to be Used: In view d the type of information req* spd tbe p~obknun der consideration, a combination of dght tezhniques h considered ada quah T h e w ill include: - direct obkrvation - the use of key informants . - ranking - informalinterviews - group interviews - map-ping , . UNIVERSITY OF IBADAN LIBRARY - workshops and bains&rmhg - report writing The first PRA techniques to be adopted will be the direct obrva- tion of the entire ardvillage through which the PRA team members will gain fusthand information ,about the pople, the economy, sodal,' cultural, spatial and other ecological aspect of the analvillage. his' method will generate additional infomation that'w ill dpplanmt of the information' gained through secondary s'ources about the Wvitlage. while going round the mealvillage for bkwation, members of tbe team will alsohold conversation with dSerent people aimed at kam- ing about the areuvillage. The use of conversation +ill be comple mented with the identification and informal. interviews 'or key informants such as school.t eachers, retired civil $ena, nts. , opi.n io. n and religious leaders in fhe srea/village. Group interviews'are also one of-them ethods to'be used toobtain information from those fleeted by,, the disease ad other members of' their households.. Another group the ~ v d l a g ewh ere 'then bas been no incidence of the di. s.e ase will also be 'hte.rv. ie &. gd f ~ rc'o mpam tive purposes. . * Ranking method will be used t6 elicit information on the most serious health problem and the type. of health facilities - ,moder, n o.r traditional, c u e o n l y used in the area/village. The use of mapping method is meant to' show the e x h t to w e & the people in the areahillage know the incidenm 'of the disease. In doing this, the people 'will be asked td'u* .a'stick to 'draw't be map-of the area on the ground showing those villages where people are badly olffected. The justification for this, is to show areas, where the disease clusteied . and in nsed of urgent attention. 4 Workshop and brainstorming will provide the,-forumf or qll the heads, the opinion leaders, the' educated, some 'of those: affected ' by the disease and the PRA team io meet for furth& iqteraction. H~E,the people them$elves will be expected t6 examine in detail the problem of the guinea-worm in the dm and the -appropriate m-es neca- SW= Finally, a. report will be writtei on the field so that appropriate government ,authority, as well ds $he villagers, can,g. o' into - wctiod .im- mediately. This 'report will be joiitly .prepar.e d b. y the Rqm and tbE people of the arealvillage. , , A' UNIVERSITY OF IBADAN LIBRARY It must b admitted that the PRA approach takes quite some time to I- and gomehow dirr"1cdt to do well. But givenits inherent ad- vantages, functionaries at the local government level responsible for the design and implementati~ao f PHC programmes should develop inter- est and nadily take io it. PRA is not only time-saving but also acient in information gathering. PRA will encourage participation of the Iocal p p k in the process of development since local insights are usually sought not only in the gathering of information but afso the design, impbentation and sustenance of projects. In a way, PRA empowers the rural people and increase their commitment to programmes and projects designed for their benefit and welbbeing. It is important at this j ~ c t i r eto draw attention to some basic re- quirements in the application of 'PRA. First, practitioners ofi the ap- proach must be willing to share sonme.of their powers with the people. At the local level, functionaries will need to share the^ powers with the ruraj people to encourage them to participate in government programmes. This is very important if the con'ventional 'top-down' ap- proach to development is to be reversed, W i t h this context, prate titioners of PR A must be humble and show basic respect 'for.3her urd people. They must also show keen interest in what the d people know, say and dg . It is certainly out of place for practitionm. to regard the nqal people as ignorant rural dwders who have no contribution to make in matters aecting their wcll&eiig and the envhonment in which they live, References Alma Ata Declaration (1978): Report of the International Conrerence on Primary Health Care. Alma Aja, USSR, 6-12 Sept., UNICEFWNO, Geneva. Chambers, Robkrt (1990) "Rapid and Participatory Appraisal for Wealth and Nutrition". Paper presented at the Silver J u b ' i ~ Celebrations of the Nutrition Society of India held at the National Institute of Nutrition, Hyderabad, India; 1st-3rd December. Cow, D.D. and Morss, E.R.: "The Notorious Nine: Critical Problems in Project Implamqtation". World Wve lop~n t1,6 , 12, 1399- 1418. 46 UNIVERSITY OF IBADAN LIBRARY Oyeneye, U0.Y.'(1985")S ocial Service Data for Planning at the Local Level" iu O.Y. Oyeneye, B. Ohwa and 0.0. Odugbemi (bds.) EEter:rive Mpagmmt at the Local Gownmtwt Levd. Fawhy of Social and Managanent Sciences, Ogun State University. The National ~nvironmentdS ecretariat (1978) P ~ p a t o rRy w al App& Hmdbook p. 2. Lagos. - UNIVERSITY OF IBADAN LIBRARY Theplace of fr aditionalMedicinehPrimaryH d t h Care Bernard E. Qwumi Department of ~ociobgy University of Badan fiadan. The Place of Traditional MediGioe in Primary Hedth Care There is a gene& concensus among social scientists that within &very culture, there are means with which the health problems of the people are maintained. This belief thus sugg~tsth at the culture dictates the cause of disease and the course of action taken. For instance P~WX (1982:15) observed that all cultures evolve meth~dso f dealing with & heahh, discomfort and maintenance of health. Similarly, Lambo (1m 1966) noted that his experience of non literate societies have demonstrated the influence or importance of cultural factors in fie managanent d the patients. To him it is culture which determk the acceptability, the success or failure of a give therapeutic orientation. This position supports Unschuld's (1976) observation thttt "were ever" westem medicine was introduced and no matter how urgent the need I for its immediate apprication was felt to be, it was never a question of i its fdling a medical vacuum." This picture was suecintly put by Pearce, (1982) she noted that the vast territory to be Icnown as Nigeria under the Britain in 19 14, after the unification, had developed various , specialist among different ethnic groups to handle their health probIems. These specialists were known as traditional or native healen with their various local names. that suited the dnerent cultures. For 'instance the Yorubas recognisd them as babalawos. The Ibos d'bia, the Hausa I Boka while the Urhobos Oboh. Who are these people and what fom UNIVERSITY OF IBADAN LIBRARY of medicine do they practice in the community? Traditional Medicine And The Practitioners The conception of traditional medicbe varies amongst authon and even between ethnic group. In other words, there are as many d m - tioos of the a n as there are researchers. According. to Ataudo (1985), traditional medicine is the medicine of the people by the people and for the people which has -t;een-practiced and handed down from generation to generation. Similarly; the World Health Organisation (WHO, 1976) defmes it as the sum total of all knowledge and.practim, whether explicable or not used in diagnosis, prevention, and elimina- tion of physical, mental or social imbalance and relying .exclwively on practical experience and observation down from generation to genera- tion whether verbally or in writing::In other words, traditional medicine is an .art which depends on availabfe nsourceS8o f nature. There are also dimerent areas of speciarization or proficiencj,; Let tw take the case of the Okpe people of Delta State, for an illustration, There are two major groups of healers d n g t he Okpe people of Delta State - The Bide (witchdoctor) and the Ohh (the 06 doctorJ. This classification is based on.t he belief that tbe ed&Ie oodd be able to resolve problems (ailment) with witchcraft undertone as it is with the Babslawo of the Ibadan Yotubas (Eulacleap.4 1971:18) while t&e Oboh who only rely on his naturaI knowledge in." h&s and barks" of plants to handle ' problems cannot resolve witchcraft related problems. It should be noted, however, that the above classiflrcation is not to suggest that witches are traditional practitioners instead it reveals tbe fact that there are traditional practitioners who in addition to their skill in the natural methods of healing have witchcraft powers that they utiIise .in the management- of illness. I t also su&mp that ,the be1iaf.h witchcraft is a potent source of diseasdmisfortune and codseqm'tly illness management is well deveIoped and en trenched .in the culture of the Okpe people. This obsemation agrees with what other researchers (Lambo 1966; Erinosho 1978; Oyebola 1980 and Odebiyi 1980) view that ill- health may be due to a number of sou- or causes - natural- ly, supernatusat or mystical and considering the fact that most problems/ailment in the developing worid are more magic* religious in nature - (Ackerknecht 1946), there is a need therefore to develop traditional medicine. UNIVERSITY OF IBADAN LIBRARY A closer smdysis of the abwc clltssihtions of the two major groyp of practitioners meals the folowing: I (i) The genera1 practitioners who perform general servicEs regardless of the problem of the ptient. They have a wide knowlede of herbal medicine as well as being able to divine the cause. of the problem, just as the Yoruba babdawo (Oyebla 1980) including rendering of ordeal services. (i) The second goup are the OracIemen/women whose role is strictly divination. Theirs is to lbcate the cause of the problem, without which no meaningful solution can be obtained. The average Ob peman believes this because llness is seen to be mostly the hand- iwork of evil machination and surreptitious in nature. The traditional Birth Attendant constitutes another gtoup of prac- - titioners among the Okpc people. They an very howledgeabIe in paf- turitiond services. These include the preparation of waist and 0th prophylactics against evil persons or spirits duaiPg pregnancy and ki rs ailment and delivery among others. Ch i The bone setters, traditional psychiatrists and 'massus arc lqp other categories discemable among the gioup. The bone settti involved in the t r a ~ ~ ~o~f cfranctu red b~news hilc the m h i a handles mental: cases. The masseues massage. To my mind, bone setter perfoms in some if 5 not all cases a skn;ice -thatb as. np alternative or equivalent source. They do not ayputate patients. Similarly, 'the trhditional psychiatrists have kri acclaimed to be more effective in the management of mental patient than the so called scientific medicine (Lamb 1966). The rpoht here is that there are same areas of proficiency where traditional medicine h e kvmgc over westm medicine. For instance Qyebola (1980) ob- served that traditional practitioners seem te cater for certain health needs of patients in the Yoruba cultural 'milieb (this is for almost every culture in Nigeria) in which Western med3m falls short of expectation. An obseriration he b d e a fter discover- ing that P cities like Lagos an& I badan - whm western' medicirk faciliities are available within easy reach .of inhabitants a large prcentage of the people still visit traditional proktitioners or have ' traditional medicine secretly bbught ta them when they are in hospital. In other words, traditional medicine wufd continue cater for some special needs becstwi1thec ulture der~1eSt he . case, and managanent pattern and the attitude of the people. Th UNIVERSITY OF IBADAN LIBRARY -is a purely socio-psycho1ogical syndrome which cannot be trampled upon in aihent management so there should be a way of identifying such areas of needs and develophgthem for a start: These practitioners acquired their knowledge either through in- heritance or apprenticeship or as a call by one spirit or the other. They practise this art as a hobby or as a form of communal service with little or no financial rewards to the people. This non fmancial ethos characterized the practice of traditional medicine till of recent. The art then was "pure" and efficaciaus because most practitioner's services were rendered to family and close community members while in others token were only given to the traditional practitioner after positive, " result or treatment have been obtained. Unfortunately, these unparalleled services were administered by .iI- literate and old people who-could not document what they did or knew consequently, some if not a11 died with a substatial part of their knowledge. It is in this realm that the developlment of traditional medicine has seen its greatest pitfall in this -country because our government has been culturally enslaved to believe that what is western in drigin .is the best an nothing eht. The situation is gradually improving today, some of our traditional ' practitioners are now literate and collaborative in their attitude towards the practice of medicine. They have revoIutionized the practice to one which shows that they (practitioners) are no longer a bunch of uneducated dirty and unorganized body to a fairly organised, less dirty and refined group consisting of full time practitioners with monetjzed services. Primary Health Care And Traditional Medicine' Today, primary Health Care is now the focus of She. government. The reason bemg that the'governmeht has identxed that the western medicine which is mosdy centred on curative, capital oriented and, sometimes unaffordable cost is digant from the people and in order to 'carry' health to the door step of the people &e primary orientation of medicine shodd be qphasised and pursued vigorously. Primary Health Care as it is conceived in the Atma Ata Declaration of 1978 is essentially hearth care based on practical, scientiiidly sound and socially acceptable methods and technology made universally ac- cessible to individuals and families in the cornunity and through their f d participation and at a cost that- the cornunity and country can+ UNIVERSITY OF IBADAN LIBRARY durd to maintaiq at every stag of their development in the spirit of &-reliance, and self-determination, Une vital point that strikes us from the above conception is the ac- ceptab'ity, ~ i ' b i l iy,t f lordability and suitanability that it preach This vividly brings to mind Mdlean Foets et a1 (1985) conception of the term PHC. PHC very often is characterized by a non s p e c i d i d and ejisy accesible sewice. 1n their study conducted in Belgium they. .c oncluded that those setvices mostly consulted without refads oon- stitute Primary Health Care. Again, from .our various development plans (rust to the fourth national development plans) and execution of goals, have we demonstrated that we can sustain and provide for the; needs of our population relying~solelyo n the westem model of! ~ ~ The kctes are the?re for dl and -dry. Research findings in Nigeria today +eaI that about 75% of thc popdation utilize traditional medicine due partly to.t he fact that it is highly accessible, 'affordable and acceptable to the generality of the population; In this light, it would not be wrongto condude tba3 tradi- tional medicine can be equated to PHC in the Niguian setting. Simplis- tic as this may sound, the integration and or recognition .of traditiod practitioners as a useful and relevant component of mediccine at the local level ' of health ' managernat in the country is indicative of my conclusions. Today the traditional Birth Attendants ari nos being .trained in an a h p t t o extend the frontiers bf.h ealth care delivery in the wuntry. Ooing by the conception of PHC as stated ahv'e q d g iven the role arid nature of traditional medicine in our society, .the p'riniacy of tradi- tional medicine within the overall healthcare needs, of the country can- not be over ernphssiscd. The bulk of the rural poor -4 to a very large extent. the majority depends on traditional hedog systems. In fact WHO' recogniaed that.h ealth fos all by the year 2000 is an illusion without, tra.d i.t ional medicine especially in the third world societies. In .wnclusion i would urge government officials .to ensure that kxd .pcactitionerso f the art in fheir domain be assisted to improve on their methuds and& provided with ~ome'httso &able the cumdty from their services. UNIVERSITY OF IBADAN LIBRARY References Ackerknecht (1946) Systems of medical beliefs and practices, ~ocjblogy of ~ e d i c n ed . Coe M. Rodney. Macgntw Hill Book Coy. 1970 New York pp, 199-159. Ataudo, E,S. (1985) Traditional Medicine and Biopsychosocial fulfil- men t in African Health. hfwnationalJ owaal.ofS oc. &*a#m d . Medicine Vol. 21 No. 12 p. 1346. Erinosho, 0.( 1976) ~ o t e son concepts of disease and illness; The Case of the Yoruba in Nigeria, N&witta Journal of h a o m $ md SO- ckf Studies. Volume-1 8 Number 3 pp. 148-149. Federal Ministry of Economic' Planning: First National Development Plan 1962-1969.L agos; p. 202. Federal Ministry of ~conomicP lanning: Second . National Develop ment Plan 1970-1974. Lagos. p. 240-249. . . Federal Ministry of Economic Manning: Third National D~elop-t Plan 1975- 1980; Lagos, Vol. 1. - Federal Min. of Economic-Planning Guideline for the 4th National Dev. Plan 1981. . . Federal Min. of Health: The ~ a t i o n a l ' ~ e aplo'l~ic y and Strategy to Achieve HeaIih for All Nigerians. Lagos, 1988. Ityavyar,' D.A . (1 987) T h e 'stab,C lass' qnd ~ e a l t h~ ervices'i n Nigeria . Mfika S p & m V ol, 3 pp, 285-315. Lamb, T.A;( 1961) The importance of cultural factors in trqhnent (with special referenrenm to't he utilization of.t he social enyird&mt) . Con/:R ep. 3rd W d d C ongms af Psychiatty. ~oxitrkalb a d a Lambo, T.A ,'( 1 966) c&unity factors ih the therapeutic management of African schizophrenic patients in: &y&iahy Excap& Medical Formdatiom Volume I page 359-363 ( P m d g s of the Fourth Wodd Congms of Psychiatry Madrid) 5th-1 lth September. Maclean, Una (1 971) Magid M d e :A A ~ R ICaTre' S~tud y A h . Tbe Penguin Press London. . . . - A Mall- Focts, Berghmans Frans.&. Janssen Lieve (1985) The Pdmary Nedth Care of 'Belgium: A Survey of the Utilization of Health s3 ' UNIVERSITY OF IBADAN LIBRARY ,Services. lirttmahbnd Journal dSm*kf Sciiwce & M&e Vol;, 20 No. 3 .pa 183. ! Odebiyi, A.I. (1980) .Socio-economic status: Ilhess behaviour and at- titude towards disease etiology in Ibadan in me Nwm9m Be- l i & d Sckce Journal Vol. 3 Nus.. 1' 8nd.2p p. 171-173. Okt, E.A. (1991) AothropoIogy in Medical Cwr icu l~P~a~pe:r presented at the Nigeria Association of Colleges 'of Medicine (NACOM) Workshop on the Integration of Social Science3 into the Undergraduate Medid Training in Nigeria. Training and Conference Centre, Ogere, Ogun State. dmuni, B.B. (1989) Physr'dm-Patien& Relatioa&p io h Alkinarivc Healthcare Syste~nA mong the Okpe Awple of Beadd Sure: An Unpublished Ph.D. Thesis submitted to the Facidty.of Social Science, University of Ibadan, Owumi, B. & Jegede, D. (1991) Primary Healthcare and improvement of the H d t h Status of the rural people in Nigeria. Resented at the 3rd Rtgional Workshop & Exhibition on rural development, 13- 17 August, 1991, University of Jos, Phtcau Strite. Oycbola, D.D.O. (1 980) Traditiond Medicine and its prmtitioners among the Yoruba of Nigerk A Qassrmtion in Sm'd &'en= aad M&& VOI- MA pp. 2 3 a . . Paync, A.O. (1984) Introductory address 'at the Workshop for trainers of traditional Birth Attendants, held at Royal Bed HoteI, Ikda, 3rd-5th October, 1984. Pearce, T.O. (1982) Medical systems and the Nigerian society, Nigerian Perspectives on Medical Soc.i o. logy: Studies in Third,W urfd Soakties Op. Cii. pp. 115-134.. Read, M. (1966). Cdtm H i c h & D i s w Lond.oi: Tavistoclr Publi- cation. Shokunbi, L. (1989) "Lambo suggests solution to poor health". Daily Thes September 13 p. 28. , Twumasi, P.A, (1988) Traditional Medicink and Prospects for Mor- tality Change in Nrica. .Rips Occasional Paper: hpact &I Cld- ture and Tradilion on FerriGiv gad MortaLiw io M r . V ol. 1 No. 1. UNIVERSITY OF IBADAN LIBRARY Unschuld Paul U, (1 976) Western medicine and traditiond healing sysd tem: Competition, Co-operation or iptegrgtion? Ethb h a d M edialire: Vol. 3 pp, 1-20. World Health Organization: '!African Traditional MedicinefpA FRD Technical Report Series. No, 1, 1976. UNIVERSITY OF IBADAN LIBRARY Voluntary Healthcare Workers and the Succesrr d PHC Beraard E. Owumi Department of Sociology University of Ibadan Xbadan, Nigeria Voluntary Healthcare Workers and the SUM of PHC Voluntarism is a conoept that is essentially rooted in the cunception of the Primary Health Care strategy for the dwdopent and advance- ment of health fox dl p p 1 e of the world -and the developing nations .in particular, The need for this strategy for atending the frontiexa of health is premised on the inadequacies manifested by the existing hedthcare s t r u m world over. Researches and &dings of shah reveal hat the present healthcan system which is tecboical, capital h-, tensive, curative and modern is easenilally elitist and: undFordabIe by a substantial proportion of the population (Mkh and Watt 1986; Ityavyar 1987), whiIe in the developing d e b , tbt modem W t h care system is inadequate nuraerieafly and alien to the rural peu@Ie. Based on these conclusions, the need for a re- examhation wnd re orientation of the present structure as it obtains was inevitable to en- suk that the health need of the people is adequately catered for. It is in the Iight of the above observation that the International Confeimce on Primary Healthcare was held in Aha- .Atti in 1978 to profer soiu- tions to the health problems of the world. It should h noted that this Conference was only the Climax of a Series. of meetings aimed at ad- dressing the health needs of the people of the'world (W.H.O. 1978). The Alma-A ta Conference declaration that health is a state of corn- UNIVERSITY OF IBADAN LIBRARY phb physical, mental and social w d - W g , and not merely the Wee of @' or W t y , i s a fundamental human right a d t he attain- ment of the highest pgssible level of h d t h is a most important world- wide social good whose reahation requires the action of many other social and economic sectors in addition to the .health sector. problematic as this conception may be, the scope of C O V m~ake J health a non diagnostic and curative phenomenon. h other words, iif- heaith could be equated to poverty or absence of potable water, electricity, good food and not necessarily malaria fever. It is m con- sonance with this conception that the muhi sectorial approach to the attabent of primary health care goal is W u I . The Conference declared: In addition to the health m r , i l l related %pars and aspects of national and commdnity dmd~p&nt, in par- ticular agriculture, animal husbandry, fpod, industry, ed=- tion, housing, public works, communications a d o ther sector; and demands the coordinated effbrt of all those see tors. ~ h ish th e more reason why nationa of the world today have started to change their management of the health status of their ddzn to the multi sectoral approach which stresses the provision of the W e facilities of life. For instance, self-reliance ~fIoIo d, provision of ade- quate potable water, good road.amngst others as a basic target of the. Nigerian government are a component or derived from the New Worrd order that andysizes health from a wholisttc point of view, Such aphorism as A31 ?*, (i) illiteracy is a disease ' 5' (ii) 'poverty is a disease, ;> ! , 3 an a tmtimony to the inevitabiiit); of the *wholistica ppbach now in vogue. Voluntary Health- Workers p&ary Healthcare as defmed in the Alma-&a declilration is basi- d l y h ealthcare based on practical, scientifrcdy sound and socidy a& ceptable me'thod and technology made universally h b f e to the individual, and fkiliw in the community and through their fdpar- irTcipwtiba and at a cpsf fiat the community and country can @ord to maintain at every stage of their development in the spirit of sd' 57 UNIVERSITY OF IBADAN LIBRARY reliance and self de-ation. It should be-re-called that the basic obstacla aforestated to th9 realisation of equitable and adequate healthare world wide was the high cost, low strength of faditiis and ~e alien ethos of the .wmm services available par ticuIar1y in the developing societies, In an attempt to meliorate the existing conditions, it was necessary to: promote maximum cornmunity and individual seIf-reliance and participation in the planning, organisation, operation and control of primary healthcare, making the fullest use of local, natibaal and other available reiourcw; and to this- end develops through appropriate education .the ability of corn- munities to participate. (FMOH, 69 78). Voluntary healthcare is thus premised on .the cost reductionist and adaptation of heaifhcare management to the envirotrmmt. In an at- tempt to realbe the target of health for all by the year 2000, the par- ticipation of the people is inevitable. In line with this ugwnent, voluntary healthcare workers variously known as Community Based Assistants (CBA), Village fiedthcare Workers 0,:Cor n- munity Heakh OfXicers (CHO), Community Wealth Assistam (CHA) and 'Badoot doctors' in the case of Cbida are considtired crucial to the attainment of the ultimate goal, This conception (VHW) is not a c M y new to the Nigerian society as far as health management is concerned. The Nigerian C o r n m e fike any other has developed its own tradttional system of health- &fore the advent of western medicine (Oyeneye 1985). This the p p k depended on and the practitioners, well recognised and respected by the community (Twumasi, 1988). The traditional healeii were not motiwted by economic gains or profit driented, the art was pmctk& as a complementary service and humanitarian in ethos (Owumi 1989). ~onse~uentl;p,a yment of services readcred were made post treatment in appreciation 'of the services. The traditional healers' services w e k thus a service to the community and mankindrand not the gains ex- pected. It is also possible to argue that the ~rimaj'~&althcaSrchee me is also not new to the Nigerian Society since the Basic Heal* Service Scheme (BHSS) is structured along the same h e ( Oyeneye 1985). 'The belief by marchers and w d d b odies 'that medicine and health management i$ environmentally and culturally based made the call for adaptation and involvement of the local people a genuhe one to ad- dress the health problems of our people. To this end>, the Nigerian UNIVERSITY OF IBADAN LIBRARY government hati taken the initiative to set the pace in order to disc the goal of health for all by the year 2000. The Nigerian VoluntaryW orkers Scheme The stmcture in 'Nigeria is such that all. levels of government are involved in the manageinent of fhe scheme. The federal government initiated and executed the fist pragmatic step towards extending the frontier of health care by creating the National Committee on Training of Traditional Birth Attendance (NCTTBA) in 1978. ?%is Committee has in fqct established strategies and guidelines for the training of TBAs and the role of the different tiers of government in the manage- ment of the primary -healthcare scheme (Payne 1984). The product of this scheme were to work in their various communities as certificated TBAs. They are of course to be provided with some software to assist them in the dispensation of services. Apart from the t*ning allowance and some kits; there is no provision Ibr wages. This practice of training TBAs is also extended to other well intentimed who are con- cerned with the health problems of the people. Such people when iden- ..med are trained to work as voluntary health - ofxicers or community based attendants. For instance, in Akinyele Local Government Areq, about four hundred village health workers have been trained to ws& in the management of health problems in their various communities. There is n.0 doubt that the scheme is a noble one and if well managed would led to the reariation of the target of health for all by the year 2000 especially .as many people woufd'now be acwsible to health of'licers at the local !eve1 with the existence of voluntary bdthcm workers, ' The basic obstacle to the realization of accessibility of health care to the generality is the low degree of commithent ofLthev oluntary workers to the scheme, In a situation like ours; where the economy is "harsh" and the survival of the citizeary gepends IargeIy on how economically productive they are, the sustenance of health for dl by the year 2000 based on voluntarism &ems an illusion. This is due to the fact that nothing is actual1 y expected from the government far ser- v h re ndered to the community. As such voluntary wo.rkers likely to have Jukewam attitude towards the managemen't of the scheme. In places where' similar schemes have succeeded, for instance, Peoples' Republic of China, participants are part of government and th6 nature of the economy encourages the approach meh Wal HU 1981). * - UNIVERSITY OF IBADAN LIBRARY , Another major problem which faces the swlx;ess of the scheme is the orientation of the amage Nigerian to healthcare delimy. Basically Nigerians see healthcafe in terms of curative rather than preventive which is the fbcus of Primary healthcare, Tn this regards, the average village patient is Likely to be less confdmt in the wtivitiw of the volun- tary health worker, Again, the non-availability of asentid f i t aid drugs due to the poor -state of the economy would greatly Uect the workability of the s c h u nder the p m t s ituation. . At1 these problems notwithstanding, if the locd government on w h o ~sh oulder primary healthcare rest can dispense substantial amount of fund to its implmentation and monitoring, the healthcart status of our people would come near enough to the ideal of health for dl by fie yar 2000, F e d d Ministry of Health; Tbe National Health Policy and Strategy 'to Achieve Health for all Nigerians. Lagos. 1988. Ityavyar, D.A. (1978) The State and Health Semias in N@&. Mr.8 S p m m VoL 3. Owumi, B.E, (1989) Physician Patient Relationship iu an Alternative Healthcare System h a n g the Okpc People of Bendel State. An Unpubbhed Ph.D. Thesis submitted to the university of Ibadaa. Oyeneye, O.Y. (I9 85) Mobilizimg indigenous resources.f or Primary Healthcare in Nigerk A note .ont he place of traditional medicine. Smid&wm wad MedkhcVol. 20 Number Ont, Payne (1 984) Introductory address for trainers dTraditiopal Birth Atten- dantrhelditRoydBedHotel,Ikeja,3rd-51hOEtobcr. , Rifkin\ S,B. &Walt GiH (1986) Why Health improves: DefSSing the &sues wncernmg comprehensive Primary Healthcare and selective primary health@. Sm-alS cbm and McdicreVol. 23 No. 6. Tch-wal Hu (198 1) Issue of healthcan fmacing in the Peoples Rqmblic of China. Sola*al&iwp and M&&eVol. 15c. . Twumasi, PA,( 1988) Traditional medicine and prospects for M d i t y Change in Africa, R P S t2xiwionalPapr Vol. 1 Number 1 United Nations Regional Institute for Population Studim. WORLD HEALTH ORGANSATION (WHO) Report of the Inma- tional Confcrtnce on Primary Healthcafe Alma-Ata USSR 612 September, 1978. UNIVERSITY OF IBADAN LIBRARY - - -- Culture, Man, and Utilization Pattern of Primary Health Care (PHC) and its - Implications For Developing Suciet ies Adewde Oke, Department of Sociology University of Ibadan ~badb. IIie primary objective of this paper is .to highlight the' intem&tionship between culture, man and utilizsition of the PHC facilities in developing societies. The paper was to be add-, to the' developing d e t h wherever they exist, this is rather a very wide 'skope, in order to keep the discussion f d and manageable, I h p e deliberately decided to concentrate on Nigerian society and d y h eavily on Nigeria. makriak I assume that participants in this workshop are alr#dy famitiar with the concepts of "culture" and "man", bu t for 'the purpose of this paper, let us re-examine briefly the two. e shall start with thc idea of man by asking what exactly is man7 The anthropologist is not totally cun-ed with the 4 6 o n , most of the answers wilI come from the philosopher and the social dentist interested in studyig the peculiarly human aspects of human behaviour. ' On the other hand, we cannot completely ignore the, qet ion everi ia some of its larger aspects. The evolutionmy swess of human line has been assured, at least in. the past by a particdar set of behadod chafacteristk that constitute man's capacity for culture. Without cull ture, he is conppletely a helpless ckaturc (Bleibtm, et al 1971). It is this point that must he kept in mind h an-attempt' to i d e r - stand the basic n'ature of human King. We urn simply say that man is a cultural.b eing. What 'is edible and what is not? Which mhds are 61 UNIVERSITY OF IBADAN LIBRARY dangerous and under what circumstaces? Which animals can men hunt and by what means?. Where can one get water when the familiar sow is dry? Bleibtreu, et a1 (Ibid). Unlike other animals, answers to there questions are not provided by 'instinct'. As individuals, men discovered important pieces of infor- mation either by accident or by trial and error. These facts enter into the tradition of the group to which the discoveries belonged, Verbal transmission to other members of the gro.up made ii unnecessary for vital bits of information to be learned anew each time their use could be of benefit. In sum, culture is a most important factor that separates man frob other animals patticularry the primates. Culture in this sense ericom- passes language, means of making a living, arrangement of family life, the focus of loyalties and ways of pemiving the world, h t h the physi- caI world and the world beyond. (Oke, 1987). Furthermore, culture puts a control on man's drive it influences its eating habits, hours of sleep, display of motion and sexual -be- haviour. It provides for reproduction, care of new family members and pattern of child-rearing Qke (ibid.). Although there is what can & regarded, as .human culture, that is ce@n basic features which ourl species, the homosapiens share together, each burn-an group h,as its own unique culture, its distinctive way of life or design for living which enables the individuals in the social group to adjust to the total set- ting. Human behaviour therefore is a produet of ,his culture ' a d -th * is no way we can separate him from his.culture. Human cdtuie, among other features, is dynamic, that is, -it is always chadgiiig. ere are several ways in whikh these changes.6ccur (Beals, 197l,'Oke, 1987). Thae can be surnmarised as foflows: 13 m n ne w items am,a dded or old items improved by invention; 2) When nj&e it& +reb orrowed from other societies; 3) When culture items unsuited to -the environ- ment are abandoned or replaced by better oues and; 4) Whm ikxb are lost because of faiiure to transmit them from one generatiori to the next. It is uow apparent that a given society's culture is bound to change - 1k over a period of time, modern scholars have recognized thip' fact, it is ' m also apparent that contemporary medicine is a p&t or human Cutturd revolution (Hahn and Kleinman, 1983, Oke, 19921, this paper explores this premise in some 'details. UNIVERSITY OF IBADAN LIBRARY SocioculturdC omponents ofPMC Today, it is wide!y accepted by various workers ia the medical and social science; that all communicable and infections diseases oc- casioned by faulty diet, clothing or housing are dependent upon sociocultural factors, even some organic diseasw have at least indirect cyltupal origin. In this sense, ii could be supated that man's physiological state is largely conditioned by sociocultural phenomena. By extension,. it can also be suggested that u-tion of medical facilities in this case, the PHC, is conditioned by certain.s bciocdhrral background factors whicd predispose the individual toward accepting the &pproach of profes- sional medicine and hence increase or demease the po&bWityo f utitii- tion (Suchman, 1972). The fundamental postulate is a familiar one, that is, khaviour is constrained by the expectations and directi4es of the qocial groups which bear significance for the individual, ~ u c b a n(ib. i d:) o b e e s : Medically relevant behaviour rather than being an exception, is for many important reasons, a type of behaviour on which the constraining mould of society rests havily. Illnw is a frequently recurring phenomenon, which genefates fun- damental concern and anxieties and which intimately invol- ves many other people besides the sick individual. As a consequence, significanx group norms and mores have evolved which sdoagly influence individual and behaviour in the health area. Perhaps, the most important variable in the area of sociocultural characteristics is socioemnornic status. It has h e n one of the most im- portant sources of social and medical diiremtiatioa especially in the advance societies. Aimost all studh have shown that upper and lower wcid classes, however defled, have diffaent values and norms and vary in both their health status and utilization of health facilities (Rosenstock, 1966, Oke, 1992; Foster, 1969; Otite, - 1987 etc); The studii have revealed that modern health care s e d & used, for example, mostly by younger or middlc- aged people, by femala, by those who axe datively better educated md having higher incorn, Other scholars ' (Worn, 1958; Wceks, 1958; stockle eta11963; da, 1966, me, 1977 etc) have also revealed an association of socidtural UNIVERSITY OF IBADAN LIBRARY fmrs with the use of modem medical facilities. These factors id& cultural and situational background, ~~ past experitam and d~~ in persundity. Most of these findhgs are relevant to the situation in Nilria with regards to the ut ikthn of PHC Mh. Nonetheless, a most important feature which most studies have not adequately addressed or addressed at all is the f&r of rival urban differences, a cultural variable although not quite unique to our society, but with a very pronounced impact; The guiding prjinciplc here is that settlemmt system is a sociocultural d t y . X shall,d evote the zest of this paper to this variable. Pattern of Utilization of PHC Faditia In Nigeria A most striking feature of the PHC delivery system in Nigeria is the d - u r b a n difkences. ¢ studies and f ~ l dob txmatim (Xp, Oke, Matanmi, 1987; Oke, Yoder, Oke Oladepo, Oyejide, 1991 etc) have consisteatly nvealed that facilities and pcrsonnd are heavily con- antrated in the urban cehtres even though fhe' bulk of Nlgcrir popula- tion (80%) live in the rural weas. This disparity in the d&i*butiotl of the facilities and resultant underutilization &n pardy be attdbukd to inappropriate health can organization. Let us talc on thk,brWy. Accessibility And Availability of Facilitia . . It is obvious that the available facilities for delivery of the PHC are not @equate buf the situation. is worsened: by mal- distribution, the ruraI population is at theloosing side,thiis fat is vividly expressed by Osuntokun (1 973); . :. three fifths of the medical personnel are concenkted in 3 or 4 major largest cities in the country ... have more doc- tors than- the rest of the country pdt together. Many Nigerians themfore from cradle to c o f i wo,uld nevk have the benefit of moilern medihc. & . Today, the position has slightly changed, the introduction of the mobile clinic hrts brought hdth care services nearer to the m d dwders:But most of the f d t i m arc still located in the 'urban centm usually in tbebhstatea nd local Govmknt.h eadqbarters. The question arks, how much distance is a ruFaI prepad to travel in W e r .to 1- thee mticsl Certaialy, he is not willing to travel a great &tan=. Field obsenra- 64 UNIVERSITY OF IBADAN LIBRARY tions reveal that many of the villagers who hpve;nat used health f-tia have not done so because of great d i t y o f travelling to the centre where thc facility is located. Some of the difficulties en- countered include poor transportation @ad roads) to urban catrcs where faditia are mostly located, Some of the villagers amnot men aord the twsportatioa, cost. Some of them arc wnfron&d with the - problem of accommodation in the city if they have to stay overnight. 'Ibis bappms quite often since most of the public health clinics (cx- ocpt cases of emergency) are closed to the pubIic too early. It is un- lilrely for them rural people to arrive in the city (from their v i lhg~) early enough to be ~ e a t e dth e same day, as such, those who do not have relatives in the city with whom they can stay overnight are very rdqctmt-t o come to the city for health care. The problem of accessibility can Be considered f e e t i n terms of soda1 distance between medicaIhea1tb workers and the rural con- sume~.T be ma1 people are generally p o ~ r?.% ey are poorly educated and lack the ability to ded with or manipulate the health system to their advantage. Neither the health workers nor the rural consumers actuallysw ant- to identify with each other, both are conscious d tb& sodal status and may unconsciously try to avoid each other. The vif Iager often express a lack of trust in the health w o r h and the health worker himself dftcn complains. of the r m l consumer's ig- norance and superstitions. The villagers are too sensitive about their inferior social position and such, they wl l come to the clinic as a last resort. Man Power Distribution - Nigeria is faced with severe shortage of aIl categories of health man- power but the probIem is worsened by mal-deployment of availabIe trained personnel. The problem is further complicated by the fact that there is scarcity of health-professionals who personally identify with rural communities and who have strong cornmimeats $0 its health needs. Many of the health workers are reluctant to serve in rural sueas where they an most needed. Most of rZlese were recruited (as students) from urban areas, thek background and value are general@ middle class and urban oriented. . They .&e being trained in Euro-hencan .therapeutic tradition and ire Western or urban oriented. They are not therefore often prepared to accommodate or tolerate rural and poor people. As a result, mi- UNIVERSITY OF IBADAN LIBRARY profmsio~~ashr e often found in rural Nieria. Serious efforts should b~ made to seasitkc students in our various hdth education program- m a and medical schools to health needs of the rural people so as to cater for a large population of the country. Wority Given to Curative Smiw In the past, there was too much concqntration on curative d o e s throughout the country. In rural areas, the concentmtion was almost entirely on curative services, Wealth centres and dkpnsary services were often provided whereas, hospitals and s p e c d i d semias arc lo- atbd in urban areas. Today, the position has improved, th= is more m3phar6s on preventive health care. The position of PHC both in rural and urban areas is now receiving government and public at- tention. It is obvious, however, that the concepts of d i s w , illness and nhabilitation are not the same among the poor and rural iUkratc as among the middle dass urban people. The rural dwellers, &nerdy are "crisis orientad", meatling that many of them do not seek medid help until incapacitated or until a symptom appears. It is further obcmcd that the ruralist perceive the body sts having a S i t e d span of utility to .be enjoyed in youth, and then with age to be suffered and a d d , Middle class urban dweller on the other hand, genedy think of the body as a "machine" to k .prmrved and kept in perfect running order. These fatalistic attitudes of ihe rural dweller are often explained in .term of their inadequate knowledge of the Principle of infectious and eommunicabIe diseases. This is usually an excuse for the relative con- ccntratidn of treatment services in rural arqs with the argument that the rural dweller wiI1 never utilize a preventivddetection service. Whether the "culture qf poverty" (assuming it actually exists) k ap- plicable to Nigerian situation awaits further research. It is obvious, however, that various health authorities in the country seem to have bought the idea and thw meager mias offered to rural-N igeria art mostly centred on treatment. Conclusion I have suggested that human behavio'ur is a manifestation or his cul- ture, man is a cultural beiig, his bohaviour is culturally conditioned. UNIVERSITY OF IBADAN LIBRARY Without culture, he k not different from other aaimals. It is thenfon imperative for health workers who must deal the dynamics m- sa who must deal with community hedth programmes to understand olnd appreciate the locd culture or subculture for ah effective h d t b programme. I have further suggested that settlement.system is a cultmi reality, hence utilization pattern.i s explained in .t= of rural-urban ditTem- as, the manner in which health care is organized is actually the most important factor which affects the proper utilization of fzdities, where availability of facditi~servicesd oes not guarantee adequate use without health professionals who personally,identify with the (ma9 communities. The priority given to curative semim is a deterrent to proper utiliza- tion, The PHC scheme is an attwnpt to offer balance health semi- at the grass-root, but the services have not mh'd most ncral areas in tht c~untry.W hile efforts. to improve curative service should not be abandoned, the rural people should be exposed also to prevent tive/de.tection serLi& by means of h d t h education programhes, provision of adequate facilitits and health and medical practitioners who are socialIy accessible. ' ' &mally, the quality of medicd and health wgrkers in rural com- munities needs much impr,ovemcnts. ?he poor image of the rural &- cal s y s b can beattributed in part to hadequate number 'and-quality of d i d pr actitioners. While we reslize that M o p i n g societies in- cluding oUr own society, are shortofhealth manpow& it is ohemd. - that the problem h worsened by 'concentrating the very few well q d f s s once' in urban slreas and thereby leaving. a 1 a . r .~pr oportion of the populatiun uncwted for. . . < . Beals, R.L* and Hoijer H. (1971) An latroductim t iA n ~ o ~ ~ g v - New York, Mad1m~Publishers. ,. Bleibtreu, Hemam et a1 (1971) Z-?&An~rtduO pIegy T&y Dd Mar, Caiifornia. 'Communic~tiohRs d d m achine lac.;- Foster, G.M. (1969) A p p l i e d ~ ~ p o I o o gByos ton. Little Brown and *WY. Hahn, R. and ~l&amanA, .M. (1983) "Biomedicine as a culhlral system". . . In Sm'al H . t o y Mt&e L?&rn& S&m ed. ' 67 ' UNIVERSITY OF IBADAN LIBRARY M. ~iabli-~almarin(iIn. -1 . I 1 Iyun, B.F; 0kd E.A. and ata and 0.0. (1987). "kbysiad B a s d h Survey %r the Ibadan Low Cost Market ~ & e dH ealth care Delivery". Ibadan. Fertility Research Unit, ~oileged Medickt University of Ibadan , Ob, E,A. (1977) "Sociomdical Investigation 'of Sickle CeU Anenah keening and Coping". Lexington University of Kentucky, (Un- pubfished Ph.D Dissertation). Oka E . k (1987) An tlotducrion to SO& Anrbro&ology. London. Marmjllan International College Edition, Oke, A. (1992) "Medicine and tbe Environment". P a p p regentad at A Symfisium on Nigerian Culture and thebEnvirom@at. me N@ M d So&@, Ibetdan Branch. Ibadan. The Institute of African Studies, University of Ibadan.. ,OhI EA. and 'Ybder P.S, (1989) "Knowledge and Practicezs Related to Diarrhoea and U d Rehydration in Mger St& Nigeria." 3d M h Co nfkmceo n D i w h d D- (AlcrmDG) P r d - hw. 118.21. . . Ob KA;,: Oladepo, 0, and - Oyejide, C.O. (i 991). '''Community PU- ticipation in a Longitudinal Utwervatic1nal Study. d 'Dhrhoeal Discas6 .Risk Facton: Pemp6on. add Coping,~ ~. W i t ~ / o n m d d A r & a c y 1 I q 8 ;~~0 121.187-195.,:::, , . Oni, E.A. Schumann, D.A. and Oke E.AL(1991) 'piamhaal D h s c Morbidity, Risk Factors and Tre~tmebti n &tow~ ~&oecod6hic Area of florin, Kwara Statc, Ngaia', I. D.i.ar rfioeal b&..R s Sep. . 9, f3). I- . . qtite, Onigir (1987) 'Impact of loterntiin'o f,,Behaviprd~ cieaees in the Mueation of H d t h Care Prof65Sioda". h Sn: Med Vol. 25 N0,6, 8 . ' ' . L , 0 , ~sunkkun,B .O. (1972). "A*: ,lntcgwted~ ~ ~ r b tao .c%hH ealtCha rc -veryw. h mbritb ih Nation& Ed. 0.0. : Mnkugbe et al. Ibadan. ?'he Caxton'Pr& (Wid Africa) LM. ,-R I.M. (1966) "why ~ e p p ~usce ~ d t Wh ' ' Ha- M m W F und Q ~ d ' ~y- 3 i 9 412-7 .' . . , . UNIVERSITY O IBADAN LIBRARY StoeJde, J.D. (1963) "On Ooing'tg the Doctor. The contribution of the Patient to the -Decision to seek medical Aid: A Selective Review'' X d m k D -.''E~ E. Gartly Joko. New York. The Free h. Weeks, H. A. (1958) "Apathy of Familks Toward Medical &re: An Exploratory Study" Ia Patients, Phpi'ciiin and flliess &fS (1958 +adition) Wolff, H.C. (1958) "Disease and the patterns of Behaviour." In .P19&&, p b * ~ rrad ah& flbid), Yoder, E.S. and Oke, A. (1989) "~thnomedifalR' esearch for Forma- tive Purposes: An Example from ~igeria."Phhdelphia. Annen- . k g S chool of Commuailcrrtions, University of P e n n s y l d Zoaa, I.#. (1966) "Cullture ma b'ympom An Analysis of Patients +ti* Complaints." Am. Sec. Rev. 3'1:diS-630. UNIVERSITY OF IBADAN LIBRARY ~s~chod~namofi PcsH C consumation in~igeria S.K. Balogun, D e m e n t of Psychology University of Ibadan Ibadan, Nigeria. Introduction . During q e r ust worksliop organized by the cw ordiiator for the $ m e people, I happened to be one of the sesgions chairman. Here, I asked the question as to why psychologists were not brought into the scene. This is .because psychologists and psychology are meant to study ma- lyse, interpret, predict and control human behaviour i.e. at 'fpe in- dividual level. hychology is interested in understanding the t o t w of human behaviow, like perception, attitude, interpersonat attrapion, cognition, cuf tura1 influence etc. Given this background, and the claim that PHC comat ion /is low in Nigeria (Jegede, 1992), one then begins to wonder - why tpe low response to PHC strategies despite the heavy investment by M, agen- cie.s and organizations concerned. Hence the need to present a psycholo&al solution to the problem(s) at hand i.e. tow levd of PHC consumation. ' 9 Theoretical Background toHBdthCuncept~lization Psychology is very in-ed ia collc~ptwktiond tenns and/or hsw .ofe on-. My attempt at addmdng the b e at hand wiU fol- ,low this pattern as well. l%eW HO d&ma h d t h as "a state of corn- pbte physical, mental and sociai ,we1b eing .and pot d y the a h c e of discass *d hhnity", but I shan in Jegede'~( 1992) conceh-that this d&dtjo~i~s limited,i n scope if we' fail t~~incorporp~styec hological dimension*H e posited that someone may have access to good medical UNIVERSITY OF IBADAN LIBRARY services, .good housing etc. but can ati l l be pych010$dy sick, u a result of hi poverty level (not only in eeonom?c twmJ do*). The psych ologieal elements involved here are attitude, perception, b haviour, interpersonal' relationship, culture, social support, to men- tion just a few. Perhaps, Ivan Illich's (1976) defmition is more applicable here, and it states inter alia: "Health designates a process of adap~ti6nI.t is not the'result of instinct, but of an autonomous yet culhvally shaped m c - tion tb so6aUy created reality. It designates the abili@ to adirpt to danging ea vkommts, to growing up aad agwjg, to health whm damaged, to suflwhgs and b the peadrrl mpvbation ofdsth. Health wnb- the future as well, and therefore includes anguish and the inner resource3 t'o live with it. .." (emphqis mine). All the emphasised concerns link up with psychological dynamics mentioned earlier. In other words, people strive to achieve a psychologid "homeostasm?.9 Le. an equilibrium, a balance beaween self and the environment (both in- ternal and external). bitlance is captured by the 'dm- below which is associated with health. Leisure -I - Tfichdividud Bnyiroxunent Genes y& or dism~d f- .e.g Infection 4 -jury m r Personality Deknera tion Smoking Over taking ;AEoohdisln C Neighburhood Housing Poverty Retireent Culture Muation Boredom Fig. 1.1. Equilibria associated $ith 'heallh' Source: Pritchard (1981) - UNIVERSITY OF IBADAN LIBRARY Health care according to Pritchard (1981) is a response to this tqui- librium and primary health are is the nearest contact W w c m the in- dividual and the health care semi&. According to him, primmy health czm should involve the following: - health maintenance - illness prevention - diagnosis and treatment - rehabilitation - Research and data gathe~g - Inhimation di'smination andm.a. ss educafrbn -; a - . (emphasis mine). If we are to adopt these objectives then PHC must b made wca- sBe, acceptable, identify nwds and maximum and justifiable use of manpower and other resources. Cueurnation of PHC in Nigeria Smce the. in~ptiono f the present military administration in Nigeria m 1985, a huge sum of money stnd efforts have been coinrmhtted and sW1 being comrriitted to PHC in the health sector. This is in form of rchabiiitation bf general hospitals (Oyeneye, 1992), training of health off-, purchase of essential drugs and so on. However, depite. this conmikent, there.& low cdnsumation in Nigeria (Agbodahor, 199% Jegede, 1992). For exa'mple, Jegede (1992) claimed that since 1977 when I EPI wps formaIly launched in Nigeria, coverage had been low, (100,'o)). This he attributed to poor logistics. Not only this, improper un- derstanding of people's perception of health related issues or behaviour can &o be the probIem. For example, it is how people perceive a prob- Iem that wilI inform what attitude to adopt or not as regard solving the "problem". *~ritchard(1 981) indicated that many health problem which individuals face are a reflection of their attitude to Iife and society, as we11 as their level of motivation at achieving a balance be- tween these and their health stitus. Another problem in PHC consuma tion is level of poverty in Nigeria Generally speaking Nigeria is poor not only in monetary terms, but in all other spheres of human endeavour. A ps~chologicallya bused mind will not be motivated to seeking all other supposedly curable meuw to UNIVERSITY OF IBADAN LIBRARY i I 1 ' I ! its health problem. Motivation aerives from depfivation and when 1 there is deprivation, there will tk need for seeking out means d res- toring balance ,@omeostasis) whi~his brought about by the depriva- tion. However, there must be facflitating factors put in proper pkce(s) for the individiial to attempt :@e ,motivated) to e k ' fredre&"' Such fatating factors include among others, con- by the appropriate authority (society & governqent agents), a d b ' i i t y of the health ameliorating facilities '(e.g. distance, cheap drugs, education) and ac- wptability by the people. Another problem identxed by Oyeneye (1992) is the poor atiitple of health.p rofessionaIs, not only in their relationship towards the people ' in need but also, in their assumptions that fhey know the need priorities ' and heaIth' problems - of the community. For example, t h y blame, people for their poor health and formulate policies and "solutions" to their without adequate input or p u t k i p a h of those people. This is psjchologically threatening in 'that them b the fear of an outsider usurping' their "righ b"; customs, beliefs and vdw. They therefore respond yith-what is psychologically known as , "rectance". This is the tendency ' to repel a th'reaf or tad r e f -b abide by a simple request. Atlother example concerning the attitude of health PK,f&n& can be drawn from a research by Balogun (1993) on V W Va ginal Fistula 0 patients. Many h d t h mistaqts were reportedly "W" by the authority at the VVF centre in .Ariua, Akwsr-Ibom State for the "aggressive" and "non- cooperative." behaviom over a period of time. If you want to encourage an indiyidual to "pgtronise your goods" you don't 'invite himher with a from on your face or a big stick in y o u hand for fear of king attacked. Such is the c a a f VYF pathta and health attendants. Finally, communication strategies being adoped by the agents con- cerned, though eKwtive in some areas, still need 8h improvement fof . consurnation of PHC to be totally effective. Psychology .of anmtmk- tion mndems itself with the some, the target, 'the c h d a nd the. prevai!iiig situation. The .source of a message e q d d l y iq the n d - community is very important e.g. the cmtqunity'head, opinion age-group representatives, and any simmt others withip then'-- munity. The same goes for the conten& of the message in terms of appeals, emotions, and the*d esired attitude change. All these 'fllust be channelled through ct proper medium like radio, jingles, dram& sketches, puppet sho wb, etc. 'Furthermore the intended target's . . UNIVERSITY OF IB DAN LIBRARY (audience) ~ I i a crh a mcpristics must also be taken into considera- tion e.g; age, sex, religion, culture, literacy level etc. Finally, the prevailing situation in the community (society or ~ u n t r y )at the time of message dissemhation is .equally important if people were to listen and eventually be persuaded to adopt the intended naessage,. All these strategies, if at &I they are being adopted, are not presently coordinated properly. Hence; the low consumation level becanse they still need to be convinced as to why their attituddvdue or customs should be jettisoned for a foreign one. This points to a fact that a lot of research and documentation need to be done. Suggtstionsf or improvement It is an established fact that psychology rely very much'on facts and f i and a great deal of pain is taken in gathering -thcsc facts. A "venture" that .is expected to change the total value orientation, cd- twal practices, attitudes, belief system and the s o d s f r u m of an individual or group of individuals need,t s undezstahd .the individual or group inside out, and this can only be best achieved *throughr esearch, data gathering and proper documentation. Thest can always serve zw points of reference to check the "problth", how to solve it and progress made so far. As pointed out by Hbwie (1979), it is better for health practitioners to question what they are doing (which is, what we are doing already) and this is the starting p,oigt. Acmrding.to Pritchd (198 1) research can be done in three. are&. (a) Clinical i.e. adding to the s u m of knowledge about the. natural history, the diagnosis and treaiment of i~ln&:~rscticc( especially in the-concernedc ommunity). . . . (b) epidemiological i.e. studies of larger popdations. (c) oprational i.e.' studying how health care is provided and how ef- fective it is. Another reIated solution to research undertaking is in treatment of specific problems identified during the research. One of such is the at- titude qf the peopIe towards .the "innovation" being introduced. A proper analysis of the attitude structure via its contents d . v a l u e weights will help in modirying the approach+ind ommunication strategy and effective utilization of the aspect of.PHC that i s being introduced. O.ne method of at~ tudec hange is that of self-persuasion (Bilogun, UNIVERSITY OF IBADAN LIBRARY 1990, Ugwuegbu, 1982). Here the individual is pnsented with att@ing but subtle inromation that is isif convincing about the d ~ i r e dat titude object. The product d attitude structure analysis is a proper under- standing of the "psyc~ol~goyf" th e people which will help in the corn- m h t i o n strategies to be adopted, On communication strategy, there is an encouragement if what is being done by BCO3, Radio o-Y-(T&~ FRCN is anything to go by. mere is effective utiIization,o f Id idoh, message.c ontents, theatrics, language etc. in disseminw information to the people abut PHC .s- Another solution is in personnel training and re-training through in- duction coum, seminars, workshops and symposi-a especidy- on in- krpcrsond relations and interpersonal communication. A Yomh adage says that "if you want to catch a monkey, then you must behave lilce one". This further suggests that you must learn the monkey life styles and other related khaviours so as to properly fit into that cul- ture. Maybe, this is why Oyeneye (1992) sugge&d Participatory Rural Appraisal Approach (PRAA) towards improving the consumation of PHC. As a health praatitioner, you are not only expected to trea ph-y or physiologically but to treat psychologically by &owing concern, feelings, understanding and care in the probltnh of tbe people in the community of interest. These wil1 dicit a mutual rapport bt-n you and the patients in order to get what must be done, done cffec- W y It is one t b i g to crave for treatment, it is another thing for treat- ment to. be available if and when it is needed. A "good' health programme is good to the extent to which it is made cheap in terrps ,of cost and accessibility. A negative occurrence could k psychologi- cirtly frustrating. It is like having a goal and placing blockades or obstacies in someone's path in order to get to the koal. Added to the above suggestion is to put in place, other supporting fadties such as food, shelter. and education. .Wi,thout these,, the in- dividual may not be motivated to seek out' the health facilities avail- able In fact he will re@ himself to what is known in psychology as "cd helplessness" ie. he has come to r d j z c that there islno point &y& to "sq~'fr'om his pr~blem,i f he is sure of getting back at it since there' is no supporting facilities"(such as the onw mentioned) to help in consolidating on whatever gain he must have achieved in the h a place, UNIVERSITY OF IBADAN LIBRARY Some of the identified problems and suggested .solutions might sound as if they are not new, but if a good'md effective PHC programme is the con&m of .the mple, then the importance Of these things would be naiizesCA fter all pychblogy is int&tcd in knowing the totality of an hdxridual's behaviour. Why would a bebaviour be enacted? What woulp be responsible for such a behaviod What things are possibly sustaXmg the behaviour? Can it be changed or eliminated? etc. As suggested earlier, (Bdoguo, 1992, a, b) o'nly through nsearch and data gathering can we understand the people better. It is ody mearch that can make us underhnd the needs and priorities of individuals or grouI of hdividuals and.m n g e them.i n orde'r of impdrtmct. There- afte ,we can now talk of meeting these needs accordingly. I, References "I . . .- Agbonlahor F.I. (1992). PHC: 'A beau:tifd concept fraught with con- straint s: The Nigerian Experience; Paper Preseoted at -&N atim- a1 Training- Workshop Fox P r b a q . H, . d t h 'C ar.r :, 0~~ raad . Cobrdinators. Ibadan. 5-9 Octokj. ... . . . Balogun, S.K. (1990). Towards heal'&$ Family Planning Attitude: A sell persuasion Approach. lndian ~/oownaolf B..e - h,a viow; Vol. 14(3), 34-40. . Balogun, S.K. (1.9~2~~)n derstandinr~u ral psychology: A &de to prioritising Community welfare needs. A Paper prrscoted at t&e , workshdji for L u d Government Commudtiw D e d o p m t Social WdLm Oflms. Ibadan .J ane 29-3rd July. . BaIop, S. K. (19 9 ~P~s~)ch ology:U nderstanding hwnan behaviour. A paper p m fed at the Workshop on R o k and FUIIC~o~f O. RS , the Whp in ihe Parlment. badan. 8-10 sept. Baldgun, S.K. (1953) A documentation on the psycho-social well- being of VVF patients Nigeria. (A monograph). Howie, J.R.G. (1979). Research in general pmcti~eC. rown ~ e Lohn- don. UNIVERSITY OF IBADAN LIBRARY Illich; I. ( 1976). &its to medkine. M&al nem- of &hee xpro*- tion of health. Boyars: London. Jegede, A.S. (1992). The use of EPl in Akinyele LG: An investigation of socio-cult uraI .factors affecting the use of heaI th faciIities, Om going PhD. proposnl). Oyeneye, O.Y.( 1992). Strategies for community participation in PHC The participatory rural appraisal approach. Paper pres~nreda t tbe National Trahrjlg Workdop for PHC Off= and Coordinators Ibadan, 5r9 October. Pritchard P. (19 8 1). Mmud of Primary ~ e d &e :I& na tm q d o~gani~tbOnx,f ord: University Press. Ugwuegbu, D.C.E. (I 982). EKectiveness of sel f-pefiuasion in producing kalthy attitude towards poIygny. In I, Gross, J. Downing-and A. d'tteurle (eds.), Sex Role, Attitudes and CYtural Clbmgml Bos- tbn: Reidel pp. 151-155. I :I . * UNIVERSITY OF IBADAN LIBRARY Problems and Solutions to PHCExecutioninNigeria C.A. Ola University ~ e athl Services University of Ibadan Ibadan, Problems and Solutions to Primary Health Care (PHC) Execution in Nigeria What ~S'PHaCll about? Primary Health Care is essential health care based on practical, scien- . tXcally sound and socially acceptable methods and technology m'ade 1 universally accessible LO individuals and families in the communityI, through their full participation and at a cost that the community and 1 country can afford to maintain at every stage of their development in the spirit or sdr-reliance and ~elf~determination. It brms an integral part both of the country's health system of which it is the central function and main focus and of the overall social ,a nd -kconomic development of the community. It is the fust Ievel of contact of individuals, the fhmly and the community ~ t thhe N ational Health system bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health : care process, The primary health care approach is essential to achieving an ac- I ceptable level of health throughout the world in the foreseeable future as an integral part or social development i n the spirit of social justice and equality. Thus the goal or health for all by the year 2000 would be attained. UNIVERSITY OF IBADAN LIBRARY The components of PWC should ideally be (1) education concerning prevaihg hedth problems and the methods of diagnosing, preventing and q h g t hem; (2) promotion of food supply and proper nutrition, ad.adequatc supply of safe water, and b d c mitation; (3) maternal and child health cam including family piaxling; im- munization against the mjor infectious-d iseases; prevention and contro1 of Iocwlly endemic. diseases; appropriate treatment of corn- m b n diseases and injuries; promotion of mentaI hedth anda provision of essentid drugs. Problemsin the Execution of the Scheme PHC is the .hub of the heilth system. Around it are arranged the other levels of the system whose actions converge on primary health care on a continuing basis. I (a)Pfknning PIanning fur PHC has to be crtrried out in communities as well as at intermediate and central levels. The Ministry of Health or i t s equivalent's responsible for formulating National health policy, ipclud- ing primary health care policy and for piornoting its adoption by & government strategies have, to be devised to translate policies into reality. Training of-p rwnnel and management .at all'levek is indispen-. sable to the planning process. .Since the planning of primary bedtb re Gvolves political, swial and economic factors, multi-disciplinary plan- ning teams are needed, especially.a t the central .level, including among others pqople with a knowledge of konomics, spcjology, poGtM scimce, and other social scieam. (5) Cq vwageandAc cessibdj1y PHC aims at providing the whole population with esseniial health care. Po~ulationc overage has orten been expressed in terms of a Numerical Ratio bctwecn scrviccs for providing hcalth~carca nd Ihc pupula- tian to be served. For example, the number of hospital beds per unit of population, the' number or doctors and nurses per unit population or the number of people far whom a health centmhas been established. UNIVE SITY OF IBADAN LIBRARY It is necessary to relate the specific components of health care kiq provided to those who require them. For example, to relate the provision of child c m tb the total number of children in the com- munity, female as' well as male, in order to make sure that such care is in fact available to a11 children. Accessibilhy implies the continuing and organised supply of care that geographically, financially, culturaIIy and technologically areee within easy reach of the ' whole community. Geogmphid accessibility means that the distances Ravel h e a nd means of transportation are acceptable td the people. Financial 'accessibility means that whatever the methods of payment used, the services can be afforded by the com- munity and country. . GIturd amssibiXi& means that the technical and managerial zhethod; used are in keeping with the cultural patterns of cmmdty. F.arrcid ami6iJity means that m e right md of care is avaitabh 'on a cuntinuing basis to those who need %, whenever they need it. (c)Human Resources People are th;: rnost'irnportmt resource of any country, but all and too often @is resource is not tap@, PHC however-has to make use of sill available resources and therefore has to m o b i i the human potential of the eatire community. This is pbsdbki: on condition that individuals and folmilies amp? w e r m ponsib'itit for. their health. Inadequate manpow& vis a vis tiaiod commuhity health workers pose enormous problem6hence their traiahg'and ktraihg should be b a d on a clear clanition of the problems involved, the tasks :to 'be per- formed and the methods;-techniques and eq~p-men.tst q . be usld. ' . (d) l;o&tics of Supply Ihe logistics of supply include planning' and budgeting for the sup- plies required, procurement or manufactare, stofage, w t i o n a nd coitrol supplies of the right qualit); and quantity have to b e ' d ~ ~ to primary health care facilities at the right time td make it possible to provide semices on a conthuing basis. Physical fadities reauired may be simple but must be clean, they ' 80 UNIVERSITY OF IBADAN LIBRARY should have spacious waiting areas, and clean toilets. (@?udgcthg . Budgeting has to ensure the preferential allocation of resources to PHC starting from communities and progressing through @e other levels. It consists basically of the allocation of cornmunit& and to sup- porting sewices of IiianciaI ceilings which are to be used for.t he par- ticular purposes defined in the PHC programme. Much time and effort Q: can be saved by the allocation of resources. - Finance for health care may come from government bation or from a social security system with contribution from individuals or employers or b o ~or. i t may come from philantmphic 8ourcw. It isi unwise far developing countries to rely solely on methods of fmanchg- health care that are cumnt in more dlluclit counuies. ~ v & yc outlt~~ has to evolve its own methods based on its own chcmqtandes and judgtiment, analysing the =@en& of others in the light of its own pol&tical, social and economic context. Extend haming may take'the ' form' of loans and grants from bilateral and multilateral source+ and countries must weigh .the advantages and disadvantap of accepting hancial support from these sources. Solutions to problems in e mtio n of the heerne Firm Nationalne ommit@ent to &nary health c& is vital but it must be clear what this commitment entab. it has been shown that primary health care has a great variety of imfilicationa and consequent- ly thai go far beyond tekhhnical considerations. National s t r a w .,& therefore required that take intd qcoont all political, sqcial and economic as weh as technical fachrs that help over&& obs& d my nature. One of the fundamental principles of primary health care tht p&- ticiption of the community at all stages. For communith to be htd- ligibly ipvolved,. they need to have easy access to the' right kind d information concerning their health situation and how they t h d m can help to improve it. - UNIVERSITY OF IBADAN LIBRARY Newspapers, Magazines, Radio, Television, Films, Plays, Posters, Community Notice Boards and any other means available can be used to secure people's enthusiasm and their willingness to get primary health care going in the right direction. hgslation will be required to. facilitate the development of primary health care and implementation of its strategy. Primary health care involves a major re-thinking of w8ys of delivery health tare. To make the community the focal point of the whole health sysim, to look for the relevant technology that countries and communities can accept and afford and to aim at the universal acaq- sibiility of health care is in many ways revolutionary, Primsuy health care will be more acceptable and easier to Implement fur all countries if they realise .that others are successfully using this approach. .For this reason, international political, moral, technical and .financial support 'are hportaht. The type of external support needed must be very care- fully identified and coordinated by the receiving country itsex The government has the nsponsibility for delining areas for which external support is needed. . , Primary health care as envisaged above, ~ r e c i d ldyu ring its evolu- tioeary phase and in devclopihg cobtries &quires consid - crable financial resources. As an expression of the international political commitment and support.'mentio,nede arlier, developed countries would do well't o increase subst%a.2h .~ :~ ~~~',@trtahnes fer of funds to the developing duntries for pwary hkalih cakiFlexibility in the use of these funds is Important so that r.e c. eiving countries can d m t e them where they are most required. Reference Primary Health Care Alma-Ata 1978. WHO, UNICEF. UNIVERSITY OF IBADAN LIBRARY PHC: A Beautiful Concept Fraught With Con- straints: the Nigerian Experience. Fetus Zgharosol Agbonlahor Department of Sociology Edo State University a p m a , me issue of whether health is a right or not-r elates to the question of whether man should be viewed as an active part$ip&t in.h is envita- mmt or whether -his action should be as b product of the h k q h y of prior and or more primitive structure Bctiqg on liim (Wallace, 1969). White the god of health planning that of eq-heslth aocess for all dtizenry epidemiological b i d e m s m t s that 6- strategies are more eflective than others. Until Jncently, most post- colonial health effort was directed at building medical, wtem and centres of excellence comparable to those obtainable in thb Edo- American world, without paying much attention to the nature of tht prevailing diseases in Africa m d -9) . This htka was, gim hpetus-b y national tlite;s apd in pruticular, M e d i d doctors whose scientific uainingand~~nkquentdenigmirvme irudebmughtrhemm~path of mnfrdnWon with Wtional heders. Over the years, it W been realfsed that aside the issue of mt, aad the fact that the illness behaviour of Africans g w be yond mere s ~ o I o @ c a l txeatment; ortfiodox medicine was simply lmot available to vast majority ofthe population ( a l a 19~75).T ~he o fficial acl~mow~ledge anento ft fiis faded to the 1978 Alma- Ata meeting to reassess .and - oft&^ declaration which viewed health as a ri@ and b r e d t hat it be made mom accessible, mordable and sociaUy relevant (Mom, 1989). The m g yth at was chosento &dualizet his was christetwd Primwry Health Crtre PHC). 1 - UNIVERSITY OF IBADAN LIBRARY In its article VI of Alma declararion, the WHO derges Primary health care 'as' essentid health care based on prac- tical, scien.tifica11y sound and socialIy acceptable methods and technslogy made universally accessible to individuals and families in the community lhrough the5 full participa- tion and at a cost that the community and country can af- ford to maintain at every stage of their deveIopment in the spirit of self-reliance and self-determination. Furthermore, it notes It is the first level of contact of individuals,'tZle f"ami1y and community with the national health system, b ~ g i n gh dth care as close as possible to where people live and work, and constitutes the first element of continuing health care - process. In the same work (Article VII, item 3) it spelt out the pri.nciples of primary health care which include:- ? 1. education concerning prevailing.h heal th -problems and the methob ' of preventipgmd. controfling them; a' i - , .. . 2. 'of food suQply and prop. er nutrition; , , : - + - L. .: - 3. an adequate sipbly p.f -sa. .r e water q d b i s i ~&#atio?; 4. maternal and child health ?are, . ir ic1, _ ' idinI g. . ;, ,f dI~ , -. ~1a~*b~ 5. immunifition -against the major- infectious diseas~;: I 6, prevention and control of locally endemic disease;as. e ': : ;-:! 7. appropriate treatment of,comrnod d h e s a n'd i n j d a ndA I . I _ . . .. . 8. provision,o ~.&~n,~:ip ae d[r u,gF, . l - , * , r : . . The present'&f(Qrt, is: an ;t;empt , ~ o , - ~ ~ + i n + i.tJh3xeR andid Programme on ~ m r n u n i z a t i ~(nE.P I) .-. aq,o ff-s4o(l.t,. of PHC' programme in Ekpoma, Edo State. Evaluq$gp is a,@taJ[eq~ of any human end.@vour as .it.n ot only shows - @a.g ap b e t w e . . ~ h ahta s been done and what. is left, but also poiits.ovt.they ay fom~d:T%%:tish e thrust .of !his study. . .. 4 - Method of Study ... . , - ' . . . -. h i , . . . . . - ..: . '. : This work is based on the analys& of E?! 'SC* .b .Ekpoma. The latter is the headquarters $ ~ s a .nw est ~ d c a~l o ~ e r m eanreta m Edo State. The study is purely exDlo~atorya nd'makes no aitemdt to test UNIVERSITY OF IBADAN LIBRARY any meaningfulis ratistical ~htimsN. onethela, it is our contention Usat studies of this nature are impo& because they depicr the phenomenon under study as it is at any particular time, set the stage for larger woks and are useful for p-g and management. The study is based on a sample of 50 women in Ekpma, drawn from a list of 250 women. The women were contacted and from the fv5,0 o f them qualikd to be interviewed. All the 50 women have been fiving in Ekpoma for at I- 6 years,. had a child in the b t 5 yean and are between 15 and 49 years of age. The nkpondents were asked a nzimber of questions in the following broad areas: social characteristics, sources of PHC/EPI information, utilhtion of EPX seqices, knowledge of vamine, causes, spread and prevention of the six dqdly d W cov ered by EPT. The analysis of the results on the ages of the interview- shows that' thp age category 26-35 years rank highest with a total of 56% of the worn- This is closely fdlowed by cohort 36-45 years .with 28%, while categories IS25 years and 46-54 years had 12% and 4'% respdvely. The examination of the wlts recorded under educational attain- ment reveab that most -women in the sample complleted primary and bad ,some sec~ndarys chool education. Thig group recorded 42% of PC sample, followed by those who completed secondary, those with HSC, OND and NCE -certificate with a total of 26%. The category of ?hose who had no schooling of any kind or had a stint in the primary school m r d e d 22%. The Ieast figure of 100/o was registered by those pho had UaiVasity d e p e and other equivalent qpdification. Tbe number of co-wives respondents.h ave'a lso formecl- part of the examined. On-the whole, the data reveal that 54% of the respon- dents have no co-wives, 36% claimed they had 1-2, 8% reported 3-4 -wives, while 2% reported 5 co-wives. Another variable considered is thebl ength of marriage 68% of tEe m p i e reported that they have been married for a period of 1-8 years, 2.294 for 9-16 years, and 10% for 17 years. UNIVERSITY OF IBADAN LIBRARY RESULTS Table I: social Characteris tics of Respoa dents Table I SN.C barac tcristics Subgroup Distribution % 1. Age 2. Educational No schoolinglSome Primary 22 attainment CompIct ed Pry. and some Secondary a 42 Completed w/OND/NCE 26 First dcgm and above 10 3. No. oFCo-wiw NIL 1-2 3-4 I - 'it ' $4- 4. Length of Marriage Occupa t ioi~d Tradi tlg grouping Teach i11glAdmin. Farming Others . <)'. ca I d . Annual 111corne -1500 15 01- 3000 3001 -4500 450 1- 6000 6001 + 7. No. or Cbildrcp 1-4 5-8 9 + The occupation grouping or respondents was also investigated. The data show that 58% of the respondents are traders. This h followed by 86 UNIVERSITY OF IBADAN LIBRARY teachers and administrators (26%). Four percent are fanhen while 1% are designated as othefs. . The annual income of respondents was also investigatd. 32% of the sample reported that they earn above H3,000.00 but not more than 344,500.00. Twenty four per cent indicated that they earn between N1,501.00 and N3,000.00 and 20% abl?*:: 344,500.00 but less than M,001.00. Eighteen per cent reported getting more than 346,001.00 and finally, 6% indicated earning between Nl.00 and N1,500,00, By the way of fmalizing this section, resporsdehts were asked to state the number of children they have, The result S*.~WS that 709'0 of the sample had 5-8 children, 28% bad 1-4 children while the remaining 2% had at Ieast 9 children. Respondents were asked whether they have ever heard about the PEK. Fifty six per cent af the sample claimed they have head about it, while 44% reported the4c ontrary. Furthermop, the 28. women who answered in the aflirmative were asked to name the source from which they rust heard about the PHC. Radio was .mentioned as the com- monest source (39%). This is followed by informal source, that is fiendslspecialists (25%). Five respondents (1 8%) reported that they fust heard of it from the TV and lady, another 5 interview- named printed inedh such as Newspapers and-magazines as their principal some. In pursuance of our investigation in this area, respondents were asked if 'they have ever heard of the EPI Scheme. Surprisingly, all .50 women were not only familiar. with the concept, but also demonstrated a good knowIedge of what. the scheme is dl about. Again radio dth 46% came out as ihe p r b q s ource of EPI-'information.T his figure is again .foIlowedk.byf, riendslspecietIists (26%), 14% -from TV, and another 14% from print media. ' . . The third and rmal -section in which respondents were intewiewed relates to the utilzation of.E PI scheme and the knowledge of the causes, spread and prevention of ~ E E diseases. -First, we asked dl 50 women if they were innoculated during their last pregnancy. The responses show*t hat only 12% were innocuIated. The remaining' 8Ph chimed they were not. Again, of rthe 6 women who were innoculated, only 1 knew the name of the. vaccine.she.t ook, wbile.2 displayed a krrowIedge of what the vaccine was supposed to prevent. Furthermore, 94% of the women took. their, Iast child for one in- noculation or the other while 6% did not. It was diff~cultf or us to keep track of the kind of vaccines received by the children since a good UNIVERSITY OF IBADAN LIBRARY number of them did not know the names ~f'the~vaccinethse y took. However, we tried to surmount this by asking them to state the number of times they took or have takenLth eir children for innocuJation. We augmented this by showing than a picture depicting'c hildren suffering from the six EPI deadly .diseases. On the whole an average of three times per woman was established fei all the innocdations. This result appears cu fious, especially as the women demonstrated adequate knowledge of EPI. In order to get to the'root of it, respondents were asked questions relating to the causes, spread and prevention of tbe six deadly diseases. The result is shown in table 11. Table I1 howledge Of EPX By Diseases Name of Knowledge of Knowledge of Knowledge of Di- Causation ' Spread' Pr.e vention , Tetanus Diptkri? 20% Wb00phg WU@I 449'0 . . . Smallpox 38% 52% 18% I . Poliomyelitis , 18% r .4 % . '20b M h l e s 30% 44% : ., 10%. -I .. > . . . 1 Beginning from-il~elo p; 48% of the sample reported that fhey h e w the cause ofl tetanus, 12% kiiew how'l he disease codd:'be spread, while 56% demonstraied some knowledge of hod to prevent the-'disease.I n the case of djphterid;.20%k new how it can occur, 6% knew how it can spread, whereas, odly 2% knew.h ow it can be prevented. under whooping.cough,4 4% knew its cau3e,' 86% knew of bow it can be con- tacted, as against 26% who informed on how it can be prevented. Knowledge about snla11pox ranks high.'38% h e w its cause, 52% knew of its prevention. In case of Poliomyelitis 18% knew its causation, 4% had knowledge: or spread and %.knew how to prevent the disease, Lastly, 30% of the respondents claimed knowledge'.ofm' easles, 44% knew about its' spread, while 10% reported knowledge of 'its prevention. UNIVERSITY OF IBADAN LIBRARY h thh section, we shall highlight some of the important findings of this work, we shall also attempt to point out the policy implication fdr PHC and suggest the way forward. The analysis shows that most of the women in .this study contracted early marriages, have a high procreation kte and do not space out &eir conception. This is supported by the fact that 64% of the sample did not read up to secondary class five. This is one area where thorn concerned with implementing PHC need to direct atteation. The WHO (1989) reports that in Zaria, girls under f 5 years of age have a maternal mortality that is nearly seven times as high 'as those of wpm in age category 20-24 years. Safe motherhood is rih index of r e p r ~ d ~fvacf- tors. Baerma, (1987) records that the makmd .age, pad-ty -and un- wanted pregnancy can mean the diarefepa between life and dca'th o f , a pregnant woman. It notes that women die more when, they get preg- nant at too early ag&or too late in life! . The findings of average 5-8 children per qoman calls to A d th e issue of parity, chld spacing and abortion. The WHO (1986)' m r d s that while infomation on parity is r n o ~ ' ~ ctod otb fain tfian &thw of age, several studies have nevertheless confirmed the incmsed'rhh of death associated 'with having many children. The itppohe of child spacing cannot be over- stressed. Chad-spacing not only e t s .a mother to recuperate after child birth, but also e l i s t e s cq~peti- tion for food among siblings. In ihc past, most Afri&p socit:ties r b g - nised this fact and 'recommended a pekiud of sexual .&stinm~fb r suckling hothers, but it would appear @af this p m 'ig' igcmsingly wing neglected. ' . Abortion has also long been recogpised as a major killer of women. This practice is outlawed in Nigeria either became of ihe shd stigma asociated with it, or the cost of pro&&g'o'ne from a medical &prt, most women keep sealed lips -about i t while w i n g aid from quacks. The result is that a good number of the cases never come wore a medical wpert un ti1 it is too late The WHO (1986) notes that abortioit accounts for 86% bf maternal deaths in Romania, 64% in Chine, 29% ' in Ethiopia and 20??i n Bangladesh. while 'the evidence from our sample does not tell us much about abortion, the ages of mo*, the number of years for which they have been married and number of children taken together point to the fact of early snarriaga, ytiw UNIVERSITY OF IBADAN LIBRARY sexuality and by implication, early intercourse. Given the fact that not all relationships end up in marriages and the fact of the social stigma associated with having children out of wedlock, it appeF that. illegal abortion will conlinu,e.to swell the rank of those women who die yearly as a result of becoming pregnant. This is one area where the practice of family planning can make the. dirr'ence in .the proportian of those women who die and*t ho% who live, since most deaths associated with reproductive factors are preventable. It will therefore help if those wn- cerned witb the implementation of ~ ~ ~ ' ~ r a ~ rarae mawmaree o f this gap and can step up family planning activities in 'this area. ' The information collected under sources of PHC and EPI infoma- tion shows some consis~encin~ reporting. Radio was established as the principal source. This finding is apt considering the fact that radio comes in all' shapes and sizes these days 'and there is also thd relative e& of taking one anywheie. This is complemented b.y .t. he' [act that trading is the major ' o ~ & ~ a ~oi fo tnh e &spbride'nts. The study reveals the importance of' interpersonal communication channei as a source of inrorrnati~no n the .two related programmes. In specifyirig the role of spicialists, &ponden@ reported that hose who give birth in hoipiials aie informed of b i n u a t i o n facility and wre told when io bring their children. It is however, very doubflul if lhis information is. available to traditional' birth attendants as the only 3 women who gave birlh in such h o m e claimed they .receiv&.Id t he infor- mation from friends, . This dembnstrates lhgt while .specia.l isls.' .d . otni s~i: i- iutea n ' i m ~ q ~ t . sources of iprbrmation -& EPJ acliaQes, a gap still, ~ i ~.atbosut kiowledgk i f the progrkne itself. This ippean to &,the reaspn for the upsurge from 28% recdrded by bbse whd have heard of the con- mpt ,ofP HC to 100% mder EPi, It wouIfl appeqr thd those. coqcerned with the implementation bf P,*H?,.C $ a prdgramme took ihe jatter for granied and &x$ct& the &bound ec~ecio. f perpetuating .EPI activities. to illuminate' the phi1,osophiLal stdtus d l ~ ~ ~ i ' tl hinikisng .is teleological, and the fact that this has mt hap. .p ened imply epitomized ' the falsity of such an assuqplion. The infurn~a(ion on thk ulil@~ipn of EPJ services :reveals lhat a. great deal of ignorancemex ists .a boui . the activities of. P~C/EPIin this ilrca. Most mothers dernqnsim(ed,lit~lgk dbwledgk oT.L he caqses, spread or prevention or'the diseases EPI '.cates f 6 i A closer. examination reveals that moihers lended 1~e xhibit more kno$ledp in ailments that have traditional history. Even he; some mothers subsciibed to the UNIVERSITY OF IBADAN LIBRARY fatalistic motion that diseases just happn. obsewation has also been made by Ogunmekan (1982). It would appear that white specialists form a significant -part of the PHC/EPI information network in this area, they are probably paying lesser attention to teaching mothers about the cam&, spread and prevention of the six -deadly dis- eases. This is further manifested in the number of women who w m innocdated during their pregnancies-Of the six women .who were in- noculated, four had educational attainment belqw m n d a q class five. Of the four, two knew what the vaccine they kook, was supposed fQ prevent, while ody one remembered the name. . I The effects of income on utilization could noi be directly rnurmnd as the women reported that they were not asked to pay for the m. This information is at variance with th?e fact that most nspondents did not complete their chiIdren's innmulation dosage. We pursued this angle with the respondents and-f ound that income: indCkdyx nmihkd itself in the excuses they gave for not completing the dosage. ~ ~ y , such excuses vary from outright lack of money .for tmuportatiot~t o; distance or ease of transportation. Others are u n h a r y delays at health centres, the number of people that are sick in their howebldk at the same time and the after effecbof innoculation on their children. The real issue here is that of the nature of health semis sought It would appear that consumers consciously distinguish among. atdm that are emergency or life-saving, -&tive, paliative ;and preventive; and that such label generally influence their attitude to'hdth servioes. This observation led Bailey - (I 9691, to conclude that udes~p,c vmtive 'semi= are free, it is very dohbtfulnw hether demand for them a n b stimulated. This study dembnstrates that free services .arern ot synonymous with high demand' for health service&:I t .wo~$d-a'ppear that when health services are ariknted. toward pmkritive.savias-'md are free consumem develop.s loppy ptilization attitude. This .is retketed' in the kind of excuses they gave for not completing t h d~os age sKpu- lated for some of the vaccines. A conscious effort is therefore needed by those charged with.co- m- dinating PHClEPZ flairs; to stimulate. the utilization of thorn asetvieee, Such effort should be able to trace't he presence of disease by draw@ a comparison between .an innocdation control group who is fm of tbq' disease and those who spurned innoculation and are currently a f k t d . UNIVERSITY OF IBADAN LIBRARY The way fornard . This study reveals a vast ignonlna abut PHCEPI activities and a low level of family planning practice, This is probably accountednfo r by the issue of low educational attainment and the fact of t h e major occupation which takes them out of the house for most part of the day. The development of httrvention.t o revers this mnd will have to take 4hw salient facts into account. The way forward is for more f d y p lanning activitim to be orgmised in this area. 5phasis should tre pIaced not.ody on getting infomtbn itcross, but also on finding rationabtion within the cultural context of u r n . Efforts should be made to step up the FPIEPI.campaign. Radio and infomd SOUTCE of frienddspeci&ts have been found 'to the most ef- ftctivt in this ma, This communication channek should be exploited. Local names -which- have rele~ance.~orerf eren= point in ~~p~ cosmol- ogy should be &hem to the vacches.,Such names.should then be trans; latedinthevarious:Iocal~ects. - > . The .use of,p oster in strategic phm in the market, drama,' cartcrop and other forms of .mars literacy . campaigri. strategy should be anployed. Exmples~o f these will include ~enlis'tiagth' e support of spe- ciabid agencies & 'Better Lxe', +ReligiousO rga&ations,. Sociai Clubs and Labour Unions. In addition, eminent personalities. like tmdi f id rulers &Id 0pinion::Ieaders should %e called--upa s. to publiay address tht issue. . . . u. . ' . Mom formal; education, espially- .#for rfe malei ehildrem is ia~gent l i d e d T his can be be-a ided by. the hc~rpor&511 of sex :education-. into the cudcula of post,primary education, T@e:importaixe.of~.fede'~ education is fecordcd,b y CwldweIl (1981); Mor e. into sthe acul-l t ~ @ practices of the -people is equally >needed. Suc& inwtigation shorn belprried out with a view'to identifying the areas that an likely to hinder PHC ,activities and to fmd ways of removing .them:,A notherv area, where research will help is an i n q u ~in t~dmtorlpatienta nd nutse/patient relationship. It may well -bw havtheobsmed hesitancy to complete :irtununization 'dos8ge has its roots here; ,If 'this ;is right, then the stage is ~t for the dewldpment of inkmention .that \v.ill lim- prove the situation. For now the only area in which .PRCh ss'made impact in Ekpoma is on the EPI Scheme;. Even this is not .without its problms. We would rather have an &~&~PHc that contributes minimally taday and hope that the co-operation of aH the social dassw UNIVERSITY OF IBADAN LIBRARY in society wi!l make the expected, significant difference tomorrow. References Bailey, R. (1969) Inquiry, Cited in Ward, G.W.( 1986) How to sell health, World He*dlh Forum Vol. 7: Boerma, T. (1987) "The magnit& of the maternal mortality problem in sub-saharan Africa" So~*iaScl jence and Mediche, 24(6). ' Cardwell, J.C. (1381) 'Maternal Education as a factor in child mortality', World Health Statist. Quart. 36. Mosley, W.H. (1989) 'Will Primary Health care reduce 1nfaht and Child Mortality? In Caldwell, J.C. and Santow, d,S elece#.md- kgs in CultmI, S O I . ~an; ~d behaviuural dete+onts of healtir; National Library of Australia, Ogunrnekan, D. (1982) 'Utilization of health services; In Akereddu- Me, E.0. (ed .) SOL-~de~vIe lopi~lenht N~k~fAia s.u rvey of piky rrnd resenn*,' Ibadan .University Press, Ibadan. . . > Olittunbosun, D. (1975) Njgr.ir?'s.ne&:/eedi ur.m ,. n iai!tJ(; &,fo. r d. , Ibad an. I . Wallace, W.L. (ed.) (1969) Sociological theory.:. an introduction. .Chicago,' A1 dine, . 1 .., - h e W HO (1986), 'hiat@mil~ o ; ~ a l,,ih td~pi ng wdmen off th+'rpidato death*, : 1WHO,~ hionicle$, (I5,): . . ' ' .' ' 1 -, .&: ' * I . 1989, 'Why do Mothers suffer and die?' Wurld.HedfhF orum, Vol. 10. . . . i . . - ' . . ' I ' UNIVERSITY OF IBADAN LIBRARY The Role of Local Govement and the Community in the Attainment of Primary HealIt 8 : 8h Ca-7 r. e (PHC) Goal: The Nigerian Experience. - Ohnola, R. A. Department Of Sociology, Ogun State University, Ago-Iwoye, Nigeria. 'm I . 'Health is Wealth' is an d d traditional &om that h been scientifi- cally proven to be a truism. In fact the (fihilosophy implied by this axiom abound in various forms h most -cultures that rnakbup the Nigerian nation. For example, a south- Western Nigeria f6lk singer once opined that of the three blood brbthers, an individual should aspire to have in life - moqy chiid md good health, good health is the eldest of them dl. There is therefore a logic i~the conscious effort being' made at every level of (any) sdiety to ihe acquisition of thism'wealp' that opens the door to olhk rich&. ow ever, it should be noted 'that despite its prhodiaI position, evidence aboundto show that health is dependent on social economic development and also con- tributes to it. Despite this realisation however various historical realities have served to create .gross inequality in the hqaIth status of people in society. This inequality has its roots in the paliticd economy and status ranking in society. Basically, it has been proven that "the gap is widen- ing between the 'haves' and the 'have-nots" in the developing world" Moreover, this gap is also evident within io&vidual.c ountries, whatever their level of development. This gap in social standards is being d a t e d in health status in society. There is therefore a widespread disenchantment with health care throughout the world. This is momo UNIVERSITY OF IBADAN LIBRARY in developing countries where health resour& an allocated main1y to sophisticated medical institutions mostly located in atban areas-t o the general neglect of the rural (disadvantaged) majorify. The alienation implication of this is obvious. This situation, has further increased.t he contact gap between those providing medical care and those mxiving it, with the disadvantage groups having little or no access to any per- manent farm of modern health care. 2. The Primary Health Care The realisation of the gross disadvantages of the hitherto existing arrangement, which have not only henbd istorted by the dictates of medical technology, but also by the misguided efforts of a medical ia- dwtry providing medical goods to society, led to the introduction of Primary Hqalth Care (PHC). It was introduced 'as a practical approach to making essential healthcare universally accessible to individw dnd families in the community in an acceptable and affordable way and with their participation'. This approach evolved over tbe.years and was formally concretised in the Alma-Ata decIaration of 1978. PHC, it is said, addresses the main health problems. in- the corn- muni t)', providing promotive, pmven tive, ctrrativu and.' rehabiltadve sewices which ~ f l e c ta.n d evolve from the economic codditions and so- cial values of the country and its communities. It is kognised asan integral part both of the 'country's heaIthcare system and- of overall economic and social development. Xn essence, it has to be co-ordhated on a nationaI basis with other levels of hea1th:system'as well as with other sectors that contribute to a country's total devel~pments trategy. king part of totaI development strategy, it was noted' that 'health ac- tivities should be undertaken concurrently with measures buch~a;ruSh&e for the improvement, of nutrition, particularly that of children ' and mothers: increase in production and employment, and a more eqiitabk distribution of personal income; anti-poverty measureq and protection and improvement of environment'. From the foregoing, there .is no doubt that PHC is very embrassive. its basic components .are: Hen1 th 'education on prevaIent health probIems; maternal ' and child health' including family planning;, en- vironmental sani taiion and the provision .of safe portable water; con- trol of Iocally endemic diseases; promation of food supply and proper nutrition, immunization; treatment of common diseases and minor in- juries; provision of essential drugs; and ' mental health. he overall UNIVERSITY OF IBADAN LIBRARY s&o-economic development implication of these various components oonsidered becomes imperative. Given its grass-root nature, community participation becomes a sine- qua-non in the measurement of its success. In addition, the Aha-Ata Conference in noting the importance of full organized community par- ticipation also stressed the ultimate se1 f-reliance; with, individuals, families, and communitiei assuming more responsibility for their own health. This is premised on the axiom 'that the salvation of the people lies with the people in themselves. To facilitate community participa- tion therefore, support were called for from groups such as Local Government Agencies, local leaders; voluntary groups, youth and women groups, consumed group, the Red Cross and similar societies, ofher non-governmental organizations and liberation. movements as well as by erccountability.t o the. people'.' The declaration also called for the support .ofa dministrators at all levels in'order that' PHC does not develop as an isolated peripheral action. 3, PHC: The Structural Arrangement In order to ensure the realisation of its major goal of an acceptable level of health throughout the world, some, structural. mangemeats were put in .place. Thearrangement which goes.with fhe catch-phrase- "health for a11 by the year 2000" -will be briefly discussed. below. Without nqssarify challenging some of the prhses and assumptions upon whiih the programme is based, we shall. however.a sk% the roles of two of the idedtified tiers in the attainment of.the PHC goal-- using some of the CNigerian experience. . ., .. At the lowest level of this structural arrangement for. PHC isathe Village BveIo pment Cornmit tee (VDC]: an health.? Its niemkrship in- dude. the following: The Village, Head ar a responsible appointee as Chairman; the Primary School Headmaster i'n .the community as Secretary or ,a literate person;.~ epresentativeso f religious groups; tep- resentatives of occupa t ionaYpiofessiona1.g roups; representatives of Non- Organisations (NGOs); representatives of youthlage group/Associations;.and any other. persons deemed fit. n e r ole of the Village, Development. Com~tee.sha11b e to: - - identify health and heal~hr elaied needs in ihe community; - plan for health and welfare of the community; - supervise the implementation of developed. hea. lth plans; - monitor and evaluate the progress and impact of the implerntn- 96 UNIVERSITY OF IBADAN LIBRARY tation of health activities; . - seIect appropriate persans in the community for training a Vilf age Heal& Worker (VHW); - seiect appropriate Tiaditiond*B irth Attendants WAS)f or training - supervise the activities of VHW and TBA; - pay compensation, in cash or kind to the VHW for his work in the community; - agree with the V H W the number of hours he shall work per day; - establish a villqge health post; - liaise with other officials living in the village to provide healthcare and other d e v e l o p k activities; - provide necessary support to '@ VHW for the purpose of Health Care Semias. In addition to the above functions; the Bamako Initiative (BI) - which is a follow-up action conference to Alma- Ata with. particular referen= to essential drugs - the VDC is ,expected to: + . : . - set drug prices f ~ trhe BL; . - manage drug revglving fund account; - deternine exemptions for dr.ugp ayment; - review monthly records OF work for and ,TBA; - propagate the advantage 6L.W cost recovery-Xmd, It is expected thstt for every 500 persotis there woidd be a corn- munity development corpmi ttee. for.P HC: With>a n.:o perational d h - tory which include meeting at lmt once a month, the indicator for the measurement of success at this community Jevel1jse xpected to-involve, among others; 'the pcentage of participating coimnunities that have a frractional VDC. . . . .. . . _# .. , . #: . , I In between the. VDC and the jdiset Ievet arrangement is .the Health facility de.ve1 committee CHEC) .wbicb is expe~tedt o oversee :the functioning of health facility in ~e community, The District. Develop- m y t Commi tke @PC] of PHC. atithe !higher levd >ise.x pected to per- form functions similar- to that of VDC. For- specific mentioning however is the additionst1 task-of: -; . ' . I - raising funds for community projects where necessary; - liaise with governmen2 and other voluntary agencies in fmding 97 UNIVERSITY OF IBADAN LIBRARY solutions to the health, social and other related probl& in the district; monitor activities at each levels of health facilities and VHWs. Membership of the DDC is equally multisectoral to ensure the in- volvement of various groups in the district. Following the DDC.CIOS~isI Yth e Local Government Area PHC Management Committee with the LGA Chairman as its head. It also include various ather relevant personalities, groups, Associations as wdl as Head of Health related departments in the LGA (e.g. educa- tion, AgriculturdDRFFI; works, etc.). It is indeed an intersectorial committee* Meting at least once in a month, its functions are: - to provide overall direction for PHC; - plan to manage PXC services; - identify training needs; - approve Iocal workshops; - budget and manage finance; - mobilize communities for elTective participation; - supervise the activities of LGA PHC Co-ordinator; - designate persons to run the drug revolvhg*funda nd monitor progress; - receive monthly reports from LGA'PHCc oordinator; . - liaise with governmental, NGOs and international agencies; - monitor.h ealth activities and heaIth facility and community levels. With regards to the Bamako initiative; the role of LGA PHC P similar that of ihe VDC- 1eveI.arrangement. ' to The grassroot arrangement highlightd above is supported by suc- cessive levels of referral facilities. Also, there are arrangements at state Ministries of Health as we11 as at the federal Ministry of Health (na- tional) not only for cb-ordination but also to supervise and provide technical and professional support. Given the deantralisation prinoiple upon which this structural arrangement is based an$ relative to earlier arrangement, one cannot but agrk.t hat some progress. has been made in the Nigerian case. The question'however is what has been the impact of PHC programme in Nigeria, partieuIarly for the pione;ering LGAs? UNIVERSITY OF IBADAN LIBRARY 4. Some Field Reports Variow field reports and isolated research outputs tend to. give us the conclusion that PHC programme has been making steady in the faqe of some odds. of which finance is not left out. This is in additilvl to vviws success storics a h lo ld by Local Govcmmcnt C h a i m n an q a r d s their area of operation. Allhough such pronouncmcnts o l m carry political overtones, we cannot totaHy rule them out as mere propaganda to catch votes* Asa t October 1990, the Federal Ministry of Health provided some reports of which we present that of two Local Government Areas as typical success stories: (a) Ife Central LGA(Now in Osun State) - establishment of 5 operational health districts; - establishment of 50 VDC; - provisionof operational bases in the districts for executingPHC activities; .+ - . house numbring and distribution of home based records (es- tablishing ,a sy hem of record keeping); - oflentation of health staff towards the principles and wnoepts or PHC; - training of over 200 TBA and VHW; - operating of the revolving drug fund system. @)- Idah LGA (Now in Kbgi State]. The s u m ,s tory here include: . - distribution to and sale of drugs at health facilities level and by VHWs and TBAs; - community rnobilisation for health activities: - extension of PHC service coverage to the remaining district of the LGAs; - production of LGA maps; - training of 249 VHWs and TBAs; - upgrading of 4 district rerenal facilities; - erection and equipping of a new .LGA (drug) st ore. Aside from these two (typical) examples, there are many strong in- dicators and media reports of growing acceptance and use of the various components of PHC especially the immunization (EPI) com- UNIVERSITY OF IBADAN LIBRARY ! ponent. There are figures and worts at various grassroot health' centres confirming the utilization of EFI propmne. Also, there are evidences to showaat community mobilization for health activih'in many communities in the country is succeeding a-w dd be inferred from growing attendance at community health centres and .even from the gradual emergence of private rural beaIth clinics. An additional prove (of growing success) can be cited in the, cast of Egbado North Local Ooverment (ENLG) in' Ogun ~ h kW.e had a course to examine some components of PHC in the process of a nrral development mearch in 1991, Here there were evidence that point tg some steady progress of PHC programme. House numbering and homebased enumerations have reached advanced stage in the W Government. Infact, it was the population figure provided by the PHC enumerators for Saala-Orile Community (ENLG) that formed the basis of the said research in the last quarter of 1991. During this period, we actually observed the activities of AyetoroKdofoyi/Sunw~W th dis- trict. We were. equally informed by Mr. M. A. kwaye (the then PHC disttict co-ordinator) of the said a m , that there are functional PHC communities at the 'village as we11 as at the LGA level in the area. Besides, we at tended, in an observer capacity; some of the- training ses- sions for some VHWs at Ayetoro (LGA WQ).In addition, we at- tended (also in an o bservir capacity) one of *the meetin@ of the VDC at Saala-Orile and went further to visit wo V W s in the With this seeming s u m s story of the grassroot IeveI,. ooe may dso need to mention that the Federal administration h Mge& has also made provisions for curnpfementary projects as well as'thc involvement of various health related departments in the country. It dong this line that we begin to appreciate the policy principle behind the estab- lishment of bodies Like Directorate for food, Roads and Rural In- frastructure (DFRRI); Better Life for Rural Women commission; Peoples Bank Project; to men tion but a few. As should be evident from our discussions earlier, these. various bodies are represented at various levels of PHC committee, 5. Some Comments Without necessarily sounding alarmist however, the arranganent dis- cussed above is not without some underlying structural problem which will no doubt mitigate the true success of PHC in Nigeria. Before rounding up this paper therefore, we shall offer .some few comments - - 100 UNIVERSITY OF IBADAN LIBRARY which we hope wiil k food for thought. .The first problem w-is. inherent in -the muttkctorial composition of the various levels of the PHC. Much as this muItkstorial develop- ment committee of PHC (at all levels) appears sound - because it in- volves all health and health refated sectors - there is nothing to compel the parties in the committee to carry-ou t whatever decisions taken, For example, the DFRRI, although represented at the LGA PHC Ievel 29 a body with its own independent programmes and policy directives. There is no legal basis for the synchronization of PHC programme with that of DFRRI. It is only assumed and expected that the ccb operation will exist. Our field experience in the course of a Non- Governmenta 1 Grassroot Associations research in Sokoto State in 1990 is a good example in this respect. Complaints abound by various Com- munity Development Association .oflicials (at the LGA) that DFRRI undertake projects in their domain without their knowing. Often times such projects are cited where they are least needed, There is therefore a need to find ways that the spirit of goodwill implied by the expected intersectorial collaboration i s legally concretisd. This will, at least, compel parties to an agreement to act. Furthermore, given our field experience this far, we doubt if there has been a meaningfur incorporation of Traditional Medical prac- titioners into the PHC actieties. This stems basically from the larger debate of Traditional versus modern medical care. It should however be noted that the Alma-Ata Conference has noted the high social standing of Traditional Medical Practitioners and Birth Attendants in local community's culture and traditions. It has therefore proceeded to recommend that with the support of formal health'sysstem~th ese in- digenous practitioners can become important allies in organizing efforts to improve the health of the community, While success storb can be said to have been recorded to some ex- tent in the case of TBAs, similar story is far from being so in the - of main stream Traditional MedicaI Practitioners. -The relation between the two (MCH and Th;lC) is still one of foes rather than that of allies. This to us is a major set-back in the grassroot involvement drive of PHC. We cannot ignore the fact that people do ding to their oldltradi- tional ways of,dohg things. And to get lhem to change we might have to go through that which they already have and believe in. While one is not here saying that changes are not taking place in terms of Hedth attitudes and values of the people at the grass-root, we should a g e at the same time that tradition st31 has a strong hold on the people. 101 UNIVERSITY OF IBADAN LIBRARY Over 70% of the people aw stilI known to patronise Traditional Medi- cal Practitioners at least as first~courseA. nd.a neglect of TMP is like1 y A.* 4- $0 mean the alienation of the people. This will no doubt slow down the rate of success in the 'Health for all by the year 2000' drive of PHC. Finally and relatedly, we still see a continuation of the 'catch-up' syndrome (modernisation drive) in the implementation of the PHC despite the decentralised structural arrangement, For example, much as the V H W is selected from amongst the people and by the people; the training outside the community implies a need to "catch-up" with that which the community ought to be. This no doubt will affect the at- titude of the people to the VHW as we11 as to his activities. . 6. Some Suggestions There is no doubt that the PHC programme is laudable and thaJ jts success is of paramount importance for a hdthier nation. To con- solidate its string >ors uccess (as evident from bur discussions above) various efforts have to be made. Some of such efforts s h o u l d v n t from our comments above. First among such ~Kortsk that there is a m t e r need for co-ordination of efforts amongst the various sectors involved in the implemen~ationo f PHC. An accord that will be legally biding is seriously needed. Lastly, as should be obvious, PHC relies so much on grass-root in- itiatives and participation. Consequently, grass-root self..o rganisation becomes a sin-qua-non.. It is on the basis of.this fh.at we posit: How strong OFw hat are the level of NGOs at he community 1ewl in Nigeria? From our field experience, their present levd of development is not thar stmng to carry the responsibility which tk FHC policy package hsSows on them, We shall necd to mobilise and develop them w k r e nowxist, The DFRRI m p W d t o do this sometimes in 1990 but l&e various government projects, ?hei nitiative did not meet with general sue's. .Wen sed the NGOs so that the people can begin to "dialogue"o n the developmento f their community through their own initiatives and elfomthat is s dwelopent effort from bottom46- the.-top rather than fmm the topbbttorn. For as it was rightIy notcd by the Alma-Ata declaration. PHC is part of a total development strategy. UNIVERSITY OF IBADAN LIBRARY References . - Bloom, L. and Ottong 3.8. (1 987); Changing Afim & hmdum'on to SbclbIow, London: Macmaan Publishers. Chap, 9 - 'Social Change: From Rural to an Urban World'. Federal Ministry of Health (1990); me Bamako I.,~tl'titti;r'w5 N&n'a; Lagos, FMH. Federal Ministry of Health (199 1); Bamako Inidative Mmtlgmtmt Mmu& Lagos, FMH. Freire, P. (1972); Pedagogy of the Oppm&, London: Penguin Boob , Maclean, U. (1 977); Magical Medicine: A Nigeriszn Cme? Study; England: Penguin Books. Okunola, R.A. (1 99 1); Social Change and R d .C !r..a&: A Gw Sfu dy of Saala -0riJe Cummunit' Unpublished M.Sc. D M - tion, Dept. of Sociology,U niversity of 1badan. WHO (1978); Primary H d h C am: Report of the International Con- f m e o n Primary Health, Alma-Ata, USSR. UNIVERSITY OF IBADAN LIBRARY Strategies For Developing the Human Resources at , Community Level Austin Isamah Department of SocioIogy University of Ibadan Ibadan. Introduction In most countries, Local Governnients are.d eggned to serve as cenm .of iocal initiatives and agencies for the implementation of grassroota development of.t he government. At present ib ~igerii,~Lor;Gllo vern- ments form the third tier of government after the Federal and State governments and they are democratic institutions under e l d cials. Being the closest tier of government to the mass of citizens, thsy have a very important role to play in the well king oPsuch people. The Local Government reforms undertaken by the Obasanjo regime in 1976 underscore this role which local .governments rue expected to PIW. The guidelines to the reforms gave as the main objectives of the reforms: i. To male appropriate servim and development activities mqmn- sive to local wishes and initiatives by developing or delegating them to local representative bodies. ii. To facilitate the exercise of democratic self government close to the local levels. iii. To mobilise human and material resources through the involve- men t of members of the public in their local development, and Iv. ~b provide a two-way channel of communicatibn b c t w m local communities and government (both State and Federal). UNIVERSITY OF IBADAN LIBRARY These objektives are still as imponant today as ?hey were in 1976 and lie at the heart of Nigeria's sort to develop the rural arerts. One of't he most important features which the local governments have to perform, perhaps even more than both the Fed& and State governments, is the area of primary health me. This is primarily be- cawe it is at the very gtassroots~lerewl bere the k u c of primary health cam is most important and it is here that the impact of a d a d primary health care programme would be most appreciated. Thus primary hcalth care officers at the local governments. m very impor- tant agents for bringing about the much needed change at the - passrootti in terms of people's attitude to health matters. Most importantly, in the course qf enhancing the well being of the mass of citizens, the primary health care system mquircs adequately trained and motivated manpower. In other words, the humin resouras of thc Local government i n this important area of health care needs to be properly developd. Very few individuals will argue with the fact that people are the most important miour& for national *elopment or on a much bwer level,,f or the efficiency of an orght ion . The= can be no doubt that no hatter the abundance of funds, the sophis- tication of technology etc.; little can be achieved if the' hurnan factor if not properly harnessed towards corporate goals. F. Harbission, an American economist had a's far back as 1964 argued for what he called Human Resources Development under the rationale that the invest- ment in people is equally as itnportdtnt as investment in material things and that a country's rite of growth is dependent aas much upon the development of human resources and the rate of human capital' f o m - tion as upon the rate ~ f ' ~ h ~ s iccapailta l formatibn. It is for this reason that governments and employers expend so much eEort and resources in developing their stock of human resources. The importance of human resources become even further heightened in such developing anas as Nigeria where a chronic shortage or capital and technology implies that a great deal of organizatimal effectiveness will depend mainly on what people rather tban machines do. Thus as itnother American soda1 sciehtist puts it, 'the quality and quantity of human resources can be effectively increased thraugh education, train- ing and .personal development'. Much of the activities involvd in human'resources development at the local government level (mainly education and training) depend very heavily on the various government for funding. UnfortunateIy, just as the State governments, .the local governments depend almost entidy 105 UNIVERSITY OF IBADAN LIBRARY on the federal govament for their funding. This is p&dy d m - tunate because local initiatives, fot instance, in the area of primary health care, would achieye very little if funding from the central government is not forthcoming. This is clearly an intoIerable situation whtch needs to be remedied. IQ other words, other souras of fmds must be sought in order to pursue the health programmes of each local govwament area apart from the regular subvention from the Fedad government which on the long ruxl might prove inadequate for all the programmes of the local government. One alternative is to suggest that local governments intensify their iptemd fund generation activities. As dskab1e as this option is, it is a relatively limited one. This is partly as a consequence of the d per- vading atmnspbere of poverty in many of the local government m, especially those in the rural areas which maka the collection of taxes and rab a very d a d t task indeed. Similarly internal revea~ege nera- tion also suffers from the unwillingness and uncooperative behaviour of a larg~p roportion' of the general populace. A peat d d o f and rates evasion takes place in Nigeria which the locoll g o v e m t s are illequipped to effectively check. Clearly some other techniques of attracting funds milst be sought to complement that which the Federal (and in rare cmcs the State) government can provide for primary.h ealth care activith. One techni- que which foms the basis of the Pr esent paper, is that of sbeking funds from non-government al sources: . There is a large number of internam tional agencies and non- governmentaI orgrnatioxu (NGOs) opratt ing both inside Nigeria and outside who could be approached ,by primary health care officers for funds to pursue some particular primary! health care programmes or. for manpower training and development purposes. Such agencies include the. WHO,' WCEF, WNDP, Carter's Global 2000, the World Bank etc. However to take advantage of the funds Which these agench m& available, the officer concerned rnust be able to present a pr~perfya r- ticulated and written proposal for the consideration of the funding agency. Proposat writing is a fairly technical task whose -pattern may 1 In fact sometimes the government i k l f usudly in conjunction with international agencies might advertise for applications for f d i fo r specific projects which primary health care oflicials might tx i n t d in. - . - d I UNIVERSITY OF IBADAN LIBRARY ltary from situation to situation, but which however has. certain laid down steps to be followed by the applicant. The mt of this paper ex- m i n e s these various steps drawing examples h m a recently advat id project on Unchocercizlsis i.e. river blindness, jointly organized by tht Federal Ministry of Health & Human Services and UNDPNorld BmkNHO Special prbpmme for Research and Training in Tr- Diseases. Steps in Pr~posaWI riting The first step we want to consider is the introduction or what m y be d e d s t background. The introduction should consist of the follow- ing thanes: i. LdentXcatibn of the reseamh p b l m : In this ation, the pmb- lem to be dealt with is infrodud aad the area within wfiicb the problem is situated is identxed. By the 'problem' M,we mam the subject with which the writer' il3 interested *andi n fb example referred to above, the problem is that of thevR r~a l iheo f r im . blindness in Nigeria and how to get the rural sdkrers of the dig- ' eases to accept the use of the drug ivermectin. Next, authoritative s o w s , e.g. other scientists, are quoted to w e ~ wsh at is known about the particular h u e and what is still unclear and needs fur- ther~in vestigation. ii. hlmature Review. Here the writer looks around for rWmt ar- ticles, books, government publications etc. on the subject and apart from citing them also comments on them. Oftmit h d a l to group the articles intd different categories related to ptkular variables or other conditions considered relevant; perhaps using sub-headings. Other types of backgrouhd i n f o ~ t i o nsh ould be presented. The purpose of literature review" p h a d y to per- UNIVERSITY OF IBADAN LIBRARY ni t a clear fomuIa tion of the probIm to emerge and it also helps in the formuIation of the hypothesis of the study. iii. Statement of rbe problem. This section takes into amount the above two wtions. It gives a more accurate approach to the issue at hand and clarifies the purpose of the study. It should beovery shoa and precise and should define the main variables.2 This sec- tion should terminate logically in a statement, preferably i t m i d , of the objectives of the,study,F or example, we can have .$hf~ol- Iowing objectives: 1. to determine iq lhe area of study, women's knowledg: of and attitudes to wirds onchocerciasj s. 2. to determine the Qaditiond role of women in the disease's . prevention; tmtm& and control. iv. StaremMr and &baalle of tbe hy@kww Essmtially problems are questions about relations among variables and hypotheses are tentative, concrete and testable answers to such problems, The role of hypotheses is qpt only't o suggest explanations for certain facts or prob1ems but also to guide in the.hinvestigation.T hus the wording the hypotheses should be done in a clear and ooncige way. It shoyld give logical arguments to show .that each hypothesis is plausible, reasonable and sound. An example of ap hypothesis -from our river- blindness proposal is thus 'that "the greater ,women's knowlddge about'the.d rug ivemectin, the greater would be their willingness to propagate ' its use both ' within their households and tHeir cpnqnunitiesn. v. Opcralionnl debition of the vw&bks3The operational definition of the variablw.does not only give precise indications as to what arq the,.f undamental characteristics of a concept. It also gives precise indications about how to observe or even meas- the characteristics under study. Stated in another way, an oprational definition is based on the observable characteristics of an object 2 A variable is defined as an mnpir& propsrty that is capable of t-g two or more values. If a property a n change in value or inkind, it can be regarded as a variable, but if it cannot take m o t~han one d u e , it a constant, kg. ?' o f the participnb of this wnferenw can b regarded as a varia. e because it is either male or female. Variables can be hdep~ndenot r indeependwt. UNIVERSITY OF IBADAN LIBRARY of phenomenon and. indicates what to do or what to observe in order to Sdentify these characteristics. Thus in thjs section, the writer should give the operational defmitions of the main vari- ables aIready identiried. . vi. S&rTme of rhe study. The reicv,ance of the problem is high- lighted considering two major aspects: theoretical and practical implications. For primary health officials, the practical implica- tions will tend to have more importance andthe potential bend& of the study must be s.tated as clearly as possible. The second main step after the introduction is the method to bc util: hi in the proposed study. The reseaher himself will have fo make a docision, based on the particular problem at. hand, which research method is must appropriate. The following methods are available .to the researcher: Observation, Sweys, Documentary nseakh' aqd Ex- pimmts. Okmtion: Although a seemingly straightforward techniqae, ob- senation must be pursued in a systematic way, following scimtiffc rules if usable and +quantifiabled ata are to be obtainad. h c m tthod can be divided into two t y p : simple observation which iri the record- ing of events as observed by an outsider. For example,- the primary M t h c are oflicial involved in the study of river blindness simply going into the community and observing and recording how many .people are amicted etc. However, a major weakness of this 'method especially when human beings are involved, is that once they become aware that they are under observation, they might change their behaviour or . cease the activity entidy. The second type of observation is participant observation, In this casi the investigation conceals the real purpose of his presence by be- coming a participant. He joins the group or comm~nitya s'qne of its members, sharing in all activities. Becoming an insider allows a deeper insight into the research problem. This method has been found to be particularly adequate for anthropoIogica1 research and studies of minority groups such,a s jag inmates or drug addicts.. Surveys: These are perhaps the most used.d ata cohection, methods by social scientists. In a m y , q uestiomains are eithersent or given directly in interviews, to a selected group of people - sometimes as many as several thousands. The mey delves a number of steps which however needgot delay us here. In our river blindness proposal, we found this method as the most useful for ow purposes. Documentary mearch: This is the systematic use of printed or writ- , 109 UNIVERSITY OF IBADAN LIBRARY ten materials for investigation. It is a less frequently used rmthod oi data coflection although there are very few pieces of k l d w ozk or s l a m vey research which do not involve some scrutiny or d o c m t a q mat&. Some of the documents most f;enuently c o d t e d io sodal dare government documents, church records, lettem or judicial records. The documents used in research yir td ly always a h in clude information and fmdings prodp~db y previous writers on tk subjmt ia question. Experiments: This can be defined .asa n attempt, within ar&M oon- ditiow established upon others. Experiments are widely wed ha the natural sciena, but the scope of experhentation is limited in the so- cial sciences. We can only bring small groups of individuals into a hbmtory setting, and in such an experiment, people know that they a q being studied and may behave daerefltly from normal. Whichever ~ t h o dthe researcher decides to use, it should incor- porate consideration of the following: a. Srr&m& (respondentdparticipants). In this section aU issues and information concerning the subjects of the mearch arc examined, among which .fnth e characteristics of the target poptdation and of thc sample, the sampling procedure-is the technique by which the sample is chosen and the size of the sample. b. Method for data cofImtio~T~h.e type of activity that the pas- ticipants will be asked to perform should be descrikd as well as the instrument to b wed. Thus the participants could be asked to complete a questionnaire schedule or participate in an expsi- ment, whichever instrument chosen, its main characteristics should be givm and a jMmtion provided as to why 'it w a f elt that this is the most suitable data coUection technique, c. Data mdps. If required by the funding agency, a statement of how the data eollccted wiU be ahalysed should be discussed. Here 3 The entire set of objects and events or group of people which is the object of the research and iibout which the marcher wants to determine &me h c t c i i a t i a is dld the population or the universe. Thus h i # it is impossible in many cases to study the entire population, it is usual to take a sample from that population. Therefore the sub-set of the whole population which is actually inwtigatcd and w h m characteristics will 'lx generalid to the entire population is d e d a sample. UNIVERSITY OF IBADAN LIBRARY the statistical tests to be applied to the data collected needs to be discussed, I In some instances, a work plan is required; This is a deMed.a- planation of the time required to undertake and complete the m h project. Some funding agencies stipulate a particular time M e d -thh which the project should be completed while others might provide just broad guidelimes. However, an example of a work plan is as fob= 1. Two months - Pilot survey of the study area io ordet to demar- cate the Iocal government and identify the hous&olds to b in- vaIved. 2. Twd months - Questionnaire design and standardization of tbe questionnaire and training of research assistants. 3. Two months - Questionnaire administration and additional infor- ' mal interview by the- principal investigators with +selectedg. roups in the study area. 4. Two months - CodinglArmaIysis of data. 5. Two months - Write up of the report and submission of report. Finally, lthe proposal shourd in most cases contain a budst, stating in clear t e r n the amount of money b@g requested for &d .showing s breakdown of how the money is to be spent. Usdly, the funding a p - cies set certain upper limits within which applicants 'ap tg .cad@ themselves. In relatively ran cases, applicants are 1eh to.:* the'i bwn judgment as to how much they require. ,The idea is qof to ask.for too much money than required as this could disqualify the- applicant' or conversely ask for too low an amouni, which may in the 'end not be sflicient to carry out the project. A sample budget for our proposed study is as follows: 1. Research Materials . and supplies a. Books, Journals, Government publications. b. Duplicating paper,, otocopying and other stationeries. c. Printing of questiomaixes -P 12,000.00 2: Transport and Accommodation a. Transport for principal investigators and research assistants from Ibadan to Enugu State. b. Accommodation for principal inyestigatbrs, research a s s i s m and reviewers. UNIVERSITY OF IBADAN LIBRARY 3. Data Collection and Analysis a. 5 research assistants employed for 3 months b. 15 interviewers employed for one month c. 5 coders to code the raw data obtained from the field. d. Computer expenses. -W 3,500.00 4. Publication, including secretarial assistance and binding - -N1,500.00 5. Miscellaneous expenses in the field: W500.00 Grand Total -? +9,500,00 The budget of course varies with the spe*c purpoa for which the proposal h muired . ,I '- Conclusion -. . It must be pointed out that the contents of the presmt pa- repre- sent only one stritegy for seeking fuhds for health programmes and human resour& development activities by primary health care or-. There of course exists other strategies, but it -is felt that officer shodd master the various steps involved in the writing of.propoaalg in order to be in a position to take advantage of ,the resotma available to the varied non-governmental organizations. References Bless, C with Achola .P.( 1988): Fu~dmeataLso. f Soak2 R v & Mdhods. An African Pmpati~eL; usaka. Harbison, F (1 964) 'High Level Manpower, prodluctivity and Economic Development in Dunlop and Diatchenko (eds) Labour Frodue tivity; New Tork. Silverman, D (1 986); Qualitative Metbodofog & Smbiog;v; &@and: Gower Publishing Co. Ltd. UNIVERSITY OF IBADAN LIBRARY Primary Health Care (PHC) andIndependentS ource of Fundingin Nigeria. Dele Jegede Department of Sociology University of Ibadan Introduction. Primary health Care (PHC): as defined by the World Health Organiza- tion (WHO) during its Alma Ata decIaration of 1978, i s "a practical approach to making mentiat health care Universally accessible to in- dividuals and families in the community in an kceptable and affor- dable way and with their full participation" (WHO,I978:). From this definition the objectives of PHC are: (1) accessibility t o the.w hole population, (2) acceptability ' to' the (3) identification of those medical needs of the population wch can be 'prevea'ted, modifd, Or twted, and (4) making use of manpower and 'resour& to m&i the medical need of the population "(Morrel et. al. in Marson et al; 1973). The last of these Objectives is the area of interest of this pa+. T& be able to make use of resources 'to meet the medical needs-of the popula- tion needs an efficient management of the available scarce. ksources. By eficiency it simply means "having power to work well and give good resuIts without wasting time or effort ". Eficient management, therefore, rerers to the way something is "organized" for "gobd results" without any "waste". Appl.ying ~hjsto funding means manap- ,merit of "money intended to be used for a certain purpose In the case of the PHC". Since PHC is the first or nearest contact between the individual and the hedth Care seryices, fund must be used for optimum benefit of th'e people. This means that it should be used for the needs of the ordinary people. It is imperative to real& that meaningful health Care delivery ser- vice cannot take place unless thek islan independent source@)o f fund- ing. As a result the WHO emphasizes the nped for community participarion in primary health Care delivery a method aimed at a cost UNIVERSITY OF IBADAN LIBRARY thc State can afford and based on the national objective of self r e l i c t The fact that the state is overburdened witb many respoasibiliti~, other than health is hindered to effectively cope with the fmding of the health care system. Much has been said about funding of the health care system in Nigeria but the problem of disparity between curative and preventive care is yet unresolved. In order to alleviate this problem PHC programme was set up. This and the need to improve health in the face of the dwindling or shrinking national health b u d ~ thsa s prompted the theme of this paper. Therefore, the paper is divided into five parts. They are: (1) The need for PHC, (2) The need for in&- pendent source of funding, (3) What is needed, (4) Approaches to ef- fective management of funds, and (5 ) Conclusion. The Need For PHC. Problems facing health sector have been sirbswned under three main headings according to a World Bank Report. They are: (1) allocatior insacient spending on cost-elTective health programmes; (2) htmd inefficiency-wasteful public programmes, and (3) inequality -inequi- table 'distribution of benetits of health mites (World Bank, 1987). It h k n ar gued that it is the I'i'iancing of exmnsive hospitals care that needs be - changed. not the existem of the heaIth car per se. One may agree with this taking into consideration the way and ' m h e r funds have always been allocated within the health sector,i n favow of hospi- tal (curative care) at the expense of PHC inthis country. For instance, Pearce (1986).indicated that: "The medical system which the Nigerian government in- * herited from the colonial ahinistration'had the hospital as its corner stone as opposed to preventive care and public health is associated with hospital work..The new government continued the same policies.. ... In 1962, expansion of public health laboratories and ihe national institutions for social and preventive medicine, over N4 miIlion was earmarked for just three hospitals in Lagos and Ibadan", . . In order to promote preventive .health care, however, the PHC was based on the same s t r a w used for the Basic Health service scheme (BHSS) in the 1970s. The provision of structures was embarked upon in addition to the evolution of a new career path for preventive heaIth worker (Mojekwe, 1 978; Orubuloye and. Oyeneye, I 982, and Jinadu, UNIVERSITY OF IBADAN LIBRARY 1988). According to Odebiyi (1988) some achievements w m m ade in the provision of these infrastuctures. In fact, the s u m s of BHSS was feasibIe only in the provigon of structures, and according to Ad;esiaa (1989) it was this development pattern that the PHC de- emp- for manpower development. The responsibiliiies of PHC are shared among the three tiers of government with full participation of the community. The Federal Government formulates the policy and provides resdurces for direct implementation, which ate carried out by the state and local govan- ments. Now the PHC Agency has been established't o sustain PHC eft forts in the country after tlie transition programme (PHC Development Agency in Nigeria, 1992). In fact, the prime function of this agency is provision and managen~ento f PHC funas. Hence, the need to generate fwlds from other sources than the government. The Need For Independent Source of Funding. The World Health ~r~anizatioiG'sl obal strategy of Health for -all by the year 2000, publishedin 1981, estimates that "the cost of acbiev- ing PHC for all peopIe in develbping countries is approximately $30 blbon-annually (or aho.ut $10 per capita) for meaty years (1980-2QOQ). The amount now being spent on health services by public sector sow- ces combined in ihe same countrtes is about 540 billion ($13.3 per capita) annually" (World Bank, 1987). Given these need$ and ap- proximate over-all spding; could PHC fund be a~cientlym anaged hi Nigeria to achieve maximum efficiency in ,PHC delivery? In order to enhance eflicient management, there should, h t , be suf- ficient fund. One problem with PHC ins Nigeria, as enumerated earlier in this paper, is insufficient allocation of fund. To compliment the .ex- ample cited earlier the situation has become more critical at the s u b regional Ievel. For instance, in .Oyo'State, the total h a t e d . capital expenditure in the health sector as a whole between. 1981 and 1985 Was just 7.9% of the state's total budget while for the same period; it was about 3.42% in Ondo State (Aguda, 1988). Aguda (Qp. cit), however, maintained that this may arise from very small government h a n u allocatians to the h d t h sector which was below 2% of the toW.~~nauaf government budgets. And Worst still, 'because of the relatively low Gross National product (GNP) compared with those of developed countries such as the United States of America, Canada, Britain, Japan and Sweden. UNIVERSITY OF IBADAN LIBRARY Despite: all these the government has taken steps to fulfil its obliga- tion as a signatory to the Alma Ata.dec1aration. At the inception of the PHC programme the Federal Government made avaiietble the sum of 34500,000 to the first 11 3 model Local Governrnenf A m (L GAS) as seed grants. This made liule or no impact .because there was no equitable distribution of the resources. In the proms of providing funds fnr PHC all t h ~1 G AF in ' r h ~rn ~intrr~ W P T Rd im.td fn make budgetary allocation for papulation aclivitics. This amount was expected to compliment the matching grants to be providd by the World Bank through the Depiirtmen t of Population .Activities @PA) of the F e d d Ministry of Health and Social Services. But it should be-nofed that , most LGAs could not provide the required budgetary allocation. On the other hanhllbrts have been directed at re-orienting the PHC,o roeramme in Nigeria.. With the intrnduction of D i g Revolving Fund (DRF) Scheme the souxe of Gnance was bcing expanded. This was as a resdt of the programme k n o k as " h e h m & o Initiative". The main objective of this programme is to strengthen Iocal fmancing an& management of PHC activities at the community level. In pukuance of this objective, the Federal Government obtained a World Bank loan of $70 million. Of.t his amount Undo State,-forb - stance, received 3438,340 million out of which H7 million was ear- marked for. essential drugs-alone (Jegede, 1992). However, right from the time of independence through first and sewnd republics, mork h nds h aye been- pumped -into health .care.s ys- tem. New hospitals were built in cities while dispensaries. , were buii t in towns and run1 areas. Expansion of MerlicaI -Schods.int he University of Ibadan and Lagos were done while new ones werebuilt in Univer- sity of Nigeria, Nsukk~,A hmadu Bdlo Univenity, lZada,U niversity of Benin and the ObaSemi Awolowo University, Ile-Ire. These develop- ment fostered the txiifiing of Medical personnel and consequently in- creased the development of the health .care system. lnspite of these developments in infrastructures, the 'facilities adable were not still adequate. Most of the hospitals were established i n the khan Onlres while the rural areas were neglected. The numbs-of Medical doctom available are nurneric~IIya nd Iocationally inadequate in additibn to the cost of the services rendered (Okediji, 1973; Pearce, 1984; and l;tyavya.r, 1987). This was ' attributed to the problem of inadequate source of funding. The table below shows the gross inadequacy of health persoanel and infrastructures due to inability of the state to 'provide adequate.f wd. UNIVERSITY OF IBADAN LIBRARY About 2$00 community Healrh Workers (Extension Workers and Of- ficers) who are specifically trained for PHC. programme were un- employed as a result of financial prob1em:Themis mal-distribution of I these cadre to the disadvantage 'of the rural and wbm poor ( m i and Jegede, 1991) Table 1 Population per Health Resources in Nigeria sin& f 960 1960 1965 1970 I975 , 1980 1986 9% Change, k 1960 Population per Nigerian Doctor 146,330 79,840 47,620 24,570 13,680 7-7s 94.7 Population pet I Doctor 47,330 29,260 24,530 1O.W 1 0 , ~ 6 ,200 86.9 Populatioh per N ' I D entist' 3.1 90,86oi,635,0001 ,462,280 685,260' 417 ,400. 128,100 96.0 Population per Denlist 1,042,240 805,140 692,660 444,600 297,300 99,000 90.5 Population ptr Veterinary SUV 963.580 597,700 480,310 -190.060 98,070- 75,970 , 92.1 Population per Phamracis t 94,220 87,570 75,630 50,m N m @ . N J S R N ) 8.600 6,100 5,040 4-17? Midwife (R.M.TSCM). 25,000 14,660 9,190 5,710 Pubiik Health Suprimtendent 1,702,300 192,780 122, I00 94,670 M d i L aboratory Technologist 1,702,300 682,000 582,320 f 80,850 Radiographer 1,702.3001,486,4UO 940,000' 444,600 Dental Technologist 6,383,700 289,500 1.73 1,000 933,660 hti?d++ Therapist ' 4,i 40,7001.778,400I ,098,400 bpulation per Hapitel Bed 2,520, 2,310 2,21.0 1.380 1,120 1,Im 54.4 AYERAGE 87.6 Source: Adapted from Federal Republic of Nigeria Health Profile - 1986, Federal Ministry of Heal t b , Lagas, pp. 13 & I 5, in Aguda ( 19 84). UNIVERSITY OF IBADAN LIBRARY Although the health care system has ma& some progress since m- dependence, yet it has not emerged from fiiinancial problem. It is now obvious that majority of the population can only benefit from a s e m a that is "primaly in nature" because the culture of the people has long promoted and supponed the traditional health care system. B&des, proximity and cost are vital utilization determinants, an ethos which traditional medicine possess and propagated by Primary Health Care (Owumi and Jegede, Op. Cit.). Hence, any programme attempting to improve the health care of the poor peuple and encourage them to par- ticipate or patronise the modern health care must aim at wooing tbem aqd making hcaW cost afLdr&ble and accessible through independent funding and eficient management. What is Needed. Figure I below shows an integrated source of independent Eunding of PHC which should be implemented by both government, private a- tor, the non-governmental organizations, the cqmmunity and the private individuais. It is a social responsibility that has to be fulFiLled to the citizenry. To ensure enective source of funding for PHC all the parties involved must either provide or make adequate provision for basic human needs. These include education, primary health care, nutrition, safe drinking water, housing, environmental sanitation, oc- cupational' safety, good communication system (information, roads, transportatioq, etc.) dectrici ty etc, FIGURE Z L NATIONAL HEALTH , HOUSEHOLD ISSURANCE SCHEME , Figure 1: An Integrated Sour= Of Independent Funding Of The Primary Health Care PHC) Delivery. 118 UNIVERSITY OF IBADAN LIBRARY The sacio-economic infrastructure-m entioned above; according to Aregbeyen (1 99 I), have direct positive effect. on health whek they an provided simultaneously in an integrated manner. Besides, they lead to -%proved standard of living which also lead to .gradual reduction in - poverty, illiteracy and ignorance. These, therefop, will reduce the cost of PHC and they remain as indirect source of funding .for PHC programmes. The figure proposes a more direct approach in which the individuals in the household, the community and the private sector will pull resources together. The role of health hsurmce scheme is very-virali n sustaining the PHC. Although, all these sources of financing wiU be determined by the level of the National policy on income which will determine ihe income of the individuals and also what accmes to households and the community. The financial capability of the private sector and the ability to finance Health Insurance Scheme (HIS) also have direci eflect on the success of PHC. They will all lead to improved health care delivery; Improved health care delivery will also Itad to healthy cqmmunity; healthy households and a hdthy and productive labour fom. While the above measures are capable of ensuring adequate sourc+ of fmancing, rr'is certain that the PMC Agency should be saddled with the responsiMlity or coordinaiing the efforts in order to mobilize tho% concerned and this has to be monitored by the Government through the Federal Ministry of Health. Towards Effective Management of PHC Funds Following the objectives of the PHC as stated earlier ia this paper, effective management of -fund shouId be the resnonsib3ity of all. The success, of the PHC programme is good financial management at all levels. It has been argued that one major impediment in. the-way of goqd financial management is lack of skill. Another predicament: of good financial management is that people usually do not have faith in public accountability (Bamako Initiative, 199 1). The strategies of financial controI at a11 levels should include the fol- Iowing: keeping of open financia1 records and books of account, com- munity participation, aod full record keeping. To achieve these objectives the following must be taken. At the community level every participating community should establish an accounting system. The account should be .operaEd regularly. To forestall. shortage oT UNIVERSITY OF IBADAN LIBRARY dnrg9 the DRF scheme shouId be maintained and accounted for. me voluntary health iorkers (VHW) who are the closest to the peogk should be allowed to maintain some im-t account for the day to day runnin~o f the health care programme in their LGA and this must be properly accounted for. The folIowing organizational structure should be used in running community PHC Finance Management Committee (FMC).T here should be a fmance committee to be headed by tlq Committee's Chairman and musthdude at least. six other mem- h.T he Treasurer &Wld supervise d i r d y the VHWmA s and make periodic check on their accounts as well as collect, on dqily basis, ' a l l proceeds from sales and cbargw. The chairman should,'o n the other hand, supervise the Treasurer who hihlself.will be under the supervision ! ' of the District Coordinator, The PHC coordinator should collect- all fmancial reports on weekly basis and make a monthly aad yearly sum- mary, The summary should be transmitted. to the State .md the F&ml G o v m m t s f or record purpose. At the facility level, all monies &ved should be.with receipt and this must be submitted on daily basis bymthe d m . A sqi~rvisingo fficer shodrt be appobted who would audit, on daily basis, income and expenditure of the facility. Fqr eirective maagment, a)l drugs issued per . d mu~st b e calculded against sales so ag-to know the difference and check fmvd,. All w- actions must be propr1y recorded and shbmitted to the PHC Coor-4 dinator on monthly basis. The LGA should perform a supervising.r ole. The LGA should make periodic checks on the VHW/TBAs aad Health facilities, There should be a monitoring and Evaluation (Ma& E) un?t+int-b e PHC Coordinator's office for financial monitoring in the LGA. All ir- regularities should be promptIy ~portedt o the PHC Coordinator immediate and appropriate adom must be taken ~ ~ t~his. thei PAiC i ~ Csordhator shwId subinit all th PHC ~CGQW toJ& auditor, on monthly ba&, for auditing. To avoid financial mis-rn-ent all the signatories to the LGA account & o d d also be s i g a a t ot~o the PHC account and the PHC Owrrdhmr inclusive. Below is the p m p d F mmial Management Model m. UNIVERSITY OF IBADAN LIBRARY Figure 11: A Mid Model of Financial Managment ~~F or Effective Management of PHC Funds At The LGA Level i CHAIRMAN LGA PHC FINANCE -I)F HCCOO-RDJNATO COMMITI'EE / T Figm II above show the pattern of relationships that should exist between the various groups of . p p l e m volvcd so as to d m n ~-8d ec- t*c fihacial .management at the gmwoot level. -411 the people in- UNIVERSITY OF IBADAN LIBRARY volved in the PHC should be accountable to the chairman of the LGA 1 Using this model it will enhance proper coordination, distribution and 1 utilization of resources as well as effective manapent of =source : for 'the optimum benefit of the people. mally, there is need to train workers in the a m o f finance. They ' . should be introduced to basic training in book keeping through regular sdmidars, workshops and -conferences. Also, they &odd be provided Nth necessary facilities to enhance adequate performaace. Conclusion In this paper I have shown that there is need for independent fund- . ding of PHC due to inability of the state alone to shoulder the burdea. The paper has also discussed the efforts made so far in order to s&t& the PHC programme and the impact on the population. It dm ex- plored possible ways of improving the imancial source. In order to make health accessible to all at d r d a b l e cost it has been suggested that there is need to avoid wasteful spending of PHC funds and encourage accountability. Available funds should be proper- ly .util&d. In as much as charges should be moderate, expenditure should be, mostly, on essential areas. ~ ~ a l edniseta ses in vdous mm- munities should be identifled so that their drugs wdd be purchad for storage. Drugs should not be purchased iridiscrhinately. Ody m- sentid drugs and materials should be of priority in this Alw, a parties involved in the PHC shquld be acmuntolble for their mh,A G- wuntability should be emph~izeda nd encoura@ to enham p o p functioning of thk PHC. References Adesina, H.O. (1988) "Monitoring and Evalupting ~f H d t b &- vices in Nigeria." Papa presented at. the' Seminar on H d l h C m and Social Policy in Nigeria, Dept. of Saciol~ua d h t b # p o l - ogy, OAU, Ile-Ire, 27-28. June. Aguda, A.S. (1988) " A m t o Health Care f d i * iR mrk Im- plications for Health Care Planning and $ O G ~ O = ~ B R B ~ ~ ~ C Development". Paper presented at the Se&err op H d # h G m andSocialPolicyin~i~eria,Dept.ofSoci~logyan h m d - om, OAU, Iie-Ife. 27-28J une. UNIVERSITY OF IBADAN LIBRARY hgbeyen, J.B.O. (199 1) "The Imperatives of p m t i v p Health cam in Nigeria." in Prodings of the International Cod- of the badan Socio-knomic Group on Devel~pm~Slta te * in 21st Century, Nigeria, (eds) Terry A, Olowu and Simi A. Akhwud, July 7 & 8. Bamako Initiative (1991) Managunent Manual Nigeria, Federal Mia- istry of Health, Lagos. Jegede, Dele (1992) "Primary Health m e ( PHC) and Independent Source of Funding in Nigeria." Paper pmcntad at the National Workshop for PHC Officers and Coordinators at the LGA levd. 6-9' Oct. Jinaay M.K. (1988) "PrLnary Health Care (PHC) as a Major M t h Policy in Nigeria: A critical appraisal of 19751984 pogranm~''~ Paper presented at the Seminar on Health Care and Social Policy in Nigeria, OAU, Ile-lfe. Mojekwe, V.1. (1978) "Role of the Nwm in the Basic Health SetvIce Scheme". Pulse M a g d e Vol. 2, No. 14, Junc, pp 14-21. OWji , F.0, (1973) '~nomiomico f H d t h Care''. in 0,0. Akinbgb et al. (eds) P&nmk lit National Heal& Ham& &ton ibadan. Orubuloye, 1.0. and 0.Y. Qyeneye (1980) "Prhry Health Care in Developing Countries: The Case of Nigeria, i Lanka and Tanzania". Social Wmce md M-6 Vol. 16,7 p . 675- 686. Owumi, B and Dele Jegede (1991) 'Binmy H d t h b and the im- provement of the health sta&." Paw pnsentdd at t8s 3rd Regional Workshop on Rural Development of the p r o m fo r Development Studits and Research h Africa of the International h t r e for L)evelopnent Studim Dcnver, Cdo* 80220, U.SA. 3 1st July - 2nd August, .University of JOB; Niir ia . P m ,T. O. (1984) "Equality in Access to Medical C . A R eview of Nigeria's Approach to Health Promotion." I& Sod& Rehw, Vol. 7, No. 1 & 2. Primary Health Care Development Agency for Nigeria (1993, Faderal Ministry of Health and Human Service, Lagus. WorId H d t h Organization (1978) "Alma Ata 1978: Primary Health CaP Report of the Interpatid Codemaw on Frimary Wth t2i- UNIVERSITY OF IBADAN LIBRARY Cart" Geneva: WHO - ffdlcbf ir all khes. No. 1. World Bank Policy Study (19 8 1) Financing Health' Services in Development Counlries: An agenda-foi reform, World Bank, Washington D.C.,U .S.A. UNIVERSITY OF IBADAN LIBRARY Participants at the first workshop 5 - 10 OcP. 19 92 Dr. F.U. Udoikpong Etim Ekpo LGA - A k w a h m Mrs 0,O.O zoemena 1g bo-Ekti Enugu State EIder O1a Arowosafe Id0 Osi Ondo Dr. Ta yo Olowokere Ido Osi Undo Mr. Charles Amanze Obioma Ngwa Abia Mrs. Jane U.E bube Obioma Ngwa Abia Mr. Isife Cletus Chuks Igbo Ekiti Enurn Mr. Hassan D; Kuta Basi Niger Mrs, L.O. Mereghi Bende' Abia . Mrs. A.1: Okpala Orumba South Anambra Ms.2 .0.O kafor Udi Enugu Mr. Ugwu AmaecRi A. Igbo-Eze south Enugu Mrs. R.N. Uwaechie Aniocha south Delta Mrs. V.1. Edoro Okpk Delta Dr. O.J. Moemeke Aniocha South . . Delta Mrs. B.M.C. Elue Aniochzt South Delta Mrs. B.C. Ubaru hiocha South DeIta Mr. 1.0. Maruru Oh pe Wta Mrs. J.G. Ajiboye Ijwu Kogi Mr. S.B. Fayemiwo Ekiti West Ondo Mr. I.E. Abuduflahi Idah Kogi Mrs. C.A. Oviovo Warri soum Ddta Mr. J.A. Olonihu Ijmu Kogi Dr. O.S. Ogbemi Warri South Delta - UNIVERSITY OF IBADAN LIBRARY 2nd Workshop March 29 -A pril 3 1993 Dr: M.Y.I. Sal-anii Tkorodu-LGA Lagos Mr. Albert Nmor Aniocha North Delta Mr. C,A. Musei - Aniocha North Delta Mrs. E.N. Ogudi Aniocha North Mti Mrs. J.E. Okorhi UgheIli north Delta Mrs. K.O. Keeji Ikorodu Lagos Mr. Allenagate A, Avoke Isoko north Delta Mr L.O. Unuraye UghdIi north a l ta Mrs, L.U, Ejedimu Isoko north Delta Mrs. P.J. Igbuwe Isoko north Delta Mrs. A.0, Bali Eti-Osa Lagos Mr. Looban 0 ,A.K abiawu Eti-osa Lagos Mrs. V.O. Edoi Ika south De1 ta Mrs. M.O. Ngenegbo Ika northeast Delta Mr. D.V. Osaikhuwomwan Uhunnmwode Edo Mrs. C.M. Ekpoudom Etira. Ekpo Akwa Ibom Chief S.M. Onyeagbo 0y i Anam bra Mrs. C.O.A chebe Oy i Anambra Dr. F.U. Udoiupong Etim Ekpo Akwa Ibom Mrs. V.I. Edoro Delta Mr. C.N. Ugbonna.. ok~e Delta Mr. E.O. Olojoba Sapeie Delta Dr. I. Taigknu - Sa ple Delta Elder M .A. Ogunniian Ona-Ara Oyo Alh. A.O. Bisiriyu Ona-A ra O Y ~ Mrs. J.O. Oyelami Ona-A ra OYO Mr. T.A.A ldnyola Ona-Am Oyo Mr. 1.A. Liwu Ona- Ara OYO UNIVERSITY OF IBADAN LIBRARY INDEX Abortion, 89 Edjelc 49. Alma - Ata 14,22,37,56,57,82, Environment 5,7. 82-84,95,97,102,113,116. EPI xii, 8,28,84,85,87,88 90,91, 99, log Sabdawo 48 Family Planning 42,79,84,90,95. Bamako Xniriativc (BI) 97,98, 1 16, 1 19 W nancial ~anagcmcnCt onimiUce Basic Health Scwicc X, 4, 14,58, (FMQ I20 f l4,115 financial Management Model Boka 48,49,50. ( F m )1 20 Budget, 114,115,116. Financial Managqent Orgmgram (FMC)1 21.' Child Spacing 89. Founh National Development Plan 2 Chincse 29,58,59. Community Hcdth Workers (CHW) 117 Dcpartmcnt of Population Activities Heallh Education 5 , 12. (DPA) 1 16 Hehlb 1nsuixkc.e Scheme Dcvclopmcnt, 3,4,27,37,39,40,43, (HIS) 119. 46,51,57,84,92, 101, Health Facility Committee 102, lW,115,116. (WC)97 Diarrhoea1 8,lO. Health Manpower 3,25. Dibia 48. Healrh Policy 5,6, Diphtheria 8,88 Health Status 6,24,72,94. District ~cvclo~rneCnoim mi ttcc. Hcalfh Systcrn 4. (DDC)9 7,98. Hypothesis 108 Documcniary 109. Dircct Observation 40,44. rug Revolving ~ u n d(D RF) 116, 120. UNIVERSITY OF IBADAN LIBRARY Sclf - Dctcrminalion 4,23,26,29,3'9, 52,58,78,84. Labour Force 1 19 Sdf ~Rcliancc4, 16, 18,29,37,52,58 78,84, %, 114 Malaria 8,10,57 Scxual Abstinence 89 Maternal Mortality 89,W Society 4,s. Matohing grants 11 6 ~ d c i ~ l t u r a l 5 , 7 , 2 4 , 4 4 , 6 3 , Measles 8,88 Sugar - Salt - Solution 10. Monitoring and EvaIuation (M&E) Survcys 109. r2o.121 Tctanus &, 88. O b h4 8,49 Third National I?cvclopmenrPlap 14 Olcikoye Ransome-Kuti 1,15 Traditional Biqh AUendaMs WA) + 26, Operational W n it ion 108 52,59,9b, 97.99, 101,120,lZl. Orthodox Mcdicine 6,7 Trgdilional Hcalers 28,58,101, 102. Traditional Mcdicine 24,29,48,50,51, Participation vii, ix, 4,6, 14, 16,21,22, TubcuI&iS 8,88. 23,36,37,38,39,46, 5 I, 57,73,78,96, Utilizalion IX. 5,61; 63,64,74.81. Bq, 113,115, 118,119, 91; 100'11a,122. Participation Observation 4,109. Polio 8,88. Vaccine 8. ProposaI 107 Variabks 108 PNCAgcncy115,119. Village Dcvclopment Committoe (VDC) , Psychodymamics 70 96,99, t OO, Psychologicd 70,71,72,73,75. Voluntary Hcdth C m (V HC) I1 Public Hcalrti 5,6, (55. 1 17. Volunury HeaIth Workers (VHW ). 28,29, 56,58,60,97,99, 100, Rehabilitation 6. 102, 120, 121. Safe Mot4erhood 89. School of H d r h T echnology 1 , l l . Seed Grants 11 6. Whooping Cough 8,88. UNIVERSITY OF IBADAN LIBRARY The. terrt is devoted to the analysis of the implementation of the Primary Health Care/ . Activities of the.&cubm of the programme, aswell as the policy makers. and.:s uggest p-ible strategres for m n ~ n g~. i . iplore goal oriented. , ' It also attempts to rekindle, awaken andinform the N i g d public of the px~macyoPfr fi-9 ' Health Care In our health quest. ' UNIVERSITY OF IBADAN LIBRARY