University of Ghana http://ugspace.ug.edu.gh RA427.9Ad9 bite C.l G370364 University of Ghana http://ugspace.ug.edu.gh COMMUNITY PARTICIPATION IN THE PRIMARY HEALTH CARE PROGRAMME IN AKWAPIM NORTH DISTRICT, EASTERN REGION BY PETER ADU-APPIAH THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF M. PHIL DEGREE IN GEOGRAPHY AND R ESOURCE DEVELOPMENT JUNE, 2002 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Peter Adu-Appiah, do hereby declare that this thesis consists entirely o f my own work carried out in the Department of Geography and Resource Development under a jo in t supervision o f Naa Professor J. S. Nabila and Dr. S. Agyei Mensah and that neither in part nor whole has this been presented for award o f another degree elsewhere. All references are duly acknowledged. Peter Adu-Appiah (Student) Naa Professor J. S. Nabila (Supervisor) Date f I Dr. Agyei Mensah (Supervispf) Department o f Geography and Resource Development University o f Ghana, Legon. University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to my mother, Mary Agyei, and my late father, A.K. Nkrumah, who in spite o f his deteriorating conditions o f health continued to support and encourage me, which have contributed in no small way to bring me where I am today. University of Ghana http://ugspace.ug.edu.gh A CK N O W LED G EM EN T From the beginning to the end, work on this project had involved many people. I am very grateful Tor their co-operation. I would like to thank particularly my brother, Alfred Akyereko Afrifa, for his encouragement and Financial support during all stages of the project. I thank Naa Professor J. S. Nabila and Dr. S. Agyei Mensah, lecturers at the Department o f Geography and Resource Development, University o f Ghana, Legon for their invaluable advice and constructive criticisms throughout the production of this thesis. I am very thankful for the time they made available notwithstanding their enormous pressure of work. The work could not have been possible without the full co-operation o f the Budget and Treasury Division of Akwapim North District Assembly particularly the officer in charge, Mr. E. K. Adusei, Mr. Paul Bediako (S. T. O.—DC), Mrs. Kate Mensah, Senior Nursing Officer and Sampson Asante all in the District Health Management Team, Tetteh Quarshie Memorial Hospital (T. Q. M. H.)—Mampong. My sincere gratitude also goes to Mr. Quaye o f Tetteh Quarshie Memorial Hospital who provided me all the necessary statistics and other information I needed to make this project successful. My final appreciation goes to my parents Madam Mary Agyei and the late A. K. Nkrumah, my brothers and sisters especially Matilda Pinamang and Cecilia Pokuah Agyemang. God richly bless you all. University of Ghana http://ugspace.ug.edu.gh ABSTRACT This study is about community participation in the Primary Health Care programme in Akwapim North District. Twenty-four years have passed since Primary Health Care (PHC) was first introduced at the Alma-Ata conference. In 1985 the World Health Organization (WHO) completed a ‘Review of PHC’. Such evaluations have shown that many o f the problems o f the PHC are concerned with the management o f PHC. An analysis of some of the management problems shows that they are deep seated and requires a fundamental reappraisal o f the existing systems. Against this background, a study was undertaken to collect data in five communities in the District, and the extent to which the community is involved in the programme was examined. This was done with the conviction that improved community participation in the concept would go a long way to reduce incidence o f diseases and also reduce the frequency o f avoidable deaths in the study area. Social and cultural values of the people in Akwapim North District were taken into account in the study since any interventions based on established values and practices are more sustainable. The study looked at levels o f community participation at both rural and relatively urban settings in the District. Though participation in general in the study area was not encouraging apart from immunization programmes, it was worse among the rural dwellers. This was due mainly to the fact that many have not met PMC personnel before. It was discovered that the socio-economic status of respondents influences Ihe degree of participation. It was also realized that intensive education about the PHC programme is required to enhance University of Ghana http://ugspace.ug.edu.gh participation. In conclusion, it can be said that community participation in the primary health care programme in Akwapim North District was not encouraging, therefore, if i recommendations made in the study would be implemented, it will enhance participation at all levels in the programme and help ensure health for all. v University of Ghana http://ugspace.ug.edu.gh CONTENT PAGE C H A PT E R ONE: B ackground of the S tudy----------------------------------------------------------1 1.1 Introduction.................................................................................................................................... 1 1.2 Statement o f the problem........................................................................ *................................. 2 1.3 Literature Review........................-................................................................................................5 1.3.1 The Concept o f PHC.......................................................................................................... 5 1.3.2 The Community Participatory Approach to PHC.....................................................12 1.3.3 Objectives o f Community Participation.................................................................... 16 1.4 The Objectives o f the Study....................................................................................................20 1.5 Assumptions-------------------------------------------------------------------------------------------------20 1.6 Conceptual Framework........................................— .................................................. ............. 20 1.6.1 Health Education Programmes-................ ..................................... — ------ ---------- 21 1.6.2 Preventive Health Services...........................................................................................22 1.6.3 Community-based W ork............................................................................................... 22 1.6.4 Organizational Development----------------------------------------------------------------- 22 1.6.5 Healthy Public Policy.................................................................................................. 23 1.6.6 Environmental Health M easures................................................................................ 23 1.6.7 Economic and Regulatory Activities........................................................................ 23 1.7 Methodology...........................-...................................................................................................27 1.7.1 Sources o f Data.............. — ........................................................................................27 1.7.2 Methods of Data Collection....................... .............................................................—27 1.7.3 Methods o f Analysis.............—..............-............. —.........-....................................... 32 University of Ghana http://ugspace.ug.edu.gh 1.8 Rationale o f the Study............................................................................................................... 1.9 The Study Area...........................................................................................................................34 C H A PT E R TW O : T he C oncept of P rim ary H ealth C a re ................................................ 37 2.1 The Origin o f PHC Programme..............................................................................................37 2.2 The Primary Health Care System in General..............................-........................................39 2.3 The Implementation o f the Primary Health Care Programme in Ghana........................44 2.4 Organization o f Primary Health Care Activities in Akwapim North District.............. 46 C H A PT E R T H R E E : E valuating the C oncept of C om m unity P a rtic ipa tion in the P rim ary H ealth C are P rogram m e: A G eneral O verview ..................................................52 3.1 The Community Participatory Approach to the PHC Programme— ............................ 52 3.2 Criteria for Evaluating Participation---------------------------------------------------------------- 55 3.3 Effectiveness o f the PHC Community Participatory Approach---------------------------- 61 C H A PTER FOUR: Levels of C om m unity Partic ipa tion in the PH C Program m e in the D istric t....................................................... ................ .......... -...................... 64 4.1 Introduction................................................................................................ -.............................. 64 4.2 Participation at the Individual Level........................................... .........................................-64 4.3 Participation at the Family Level....................... ................... ............................ — ...............66 4.4 Participation at the Community Level................... ....... ........................-.............................. 68 4.5 Participation at the Health Institutional Level...................... -................... — .....................70 University of Ghana http://ugspace.ug.edu.gh C H A PT E R FIV E: A ssessm ent of the C om m unity Partic ipa tion in the P rim ary H ealth C are P rog ram m e and the H ealth of the People...................................72 5.1 Socio-economic Impact o f Community Participation........................................................72 5.1.1 Morbidity and Mortality Levels...........................................................-.......................72 5.2 Pattern o f Diseases-----------------------------------------------------------------------------------------78 5.3 Education..................................................................................................................................... 81 5.4 Programme F inancing------------------------------------------------------------------------------------ 85 5.5 Sustainability o f the Primary Health Care Concept............................................................ 86 5.6 Initiatives in Primary Prevention Methods........................................................-.................. 91 5.6.1 Expanded Programme on Immunization..........— ................................------ ---------92 5.6.2 Nutrition Education.......................... -............................................................................95 5.6.3 Utilization o f Clean Water........................................................ —................................. 97 5.6.4 Environmental Sanitation— ..........— ---------- --------------------------------------------- 99 5.6.5 Awareness Programmes— ------ ------------ ----- ------------- ------------------------------100 5.7 Inhibiting Factors o f the Primary Health Care Programme................. - ............... ....... 101 C H A PTER SIX: Sum m ary , Conclusion and R ecom m endations.......................... —105 6.1 Summary................................................................................................................................... 105 6.2 C onclusion............................................................................................................................... 107 6.3 Recom m endations................. — ...............-..................— ................................................. 108 6.3.1 Community Sensitization, Motivation and Mobilization........ ........................... 108 6.3.2 Health Education by Health Workers..........................................-........................... 110 6.3.3 Adaptation from other Societies.......................... —----- ------------------- ----------- 1 10 University of Ghana http://ugspace.ug.edu.gh 6.3.4 Strengthening Community Initiative..........................................-.............................HO 6.3.5 Fusing Tradition with Modernity where Applicable............................................111 6.3.6 Refresher Courses for Health W orkers....................................................................111 6.3.7 Community Contributions......................................................................................... 112 6.3.8 Strengthening Intersectoral Collaboration----------------------------------------------- 112 6.3.9 Involving Prominent Personalities in Society in Health Education..................112 Bibliography................................................................................-..................................................114 Appendix 1 ..................................................................................................................................... 121 Appendix 2.......................................................................................................................................125 Appendix 3a--------------------------------------------- ------------------------------------------------------- 129 Appendix 3b.................... ....... ............................ -............. — ................ .......... ........................... 130 Appendix 3c.......................................— ....................................... - ........................ ....... ............. 131 Appendix 4— Alma-Ata Declaration.............-..................— ......................... .......................-132 LIST OF TABLES Table 1.1 Design for Selection o f Houses for Questionnaire Interview at the Sample Towns and Villages— ................. -................................-.............................. -................ 29 Table 1.2 Design o f Selected Towns and Villages for Questionnaire Interview................30 Table 2.1: Health Facilities in the District...................................................................................48 Table 3.1: Quantitative and Qualitative Indicators for Evaluating Participation................ 59 Table 5.1 Top 10 Causes o f Deaths.................................................... ................... -................ -7 8 Table 5.2 Top 10 Causes of Consultation/Morbidity----------------------------------- ---------— 81 University of Ghana http://ugspace.ug.edu.gh Table 5.3 Response on how to Improve Community Participation........ ............................ 83 Table 5.4 How Often the People in the Community Meet Primary Health Care Personnel................................................................................. -..........................................................84 Table 5.5 Immunization as a Necessity for Sound Child Health.......................................... 94 Table 5.6 Immunization Monitor— 2000: Akwapim North District.................................... 95 Table 5.7 Levels o f Food Production and Food Availability for the Past Ten Years----- 96 Table 5.8 Degree o f Access to Potable water for the Past Ten Years.................................99 Table 5.9 Level o f Formal Education in the Sampled Towns and Villages...................... 103 LIST O F FIG U R ES Figure 1.1 A Framework for Health Promotion Activities................................................. —21 Figure 1.2 Community Participation, Primary Health Care and Health Promotion Nexus.................................................................................................................................................. 25 Figure 1.3 Map o f the Area................................................................ ......................... ....... .........36 Figure 2.1 Map o f Akwapim North District Showing Locations o f Health Institutions—51 Figure 3.1 A Model for Primary Health Care Participatory Approach.................................53 Figure 3.2 Quantitative and Qualitative Dimensions o f Evaluation-.................................... 57 Figure 5.1 Out-patients— Morbidity: T. Q. M. H.— 1997-2000.............. ..................... .........73 Figure 5.2 Out-patients— Morbidity: Okuapeman Community Clinic— 1997-2000.......74 Figure 5.3 Out-patients— Morbidity— Adukrom Health Centre................. ..........................74 Figure 5.4 Out-patients— Morbidity— Okrakwajo Health Centre------------------- ............-74 Figure 5.5 Response on Knowledge o f Primary Health Care.................... -............-............76 Figure 5.6 Response on Whether they Consult Community Health W orkers-------------- 77 x University of Ghana http://ugspace.ug.edu.gh Figure 5.7 Health Status Since the Past Ten Years....................... ............. ............. -............. 79 Figure 5.8 Reasons for Improvement...........................................................................................80 Figure 5.9 Response o f Those Haven’t Met Primary Health Care Personnel Before.......84 Figure 5.10 The Degree of Response to Im m unization-................ -.........— ........................ 93 University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE BACKGROUND OF THE STUDY 1.1 Introduction Mortality levels in Sub-Saharan Africa are very high as compared to the rest o f the world. W hereas levels range between 40 and 60 years in life expectancy at birth in Sub-Saharan Africa, it is over 70 years in the developed countries (W orld Population D ata Sheet, 1994). In recent years, however, various governments have been making attempts to reduce the high morbidity and mortality patterns. These attempts call for strategies and actions in the health sector to be based on the concept o f Primary Health Care (PHC). This has brought mortality decline in Sub-Saharan Africa in recent years. For example, under-five mortality rate has decreased from 120 per 1000 live births in 1970 (UN/WHO, 1999) to 69 per 1000 live births in 1995 (World Population Data Sheet, 1995). In the past, the principal efforts o f health practitioners have been directed at the treatment o f infirmity rather than at its prevention. There are compelling reasons to believe, however, that this strategy will in the long run be a losing battle. Consequently, many workers in the general field o f community health have argued that primaiy prevention, that is attempt to prevent infirmity and, therefore, to reduce the rate o f occurrence o f disorder in the population at large, is in the long run the only acceptable strategy that we have available to us. The purpose o f these activities is to prevent the occurrence o f ill health rather than to merely limit its duration once it has already occurred (Bloom, 1968). 1 University of Ghana http://ugspace.ug.edu.gh The role o f PHC in international health is associated with the worldwide conference that was held at Alma-Ata and that proclaimed “Health for all by the Year 2000” (WHO/UNICEF, 1978). The participants at the conference proposed (hat the delivery o f PHC should be made available to people throughout the world and that this care needed to be based on current technology and acceptable practical methods. It also proposed that members o f communities needed to be involved in all aspects o f the planning and implementation o f health services. This research seeks to find out the extent to which the community, which is the main beneficiary o f the programme, is involved. It will also study the role o f the health providers in the discharge o f their duties to help ensure health for all. M oreover, the physical facilities such as hospitals, health centres, clinics and how well they are equipped would also be looked into. 1.2 S ta tem ent of the Problem H alf a century ago, the estimated infant mortality rate worldwide was 156 per 1000 live births, now it is 54 per 1000. Average life expectancy was about 46 years then; now it is 66. Smallpox was still called “the scourge o f the human race” ; now it is 20 years since the last person died o f the disease. Paralysis from poliomyelitis was dreaded in both rich and poor countries; now the disease is close to being eradicated worldwide. The prospects are also good for eliminating leprosy, measles, neonatal tetanus and micronutrient deficiencies (Bryant et al/WHO, 1998, vol. 19. No. 1 p. 1). Many other favourable contrasts o f these kinds can be drawn, and one could say that for the world as a whole, human health has improved more during the last half century 2 University of Ghana http://ugspace.ug.edu.gh than in any other period we know about. This reflects the much wider process o f economic and social development, but it is also the result o f remarkable achievements in the health sector. However, we should also look at some o f the other changes that have occurred. During the same 50 years, the world’s population has increased considerably, gaps between the rich and the poor have widened, a number o f hitherto unknown lethal diseases have appeared and shown their capacity to spread with frightening rapidity, health hazards caused by environmental deterioration are increasing, the costs o f heath care are spiraling, and the absolute number o f people w ithout access to the basic necessities for health is increasing, despite the continued increase in coverage with essential services. Formidable problems have been solved, but others have replaced them. With the emergence o f HIV/AIDS, which has the capacity to wipe o ff human race on the face o f the earth, if unchecked, there is the need to embark on vigorous measures to improve or protect the health status o f people all over the world. The Alma-Ata conference in 1978 was an important milestone in the struggle for health. The conference was organized in response to wide spread dissatisfaction w ith the existing health services. Despite great efforts by countries and the W orld Health Organization (W HO) in the late 1960s to improve and extend services, large numbers o f people, particularly in the rural areas o f developing countries, remain with no access to health care. Primary Health Care was seen as the route to health for all. Primary Health Care as outlined at Alma-Ata calls for three developments; universal availability o f essential health care to individuals, families, and population groups 3 University of Ghana http://ugspace.ug.edu.gh according to need; involvem ent of com m unities in p lanning, delivery and evaluation of such care (com m unity p a rtic ip a tio n — author’s emphasis); and an active role for other sectors in health activities. Making essential care universally available calls Tor a more equitable and efficient use o f health resources. The conference provided a green light for implementing primary health care concept, but passing resolution is one thing, implementing them is quite another. Very little has been done towards the attainment o f the objectives set at Ihe Alma-Ata conference since 1978. Eight specific elements o f PHC were identified at Alma-Ata. At the level o f individual, the family and the community these eight elements must come together to constitute PHC. At the level o f central bureaucracy each element exists in a separate government ministry. Hence, intersectoral collaboration is a key element o f PHC. However, because o f rigid compartmentalism in government ministries there has been more discussion than action outside the health sector (Ebrahim and Ranken, 1988). Hence, flexibility and adaptation in long established bureaucracies are essential. For an uninhibited development o f PHC it may be necessary to take a careful look at existing organizations and structures, both within the administration and at the community level. One basic element in the PHC is the full involvement o f the community in all aspects in the discharge o f PHC programmes. My personal experience in Asante Akim North District when I was attached to (he PHC Unit at Agogo Hospital revealed that this aspect, that is, Ihe involvement o f Ihe people, needs revolutionary measures to improve upon it. During this period, whenever some o f my colleagues and 1 visited 4 University of Ghana http://ugspace.ug.edu.gh the people and talked about preventive health care, what we were usually told was “you little kids what do you know to tell me what is good for me” The people in the area were not willing to abandon their old ways o f life, which could be disastrously detrimental to their health. A typical case in point is what is happening in W assa Akyempem, a mining town near Tarkwa. A town o f about 10,000 residents prefers to seek medical treatment from spiritual centres like “Nkaba” Gardens, fortune-tellers and malams. Their resort to unorthodox methods o f healing has rendered a modern clinic built by Satellite Goldfields Limited (SGL) a white elephant. According to a medical assistant in charge o f SGL clinic, Mr. W ilson Enyi Okpa, attendance is so poor that for three or four consecutive days, nobody from the community would report for treatment (Mirror, March 25 2000, p. 1). This study sought for solutions to these problems so that the people would accept and participate in the process o f health delivery to ensure Health For All (HFA). 1.3 Literature Review Review o f the literature is divided into three main sections. These are the concept o f the PHC programme as an alternative form o f health delivery system; the community participatory approach to PHC; and the objectives o f community participation. Each section is reviewed below. 1.3.1 The Concept o f PHC A great deal has been written about primary health care before and after the Alma-Ata Declaration in 1978. Almost all nations o f the world were represented at the meeting and discussions ranged far and wide. The unanimity o f the decision indicates that PHC is considered desirable and possible in all types o f political, social, economic and cultural environments (Ebrahim and Ranken, 1988). A number o f publications by 5 University of Ghana http://ugspace.ug.edu.gh the World Health Organization, in its series “Health For all”, provides clarification on strategies, managerial processes, monitoring and evaluation. There has also been a wealth o f literature in scientific journals and in the form o f books. This is because the concept o f PHC is more than a programme. It entails change. It requires changes in concepts and ways o f thinking. Its implementation is a process that calls for wide- ranging changes in established systems and institutions as well as in communities. The question o f how to ensure the “Health For All People” and the ensuing debate during the 1970s and the appointment o f Dr. Halfdan M ahler as the D irector General o f WHO in 1973 played a very active part in stimulating debate on these questions. It was during this period that the idea o f Health “For All by the Year 2000” began to emerge as a suitable visionary goal, and that o f primary health care as a realistic strategy for attaining it (Bryant et al/WHO, 1998, p.80-81). Initially, many regarded PHC as a rudimentary form o f medical care, on a par with traditional healers, “barefoot doctors’', and the like (Bryant et al/WHO, 1998). They saw it as suitable mainly for places in which no modem medicine was available. Situations in some developed countries particularly, the United States seem to give credence to this assertion. As a WHO member nation, the United States has endorsed PHC as a strategy for achieving Health for all by the Year 2000. However, PHC with its emphasis on broad strategies, community participation, self-reliance, and a multidisciplinary health delivery team, is not the strategy for improving the health o f the American people (Stanhope and Lancaster, 1984). 6 University of Ghana http://ugspace.ug.edu.gh However, experiences in four industrial countries w ith different socio-economic settings— Canada, Finland, Hungary and the Netherlands— are indicative o f the relevance o f the programme in the advanced countries (WHO, 1990, pp. 30-53; 98­ 132; and 188-201). A typical example is the striking reduction in mortality from ischaemic heart disease and injuries in Canada, which must be due at least in part to a reduction in risk factors as a consequence o f preventive programmes (WHO, 1990). The cost o f health care is increasingly becoming more expensive. In 1994 for instance, Americans spent $982 billion, or nearly 14% o f the gross domestic product (GDP), on health care (Shalala, 1994). This percentage is 40% higher than in Canada, the country that spends the next largest amount (Altman, 1995). This figure is expected to rise to 2.1 trillion or 20% o f the GDP by the year 2003, i f nothing is done to halt this course (Shalala, 1994). These increased costs have been accompanied by another significant problem, which is more pronounced in developing countries; poor access to health care. PHC plays important role here since it provides the most affordable health care available to all. Because o f the concern to cost, access, and quality o f health care, significant change is expected in the next decade. According to Stanhope and Lancaster (1996), several trends including demography, technology, and economics, will have an impact on the way these changes will evolve. Bryant et al/W HO (1998) consider inadequacies in information systems, decision­ making mechanism and other support systems as the areas that need attention for strengthening health care. They believe that “the concept o f PHC is still not understood clearly enough”; and that scientific medicine— abetted powerfully by market forces— pushes on as if equity problem did not exist” (Bryant et al/WHO, 7 University of Ghana http://ugspace.ug.edu.gh 1998, pp. 107-115). One could not agree more with them as far as information management in the health sector is concerned. Information must flow among various health institutions, which have common problems on hand. For instance, records o f a patient transferred from one health centre to another must be sent to the receiving centre for purposes o f continuity and an effective administration o f the ailment. The means through which such information should be transferred should be cost effective and fast enough. It has been argued that hospitals and PHC are different poles o f the health care system, and that money spent on one means less for the other. Some people would prefer to enhance the position o f PHC at the expense o f hospitals. Others, who see hospitals as the repository o f the best that medical care has to offer, believe they should not waste their time on other facets o f health care (Bryant et alAVHO, 1998). At a meeting on the role o f PHC, held in February 1997 in Gombe State, Nigeria, to reconcile these tw o points o f view, PHC was seen as a key to attaining health for all, but hospitals must not be allowed to remain aloof. The W HO’s call for “Health for All by the Year 2000” heralds the greatest exercise in management by objectives undertaken on a global scale. Many countries have responded with national policies, statements o f intent and plans for including PHC into the national planning process. According to Ebrahim and Ranken (1988), however, there has often been less success in the translation o f these plans into actions, except in the case o f a few countries and several pilot projects. W hereas the pilot projects have helped to evolve the basic technology o f PHC and have provided a 8 University of Ghana http://ugspace.ug.edu.gh measure o f the required administrative support, there has been less evidence o f success in applying the system. W orld Health Organization (1990) observes that finance has been a major problem, which hinders the development o f PHC programme. Given that the proportion o f government resources devoted to health in poor countries is already small and not deployed in the most cost-effective way, the challenge in some o f these countries is to maintain the levels o f development already reached. N ew sources o f finance and improvement in the use o f existing resources hold out the hope o f gains in PHC without additional central government funding. Those responsible for political and administrative decisions are often inadequately supplied w ith data in the health sector (W oelk and Moyo, 1995). Increasingly health management systems are being set up to make up for the deficiency. This is an institutionalized and systematized form o f collecting, processing and presenting health information, w ith the aim o f using the data for management, planning and decision­ making. Another important area is the monitoring o f disease, especially the tropical diseases with a high incidence rate such as M alaria (Kirton et al, 1992) and Tripanosomiasis (Sleeping Sickness) (Rogers and William, 1993). Geoinformation Systems (GIS), sometimes w ith the help o f satellite data, are nearly always used for such complex subject material. Because o f their analytical capabilities, these provide new scope for investigating mechanisms by which diseases are spread as well as their control (M ott et al, 1995). These systems, however, make very high demand on the qualifications o f the user and the costs o f installing a GIS are comparatively high 9 University of Ghana http://ugspace.ug.edu.gh (Bogarts, 1991). They are therefore, only o f limited use in the daily routine o f a developing country like Ghana. The W orld Bank asserts that health is now considered as a basic component o f human capital and, hence, an important basis for development (The Bank, 1986). This is very true for several reasons. For instance, improving the health status o f women would not only free them from the danger o f diseases, but it will also increase their capacity to participate in the economy. Also, as traditional support systems decline in influence and an increasing number o f women come into contact with the modern health care system, the health sector becomes a major focus o f activities for the promotion o f values on breast-feeding, small family size and birth control. A major portion o f literature in health and population has concerned itself with measuring the health status o f population. According to Barke and O ’Hare (1986, p. 55), the simplest way o f measuring the health service provision and, hence, the health status o f a population is through the use o f life expectancy. They notice that even though life expectancy in the less developed countries has increased by a dramatic 50% between the 1940s and the 1970s, it still remains far below that o f the more developed countries. Life expectancy at birth is only 55 years, a reflection o f the low health status o f the population resulting from low availability o f health service. M any authors have tried to establish a relationship between the Gross National Product (G.N.P.) and health levels. Goldthorp (1993, p. 23) has found out that G. N. P. and health service provision are not everywhere related. He observes that in Sri Lanka, Cuba, China and Panama, the health levels and the level o f health service 10 University of Ghana http://ugspace.ug.edu.gh provision are higher than incomes suggest while in the M iddle East, the health levels are lower than suggested by incomes. He advances that in Sri Lanka, there exists an active health programme based on PHC while in the M iddle East little has been done to improve on the health status among the majority o f the people. Barke and O'Hare have also noticed that, Tanzania, one o f the poorest countries in the world has achieved a greater health level than its G. N. P. suggests due to a vigorous programme o f primary health care. Inasmuch as one would not find any difficulty accepting the findings o f both Barke and O ’Hare, and Goldthorp, one must not lose sight o f the fact that, all things being equal, a country with higher G.N.P. relative to its total population (GNP per capita) will perform better in the area o f health service provision, than a country with a smaller G.N.P per capita. Other findings on health service provision have focused on the relationship between health care delivery and the social environment. In a study o f Costa Rica using multiple regression analysis, Rosero (1988) finds out that the expansion o f PHC accounted for 43% decline in infant mortality between 1972 and 1980 while increased secondary medical care accounted for 32% as against 25% for economic progress. Orugubole and Caldwell (1983) believe that mortality decline in rural Nigeria is not really a matter o f overcoming ignorance but providing a sufficient density o f health service o f a reasonable calibre. Adeokun (1986) sees it in a slightly different way. He is o f the opinion that mortality decline can only be achieved through increase in the number o f medical doctors, massive public education, reduction o f economic difficulties and the reduction o f population growth. The tw o positions taken by Orugubole and Adeokun are necessary for total development o f the health sector. 11 University of Ghana http://ugspace.ug.edu.gh It has been a priority o f many governments in developing countries to provide access to medical care especially for children. This concern has led many governments to establish large public health care system that provides medical care free o f charge (de Ferranti, 1985). The recent financial crisis in the Third W orld has induced many o f these governments and international donor agencies to re-evaluate the policy o f free access and to consider charging user fees for medical care. Proponents o f this policy argue that revenue from it can be reinvested to improve allocative efficiency (de Ferranti, 1985; Jimenez, 1986). Opponents o f this view argue that user fees will cause substantial reductions in medical care utilization especially among the poor (Cornea et al, 1987; Gilson, 1988). There is no doubt that health institutions need to be adequately equipped to meet the health needs o f the people. However, questions are asked as to whether the revenue generated from user fees will go to improve the institutions with which it was intended for. There is also the question o f affordability considering the generally low-income status o f majority o f the people especially in developing countries. 1.3.2 The Community Participatory Approach to PHC The philosophy o f community participation is not new in development circles. It made its way into International Development Assistance Thinking (IDAT) during the late 1960s and early 1970s (Cook and Donnelly-Roark, 1994). Some studies that evaluated the failure o f the first two decades o f International Development Assistance to eliminate world poverty suggested that the mere transfer o f western models might not respond very well to the realities o f life in the developing world. Participation in planning by the beneficiary communities was, therefore, recommended as a way o f ensuring that projects serve the needs and priorities o f the beneficiaries and also 12 University of Ghana http://ugspace.ug.edu.gh would be appropriate to their political and socio-cultural context (Huntington and Nelson, 1976; Chambers, 1983). Also a review o f the Bank’s financed projects in mid 1980s shows that failure to attend to social variables (through participation) in project design and implementation led to the failure to attain project aims and sustainability (Kottak, 1985). The concern for popular participation in development in Africa is a recent development, and according to Cook and Donnelly-Roark (1994), it is the brainchild o f NGOs. The NGOs took the initiative at the UN General Assembly in 1988, w hich led to the organization o f the International Conference on Popular Participation in the Recovery and Development Progress in Africa, held in Arusha, Tanzania in 1990. The agencies, Government and Non-governmental Organizations at the conference adopted an “African Charter for Popular Participation in Development and Transformation” also known as the ARUSHA DECLARATION (Cook and Donnelly- Roark, 1994, p. 86). This charter, among other things, called for the establishment o f new partnership with the people, ensures the involvement o f women at all decision­ making and protects people’s basic human rights. The principle o f popular participation in social and economic development programmes, including health development is now widely accepted. For about two decades now, the development community in Africa has moved away from top-down approaches towards more participatory bottom-up approaches. This is due to the recognition that participation is crucial i f not the ultimate way to achieve both short-term development and long-term sustainability. In the same vein, health providers are beginning to appreciate the necessity for incorporating local participation into health care delivery system. 13 University of Ghana http://ugspace.ug.edu.gh Participation in development is said to be development to be achieved w ith the people and for the people. Brown and W yckoff-Baird defined community participation broadly as “a continuum, from limited input into decision-making and control to extensive input into decision-making and ultimate stewardship o f the resources” (Brown and W yckoff-Baird, 1992, pp.43-52). At the level o f specific policies and programmes, however, the concept is understood and interpreted in different ways and is very much influenced by political and socio-economic milieu. For instance, participation has been defined as “a way o f factoring local behaviour and beneficiary assessments o f risks, costs and benefits into project design.. .those assessments consist o f rational economic decisions in the context o f the social/cultural and economic environment, they are inclined to be misunderstood by, or better still the decision in question” (Cook and Donnelly-Roark, 1994, p. 85). Paul (1987) portrays the controversy surrounding the definition o f participation. He argues that, the definition o f participation is a matter in which there is considerable disagreement among development scholars and practitioners. For certain activist groups, participation has no meaning unless the people involved have significant control over the decisions concerning the organization to which they belong. Development economists tend to define participation by the poor in terms o f the equitable sharing o f benefits o f projects. Yet others view participation as an instrument to enhance the efficiency o f projects or as the co-production o f services. Some would regard participation as end in itself, whereas others see it as a means to achieve other goals. These diverse perspectives truly reflect the differences in the objectives for participation that might be advocated by different groups (Paul, 1987, P- 2). 14 University of Ghana http://ugspace.ug.edu.gh It appears there is no single definition for participation so long as the milieu o f community participation varies. Perhaps what matters is whether there is unanimity or not academic work on participation must go on. In line with the research work going 011 in the midst o f diversity, World Bank, in its in-depth study o f twenty bank-support operations that are considered participatory, defined popular participation as a process by which people, especially disadvantaged people, influence decisions which affect them (W orld Bank, 19 9 1 a). Here the disadvantaged people refer not only to the absolute poor, but also to a broader range o f people who are disadvantaged in terms o f literacy, ethnicity, and gender among others. Also ‘influence’ as used implies more than mere involvement in project implementation or sharing in the project benefits. This definition is inciting and purposeful. However, the operating definition o f community participation for this research is that by Paul as “an active process by which beneficiary/client groups influence the direction and execution o f a development project with a view to enhancing their well being in terms o f health, income, personal growth, self reliance or other values they cherish” (Paul, 1987, p. 3). This definition first o f all implies that, the context o f participation is the development/programme o f which the Primary Health Care concept is no exception. Secondly, the focus is on the ‘active process’ by which beneficiary communities/groups ‘influence’, rather than being influenced by government agency or non-governmental organization. The beneficiaries become the object and subject o f development, which is the brain behind community participation. Thirdly, the involvement o f the beneficiary communities is not for mere sharing o f project benefits or like the practice o f democracy where 'participation is just by 15 University of Ghana http://ugspace.ug.edu.gh voting’, but rather participate to ensure that their needs are reflected and they as well w ork towards its realization. However, health matters are highly specialized area, which requires considerable period o f training to play any meaningful role in its delivery. In view o f this community participation in the primary health care is highly restricted to functions, which are not highly technical and can be performed by some level o f training. This notwithstanding, if a PHC programme is well designed and the roles to be performed well defined, popular participation would not be a problem even among people with little educational background. Lastly, community participation refers to a process and not a product. It, therefore, presupposes that participation is an on going process and not static. It has feedback loops to ensure self-assessment to ensure realization and sustainability o f the project. From the operational definition, it is w orth cautioning that community participation in the project context should not be construed to mean that the nature and scope would be uniform in all cases. In defining community participation it is important to recognize that the community is self defined entity. Only those within the community know who belongs and who does not. Communities are made up o f different stake holders that have a variety o f defining characteristics, for example, gender, class, power, ethnicity, religion, age, etc. (BSP, 1993). 1.3.3 Objectives o f Community Participation Notwithstanding the variations in the nature and scope, community participation seeks to achieve one or more o f the following objectives: empowerment, beneficiary capacity building, increase project effectiveness, improving efficiency and project cost sharing (Paul, 1987). These are discussed in turn: 16 University of Ghana http://ugspace.ug.edu.gh i Empowerment: According to Farrington et al, (1993), the shift in some branches o f development theory during the 1980s away from the prescription o f top-down approach, towards an alternative development model, has at its root a conception o f empowerment as a form o f social change brought about by local problem-solving technique acquired through participation. Development, therefore, should lead to an equitable sharing o f power and to a higher level o f people, in particular the weaker groups’, political awareness and strengths. Any project or development activity is then a means o f empowering people so that they are able to initiate actions on their own and thus influence the processes and outcomes o f development. Empowerment aspect o f development is one that places emphasis on enhancing decision-making, autonomy, local self-reliance, direct (participatory) democracy, and experiential social learning. Its starting point is the locality, because civil society is most readily mobilized around local issues. In reality, empowerment would not be realized from top-down development approach either imposed from outside or our immediate leaders, rather it should be brought about through people’s own involvement in development. ii Capacity building. Another objective o f community participation closely related to empowerment is building the capacity o f beneficiaries w ith regards to decision­ making. By capacity building we mean the efforts aimed at strengthening the skills and knowledge o f the beneficiaries so that they could take on responsibilities for managing segments o f the project themselves (Paul, 1987). Capacity building is believed to be the in-built mechanism to ensure sustainability o f a project, especially foreign supported projects, after the withdrawal o f the supporting agency concerned. 17 University of Ghana http://ugspace.ug.edu.gh In most cases beneficiary participation in especially monitoring and evaluation makes the project ongoing and self-sustaining (Cook and Donnely-Roark, 1994). The ability to empower and build genuine capacity o f beneficiary communities and untrained elected officials need ongoing skills upgrading, so that beneficiaries can manage local planning at all stages o f the project cycle without continual donor support. In the words o f Oakley “participation helps to break the mentality o f dependence which characterizes much development work and as a result, promotes self-awareness and confidence and cause rural people to examine their problems and to think positively about solutions” (Oakley, 1991, p. 172). Participation in essence, is concerned with human development and increase people’s sense o f control over issues, which affect their lives, help them to learn how to plan and implement and on a broader scale prepare them to participate at both regional and national levels o f decision-making. In short, capacity building through participation ensures high likelihood o f project sustainability. iii Effectiveness. Community participation also has the power o f increasing the effectiveness o f the programmes as instruments o f health promotion and rural development. Effectiveness refers to the degree to which a given objective is achieved. In the view o f Oakley (1991), many development projects, in the past, have not been effective in achieving their objectives because local participation has often been overlooked. Participation allows local people to have a voice in determining objectives, make their local knowledge and resources available, which contribute to 18 University of Ghana http://ugspace.ug.edu.gh better design, setting realistic objectives to meet the needs o f the people and implementation after careful consideration o f local constraints and for that matter project effectiveness. iv. Efficiency. Participation is believed by many writers to have the power to ensure efficiency because o f timely beneficiary input. Efficiency implies greater chance that available resource will be used judiciously. It expresses cost-benefit or input-output relationships (Paul, 1987). Participation minimizes misunderstanding, prom otes interaction, agreement and cooperation and thus, time and energy spent by professionals explaining or convincing people o f a project’s benefits. It is also cost- efTective since, if rural people are taking responsibility for a project, fewer costly external resources would be required and highly paid professional staff will not be tied down in the details o f the project (Oakley, 1991). v. Cost sharing'. Community participation is also meant to ensure that beneficiary communities contribute in their own small way, either in the form o f labour, cash or undertake project maintenance. This issue o f cost sharing, in essence reduces the burden o f the financiers while al the same time putting the sense o f ownership in the beneficiaries It could also be taken to mean a way o f preventing abuse and misuse. vy. Sustainability. Oakley has argued strongly that an important aim o f making participation part o f a project is to ensure the sustainability o f the project after the withdrawal o f the development partners (Oakley, 1991). According to him, experience suggests (hat externally motivated development projects frequently fail to sustain themselves once the initial level o f project support and input either diminish or are withdrawn. Participation is, therefore, seen as an antidote to this situation in that it can ensure that local people maintain the project’s dynamics. Others including Haile 19 University of Ghana http://ugspace.ug.edu.gh (1980), have argued that participation ensures understanding o f the project hence, their ability to extend the project even after the withdrawal o f the initial funding. 1.4 The Objectives of the Study The main objective o f the study is to find out extent o f people’s participation in the Primary Health Care programme in Akwapim North District. Specifically, the study seeks to achieve the following: a) Assess the nature o f the health delivery system under the PHC concept. b) Investigate what factors influence participation in the programme and recommendations made to improve community participation. c) Evaluate the effectiveness o f the participatory approach to PHC programme. 1.5 Assumptions i) Success o f the PHC programme depends on community involvement or participation. ii) Immunization is very necessary for child health. 1.6 Conceptual Framework The framework for health promotion activities devised by Ewles and Simnett (1992) provides a useful model to help clarify the activities with which the health promoter may be involved. It is not the intention o f Ewles and Simnett that the framework should be viewed as a rigid classification. Indeed they are at pains to point out that activities may not always fall neatly into the identified categories and that overlap will inevitably occur. They also stated clearly that the framework cannot encompass the entire gamut o f activities and that some health promotion will occur both informally 20 University of Ghana http://ugspace.ug.edu.gh and accidentally. O f great importance, according to the authors, is that health promoters should be aware that health promotion embraces a wide range o f activities. The framework comprises seven areas o f health promotion activities as shown in figure 1.1, and is concerned with “planned, deliberate activities” . Each o f these seven areas will be considered individually and suggestions as to how such a framework can be applied to PHC as a strategy in promoting community health will be provided. F igure 1.1: A F ram ew ork fo r H ealth P rom otion A ctivities Source: Ewles and Simnett (1992). 1.6.1 Health Education Programmes: The majority o f health promotion programmes fall into the category o f primary health education, that is, education directed at “healthy” people. Example o f such education includes general life style, healthy eating, fitness or exercise, sexual health, good hygiene and many more. However, it is unrealistic to expect that all members o f the population will always be at an optimum state o f health and strategies for both secondary and tertiary health education are required. For example, a community nurse 21 University of Ghana http://ugspace.ug.edu.gh may adopt the role o f facilitator o f a “sensible drinking group” set up specifically to help those for whom excessive consumption o f alcohol has become a contributory factor towards their present state o f ill health. Such practices can be replicated or incorporated into the operations o f the PHC unit in the Akwapim North District. 1.6.2 Preventive Health Services: A prime function o f primary health care is the provision o f preventive health services. A type o f services offered is variable and depends on the size and nature o f the communities as well as the philosophy o f the PHC unit. But it is likely that the majority o f PHC units provide both voluntary and statutory health screening and many offer immunization programmes. This aspect o f the framework is one o f the most frequent routines being carried out by Tetteh Quarshie Memorial Hospital in conjunction with the M inistry o f Health, especially immunization/vaccination against childhood killer diseases. 1.6.3 Community-based Work: The village level provides an opportunity for people to engage in self-help activities. Such activity is “community-led”; the communities identify their own health needs and actively participate in addressing them. An example could be a group o f people who have concerns about their health and set up their own health related discussion group, facilitated by the community health nurse. 1.6.4 Organizational Development: Recent years policy development in PHC has tended to focus on sexually transmitted diseases especially HIV/AIDS, nutritional and maternal and child health care, family planning, and immunization. 22 University of Ghana http://ugspace.ug.edu.gh 1.6.5 Healthy Public Policy: Community health nurses are well placed to influence management about policies that may affect the wider population, for example, policies aimed at improving and increasing facilities for immunization. 1.6.6 Environmental Health M easures: In recent years environmental issues have been high on the agenda o f PHC professional, not only in relation to improving physical conditions o f the environment, but also in respect o f the effect o f working activities on the health and well-being o f the community at large. 1.6.7 Economic and Regulatory Activities: In about four decades ago, government legislation has attempted to provide safeguards in respect o f ensuring sound delivery o f health services in Ghana. The Food and Drugs Law, and the Private Hospitals and Maternity Homes Act (1958) were enacted to ensure that curricular and examination methods conform to professional standards. A regulatory body was to be established for the regulation o f traditional and alternative medicine aimed at integrating services and based on registration o f practitioners and associations at district, regional and national levels (MoH, 1996, p. 20). All said and done, cooperation is essential if legislation is to be successful as a measure o f health protection. It must be emphasized here that, the various health promotion areas are not treated in isolation by fragmented institutions and policies. They are linked in a complex nexus with the community. The model is, therefore, modified as shown in figure 1.2 to show how sustainable development o f the PHC programme can be achieved through community participation. This new model is based on the idea that sustainable 23 University of Ghana http://ugspace.ug.edu.gh development cannot be achieved when programmes and policies leave out the beneficiaries. This implies that any programme that seeks to promote the health status o f the people must involve the local people, whether government or non­ governmental agency is implementing it. In this way, the model argues that participation will ensure sustainable primary health care, which will lead to sustainable development in health, that is, health development that meets the needs o f the present generation w ithout compromising the ability o f future generations to meet their own health needs. 24 University of Ghana http://ugspace.ug.edu.gh Figure 1.2: Community Participation, PHC and Health Promotion Nexus COMMUNITY PARTICIPATION OTHERS Groups in the Activities Government. Community NGOs, Individuals, women, men, the identification, etc. poor, opinion planning, leaders, district implementation, PHC units etc. monitoring, z evaluation AREAS OF HEALTH PROMOTION EXAMPLE IN PRIMARY HEALTH CARE SUSTAINABLE PHC PROGRAMMES Environmental Health Measures environmental capacity building, cleanliness empowerment, education, Health Education Programmes lifestyle issues evaluation, enabling (Primary, secondary, tertiary) nutrition related environment topics Economic and Regulatory government Activities directive Preventive Health Services immunization, voluntary and statutory screening Healthy Public Policies improved facilities for disabled Organizational Development training of community health workers Community-based work self-help weight control group Source: Adapted from Ewles and Simnett (1992). For the PHC programme in the district to flourish for the benefit o f the people and to ensure its sustainability there is the need to rope in all stakeholders— the communities, medical personnel, government and non-governmental agencies. The people in the community must be empowered to build the necessary capacity to take 25 University of Ghana http://ugspace.ug.edu.gh up certain aspects o f the programme in the structure o f the programme or if it happens that a programme initiated by foreign agency left it the host community could step in and continue so as to ensure its sustainability. The seven areas o f health promotion are very relevant to the D istricts PHC programme for the following reasons. In the first place, the District is predominantly rural except some few towns, which are dotted along the main road linking Accra and Koforidua. Consequently, majority o f the people are not served w ith modern health facilities. It is, therefore, important that health education and preventive health services are intensified to obviate imminent catastrophic outbreak o f diseases. Secondly, the existence o f Centre for Scientific Research into Plant M edicine in the district will facilitate adoption o f the fourth item in the Areas o f Health Promotion in figure 1.2 which is captioned Healthy Public Policies and especially when the clarion call at this stage o f the country’s development is availability o f alternative medicine in herbal medicine. In a community where majority o f the people are not gainfully employed and for that matter poor, the important role herbal medicine can play cannot be over emphasized. It is, therefore, imperative that conscious effort is made towards integrating herbal medicine into any health policy design to improve the status to the people in the district in particular and the country as a whole. In summary, the framework for health promotion activities can be used to guide the health-promotion w ork o f a practising community health nurse and is a useful reminder that such w ork covers a broad range o f activities. But as well as recognizing the areas o f health-promotion activities, community nurses need to acquire and develop skills and abilities which will enable them to put their knowledge o f health promotion into practice. 26 University of Ghana http://ugspace.ug.edu.gh 1.7 Methodology 1.7.1 Sources o f Data The study drew on two main sources o f data— Secondary and Primary. Secondary data comprised published and unpublished sources. A greater part o f the information was obtained from W orld Health Organization (WHO) magazines, W orld Health Forum series, Internet and United Nations Children Fund (UNICEF) publications. In addition, information from the W orld Bank publications, Akwapim N orth District Administration and Tetteh Quarshie Memorial Hospital was also used. The primary data was collected from some selected communities in Akwapim North District. The choice o f the district is based on the fact that it is one o f the numerous districts in Ghana where Primary Health Care programme is vigorously being pursued. Also, the district is one o f the areas in Ghana where income level is low because the area is neither industrial nor agricultural. Based on these, the District was chosen since the PHC programme is largely geared towards improving the health o f the underprivileged in society. 1.7.2 M ethods o f D ata Collection The study employed a wide range o f research techniques. A questionnaire designed on the basis o f the outlined objectives was administered in some towns and villages to collect information on the programme’s outset and design, funding and implementation, management and maintenance and more importantly, the communities’ involvement in the primary health care programme. 27 University of Ghana http://ugspace.ug.edu.gh The selected towns and villages are Akropong, Mampong, Tinkong, Kurutuase, and Asempaneye. Stratified sampling technique was used in the selection o f towns and villages. All settlements in the District were divided into three categories based on total populations. The first category consists o f settlements with population between one and five hundred people, which is mainly rural. The second category is settlements o f between 501 and 2000 people which is the intermediate between the rural and urban settings. The final category consists o f settlements o f over 2000 people, w hich is relatively urban in outlook. This was done to enhance comparisons o f the rural and urban settings as far as involvement in the PHC programmes is concerned. Akropong was chosen as a sample town because it is the largest settlement in the District in terms o f population size besides it being the capital o f the District. Mampong was also chosen due to the fact that it houses the only hospital in the District and also the second largest town in the District. Kurutuase and Asempaneye (first category) and Tinkong (second category) were selected randomly through lottery technique. In this instance, all villages with population between one and five hundred were numbered and folded and randomly picked. The same procedure was applied to settlement with population o f between 501 and 2000. Two sets o f questionnaire were also designed after a reconnaissance visit to the area in November 2000 and later administered in M arch 2001. Additional information was gathered in May 2001 to supplement what was gathered earlier on. In all 100 houses were visited in five selected towns and villages in the district. Two persons were selected from each house and whoever was selected must be more than 15 years 28 University of Ghana http://ugspace.ug.edu.gh especially those in the reproductive age group. Table 1.1 shows the design for selection o f houses. T able 1.1: Design Tor Selection or Houses for Q uestionnaire Interview a t the Sam pled Towns and Villages. Town/village Total Number o f 1 louses No o f Mouses Selected Akropong 2282 30 Mampong 1509 28 finkong 137 18 Kurutuase 32 14 Asempaneye 28 10 Total 3988 100 Source; Author's construct, 2001 In the sampled towns and villages, systematic random technique was used to select houses. Depending on the size o f the town or village, houses were selected in an orderly manner. For example, in Mampong a relatively bigger town, every tenth house as against a fourth in Asempaneye, a smaller village, was selected starting from a specific point in space. In each o f ihe towns or villages selected, attempt was made using (he housing units to divide respondents into the relatively rich and poor. The total number o f houses selected in each town or village was not proportional lo the number o f houses in lliat town or village. This is because this study focuses more on rural people who are generally the poor and underprivileged and cannot, therefore, most often afford costs o f hospital-based health care. Sampled villages have proportionately higher sample size than Ihe towns. A total o f 200 respondents were selected from all (he selected towns and villages. Ninety percent o f the respondents 29 University of Ghana http://ugspace.ug.edu.gh were women while the remaining 10% w ere men. These percentages w ere chosen on the premise that it is usually women who are mostly in charge o f health issues in a family and who attend to hospital for family planning, nutrition and maternal and child health education among others. The questionnaire consisted o f variety o f closed and open-ended questions asked in the commonly spoken Twi language. M ost questions were open-ended in which interviewees were asked to give reasons, opinions or comments. The close-ended questions demanded ‘Yes or N o’ answers. Some o f the questions to the people in the community were: D o the people in the community take part in the PHC programmes? I f yes what aspects o f the programme are the people involved in? H ow many children do you have? Have you immunized them against the major childhood killer diseases? I f yes, do you see immunization o f children as necessary for sound child health, etc. Table 1.2 shows the sampled towns and villages. Table 1.2: Design of Selected Towns and Villages for Questionnaire Interview. TO W N S/V ILLA G ES TO TA L PO PU LA TIO N SA M PLE SIZE (2000 Census figures) MALE FEMALE Akropong 9974 6 54 Mampong 9152 5 51 Tinkong 1229 4 33 Kurutuase 176 3 25 Asempaneye 108 2 17 Total 20639 20 180 Source: Author’s construct, 2001. 30 University of Ghana http://ugspace.ug.edu.gh All the selected houses were covered. In a situation where all the house members present were not o f the right age, the house is revisited until all the potential interviewees were covered. In a situation w here there were a large number o f people who qualify to be interviewed, the first two to have contact with were interviewed but others normally joined in the discussion to give some vital information, which were often recorded on a tape. In addition, personal in-depth interviews were organized for some opinion leaders, assemblymen, health officials, and NGOs, who have something to do with the PHC programme in the district. About 30 patients or those who brought their sick relatives to health institutions for medical care were interviewed. Participant observation method o f data collection was also applied. Here, on three occasions, the author accompanied the PHC unit personnel in Mampong to embark on their periodic outreach programmes in Osubeto, Odwobi and Awoyekrom. These outreach programmes helped me acquaint m yself with the actual w ork on the ground and to have a deeper appreciation as far as primary health care programme is concerned. One other mode o f data collection, which was extensively utilized, is Focus Group Discussion (FGD). The focus group discussions covered the District Health M anagement Team (DHMT) in Mampong Tetteh Quarshie Memorial Hospital, Women and M en's groups in the five sampled towns and villages selected. In all an average o f nine people were involved in each discussion and lasted averagely about 49 minutes. Two assistants were employed to play the roles o f a moderator and a note-taker respectively while the author acted as a supervisor and making sure the 31 University of Ghana http://ugspace.ug.edu.gh tape recorder functioned properly and also to make sure conducive atmosphere was created for uninterrupted flow o f discussions. 1.7.3 M ethods o f Analysis Analysis o f the data was done using both qualitative and quantitative approaches but more emphasis was placed on qualitative analysis. Quantitatively, elementary tools o f statistical description such as distributions, percentages, averages, and measure o f dispersion, supplemented by suitable diagrams were used. Also, descriptive analysis using what other countries, particularly N icaragua and Gambia, have done in their attempt to utilize the strategy o f primary health care to improve health delivery was used. 1.8 Rationale of the Study Health is very important for development, and poor health has been identified as one o f the greatest obstacles to development in the Third World. Ill health consumes the scarce financial resources o f most Third World countries and reduces the availability and productivity o f labour (Barke and O ’Hare, 1986). It is, therefore, important that health o f people must be safeguarded always. The rationale for investigating community participation in the PHC programme is basically due to the fact that, hardly do we find a systematic study on the response o f community to the PHC programme in Ghana, notwithstanding the concept’s immense potential as a readily accessible and affordable means o f disease control and prevention. My personal experience during post Advance Level National Service as a PHC facilitator also stimulated the urge to conduct this research to find solutions to 32 University of Ghana http://ugspace.ug.edu.gh these teething problems. The principle o f “go to the people, learn from them, and start from what they know” is as valid in the field o f health as in any other field o f development. Past experience, for instance, in India has shown clearly that little can be achieved unless the community identifies with a programme and can recognize its benefits for itself. Community participation is one o f the cardinal principles o f achieving the objectives o f primary health care concept. It may perhaps be universally acknowledged as the cornerstone o f sustainable health programmes. Community participation may also be seen as the key to utilization o f available health care services. It has often been emphasized that community participation/involvement in health care should fully comprise all disciplines o f development process e.g. needs assessment, priority settings, planning/strategy development, resource mobilization, project development, implementation and utilization, and monitoring and evaluation. Discussions with health managers and service providers have, however, revealed very little community involvement in above areas. The discussions have shown that community involvement/participation in health programmes, occurs mostly in areas like: i. Contributions through development levy. ii. Communal labour. iii. Utilization o f available service. Health workers often complain o f poor community participation when they are referring to: a) Low attendance o f Maternal and Child Health clinics/immunization programmes. b) Low out-patients attendance. c) Low attendance o f nutrition rehabilitation centres etc. 33 University of Ghana http://ugspace.ug.edu.gh Community participation as envisaged and planted in the principles o f PHC has not been nurtured to mature. It is against this backdrop that the major constraints to effective community participation were studied. Such studies facilitate a more meaningful community involvement/participation and promote the health and well being o f the people. 1.9 T he S tudy A rea The study was carried out in Akwapim North District, which is one o f the 15 districts in the Eastern Region o f Ghana (see figure 1.3). The District lies approximately between latitudes 6° 081 and 5° 521 north o f the equator and between longitudes 0° 191 and 0° 011 west o f the Greenwich Meridian. The District is bounded by five districts. These are Akwapim South in the southwest, Suhum Kraboa Coaltal in the east, New Juaben in northwest, Yilo Krobo in northeast and Dangbe West in the south. The dominant physical features in the District are ridges called Akwapim Ridge, and valley, which make the topography o f the land highly undulating. The relatively high scarps in the District make it one o f the coolest areas in the country. Administratively, Akropong is the capital o f the District and it is approximately 64 kilometers from Accra, the nation’s capital and lies northwest o f it. In terms o f health delivery, Mampong can be said to be the capital o f the District since it houses the only hospital in the District where the DHMT is also located. The District has a total population o f 108,638 and two constituencies, namely: Okere and Akwapim North. There are (hree main ethnic groups These are Twi, Guan and Okere (Kyerepon) speakers. However, there are other minority groups such as the Gas, (he Ewes, and Northerners. 34 University of Ghana http://ugspace.ug.edu.gh A visitor’s first impression o f the District is one o f relative prosperity especially in towns like Mampong, M amfe and Akropong, the district capital. The District is a mountainous region with orderly arrangement o f valleys, hills and plains. History has it that the Akuapems were largely farmers who used their land in the past for the growing o f oil palm, food crops such as plantain, cocoyam, com etc. According to available account, in the latter half o f the 19th century, when cocoa was first introduced in the Akuapem area, the palm oil industry was losing popularity and the farmers rushed into new cocoa industry to take advantage o f its higher profit. The resultant clearance o f the forests for cocoa cultivation exposed the soil to weather vagaries. Consequently, cocoa tree lost its great economic importance in the whole o f Akuapem state. This set in motion large movement o f people in search o f favourable lands elsewhere for cocoa cultivation. This has stifled the growth o f population in this district as the district is at the moment neither industrialized nor commercialized rural economy. 35 University of Ghana http://ugspace.ug.edu.gh Figure 1.3: Map of the Study Area MAP OF AKWAPIM NORTH DISTRICT SHOWING SOME TOWNS AND VILLAGES 36 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO THE CONCEPT OF PRIMARY HEALTH CARE 2.1 The Origin of the Primary Health Care Programme The PHC movement officially began in 1977 when the 30th WHO Health Assembly adopted a resolution accepting the goal of attaining a level o f health that permitted all citizens o f the world to live socially and economically productive lives. At Alma-Ata in 1978, WHO and UNICEF together endorsed the policy o f community-oriented primary care (COPC). However, the idea girding and framing this approach had first been given full expression in practice some four decades earlier (WHO, 1999, p. 436). The locale was the southern tip o f Africa, far removed from the intellectual driving forces o f the English-speaking world before the Second World War. Alma-Ata conference was held from 6-12 September 1978, under the chairmanship o f B. V. Petrovsky, Minister o f Health o f the then Soviet Union. Delegates from 134 countries attended. O f course, there were dissenting voices as well, stressing the absurdity o f aiming for such a patently unachievable goal as “Health For All”, especially in the light of WHO’s own maximaist definition of health as “a state o f complete well­ being” This resolution, nonetheless, became known by the slogan “Health For All by the Year 2000” and captured the official health target for all member nations o f World Health Organization. In 1981, WHO established global indicators for monitoring and evaluating the achievements o f Health For All by the Year 2000 target. In WHO (1986) these indicators are grouped into four categories: health policies; social and economic development; provision of health facilities; and health'status. An important part of the global indicators is the emphasis on health as arf objective o f spcio-economic 37 University of Ghana http://ugspace.ug.edu.gh development (Mahler, 1981). In this context, health improvements are a result of efforts in many areas including agriculture, industries, education, housing, communications, and health care. Because PHC is a much political statement as a system of care, each United Nations member country interprets PHC in the context of its own culture, health needs, resources, and system o f government. Although the original definition o f PHC has at times been misunderstood, it is important to understand the Alma-Ata declaration as the basis for PHC and the global evolvement of this strategy over the past 10 to 15 years. For instance, as a WHO member nation, the United States has endorsed PHC as a strategy for achieving the goal o f health for all by the year 2000. However, PHC, with it emphasis on broad strategies, community participation, self-reliance, and a multidisciplinary health care delivery team, is not the primary strategy for improving the health of the American people (Stanhope, 1996). The national health plan focuses more on disease prevention and health promotion in the areas of most concern in the nation. Since the Alma-Ata conference, the outgrowth and interest in world health and how best to attain it, have been tremendous. This interest is reflected in a g ro w in g need among people around the world to know and understand the issues and concerns that affect health on a global basis. This is important in the light of the fact that many countries have not yet experienced the technological growth in their health care systems that has been realized by more developmentally advanced countries such as the United States. 38 University of Ghana http://ugspace.ug.edu.gh 2.2 The P rim ary Health C are System in General Primary Health Care is generally defined as essential care based on practical, scientifically sound and socially accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage o f their development in the spirit o f self­ reliance and self-determination (WHO, 1978). It includes comprehensive range o f services as public health, prevention and diagnostic, therapeutic, and rehabilitation services. Full participation means that individuals within the community help in defining health problems and developing approaches to address the problems. The setting o f PHC is within all communities o f a country and permeates all aspects o f society. PHC encourages self-care and self-management in health and social welfare aspect o f daily life. People are educated to use their knowledge, attitudes, and skills in activities that improve health for themselves, their families and their neighbours. The desired outcome from the PHC strategy is the individual, family and community self­ reliance and competence. A PHC system is organized in such a way that the care gradient rises from the village level up to the national level. Operated efficiently, the PHC system will make available, through its referral system, highly specialized care to any villager who requires it. The most peripheral level o f care will carry out simple functions, which are within the competence of the peripheral health worker. The various levels are briefly explained below: The Village Health Post: The simplest health facility is the village health post. The health post may be the home o f the village health worker or a room in the house o f the village head. It could be a structure built by the villagers and operated by the village 39 University of Ghana http://ugspace.ug.edu.gh health worker who may be the trained traditional birth attendant, healer, or the local peasant farmer. The health post offers elementary health care to the villagers who may number from 100 to 4000. The village health worker’s responsibilities depend on the health needs o f the community, on his orientation, the specific tasks assigned to him to perform such tasks. These tasks may include the administration o f prophylaxis against specific diseases such as malaria, vector control, control o f communicable diseases, maternal and child health, food hygiene and nutrition assessment o f children aged 1-5 years, environmental sanitation with emphasis on the teaching o f hygienic methods of disposing o f human and domestic wastes, the diagnosis and standard treatment o f specific minor ailments, health education, follow-up care, and the administration o f routine medications to patients with chronic ailments such as leprosy and tuberculosis. The recognition o f patients with conditions, and their referral to the next higher level o f service and record keeping, are important functions o f the village health worker. The Health Centre: This is usually a health unit o f the Ministry o f Health. There is an increase in personal and community preventive health activities and more intensive health education activities. A health centre gives a wider health care coverage to a larger population often ranging between 20,000 and 80,000, depending on the population density o f the areas served by the centre. Some health centres have mobile clinics attached to them which use itinerant health workers in the villages for which the health centre is responsible to carry out maternal and child health and communicable disease programmes. 40 University of Ghana http://ugspace.ug.edu.gh The composition o f the staff o f a health centre is more varied and reflects the extent of the services carried out in the health centre. The staff may comprise all, or a combination o f the following; namely a medical officer who may either be a permanent staff member or as a consultant who visits the health centre on a regular basis. The services offered in a health centre should include all the activities which a family would require for health promotion and health maintenance, for the care and cure of any ill health which does not require prolonged hospitalization and for necessary rehabilitation. The health centre works in close collaboration with the district hospital. In some administrations the medical officer in charge o f the district hospital is also in charge o f the health centre. The health centre may then depend on the district hospital for logistic support and medical and other supplies. Patients are referred from health centre to the district hospital. The District Hospital: This unit gives relatively more comprehensive medical and health coverage to a larger population than the health centre and its staff include medical officers, nurses, medical assistants, midwives, public health technicians, laboratory technicians, drivers and other such paramedical personnel as in the health centre. Health posts, health centres and the district hospital comprise the network of PHC in the rural area. There are general hospitals’ outpatients departments and comprehensive health centres in large towns, which, because they are the first point of contact to town dwellers, will also be giving primary health care to these people. Patients from a district hospital are referred for more advanced health care to general 41 University of Ghana http://ugspace.ug.edu.gh or specialist hospitals such as paediatrics, orthopaedic or psychiatric hospitals and from any o f these when necessary to a university teaching hospital. The need for a clearly defined chain o f referral is critical to effective health care. It is essential to have a good and sufficient communication system between the staff at the point from where the patient is referred and the staff at the point to which the patients is referred. At the completion o f treatment the patient should be returned to the unit from where he was referred, to enable him to continue his treatment and his rehabilitation. This is vital for continuity o f care but it is an area, which is sadly neglected by many health institutions in the developing countries. The PHC workforce comprises a multidisciplinary team of health care providers. Team members include many professionals such as generalist and public health physicians, nurses, dentists, pharmacists, optometrists, nutritionists, community outreach workers, mental health counselors, and other allied health professionals. Community members are also considered important to the team. Central to the concept o f PHC is that individuals, families, and communities take the major responsibility for their own health. The roles of the health professionals and health systems are to assist and support this process. The implications of this concept are serious for a health system, which has monopolized health care. New roles are now being demanded o f health professionals and institutions. Their functions must change from being providers of health services to enablers. 42 University of Ghana http://ugspace.ug.edu.gh Enabling skills and methods are not widely understood and taught within the present health systems. Methods and techniques o f working with communities have much in common with those working in large organization, even though Ihe way in which they are applied would vary greatly from place to place. PHC asks for a bottom-up approach For setting targets and identifying needs. They in turn determine top-down actions and decisions. In other words, health system s and related organizations need to set their objectives and determine their activities in relation to those expressed by the communities in which they serve. Such working style calls for a continuing process o f dialogue, popular consultation, organizational adaptation and change. Recognizing that there would be differences among countries with respect to the implementation o f PHC because o f local customs and environments, it was anticipated that several major components should be included in each plan. These components included: a) an organized approach (o health education tlial involves professional health care providers and Irained community representatives; b) aggressive atlenlion lo environmental sanitation, especially food and water sources; c) the involvem enl and training o f community and village health workers in all plans and intervention programmes; d) Ihe development o f maternal and child health programmes that would include immunization and family planning; e) initiation o f preventive programmes (hat are specifically aimed at local endemic problems such as malaria and schislomiasis; 43 University of Ghana http://ugspace.ug.edu.gh f) accessibility and affordability of services for the treatment of common diseases and injuries; g) the availability of chemotherapeutic agents for the treatment of acute, chronic and communicable diseases; h) the development of nutrition programmes; and i) Promotion and acceptance of traditional medicine. The aim of participants at the Alma-Ata conference was to emphasize universal access and participation and to encourage a reallocation of resources, if needed, to reduce the inequality o f health care that existed among the nations of the world. They encouraged community participation in all aspects o f health care planning and implementation and the delivery of health care that was 'scientifically sound, technically effective, and socially relevant and acceptable’ (WHO/UNICEF, 1978, p. 2). 2.3 The Implementation of the Primary Health Care Programme in Ghana The health education in the country, including access to health services, is at present substantially below expectation. This is reflected in the low life expectancy (currently around 56 years at birth compared to average of 62 years for all low income countries); and high rates of infant, child and maternal mortality (Ghana Vision 2020, 1997). In addition to poor health outcomes there are systematic problems that affect the delivery, efficiency and efficacy of health services. There is, therefore, the need for 44 University of Ghana http://ugspace.ug.edu.gh introducing programmes that will help establish a broad enabling environment for health. The Government of Ghana pursued a policy, with the goal o f achieving health for all by the year 2000, through a decentralized Primary Health Care (PHC) delivery system. Before the Alma-Ata declaration o f PHC in 1978, the country had started some form o f PHC programme on a pilot basis. The Ministry o f Health has taken the PHC as a cornerstone o f health service delivery in the country. All the components of the PHC as enshrined in the Alma-Ata Declaration are being implemented in the country through various health delivery programmes. Significant among these are programmes geared towards the promotion o f health o f mothers and children. As a result, much emphasis has been placed on the Expanded Programme on Immunization (EPI) and Maternal and Child Health (MCH) programmes. Thus the goal o f the health sector is to maximize the total amount o f healthy life of Ghanaians and all persons resident in Ghana, regardless o f age, sex, origin, ethnic group, religion, political affiliation or socio-economic standing. The government o f Ghana, as a way of addressing the difficulty o f reaching rural areas and neglected urban communities with modem health care, has been pursuing PHC initiative, in the hope o f providing basic health care to the disadvantaged population in those communities. The Ministry of Health designed a PHC delivery system consisting of three tiers: These are: i) Level A; ii) Level B; and iii) Level C. Level A is community based and consists o f a community/village clinic, operated by a Community Health Worker, who is a volunteer. Also operating at Level A are 45 University of Ghana http://ugspace.ug.edu.gh Community Heath Inspectors and Traditional Birth Attendants. Level B and C form the first referral points as well as the principal management foci o f the PHC system. The formal health services operations start at B, with Medical Assistants, Nurses, Midwives, Disease Control and Nutrition Technical Officers operating at Health Centres. The Level C, that is, the district level, is a self-contained segment of the National Health System with a District Health Management Team (DHMT) taking responsibility for the implementation of PHC activities in the district. Currently, management of health services in the District has taken a step further with the formation of sub-districts, each unit with a management team. Currently, the PHC programme in the District has been divided into five sub-districts. Among the six key problem areas for the health sectors, identified by the Government of Ghana and UNICEF in a situational analysis o f children and women in Ghana in 1990, are diarrhoeal disease control and immunization o f children against vaccine- preventable diseases. Since these two problems can be tackled within the context o f the PHC, ongoing efforts at dealing with the problem have been within that context and form part of child health services which are also a part o f Maternal and Child Health (MCH) services o f the Ministry o f Health, Ghana. 2.4 Organization of PHC Activities in Akwapim North District Akwapim North District is one o f the districts in the Eastern Region, which is relatively served with a number of health institutions. Currently, there are 16 Maternal and Child Health and Family Planning centres located in the various health centres 46 University of Ghana http://ugspace.ug.edu.gh and in the Tetteh Quarshie Memorial Hospital (T.Q.M.H.) at Mampong. The health centres are located in towns such as Akropong, Larteh, Twumgoaso, Aseseso, Amanfrom, Adawso, Yensiso and Kwamoso among others. Like the national PHC programme, the Akwapim North District PHC programme is divided into three main tiers—Level A; Level B; and Level C. Level A deals mainly with minor injuries, care o f pregnant women by the traditional birth attendants, education o f communities on pressing health issues such as family planning, HIV/AIDS, nutrition related topics etc. The Level B serves as the first referral point for the Level A. In addition to the 16 Maternal and Child Health/Family Planning centres, the District is divided into 5 Sub­ districts, and has 3 private clinics namely, Yensiso Clinic, All Saint Maternity Home and Obosomase Clinic. Level B coordinates the activities in both Level A and C. At the district level (Level C) there is one main hospital in the district namely Tetteh Quarshie Memorial Hospital which is located at Mampong. Tetteh Quarshie Memorial Hospital houses the District Health Management Team, which supervises and coordinates the activities o f the health institutions in the District. The PHC unit in the hospital apart from its traditional role as supervisory and coordination o f all the health programmes in the district, it also embarks on regular outreach programmes in areas where there are no static PHC units. Even though, the health institutions lack logistical and financial support and faces acute personnel inadequacies, they appear to be doing their best to help the people in 47 University of Ghana http://ugspace.ug.edu.gh the district who seek medical help from them if one considers the fact that Doctor- Palient ratio in the district is over 12070 in the year 2000. Table 2.1 g ives a brief insight into the extent to which the district is equipped with health facilities and the follow ing description o f the main hospital in the district, Telteh Quarshie Memorial, g ives a rough idea about the state o f health institutions in the district. Tabic 2.1 Health Facilities in the District LEVELS NUMBER OF HEALTH INSTITUTIONS NUMBER OF DOCTORS IN THE DISTRICT Level A Not Available No Doctor Level B 15 Health Posts and Health Centres Visiting Doctors from T Q M i l — Mampong Level C 1 Hospital 9 Source: T.Q.M .H., 2000. Tetteli Quarshie Memorial Hospital Records show that a son o f the then Gold Coast, from Christiansborg (Osu) Accra, by name Tetteh Quarshie introduced cocoa into this country in 1879 and that the first cocoa plantation was cultivated at Mampong Akuapem in the Eastern Region. Through the ages this cocoa crop established itself as the main export crop and indeed the backbone o f the econom y o f this country. It was, therefore, befitting that a monument be raised in memory o f this worthy son o f the land. The joint provincial chiefs initiated this idea in 1950, which voted an amount o f $25000 for a children’s clinic. The following Akuapem doctors— the late Dr. Asiedu Ofei, the late Ansah Koi, and the late Dr. Oku Ampofo took up the matter and a local board for the project was set up in 1952. A large hospital was rather contemplated by this board and who presented a proposal to Ghana Cocoa Marketing Board (GCM B) for assistance. 48 University of Ghana http://ugspace.ug.edu.gh In 1955, a Legal Trust Board o f ten members, known as M anaging Trustees was set up with a capital grant o f $450,000 from the Ghana Cocoa Marketing Board (GCMB). This original capital grant was later supplemented by another $120,000 from the same GCMB. After a considerable controversy about the location o f the hospital, Mampong Akuapem was finally selected. Therefore, in appreciation o f Tetteh Quarshie’s effort in bringing cocoa to Ghana, the president o f the first Republic o f Ghana, Osagyefo Dr. Kwame Nkrumah o f blessed memory, laid the foundation stone o f the hospital at Mampong Akuapem on 4 March 1959. At the function, Dr. Kwame Nkrumah said “this foundation stone is being laid in honour and memory o f Tetteh Quarshie, pioneer o f the cocoa industry in Ghana, and as a token o f debt this country ow es to farmers”. The hospital was completed and started admitting patients in February 1961. The hospital was constructed with a bed capacity o f 150, Facilities at the T.Q.M.H. as at the year 2000 are the following: 1. OPD with ten consulting rooms 2. An Ophthalmology Department 3. ORL/ENT 4. X-Ray Department 5. Traumatology 6. An Obstetrics and Gyaenacology ward with two theatres 7. Pharmacy N. Laboratory/Administration Complex 9. Energy Recovery/Casualty Wards 10. Isolation Ward 49 University of Ghana http://ugspace.ug.edu.gh 11. Medical Ward 12. Surgical Ward 13. Maternity Ward 14. Paediatric Ward 15. V.I.P. Ward 16. Three Well-Equipped Theatres The following arc also available: Catering department with staff canteen; laundry; C.S.S.D .; maintenance; an endoscopy set; Electrocardiograph Madeira; an ultra-sound machine; 14 cots; 5 radian warmers; 6 transportable incubators; 17 baby cradles; 11 IBM computers; 11 printers; 2 power generating plants; 5 microwaves; 1 colour TV. The present bed capacity o f the hospital is 170 excluding cots, which are 16 in number and 5 incubators. The hospital also has 9 doctors, 50 nurses and ] 12 paramedical staff. The catchment area o f T.Q.M.H. covers approximate population o f 154,450. This includes Akwapim North, part o f Akwapim South and D odow a and its surrounding areas. Figure 2.1 is a map showing towns where the various health centres are located in the District. 50 University of Ghana http://ugspace.ug.edu.gh Figure 2.1: MAP OF AKWAPIM NORTH DISTRICT SHOWINGLOCATIONS OF HEALTH INSTITUTIONS 51 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE EVALUATING THE CONCEPT OF COMMUNITY PARTICIPATION IN THE PRIMARY HEALTH CARE PROGRAMME: A GENERAL OVERVIEW 3.1 The Community Participatory Approach to the PHC Programme Community participation is one o f the most essential principles in development cooperation. What is meant by this term is that the people should be directly involved in a project’s conception, planning, implementation and accept that it is their own effort. Like the concept o f sustainable development o f which it is a component, the word participation is often used without providing a clear and definite statement of what it means. An examination o f project files o f PHC revealed a methodological approach to participation that do not vary widely from the four principles o f participation identified by Oakley (1991) as: emphasis on participation rather than quantitative outcome; ensuring balance between awareness creation and economic activities; building where possible on local base; and maintenance o f regular contact between people and project staff. Perhaps we may argue that the participatory approach o f PHC programme emphasized more on the process of participation and building local base, i.e. traditional institutions, as against other principles. The ideological base o f the programme as observed from the methodology was the assumption of an existing local capacity and that the existing institutions are capable o f ensuring participation but what is needed is intensive education and awareness creation. 52 University of Ghana http://ugspace.ug.edu.gh It is in recognition o f this that the people of Akwapim North District should be made to play an important role in decision-making, planning, implementation, monitoring and evaluation of primary health care activities. The observed participatory approach to the delivery o f health services can be summed up diagrammatically in figure 3.1 The participatory approach to the PHC programme as summarized in figure 3.1 indicates the building blocks or the key groups involved. Figure 3.1: A Model for PHC Participatory Approach Source: Author’s construct, 2001. The Central role o f coordinating activities between all stakeholders is given to the District Health Management Team at the Tetteh Quarshie Memorial Hospital in Mampong who interacts and acts with the Sub-district Health Management Teams, the various PHC units, Traditional Birth Attendants, Village Health Workers, 53 University of Ghana http://ugspace.ug.edu.gh volunteers among others. This group constitutes the engine of the PHC programme; they take major decisions on the programmes, which the PHC units implement. The PHC units’ personnel are employed by the Ministry o f Health to steer the affairs o f the areas within their jurisdiction under the decentralization process of Ghana. They also mobilize people for health promotion campaigns such as immunization, HIV/AIDS awareness programmes etc. Actively involved in these programmes are Tetteh Quarshie Memorial Hospital, Health Posts/Health Centres in the district, and the communities. This group constitutes the decision-making body but the District Health Management Team (DHMT) coordinates any decision on the PHC programme. The DHMT was formed, among other purposes, to coordinate between the Ministry o f Health, and health institutions on one hand and the communities who are the beneficiaries and part implementers o f the PHC programmes. They conduct periodic outreach programmes. The DHMT also provides technical assistance to the personnel o f PHC units. The PHC units in turn give training to the Traditional Birth Attendants and community health workers. They organize and supervise immunization/vaccination campaigns and provide education o f pressing national health issues. Another important component of this group is the community. Even though the cardinal principle o f primary health care is community participation in all aspects of the programmes, it is here that one cannot really identify precisely where the 54 University of Ghana http://ugspace.ug.edu.gh community is actually involved apart from being called upon to participate in national immunization campaigns and being advised to breastfeed their new-born babies. One area the community is seen to be part is maternal and child health programmes. Even here, they are only beneficiaries of the services and no role for them as far as decision-making, planning, implementation and evaluation are concerned. As far as major policies and directions and the financing of the PHC programmes are concerned, the Ministry o f Health is the sole player even though non-governmental organizations do play a limited part in these aspects. For example, the Presbyterian Church o f Ghana is actively involved in the implementation and financing o f PHC programmes in Agogo Presbyterian Hospital in Asante Akim North District. In Akwapim North District religious bodies and NGOs are doing similar thing. Example is All Saint Maternity Home owned by the Roman Catholic Church. 3.2 Criteria for Evaluating Participation Participation has now become an accepted and recognizable objective in development programmes and projects but the issue o f its evaluation has come into question. Whereas concerns for participation in development emerged in mid 1970s, interest in its evaluation is a recent development (Oakley, 1991). The crux o f the matter is that both conceptually and methodologically, the evaluation of participation is still in its relative infant stage. It is against this background that Lassen (1980) commented on a paucity o f practical ‘guide-lines’ on how to evaluate participation. Rahman (1980) has questioned whether it is possible to have a general analytical framework for evaluating participation in development projects. However, some schools o f thought 55 University of Ghana http://ugspace.ug.edu.gh have begun to question the issue and to experiment with different ways although they lack authoritative insight to the complex issues. Oakley in 1991 made some important points that worth noting. To him, the parameters and the content o f any evolution o f participation will necessarily be linked to the operational understanding o f participation. On the one hand, if this understanding is limited to the notion o f economic benefits derived from successful projects, physical attendance at project activities or extended project coverage, then evaluation will probably be largely quantitative. On the other hand, if the operational understanding is more closely linked to participation as a process with a series of qualitative objectives, then the evaluation will demand an alternative form. That is, it cannot be assumed that the more commonly used quantitative, linear approach to evaluation would be appropriate to evaluation o f participation. Clearly, there would be a quantitative dimension to participation; there would also be a qualitative dimension, which needs to be evaluated. The evaluation o f participation would be concerned with the analysis o f a dynamic quantitative process and not merely the measurement of a static physical outcome. However, this concern has come up against a basic problem of how to evaluate participation. Paul (1987) has stated that it is not an easy task to evaluate the outcome o f participation in relation to its objectives. The central problem is how to disentangle the process of participation from project structure and factors, which influence the functioning o f this structure. There is also the problem of identifying and explaining the project’s influence, as opposed to that of other socio-political forces on the process o f evaluation. 56 University of Ghana http://ugspace.ug.edu.gh In essence the question here is what form o f evaluation would be more appropriate to the understanding o f the process of health promotion programme? In reality there would be in one sense two broad outcomes of participation, which serve as a foci for evaluation: Here, participation is evaluated in terms o f tangible or physical contributions or outcome of the project or programme. In that case, we may look at man-hours spent on the programme, the number of outreach programmes conducted, amount o f money spent by local people as against that o f the foreign or from external sources and share o f social and economic benefits between all interested parties. The second process would be qualitative evaluation. This concerns with describing the characteristics and properties of a process like participation over a period of time and then with interpreting the data and information available in order to make statements concerning the nature of the participation, which has occurred. Essentially qualitative and quantitative evaluations are two complementary but distinct approaches that have been summarized graphically by Oakley as follows: Figure 3.2: Quantitative and qualitative dimensions of evaluation Quantitative evaluation: Measurement------------------------------------------ ---- ► Judgement Qualitative evaluation: Description (excluding quantification) “ ►Interpretation Source: Oakley, 1991. At this critical point, the observable concern of this study is a search for an approach, which is not based exclusively on the measurement of material or economic 57 University of Ghana http://ugspace.ug.edu.gh outcome, but also able to explain what happens in the health delivery system as primary health care programme in Akwapim North District that seeks to promote participation. The context o f PHC is health delivery system with improve health for all as a critical aim. These are relatively abstract concepts, which though have quantitative characteristics, have more qualitative dimensions and that its analysis requires more qualitative concerns. Participation is a phenomenon that occurs over time and cannot be measured simply by ‘single snap-shot’ form o f exercise. In this case, this evaluation process will emphasize more on qualitative analysis of the process but will not shun quantitative analysis. The quest for indicators for the purpose o f evaluation o f participation has been a marathon phenomenon. There are numerous agencies, individuals and groups working to find indicators for evaluation purposes for instance Oakley (1985), FAO (1991), to mention but few have tried to harmonize field-bases indicators for evaluating participation but most o f these were on quantitative indicators. We understand indicators to mean the means by which the outcome o f a project can be understood and, in one form or another, measured or explained. It is argued in some circles that indicators should accurately reflect changes that have taken place, they should be identifiable and observable, should be intelligible and above all unambiguous in order to avoid confusion. In terms o f relevant indicators of process o f participation, Hamilton (1978) suggests that we should identify ‘critical traits’ Lassen (1980) also refers to ‘vital signs’ 58 University of Ghana http://ugspace.ug.edu.gh whereas Charlick (1984) proposes that the ‘what, ‘how ’ and ‘w here’ o f participation should be the basis for evaluation. Conversely, Rifkin, et al, (1988) have developed a broad continuum from ‘wider to narrower’ participation as two extremes within which it should be evaluated. Oakley has suggested both quantitative and qualitative indicators, which have been summarized in table 3.1. In spite o f these numerous suggestions, diversity in opinions on appropriate indicators o f participation is not likely to end today so long as project context and objectives differ. Table 3.1: Quantitative and Qualitative Indicators for Evaluating Participation Quantitative Qualitative Economic -The measurable economic benefits of a Organization­ -Allocation of Indicators project by the use of commonly al growth specific role to emploved quantitative techniques as project group who is participating in the project’s members benefit: An analysis of those sections of -Emerging the rural people who have directly leadership benefited and a quantitative assessment structure and of this benefit and their lives and the formalization of future ability to sustain the level group structure. Organizat­ -Percentage of rural adults within a Group -Changing nature ion project area who have knowledge of the behaviour of involvement existence of the project organization. of project group Indicators members and -Percentage of rural adults within a emerging sense project area who are formal members of of collective will the organization meetings. and solidarity. Participation -Number of project groups or Group self­ -Increasing in project associations of project groups formed. reliance ability of activities -Number and attendance rates at project project group to group meetings. propose and to -Total workdays contributed by consider course members to acquire positions in other of action formal organizations. Develop­ -Number of project members who ment received some kind of formal training momentu­ from the project. m -Internal sustainability, or the ability of the project group to maintain its own development momentum Source: Oakley (1988). 59 University of Ghana http://ugspace.ug.edu.gh It is against this backdrop that Oakley (1991) suggests field-based indicators based on aims and objectives o f the project concerned as most appropriate for the project’s evaluation. The aims and objectives of primary health care programme participatory approach, although not so different from other development programmes could not be evaluated in the same way as Oakley (1988) or Uphoff (1988). However, it must fall in line with acceptable criteria. It is in line with this that critical traits as decision-making and control; local resources used in the implementation; local knowledge, number of local people involve in the processes of health delivery, hospital attendants, response to mass programmes such as immunization campaigns and film shows intended to give health education, and share of benefits are selected in this study for evaluation of the participatory approach of PHC programme in Akwapim North District. Under decision-making/control, pertinent questions to be answered include decision/control over the fixing o f programme facility user charges, when and where to conduct educational programme in order to get maximum attention, how much to give volunteer health workers and where to incorporate traditional healers into the programme. Questions relating to local resources used in the implementation o f the programme centre on labour: skilled (paid) and unskilled (unpaid). For the assessment o f local knowledge, efforts were made to know the number of respondents aware of the PHC programme and its financiers, training received for the purpose of participating in the programme activities; and the importance of the programme. 60 University of Ghana http://ugspace.ug.edu.gh 3.3 Effectiveness of the PHC Community Participatory Approach The Government o f Ghana through the Ministry of Health introduced the primary health care programme in Akwapim North District. The actual year in which the programme was introduced could not be told, as there was no official record in this regard. Some officials guesstimate somewhere 1982-83. The participatory approach o f PHC appears to be working effectively though a lot more could be done. A critical examination o f the participatory approach o f PHC reveals that: a) the ultimate power is in the hands o f the district health management team on behalf o f the Ministry of Health; b) the day to day administration of the programme is in the hands of the PHC units in the District; c) the implementation o f the programme rests on the health institutions, the TBAs, Community Health Workers among others; and d) at the implementation stage, the community plays very limited role. The community is the direct beneficiary o f the programme. The programme participatory approach is structured such that coordination and monitoring of activities are done in a way that makes the implementation o f the programme easier and follow-ups simpler. The sub-districts prepare and submit monthly reports of their activities to the District Health Management Team at Tetteh Quarshie Memorial Hospital. This enables the DHMT to scrutinize the activities at the sub-district level, which ensures checks and balances in the programme. 61 University of Ghana http://ugspace.ug.edu.gh The District Health Management Team together with health experts have a duty to give regular refresher courses to the Village Health Workers, Traditional Birth Attendants and other health volunteers in the district. The district health management team also collects, collates and records all reports from the five sub-districts for analysis and a projection into the future. The PHC units are expected to embark on regular outreach programmes to complement the efforts of the health institutions and the community health workers. These are done in areas where there are no permanent health providers and promoters so that no one is left out in the quest to give health to the people. On the day-to-day administration of the programme the PHC units have been effective to some extent, though there are some setbacks. The units face huge financial and logistics problems, which hinder smooth implementation o f their programmes. For instance, the units lack motorbikes and other means of transport to visit all areas under their care. Community participation in Primary Health Care concept presupposes that the health of the people should rest in their own hands with medical personnel only serving as enablers to the people. However, the nature of health delivery is such that one has to acquire the requisite knowledge in medical field to perform any meaningful role in health promotion. This makes it difficult for ordinary person with no knowledge as far as medication is concerned to administer health services. The people in the community participate in the programme through their response to the primary health care activities such as disease prevention education, immunization, weighing, attending for medical aid as soon as one feels signs of infirmity etc. However, the specialized nature of medical field should not be used as an excuse to preclude the 62 University of Ghana http://ugspace.ug.edu.gh people at the grassroots from participating since adequate training can ensure their full participation in the programme. Heath workers in most developing countries have failed in establishing an ongoing dialogue and rapport with the communities they serve. Countries like China and Cuba which have achieved a breakthrough in health in a remarkably short time ascribe their successes largely to popular awareness and participation in health activities and not to advanced technologies operating from within hospitals (Ebrahim, 1985, p. 150). It should be emphasized that the success o f a community-based health programme is to be judged not so much by the improvements in vital statistics as by the increased knowledge and skills o f the people to manage and solve their health problems. A tangible evidence o f such an approach will be the extent to which local resources and initiatives have been mobilized for sustained efforts over time. 63 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR LEVELS OF COMMUNITY PARTICIPATION IN THE PRIMARY HEALTH CARE PROGRAMME IN THE DISTRICT 4.1 Introduction This chapter identifies four levels as far as participation is concerned in the primary health care programme in general terms and the extent to which the various categories participate in the programme in Akwapim North District. The four levels o f participation are: the individual, the family, the community and the health institutions as discussed below. 4.2 Participation at the Individual Level The level ‘A ’, which is community-based, consists o f 25 V illage Health Committees, 5 Private M idwives, 77 trained Traditional Birth Attendants and a number o f volunteers. There are also an unspecified number o f people who operate without proper documentation and licensing even though their activities are considered inimical to the health o f the people, yet they are 'necessary ev ils’ especially in places where modern health facilities are not available or accessible to them due to high medical bills or their remoteness to the nearest health centre. The roles o f village health committees are m obilizing and helping health personnel to organize health promotion programmes as mass immunization campaigns, HIV/AIDS education, and community clean up exercises. They also assess the health needs o f the people and take remedial measures to address them in collaboration with and support from the district assembly and other stakeholders. For instance, if a village faces the problem o f accessibility to health care the com m ittee deliberates on this and com es out with appropriate measures to deal with it. 64 University of Ghana http://ugspace.ug.edu.gh Individuals in a community have important roles to play as the impact o f their services is better felt than what the orthodox hospital-based curative services can provide for the poor. For instance, it has been the experience in several countries that when health care is being provided through auxiliaries, village health workers (VHW) and trained traditional birth attendants (TBA), over 80-90 percent of the clients tend to be families from the poor and low-status groups. It is, therefore, important that more people are given the training as village health promoters (VHP) in order to reach majority o f the people. The Centre for Rural Integrated Environmental Development (CEFRIEND) is doing marvelously well in this direction. This local NGO has trained some youth in the district to serve as Peer Educators (PEs) and Village Health Promoters (VHPs) whose main functions are to educate their peers and advise those who encounter health problems and to make the health services more relevant to their problems. They also promote the sale and use o f condoms to help check the spread of HIV/AIDS and to prevent unwanted pregnancies in the area. This means shifting the emphasis to preventive and promotive aspects of health care from the predominantly curative care to which most health workers have been conditioned by their training. Unfortunately this curative care is almost inaccessible to majority of people who are poor and cannot afford such services thereby alienating them from the available health services. While the community is familiar with Western health care facilities, the traditional system is still popular. These included herbal therapies, spiritual healing and the use of ‘fetishes’ This has its precursor for the way and manner our forefathers approached the sick, which was predominantly based on spirituality and was bequeathed to the present generation through so many years of sustained practice. 65 University of Ghana http://ugspace.ug.edu.gh To ascertain the involvement of the people, the research sought to find out the level of participation in the implementation o f primary health care programme. Among 200 respondents who were interviewed, 57% (114) of the people do not play any role in the programme while only 27% (54) said they play one role or another. The remaining 16% did not respond to that question. This prompted a follow-up special interview of five o f them to find out why they could not answer a simple ‘Yes or No’ question. It was then realized that they did not know what primary health care programme is all about resulting in their inability to answer some of the questions. There were questions on number of people trained or given some form of training in order to participate in the programme. Participation at the individual level is, therefore, only visible by 77 trained traditional birth attendants and five private midwives. 4.3 Participation at the Family Level Primary Health Care is proposed to act as an ‘enabler’ It enables individuals, families and communities to achieve health through better awareness and by bringing together services and resources to provide basic needs and basic health care. Dealing with health provision and management has been realized to be multifactoral in dimension, which must be tackled from all fronts in order to ensure health for all. Many programmes designed to ensure ‘Health for All’ cannot be achieved without the provision o f basic needs such as nutrition. Thus, some have focused on improving nutrition as a means to better health, integrating other health activities with a range o f nutrition-improvement measures. Changes in household behaviour have been viewed as the key to success, and a variety of interventions have to address this need. Important among these have been growth monitoring—a recurring activity which not 66 University of Ghana http://ugspace.ug.edu.gh only facilitates interaction between the health system and needy children and their mothers but is also an instrument, which helps all members o f a family target their efforts and measure their achievements, thus enabling overall improvement of health status. Regular growth monitoring is a communication strategy to improve child­ rearing behaviour, addressing nutrition as well as overall health care. It calls upon households to utilize their own resources, thus potentially reducing dependence on outside technologies and resources. It calls for continuous attention to the needs o f each child, thus introducing ‘care’ as the critical factor in nutrition rather than health or even food itself. At the family level parents have a duty to educate their children on pressing national health issues which can go a long way to complement efforts of government, multinational organizations, non-governmental organizations and other stake holders in their attempt to fight dreadful diseases like the HIV/AIDS. Campaigns against vaccine-preventable diseases aimed at eradicating such diseases, as poliomyelitis, diphtheria etc. must also be zealously participated by parents. Family level participation in the primary health care programme in the Akwapim North District is on the low side considering the fact that parents do not freely and easily discuss matters critical to health o f the children especially reproductive health issues which have long lasting implications not only on the mother but also the child as well. In terms of decision-making, implementation, monitoring and evaluation, families cannot be said to be actively involved in the programme. The evaluation of participation includes the financing of the programme. Information on participation was gathered on the basis o f local resources used in the implementation o f the 67 University of Ghana http://ugspace.ug.edu.gh programme and any other physical materials used. It was found out that no special monetary burden is put on the people in the study area and that the only way funds are sourced from the people is when they utilize health services and a fee is paid. The Ministry of Health and for that matter the central government has always been the sole financier of the programme. According to the planning officer at the Akwapim North District Assembly, Mr. E. K. Adusei, the assembly gives financial and logistic support occasionally to the PHC units. 4.4 Participation at the Community Level Community involvement in health is one of the precepts o f ‘Health for AH’. And yet, throughout the decade of the 1980s, experience of community-generated, community- led and community-implemented health care has been limited. Even when examples have been found, it has been difficult to document and understand the essential ingredients of these experiences, which have wider applicability and use in accelerating community participation in health care. It is not unusual to find that the village community considers health services as part of the government administrative system and as something imposed on them by an 'outside’ authority (as it is the case in Wassa Akyempem, page 5—Mirror, 25 March 2000). The lack of communication between health personnel and the villagers, together with the social, cultural and educational gaps between them, often leads to alienation of the people. This encourages the community to resort to traditional methods based on superstition and indigenous practitioners even though they may be more expensive in monetary and casualty terms. The conventional health practitioners, therefore, have a duty to make sure that they bridge the gap between them and those they interact with so as to gain their full participation in an attempt to promote health. 68 University of Ghana http://ugspace.ug.edu.gh For sustainable developm ent o f any community initiated programme com m unities have to design and implement specific com m unity-level actions in large-scale programmes. By and large, these efforts are aimed at tackling critical, widespread health problems. But community involvement is ensured from the inception o f the programme through careful design and introduction o f programme elements. It is sustained by continuous assessment and feedback. Accountability is the cornerstone o f these larger-scale community-based programmes. It should not be seen to be hijacked by few groups o f people who will lord it on others just because they have been given som e responsibilities to manage certain aspects o f the programme. Another area o f evaluating participation is the people’s response to health promotion activities such as immunization/vaccination, and hospital/clinic attendants. Available records show that a lot o f people take keen interest in immunizing their children. From table 5.6 in page 96, 81% o f the children bom in the year 2000 were immunized for B C G representing 4373 o f 5350. In table 5.6 the 5350 represents the number o f infants between 0 and 11 months in the year 2000. Women In Fertility Age (WIFA) as o f the same period was 22% o f the estimated population o f 133760 in the same period. Appendices 3a, 3b, and 3c in pages 129, 130 and 131 show immunization figures for the months o f January, June and Decem ber 1999 respectively. Participation at the community level in the district generally is not widespread as no definitive programmes have been laid down to get the entire community on board in the PHC programme. 69 University of Ghana http://ugspace.ug.edu.gh 4.5 Participation at the Health Institutional Level Among other functions, there are three main areas of hospital involvement towards health promotion viz. direct support to PHC, community health development activities, and basic and continuing education of health personnel. This outlines the main processes through which hospitals can become the springboard of PHC within their catchment areas. If these processes are to get firmly rooted and flourish hospitals will have to change their culture. Instead of being the receiving station of cases referred by the peripheral clinics the emphasis should be on an outgoing flow of information, technical support, materials and equipment to strengthen the peripherals. Coverage has to have priority over diagnoses of rare diseases; better nutrition through local food production over treatment of deficiency disorders; intersectoral activities over individualism. Such a change of emphasis requires a great deal of reorientation of the training of hospital personnel and their operations. The health institutions in the District have a full range of PHC activities including maternal and child health care, control of endemic diseases, health education, domiciliary visits and basic curative care. Some health institutions have helped in the formation of health development committees in their localities, and the training o f village health workers and TBAs to serve as a catalyst for improved health. The work of the Village Health Workers is mostly on a voluntary basis initially, although they derive some small profit from the sale of medicines. The health team plays a key role in facilitating the villages to undertake the self-study and community actions that lead to a broader achievement of health for all through regular workshops aimed at creating awareness, empowering the people to take their 70 University of Ghana http://ugspace.ug.edu.gh own initiative, and sensitizing them about taking their health into their ow n hands. The community leaders, therefore, choose a member o f the community, get him or her trained as a community health worker to enable him or her provide community services. The person chosen could be a reproductive health promoter who is highly motivated not because he/she receives fat salary from any quarters but because he/she has been trained to accept the fact that if couples have six or eight or ten children, it is not good for his/her community and most importantly the reproductive health o f the mother. Besides, village health worker knows that he/she is doing something good for the people which urges him/her on to want to continue providing these services without any meaningful remuneration in return o f the services he provides. In areas where there are no static PHC units the District Health Management Team trains peer educators who act as community-based distributors and health promoters w hose functions include advising and referring critical cases o f infirmity to the health post or health centres as appropriate. Community-based Distribution (CBD ) o f contraceptives can be helped or hindered by gender norms. Community-based services that bring contraception counseling and information into peoples’ homes can help wom en obtain control over their fertility, and thereby enhance their autonomy and self-esteem . CBD programmes can com pensate for the lack o f health-care facilities available to men. And, community-based programmes can improve the status o f fem ale workers, who may have limited opportunities for employment. Since hospitals are expected to play limited role in the promotion o f health it reinforces the fa,ct that enabling environment is created for the communities to manage their health matters. Hospitals are expected to play a pivotal role in this direction. 71 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE ASSESSMENT OF THE COMMUNITY PARTICIPATION IN THE PRIMARY HEALTH CARE PROGRAMME AND THE HEALTH OF THE PEOPLE 5.1 Socio-economic Impact of Community Participation Participation has been defined as “a way o f factoring local behaviour and beneficiary assessments of risks, costs and benefits into project design.. those assessments consist of rational economic decisions in the context of the social/cultural and economic environment” (Cook and Donnelly-Roark 1994, p. 4). Community participation is essential for the development o f every project. People’s involvement in activities meant to benefit them has a great deal of impact on that activity which will also go a long way to determine the extent to which the people are going to benefit from it. The socio-economic impact of community participation in the primary health care programme in Akwapim North District is going to be analyzed in the light of morbidity and mortality levels, disease pattern, education and financing of the PHC programme. 5.1.1 Morbidity and Mortality Levels To study spatial and temporal variations in morbidity and mortality, it is necessary to use comparative measures or indices of morbidity and mortality for the periods and areas under consideration. The basic measures are essentially rates of incidence, relating the number of out-patients and deaths to a unit of population, commonly 1000, in a particular interval of time. The interval is invariably one year, to avoid the complicating effect o f seasonal morbidity and mortality variations on comparability of rates. Unfortunately, for the analysis of these two variables the unit o f population is not clearly defined as the catchment areas of the health institutions selected are not 72 University of Ghana http://ugspace.ug.edu.gh well defined. In view of this, records of the top three diseases are going to be used to assess the frequency of out-patients in T.Q.M.H., Okrakwajo Health Centre, Adukrom Health Centre, and Okuapeman Community Clinic. Fig. 5.1: Out-patients-Morbidity: T.Q.M.H.-1997-2000 7000 6000 | 5000 I 4000 □ Malaria □ **URTI | 3000 □ Dianrtioea ■S 2000 S 1000 0 Ll Ll I 1997 1998 1999 2000 Years Source: T.Q.M.H. Annual Reports, 1997-2000. A careful look at figure 5.1 shows almost a constant figure in 1998 and 1999, and a slight decline in 2000 of malaria cases reported at the Tetteh Quarshie Memorial Hospital. However, malaria cases rose sharply from 4375 in 1997 to 6386 in 1998 an increase of 46%. The rehabilitation work that took place at the hospital in 1997 that led to the closure of some o f the departments was used to explain the marked difference between 1997 and the remaining years. **URTI—Upper Respiratory Tract Infection. 73 University of Ghana http://ugspace.ug.edu.gh The increase in cases o f out-patients as far as URTI is concerned is not abrupt as it is the case o f malaria. The percentage increase was 9. On the other hand diarrhoeal cases increased by 39% between 1997 and 1998. The following figures represent the three other health centres. Fig. 5.2: Out-patients--Morbidity: Okuapeman Community Clinic-1997­ 2000 •c22 2500 •2 2000 □ Malaria ?■ 1500 3 □ **URTI O 1000 *o♦- □ Diarrhoea500 o 0 □_ □ = . 1997 1998 1999 2000 Years Source: T.Q.M.H. Annual Reports, 1997-2000. Fig. 5.3: Out-Patients—Morbidity Fig. 5.4: Out-Patients—Morbidity Adukrom Health Centre Okrakwajo Health Centre 4500 2000 u> 4000 C 3500 I! 1500 3000 □ Malaria I □ Malaria9- 2500 1000 3 □ "URTI2000 □ "U R T I o 1500 □ Diarrhoea □ Danhoea■C 500 1000 z 500 nmi i mu £0 0 1997 1998 1999 2000 1997 1998 1999 2000 Years Years Source: T.Q.M.H. Annual Reports, 1997-2000 74 University of Ghana http://ugspace.ug.edu.gh Available statistics in Okuapeman Community Clinic show a consistent decline of reported cases o f all the three diseases from 1997, reaching a minimum level in 1999 and rising again in 2000 as shown in figure 5.2. For example, malaria cases fell from 2154 in 1997 to 1509 in 1999, a decrease of 30% and rising again to 2257 in 2000, an increase o f 50% from the 1999 figure. At Adukrom Health Centre, malaria out­ patients records were similar to that o f Okuapeman Health Centre. In 1997, 4255 malaria cases were reported but dropped to as low as 3459 in 1999, a decrease of 17%. It, however, increased by 13% between 1999 and 2000. There was a steady decline of URTI from 1379 to 1114 and a further drop to 1019 and to 939 in 1997, 1998, 1999 and 2000 respectively. Diarrhoea cases were relatively stable apart from an initial increase from 430 in 1997 to 522 in 1998, which was relatively a significant increase of 21% though. In Okrakwajo Health Centre, the trend is quite distinct from all other centres discussed, in the sense that the three diseases selected follow the same trend. When one changes all others change. For instance, malaria cases increased from 1622 in 1997 to 1841 in 1998; URTI increased from 522 to 654; and Diarrhoea also followed the same trend when it increased from 300 to 334. This does not necessarily mean that a change in one causes the other. In fact, when further investigations were conducted at the various health centres for an explanation for why the disease patterns were the way they were, various reasons were given which would be discussed shortly together with response from respondents in the communities. All these changes happened between 1997 and 1998. Reported cases in the three diseases declined from 1998. One significant thing about the pattern of these diseases is that the rates of change are almost the same for all the three diseases in these health centres. When Dr. Obeng 75 University of Ghana http://ugspace.ug.edu.gh Agyemang was asked to give his views on the reported decline o f out-patients in Okrakwajo Health Centre, he intimated that the people in the community have been conscious of their own health thereby contributing immensely to the decline of incidence of diseases in that area. He attributed this to the work of health promoters and peer educators who are providing counseling services to the people in the district. Further probing from respondents in the community was done to find out whether the PHC concept has had an impact on the rate with which people fall sick. When they were asked if they knew anything about the PHC concept, their response is represented by figure 5.5. Fig. 5.5: Response on Knowledge of PHC 18 (9%) 30 (15%) □ Y E S - H □ NO□ D ont know 152 (76%) Source: Data Based on Fieldwork 2001. Further question was asked on whether there are community health workers in the sampled towns and villages, and if there were do they consult them when they fall sick, the following figure represents their position on the latter questions. 76 University of Ghana http://ugspace.ug.edu.gh Fig. 5.6: Response on w h e th e r they consult **CUW $ 14 (7%) a i e s I □ NO t84 (93%) Source: Data Based on Fieldwork, 2001. From the responses of the people in the communities, it appears that the primary health care programme contributed significantly towards the reduction o f reported cases o f out-patients in the various health institutions. Out of 200 respondents, 152 (76%) confirmed that they knew something about PHC. A further 186 (93%) attested to the fact that they mostly consult these community health workers whenever they fall sick. The probable inference from these is that a good number of infirmities may have been attended to by CHWs in which case they may not be reflected in the available records at the health institutions, which could also partly explain the apparent reduction of out-patients. However, the impact o f preventive services on the number o f out-patients cannot be ruled out. But for the year 2000 where there were increases in frequency o f diseases in Okuapeman and Adukrom Health Centres, all thing being equal, one could have safely asserted that, generally there has been a steady improvement in health of the people in the community. Mortality pattern on the other hand, has some striking characteristics completely distinct from the morbidity pattern discussed above. Unlike the morbidity pattern where there was falling morbidity occurrence in almost all the health institutions **CHWs— Community Health W orkers 77 University of Ghana http://ugspace.ug.edu.gh studied, mortality shows a consistent increase in T.Q.M.H. from 41 in 1997 to 129 in 1998, a sharp increase o f 215%. The number o f deaths increased further from 129 to 217, which is 68% increase in 1999, and to 264 in 2000. Table 5.1 shows the top 10 causes o f death in T.Q.M.H. Table 5.1: Top Ten Causes of Deaths CONDITION/CAUSE OF DEATHS TOTAL % OF TOTAL 1. Hypertension 47 12.3 2. Congestive Cardiac Failure 38 9.9 3. Anaemia 37 9.7 4. Cardio Respiratory Failure 37 9.7 5. Cardio Vascular Accident 29 7.6 6. Pneumonia 22 5.7 7. Cardiac Arrest 19 5.0 8. Malaria 16 4.0 9. Diabetic Mellitus 14 3.7 10. Intracranial Hemorrhage 13 3.4 Total of All Others 111 29.0 GRAND TOTAL 383 100.0 Source: T.Q.M.H. Annual Report, 1999. 5.2 Pattern of Diseases The disease pattern in the District shows consistently high figures for malaria cases in all the health centres where data were collected. A careful look at available figures in health institutions quoted in pages 74 and 75 depict a slight declined in morbidity. For instance, reported cases of malaria dropped from 1622 to 1251 in Okrakwajo Health Centre. Opinions o f respondents were sought on how they see the health conditions of the people in the district for the past ten years and the following is what they had to 78 University of Ghana http://ugspace.ug.edu.gh Figure 5.7: Health Status since the Past Ten Years Source: Data Based on Fieldwork, 2001. About 66% of the respondents believe that the health status o f the people in their communities has improved. These improvements were attributed to availability of essential drugs even though many believe that they are too expensive. They also believe that it is the results o f God’s protection, immunization campaigns and improvement in environmental cleanliness thereby reducing environment-induces diseases. Thirty-seven out of the 200 respondents, which constitute 19%, were o f the opinion that conditions o f health have actually deteriorated. The remaining 15% believe there has been no change in the health status of the people for the past ten years. Figure 5.8 shows the distribution o f reasons assigned by respondents as the forces behind the improved health status. “A”, “B” and “C” represent availability o f drugs; 79 University of Ghana http://ugspace.ug.edu.gh preventive health education and immunization; and God’s protection respectively in figure5.8. Fig. 5.8: Reasons for Improvement 120 100 A i n ? - 80 60 40 20 4 - - — \ — 18 0 ---------------------------------- 1-------------- 1 A B C Ot her s Reasons Source: Data Based on Fieldwork, 2001. Note: ‘A’ denotes Availability o f Drugs; ‘B ’—Preventive Health Education and Immunization; ‘C’— God’s Protection. The 132 respondents who share the opinion that health status o f the people has improved, 7% (9) of them believe that it was due to improved availability o f drugs while 77% (102) were o f the view that it was largely because of preventive health education given to the people. The 14% (18) of the respondents designated “others” attributed the perceived improvement to factors such as improved accessibility in terms o f number of lorries plying the area which enables them to access the health facilities in the district, increased number of health centres, the urge of some of the health personnel to deliver high quality services to their patients among others. Two respondents did not give any reasons. Table 5.2 shows the top ten causes of consultation at T.Q.M.H. in 1999. 80 University of Ghana http://ugspace.ug.edu.gh Table 5.2: TOP TFN CAUSES OF CONSULTATION/MORBIDITY CONDITION/CAUSE TOTAL % OF TOTAL 1. Malaria 6413 27.0 2. Upper Respiratory Tract Infection 1906 8.0 3. Diseases of Oral Cavity 1521 6.4 4. Pregnancy Related Complications 1504 6.4 5. Accidents (Fractures, Burns etc.) 1246 5.2 6. Hypertension 1124 4.7 7. Acute Eye Infection 1122 4.7 8. Gynaecological Disorders 928 3.9 9. Disease of Skin 712 2.9 lO.Diarrhoeal Disease 592 2.5 Total of All Others 6676 28.3 GRAND TOTAL 23744 100.0 Source: T.Q.M.H. Annual Report, 1999. 5.3 Education The focus of this research, with regards to the impact of education on community participation, is whether health education has impacted on people’s attitude towards involvement in all facets of the programme, from the perspective o f respondents who are the object and at the same time the subject of analysis. There are a number of agencies involved in health education programmes apart from what is given to pupils through formal education in classrooms. Other agencies such as Plan Parenthood Association of Ghana (PPAG), PHC units, and non-governmental organizations particularly CEFRIEND, as far as the district is concerned are also involved in health education. The PPAG is mainly involved in family planning and related issues. Its activities are conducted mostly in the form of organized forums where resource personnel are 81 University of Ghana http://ugspace.ug.edu.gh invited to deliver a talk on family planning related topics after which the floor is usually opened for the people to asked question bothering their minds. Most respondents reported that film shows are the most interesting aspect of PPAG’s educational programme. There is a white lady from Canada called Margaret Scott, who has shown great concern on the health of the people. She has been going round the district meeting and educating the people about the need for one to protect and safeguard his or her health at all times. It is also common knowledge that this woman sometimes provides drugs and other items to needy people from her own resources. One thing gathered from the respondents was that they like this woman and are ready to listen to her any time she is willing to talk to them. This is one of the surest ways of getting the people involved in the PHC programme. The PHC units with its affiliate sub-division such as Maternal and Child Health (MCH), Family Planning, Food and Nutrition etc. are the main foci of analysis in terms of people’s participation in the PHC programme. PHC units undertake educational programmes in various forms. One of them is sending some of their personnel to go out and talk to the people on pressing health issues, which are of grave concern to the Ministry of Health and for that matter the government. In places where there are no static PHC units regular and periodic (normally monthly) outreach programmes are embarked upon in order to reach out to communities, which may not have access to PHC services due to technical or financial problems. The Maternal and Child Health together with Nutrition divisions concentrate more on family planning and reproductive health. Matters usually discussed include breastfeeding, child 82 University of Ghana http://ugspace.ug.edu.gh bearing and child spacing, eating habit for mother and child among a host of other preventive health measures. Health education is a cardinal element not only to MoH or PHC units but also the beneficiaries of the programme themselves. This was demonstrated when they were asked ‘what they, the respondents, think should be done to encourage people’s participation in the PHC programme’ Table 5.3 represents the views o f the respondents. Table 5.3: Response on how to Improve Community Participation Responses No of Respondents Percentage (%) Involve them in decision-making process 8 4.0 Involve them in implementation stage 3 1.5 Educate them about PHC programmes 182 91.0 Give them financial incentives 2 1.0 Others 5 2.5 Total 200 100.0 Source: Data Based on Fieldwork, 2001. From the table above, it can be seen that the majority o f respondents have a conviction that for people to avail themselves with the PHC concept and to fully involve themselves in its programmes they must be well informed about what it stands for. As many as 182 respondents share this view, which constitutes 91% of total respondents. In spite o f the huge role health education can play towards whipping up community’s interest for improve participation in the primary health care programme, it was realized that, not enough has been done in this direction. ‘How often respondents 83 University of Ghana http://ugspace.ug.edu.gh come into contact with the PHC personnel for such educational programmes’, the result was not encouraging. It is even worse in the case o f rural communities as Table 5.4 and Figure 5.9 depict. Table 5.4: How Often the People in the Community Meet PHC Personnel Response No. of Respondents Percentage (%) Once Every Three Months 17 9 Once Every Six Months 74 37 Once Every Year 57 28 Not at All 40 20 Others 12 6 Total 200 100 Source: Data Based on Fieldwork, 2001. Out o f two hundred respondents, 20% of them had never met any PHC personnel as far as dissemination o f health educational issues are concerned. The problem is more pronounced in the rural areas as compared with the relatively urban areas*. Fig. 5.9: R esponses of Those Haven't M et PHC Personne l Before 56 (2 8 %) □ R u ra l □ U rb an 144 (7 2 % 1 Source: Data Based on Fieldwork, 2001. * See page 30 for sampled towns and villages and their total populations. 84 University of Ghana http://ugspace.ug.edu.gh A further 57 respondents stated that they meet their PHC personnel for similar exercise once every year. This together with “not at all” respondents constitutes 49% of those who do not have access to the people who are supposed to educate them on regular basis. The most unfortunate thing about this phenomenon is that majority of this category o f people are rural dwellers who need this type o f education more than any other category of people. Under this circumstance, the very people who are supposed to ensure that the programme runs effectively seriously undermine the cardinal principle of PHC, which is community participation. There is, therefore, the need to take a critical look at this to ensure that optimum participation of the communities is achieved at all times and places. 5.4 Programme Financing Money to some people ‘is not only the most important thing but the only thing’. One serious setback to successful implementation of PHC activities is money (WHO, 1990). Interviews with health personnel in T.Q.M.H. revealed that the most daunting problem inhibiting the progress of PHC programmes is financial resources to procure the necessary logistics for smooth running o f its activities. As Madam Juliana Addo, senior community health nurse at T.Q.M.H., puts it “the goal o f the Primary Health Care concept was to achieve health for all by the year 2000 even though that has proven to be a mirage. This means providing free medical care to large numbers of people who really need medical care but who cannot afford it themselves. Meanwhile the Ministry of Health which is the main financier of the programme lacks adequate financial resources to cater for all that is needed to promote PHC programmes efficiently”. 85 University of Ghana http://ugspace.ug.edu.gh Fieldwork reveals that the PHC programme is w holly financed by the central government subventions through the Ministry o f Health with occasional help from the district assembly and a non-governmental organization called CEFRIEND especially when there is Mass Immunization Campaigns. Apart from these sources little revenue is generated from the small fees they collect from regular child check ups, what is referred to as ‘W eighing’ This aspect o f the programme is one o f the crucial areas where community participation is badly needed especially in a developing country like Ghana where w e are often told that ‘the government alone cannot do this or that’ The people can be educated and convinced to understand that it is in their interest to contribute a token towards the running o f the programme so that they can derive maximum benefit from it since the programme is there to serve their interest. The PHC programme in Akwapim North District is not endowed with enough resources like all others in the country apart from that o f the Asante Akim North District where the programme is given a cushion in both logistical and financial terms to complement their effort, from Presbyterian Church o f Ghana, which established A gogo Hospital, and virtually run the PHC unit. With no such privileges in Akwapim North District and governmental sources w oefully inadequate the only option available to them is to generate funds internally for the day-to-day running o f the programme. S.S Sustainability of the PHC Concept The strength and future sustainability o f Primary Health Care programme dwell on its econom ic, social and health programmes not as separate programmes or entities but rather as integrated whole. It is asserted that programmes that treat econom ic, social 86 University of Ghana http://ugspace.ug.edu.gh ( i nc lud ing heal th), and ecologi ca l p rog ra mm es separately wou ld not be sus tainable. Pr imary Hea l th Ca re p r o g r am m e in o rder to en su re sus ta inab l e heal th deve lopment , sough t to p romo te comm un i ty part icipat ion, conse rve the social norms and t radi t ions such as tradi t ional health del i very sys tem, and preservat i on o f the env i r on men t to r educe spr ead o f diseases. Th is research has as one o f its bas i c objec t ives a cri tical examinat i on o f fac tors which in f l uence par t ic ipat ion in the PMC p ro g r am me in the district so as to find ou t i f new ideas could be i ncorpora t ed into the p r o g r a m m e to improve eff iciency, therefore , ma k in g it s us t a inab l e— including cont r ibut ion to improvemen t o f heal th o f the people, cul tural identi ty, and social cohes ion and part icipat ion, Med ica l l y , the cont r ibut ion so far made by the concep t o f pr imary heal th ca re to the heal t h s t atus o f peop l e c anno t be overemphas i zed . This asser t ion is largely man i fes t ed in Nicar agua . Unde r the d ic t atorship o f So mo za in that count ry, health ca re was abysma l for the vast major i ty o f Nicaraguans . The ave rage life expec t ancy was 54 years o f age for men and 52 for w o m en w ho we r e (he hardes t hit by ma ladmin is t ra t ion exhibi ted by Somoza . Malnut r i t i on was r ampan t and af fected 7 o f eve ry 10 chi ldren. Chi l dren be tween the ages o f I and 2 years exhibi ted a mor ta l i t y ra t e o f 2 0% , with infant mortal i ty compr i s i ng 120 o f 1000 live bir ths in the urban areas and 300 o f 1000 live bir ths in the rural areas Th e ch i e f c auses o f dea ths a m o n g older chi ldren included tetanus, measles, and dehyd ra t i on from gast roenter i t i s and diar rhoeal condi t ions , wh ich are all preventable. R7 University of Ghana http://ugspace.ug.edu.gh In July 19, 1979, the Sandinista government took control o f Nicaragua after a very bitter and hard-fought revolution. One o f the postwar initiatives was the formation and implementation o f countrywide health drive that was designed to provide universal access to primary, preventive, and community care services for all Nicaraguan residents. The Sandinista campaign promoted health education and the training o f health care volunteers to promote personal and environmental cleanliness and good nutrition and to provide vaccinations against preventable diseases in local villages and communities. In addition, the government wished to initiate a plan to eradicate polio and malaria. All available nurses who were working in Nicaragua were engaged to assist in these activities. Furthermore, a call went out worldwide for nurses and physicians who were trained in primary care, community, and public health to assist the Sandinista government with their effort. Nicaraguan nurses received special training in maternal and child health and were taught the principles o f community and public health. They staffed many neighbourhood and rural clinics and provided free parental care, medications and food supplements. As part o f this programme, all infants and children were guaranteed free primary and disease preventive health care. Popular participation was the order o f the day and they succeeded in gradually improving the health o f the people. This clearly shows that when people are encouraged, made to take active part and leave the control over the programme in their hands, with governing agency or department playing monitoring and supporting roles, it will go a long way to influence the extent to which they will participate and the effectiveness o f the programme 88 University of Ghana http://ugspace.ug.edu.gh Unfor tunate ly, the effor ts o f the Sandini st as w e re d issolved as a resul t o f anothe r b loody polilical revolut ion. N icar agua lias be c om e one o f the poores t countr ies in the Wes t ern He misphe re and fall behind Haiti , whi ch has held that dis t inct ion for decades . Universa l a ccess lo pr imary and preven t ive care no longer exis ts Nei ther pol io nor malar ia has been eradi ca ted (McGui re , 1995) An o the r count ry w h e re part icipat ion by com mun i t i e s has helped in en su r ing the succes s o f a p r og r am m e des igned to improve the heal th o f the people is the Gambia . In the G a m b ia a commun i ty -ba sed s t ra tegy was tested, in wh ich a tradi t ional snack food was p romoted as a d ie t ary suppl emen t to improve w o m e n ’s nutr i t ion dur ing p r e gnancy (W H O , 1996). Th e resul ts sugges t h o w co mm un i ty nutr i t ion p rog r amm es can be des igned so as to ensure sustainabi l i ty. By and large, the lessons learned are a l so app l i cab l e lo o ther types o f comm un i t y heal th p rog ramme . Wha t necess i ta ted the adopt i on o f this s t ra tegy was that wo men in rural areas o f the G ambia we re nutr i t ional ly s t ressed because o f heavy workloads , c losely spaced p regnanci es , and d ie t a ry def i cienci es I'heir poo r nutri t ional s ta tus cont r ibut es lo compl i ca t ions dur ing p r egnancy and chi ldbir th, maternal and neonata l mortal i ty, maternal anaemia , and low bir th weight o f babies. T h e Ga m b ia Food and Nutr i t ion Associat ion, a non-governmenta l organi za t i on, which has been involved in commun i ty -ba sed and nutr i t ion projects s i nce 1990, and has been ac t i ve in s eeking ways to improve w o m e n ’s nutri t ional s ta tus got involved in ame l ior a t i ng the prob lem The Associat ion tested a commun i ty -ba sed s t ra tegy involv ing (he p romo t ion o f fu ln ktviya, a tradi t ional snack food made wi th millet, 89 University of Ghana http://ugspace.ug.edu.gh sugar and groundnut paste, all o f which are produced locally, as a dietary supplement for pregnant wom en during the rainy season. Some key components o f the project were: • training o f local w om en’s community management com m ittees to coordinate the preparation and distribution o f futu kanya, • education on nutrition for male and fem ale members o f the community; • community involvement in all phases o ffutu kanya production; • regular supervision o f participating villages by project staff; and • collaboration with local staff o f the Ministry o f Health. The results o f the evaluation showed that the project was quite successful in terms o f community involvem ent in the production and promotion o f futu kanya. Virtually all the community interviewees reported that futu kanya had a positive effect on the pregnant women who consumed it. They stated that these women had more energy than during previous pregnancies and that babies were born big and strong and remained healthy subsequently. Exam ples o f situations where attempts have been made to improve the health o f majority o f the citizenry through vigorous and determined community participation in the PHC concept can be found in countries where health status has been said to be higher than income suggests. Such countries include Burkina Faso, Tanzania and India. All these examples go to confirm the assumption that “community involvem ent or participation is o f paramount importance for the effective implementation o f the PHC programme” . 90 University of Ghana http://ugspace.ug.edu.gh Field investigations reveal no such intense approach towards execution o f PHC programmes in the Akwapim North District, as it were in Nicaragua and in the Gambia. N o specific programmes have been designed to capture the entire community the way it was in the Gambia. There is, therefore, the need to invigorate our approach to all activities concerning PHC programme. This can be done by embarking on nationwide educational crusade to sensitize the people for full participation o f all including politicians, medical and paramedical personnel, teachers and practically any body w ho can contribute his/her quota to uplift the concept o f PHC to the level where its benefits can be utilized by all. It is only when people are informed and believe that they are going to derive benefits from something that they will put maximum effort into it, which will go a long way to enhance its long-term sustainability. 5.6 Initiatives in Primary Prevention Methods M ost childhood deaths in the developing countries can be prevented if children are adequately breast-fed, correctly weaned and protected with immunizations against com m on childhood communicable diseases. One o f the major roles o f family health is the promotion o f preventive paediatrics. Preventive paediatric starts during the prenatal period when health workers must com m ence the orientation o f pregnant wom en about the need and the importance o f breast-feeding. It also includes the necessity for adequate balance meals to prevent anaemia and premature or small-for- date babies, and the need for tetanus prophylaxis. Over the years, the main efforts o f health practitioners have been focused too much on diagnosing and treating diseases rather than preventing them. In a country where incom e level is so low to the point that many people do not think o f visiting medical 91 University of Ghana http://ugspace.ug.edu.gh centres when they fall sick making avoidable deaths a common feature in Ghana in particular and developing countries in general. This makes it imperative to direct much resource towards disease prevention in which case resources that the government spends in importing sophisticated medical equipment and drugs, which are severe drain on our limited foreign earnings, can be directed to other areas for the betterment o f all Ghanaians. The following are some o f the preventive health activities. 5.6.1 Expanded Programme on Immunization (EPI) Immunization is one o f the most powerful weapons for the primary prevention o f infectious diseases. Smallpox was once a serious disease, which infected many people. It has now been eradicated as a result o f well-organized vaccination campaigns. Poliom yelitis, whooping cough, diphtheria, tetanus, tuberculosis and m easles are all serious diseases, which can be effectively prevented by immunization. Fortunately, the people o f Ghana are ready to respond to calls on immunization as shown by respondents in the study area. When they were asked whether they have immunized their children against the six childhood killer diseases the response was overwhelm ingly positive as shown in figure 5.10. 92 University of Ghana http://ugspace.ug.edu.gh Fig. 5.10: The Degree of Response to Immunization Response Source: Data Based on Fieldwork, 2001. From the figure 5.10, out o f 200 respondents interviewed 184, which is 92%, have immunized their children w hile only 16 respondents have not and out o f the 16 is 81% w ho are yet to give birth or have not been able to g ive birth at the time these interviews took place. The three respondents, who have not immunized their children when asked to explain w hy they have not immunized their children, could not give any reasonable answer. W hen probed further to find out whether their decisions were based on religious beliefs or tim e constraints, or any other factors, they could not confirm or deny that as well. Moreover, respondents were asked i f they see immunization o f children as necessary for sound child health, there was a 100% positive response. When asked what they have observed to make them think that immunization is necessary for sound child health. Table 5.5 summarizes their views. 93 University of Ghana http://ugspace.ug.edu.gh Table 5.5: Immunization as a Necessity for Sound Child Health Reasons Number o f Respondents Percentage (%) They don’t fall sick frequently 31 17 It has prevented some diseases 58 31 They look stronger 11 6 They are not deformed 17 9 Protected them from sickness 62 34 Others 5 3 Total 184 100 Source: Data Based on Fieldwork, 2001. Immunization aspect o f health promotion is very crucial to this study as it forms the integral part o f the second assumption, which states, “Immunization is very necessary for child health” It is o f absolute necessity that all children in the catchment area o f a family health care service be given full immunization coverage within 12 months o f their registration at the clinic. The clinic supervisor must regularly evaluate the immunization coverage o f the children. It is unreliable to use the number o f daily immunization as a yardstick for the effectiveness o f immunization activities since it is possible that only a fraction o f children who attend the clinic com plete their immunization schedule. Regular random sampling o f the immunization cards o f the children who attend the clinic must be carried out. If mothers do not bring the children to clinic, as they should, the clinic staff should extend its immunization service and go into the houses to immunize the children. A careful look at the immunization monitor in page 95 (table 5.6) shows 81% immunization rate o f BCG which is given soon after a child is born whilst for the TT ’2 the rate fell to 50% which is due mainly to the fact that it is given som e months after a child’s birth. The immunization status o f every 94 University of Ghana http://ugspace.ug.edu.gh child at every visit to the clinic must be checked, and if the child is well and due for an immunization, it must be given before leaving the clinic. Health workers must constantly remind mothers that most children w ho are unprotected against childhood com municable diseases will suffer these diseases and die, becom e maimed or suffer long periods o f ill health. The schedule o f immunization w ill depend on a countiy’s health profile but all the developing countries will protect their children against tuberculosis, diphtheria, pertussis, tetanus, poliom yelitis and measles. Table 5.6: Immunization Monitor—2000, Akwapim North District Estimated Population (Year 2000) = 133760; WIFA (22% 133760); 0-11 Months (5350). Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec B.C.G Actual 356 344 437 382 400 407 411 370 341 273 346 307 Cumulative 356 700 1137 1519 1919 2326 2737 3107 3448 3721 4066 4373 Percentage 7 13 21 28 35 43 51 58 64 69 76 81 Measles Actual 268 283 345 302 297 292 304 231 231 238 245 213 Cumulative 268 551 896 1198 1495 1787 2091 2322 2553 2791 3036 3249 Percentage 5 10 16 22 27 33 39 43 47 52 56 60 DPT’ 3 Actual 310 340 383 357 319 303 292 266 336 297 299 256 Cumulative 310 650 1033 1390 1709 2012 2304 2570 2906 3203 3502 3758 Percentage 5 12 19 25 31 37 43 48 54 59 65 70 O PV 3 Actual 316 343 382 374 325 321 294 272 326 286 295 254 Cumulative 316 659 1041 1415 1740 2061 2355 2627 2953 3239 3534 3788 Percentage 5 12 19 26 32 « 44 40 55 60 66 70 T T 2 Actual 192 276 316 188 225 221 246 207 237 286 240 186 Cumulative 192 468 784 972 1199 1418 1664 1871 2108 2394 2634 2820 Percentage 3 8 14 18 22 26 31 34 39 44 49 50 Y/Fever Actual 189 206 274 314 292 341 352 186 266 208 271 487 Cumulative 189 395 669 983 1275 1616 1968 2154 2420 2628 2899 3386 Percentage 3 7 12 18 23 30 36 40 45 49 54 63 Source: Immunization Returns, T.Q.M.H., 2000. 5.6.2 Nutrition Education M ore than half o f the children in the developing countries are malnourished (Adegoroye, 1983). Because o f this they are very susceptible to infections and disease 95 University of Ghana http://ugspace.ug.edu.gh germs, which are rampant because o f countries’ poor socio-environmental conditions. Family health workers must equip fam ilies with the necessary information to enable them to select, prepare and serve nutritious meals prepared from suitable and locally available foodstuffs to their families. Individual and group health education concerning nutrition, food demonstration classes and daily supervision o f feeds are som e o f the activities, which a family health clinic should include in its nutrition education programme. In addition to regular w eighing o f children at the clinic, health workers must identify, during their visits to the homes, children who show signs o f incipient malnutrition. Investigations into food situation in the District unfortunately portray a gloom y picture according to the respondents. They were asked to g ive their impressions on levels o f food production and access to food for the past ten years, whether there has been an ‘increase’, ‘decrease’, or ‘no change’, their view s are represented by table Table 5.7: Levels of Food Production and Food Availability for the Past Ten Years Response Number o f Respondents Percentage (%) Increasing 14 7 Decreasing 86 43 N o Change 100 50 Total 200 100 Source: Data Based on Fieldwork, 2001. 96 University of Ghana http://ugspace.ug.edu.gh Majority o f the people in the study area conceded that there has either been a decline in food production and for that matter its availability or there hasn’t been any significant change in these two variables over the past ten years. Only 7% (14) out o f the 200 respondents believe that there has been som e increase in food production and availability in Akwapim North District. This scenario particularly calls for pragmatic approaches in solving the problem o f food inadequacy in the District in order to forestall any calamitous eventuality since lack o f food could easily compel people to eat any food they could lay hands on notwithstanding the health problem that could result from it. 5.6.3 Utilization o f Clean Water Water is the most common substance on earth. It covers more than 70% o f the earth’s surface (The World Book Encyclopedia, 1993, p. 116). It fills the oceans, rivers, and lakes, and is in the ground and in the air w e breathe. Water is everywhere. Without water, there can be no life. In fact, every living thing consists o f water. Our body is about two-thirds water. Our demand for water is constantly increasing. W e live in a world o f water. But almost all o f it— about 97 percent— is in the oceans. This water is too salty to be used for drinking, farming and manufacturing. Only about 3% o f the world’s water is fresh (unsalty). Most o f this water is not easily available to people because it is locked up in icecaps and other glaciers. By the year 2000, the w orld s demand for fresh water may have doubled what it was in the 1980s. As our demand for water grows and grows, w e will have to make better and better use o f our supply. Unfortunately, much o f our water is being polluted. Water pollution is one o f our most serious environmental problems. It occurs when water is contaminated by such 97 University of Ghana http://ugspace.ug.edu.gh su bstances as hu m an and o th e r an im al w astes , to x ic chem ica ls , m eta ls and oils. P o llu tio n can a ffec t rain , rivers, lakes, oceans, and th e w a te r ben ea th th e su rface o f th e earth , called ground water. Polluted water may look clean or dirty, but it all contains germs, chemicals, or other materials that can cause inconvenience, illness, or even death. Impurities must be removed before such water can be used safely for drinking, cooking, washing, or laundering. The effects o f water pollution on the health o f humans are enormous. Water polluted with human and animal wastes can spread typhoid fever, cholera, dysentery, and other diseases. About 75% o f the United States community water supplies are disinfected with chlorine to kill disease-causing germs (The World Book Encyclopedia, 1993). However, disinfections do not remove chemicals and metals, such as polychlorinated biphenyls (PC B’s), chloroform, arsenic, lead, and mercury. In our situation in Ghana, because o f low level o f technology and income, w e cannot afford the U. S. example so what is for us is to m obilize whatever resources available to protect our natural sources o f water. It is also necessary to educate people to treat impure water before drinking, cooking, or any other use one wants to put it to. A probe into the availability o f water in the District for the past ten years revealed the following. 98 University of Ghana http://ugspace.ug.edu.gh Table 5.8: Degree of Access to Potable Water for the Past Ten Years Response Number o f Respondents Percentage (%) Increasing 28 14 Decreasing 80 40 No Change 92 46 Total 200 100 Source: Data Based on Fieldwork, 2001. To most respondents interviewed, access to pure water is really a problem and it is increasingly getting out o f hand. The three villages— Tinkong, Kurutuase and Asempaneye— rely on hand dug wells, which dry up during dry months o f every year according to some opinion leaders in the villages. In Akropong and Mampong where they have som e sort o f pipe-borne water, the situation is no different, as there is highly intermittent flow o f water, thereby forcing the inhabitants to walk long distances for well-water which is equally unreliable. Generally, 40% (80) o f the respondents assert that access to potable water has deteriorated in the past ten years, whilst 46% (92) believes that there has been no change in access to water. In view o f this, education on the use and treatment o f water is essential if a significant reduction o f incidence o f diseases is to be achieved. 5.6.4 Environmental Sanitation. M ost disease causing agents live in the environment. Their survival depends on the state o f the environment. The health o f the people, therefore, indirectly depends on how the environment is kept. In spite o f the role environment plays towards the health status o f people, it has been in many ways polluted. Environmental pollution refers to 99 University of Ghana http://ugspace.ug.edu.gh all the ways by which people pollute their surroundings. People dirty the air with gases and smoke, poison the water with chem icals and other substances, and damage the soil with too many fertilizers and pesticides. People also pollute their surroundings in various other ways. For example, they ruin natural beauty by scattering junk and litter on the land and in the water. They operate machines and motor vehicles that fill the air with disturbing noise. Nearly everyone causes environmental pollution in some way. Environmental pollution is one o f the most serious problems facing humanity today. Air, water, and soil— all harmed by pollution— are necessary to the survival o f all living things. Badly polluted air can cause illness, and even death. Polluted water kills fish and other marine life. Pollution o f soil reduces the amount o f land that is available for growing food. When the respondents were asked to give their impressions on the environmental sanitation o f their area in the past ten years, 50% (100) agreed that there has been some form o f improvement in sanitary conditions in their areas while 37% (74) said it is actually deteriorating. The remaining 13%, which makes up 26 o f the 200 respondents declared that there has been no significant change in the environmental conditions in their areas. 5.6.5 Awareness Programmes Creating health awareness among people especially in rural areas where access to health facilities is almost always a problem, either because o f non-existence o f medical facilities or the people simply cannot afford it, such exercise needs to be 100 University of Ghana http://ugspace.ug.edu.gh tackled from all fronts. In the first place, the Health for All goals require that nurses not only provide highly specialized care at the primary level, with roles including those o f facilitator and manager o f health care. The central concern o f nurses in primary care should be the prevention o f disease and disability. This requires them to educate individuals and families on healthy life styles, and communities on the primary prevention o f ill health and on protective and supportive measures. Nurses also have a duty to educate other categories o f health care personnel. With the arrival o f the Primary Health Care approach comes with the involvem ent o f nurses in diagnostic and intermediate levels. Nurses are today required to teach community health workers and traditional birth practitioners to carry out many o f the functions that nurses themselves have normally performed. They also have to undertake tasks and responsibilities formerly reserved for doctors, including the examination o f patients, the treatment o f acute conditions, the identification o f sources o f health problems, and the prevention o f major diseases. The roles enumerated above are crucial and nurses have to play them with utmost dexterity since it is they who are closer to the people and interact more with them. 5.7 Inhib iting Factors o f the Prim ary H ealth Care Program m e Several red lights have been encountered in the implementation o f primary health care programme. One serious check to PHC is money. Resources are inadequate at all levels. The staffing levels required for optimum running o f the health units have not been met, and this has hindered the integration o f activities. Shortage o f funds, moreover, curtails the services the health units can offer. The Ministry o f Health has difficulty in supporting the costs o f projects originally financed by external resources. 101 University of Ghana http://ugspace.ug.edu.gh Another red light has to do with weak management. Even if additional health resources were made available to the health budget from inside or outside the country, very little improvement in PHC would be realized if they were used in the same way. M ost health resources go to providing unnecessarily sophisticated curative health care, which is becoming more expensive to those who have to use it. Little money is left for health promotion, disease prevention, and the provision o f curative care to the rest o f the population. The concept o f PHC has not been properly assimilated by all health workers or indeed by the population as a whole. In the eyes o f many, PHC is limited to services offered by community health workers. N ot all managers o f health units have been trained in health services management. Since resources have not been adequately decentralized, there is no incentive for those in charge o f units to engage in micro planning for their areas. M ost ministries o f health do not have the ability to undertake the dual tasks o f delivering health services and mobilizing communities for more than routine activities over short periods o f time. Self-help schemes to build clinics, improving water resources or building access roads have been som e o f the few exam ples o f activities undertaken. The enthusiasm soon wanes after the task is completed, and without continuing support or encouragement interest is not sustained. Some difficulties arise from the level o f socio-econom ic development o f the country as a whole. For example, the low level o f literacy hampers health activities. In the study area, illiteracy is pervasive especially in the rural settings o f Tinkong, Kurutuase and Asempaneye. As many as 35% o f the 20 respondents in Asempaneye, a village, were illiterates whilst only 3% have had no formal education at all in a relatively urban area 102 University of Ghana http://ugspace.ug.edu.gh o f Akropong the district capital. Further, among the 84 rural respondents, there was not a single graduate from any tertiary institution. Table 5.9 shows level o f education in the various sampled communities. Table 5.9: Level of Formal Education in the Sampled Towns and Villages LEVEL OF FORMAL EDUCATION Towns/villa­ No Basic Secondary/ Tertiary No. of Percentages ges Education Technical Respondents Akropong 2 29 25 4 60 30 Mampong 2 31 22 1 56 28 Tinkong 8 16 12 0 36 18 Kurutuase 7 13 8 0 28 14 Asempaneye 7 8 5 0 20 10 Total 26 97 72 5 200 100 Source: Data Based on Fieldwork, 2001. The greatest o f these problems is that o f supervision. Where the network o f health service is not properly organized, the village health worker remains unsupervised, and this is very dangerous to the community as well as the health worker. Health workers who operate in static units such as the health post are often tied down to their units by a heavy curative workload which prevents them from looking beyond the confines o f the four walls o f the health post. Community health aides/assistants are paid by the central government and because the government is usually financially handicapped they employ only a few o f these cadre o f health workers who are expected to supervise an unrealistic number o f villages and village health workers. Unfortunately most workers do not posses the means o f transport to make them mobile enough to carry out their supervisory functions. In fact, at the Tetteh Quarshie Memorial 103 University of Ghana http://ugspace.ug.edu.gh Hospital, where the general overseeing and coordinating body is housed, the only mode o f transport for such activities is two motor bikes which are also in demand for other purposes thereby putting too much pressure on them and also not getting access to them at the right time. Furthermore, most o f the community health aides/assistants also lack supervision by a higher authority. The result is that the village health workers are left to their own devices. Many o f them take on more curative functions than they have been taught, and the preventive and promotive aspects o f their functions are neglected. 104 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX SUMMARY, CONCLUSION AND RECOMMENDATIONS 6.1 Summary The world’s attention has been directed to the need for the adoption o f technologically practicable and socially acceptable health care programme to put a halt to numerous avoidable infirmities and deaths since the Alma-Ata Declaration in 1978. The solution, therefore, lies in the adoption o f sustainable health development approach where people— nation-states, communities and individuals— decide on their own needs and work vigorously for its accomplishment. This participatory research project describes a mechanism by which individuals from communities are involved with the process o f identifying and examining the health problems o f their community and the potential ways to design solutions for them. A comparative analysis o f programme process and product from different settings around the world was used to determine the success and failures o f the programme. One typical example is Sandinista government approach to primary care in Nicaragua in the early 1980s. Primary health care is a programme seeking to achieve sustainable health development through community participation in the promotion o f health. In line with this, the programme was conceptualized in a manner that incorporates all sectors o f the economy. This is based on the fact that, health cannot be promoted in isolation and without a corresponding improvement and support from other sectors. The primary health care programme in Akwapim North District like all others in the countiy has three tiers: namely Level A, Level B and Level C. All these levels must 105 University of Ghana http://ugspace.ug.edu.gh coordinate effectively for rural-based primary health care to be carried out successfully. The participatory approach was based on a model where there is a bilateral interaction between the communities as a group and the Ministry o f Health. In fact, the success or failure o f the programme depends on each side fulfilling its part as far as the programme’s activities are concerned. Various governmental agencies com e under Ministry o f Heath to perform primary health care functions. These are the health posts, health centres and T.Q.M.H. in Mampong as far as PHC in the District is concerned. The communities consist o f the general public, the opinion leaders, the trained community health workers and traditional birth attendants. The Ministry o f Health through its affiliate agencies performs various roles such as defining policy direction, decision-making, planning, implementation, monitoring and evaluation o f the programme. For instance, the ministry determines the health policy o f the country w hile the PHC units and the health institutions implement whatever is outlined in the health policy in line with the goals and aspirations o f primary health care concept. The role o f the community is found in areas o f receiving the services o f the health personnel and to a limited scale, supporting implementation o f the primary health care programme by such people as traditional healers, traditional birth attendants, and community health workers. At the sub-district level, the sub-district health management committee organizes and coordinates all the activities in the primary health care programme while the district health management team supervises and coordinates all programmes in the District. 106 University of Ghana http://ugspace.ug.edu.gh The role o f the community in the implementation o f primary health care programmes is restricted mainly due to the technical nature o f health issues that require specially trained people to deliver, and to a larger extent the lack o f well defined roles to be played by the people in the study area. This notwithstanding the community cannot be left a loof since one o f the objectives o f the PHC concept is to transform the community from being receivers to enablers who can take their own health maintenance into their own hands. It implies that, the community be given som e basic education and training that can enable them practice lifestyles required to ensure healthy living. Unfortunately, this is the area where not much, if any at all, has been done. The area where there is a significant level o f community participation is the people’s willingness to respond to immunization/vaccination campaigns as shown in page 95. It is apparent that the people in the district are aware o f the consequences o f failure to immunize ones child against the major childhood killer diseases. 6.2 Conclusion Based on the background o f the general objective o f this study to analyze the participation o f the people o f Akwapim North District in the Primary Health Care programme, the analysis has shown a low level o f community participation in some aspects o f the programme. From the above findings it can be concluded that, the level o f community participation in the primary health care programme in the Akwapim North District is extremely limited. Apart from communities responding to few programmes such as film shows meant to educate them on specific health issues, they 107 University of Ghana http://ugspace.ug.edu.gh remain more or less a loof in almost all processes o f decision-making, planning, implementation, monitoring, and evaluation o f PHC programmes. In contrast, however, there is high level o f knowledge about preventive health measures, which is manifested in respectable response to immunization and other related measures such as weighing. There is an urgent need to correct this fundamental problem, which is very critical to the programme. The ability o f a country to develop highly depends on the health status o f her people. With the increasing threat o f the most dangerous disease, HIV/AIDS, which has the capacity to decimate human population i f not checked, mankind has no choice than to involve all and sundry in the fight not only against HIV/AIDS but malaria, URTI, and all life-threatening diseases. In fact, community involvem ent in the primary health care programme really needs attention; many lives are lost from avoidable and preventable diseases due to lack o f knowledge o f basic health issues. 6.3 Recommendations 6.3.1 Community sensitization, motivation and mobilization Central to effective community health care are sensitization, motivation and mobilization o f the community. Community health care belongs to the people. The target community should be sensitized to the need for community health care until it becom es the com m unity’s felt need. They should be motivated to want to do something to meet this felt need and to improve health care in their community, and be encouraged to m obilize the required human and material resources to do so. Community mobilization is getting people involved and committed to achieving a 108 University of Ghana http://ugspace.ug.edu.gh goal. The people should be assisted to becom e more aware o f their community, take an in-depth look at that community, identify the felt as well as the real needs, have a b elie f or faith that something can be done to relieve these needs and that most o f the resources to achieve these are within the competence o f them, possess a desire and a w illingness to use such resources to ensure the continued existence and improvement o f their community. It is definitely not an easy process. It is time-consuming, requires tenacity, persistence, patience, forbearance, a positive outlook, a love o f people and a tolerance and an understanding o f those who may appear difficult to win over. Health workers have a responsibility for community mobilization, and this is where a resident health worker is at an advantage over another health worker who lives away from his community. For effective community mobilization the health worker must possess a thorough knowledge o f his/her community. H e/she must make him /herself acceptable to the community and speak the language o f the people. The health worker must identify with the villagers; share their concerns, hopes and aspiration for improved health and social status; recognize community needs, be approachable; demonstrate good conduct and appearance; be a good role model, identify opinion, group and community leaders; possess a clear understanding o f the hierarchical structure o f the community and move through such structure in all matters concerning the community. H e/she must participate in community activities and festivities, organize and hold meetings with community groups, make useful and practical suggestions, respect other people’s opinions and be w illing to learn from others. The community health worker must, when required, supply technical resources, identify 109 University of Ghana http://ugspace.ug.edu.gh formal and informal health agents in the community and collaborate with them to m obilize the community to desire and to work to achieve a better standard o f health. 6 .3 .2 Health Education by Health Workers Health education should run like a thread through, and be built into all clinic activities. Health education must be carried out at group and individual levels in the clinic or health centre. Traditionally, a health worker before the beginning o f a clinic gives a health education talk on a specific topic o f common concern. This should be carried out with the full involvement and participation o f people w ho are old enough to join in. However, nothing like this is done in most health institutions today. The closest they have com e to is the morning devotion before the commencement o f clinical activities. This form o f health education must be reintroduced and vigorously enforced so as to keep incidence o f diseases to the barest minimum. 6.3.3 Adaptation from other Societies Moreover, the Nicaraguan and the Gambia exam ples can be replicated in the District especially so when food is a scarce commodity. It shouldn’t necessarily be futu kanya as was the case o f the Gambians but something that suits the peculiar conditions o f the study area. 6.3.4 Strengthening Community Initiative There is the need to inculcate the sense o f community responsibility and ownership in health development programmes. Community involvement ranges from participation in activities defined by outsiders, to the management and ownership o f activities developed primarily by community members themselves. The community must be 110 University of Ghana http://ugspace.ug.edu.gh encouraged and guided to set out their own health programmes that will promote their status o f health. Compatibility with community norms and values is also very essential in every programme designed to promote the health o f the community. Traditional norms and practices must be built on, to win widespread acceptance and involvem ent o f the people. Programmes design to boost the health status o f the people, which require the participation o f the community, must be in consonance with the traditions o f the people. 6.3.5 Fusing Tradition with Modernity where Applicable It is also crucial to build on existing social units and roles o f the community. It is always easier to develop the existing activities in collaboration with traditional communicators, traditional birth attendants and the community management committees, the intention being to build on their established roles. For instance, i f it is HIV/AIDS awareness programme that has to be carried out, it will have the required impact if the health worker and/or the traditional birth attendant are effectively used as a medium o f communication to the people. 6.3.6 Refresher Courses for Health Workers There should be motivation, training and supervision o f community actors. The roles o f key community actors involved in health promotion programmes must be carefully defined and regular, adequate training given to them. It was realized during the fieldwork in March 2001, that the community health workers were not adequately supervised and updated on current happenings in the field o f health. I l l University of Ghana http://ugspace.ug.edu.gh 6.3.7 Community Contributions An important means through which sustainability o f a programme can be ensured is community contribution o f resources towards the running o f the programme. The programmes in the District are w holly financed by the government in which case a delay in the release o f funds by government stalls their implementation. It is, therefore, recommended that programme managers, in conjunction with community members, should attempt to identify strategies such that communities contribute a progressively greater amount o f the resources required to sustain the programme. 6.3.8 Strengthening Intersectoral Collaboration Collaboration with community development agents in other sectors apart from health should also be strengthened. This can be achieved by collaborating with such sectors as agriculture, communications, environment and education among others, so that any efforts embarked upon by the Health Ministry can be complemented by other ministries. The health sector personnel should reinforce, for example, the maternal nutrition intervention during contacts with members o f the community and to attempt to collaborate with educational or agricultural agents. Support for community-based interventions from development agents working in various technical fields could contribute to sustainability o f the PHC. 6.3.9 Involving Prominent Personalities in Society in Health Education Fieldwork reveals that not much education has been given to the people about the primary health care programme. Communities and households are unlikely to be motivated to solve their own health problems and to remain committed to doing so unless they have an understanding o f them and their root causes. It is, therefore, 112 University of Ghana http://ugspace.ug.edu.gh imperative that the educational aspects o f the programme must be adequately enforced. In this regard eminent people and those who command the respect o f the communities can be encouraged to take active part. Personalities like Margaret Scott, the Canadian volunteer, the Member o f Parliament o f the area or any such personalities who can easily catch the attention o f the people can be encouraged to give a talk on pressing health issues so as to get the needed m essages to the target population. It is hoped that if all the recommendations mentioned above are implemented and strictly complied with, the concept o f PHC would be rejuvenated and popular community participation improved for a better health for all. 113 University of Ghana http://ugspace.ug.edu.gh BIBLIOGRAPHY Abramson, J. H. (1984V Application o f Epidem iology in Community Oriented. Care. Public Report 99 (5) in Stanhope and Lancaster, 1996. Altman, S. H. (1995): “ What can w e Learn from other Countries about the Mix and Interrelationships o f Primary Care and Specialty Care on Access, Quality and Cost”? Paper presented at the National Primary Care Conference, Washington, DC, March 1992. Adegoroye, A. (1984): Preventive Paediatrics— Community Health Care. Macmillan Publishers, Basingstoke, London. Adeokun, L. A. (1986, p. 25): “Health Intervention Programmes, The Case o f Nigeria’': Health and Social Policy and Mortality Prospects, I.U.S.S.P. Paris. Barke, M. and O ’Hare, G. (1986, p. 55): The Third World— Conceptual Frameworks in Geography. Longman, Edinburgh. Biodiversity Support Programme, (1993): African Biodiversity Foundation for the Future. A framework for Integrating Biodiversity Conservation and Sustainable Development, Professional Printing Inc., Maryland. Bloom, B. L. (1968): The Evaluation o f Primary Prevention Programmes, in Health and the Social Environment, by Insel, P.M. and M oos, R. H. (1974, p. 291), D. C. Heath and Company. Bogarts, T. (1991): Geographic Information Systems for Health and Environment. Cities 18, H .l, 17. Brown, M. and W ychkoff, B. (1992, p. 43-42): Designing Integrated Conservation and D evelopment Projects. Washington DC, Biodiversity Support Programme. 114 University of Ghana http://ugspace.ug.edu.gh Bryant, J. H. Khan, K. S. and Hyder, A. A./WHO (1998): Ethics. Equity and Renewal o f W HO’s Health Forum. 1977, in WHF, vol. 19, No. 3, p. 298. Chambers, R. (1983): Rural Development: Putting the Last First. Longman, London. Charlick, R. B. (1984): Animation Rurale Revisited. Centre for International Studies, Cornell University, Ithaca, N ew York. Cook and Donnelly-Roark, (1994): “Public Participation in Environment Assessment in Africa”, in Environmental Impact Assessment and Developm ent, (ed.) Goodland and Edmundson, World Bank, Washington DC. Cornea, G.; Jolly, R. and Steward, F. (1987): Adjustment with a Human Face. Oxford, Clarendon Press. de Ferranti, D. (1985): Paving for Health Services in D eveloping Countries: An Overview, Staff Working Paper 721, World Bank, Washington DC. Ebrahim, G. J. (1985): Social and Community Paediatrics in Developing Countries— Caring for the Rural and Urban Poor, Macmillan Publishers Ltd., Houndmills, Basingstoke, Hampshire RG21 and London. Ebrahim, G. J. and Ranken, J. P. (1988): Primary Health Care— Reorienting Organizational Support. Macmillan Education Ltd., London and Basingstoke. Ewles, L. and Simnett, I. (1992): Promoting Health: A Practical Guide, in Bamford, 1995, pp. 149-157, Chapman and Hall, 2-6 Boundary Row, London. Farrington, J. and Bebbington, A. (1993): Reluctant Partners? NGOs. the State and Sustainable Agricultural Developm ent. Routledge, U. S. A 115 University of Ghana http://ugspace.ug.edu.gh Food and Agriculture Organization (1991): “Food and Agriculture Organization Statistics Series”, vol. 45, No. 109, Basic Data Unit, Statistic D ivision FAO, 00100 Rome, Italy. Ghana— Vision 2020 (1997): The Medium-Term Developm ent Plan (1997-2020), Government o f Ghana, National Developm ent Planning Commission, Accra, Ghana. Gilson, L. (1988): “Government Health Charges: Is Equity Abandoned” Discussion Paper No. 15, London School o f H ygiene and Tropical M edicine, Evaluation and Planning Centre for Health Care, in Alderman and Gertler, 1989. Goldthorp, T. (1980): “Community Participation in Rural Water Supply Developm ent” in Rural Water Supply in D eveloping Coutries, IDRC, Ottawa-Canada. Hamilton, D. (1978): Beyond the Number Game. Beverly, California. Huntington, S.P. and Nelson, J. M. (1976): N o Easy Choice: Political Participation in D eveloping Countries. Harvard University Press Jimenez, E. (1986): The Public Subsidization o f Education and Health in D eveloping Countries: A Review o f Equity and Efficiency. The Research Observer, 111-129. Kirton, U.; Pener, H.; Costin, C.; Orshan, L.; Greenberg, Z.; and Shalom, U. (1992): Geographic Information System in Malaria Surveillance: M osquito Breeding and Imported Cases in Israel. Am. J. Trop. Med. Hyg. 50, 550-556. Kottak, C. (1985): “When People D on’t Come First: Some Sociological Lessens 116 University of Ghana http://ugspace.ug.edu.gh from Completed Projects” in Cernea M. (ed.) Putting People First. Sociological Variables in Rural Developm ent, 2nd ed., 1991. Oxford University Press, N ew York. Lassen, C. A. (1980): Reaching the Assetless Rural Poor. Monograph Series 11, N ew Delhi, India Socialist Institute. Mahlar, H. (1981, p. 5-22): ‘The Meaning o f Health for all by the Year 2000”, World Health Forum 2(1) in Stanhope, 1996. McGuire, S. (1995): “Personal Communication”, University o f Texas at El Paso, in Stanhope 1996, p. 61. Mirror, (March 25, 2000): “V illage Boycotts Clinic— They Resort to Fortune Tellers and Mallams”, No. 2365, Graphic Communications Group LTD. Accra, 2000. MoH, (1996, p. 20): Health Sector Five Year Programme o f Work. Ministry o f Health, Accra, Ghana. Mott, K. E.; Nuttal, I.; Desjeux, P. and Cattund, P. (1995). “N ew Geographical Approach to Control some Parasitic Zoonoses”: Bulleting o f the World Health Organization 73, H. 2, 247-257. Oakley, P. (1985): A Manual for the Monitoring and Evaluation o f the PPP. Rome, Food and Agriculture Organization. Oakley, P (1988’): The Monitoring and Evaluation o f Participation in Rural Developm ent. Rome, Food and Agriculture Organization. Oakley, P (1 99n : Projects with People: The Practice o f Participation in Development. International Labour Organization, Geneva Orugubole, I. O. and Caldwell, J. (1983): “The Impact o f Public Health Services on Mortality Differentials in Rural Nigeria”, Population Studies 117 University of Ghana http://ugspace.ug.edu.gh Developm ent 3. Paul, S. (1987), p. 2): “Community Participation in Development Projects”: The World Bank Experience, World Bank Discussion Paper 6, Washington DC. Population Reference Bureau (1995): “World Population Data Sheet”, Washington DC, U. S. A. Rifkin, S.; Muller and Bicham (1988): “Primary Health Care— On Measuring Participation”, in Social Science and Medicine, vol. 9, pp. 931-940, Elmsford, N ew York. Rahman, A. (1983): “SARINKA’S Grass-roots Participation in the Philippines”, W ED Paper, International Labour Organization, Geneva. Rosero, L. (1988): “Costa Rica Saves Infant L ives”, World Health Forum— An International Journal o f Health Developm ent, vol. 9, No. 3, pp. 434-443, Geneva. Shalala, D. E. (1994): Health Care Reform Isn’t Dead. The Washington Post, in Stanhope and Lancaster, 1996). Stanhope, M. and Lancaster, J. (1984, p. 29): Community Health Nursing— Process and Practice for Promoting Health. The C. V Mosby Company. Stanhope, M. and Lancaster, J. (1996, pp. 35-90): Community Health Nursing— Promoting Health o f Aggregates. Families, and Individuals. The C. V M osby Company. Starfield, B. (1992): Primary Care: Concept. Evolution, and Policy. N ew York, Oxford University Press, in Stanhope and Lancaster, 1996. The Bank (1986): Population Growth and Policies in Sub-Saharan Africa: A World Bank Policy Study, Washington DC. The World Book Encyclopedia, 1993 edition, World Book, Inc. 118 University of Ghana http://ugspace.ug.edu.gh Turner, C. E. (1971, p. 352): Personal and Community Health. The C. V. Mosby Company. U N (1999): Health and Mortality Issues o f Global Concern. United Nations, N ew York. Uphoff, N. (1988): “Participatory Evaluation o f Farmer Organizations" Capacity for Developm ent Task”, in Agricultural Administration and Extension, No. 30. W HO/UNICEF (1978): “Alma-Ata 1978 Primary Health Care Conference”, WHO, Geneva. WHO (1983): “Primary Health Care— Community Health Workers’ : What is their Real Value? In World Health Forum— An International Journal o f Health Developm ent, vol. 4, No. 3, (ed) M. P. Dandare and Ushah, Geneva. WHO (1986): “World Health Statistics Annual”, Geneva. WHO (1990, pp. 30-53, 98-132; and 188-201): “Achieving Health for all by the Year 2000”— Midway Report o f Country Experiences (ed) E. Tarimo and A. Creese, WHO, Geneva. WHO (1996): World Health Forum— “An International Journal o f Health Developm ent”, vol. 17, No. 1, by J. Aubel and K. Sampa-Ndure, Geneva. WHO (1999): Bulletin o f the WHO— “Incorporating World Health Forum and World Health Statistics Quarterly”— The Journal o f Public Health, vol. 77, No. 5, pp. 367-452, by Feachem, Geneva. W oelk, G. B. and M oyo, I. M. (1995, pp. 297-301): “Developm ent o f a Computerized Information System ”, in the Harare City Health Department, Methods o f Information in M edicine 34. H. 3. 119 University of Ghana http://ugspace.ug.edu.gh World Bank (1991a): “A Common Vocabulary: Popular Participation Learning Groups” in Cook and Donnelly-Roark, 1994— Environmental Assessment and Developm ent, (ed.) Goodland Edmundson, an IAIA- - World Bank Symposium, World Bank, Washington DC. World Population Data Sheet (1995): “Population Reference Bureau, Demographic Data Estimates for the Countries and Regions o f the World, Book Edition. 120 University of Ghana http://ugspace.ug.edu.gh APPENDIX 1 DEPARTMENT OF GEOGRAPHY AND RESOURCE DEVELOPMENT, UNIVERSITY OF GHANA. LEGON Questionnaire on— Community Participation in the Primary Health Care Programme in Akwapim North District— for Respondents o f the Communities in the District. Note: Please Tick Where Necessary PERSONAL DETAILS 1. Sex: a] Male[ ] b] Female[ ] 2. H ouse number:................................................................................................. 3. A ge:................................................................................................................................ 4. Occupation: a] Unemployed[ ] b] Teaching[ ] c] Farming[ ] d] Business[ ] e] Others(specify)............................................ 5. Religion: a] Christianity[ ] b] Islam[ ] c] African Tradition[ ] d] Others(specify)............................................................................... 6. What is your level o f formal education? a] N o Education[ ] b] Basicf ] c] Secondary or T echnical ] d] Tertiary[ ] 7. Personal/individual income level (per month) in cedis. a] Zero-20,000[ ] b] 20 ,000-100,000[ ] c] 100,000-200,000[ ] d] 200,000-500,000[ ] e] 0ver-500,000[ ] GENERAL INFORMATION 8. What is the name o f the town or village you live in?:................................ 9. H ow many children do you have?:............................................................................ 9 .1 Specify their ages if any: a] First child............. b] Second child.................. c] Third child.................... d] E tc......................... 9 .2 Have you immunized them against the major childhood killer diseases9 121 University of Ghana http://ugspace.ug.edu.gh a] Y es[ ] b] N o[ ] 9.3 If yes, do you see immunization o f children as necessary for sound child health? a] Y es[ ] b] N o[ ] 9 .4 If yes why do you say so .......................................................................... 9.5 If you don’t take part in immunization programmes, what is/are the reason(s)?.................. Is it: a] Religious[ ] b] Cultural[ ] c] F inancial ] d] Time constraints[ ] 10 W hich o f the following is your first point o f call whenever you have health Problems? a] Community health worker in this town or villagef ] b] Hospital, clinic or health centre near you[ ] c] Faith healerf ] d] Herbalist[ ] e] Others(specify)................................... 11. D o you know any thing about primary health care (PHC) programme? a] Y es[ ] b] N o[ ] 11.1 I f yes, do you play any role in this programme? a] Yes[ ] b] N o[ ] 11.2 Since when did you becom e aware o f PHC programme?....................................... 12. Was the PHC programme identified and planned by the Ministry o f Health in the District? a] Y es[ ] b] N o[ ] 12.1. If no, who was/were responsible for that? S p e c ify ............................................. 13. Which aspects o f the programme do you like? Specify ................. 14. Which aspects do you dislike? Specify....................................................................... 14.1 H ow could it be changed? Specify.................................................................. 15. D o you take part in Mass Immunization Programmes embarked upon periodically by the Ministry o f Health? a] Yes[ ] b] N o[ ] 15.1 If yes, how many times have you taken part? Specify............................. 16. Have you realized any improvements on the health o f your children as a result 122 University of Ghana http://ugspace.ug.edu.gh o f these immunization programmes? a] Yes[ ] b] N o[ ] 16 .1 If yes, what kind o f improvement?............................................................ 17. H ow often do you meet the PHC personnel in your area? a] Once every three months[ ] b] Once every six months[ ] c] Once every year[ ] d] Not at all[ ] e] Others(specify)........ 18. What usually do the PHC personnel discuss with you? Specify ............................ 19. W ho implement the plans and programmes o f the PHC programmes? a] The people in the community[ ] b] The personnel from PHC c] The people in the community in conjunction with PHC personnel[ ] d] Others(specify).......................................................... 20. Are the people in this community actively involved in the planning, decision­ making, implementation and evaluation o f the PHC programme? a] Yes[ ] b] N o[ ] 21. Do you have community health worker in this town or village? a] Yes[ ] b] N o[ ] 21.1 If yes, do you consult him/her when you face health problem? 21.2 If you don’t consult him/her can you tell why? Is it because o f a] Financial constraints[ ] b] Religious beliefs[ ] c] Cultural background[ ] d] Others(specify)............. 22. What do you think should be done to get people actively involved in the PHC Programmes? a] Involve them in the decision-making process[ ] b] Involve them in implementation stage[ ] e] Educate them about PHC programmes[ ] d] Give them financial incentives[ ] e] Others(specify).. 23. H ow do you assess the health situation in this town or village for the past ten years? a] Improving[ ] b] Deterioratingf ] c] No change[ ] 123 University of Ghana http://ugspace.ug.edu.gh 23 .1 Give reasons...................................................................................... 24. Level of/access to the following for the past ten years; Increasing Decreasing No Change a] Health Facilities ................ ................... .................. b] Sanitation .................. ................... .................. c] Food Production .................. .................. .................. d] Potable Water .................. ................ ................ 25. In what ways has the community benefited from the PHC programme?........... 124 University of Ghana http://ugspace.ug.edu.gh APPENDIX 2 DEPARTMENT OF GEOGRAPPHY AND RESOURCE DEVELOPMENT, UNIVERSITY OF GHANA. LEGON Questionnaire on— Community Participation in the Primary Health Care Programme (PHC) in Akwapim North District— for Officials o f the PHC Units Note: Please tick where necessary PERSONAL DETAILS: 1. D ate:................................ 2. Nam e o f respondent:.................................. 3. Sex: Male[ ] Female[ ] 4. Status o f respondent:...................................................... 5. Religion: a] Christianity[ ] b] Islam[ ] c] African Tradition[ ] d] Buddhism[ ] a] Others(specify)................................... GENERAL INFORMATION 6. H ow did the PHC programme introduce in the district?................................ 7. H ow were the aims and objectives determined?................... 8. What roles do the opinion leaders in the community play in the programme formation and im plem entation........................... 9. D o you organize immunization/vaccination programmes in the district'’ a] Y es[ ] B] N o[ ] 9.1 If yes, what kinds o f immunization/vaccination9 a] immunization against dysentery[ ] b] immunization against whooping cough[ ] c] immunization against diphtheria[ ] d] others(specify)........................... 9.2 Who supervises these immunization programmes if there are any?........... 125 University of Ghana http://ugspace.ug.edu.gh 9.3 Who finances these immunizations?............................................................ 10. What has been the response o f the communities during immunization campaigns? a] Very encouraging[ ] b] Fairly encouraging[ ] c] Not encouraging[ ] d] Poorly responded to[ ] e] O thers(specify)............. 11. What is your assessment o f the impact o f the immunization programmes on the Health o f children? a] N o improvement[ ] b] Considerable im provem ent ] c] Others(specify)........................... 12. D o the people in the community take part in the PHC programmes? a] Yes[ ] b ]N o [ ] 12.1 I f yes, what aspects o f the programme are the people involved in? a] Decision-m aking process[ ] b] Implementation programmes[ ] c] Evaluation stage[ ] d] Others(specify)........................ 13. Are those involved in the programme given som e kind o f remuneration? a] Y es[ ] b] N o[ ] 13.1. If yes, what form does it take?.................................................. 14. H ow often do you conduct outreach programmes? a] Once every w eek[ ] b]Once every month[ ] c] Once every four months d] Others(specify........................... 15. What usually is the response o f the communities when you undertake these outreach programmes? a] Satisfying[ ] b] Appalling[ ] c] Encouraging[ ] d] Not encouraging[ ] e] O thers(specify)... 16. D o you have static PHC units in the District? a) Yes[ ] b]Not[ ] 16.1 If yes, how many static units are there in the District?.............................. 17. Can you tell where at least three o f the static units are located. a ] ................................ b ] ................................ C] ................................ 126 University of Ghana http://ugspace.ug.edu.gh 18. H ow will you rate the performance o f the static PHC units in the villages. a] Excellent[ ] b] Very good[ ] c] Good[ ] d] Bad e] Very bad[ ] 19. Would you recommend that the practice o f the PHC concept is a waste o f money so the government should concentrate on hospital-based health care or that more funds should rather be channeled into PHC programmes in order to improve efficiency and achieve results? a] Concentrate on hospital-based health care[ ] b] Shift resources from hospitals to PHC programmesf ] c] Strike a balance between the two[ ] d] Others(specify)..................... 20. H ow do you assess the state o f the PHC programme in the District? a] So far so good[ ] b]Not all that bad c]Not good[ ] d] There is room for im provem ent ] e] Others(specify).................. 21. Which category o f people utilizes the PHC services? a] High income earners[ ] b] Middle income earners[ ] c] Low income earners[ ] d] Poor peoplef ] e] Others(specify)............................................................................... 22. H ow long does it take to train a community health worker9 a] One month[ ] b] Two months[ ] c] Three months[ ] d] Four months[ ] e) Others(specify)........................................................ 23. What do you think should be done to mobilize and empower local people for improved health? a] Give them financial incentives[ ] b] Give them education on health related issues[ ] c] Give them incentives in kind[ ] e) Others(specify).................. 24. What are some o f the lessons learned from the programme?................................... 25. D oes any NGO play a role in the PHC programme? a] Yes[ ] b] No[ ] 127 University of Ghana http://ugspace.ug.edu.gh 25.1 If yes, what is the name o f that N G O ?............................................... 25.2 What specific roles do the NGOs play?....................................................... 26. Are those involved given some form o f remuneration? a] Yes[ ] b] N o[ ] 26.1 If yes, what form does it take?.................... 27. D o you foresee any problems associated with or likely to inhibit smooth operations o f the PHC programme in future? 27.1. I f yes, what kind o f problem?..................................................... 28. D id the programme have a special design because they want local people to participate? a] Yes[ ] b] N o[ ] 29. What is the common sickness in this community, if any?............................. 30. When sick where do the people normally go for treatment? a] Hospital at Mampong[ ] b] Nearest clinic or health centre[ ] c] Herbalists or faith healers[ ] d] Community health worker[ ] Others... 31. Have you observed any change in disease pattern o f this area? a] Y es[ ] b] N o[ ] 31.1 I f yes, since w hen?............................................... 31.2 What could be the possible cause(s)....................................... 32. Comment briefly on the health situation o f the people in this town or village..................................................................... 128 University of Ghana http://ugspace.ug.edu.gh s < ON ia .£ 1 1 1 /"■, CNt— H CN 1 i 1 i i i i I l 1 •/"I - i o — 0 0 o O = CN O < NO CN o H H - i i 1 NO ■ 1 i O n CN i i C*~i- (N (N i V O o — o o OO ON O < O ' CN o ON i - H ~ r n ON i i - i - I i X 2 a i CN OO CN NO H «cr NO CN NO Ui © — O ' aa> cC O < • un o o c H H ~ _o •*-< cd ^ 4- i l 1 1 1 1 N' O ‘23 -■ £ i l 1 1 - I i e O) iS~, rO o n [■"- o ON Ia—o C/3 0c1 octJ c£/■ co 0 c £ ° c Q EE ? eau ! H* C,2 < 1 APPENDIX 3a A K W A P I M N O R T H D I S T R I C T M O N T H L Y I M M U N I Z A T I O N R E T U R N S F O R J A N U A R Y District Meas le s DPT I D P T 2 MCH 1 2 1 2 ­ 1 2 ­ 24+ 1 2 ­ 2 4 + 0 -1 1 1 2 ­ 2 4 + 0 - 1 1 23 23 2 3 Clinic 23 23 --------------------- 25 25 30 30 27 2 7 4 0 4 0L 30 27 34 22 22 23 2 3 Aseseso 20 27 2 Q Nven>t 20 20 20 36 2 5 3 0 Larteh 20 20 +PZ University of Ghana http://ugspace.ug.edu.gh o < h- f—1 OO CN ŝO 00 ■ ! I I ' l ' CN o i OQNON\ OO CM OO OOc — O < - rn ON r - h h J *n r - I i r - . 1 i I D APPENDIX 3c District Ii C G M easles DPT. 1 DPT. 2 MCH 12­ 12­ 24+ 12­ 24+ 0- 24+ 12­ 24+ Clinic 23 23 23 n 23 j . ... - 29 22 25 20 20M amoons Kw:imoso Aseseso 20 36 20 20Twum Goaso Larteh 20 27 11 -o University of Ghana http://ugspace.ug.edu.gh APPENDIX 4 ALMA-ATA DECLARATION tn the international conference that took place in Alma-Ata in 1978, the following is the unedited report o f what became known as Alma-Ata Declaration: The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day o f September in the year nineteen hundred and seventy-eight, expressing the need for urgent action o f all governments, all health and development workers, and the world community to protect and promote the health o f all the people o f the world, hereby makes the following declaration: I The conference strongly reaffirms that health, which is the state o f complete well­ being, and not merely the absence o f disease or infirmity, is a fundamental human right and that attainment o f the highest possible level o f health is a most important worldwide social goal, the realization o f which requires the actions o f many other social and economic sectors in addition to the health sector. II The existing gross inequality in the health status o f the people, particularly between the developed and developing countries and within countries, is politically, socially, and economically unacceptable and is, therefore, o f common concern to all countries. III Economic and social development, based on a new international economic order, is o f basic importance to the fullest attainment o f health for all and the reduction o f the gap between the health status o f developing and developed countries. The promotion and 132 University of Ghana http://ugspace.ug.edu.gh protection o f the health o f the people are essential to sustain economic and social development and contribute to a better quality o f life and to world peace. IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care (author ’s emphasis). V Governments have a responsibility for the health o f their people, which can be fulfilled only by the provision o f adequate health and social measures. In the coming decades a main social target o f governments, international organizations, and the whole world community should be the attainment by all peoples o f the world by the year 2000 a level o f health that will permit them to lead a socially and economically productive life. PHC is the key to attaining this target as part o f development in the spirit o f social justice. VI Primary health care is essential care based on practical, scientifically sound, and socially acceptable methods and technologies made universally accessible to individuals and families in the community and country can afford to maintain at every stage o f their development in the spirit o f self-reliance and self determination It forms an integral part both o f the country’s health system, o f which primary health care is the central function and main focus, and o f the overall social and economic development o f the community. It is the first level o f contact for individuals, the family, and the community with the national health system bringing health care as 133 University of Ghana http://ugspace.ug.edu.gh close as possible to where people live and work, and it constitutes the first element o f a continuing health care process. VII Primary Health Care 1. reflects and evolves from the economic conditions and socio-cultural and political characteristics o f the country and its communities and is based on the application of the relevant results o f the social, biomedical, and health services research and public health experience; 2. addresses the main health problems in the community, providing promotive, preventive, curative, and rehabilitative services accordingly; 3. includes education at least education concerning prevailing health problems and the methods o f preventing and controlling them; promotion o f food supply and proper nutrition; an adequate supply o f safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control o f locally endemic diseases; appropriate treatment o f common diseases and injuries; provision o f essential drugs; 4. involves, in addition to health sector, all related sectors and aspects o f national and community development, in particular agriculture, animal husbandry, food industry, education, housing, public works, communication, and other sectors; and demands the coordinated efforts o f all those sectors; 5. requires and promotes maximum community and individual self-reliance and participation in the planning, implementation, operation, and control o f PHC making 134 University of Ghana http://ugspace.ug.edu.gh fullest use o f local, national and other available resources; and to this end, develops through appropriate education the ability o f communities to appreciate; 6. should be sustained by integrated, functional, and mutually-supportive referral levels, leading to the progressive improvement o f comprehensive health care for all, and giving priority to those most in need; 7. relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries, and community workers, as applicable, as well as on traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs o f the community; and VIII All countries should cooperate in a spirit o f partnership and service to ensure primary health care for all people since the attainment o f health by people in any one country directly concerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation o f primary health care throughout the world. X An acceptable level o f health for all the people o f the world by the year 2000 can be attained through a fuller and better use o f the world’s resources, a considerable part o f which is spent on armaments and military conflicts. A genuine policy o f independence, peace, detente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration o f social and economic development o f which primary health care, as an essential part, should be allotted its proper share. 135 University of Ghana http://ugspace.ug.edu.gh * * * The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit o f technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, non-governmental organizations, funding agencies, all health workers and the whole world community to support national and international community to primary health care and to channel increased technical and financial support to it, particularly in developing countries. The conference calls on all the aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content o f this Declaration. 136