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BOOK NUMBER I
& A 5 5 1 - G 5
.T.K. e. s. e. .s. . fitoom
ACCESSION NO.
e a a 0 69 2  1070 5 4 0 9  i
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SERVICE UTILIZATION AT THE KINTAMPO 
HEALTH CENTRE: IMPLICATION FOR POLICY FORMULATION.
BY
DANIEL BLAY
A DISSERTATION SUBMITTED TO THE 
SCHOOL OF PUBLIC HEALTH, LEGON
IN PARTIAL FULFILMENT FOR THE AWARD OF THE DEGREE OF 
MASTER OF PUBLIC HEALTH DEGREE OF THE 
UNIVERSITY OF GHANA
1996
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DECLARATION
I declare that all the work in this study has been the result 
of ray own research, except where specific references have been 
made, and that it has not been submitted towards any other degree, 
nor is it being submitted concurrently in candidature for any other 
degree.
DANIEL BLAY 
(STUDENT)
(SUPERVISOR)
MR. K. SENAH 
(SUPERVISOR)
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DEDICATION
This study is dedicated to all those who are contributing to 
existing knowledge.
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CONTENT
PAGE
ACKNOWLEDGEMENT ... ■ • ■ • - • vi 
ABSTRACT ... • • ■ ■ ■ ■ • ■ • vii
CHAPTER ONE
1 .1 INTRODUCTION ... ... 1
1 .2 STATEMENT OF PROBLEM ... 6
1 3 OBJECTIVE OF THE STUDY ... 7
1 4 DEFINITION OF CONCEPT ... 7
1 .5 METHOD ... ... * 8
1 5 1 TARGET GROUP ... 8
1 5 2 SAMPLING TECHNIQUE ... 8
1 5 .3 DATA COLLECTION . . . 9
1 5 .4 DATA ANALYSIS ... 10
1 5 .4 LIMITATIONS ... . . 10
1 6 CONCEPTUAL FRAMEWORK ... 11
1.7 LITERATURE REVIEW . . . 12
CHAPTER TWO
2 1 KINTAMPO: A DESCRIPTIVE PROFILE 20
2 2 GEOGRAPHY ... ... 20
2 3 DEMOGRAPHY ... ... • 21
2 4 ECONOMIC ACTIVITIES ... 22
2 5 EDUCATION ... ... 23
2 6 POLITICAL ORGANIZATION ... 24
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2.7 TRANSPORT AND COMMUNICATION 24
2.8 HEALTH FACILITIES ... 25
2.9 ENABLING ENVIRONMENTAL FACTORS 
TO HEALTH ... ... 26 
CHAPTER THREE
3.1 KINTAMPO HEALTH CENTRE ... 30
CHAPTER FOUR
4.1 RESULTS ... ... 33
4.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS 
OF RESPONDENTS ... ... 33
4.3 POTENTIAL CLIENTS ... 36
4.4 REASONS FOR USING FACILITY 37 
4.5 NON-USERS ... 39
CHAPTER FIVE
5.1 DISCUSSION ... 42
5.2 CONCLUSION 49
5.3 POLICY IMPLICATION 50
APPENDIX ... ... 52
REFERENCE 56
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ACKNOWLEDGEMENT
I acknowledge with special thanks the advice and suggestions 
offered hy my Supervisors, namely: Dr. Nana Enyimayew, Mr. K. Senah 
and Dr. Sam Akor, with whom I discussed the study at every stage. 
They were patient and cheerful and I have henefited enormously from 
their eagle eyes. I am very grateful to them.
My deepest thanks are due to Dr. E. Adzotor for the home he 
gave me during my stay at Kintampo and to Gladys and Children for 
their kindness while in Sunyani.
The financial assistance and cooperation given from the 
Ministry of Health and the School of Puhlic Health, Legon are very 
much appreciated.
I owe a particular debt to Dr. Paul Arthur for the incredible 
support provided and the suggestions offered.
I thank Dr. Bonsu, the Senior Medical Officer - PH# Brong 
Ahafo, for the constant encouragement and assistance.
I am grateful to the fallowing for their support:
Mr. Abraham Quansah, Legon, for the typing work; Mr. Clement, Mr. 
Frimpong, Mr. Aryee, Mr. Adinkra and Dr. Adu Gyamiri, all of 
Kintampo, also to the Techiman Holy Family Hospital and the 
Regional Biostatistics Unit, Brong Ahafo.
Finally, my thanks to those who know that I am aware of their
help.
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ABSTRACT
From the early 1980s utilization at outpatient services at 
government health facilities declined considerably, of which the 
Kintampo Health Centre was a typical example.
The main focus of this study was therefore, to find out the 
factors that influence utilization at the Kintampo Health Centre.
The study was descriptive. Questionnaire and available 
routinely collected data from health institutions were used. 
Sampling was purposive and adults above 19 years were interviewed.
The findings show that, the following factors influence 
utilization of services:
Proximity
- Presence of competent doctor
- Availability of drugs
Facilities such as operating theatre 
Cost
- Attitude of health providers and
- Clean environment
The result of the study imply that, the demand for health care 
in rural health centres, such as the one at Kintampo, can be 
significantly increased if, technically competent and courteous 
personnel such as medical doctors, with facilities to work with in 
a very clean environment are available.
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CHAPTER ONE 
l.i INTRODUCTION
This study is about the factors that influence service 
utilization at the Kintampo Health Centre. Health facilities are 
there to restore and improve the health of the people. Thus people 
demand health care in order to stay in good health. According to 
World Bank 1994 Report, poor health increases suffering and reduces 
people's alertness and their ability to cope with and enjoy life. 
It shackles human capital and undermines socio-economic environment 
conducive to entrepreneurial activities. Good health is a
crucial part of well-being, as the old Arab proverb indicates, "he 
who has health has hope, and he who has hope has everything. "
Improved health contributes to economic growth, as it reduces 
production losses caused by worker illness and it increases the 
enrolment of children in school and makes them better able to 
learn. The economic gains are relatively greater for poor people, 
who are typically most handicapped by ill health.
The negative effect of poor health on economic activity is 
very alarming. For example, in Nigeria, guinea worm disease 
temporarily incapacitated 2.5 million people in 1987- It was 
estimated that, the net effect of the disease was a reduction in 
rice production by $50 million. (UNICEF 1987).
A study in India showed that, leprosy seriously deformed 
nearly 30 percent of those affected by the disease and shortened 
their working lives. The study estimated that, the elimination of
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deformity would more than triple the expected annual earnings of 
those with jobs. The study also indicated that, the prevention of 
the deformity in all of India's 645,000 lepers would have added an 
estimated $130 million to the country's 1985 G N P . This amount was 
believed to be equivalent to almost 10 percent of all the official 
development assistance received by India in 1985. Yet leprosy 
accounted for less than 1 percent of the country's disease burden. 
(World Bank 1993 ) .
Good health permits the use of natural resources that had been 
totally or nearly inaccessible because of diseases. To take a 
classic example, in Sri Lanka, the near-eradication of malaria 
during 1947-77 was estimated to have raised the national income by 
9 percent in 1977. The cumulative cost was $52 million, compared 
with a cumulative gain in national income over the thirty-one years 
of $7.6 billion, implying a spectacular benefit-cost ratio of over 
140. Areas previously blighted by mosquitoes became attractive for 
settlements. (World Bank 1993).
In recognition of the importance of health, governments all 
over the world continue to invest large sums of their earnings in 
health. For example, of the $1,700 billion (8 percent of global 
income) spent on health in 1990 by all nations of the world, 
governments spent more than $1,000 billion (nearly 60 percent). Of 
the $170 billion spent on health in the developing countries, 
governments spent nearly half the amount. (World Bank. 1993).
The government of Ghana continues to invest huge amounts of 
its scarce resources in the health sector. The total expenditure
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for 1993 was 73.37 billion cedis. This showed an overall increase 
of about 39 percent (in nominal terms) over the previous year's 
expenditure. A total of 5.1 billion cedis was spent on capital 
projects in 1993. This was about 46 percent increase (in nominal 
terms) over the 1992 expenditure. The Ministry of Health capital 
provision as a percentage of total government capital budget 
increased from 3.5 percent in 1905 to about 8.0 percent in 1995. 
(Ministry of Health, 1994 ) .
The huge investment has yielded some remarkable results. For 
example, life expectancy has improved from 49 years, in 1960 to 55.7 
years in 1994 ; and infant mortality rate is estimated at 82 deaths 
per thousand live births as against 111 deaths per thousand live 
births in 1970.
This shows that there has been improvement, but there is more 
to do. For example, life expectancy in Ghana is 55.7 years, 
compared with 62 years for low-income developing countries. The 
country's infant mortality rate is 82 deaths per thousand live 
births compared with 71 deaths per thousand live births for low- 
income developing countries and 3 8 deaths per thousand live births 
in middle-income developing countries. (World Bank 1993).
Table 1.2 shows that 44.4 percent of the adult labour force 
experienced illness or injury between 1988 and 1989, with 26.4 
percent inactive. These show the burden of ill health in the 
country's labour force. These workers lost about 5 full days of 
work on average and the cost of treatment amounted to about 7 
percent of their normal monthly earnings. This shows that the
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economic effects of adult labour force illness are substantial.
Table 1.2 Economic Burden of Illness for the Labour Force 
Ages 20 - 50 years in Ghana. 1988-89.
Workers experiencing illness/injury 4 4.4 1
{percent)
Workers inactive due to illness/injury 26 . 4
{percent)
Average work days lost to ill or injured workers 4 . 8
Share of normal monthly earning used to treat
illness/injury {percent) 6 . 7
Source: King, E and Wang, Y. 1993. The Economic Burden of
Illness: Evidence from Developing Countries. World 
Bank, Population, Health and Nutrition Department, 
Washington, D.C.
The government has recognised that good health is a 
prerequisite for socio-economic development. As a result it has 
and continues to put in efforts to improve the health of the 
people, especially those in the rural areas. Health centres are 
being established and existing ones expanded. However, the 
government's ability to finance and expand health services has been 
undermined by unstable economic performance. For example, 
according to World Bank 1995 Report; the average annual rate of 
inflation increased from 35.2 percent in 1970-80 to 40 percent in 
1980-91. The per capita GNP had fallen from US$539 in 1974 to 
about US$400 in 1991. In 1985, it was estimated that about 48 
percent of the population was below absolute poverty level. The 
problems were also compounded by the high rates of population 
growth estimated at between 2.6 and 3.1 percent per annum.
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As a measure to ensure sustainability and efficiency in the 
delivery of health care service, higher user-fees was introduced in 
Ghana in 1983 and increased in 1985 at all government health 
facilities.
Utilization of out-patient services dropped sharply and it was 
attributed to the higher user-fees (Waddington and Enyimayew 1989) .
In Ghana efforts are being made to improve utilization after 
the 1980s set-backs. This study at Kintampo Health Centre, is 
intended to be a contribution to the effort to improve the 
productive life of the people.
1.2 STATEMENT OF THE PROBLEM
In September 1995, during my practical fieldwork at the 
Kintampo Health Centre, examination of the records of service 
utilization from 1983 to 1995 showed a sharp drop followed by 
fluctuating levels. According to the records, in 1983 the 
Outpatient Department recorded a total of 55,368 patients. 
However, this figure dropped to 8,246 in 1986, followed by a slight 
increase to 13,597 in 1990. In 1995, I have estimated it to be 
about 18,500, representing about 33.4 percent of the 1983 level. 
(See Table 1.2 and figure 1.1) .
Despite the huge investment in the health centre, it was 
evident that demand for its services was far below expectation. 
Thus virtually rendering the health facility of little practical 
use tc the people. However, a health centre is built to help 
restore and improve upon the health of people. .Thus, if Kintampo 
Health Centre is not doing this, then a problem exists.
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Table 1.2 Out Patients Attendance Kintampo Health Centre 
1983 - 1995 (January - October)
Y E A R A T T E N D A N C E
19 8 3 5 5,3 6S
1984 27,192
1985 20,254
1986 8,246
19 8 7 13,036
1989 12,772
1990 13,604
1991 13,597
1992 8,138
j 1993 9/932
1994 15,254
1995 (Jan. Oct.) 15,421
1.3 OBJECTIVE OF THE STUDY
The overall objective of the study is to determine the factors 
influencing service utilization at the Kintampo Health Centre and 
use the findings to recommend policies that, will improve 
utilization of government health facilities.
In furtherance of this objective, the specific objectives of 
the study will be to:
study the outpatient utilization pattern.
find out clients' perspective of the service they receive
and reason for using and not using the health facility.
- analyse the findings and discuss the policy implication 
of the findings.
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r / f  J7j OUTPATIENTS ATTENDANCE - KINTAMPO H/CTR
J  1983-1995
60000
50000
40000
30000
20000
10000
1983 1984 198S 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
Fig. 1.1
• Year
For 1995, allcudancc is for Jan - Oct.
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1.4 DEFINITION OF CONCEPT
Using Tanahashi 1978 definition, utilization is regarded as 
the relationship between service capacity and output. It is 
normally expressed as the ratio between output and capacity.
It is assumed that, for one to use a health service, first it 
must be relevant to his problem, be within reach and affordable.
For the purpose of this study, I am assuming the capacity of 
the service at the Kintampo Health Centre to be the 1983 OPD 
attendance number, because it is the highest ever/recorded.
In the case of the service utilization, I am looking at the 
outpatient attendance only, because reliable information is 
available.
1.5 METHODS
The study is descriptive.
1.5.1 TARGET GROUP
The study population consisted of adults of 18 years and above 
who can take decisions for themselves with regard to the use of the 
health centre. Guardians of young people below 18.*years were also 
interviewed since they took decisions concerning the health of 
their wards or children.
1.5.2 SAMPLING TECHNIQUE
The Kintampo township is divided into five administrative 
zones by the District Administration. For the study, all the five
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zones were covered. In each zone twenty-five compounds were 
randomly selected. At the centre of each zone, a pen was spinned 
and the direction of the point of the pen was where, we started from 
the first compound. From this point, every fourth compound was 
taken. At the end of the row of compounds, we balloted and the 
right-hand direction was chosen. The movement was zig-zag.
This sampling method was used because the compounds were not 
systematically numbered. Also, mapping and numbering the compounds 
was not feasible, because of the limited time and the cost 
involved.
In each compound, one adult was interviewed. This was the one 
seen first by the research team. This was done so that the 
previous respondent's views do not influence the next respondent.
Two research assistants were recruited from the Health 
Research Unit at Kintampo. Both were males and have been with the 
Unit for the past one year after completing their secondary school 
education. They were natives from the District.
They were given a two-day training. The objectives of the 
study were made clear to them. The questionnaire was shown to 
them. They were asked to interpret the questionnaire in the Akan 
language which is the common language spoken in the district. This 
was to let them understand the questions and also be able to 
communicate effectively with the respondents. They were briefed on 
how the compounds were to be selected and those to be interviewed.
The questionnaire was pretested in five areas which were not 
part of the sampled areas. After the pretesting, a number of
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questions were modified or deleted to make them clear to the 
respondents.
1.5.3 DATA COLLECTION
Data collection lasted three days. For the first two days we 
worked together, but on the last day we separated into three teams.
Routinely available data from the Kintampo Health Centre and 
the Regional Biostatistics Unit in Sunyani were collected. The 
data was obtained from the monthly returns books kept by each 
institution. The information I collected was monthly number of 
outpatient attendance.
Outpatient attendance of the Holy Family Hospital at Techiman 
was collected from the Management Information System Unit of the 
hospital, which indicates the number from the Kintampo District.
Qualitative information was also collected from the 
respondents and the service providers, through in-depth interviews. 
In all fifteen health providers were interviewed. Ten of them have 
been at the health centre for over ten years.
Views sought from them ranged from issues such as the history 
of the health centre, infrastructures and .'personnel and 
improvements that they think are needed at the health centre.
1.5.4 DATA ANALYSIS
The data collected was analysed by hand using manual sorting 
and tally counting.
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Dummy tables and tabulations made with frequency counts were 
used to summarize the data into statistical tables.
1.5.5 LIMITATION
The sample size was not based on any statistical calculation 
and the number was not large enough. The study was limited to the 
Kintampo township. However, being the administrative capital 
almost all the people from the other sub-districts are well 
represented. The training and pretesting of collection tools could 
make up for the small sample size.
Since the area map was not available and the compounds were 
not systematically numbered, there could be errors in the selection 
of compounds.
1. 6 CONCEPTUAL FRAMEWORK
This study focuses on the concept of utilization. According 
to Tanahashi, utilization refers only to the service and its 
measurement is only indirectly related to the size of the target 
population.
From Fig. 1.2 one can see that the number of people for whom 
the service can be provided expresses the service capacity and 
indicates the potential of the service. On the other hand, the 
number of people who have received the service expresses the 
service output and indicates the actual performance of the service.
Moseley (1979) identified accessibility which he referred to 
as 'get-at-able' to affect utilization. Relating to Fig. 1.2
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health facilities are established for a greater number of people, 
but most invariably only a few actually enjoy the service. This 
means that, there are some factors both visible and hidden that act 
together to affect utilization. It has been shown that factors 
other than physical availability may intervene to distort 
utilization. Some of the factors may be the recognition of the 
need to use the facility. Also the financial ability to use it and 
the quality of care provided at the facility are also prominent.
Figure 1.2 Schematic Model of Health Service Coverage
and Utilization
UTILIZATION
SERVICE CAPACITY------------------------------- >SERVICE OUTPUT
Source: TANAHASHI, T. 1978. Health Service Coverage and its 
Evaluation. WHO Bulletin. 56(2) p. 295-303.
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1.7 LITERATURE REVIEW
This section locks at what others have done a n ^  
findings. This is to give us background information about service 
utilization.
The intention of setting-up a health facility is for the 
facility to intervene successfully in the health problems of the 
people.
STUDIES IN UTILIZATION
The issues of who uses which health services, how much and 
when have been a pre-occupation of scientist for many years and 
more recently of health planners.
The study of health care utilization has its genesis in 
Jarvis's detection in the mid 19th century of an inverse 
relationship between distance from mental hospital and admission 
rates.
Despite the fact that in developed countries, many studies 
have identified a range of variables influencing utilization 
behaviour and of late the developing countries, there is still 
imperfect understanding of exactly how and why services are used.
As noted by Stock 1987, it is difficult to focus on how people 
conceptualize health issues and how and why they decide to 
implement various therapeutic strategies. The complexity of the 
field was clearly identified in the early part of 1970 in 
McKinlay's 1972 review of approaches to the study of utilization.
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The merits and shortcomings of single - factor explanation of 
utilization behaviour are increasingly becoming apparent as a 
number of discrete but often interrelated variables, such as costs, 
quality and distance, appear to influence health care utilization.
(Phillips 1990) .
MODELS IN UTILIZATION
For services to be well organized in order to serve as many 
people as possible, empirical studies of health care utilization 
and in-depth knowledge of its characteristics and influences needs 
to be looked at. In line with this, models have been applied in 
the field of public health to determine and predict health services 
utilization. The models have helped to illustrate the
interrelations among variables influencing health care usage. The 
majority of the models have evolved since the late 1950s.
Many of the earlier models hold implicitly that 
underutilization is the main problem in social services such as 
health, and that this should be a concern for health planners and 
providers who wish to optimise the use of facilities for their 
intended population. However, later models appear to regard 
underutilization as less important.
Most of the earlier models stressed on the psychological 
readiness to act, whereby a person believes he/she is sick. 
However, Suchman 1964, placed great reliance on social group 
influence and less emphasis on the psychological state of 
readiness. This model recognizes the fact that, the accessibility
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of family or friends in an individual' s social network can 
therefore influence the extent to which he or she can avail himself 
or herself of these sometimes valuable alternative resources in 
health care and so can directly influence utilization behaviour. 
This aspect of the model might be cf relevance to health care 
utilization in Ghana, where lay persons perform important advisory 
or even curative roles.
The majority of the models today recognize the existence of 
various predisposing factors such as family size and health belief, 
enabling factors such as the community's health resources and 
socio-economic status and finally the need factor which is measured 
by illness. However, it is also possible to envisage utilization 
as the product of characteristics of patient, provider and system. 
(Aday and Andersen, 1974).
Utilization as stated earlier in this section, is the outcome 
of many complex interactions among many variables and factors, 
visible and hidden, which act at different stages. It is 
impossible to observe the whole process.
Factors documented in studies of utilization tend to vary from 
one academic discipline to another, for example, the economists 
emphasize on cost factors, while the psychologists stress on 
various behavioural factors. (Phillips 1990).
However, many researchers for example Lee 1980“ are of the view 
that, it is the experience of illness rather than the biological 
reality of disease that causes people to consult other persons 
about their health. They have pointed out that the belief of
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individuals and groups about the behaviour they should undertake 
for any given condition can be crucial in determining utilization.
COST OF SERVICES
The cost of using health care are usually expressed in user 
charges. However, making a choice in a world of scarcity requires 
giving up something else. Thus, the actual cost of using health 
care services is given by the opportunity cost, that is the cost or 
value of the good or service foregone. Akin et al 1985, point out 
that, the opportunity cost of using health care is approximated by 
the sum of the price paid to reach the facility, the price paid for 
the service and the price paid for any medicines. Prices have two 
components: a cash monetary cost and an indirect cost in terms of 
time .
Concern remains widespread that, the introduction of user-fees 
in government-operated facilities could deny the poorest people 
access to modern health facilities. This assertion is from the 
fact that higher prices would reduce demand for the services due to 
affordability. However, opinion polls taken before the
implementation of user-fees in Tanzania revealed that 87 percent of 
respondents agreed with the statement: "People will pay, provided 
they are assured of good service." Some 76 percent also agreed 
that if good services is provided, people will give what little 
they have to pay for treatment. (Mujinja and Mabala 1992) .
A study in Ghana by Waddington and Enyimayew 1989 found out 
that, the introduction of user-fees in Ghana led to a general
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decline in utilization of OPD services but the decline was more 
marked in rural population. However, it was also realized that 
most of the people were critical about the quality of services at 
the government health facilities.
A study by Mwabu 1986 in rural Kenya indicated that, choice of 
service in free government clinic, pharmacy, mission clinic or 
traditional healer, varied depending on the nature of the illness. 
It was found out that, although fairly well dispersed in the area, 
government clinics were used by only about 30 percent of the 
respondents. The proportion using government facilities was found 
to have declined for subsequent visits. .
This suggests that factors other than direct costs were 
influencing behaviour.
Charging user-fees clearly affects the use of health services, 
but the negative impact of prices on the demand for services can be 
greatly offset, by improving the quality of services offered.
Experience from the Bamako Initiative reveals that, users are 
more willing to pay for tangible products such as drugs.
DISTANCE
Distance was one of the earliest factors found to act as a 
barrier or disincentive to attending health facilities. However, 
where there is a good road network or good and affordable 
transport, its effects will be less severe.
The effects of distance on utilization of health services have 
been of major interest to medical geographers. Studies have
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identified a negative relationship between distance and 
utilization. However, this relationship may vary according to 
illness and that it is not necessarily always negative or constant. 
(Phillips 1990) .
Distance decay is well-recognized spatial phenomenon which 
means that as a service or facility becomes more distant fewer 
people will patronize it. In general, studies tend to confirm a 
more or less gradual fall-off in utilization rates over distance, 
although the steepness of decline varies considerably from facility 
to facility. Distance decay is also known to operate differently 
for different social groups.
It is generally agreed that, only those close to a facility 
can derive full benefits from its services. Fosu 1986 indicated in 
a survey of health centre utilization in Ghana, that, 70 percent of 
attenders came from within a 3-mile radius, although the residents 
of this area comprised only 23 percent of the health centre's 
catchment population. Only 27 percent of attenders had come from 
beyond 4 miles, but 73 percent of the health centre's catchment 
population lived at that distance.
This implies that, if the maximum travel threshold is 
exceeded, utilization of health services will tail off 
considerably.
AGE AND SEX
Age and sex have long been identifies two variables
influencing utilization rates and types of services used. There
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have been some suggestions that elderly people are more likely than 
younger age groups to use traditional practitioners. Age however, 
does not necessarily have a clear influence on utilization rates. 
However, women with children under 5 years are bound to use the 
service more due to the fact that, those under 5 years are more at 
risk in terms of health.
EDUCATION
One of the recent issues of interest is the effect of 
education on utilization of health services. It has been observed 
that, education enhances both the knowledge of the use of health 
services and how to use them effectively. However, its effects are 
linked with income and socio-economic status.
A study in Cote d'Ivoire, found out that, having some 
education was associated with a higher use of hospitals as a source 
of primary care than was having no education (Lasker 1981) .
PLURALISTIC HEALTH CARE SYSTEM
Another important factor that seems to impinge on utilization 
in most parts of Ghana is the existence of pluralistic health care 
systems, which gives people a wider choice of types of therapies to 
utili ze.
It is known that, the use of various types of service will be 
much influenced by cultural prescriptions and the experience and 
opinions of others. Many patients may regard more than one type of 
therapy as appropriate.
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Most patients use two or more types of therapy concurrently. 
The choice of a modern therapy may follow non-success with a 
traditional remedy and vice versa.
In a study conducted by 0januga and Lefcowite 1982 in Nigeria, 
four types of consumers were identified:
1. those who used either western or traditional medicine 
exclusively.
2. those who used traditional medicine first and when 
dissatisfied, modern medicine.
3. those who went from modern to traditional medicine.
4. those who use both types simultaneously.
In Ghana, those who used both types simultaneously, are likely 
to be the dominant group, but study needs to be done to ascertain 
the fact. Thus in pluralistic health care system, patient 
satisfaction plays a major role as to which health care facility to 
use when sick.
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CHAPTER TWO 
2.1 KINTAMPO: A DESCRIPTIVE PROFILE
In this chapter we shall describe the Kintampo District, 
because the study took place in this area. It is important for 
readers to have a brief idea as to how the area looks like.
Specifically in this chapter we shall discuss in brief, issues 
such as, geographical location, population structure and social 
services of the district.
The district is one of the thirteen districts in the Brong 
Ahafo Region in Ghana. The district was carved out of the former 
Nkoranza and the Wenchi District in 1989.
2 .2 GEOGRAPHY
The district covers a total area of 7162 sq.km and forms part 
of the Kwahu-Wenchi range. It is believed that, its headquarters, 
Kintampo is the mid-point of Ghana. It is about 460 km from Accra, 
the capital of Ghana and 13 0 km from Sunyani, the regional capital 
of Brong Ahafo. The vegetation is high savannah grassland with 
secondary forests concentrated along the river valleys. The land 
is well-drained with a lot of streams most of which are perennial. 
The district has two rainy seasons corresponding to the farming 
seasons. The major season is from March to June and the minor from 
mid-July to November.
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Fig. 2.1 A MAP SHOWING THE STUDY AREA : KINTAMPO DISTRICT
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2.3 DEMOGRAPHY
The district has a population of 140,125 (projected from the
1984 census), and a population density of 19.1 per sq.km. The 
annual growth rate is between 2.6 to 3 percent.
The population structure depict a typical developing country 
population structure with children up to 14 years representing 
about 47 percent of the total population (Table 2.1). This is 
almost similar to the national figure which is about 45 percent-
Table 2.1 ESTIMATED POPULATION STRUCTURE OF KINTAMPO DISTRICT
From table 2.2 it could be seen that about 32.8 percent of the 
total population in the district comes from the administrative 
capital and its surrounding areas. This is similar to the picture 
in Ghana, where a little over 3 0 percent of the population lives in 
urban areas.
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Table 2.2 PROJECTED POPULATION BY SUB-DISTRICTS, 1995
SUB-DISTRICT P O P U L A T I O N PERCENTAGE
Kintampo 45,939 32 . 8
Eawadawa 21,798
New Lcngoro 19,228 13 . 7
Kunsu 15,068 10 . 8
Jema 14,976 10 . 7
Amoma 12,469 8 . 9
Anyima 10,647 7.6
TOTAL 140,125 100
Source: District Profile. 1994.
There are 150 settlements with numerous scattered hamlets. 
This militates against developmental facilities such as clinics and 
schools, because they have population of less than 500.
The Brong and Mo are dominant ethnic groups, with a large 
immigrants population from the northern part of Ghana, namely: 
Dagcmba, Konkomba and Dargati. From the south Dangbe and Ewe have 
settled mainly along the banks of the Volta River for the purpose 
cf fishing and farming.
2.4 ECONOMIC ACTIVITIES
Subsistence farming is the main occupation of the people. 
Yam, maize and tobacco are the main food and cash crops produced. 
Vegetables and legumes are also produced on significant scale for 
consumption and for sale. Poultry and livestock are kept for 
domestic purposes.
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The district has a very important market, which is an 
incentive for good economic activities. The market day is on 
Wednesdays.
2.5 EDUCATION
Although statistical figures are not available, casual 
observation shows that, the literacy rate in the district is very 
low.
Just about 19 percent of children under 5 years are in School 
and nearly 61 percent of children of school-going age are in 
primary school. As we move to the higher levels the situation 
worsens. For example, only 17 percent and 3 percent of children 
who are supposed to be in J.S.S. and S. S. S. respectively are in 
school.
Table 2.3 DISTRIBUTION OF SCHOOL ENROLMENT BY CATEGORIES
IN THE KINTAMPO DISTRICT, 1995
CATEGORY NUMBER OF SCHOOL TOTAL ENROLMENT
Kindergarten 70 4351
Primary 119 14191
J. S . S . 41 4048
S. S. S. 2 633
Source: DHMT. 1995. District Profile.
This shows a high drop-out of children at the higher levels. 
This situation is of great concern, since households with highly
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educated members enjoy better health.
2.6 POLITICAL ORGANIZATION
The district has Kintampo as both the administrative and 
traditional capital.
In line with the new local government system, the District 
Chief Executive is the political head. The District Chief 
Executive is supported in the day-to-day running of the district by 
the District Assembly, the Executive Committee within the Assembly 
and the various Sub-Committees, such as the Economic Development 
and the Social Services.
In the traditional sector, there are problems which are yet to 
be resolved. For example, there is misunderstanding between the 
Brongs and the Mos as to who have right over the district. In view 
of this, there is no paramount chief and no clear line of 
authority. Thus mobilization of the communities for community 
development is lacking.
2.7 TRANSPORT AND COMMUNICATION
There are two first-class roads in the district; the Techiman 
to Tamale (through Kintampo) and Techiman to New Longoro. They 
form part of the national trunk road network linking the north to 
the southern part of the country. Also there are two stretches of 
second class roads. Most of -he communities are linked by third 
class roads and permanent tracks, most of which become virtually 
unmotcrable during the rainy season.
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This makes health outreach programmes very difficult and
sometimes virtually impossible.
2.8 HEALTH FACILITIES
Up to the latter part of 1994, health services had been 
provided from 2 health centres; Kintampo and New Longoro health 
centres. Three new rural health centres have been constructed in 
addition to the two. There are three private maternity homes in 
the district. There is an MCH/FP Clinic at Jema in addition to the 
one at the Kintampo Health Centre.
In all 91 out of the 150 communities are provided with 
outreach services. These services include growth monitoring, 
immunization, health education, MCH/FP services and common ailment 
treatment.
Table 2.4 DISTRIBUTION OF HEALTH FACILITIES IN KINTAMPO
DISTRICT, 1995
SUB-DISTRICT HEALTH FACILITY NUMBER
Kintampo Health Centre 1
Private Maternity Home 2
Jema MCH/FP Clinic 1
Private Maternity Home 1
Amoma Health Centre 1
Kunsu Health Centre 1
Anyima Health Centre 1
New Longoro Health Centre 1
Dawadawa Served from Kintampo 
Health Centre.
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There is a National Rural Health Training School and a Health 
Research Unit. The school trains Technical Officers in Disease 
Control and Nutritional Officers. The Research Unit which started 
about a year ago is researching in vitamin A supplementation for 
infants.
The population-bed ratio for the district is about 3,500, 
while for the Brong Ahafo Region is 1,257 and for Ghana is 1,204. 
The population per doctor in the district is about 70,062, while in 
Ghana there is 1 doctor to 21,3 00 persons. WHO recommends a 
minimum of 1 doctor to 10,000 persons ratio for developing 
countries .
This shows how woefully inadequate health resources are in the 
district. This may affect the quality of care, if available to 
potential clients.
2 . 9  ENABLING ENVIRONMENTAL FACTORS TO HEALTH
The entire district has no access to conventional water 
supply. From Table 2.5 it could be seen that, rivers and streams 
are the major sources of drinking water for the people. It is 
estimated that about 25 percent of the population have no access to 
safe drinking water.
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Table 2.5 SOURCES OF WATER SUPPLY, KINTAMPO DISTRICT, 1995 .
Apart from the bore holes and some of the hand dug wells, the 
water supply sources are not protected from contamination.
Indiscriminate defaecation is still practiced. There are only 
seven KVIPs in the district and six septic tanks. The majority of 
the people use pit latrines.
Table 2 6 HUMAN EXCRETA DISPOSAL FACILITIES - KINTAMPO, 1994
T Y P E N U M B E R
KVIP 7 
Septic tank 6 
Bore hole latrines 2 3
Pit latrines Available in all communities
Source: District Profile. 1994
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It could be seen that good human excreta disposal facilities 
are inadequate.
Crude dumping of solid waste is the most common practice.
There is no proper drainage system in the district. Burrow 
pits can be found all over, as a result of erosion. Most of them 
are choked with solid wastes and are good breeding sites for 
mosquitoes and contamination of drinking water sources.
Good sanitary practices are extremely important to health. 
The poor sanitation in the district is a major health risk. Quite 
expectedly therefore, communicable diseases feature prominently in 
the OPD attendance. Malaria and Diarrhoea continue to dominate in 
the top five diseases reported at the OPD (see Table 2.7). For 
example in 1993 there were 2256 reported cases in malaria, but in 
1994 the number rose to 6067, an increase of about 169 percent. In 
the case of diarrhoea the increase was 54.5 percent. The reported 
cases in 1993 was 789 and in 1994 there were 1219 cases.
Table 2.7 TOP 5 DISEASES IN OPD ATTENDANCE, KINTAMPO DISTRICT
1993-94
D I S E A S E 1993 1994 % INCREASE
Malaria 2256 6067 168.9
Diarrhoea 789 1219 54 . 5
Accidents 125 1015 712 . 0
Skin Diseases 100 816 716 . 0
Intestinal worms 217 675 211 . 0
Total 3487 9792 180.8
Source: District Profile. 1994
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The immunization coverage in the district is low. The 
district is behind the SO percent goal of the health sector. For 
example, the coverage for DPT3 and OPV3 are 34 percent and 36 
percent respectively. The previous years were 26 percent for DPT3 
and for 0PV3 25 percent. Table 2.0 below shows the immunization 
coverage of the district over a two-year period.
An enabling environment for good health has been impeded by 
these factors and others.
Table 2.8 IMMUNIZATION COVERAGE, KINTAMPO DISTRICT 1992-94
1992 (%) 1993 (%) 1994 (%)
BCG 44 63 61
DPT3 26 26 34
0PV3 24 25 36
MEASLES 38 50 87
Source: District Profile. 1994
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CHAPTER THREE 
3.1 KINTAMPO HEALTH CENTRE: A DESCRIPTIVE PROFILE
In this Chapter, I present a description of the Kintampo 
Health Centre where the study was undertaken. This exercise is 
necessary to provide a background for the appreciation of the 
peoples' attitude towards the centre.
LOCATION
The health centre is located in the administrative capital of 
the district. Thus almost the mid-point of the district. 
Therefore, it is within the reach of about 52 percent of the total 
population of the district.
HISTORICAL ORIGIN
The Kintampo Health Centre was built by the British Reserve 
Force in then Gold Coast. It was to offer medical services to the 
British forces who were then stationed in that part of the country. 
It was handed over to the Ministry of Health when the British 
forces left the country.
Currently, it is the principal health facility in the district 
and it is in the process of being upgraded into a District 
Hospital.
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STRUCTURES
The structures are the same as left by the British. Few have 
been renovated and the rest are in bad state. The only new 
structure is the small block which houses the male, female and the 
children wards. There are few residential blocks for the staff.
FACILITIES/SERVICES
The health centre has about twenty beds. Out-patient clinic 
consultation is provided at the centre by two doctors and a medical 
assistant. It is the main services provided. Minor surgical and 
obstetrical services are offered. In-patient services are very 
minimal. There is a pharmacy department, while the laboratory and 
x-ray services are being set-up. There is an operating theatre but 
at the moment not functioning. The Maternal and Child Health Unit 
offer services such as antenatal services which are held twice a 
week, child welfare clinic and family planning services. The unit 
also undertake outreach services, during which curative treatment, 
immunization, health education and maternal and child health 
services are provided.
PERSONNEL
Currently, there are two medical doctors after almost eight 
years without one. There is a medical assistant and a dispensing 
technician. The following categories of nursing staff are 
available:
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Senior Nursing Officer 1
Staff Nurse/Midwife 2
Staff Nurse 1
Staff Midwife 1
Enrolled Midwife 1
Senior Enrolled Nurse 2
Enrolled Nurse 3
Community Health Nurse 5
Ward Assistant/Orderly 8 
There are few paramedical staffs
CURRENT DEVELOPMENTS
As stated earlier, the health centre is in the process of 
being upgraded into a District Hospital. As a result, a new and 
higger out-patient department is being built.
The operating theatre is also being renovated.
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CHAPTER FOUR 
4.1 RESULTS
In this chapter, I will focus on the findings obtained from 
the questionnaire. More specifically to try to answer why 
potential clients use or do not use the health centre at Kintampo.
I begin with the socio-demographic characteristics of the 
respondents. There were 1Q8 respondents in all.
4.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF 
RESPONDENTS
Socio-demographic characteristics were not investigated to see 
how they affected service utilization at the Kintampo Health 
Centre. However, it is important to see whether the respondents 
are a true reflection of the people in the district.
AGE
In all 55.6 percent of the respondents were within the age 
group 15 - 44 years, while 36.1 percent were in the 45 - 60 year 
group. The 61 and above year group, represented 8.3 percent. This 
is consistent with the population structure of the district (see 
Table 2.1).
GENDER
There was a little higher female respondents (51 percent) than 
male (49 percent) . This is not the true reflection in the
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district, where males constitute about 51 percent of the population 
and female 49 percent. The reason could be due to the fact that, 
women stayed at home during the period when interviews were held 
than men.
OCCUPATION
Occupation is said to affect service utilization, since those 
in the higher income brackets turn to use health services more than 
those in the lower group.
In this study, it was not possible to group the respondents in 
the different income groups. As a result it would not be possible 
to state whether the finding is consistent with the above stated 
fact .
From the data, about 34.3 percent of the respondents were 
farmers with traders constituting 26.9 percent. The unemployed 
were 15.7 percent, while 7.4 percent were teachers. Another 15.7 
percent were engaged in other occupations such.as, dress-makers, 
clerks and drivers.
RELIGION
In a pluralistic health system, like Ghana, one's religious 
belief may affect his choice of where to go for treatment when 
sick. This study as already stated, did not look at the 
relationship between religion and service utilization. The 
respondents were asked of their religious belief to see whether it 
reflects the general trend in the district. Of the total
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respondents, 58.4 percent were Christians and 32-4 perqent were 
muslim. The traditionalists represented 4.6 percent and another 
4.6 percent belongs to no religious group.
EDUCATIONAL STATUS
It is believed that, those with higher education are more 
likely to use health facilities than those with low educational 
level.
Table 4.1 provides an analysis of the educational levels of 
the respondents. It is expected that, lower educational level 
respondents will dominate to reflect with the general situation in 
the district. In all, 57.4 percent of the respondents have had no 
education, while 5 percent were primary school leavers. A total of 
25 percent were middle school/JSS leavers, with 8 percent having 
secondary school/SSS education. Just 8 percent were of post­
secondary school levels.
Table 4 .1 Breakdown of Educational Levels Among tlie Respondents
EDUCATIONAL LEVEL FREQUENCY PERCENTAGE
No Education 62 57 . 4
Primary School 5 4 . 6
Middle School/JSS 25 23 . 2
Secondary School/SSS 8 7 . 4
Post-Secondary 8 7 . 4
TOTAL 1C 8 100
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MARITAL STATUS
There are no available data in the district to compare with. 
However, married respondents were expected to dominate, since 
divorce is not common in most rural areas in Ghana. Also adults in 
rural areas marry in early age. Of the total respondents, 63.9 
percent were married while 24.1 percent were single. Those 
separated represented 7.4 percent and widows constituted 4.6 
percent of the respondents.
4.3 POTENTIAL CLIENTS
When one becomes ill, there are various places where he can go 
for treatment. The decision as to where to go are influenced by 
various factors, such as cost of service, distance and quality of 
care. (Shaw and Griffin 1995).
In this study out of the 89 potential clients, 66.3 percent 
used the health centre and 33.7 percent did not use the facility. 
They either went to other places for treatment or decided to stay 
at home.
4.4 REASONS FOR USING FACILITY
Users have various reasons for deciding to use a particular 
health facility when ill.
In this study, the most frequently mentioned reasons for using 
the health centre were proximity 66.1 percent and the presence of 
a medical doctor 64.4 percent (see Table 4.2).
The importance of these two factors have been identified in 
other studies. For example, the positive impact of the presence of
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a medical doctor in utilization was identified by Wong, Popkin, 
Guilkey and Akin 1987 in Philippines. The study found out that, if 
the professional providing care at public health facility was not 
a medical doctor, the demand tends to reduce. Phillips 1986 
identified the negative relationship between, distance and 
utilization.
Other reasons were mentioned by clients, why they used the 
health centre. For example, the availability of drugs accounted 
for 40.7 percent while trust in the health centre was 30.5 percent.
This confirms the assertion made by McKinlay 1972, that 
service utilization is affected by different groups of factors.
By trust in the health centre, users meant, they have the 
confidence that they would get appropriate treatment for their 
illness. In terms of low cost, they were comparing with the cost 
of attending the Holy Family Hospital at Techiman, which is the 
nearest hospital in the area. The cost of transportation was taken 
into consideration.
Table 4.2 DISTRIBUTION OF RESPONSES BY CLIENTS FOR USING
KINTAMPO HEALTH CENTRE BETWEEN JAN. TO OCT. 1995
R E A S O N S FREQUENCY PERCENTAGE
Proximity 39 66 . 1
Presence of Medical Doctor 38 64 . 4
Availability of drugs 24 4 0.7
Trust in the Health Centre 18 30.5
Facilities 9 15.3
Low cost 9 15 .3
Severity of Sickness 3 5 . 1
Good human relationship 1 1 . 7
Improved Sanitation 1 1 . 7
There were 5 9 respondents and some gave more than one reason
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When asked, what will make them continue to use the health 
centre, the following reasons were given. (See Table 4.3) 
Frequently mentioned reasons were availability of facilities 76.3 
percent (such as operating theatre and adequate wards) and 
availability of drugs 64.4 percent. Drugs were of concern to the 
clients as a female teacher remarked, 11good and non-expiring drugs 
should be available so that we do not have to buy drugs outside the 
hospi tal. "
Also commonly mentioned reasons were low cost 33.9 percent, 
more qualified personnel 32.2 percent and good human relationship 
was 27.1 percent. The following opinions support these findings. 
"Money should not be collected in every room, rather, there should 
be one final charge and receipt be issued for all money that are 
paid, " said a male farmer. A female trader also said: 1 the 
hospital workers should be gentle and be polite to the patients. 
They should not shout at us" .
Proximity, the presence of a medical doctor, availability of 
drugs, cost of service and human relationship, all played a 
significant role in the demand for the Kintampo Health Centre. 
Table 4.3 DISTRIBUTION OF RESPONSES BY CLIENTS FOR CONTINUOUS
USE OF THE HEALTH CENTRE
EXPECTATIONS FREQUENCY • PERCENTAGE
Availability of facilities 45 76 . 3
1 Availability of drugs 38 64 . 4
Reduce cost 20 33.9
More qualified personnel 19 32 . 2
Good human relationship 16 27.1
Good sanitation 14 23 . 7
Short waiting time 1 1 . 7
There were 59 respondents and same gave more than one reason.
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4.5 NON-USERS
There are instances when the facility is there, but other 
factors will make it look as if it does not exist. This happens 
when those who are supposed to use it decide not to, for various 
reasons.
In the study, various reasons were given by respondents, why 
they did not use the facility (see Table 4.4). The commonly 
mentioned reasons were high cost 46.7 percent,, lack of drugs 20 
percent. Other reasons mentioned were lack of trust 17 percent, 
poor sanitation 16.7 percent and inadequate facilities 13.3 
percent.
Table 4.4 DISTRIBUTION OF RESPONSES FOR NOT USING THE
KINTAMPO HEALTH CENTRE
R E A S O N S FREQUENCY PERCENTAGE
High Cost 14 46.7
Lack of drugs 6 20 . 0
Poor human relationship 6 20 . 0
Lack of trust 5 17. 0
Poor sanitation 5 16 . 7
Lack of facilities 4
No money 4
Long waiting time 3 IQ . 0
Sickness not severe 1 3 . 3
Net hospital sickness 1 3 . 3
There were 3 0 respondents and same gave more than one reason.
When asked what will make them use the health centre, the 
most frequently mentioned reasons were availability of drugs 76.7
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percent, adequate facilities 50 percent and competent doctors also 
50 percent. Other reasons mentioned were reduced cost 46.7 percent 
and good human relationship 26.7 percent (see Table 4.5).
Table 4.5 DISTRIBUTION OF RESPONSES THAT WILL MAKE
THE NON-USERS TO USE THE HEALTH CENTRE.
R E A S O N S FREQUENCY PERCENTAGE
Good drugs 23 76 . 7
Adequate facilities 15 50
Good Doctors 15 50
Reduced cost 14 46 . 7
Good human relationship 8 26 . 7
Availability of herbal drugs 5 16 . 7
Free for the Aged 2 6 . 7
There were 3 0 respondents and some gave more than one reason.
For those who were not sick or none of their household members 
were sick during the period of investigation, the most frequently 
mentioned reasons why they will use the health centre were 
proximity 84.2 percent, presence of a medical doctor 68.4 percent. 
Other reasons mentioned were availability of drugs 21.1 percent and 
low cost 15.8 percent.
From the results, it could be seen that respondents are 
looking for competent doctors and not just a medical doctor. The 
cost of services is also important to them, as expressed by a male 
farmer, ”money should not be collected in every room, rather, there 
should be one final charge and receipt be issued for all money that 
are paid." Respondents are prepared to pay for quality services. 
"We go there because there has been an improvement of the services
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at the health centre", said a female trader. This was also 
emphasized by an elderly woman, who said: "they should give us good 
services as done in Techiman Holy Family Hospital. Since we have
to pay, because God has left us alone."
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CHAPTER FIVE 
5.1 DISCUSSION
Of the respondents who used the health centre, proximity (66.1 
percent) was the most frequently mentioned reason why they used the 
health facility. Of those who were not sick during the study 
period, if they were sick or any member of thei£ household was 
sick, of the factors that will make them use the health centre, 
proximity (84.2 percent) was the most frequently mentioned. This 
agrees with other studies, such as the one by Fosu 1986, which 
indicated that more people will use a health facility if it is near 
them.
However, a study by Haran, Dovlo and Offei 1994, about quality 
of care in hospitals and health centres in Eastern Region of Ghana, 
they found out that, among hospital respondents, only 33 percent 
found proximity to be very important compared to 56 percent who 
thought it unimportant, but well over 73 percent of the health 
centre respondents regarded proximity as very important. Though 
the method used in the study is different from the one used in 
Kintampo, there seems to be agreement as far as health centres are 
concerned, that proximity is a very important factor in 
utilization.
We must not lose sight of the fact that, there are more to 
utilization than just the proximity of a facility. For example, in 
the study, of the 8 9 respondents who were sick or a member of whose 
household was sick, 30 (33.7 percent) did not use the facility,
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despite the nearness of the facility.
This serves to remind us that, proximity interacts strongly 
with other factors to influence utilization.
The results of the study, shows the importance of proximity in 
utilization of health services. People are more prepared to use 
facilities near them and most invariably it is their first choice.
Cost of services seems to be a great barrier to utilization. 
For example, in the study, of those who were sick, but did not use 
the health centre, cost (46.7 percent) was the most frequently 
mentioned reason why they did not use the facility. For them to 
use it, reduced cost (46.7 percent) was one of the four most 
frequently mentioned reasons. Even for those who did use the 
health centre, reduced cost (33.9 percent) is one of the three most 
frequently mentioned reasons, that will make them continue to use 
the health centre.
Looking at figure 1.1 in chapter one, one could see that, the 
introduction of user-fees in 1983 and 1985 were. followed by sharp 
drops in utilization. This is similar to other findings, for 
example, the study by Waddington and Enyimayew, 1989, in Asante 
Akim in Ghana, found out that, there were sharp drops in 
utilization in 1983 and 1985 when user-fees were introduced in 
Ghana. The possible explanation could be that, the price increase, 
did not go with improved quality of care. However, a study in 
Rwanda by Shepard et . al. 19 92 , to examine whether households would 
be willing to pay more for health care, showed that, the preference 
for the higher fees was overwhelming (88 - 93 percent) and the
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preference was aa strong in low-income households as amongst 
normal- income households.
The behaviour of utilization and cost can also be seen in 
figure 6, in appendix. Here, on the first two occasions when OPD 
fees were increased, attendance fell the subsequent months, but on 
the third occasion, an increase in OPD fees corresponded with an 
increase in attendance.
This seems to imply that, there are some other factors, which 
if well addressed, could off-set the effect or some of the effects 
of cost on utilization. This goes to confirm that, multiple 
factors act together to affect utilization.
It was observed that, the people were more concerned with the 
unapproved fees charged at the health facility. As a male farmer 
remarked, "money should not be collected in every room, rather, 
there should be one final charge and receipt be issued for all 
money that are collected. u
This suggests that, clients are more than willing to take 
responsibility of their health care issues, by paying the approved 
price for the service. This fact is supported by the statement of 
S. Ofosu Amaah 198 9, that, 11 in the African traditional system, 
every community and family understood the need to compensate the 
providers of health services in some form and that free health care 
conflicted with this tradition and undermined it."
We know that, the effect of higher user fees on utilization 
has important policy implications. If higher prices substantially 
reduce demand, then the social benefit of promoting access to
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health care would be considerably reduced.
T h u s  every effort must be made to reduce the unnecessary high 
cast of services at government health facilities.
At the Kintampo Health Centre, there is a single block used as 
male, female and children wards. The operating theatre is not 
functioning. The X-ray and laboratory departments lack equipments 
and materials to work with. All these turn to make the health 
centre unattractive to clients.
No wonder, availability of facilities (76.3 percent) was the 
most frequently mentioned reason that will make those who used the 
health centre continue to use it and for those who-'did not use the 
health centre, availability of facilities (5G percent) was one of 
the three most frequently mentioned reasons, that will make them 
use the facility.
Waddington and Enyimayew 1989, found out that, the physical 
facilities of an institution were another most important component 
of perceived quality.
Facilities usually enhance the clients satisfaction and 
willingness to use the health facility again. It relates to the 
physical appearance, materials and equipments as well as comfort, 
cleanliness and privacy.
Drugs play a very important role in making . people use the 
health facilities. For example, for continuous use of the health 
centre by those who used the facility during the period of the 
study, availability of drugs (64.4 percent) was the second most 
frequently mentioned reason. The reasons why those who were sick
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and did not use the health centre, availability of drugs (20 
percent) was one of the three most frequently mentioned reasons, 
and for them to use the health facility, availability of drugs
(76.7 percent) was the highest most frequently mentioned reason. 
It is important to take note that, not just drug, but good quality 
was the demand of the clients. A female teacher remarked, "good 
and non-expiring drugs should be available so that we don't have to 
buy drugs outside the hospital."
The importance of drugs was expressed by Annis 1981. He found 
out that, MOH health centres in Guatemala have a poor drawing power 
of potential clients because among other things, was the lack of 
drugs.
Waddington and Enyimayew 1989, also found out that, the 
availability of drugs was a very important factor in the patients' 
perception of quality of service. They observed that, many times, 
patients expressed their resentment at being charged a consultation 
fee and receiving a prescription but no drugs.
Haran, Dovlo and Offei 1994, also found out that, among the 
various list of factors, patients identified availability of drugs 
as the second most important factor after the presence of a doctor 
in the quality of care.
From the study, the presence of a medical doctor (64.4 
percent) was the second most frequently mentioned reason, that made 
those who used the health centre use it. For those who did not use 
the health centre, the presence of good medical doctor (50 percent) 
was one of the three most frequently mentioned reasons that will
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make them use it.
As stated earlier, Haran, Dovlo and Offei 1994, found out 
that, out of the 7 factors listed, respondents placed the presence 
of doctor (69 percent) as the most important quality factor.
However, clients are not looking for just a medical doctor, 
but a competent one, in whom they can put their confidence. For 
example, of the various factors enumerated by those who used the 
health centre as the reasons for using the facility, trust, was one 
of the four most frequently mentioned. For those who did not use 
the health centre, lack of trust was one of the four most 
frequently mentioned reasons and for them to use it, good doctors 
(50 percent) was one of the three most frequently mentioned 
reasons. Phillips, 1990, also stated that, Filipino mothers always 
wanted better-trained personnel to attend to them.
The patient always comes to the medical doctor in full 
confidence that he will be helped and that creates a strong 
intimate relationship between medical doctors and patients. To 
enhance utilization, this strong intimate relationship must be 
maintained by the presence of not just a medical doctor, but a 
competent medical doctor.
Poor human relationship ranked as the second most important 
reason for not using the Kintampo Health Centre after high cost of 
service.
Studies elsewhere have also demonstrated the importance of 
good human relationship in client perception on the quality of 
care. A classic example was the study by Waddington and Enyimayew
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1989, which observed that, the public regarded the attitude of 
staff as extremely important. They stated that, "it was an issue 
about which people were most passionate. "
It has also been found out that, patients often tend to 
evaluate quality in terms of the perceived efficacy or 
appropriateness of treatments. However, when lay people cannot 
judge the contribution of technical intervention to their well­
being, bedside manner of the professional's presentation (effective 
behaviour) becomes crucial. (Phillips 1990]
Really, attitude of providers is of great concern to clients 
and potential clients, as seen by the expression of an elderly 
woman, 1 the hospital workers should be gentle and be polite to the 
patients, that is, they should not shout at us."
While good human relationship by itself will not relieve the 
symptoms of clients, its presence attracts them to the facility. 
Another classic example is a clean environment.
Though quantitative studies were not done, observation from 
the results and the discussions shows that, U = f (P# CD, HR, F, 
CE, C# D) ,
U = utilization
f = function
P = proximity
CD = technically competent medical doctor
D = availability of drugs
HR = human relationship
F = facilities (eg. wards, operating theatre 
drugs).
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C = cost of services 
CE = clean environment 
However, detailed studies need to be done to ascertain this model.
5.2 CONCLUSION
The study was sufficiently modest in its requirements, that it 
could readily be replicated in other health centres for rapid 
assessment of factors affecting utilization and improve upon it.
The most important factors that tend to influence utilization 
were proximity, presence of technically competent medical doctor, 
direct cost of service, drugs and facilities (physical 
infrastructures and materials).
These findings were in agreement with previous studies done 
elsewhere.
A minimum level of physical access is paramount, however, the 
perceived quality of health care and faith in the provider may be 
traded off against considerable travel-time for many potential 
clients.
There is the willingness to use and pay for the service at the 
health centre, if the illegal fees are abolished and the quality of 
care improved.
The study shows a relationship linking providers attitude 
towards clients and utilization. If the effective behaviour of 
providers is disagreeable to clients, this may deter utilization.
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Clients who are poorly treated are likely to avoid using the 
facility next time.
There is also a relationship between clean environment at the 
health facility and utilization. This suggests that utilization 
can improve if good and clean environment is kept to attract 
potential clients.
5 . 3  POLICY IMPLICATION
A policy design to increase the use of health facilities, by 
decreasing cost of service and providing facilities at the door 
steps of the people would be expected to do little to increase 
demand for these services, if the quality of care is not improved. 
Quality of care is multifaceted and detailed research needs to be 
done to identify which of the facets would improve utilization 
considerably.
Governments and NGOs should not rush in putting up health 
centres without first making sure that, the various factors that 
influence utilization are well taken care off. *
Satisfactory standards have occurred in our health facilities 
as a result of discoveries of scientists, economic policies and 
advances in technology. However, some have stemmed from a desire 
for social equity, for example, a simple love of humanity. It is 
with improvements in quality of care inspired by these beliefs 
that, medical ethics should be seriously taught at our Medical 
Schools and other health institutions.
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At the Regional level:
- Health information systems should be established and 
equipped with the necessary equipment and personnel at 
the districts.
The Districts should:
- place a suggestion box at the health facilities in the 
districts to collect suggestions from clients for 
improvement of services.
periodic collection of views of clients concerning the 
services they are receiving through interviews.
- organise In-service training for all personnel with 
support from the region, as to how to receive and 
communicate politely with clients and also to upgrade the 
technical competence of personnel.
Set-up libraries with the support of the District 
Assembly, at all health centres.
establish incentive package such as, cash award; 
opportunity for further studies and recQgnition of good 
work .
measures aimed at quality improvement must be integrated 
into the daily activities of health care delivery, 
the DHMT together with the District Assembly must ensure 
that dilapidated structures are rehabilitated and the 
surroundings kept clean with facilities like adequate 
water supply.
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APPENDIX
Tahle 6. WORKLOAD FROM KINTAMPO DISTRICT ON HOLY FAMILY HOSPITAL 
TECHIMAN 1987-1995 (JANUARY - SEPTEMBER)
Y e a r TOTAL ATTENDANCE FROM KINTAMPO 
(OPD) DISTRICT
1987 6 4,2 72 10,283 (16%)
1988 66, 611 11(,323 (17%)
1989 67,773 12,199 (18%)
1990 6 8,080 13,616 (20%)
1991 62,913 11,324 (18%)
1992 69,480 12,506 (18%)
1993 50,375 5, 642 (11.2%)
1994 63,216 5, 816 (9.2%)
1995 (Jan-Sept.) 57,390 4, 758 (8.2%)
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Fig S.l OPD A T T E N D A N C E  KHC J U N E  ‘94 -OCT '95SHOWING PERIODS OF INCREASE IN OPD FEES
2000 O.
A 1U00 0)
T 1600 i i 1 \ I" o
T 1400 O *
E 0120rf̂
N
D 1000
•
A 800
N 600
C 400
fc 200
0
JUN JUL AUGSEPOCTNOVDEC JAN FEB MA APRMAYJUN JUL A U G S E P O C T
MONTHS
© OPD ATTENDANCE
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KINTAMPO DISTRICT
FACTORS AFFECTING UTILIZATION AT THE KINTAMPO HEALTH CENTRE
HOUSEHOLD QUESTIONNAIRE 
HOUSE NUMBER............
BACKGROUND INFORMATION
1. AGE 2. SEX M F
3. HIGHEST EDUCATION 4 . MARITAL STATUS
(a) No Education (a) Married
(b) Primary School (b) Single
(c) Middle School/JSS (c) Divorce/Separated
(d) Secondary School/SSS (d) Widow
(e) Post Secondary School
5. OCCUPATION 6. RELIGION
a. Christian 
b ‘ Islam
c. Traditional
d . None
e . Other
7. HAVE YOU OR ANY MEMBER OF YOUR HOUSEHOLD BEEN SICK 
DURING THIS YEAR?
1 . YES 2 . NO
If Yes go to question 8 
If No go to question 13
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8 ■ DID YOU GO TO OR SEND THE PERSON TO THE KINTAMPO HEALTH 
CENTRE?
1. YES 2• N0
If Yes go to questions 9 and 10 
If No go to questions 11 and 12
9. WHY DID YOU GO TO THE KINTAMPO HEALTH CENTRE?
1 .
2
3
4
5
10. WHAT IMPROVEMENTS WILL MAKE YOU CONTINUE TO USE THE KINTAMPO 
HEALTH CENTRE?
1 .
2
3
4
5
11. WHY DID YOU NOT USE THE HEALTH CENTRE? 
1 .
2
3
4
5
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12. WHAT WILL MAKE YOU USE THE KINTAMPO HEALTH CENTRE? (PROMPT)
2
3
4
5
13. ASSUMING YOU OR ANY MEMBER OF YOUR HOUSEHOLD IS SICK, WILL YOU 
USE THE KINTAMPO HEALTH CENTRE? 1. YES 2 NO
If Yes, give reasons 1
2
3
4
5
If No, give reasons 1
2
3
4
5
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