CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

At the assemblage of world leaders in 2000 to define global development goals for the millennium, child mortality was identified as one key indicator of development. It was thus identified to be monitored as an indicator of social, economic and health development for different countries and zones in the world. Targets were set for attaining the millennium development goals (MDGs). For instance, it was expected that by 2015, global child mortality rate would be reduced to 45/1000.

To achieve this target, global efforts were galvanized to produce technologies that would ensure child health the world over. The production and distribution of effective vaccines and technology that protect children against the known childhood killer diseases were promoted. The primary healthcare (PHC) system in every country of the world was identified as the main driver for successful struggle against childhood deaths. The PHC centres were expected to provide the platform for the delivery of ante-natal and post-natal care for women, during which the babies would also be immunized against childhood killer diseases. Consequently, one primary function of the health centers was to promote access to health interventions and thus reduce childhood mortality.

In 2004, the United Nations established the Inter-Agency Group for Child Mortality Estimation (IGME) to advance the work of monitoring the progress towards MDG4 which targets the reduction of under-five mortality rate by two-thirds between 1990- 2015 as global momentum and investment for accelerating child survival and growth (UNICEF, 2010). This has prompted a renewed focus on the issue of access to health interventions. Thus while addressing the World Health Assembly in 2005, Bill Gate (2005) called on world players in global health to devote more thinking and funding to promoting access to interventions that exist for good health. The study proposed here is intended to examine the issue of access to PHC services in Nigerian rural communities, employing data from Offa Local Government Area (LGA) of Kwara State.

1.2 Statement of the Problem

Commonly defined as one’s ability to obtain and appropriately use good quality health technologies and commodities as and when needed for good health (Ensor & Cooper, 2004), effective access to healthcare programs by women and children remains limited and problematic in Nigeria. For instance, the 2008 Nigerian Demographic and Health Survey (NDHS) revealed that only 23 % of children aged 12-23 months, the age by which they should have received all vaccinations, were fully vaccinated. Fifty percent received vaccinations for BCG and 41% for measles. Fewer children received DPT 3 (35 %) and polio 3 (39 %), compared with those who received DPT 1 (52 %) and polio 1 (68 %). Only 19 % of children are fully immunized by 12 months of age.

Overall, 29 % of children in Nigeria have not received any vaccinations.

Similarly, the ownership and use of insecticide treated nets (ITNs) leaves much to be desired. Only 8% of households covered in the 2008 NDHS had at least one ITN, while only 3% owned more than one ITN. The average number of ITNs per household was less than one. This is worrisome considering the large sizes of households in Nigeria.

The vigorous distribution and promotion of the use of insecticide-treated nets (ITN) among pregnant women and children under-5 years of age has not yielded the expected result of controlling malaria, especially among these groups of people. Only 8 % of households own more than one mosquito net. Worse still, only 3 % own more than one ITN. The average number of ITNs per household is less than one. This falls short of the target of at least two ITNs per household, despite the tremendous progress in net production and availability in Nigeria.

Access to these life saving technologies differ among people in different demographic clusters. The 2008 NDHS shows that while more children (<5 years) in the rural areas (12.6%) than those in the urban areas slept under any net, only 5 % of the children (<5 years) in the rural areas compared to their counterparts (6.5%) in the urban areas slept under ITNs. Fewer children in the lowest quintile (2.5%) compared to 8.0% in the highest quintile slept under ITN. The picture is not different with access to immunization.

According to Frost and Reich (2008) the prevailing child mortality rate in developing countries is because many people do not have access to healthcare programs especially the rural dwellers. The low child health status and poor uptake of interventions designed to promote child health in Nigeria are largely attributable to poor antenatal care (ANC) practices, lack of access to and weak health systems. The situation is further aggravated by poverty and ignorance, which account for women’s inability to access critical ANC services and counseling on important safety measures, drugs and other interventions like ITN use (Onokerhoraye, 2000). In many cases, medical facilities are few and thinly spread. In the hard to reach rural areas, with difficult terrain and poor road network, modern health facilities are luxuries the dwellers can hardly afford, even when they wish (Okonofua, 2010). Attendance at ante natal clinics (ANC) is very poor for a number of personal and logistic issues confronting mothers especially with respect to distance, means of transport and sometimes attitude of health staff.

Nigeria is signatory to several agreements reached at international conferences in 1993 to solve the problem of poverty, hunger, malnutrition and child survival in the world. But it is a sad commentary to note that 18 years after this historic movement began, several millions of children have been left behind (Ogundipe, 2008). Ojanuga (2009) opined that child mortality rate is still on the increase and is buoyed by sociocultural factors which negatively impinge upon physical well being and accessibility to appropriate healthcare programs.

There is also the problem of low education especially health education among the rural dwellers. This has limited the abilities of community members to make rational choices (Federal Ministry of Health and Social Services, 1998). According to Ugwueje (2008), education acts as a very important variable because it alters other features of household living conditions such as knowledge of proper health facilities, perception of illness and disease etiology and personal illness control measures.

Furthermore, World Bank (2002) observed that economic hardship is one of the major causes of the increased child mortality rates in Africa. Resources to buy adequate and high quality foods have declined in most families and this has affected the feeding practice of the children (Rokx & Brown, 2002). In her study, Onyeneho (2005) argued that failure to access child health programmes in developing countries depends upon bridging gaps in delivery and community utilization of services.

The foregoing problems and issues tend to suggest that increased child mortality in the country is related to poor access to Primary Healthcare programs. While the problem may be the same in most Nigerian communities, the actual manifestation and explanatory factors may differ from one locality to another even among social groups within the same society. This agrees with the view of Frost and Reich (2008:xi) when they concluded that “just because a good health technology exists, does not mean that it will be delivered, used or achieve its potential to bring good health”. It is therefore, the major challenge of this study, to identify the factors that affect access to primary healthcare programs and their effects on child mortality in Offa Local Government Area of Kwara State.

1.3 Research Questions

Based on the foregoing, the following research questions are formulated to guide this study:

1. What is the situation of infant and child health in Offa Local Government Area of Kwara State?

2. What is the level of uptake of technologies for child survival in Offa Local Government Area?

3. What are the cultural factors affecting access to Primary Healthcare programs in Offa Local Government Area?

4. Is the cost of healthcare programs an impediment to access to healthcare programs in the Local Government Area?

5. What are the implications of the mother’s level of education on accessing healthcare services in the Local Government Area?

7. Are there spatial differences in access to Primary Healthcare programs by communities in Offa Local Government Area?

8. What are the consequences of poor access to Primary Healthcare programs on the child health in the Local Government Area?

1.4 Objectives of the Study

The main objective of the study is to examine the prospect and challenges of primary healthcare programme in rural community in Offa Local Government of Kwara State. The specific Objectives of the study are:

1. To ascertain the health situation of children in Offa Local Government

2. To find out the level of uptake of technologies for child survival in the Local Government Area.

3. To ascertain the cultural factors affecting access to Primary Healthcare programs in Offa LGA.

5. To find out how the cost of healthcare programs impedes access to healthcare programs in the LGA.

6. To identify the implications of mothers level of education on accessing healthcare programs in the LGA.

7. To find out the effects of distance in accessing Primary Healthcare programs in Offa LGA.

8. To ascertain the consequences of poor access to Primary Healthcare programs on child survival.

1.5 Significance of the Study

The population situation in Nigeria shows that the level of mortality, especially infant and child mortality is still high. To this effect, this study has both theoretical and practical relevance.

Theoretically, this study stands to provide additional knowledge to the body of existing literature on child health in Nigeria and other developing countries with particular reference to rural areas. The result of this study will serve as good base or guide for future reference and it will also encourage further research on the health of the children in the rural areas since currently, it demands for proper attention. Furthermore, this study will provide relevant information on the factors that affects childhood mortality and poor utilization of primary Healthcare programs especially in developing countries. The study will provide empirical data to test the relevance of some of the existing theories on child health in rural Nigeria.

Practically, the findings of this study will reveal the factors that militate against proper utilization of primary healthcare programs and its effects on child mortality. The result from this research will also help planners design relevant, persuasive health messages that will help change the people’s attitude on the utilization of primary healthcare programs and create more awareness on the situation of child mortality in the country. More important, the process of interviewing and supply of responses to the questions will afford the people in the study communities the opportunity to review their child health practices for the better.

1.6 Definition of Concepts

Access to Healthcare programs: Access to healthcare programs is defined as one’s ability to obtain and appropriately use good quality health technologies and commodities when needed for good health (Frost & Reich, 2008).

Childhood Mortality: “Mortality refers to decrement process by which living members of a population gradually die out” (Preston, Heuveline, & Guillot, 2001:92). Childhood mortality refers to death of persons under-5 years (WHO, 2020). It is measure by the number of deaths occurring between the first year of birth and the fifth birthday in a given population.

Infant Mortality: This is the death occurring during the first year of life (UNICEF, 2010). In this study it will refer to the death of person aged 12 months or less.

Mortality Rate: This is a measure of the number of deaths (in general, or due to a specific cause) in some population, scaled to the size of that population, per unit time. It

is typically expressed in units of deaths per 1000 individuals per year (http://en.wikipedia.org/wiki/Mortality_rate, accessed 06/05/2020). Kpedekpo (1982) defines mortality rate as the number of deaths per 1000 people in a particular population in a given point in time.

Neo-natal Mortality: The neonatal period commences at birth and ends 28 completed days after birth. Neonatal mortality thus refers to deaths during the first 28 completed days of life (WHO, 2020). In this study, it will be seen as the phenomenon of death among children within the first 28 days of life.

Primary Healthcare: According to WHO (1978), Primary healthcare is defined as essential healthcare based on practical, scientifically sound, and socially acceptable methods and technology made accessible to individual and families in the community through their full participation and at a cost that the community and country can afford to maintain in the spirit of self-reliance and self-determination.

Primary Healthcare programs: This refers to the provision of primary healthcare, including preventive healthcare programs and education (Texas Department of Health

Services, 2007). In this study, it will include provision of the first course of health management, especially education and preventive services. It entails basic curative, preventive and promotional healthcare programs. In this study focus will be on the provision of basic curative, preventive and promotional healthcare programs in government established healthcare centres.

Rural Communities: According to Mendelson and Bollman (1998), rural communities are populations living outside the commuting zones of larger urban centres. Plessis, Beshiri, Ballman and Clemenson (2002) defined it as population living in towns and villages outside the commuting zone of larger urban centres with population of 10,000 or more. They however suggested that the appropriate definition should be determined by the question being addressed. Thus in this study, rural communities will refer to areas that are outside the urban areas or cities. They have health facilities that provide primary healthcare while people with serious health problems are usually referred to secondary and tertiary health facilities in large urban centres.

Socio-Economic Factors: Smith (2000) defined socioeconomic factors to include income, ethnicity, sense of community and other such factors. In this study socioeconomic factors will refer to education, gender, occupational, income and legal factors that influence the ability of mothers to access primary healthcare programs. Under-five Mortality Rate: WHO (2006) defined it as the probability of a child born in a specific year or period dying before reaching the age of five expressed per 1000 live births. In this study, it will be taken as a measure of the proportion of children dying between birth and age five per thousand births.

Utilization of Primary Healthcare programs: Nteta, Mokgatte and Oguntibeju (2010) conceptualized this as the practice of visiting and receiving primary healthcare programs from primary healthcare centres in the communities. In this study it will refer to the manner in which the study subjects use primary healthcare programs in their communities for the prevention of health problems in their children under five years old.