LIST OF ABBREVIATIONS
AHRQ-Agency for Quality Management
ANSEPA -Anambra State Environmental Protection Agency
ARI-Acute Respiratory Infection
BASICS-Basic Support for Institutionalizing Child Survival
BFHI-Baby Friendly Hospital Initiative
CAPA-Catchment Areas Planning and Action
CAHPS-Consumer Assessment of Health Plans Study
CDD-Control of Diarrhoeal Diseases
CMR-Child Mortality Rate
COPE-Client Oriented Provider Efficient
CQM- Continuous Quality Management
E B M- Evidence Based Medicine
EPI-Expanded Programme on Immunization
EFQM-European Forum for Quality Management
EOQ-European Organization for Quality
FGD – Focus Group Discussion
FPS-Family Planning Services
HTA-Health Technology Assessment Programme
IMCI-Integrated Management of Childhood Illnesses
IMR-Infant Mortality Rate
ISQua-International Society for Quality
JCHEW-Junior Community Health Extension Worker
KII – Key Informant Interview
LGA- Local Government Area
MCH-Maternal and Child Health
MDG –Millennium Development Goals
MMR- Maternal Mortality Rate
NITEL -Nigerian Telecommunication PLC
NNLG -Nnewi North Local Government Area
NPC -National Population Commission
NPHCDA-National Primary Health Care Development Agency
NPI-National Programme on Immunization
ORT/ORS-Oral Rehydration Therapy/Salt
vii
PMTCT- Prevention of Mother to Child Transmission of HIV/AIDS
PHCN -Power Holding Company of Nigeria
PHC -Primary Health Care
PHN-Public Health Nurse
PRICOR- Primary Health Care Operation Research and Quality
PSRO- Professional Standards Review Organization
QA-Quality Assurance
SCHEW-Senior Community Health Extension Worker
SPA-Service Provision Assessment
SSS-Salt Sugar Solution
TQM- Total Quality Management
UNICEF –United Nations Children’s Fund
USAID-United States Agency for International Development
WHO – World Health Organization
viii
TABLE OF CONTENTS
TITLE PAGE
Title Page i
Approval Page ii
Declaration iii
Dedication iv
Acknowledgement v
List of Abbreviations vi-vii
Table of contents viii & x
List of tables xi
List of figures xii
List of Appendices xiii
Abstract xiv
Chapter One
1.0 INTRODUCTION 1
1.1 Problem Statement 2
1.2 Justification of the study 2&3
1.3 Aim and Objectives 3
Chapter Two
2.0 LITERATURE REVIEW 4
2.1 Background to the study: Child Health Services. 4
2.1.1 Child Survival Strategies 6
2.1.2 Integrated Management of Childhood Illnesses 6
2.1.3 Acute Respiratory Tract Infections 7
2.1.4 Control of Diarrhoeal Diseases 7
ix
2.1.5 Breastfeeding Initiative 8
2.2 Historical Perspective of Quality of Health Care 8
2.3 Quality of Care 10
2.4 Quality Assessment 10
2.4.1 Structure 10
2.4.2 Process 11
2.4.3 Outcome 11
2.5 Quality of Health Care for children 11
2.6 Quality of PHC and Child Health Services in Nigeria 12
2.7 Availability of child health services 14
2.8 Health Resources for Primary Health Care 15
2.8.1 Manpower 15
2.8.2 Availability of equipments, drugs and supplies 16
2.8.3 Health Care Financing 17
2.9 Supervision 17
2.10 Clients’and Providers’ satisfaction 18
Chapter Three
3.0 METHODOLOGY 19
3.1 Description of the study area 19&20
3.2 Study Design 20
3.3 The Study Population 20
3.4 Inclusion and Exclusion Criteria 20
3.5 Sample size 21
3.6 Sampling Technique 22&23
3.7 Methods of Data Collection 23
x
3.8 Pretesting 24
3.9 Data Entry and Analysis 25&26
3.10 Ethical Consideration 26
3.11 Anticipated constraint 27
Chapter Four
4.0 Results 28-53
Chapter Five
5.0 DISCUSSION 54-57
Chapter Six
6.0 CONCLUSION AND RECOMMENDATIONS
CONCLUSION 58
RECOMMENDATIONS 58&59
REFERENCES 60-65
APPENDICES 66-86
xi
LIST OF TABLES
Table 1: Socio-demographic characteristics of the caregivers.
Table2: Age distribution of children brought to the health facilities
Table 3: Relationship of caregiver with the ward
Table 4: Time taken to reach facility from home
Table 5: Days child health services are available by health facility
Table 6: Distribution of health care workers by cadres at all the facilities.
Table 7: Availability of equipments
Table 8: Availability of essential drugs
Table 9: Availability of child health record forms and quality of records
Table 10: Observed state of Physical Infrastructure of the health facilities
Table 11: Amenities and sanitation
Table12: Condition of the Immunisation and the Consultation areas
Table 13: Sources of funding and user-fee charges
Table 14: Supervision Tools
Table 15: Perception of the problems encountered in the health facilities.
Table 16: Level of satisfaction with child health services received.
Table 17: Suggestions for improving quality of Child health services
xii
LIST OF FIGURES
Figure 1: Means of accessing health facilities
Figure 2: Reasons for not visiting the nearest facility
Figure 3: Services received during visit to health facility.
xiii
LIST OF APPENDICES
Appendix I = Map of Anambra State showing Nnewi North LGA
Appendix II = Map of Nnewi North LGA
Appendix III = The Health Facilities selected for the study
Appendix IV = FGD Guide for Clients Receiving Maternal Health Services
Appendix V = KII Guide for Facility Heads of PHC Facilities
Appendix VI = Client Interview Form.
Appendix VI=Client Interview Form
Appendix VIII= Informed Consent
xiv
ABSTRACT
Background.
Children as a vulnerable group bear an undue share of the global burden of
disease. Attention to the provision of quality child health services can prevent
many diseases that cause severe illness and death in children in developing
countries. Child health services form part of the maternal and child health
services, one of the components of primary health care. Quality child health
services if made available at the primary health care level will produce an
effective and efficient outcome; reduce child morbidity and mortality and
ultimately the attainment of the MDG – 4. The study was conducted from 15th
September to 30th November, 2009 to assess the quality of child health services in
the Public PHC facilities in Nnewi North LGA of Anambra state.
Methodology.
The study was a cross – sectional descriptive study that assessed the quality of
child health services and its determinants in the LGA using both qualitative and
quantitative methods. Focus group discussion of caregivers and providers of child
health services as well as key informant interviews of the facility heads and the
LG PHC coordinators were conducted. A checklist adapted from the minimum
requirements for a primary health centre developed by the National Primary
Health Care Development Agency was used in assessing the health resources
available for child health services in NNLG. A total of 305 caregivers utilizing
child services in the public PHC facilities in NNLG selected by stratified sampling
with proportionate allocation were interviewed. In addition, some selected health
care workers, facility heads and the health facilities providing child health services
were included in the study.
Result.
The result from the study showed the quality of child health services as poor. This
is as evidenced by inadequacy of basic amenities, inadequate staff distribution.
The providers were not motivated due to delayed promotion, insufficient training
opportunities. The caregivers corroborated the managers’ views that equipments
were sufficient, were not shared by the caregivers and providers of child health
services.
Conclusion.
It was concluded that the quality of child health services in NNLG was poor. There
is a need for the LGA authorities to provide minimum equipment package, drugs
and supplies as well as make funds available for the delivery of quality child
health services. There is also a need for the adoption of quality of care action plan
at the LGA to improve the quality of child health service delivery which is a step
towards the attainment of the MDG4.
1
CHAPTER ONE
1.0 INTRODUCTION
Children and women form three-quarters of the population in low and middle income
countries such as Nigeria. They are also the most vulnerable and most sensitive to their
environment. As such, children bear an undue share of the global burden of diseases.1
Although major gains were made in the reduction of childhood health indicators in the
previous decade, observations are that stagnations or even reversals were seen in many
countries since the 1990s.
1 One of the reasons given for this is low level of utilization of
quality health services. Another reason is that the concept of quality has not received
much attention in these developing countries, coupled with economic decline, political
instability, and emigration of health professionals amongst other factors.
1
This has drawn the interest of many international agencies like the United Nations
Children’s Fund (UNICEF), World Health Organization (WHO), Rockfellers
Foundation, among others to plan programmes for interventions on these alarmingly
poor health indices.These intervention programmes have been developed through
integrated approaches (Primary Health Care, Integrated Management of Childhood
Illnesses), selective parallel programmes (Child Survival Strategies) and development
programmes. The latest of such commitments by these international agencies, were
made at the Millennium Summit in September 2000, from which the Millennium
Declaration, and subsequently, the Millennium Development Goals (MDGs) emerged.
Also at the UN General Assembly’s Special Session on Children in May 2002, this issue
resulted in the outcome document ‘A World Fit for Children’. These two compacts
complement each other, and taken together, form a strategy – a Millennium agenda – for
protecting childhood in the opening years of the 21st century.
In the year 2000, representatives of 189 nations, including 147 heads of state and
government, gathered at the United Nations for a historic Millennium Summit. They
adopted a set of goals, the Millennium Development Goals (MDGs). Achieving these
goals by the target date of 2015 will transform the lives of the world’s people. The
MDGs are made up of 8 goals, 18 targets and 48 indicators out of which 3 goals, 8
targets and 18 indicators, are directly related to health. 2.
The Millennium Development Goal number four, is about the reduction of child
mortality.2,3. The main target of MDG 4 is to: reduce under – five mortality rates
(U5MR) by two-thirds between 1990 and 2015. The indicators numbers 13,14 and 15
are: under – five mortality rates (U5MR), infant mortality rates (IMR) and the
proportion of 1 year old children immunized against measles.
2,3. U5MR and IMR
measure such indices as: the level of immunization against common childhood diseases;
the nutritional state and health knowledge of mothers; availability of maternal and child
health services within five kilometers or 30 minutes walk.
2, 3.
2
These children form the base of the nation’s human resource development and it is only
ideal that the society provides the supportive and enabling environment for the optimal
attainment of their innate qualities. Assessment of the quality of these child health
services that are offered through Primary Health Care facilties in the LGA is a way of
assessing the progress towards the attainment of MDG 4, and is undertaken in this study.
1.1 PROBLEM STATEMENT
High rates of under–five and infant mortalities still persist.These unnecessary mortalities
reflect a significant breakdown of basic services, and in particular of primary health care
in the country. 4 Coverage and utilization of these interventions are correspondingly low.
The Nigerian health situation makes it a major sector in the global achievement of
MDGs 4.
4
Achieving the MDG 4 means tackling such problems as low immunization coverage,
inadequate provision of clean and potable water, lack of infrastructures like good roads
and transportation in the rural areas. Other problems to tackle include: unavailability of
basic obstetric and neonatal care in most health facilities, low education level of
mothers, unwholesome sale of expired drugs in the rural areas and urban slums. It is also
necessary to increase political will on the part of government, as health budget still
remains about 5% of national budget.
5
Quality of care reflects how the available resources have been utilized to produce an
effective and efficient outcome. However, very few studies have been done on the
assessment of the quality of primary health care in most developing countries. This
number further dwindles when the quality of child health services is particularly referred
to.
In the Nigerian health system, formal mechanisms to assess quality of care are yet to be
developed.2 Evaluation of PHC programmes has focused mainly on coverage. A little
attention is paid to assessing the quality of service provided.6 An assessment of the
quality of the health service will indicate the degree of its worth and is no doubt a step
towards determining its effectiveness and ultimately the attainment of the MDG-4.
1.2 JUSTIFICATION OF THE STUDY
Globally, the quality of health care services for children can be better than what it is,
especially as these children constitute one of the vulnerable groups in the society. In
Nigeria high childhood morbidity and mortality from preventable causes remain major
public health problems. How then can we achieve the MDG-4, when the deficiencies in
the health system account for these alarmingly poor health statistics?
3
Assessment of the quality of child health services serves as an appraisal of the degree of
worth of these services to meet the identified needs as contained in the Millennium
Declaration. It is necessary to ensure that the limited resources allocated to health care,
inspite of growing demands is effectively utilized to meet the health needs of the people.
Quality assessment is also a managerial process to ensure that standards are maintained
with the aim of improving the effectiveness of services. Assessment of health service
effectiveness is a wider concern for assurance of quality of care
It is also important in this era of health sector reforms so as to serve as a basis for
recommendation of appropriate intervention towards the improvement of the quality of
child health services with a consequent reduction of morbidity and mortality in
children.This will facilitate the attainment of MGD-4 which is to reduce child
mortality.The study would also contribute to research in the quality of child health
services in Nigeria.
1.3 AIM AND OBJECTIVES
Aim
To assess the quality of child health services and its determinants in the PHC facilities
of Nnewi North Local Government (NNLG) Area Anambra state.
Specific objectives
1. To determine the availability of child health services in PHC facilities of NNLG
Area Anambra state.
2. To examine the health resources (human, material and financial) available for the
provision of child health services in PHC facilities of NNLG Area Anambra state.
3. To study the quality of supervision of child health services in the PHC facilities.
4. To assess the level of clients’ satisfaction with care received at these PHC
facilities.
5. To identify factors influencing the quality of child health services in NNLG.
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