Factors militating against effective implementation of primary health care (PHC) system in Nigeria

Objectives: This study aimed to evaluate the factors that militate against effective implementation of a primary health care (PHC) system in Nigeria. Materials and Methods: The study was conducted at four selected PHC centers in Enugu State from November 2014 to January 2015. The primary health center was chosen by systemic sampling from about eight primary health centers in Enugu metropolis. The sixteen-item questionnaire was elaborated with the Likert scale. Data retrieved were collected with the aid of a structured study pro forma and analyzed using SPSS Version 18. Results: A total of 169 health workers were recruited from four primary health centers. The mean age of all participants was 38.42 years standard deviation (SD) = 9.8, while the male: Female ratio was 2:1. Among the subjects, 59% were aged 30-39 years. Existing equipment and manpower on one hand and job security and salary on the other hand are negative factors in the implementation of PHC; the respondents believed that adequate supply of gloves, needles, bandages, good access to drugs and medications, a good cold chain system, and full implementation of immunization programs all exist in PHC centers. Adequate community participation, culture and religion, access to safe and clean water, and steady electricity, on the other hand, are nonexistent in the PHC centers in the study. Conclusions: The PHC centers studied showed that much remains to be desired, especially in terms of manpower, communication, and the remuneration of health workers.

Keywords: Factors, Likert scale, Nigeria, primary health care (PHC)

Inequalities in the burden of disease and access to health care are a serious issue in Nigeria. This is also true of other African countries, such as Uganda. ^[1] In 1983, the Federal Ministry of Health set up a committee to develop a National Health Policy, in which primary health care (PHC) was identified as a cornerstone to a National Health System. Strategies were adopted for the promotion of community mobilization, involvement of other sectors, functional integration, strengthening of managerial processes, and manpower. ^[2]

In August 1987, the federal government launched its PHC plan, which is seen as the cornerstone of health policy intended to affect the entire national population; its main stated objectives included the following: Accelerated health care personnel development; improved collection and monitoring of health data; ensured availability of essential drugs in all areas of the country; implementation of the (then) Expanded Program on Immunization (EPI); improved nutrition throughout the country; promotion of health awareness; development of a national family health program; and widespread promotion of oral rehydration therapy for treatment of diarrheal disease in infants and children. ^[3] The implementation of these programs, however, has been hampered by several factors. For instance, the distribution of health care providers in Nigeria and even in countries like Kenya has been skewed against many rural areas, with many doctors found in the urban areas and fewer in rural facilities. Furthermore, health workers at all levels are lacking. ^[4] Health sector jobs are not attractive, and a compensation package for workers is nonexistent. ^[5] Training and retraining, a good road network, and immunization are all at a low ebb. Distance between service points, perceived quality of care, and availability of drugs are farfetched. The other barriers are the perceived lack of skilled staff in public facilities, late referrals, health worker attitudes, costs of care, and lack of knowledge. ^[6]

The poor and inappropriate management of our PHC system, poor welfare packages for the health workers, bad roads, and poor political will in particular have been critical barriers to effective health service delivery. For instance, the reported national coverage in Nigeria for full immunization is less than 13%, one of the lowest rates in the world. This low coverage is traceable to political unrest and insurgency in the northern part of the country.

This study was therefore aimed at evaluating the factors that militate against the effective implementation of primary health care system in Nigeria. The findings from this study may help to improve the management of children in health centers. In addition, they would also form a database on which further studies can be built and carried out.

Study design

This was a cross-sectional study that aimed to determine the factors that militate against the effective implementation of PHC system in Nigeria.

Study area and period

The study was conducted at a selected four PHC centers in Enugu State from November 2014 to January 2015. The health centers were selected randomly from the four districts of the city.

Study population and study procedure

The source populations all comprised health workers in the selected PHC centers. Consent and approval were given by the head of each health center and the confidentiality of responses was also affirmed. The primary health center was chosen by systemic sampling from about eight primary health centers in Enugu metropolis. Health workers who visit the health center regularly, are employed as full-time workers, and gave consent were included in the study, while part-time health workers and those who did not consent were excluded.

Health workers who fulfilled the inclusion criteria were consecutively recruited into the study.

The instrument employed for data collection was a structured, self-administered questionnaire. The questionnaire contained all relevant items ranging from work load, terms of service, immunization, housing and workers’ remuneration, waste management, to environmental protection.

The sixteen-item questionnaire was elaborated with a Likert scale. A Likert scale is a psychometric scale that is widely used for scaling responses in survey research. ^[7] A Likert scale measures attitudes and behaviors using answer choices that range from one extreme to another. Unlike a simple “yes/no” question, a Likert scale uncovers degrees of opinion. ^[8] By converting the nominal scale such that Strongly Agree = 5, Agree = 4, Undecided = 3, Disagree = 2, Strongly Disagree = 1, and hence using a cutoff point that is the average of the scores = 3.00 (that is, 5 + 4 + 3 + 2 + 1 = 15; 15 χ 5 = 3), it is assumed that any mean of 3.00 and above should be interpreted as positive, while any mean below 3.00 will be interpreted as a negative factor.

Data analysis

Data was analyzed with the Statistical Package for the Social Sciences (SPSS) Chicago, software, version 18. Data presentation was in form of tables. Pearson’s chi-square was used to test for the relationship between categorical variables. Statistical significance was set at P < 0.5.

[Table 1] shows the demographic variables of the subjects. A total of 169 health workers were recruited from four primary health centers. The mean age of all the participants was 38.42 years SD = 9.8, while the male:female ratio was 2:1. Of the subjects, 59% of the subjects were aged 30-39 years.

The respondents opined that increased workload, safe and efficient transport to work, and government participation are positive factors in the implementation of PHC. Existing equipment and manpower on one hand and job security and salary on the other hand are negative factors in the implementation of PHC in this setting. This means that the respondents believe that there is not enough equipment and manpower, and no good job security and good salary for primary health workers [Table 2].

[Table 3] shows that the respondents opined that adequate supply of gloves, needles, bandages, good access to drugs and medications, a good cold chain system, and full implementation of an immunization program all exist in the PHC centers, and all contributed positively to its development.

[Table 4] shows that the respondents believed that good disposal of hospital waste, a good referral system, a good record system, and a modern toilet disposal system (water cistern) are operable in all the PHC centers studied, and all contributed positively to its development. Adequate community participation, culture and religion, access to safe and clean water, and steady electricity, on the other hand, are nonexistent in the PHC centers. Moreover, respondents also noted that culture and religion have a negative impact on the implementation of PHC.

[Table 5] compares the correlation between gender and the implementation of PHC. There is a strong negative correlation between gender, and culture and religion (X ² = -0.24, P = 0.00), and a strong positive correlation between gender and the referral system (X ² = 0.23, P = 0.03) and the record system (X ² = 0.17, P = 00.03).

We observed from this study that health workers agreed to the fact that increased workload, safe and efficient transport to work, and government participation are in existence in all the PHC centers studied, while equipment and manpower on one hand and job security and salary on the other hand are not available.

In low-and middle-income countries, health workers are essential for the delivery of health interventions. However, inadequate health worker performance is a very widespread problem. ^[9] For instance, a 2008 report indicates that the Ministry of Health in Kenya had a very high vacancy level. ^[10] In fact, there are 1.5 health care workers per 1,000 population in Kenya, which falls below the standard figure of 2.3 per 1,000 population reported in analyses by the World Health Organization (WHO). ^[11] Other factors, in this study that were seen to strongly impede the flow and establishment of PHC are the lack of both job security and good salaries. These factors dampen the motivation of primary health workers.

Health worker motivation (defined as the extent an individual is willing to exert and maintain effort toward the achievement of an organization’s goals) is a critical barrier to effective health service delivery. ^{[12],[13],[14]} In the foregoing, several factors characterize motivation of health workers and these include financial aspects, career development, continuing education, health facility infrastructure, availability of resources, relationships with the management of the health facility, and personal recognition. Indeed, there should be a clarion call to develop strategies that include and emphasize more incentive mechanisms for health care providers, especially in rural areas, to encourage them to work and remain in these regions. ^[15]

It is gratifying to note from this study that adequate supply of gloves, needles, bandages, good access to drugs and medications, a good cold chain system, and full implementation of an immunization program all exist in our PHC centers and have all contributed positively to its development and implementation. It is a well-known fact that between 2000 and 2004, the African region in general and Nigeria in particular have made considerable progress in increasing routine immunization coverage. Third-dose diphtheria-tetanus-pertussis (DTP3) coverage, a widely recognized indicator of the strength of routine immunization services, has also increased from 54% in 2000 to 69% in 2004 across the African region and Nigeria. ^[16]

Existing community participation, culture and religion, access to safe and clean water, and steady electricity are the factors that had negative impact on the implementation of PHC. It may be noted that in a remote PHC service, in the Kimberley region of Australia, a unique community-initiated health service partnership was developed between a community-controlled Aboriginal health organization, a government hospital, and a population health unit, in order to overcome the challenges of delivering PHC to a dispersed, highly disadvantaged Aboriginal population in a very remote area. ^[17] This formal partnership enabled the PHC service to meet the major challenges of providing a sustainable, prevention-focused service in a very remote and socially disadvantaged area. ^[18] Culture and religion also pose a serious barrier against the implementation of PHC. Our finding is supported by that in rural Egypt, where religion dominates treatment of illness, as seen in the widespread use of amulets, visits to saints’ shrines, and similar traditions of folk religions in healing practices. ^[19]

The PHC centers studied showed that much remains to be desired, especially in terms of manpower, communication, and the remuneration of health workers.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.156701

[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]