University of Ghana http://ugspace.ug.edu.gh RA552. G5 M52 bite C .l G379400 University of Ghana http://ugspace.ug.edu.gh ACCESSIBILITY TO AND UTILIZATION OF PRIMARY HEALTH CARE IN THE GA, DANGME EAST AND DANGME WEST DISTRICTS OF THE GREATER ACCRA REGION BY CHARLOTTE MONICA MENSAH THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF PH.D DEGREE IN GEOGRAPHY AND RESOURCE DEVELOPMENT NOVEMBER, 2003 University of Ghana http://ugspace.ug.edu.gh GOD MOVES IN A MYSTERIOUS WAY HIS W ONDERS TO PERFORM ; HE PLANTS HIS FOOTSTEPS IN THE SEA, AND RIDGES UPON THE STORM. WILLIAM COWPER (1731-1800) University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that, except for„references to other people’s work which have been duly acknowledged this work is the result o f my own research and that it has neither in part nor in whole been presented elsewhere for another degree. CHARLOTTE M ONICA MENSAH (Candidate) NAA PROF. JOHN S. NABILA (PRINCIPAL SUPERVISOR) ..........' t M i A * ................ PROF. ELIZABETH ARDAYFIO-SCHANDORF (SUPERVISOR) DR.M ARIAM A AWUMBILA (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh DEDICATION Dedicated to the glory o f the Father, the Son and the Holy Spirit, and to my parents, the late Mr. John K. Abakali and Mrs. Joana Abakah; and to m y darling husband, Mr. Eric Nii Yarbcfi Mensah. University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS To God alone be all the glory and honor for the great things He does daily in our lives. I am particularly grateful to God Almighty, my Heavenly Father and the Holy Spirit, my Senior Partner, for their full sponsorship o f my studies. W ithout their help, I could not have done it. I appreciate their love and support so much. I am also grateful to the Government o f Ghana for a 3-year Bursary sponsorship package. To m y darling husband, Nii Yarboi, T say thank you for your financial and moral support. I wish to express my gratitude to my supervisors, N aa Prof. J.S. Nabila, Prof. (Mrs). Elizabeth Ardayfio-Schandorf, Dr. (Mrs) M ariama Awumbila and Dr. Samuel Agyei-Mensah, all o f the Department o f Geography and Resource Development, University o f Ghana, Legon, for their immense constructive criticisms and suggestions which have been instrumental in shaping this thesis and bringing it to its present form. I am truly grateful to Prof. P.W.K. Yankson, Prof. George Benneh, Prof. Jacob Songsore, Prof. Alex B. Asiedu and all the lecturers in the Department for their encouragement and help throughout this study. I say a big thank you to the NUFU programme o f the Norwegian Ministry o f Foreign Affairs for availing me o f the opportunity to spend a semester at the Geografisk Institutt o f the Norwegian University o f Science and Technology (NTNU) Trondheim, where I updated m y literature review, participated in some lectures and seminars on Health Development issues, as well as processed some o f my research data with the help o f Kyrre Svarva*(IT Consultant). I appreciate the support and encouragement o f both the staff and University of Ghana http://ugspace.ug.edu.gh the students. Special mention is made o f Prof. Aase, Prof. Lund, Stig. Bodil, Nina, Chamila, Jyoti and George Owoisu for their special attention and care throughout my wonderful stay in Trondheim. I am thankful to Emelia Agyen, Angela and Israel Aflu, David and Joseph Kukula, Charles Agyemang, M aku Martey, Naki Odonkor, N aa Atsoi Sowah and Vida Adjei for their great help as Research Assistants in the Ga, Dangme East and Dangme West Districts. I am grateful to Dr. Yao Yarbani, Dr. Irene Agyepong and Dr. Em estina Mensah-Quainoo o f the Ada, Dodowa and Amasaman Health Centres, as. well as the medical assistants, nurses and other medical personnel for their immense support and help in my field survey. To my darling husband, Nii Yarboi and his family, m y sweet mother, Joana, and my daughters, Em elia and Doris, m y brothers John and Alfred, and sister, Joe-Star and their families, I say a big Thank you. God bless you. To all m y friends, especially Florence Simpson, Fauslie and W illie Tengey, Osei and Dinah Osei-Tutu, Sister Mabel Sey, Sister Laudy Kankam, Sandra Cofie, Joana and Peter Acquah, Sarah Ankrah, Dr. Eric Kra and the late Nora Taylor (who died before she could complete her Ph.D), I say Thank You for your love and encouragement. To my seniors and colleagues, especially Prof. Daniel Buor, Dr. Dr. Richard Kofie, Osman Alhassan, Dr. M organ Attuah, Mr. Albert Allotey, Mr. Opoku Pabi and M r Fiah, I express appreciation for their suggestions anytime it became necessary to confer with them. I am really grateful to Mr D.J. Drah (Senior Technician) for the excellent maps and diagrams he produced for me. 1 say a big thank you to M r Richard Asamoah for his University of Ghana http://ugspace.ug.edu.gh untiring efforts in typing the manuscript also to M rs Jem im a Anderson, English Department, for helping with the editing and proof reading. I am grateful to M r Jude Hama, M r Yaw Abaidoo, Mr Awuku Kwasi and all my colleagues at the Scripture Union for their encouragement and support. I cannot forget the House o f Zion Ministries Int. • (Pokuase), especially M ama Esther Amoaku, M am a Ram ona Kwami, Sister Mona, Apostle De Love, Bro. M ichael, Pastor Norbert Marfo and Sister Doris Amaka for their enthusiastic prayer support for me throughout my studies. I am most grateful to the men and women in the study areas for allowing my field assistants and I to experience this first hand. They gave permission to my team and I to enter into their homes and lives and gave up precious amounts o f free time to answer our never-ending questions. To all m y loved ones, my sons and daughters from St. M onica’s Secondary School, M ampong-Ashanti and Accra High School and all Scripture Union Groups in Ghana, I say God bless you and grant you the grace lo excel in all your endeavours. W hile I sincerely share the credit for this work with all the people mentioned above, the responsibility for any short-coming is solely mine. Charlotte M onica Mensah v University of Ghana http://ugspace.ug.edu.gh ABSTRACT The study examined the accessibility and other socio-economic forces that influence the utilization o f primary health care services in the rural parts o f the Greater Accra Region o f Ghana. Three administrative districts, Ga, Dangme W est and Dangme East, were selected for study. Both qualitative and quantitative data were used. Questionnaire and interview schedules reinforced by focus group discussions and observations, were the main research instruments. Descriptive and multivariate techniques are the analytical tools. The main factors that influenced utilization as established by the empirical research, have been income, distance, transport and service costs, waiting and travel times, educational status in the analysis. The researcher establishes that, the main factors that influence utilization o f primary health care services in the rural parts o f Greater Accra Region are income and distance. The other factors are service costs, transport cost and waiting time. Income shows a positive relationship with utilization, w hilst service cost exhibits a negative relationship to validate the hypotheses. Income makes a stronger impact than distance, service cost and waiting time. The impact o f education, though statistically significant, is weak. There were differences by place o f residence, and also by health status (patient and non­ patient). W ith regard to income, the impact at the Ga District is stronger than that o f the Dangme W est and Dangme East Districts, whilst non-patients are more affected than patients. W ith regard to distance and utilization, the Dangme East and Dangme West Districts show a stronger negative impact than the Ga District, whilst the impact o f patients is stronger than non-patients. Waiting time and service costs have a greater impact in the Ga District than in the Dangme W est and Dangme East Districts. For health status, patients are more affected by distance than non-patients. Several recommendations have been made to enhance utilization and the quality o f health and health care. These include among others the strengthening and upgrading o f primary health care facilities in the rural districts, improvement o f the quantity and quality o f medical and paramedical staff and the introduction o f a National Health Insurance Scheme. University of Ghana http://ugspace.ug.edu.gh ACRONYMS AMA Accra Metropolitan Assembly BCG Bacillus Calvette Guverin CDR Committee for the Defence o f the Revolution CHNs Community Health Nurses CWC Child Welfare Clinic DHA District Health Administration DHMT District Health Management Team DHT District Health Team DPCU D istrict Planning Coordinating Unit DPT Diphtheria, Pertussis, Tetanus EPI Expanded Programme on Immunization GAR Greater Accra Region GDHS Ghana Demographic Health Survey GLSS Ghana Living Standards Survey HIV Human Immuno-deficiency Virus IUD Inlra-uterine Device MCH/FP Maternal and Child Health and Family Planning MOH M inistry ofH ealth NDC National Democratic Congress NID National Immunisation Days OPD Outpatient Department University of Ghana http://ugspace.ug.edu.gh OPV Oral Poliomyelitis Vaccine PDC People’s Defence Committee PHC Primary Health Care SAP Structural Adjustment Programme SRN State Registered Nurse TBA Traditional Birth Attendant UNESCO United Nations Eduacational, Scientific and Cultural Organization UNICEF United Nations Children Fund WHO W orld Health Organization University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Declaration ... i Dedication ... ii Acknowledgements ... iii Abstract ... vi Acronyms ... vii Table o f Contents ... viii List o f Tables ... xviii List o f Figures ... xiv C H A P T E R O N E: IN T R O D U C TIO N 1.1 Tntroduclion ... 1 1.2 Statement o f problem . .. 4 1.3 Objectives ... 9 1.4 Literature Review .... 9 1.4.1 Definition o f Health and Primary Health Care . . . 9 1.4.2 Perception o f Health Systems ... 11 1.4.3 Accessibility and Utilization o f Health Services . .. 12 1.4.4 Distribution o f Health Services ... 19 1.4.5 Traditional Health facilities ... 21 1.4.6 Health Insurance in Developing Countries ... 24 1.5 Conceptual Framework ... 28 ix University of Ghana http://ugspace.ug.edu.gh 1.5.1 Aday and A nderson’s Accessibility Framework 1.5.2 The Andersen - Newman Model 1.5.3 The M athematical Models 1.5.4 D utton’s Utilization 1.5.5 Adapted Hypothetical Model 1.6 Statement o f Hypotheses 1,7 Organization o f study C H A P T E R T W O : R E SE A R C H M ETH D O L O G Y 2.1 Introduction 2.2 Types and sourccs o f Data 2.3 Research Instruments 2.4 Sampling Design 2.4.1 Sample Frame 2.4.2 Sample size 2.4.3 Sampling M ethods 2.5 Techniques o f Data Analysis 2.6 Limitations o f the Data 2.7 Conclusion University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE: THE STUDY AREA 3.1 Introduction ... 57 3.2 Background ... 57 3.2.1 Administrative Divisions ... 57 3.2.2 Physical Conditions ... 58 3.2.3 Population ... 59 3.2.4 Health Conditions ... 60 3.2.5 Transportation Network ... 61 3.2.6 Employment, Income and Education Status . . . 61 3;3 Conclusion ,.. 68 CHAPTER FOUR: PRIMARY HEALTH CARE SYSTEM IN THE GA, DANGME EAST AND DANGME WEST DISTRICTS 4.1 Introduction ... 69 4.2 Objectives o f Prim aiy Health Care ... 69 4.3 Spatial Distribution o f PHC facilities in the study area ... 72 4.4 Implementation o f Primary Health Care ... 79 4.4.1 Immunization . . . 84 4.4.2 Maternal and Child Health/family planning ... 87 4.4.3 Food Supply and Nutrition ... 89 4.4.4 W ater and Sanitation ... 90 4.4.5 Prevention and Control o f locally endemic diseases ... 91 University of Ghana http://ugspace.ug.edu.gh 4.4.6 M anagement o f Common illnesses and injuries ... 92 4.4.7 Provision o f Essential drugs ... 93 4.4.8 Community mobilization and awareness ... 95 4.5 Level o f achievements o f PHC ... 97 4.6 Bottlenecks in the implementation .. . 120 4.7 Conclusion .. . 123 CHAPTER FIVE: HEALTH STATUS OF PEOPLE 5.1 Introduction .. . 125 5.2 Household Disease Patterns .. . 125 5.3 Disease Patterns o f Respondents .. . 131 5.4 Differences by place o f rcsidcncc ..,. 134 5.5 Variations by Demographic and Socio-Economic V ariables .,.. 136 5.6 Factors affecting the health o f the people .... 140 5.7 Conclusion . .; 146 CHAPTER SIX: FACTORS OF PHYSICAL ACCESSIBILITY AND UTILIZATION 6.1 Introduction . .. 148 6.2 General Utilization o f PHC Services ... 148 6.3 Distance to health facilities . . . 150 6.4 Respondents’ Distance Preference to health facilities ... 152 University of Ghana http://ugspace.ug.edu.gh 6.5 Distance and Utilization ... 154 6.6 Travel and W aiting times and Utilization 155 6.7 Conclusion 157 CHAPTER SEVEN: OTHER FACTORS AFFECTING UTILIZATION 7.1 Introduction 158 7.2 Service Cost 158 7.3 Transport Cost 160 7.4 Age and Sex 161 7.5 Employment 164 7.6 Formal Education 163 .7.7 Income 165 7.8 Disease Type 165 7.9 Type ofH ealth Facility ... 167 7.10 Conclusion 169 CHAPTER EIGHT: SYNTHESIS OF UTILIZATION OF PRIMARY HEALTH CARE 8.1 Introduction ■■■ 170 8.2 The Variables ... 170 8.3 M ultiple Regression Modelling ... 174 8.4 Conclusion ... 178 xiii University of Ghana http://ugspace.ug.edu.gh CHAPTER NINE: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 9.1 Introduction 179 9.2 Summary o f Findings ^ 9.3 Conclusions 184 9.4 Recommendations 186 References 188 Appendices - ■ • xiv University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES 2.1 Sample Frame ... 45 2.2 Allocation o f respondents to settlements and health institutions in sample districts ... 47 2.3 Sample proportion o f households in the selected districts . . . 48 2.4 Sample allocation to health institutions ... 48 2.5 Allocation o f respondents (patient) to the districts by sex ... 49 2.6 Allocation o f respondents (patients) to the districts by age ... 49 2.7 Income categorization by income quintile .. . 50 2.8 Quantitative Codes for selected variables ... 53 2.9 Codes for grouped data ... 53 3.1 Basic population statistics o f the Ga, Dangme East and Dangme W est Districts ... 59 3.2 Non-Patient and patient respondents and their occupation in the study area ... 62 3.3 . Distribution o f small-scale industries in the Dangme W est District ... 63 4.1 The distribution o f health institutions in the Ga District ... 75 4.2 Distribution and type o f health units in the Dangme W est District ... 77 4.2b Female respondents who immunized their children in the study area ... 85 xv University of Ghana http://ugspace.ug.edu.gh 4.3 Percentage o f female respondents in the Ada, Amasaman and Dodowa Health Centres who received antental care ... 85 4.4 Percentage o f female respondents in the communities who received antenatal care ... 86 4.5 The level o f knowledge and use o f contraceptives in the Ga, Dangme East and Dangme West Districts ... 88 4.6 Type o f contraceptive used by women ... 89 4.7 Opinions o f respondents concerning the cost o f drugs in the various health institutions and communities in the study area ... 91 4.8 Opinion o f respondents on ways to improve health services ... 94 4.9 Respondent’s attitudes to clean up campaigns ... 96 4.10 Respondents’ ideas on whose responsibility it is to clean the environment ... 97 4.11 The major causes o f death before serious immunization was started ... 98 4.12 M ajor causes o f child mortality (1979-83) in the Greater Accra Region.. 99 4.13 Top ten causes o f death in children (1-23 months) ... 99 4.14 Top ten causes o f death in children (2-5) years in the Greater Accra Region ... 100 4.15 Distribution o f households by locality and type o f toilet (percentage)... 103 4.16 Health services coverage by sub-district (based an actual population, Dangme W est District ... 105 4.17 Immunization Coverage in the Dangme W est District - Jan-Dee. 2000 ... 105 4.18 Immunization coverage in the Ga District 1998-2000 ... 107 4.19 M a in Sources o f information on HIV/AIDS ... 109 4.20 Trends in some MCH/FP indices over time Jan-Dee. 2000 , ... 113 xvi University of Ghana http://ugspace.ug.edu.gh 5.1 Top Ten diseases seen at OPD, Dangme East 1997-1999 ... 126 5.2 Top Ten diseases recorded at OPD in the Ga, Dangme East and Dangme W est Districts, 1999 ... 126 5.3 The primary health care facilities in the Ga, Dangme East and Dangme W est Districts ... 128 5.4 Common household diseases as reported by respondents in the Ga, Dangme W est and Dangme East districts .... 130 5.5 Common diseases affecting individual respondents in the Ga, Dangme W est and Dangme East districts 132 5.6 Differences in common household diseases n the Ga, Dangme W est and Dangme East Districts ... 136 5.7 Classification o f respondents by income (per m onth in ‘000s cedis) ... 137 5.8 Classification o f respondents by education . . . 137 5.9 Classification o f respondents by employment . . . 137 5.10 Classification o f respondents by marital status ... 137 5.11 Respondents in the districts by age ... 139 5.12 Respondents in the districts by sex ... 140 5.13 Availability o f electricity and water supply in the selected settlements in the Ga ... 142 5.14 Respondents ’ responses on the sources o f environmental pollutions in the study area ... 144 5.15 Human excreta disposal in the various communities ... 145 6.1 General utilization o f Primary Health Care Services for total sample and districts ... 148 6.2 General utilization o f Primary Health Care Service for patients and non-patients ... 149 6.3 Distances from respondents’ homes to the nearest health centcr and community clinic ... 150 xvii University of Ghana http://ugspace.ug.edu.gh 6.4 Distances from respondents’ homes to the nearest health centre and community clinic by place o f residences ... 151 6.5 Distances from respondents’ homes to the nearest Primary Health Centre/Clinic by health status .. 152 6.6 Percentage distribution o f respondents who use health centres and Community clinics regularly by distance from home to other health facilities by total sample and district ... 154 6:7 Percentage distribution o f respondents who use health care services regularly by travel time to health facilities by total sample and d is tr ic t... 155 6.8 Percentage distribution o f respondents who use the health facility regularly by waiting time at the health centre by total sample and district... 156 7.1 Responses o f respondents to their use o f alternatives to PHC services ..158 7.2 Percentage distribution o f respondents who use health facility regularly by transport cost by total sample and district ... 160 7.3 Percentage distribution o f respondents who use the health facility regularly by age by total sample and district ... 161 7.4 Percentage distribution o f respondents who use the PHC facilities regularly by sex by total sample and district ... 163 7.5 Percentage distribution o f respondents who use the health facilities regularly by employment by total sample and district ... 164 7.6 Percentage distribution o f respondents who use the health facilities regularly by educational status by total sample and districts ... 165 7.7 Percentage distribution o f respondents who use health facilities regularly by income status by total sample and district. ... 165 7.8 M ost prevalent diseases with high regularity o f reporting at health facilities ... 166 7.9 Percentage distribution o f respondents who utilize health facilities regularly by type o f facility ... 168 7.10 Responses o f respondents.to whether public hospitals are better than private mission hospitals ... 169 xviii University of Ghana http://ugspace.ug.edu.gh 7.11 Reasons why private mission hospitals are better than public hospitals ... 169 8.1 M ultiple Regression Coefficients o f independent variables on ■ utilization on total sample ... 175 8.2 M ultiple Regression Coefficients o f independent variables on utilization for patients and non-patients ... 176 8.3 Multiple Regression Coefficients o f independent variables on utilization for districts ... 177 xix University of Ghana http://ugspace.ug.edu.gh LIST OF MAPS AND FIGURES 1.1 A Framework for the study o f Access to Health Services ... 28 1.2 D utton’s Utilization Model ... 33 1.3 A Hypothetical Model o f Accessibility and Utilization Services ... 37 3.1 Greater Accra Region ... 56 4.1 Spatial Distribution o f Primary Health Care facilities in the Ga, Dangme West and Dangme East Districts ... 74 4.2 Sphere o f influence o f PHC facilities is the study area ... 76 4.3 Organizational Structure o f PHC system showing managerial and communication structure ... 80 4.4 The Role o f Traditional Healers in the Ga, Dangme West and Dangme East Districts ... 122 6.1 Percentage distribution o f respondents’ distance preference for traveling on foot to health facilities ... 154 6.2 Percentage distribution o f respondents’ preference for motorized Transport to health facilities ... 154 7.1 Responses o f respondents to their use o f alternatives to PHC services ... 159 xx University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE: INTRODUCTION 1.1 INTRODUCTION The concern about good health is a universal issue. Health remains a critical situation in sub-Saharan Africa. Many people still die from preventable diseases such as diarrhoea and malaria (WHO, 1998). Malaria has been responsible for 20,000 deaths in children under five years old annually in Ghana (UNICEF, 2003). Millions of others waste away due to poor sanitation and unclean water. Infant and maternal mortality rates are still high (UNICEF, 2002). About 76 percent of the countries with high infant mortality rates are in sub-Saharan Africa. The risk of maternal death for African women is one in 20, but for developed countries, the risk is one in 10,000 (UNICEF, 2003). In developing countries, medical facilities are not adequate to promote qualitative health care. Most governments in these developing countries are unable to provide sufficient health care for their people because of financial and economic challenges (Okojie, 1994). Hospital based medical care is expensive yet it fails to reach the majority of the population particularly in rural areas. At a historical meeting organized by WHO and UNICEF in 1978 in Alma Ata, USSR, all participating nations of the world agreed to obtain health care for all by the year 2000. This was to be achieved through the strategy of Primary Health Care. The Declaration of Alma Ata defined Primary Health Care as “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally acceptable to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain, in the spirit of self-reliance and self­ determination” (WHO/UNICEF, 1978). Components of PHC include health , education, water, sanitation, agriculture and related economic development activity. PHC was to be 1 University of Ghana http://ugspace.ug.edu.gh an integral part o f the health policy of Ghana. The Ministry of Health had drawn its own strategy for PHC as far back as 1977 (Adjei, 1984). In rural areas, there are few health institutions. They are located in such a way that some sections of the population are far away from them. Accessibility to health facilities is important for their effective use (Phillips, 1990). The poor transport network in the rural areas of developing countries serves as a barrier to accessibility. Roads linking health institutions and rural settlements especially, are in deplorable state and distances tend to be long. This difficult situation places on such communities high transport costs that they cannot afford. Spatial accessibility rests on four principal factors of distance, intervening obstacles, transport cost and transport time. In developing countries, there is a relationship between the distance a patient covers from home to hospital or health centre and the use made of it; the greater the distance, the lower the utilization (Buor, 2002). Distance and transportation factors per se, however, do not offer comprehensive explanation of hospital attraction and service areas. Physical accessibility cannot be considered isolated from super structures like socio-economic, cultural, religious and even political factors. UNICEF (2002) has reported that, there is a well-established correlation between income and health status. Countries with incomes above average have better access to high quality foodstuffs and quality medical services (UNESCO, 1980). Rich people can afford high cost of medical care, but the poor suffer financially. It is also a fact that in the developing countries, the formally educated patronize the hospitals more than the uneducated, and that the urban population tends to patronize more than the 2 University of Ghana http://ugspace.ug.edu.gh rural (Buor, 1988). Whereas the formally uneducated with financial means may tend to rely on traditional therapy, the formally educated in the same category would tend to avail himself of orthodox health care, even where there is the impediment of distance (Buor, 2001). Socio-economic factors thus largely influence utilization of orthodox health services. The adoption of the International Monetary Fund (IMF) - World Bank - initiated Structural Adjustment Programme (SAP) by some developing countries has had negative repercussions on the utilization of health services by the poor masses (Anyinam, 1989; Audibert. et al, 2000). It is evident that the SAP has not been able to eliminate poverty, which is the main cause of poor accessibility and utilization of health services in developing countries (Delvin and Yap, 1993). Delvin and Yap emphasize that the moderated levels o f poverty and political stability are not consistent with SAP prescriptions of free trade and unrestrained markets. Several workers have lost their jobs, subsidies on essential services like health services have been removed, and local currencies heavily devalued. The outcome is a high cost o f living and negative repercussions on the use of essential social facilities. Inaccessibility of health services to a greater part of the population, due to spatial separation and high service costs, may result in the use of traditional therapy and abuse of drugs, which have the over-all repercussion of weakening potential manpower and productive capacities (Ansah et al, 2001). Accessibility and utilization problems could be seen in the light o f problems such as of lack of resources to provide the necessary input for qualitative health services. This calls for the need to increase the output of primary health services, to cater foj the greater proportion of the population. In developing 3 University of Ghana http://ugspace.ug.edu.gh countries, primary health care facilities are concentrated in the urban areas, which constitute less than 40 percent of the total population. This calls for alternative approaches to the current delivery system like the integration of scientific and traditional health systems, since traditional health facilities are more readily available than orthodox medicine to the majority of the population (Tsey, 1997). Research on accessibility and utilization of health services has focused on urban health care rather than rural primary health care. The import of primary health care in the rural areas has been neglected. Such an omission is prerequisite for a comprehensive policy framework. A research into the problem of accessibility and utilization of orthodox Western medicine in a developing nation like Ghana was thus urgent, to reveal the deficiencies in the accessibility of health care, and socio-economic and demographic factors which hinder utilization of primaiy health care, and also, to find alternative forms of service delivery which would ensure that a greater part of the population is provided with basic health services. 1.2 STATEMENT OF THE PROBLEM A World Bank sector study, revealed that in Ghana as a whole, only a quarter of the population has access to health facilities (The World Bank, 1997). Studies on tire Ghana health situation revealed that the primary cause of poor health facilities that affected accessibility are financial constraint (Smithson, 1993). Apart from the inadequacy of the health facilities, their distribution pattern is urban-biased. The three most urbanized settlements - Accra, Kumasi and Sekondi-Takoradi - had more than 70 percent o f health facilities in the country (Ministry of Health, Accra, 1998). 4 University of Ghana http://ugspace.ug.edu.gh In the Greater Accra Region, over 70 per cent of health facilities (public and private) are concentrated in the Accra-Tema Metropolis alone (Ministry of Health, 1999). In Ghana as a whole, health takes only 4.7 per cent o f GDP (The World Bank, 2000). In the Greater Accra Region, the Accra-Tema metropolis has all the specialist and advanced health institutions such as the Korle Bu Teaching Hospital, Police and 37 Military Hospitals, Tema General Hospital, all the polyclinics in the region, as well as numerous private hospitals and clinics. Only a limited number of settlements in the rural areas have isolated health centres and community clinics. Majority of the rural dwellers have no access to the basic health care service (Agyepong, 1999; Mensah-Quainoo, 1997). The accessibility to primary health care hinges on distance and intervening obstacles, cost of movement and transport time on one hand, and socio-economic, cultural and other human factors on the other. The distances from most settlements to the health centres in the rural areas are quite long, some settlements exceeding 20 kilometres from the nearest health centre. In developing countries, the ideal distance which most patients are expected to travel for health care at the nearest health centre is 3 kilometres. King and Jolly (1966) discovered that in Uganda out-patient attendance per person per year halved for every additional 3.2 kilometre distance from the patient’s home to the hospital. In the Greater Accra region, the Ga, Dangme East and Dangme West districts show a contrast to conditions in the urban areas, regarding the quantity of health facilities and accessibility to them. There is a deficiency in the spatial distribution of health facilities in all these rural districts. For example, in the Dangme West district, the Osudoku sub district with an area coverage of 37807 sq km has two health posts, Great Ningo covering an area of 5846 sq.km. has one health centre, Prampram with a land area of 1272 sq.km 5 University of Ghana http://ugspace.ug.edu.gh has one health post, and Dodowa sub district with a land of 2428sq. km has two health centres (Agyepong, 1999; Mensah Quainoo, 1997). The islands located in the . Volta Lake area of the Dangme East'District face a more serious situation of being accessible only by canoe. No community clinics are available for the people on the islands. The World Vision-sponsored health centre facility at Pediatorkope, the biggest island is not patronized by the islanders since no senior medical officer is willing to reside on the island and work there. It is currently functioning as a community clinic, manned by a community nurse/midwife, and two public health nurses who do some outreach programmes in the area, travelling by boat. Apart from the long distances to health centres, especially in the rural areas, the poor nature of the roads impedes accessibility. The few drivers who take the risk to ply some of the roads charge high fares which cannot be borne by most people who prefer either walking or abandon the idea of attending the health centre altogether. The status of accessibility in the Dangme East and Dangme West Districts shows a contrast with that of the Ga District which is closer to Accra and has better access to the hospitals and clinics in the metropolis where taxis and mini-buses, “tro-tro” are readily available. The further a settlement is away from Accra, the greater the accessibility problem. During the rainy season all the roads in these three rural districts, with the exception of the major roads linking Accra directly from the district capitals, become immotorable. It costs a minimum of 020,000-030,000 to hire a taxi to cover distances less than 8 kms. High transport cost imposes a restraint on attendance. Walking distances are preferred in all the settlements, even on the islands in the Dangme East district where the inhabitants are forced to travel by boat to the Ada Health Centre, after long distances of 6 University of Ghana http://ugspace.ug.edu.gh walking across the island.. The high cost of health services is a disincentive to some patients in the districts capitals and well as all the settlements in the study area. High service cost is partly the outcome of the introduction of Structural Adjustment Programme. It has led to the removal of subsidies on essential services like health and education, and even agricultural inputs. The cash and carry system, which enjoins on the user of health service to pay fully for the cost of service, was introduced in the mid-80s as a product of the SAP. Sowa (1993) has found that declining hospital attendance in 1984 could be attributed to the overall crisis of the economy, but the continued drop through 1986 could be due to the introduction of hospital fees. Both in Ihe rural and urban areas, poverty is a very important factor which influences utilization. Through health education, some rural uneducated are beginning to embrace scientific medicine. Inability to bear the cost of health services, however makes them unable to use orthodox health services. Buor (1988) in an analysis o f income and hospital attendance in the Ashanti Region concluded that the high income earners attend hospital more often than low-income earners. Education, which is a superstructure in accessibility, is a tool that can break the barriers to hospital attendance. A teacher in the rural area is more likely to find means of overcoming the accessibility problem than an uneducated farmer, even when both of them earn the same annual income. The educated have knowledge of the basic sciences, so are aware of the implications of the use of untested traditional medicine, and self medication. They will thus find any means to overcome the problem of physical inaccessibility to receive medical attention from an orthodox institution (Buor, 2001). , 7 University of Ghana http://ugspace.ug.edu.gh Employment status also influences hospital utilization. Employed people have more access to financial resource than the unemployed. Political factors can also affect accessibility. The decision to site institutions at specific places is in some instances, influenced more by political considerations than locational viability. Religious prejudice and politics can keep some people away from specific health institutions. Quality of health service is an invaluable index of utilization. The islanders in the Dangme East districts for example bypass the community clinic at Pediatorkope because they know the quality of health care available there is far less than what is provided at the Ada Health Centre, and even more recently, the district hospital at Faithkope. Morbidity condition of a patient when the health situation assumes a critical dimension also influences the utilization of a health care facility. Relations and friends make great efforts, under such critical situations, to overcome the hindrances to accessibility. They make great sacrifices and contributions to help their beloved one. The inability of patients to afford the cost of health services and the poor attendance due to poor physical accessibility to health centres is likely to result in their resorting to traditional therapy and self-medications with their negative repercussions. There was thus the need for a research into the accessibility problem which is more endemic in the rural areas, examine its gravity in impeding die progress of health care and suggest solutions based upon observed patterns. 8 University of Ghana http://ugspace.ug.edu.gh 1.3 OBJECTIVES The general objective of the study is to analyse the accessibility and utilization of primary health care facilities and services within the Ga, Dangme East and Dangme West Districts of the Greater Accra Region. The study specifically seeks to; 1. Analyse the factors that account for the current spatial distribution of Primary Health Care facilities in the above mentioned selected districts. 2. Examine access to primary health care services in the districts mentioned 3. Assess the utilization factors in the three districts. 4. Give recommendations on the effective use of health services. 1.4 LITERATURE REVIEW 1.4.1 Definition of Health and Primary Health Care World Health Organization (WHO) define health as “a state of complete physical and mental and social well being and not the absence of disease or infirmity” (Melinda et, al, 1984). Research suggests that health, at all levels of definition, goes well beyond health care (Dutton, 1986; McKinlay, et.al, 1989). It embraces strategies that can prevent the need for clinical services. Health and its relation to society has always been an important theme within Geography. Kleinman et.al (1978) identify three sectors of health care. These are the popular sector, the folk sector, and the professional sector. The popular sector includes all the therapeutic options that people utilize, without consulting either folk healers or medical practitioners. In the folk sector, individuals specialize in forms of healing that are either sacred or secular, or a mixture of the two. The healers are not part of the official medical system, and occupy an intermediate position between the popular and professional sectors 9 University of Ghana http://ugspace.ug.edu.gh (Cecil, 1984). The professional sector comprises the organized, legally sanctioned healing professions, such as modern Western scientific medicine, or allopathy. It includes not only physicians of various types and specialities, but also the recognized para-medical professions such as nurses, midwives, or physiotherapists. In most countries including Ghana, scientific medicine is the basis of the professional sector, but traditional medical systems may also become “professionalised” to some extent. In India, for instance, 91 Ayurvadic and 10 Unani medical colleges receive government support (Cecil, 1984). In Ghana, a few medical doctors have entered into the area of folk medicine. A research institution on plant medicine receiving government support has been established at Mampong Akwapim in the Eastern Region. The relationship between folk and professional healers tend to be marked by mutual distrust and suspicion. In the Western world, modern medicine views folk healers as “quacks” and “charlatans”. The Declaration of Alma Ata defined Primary Health Care as “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally acceptable to individuals and families in the community through their full participation and at cost that the community and the country can afford to maintain, in the spirit of self-reliance and self-determination” (WHO , 1978). The main aim of PHC is to shift health care delivery from its overconcentration on curative forms to preventive and promotive aspects of health care on a community-based level (Ministi^ of Health, 1994). The concept of PHC involves in addition to the health sector, all related sectors and aspects of national and community development to food, industry, education, housing, water supply, and communication (Bias and Limbambala, 2002; Carrin et al, 2000). 10 University of Ghana http://ugspace.ug.edu.gh 1.4.2 I’erceplion of Health Systems Perception of various health systems has significant impact on utilization of health services. Perceptions have psychological significance that is very important in medical care. Traditional societies see orthodox medicine as inefficient in treating certain diseases (Okafor, 1983). Abugri’s (1995) work in Northern Ghana indicates that aetiology as defined by society and understood by the people was particularly important in the selection and use of various therapeutic options in the area. There is a general belief that witchcraft or sorcery is an important cause of illness. Therefore, if one’s sickness is attributed to supernatural causes the therapeutic option will not be biomedical, but a diviner or a witch doctor. Buor’s (2001) study in the Ashanti Region shows that there could be attitudinal changes due to the level o f education, place of residence, religion and family composition. He found the formally educated more scientific-minded and they sought scientific explanations to existing phenomena. Religion as a tool also affected changes in attitudes towards superstition and cultural beliefs (Attanapola, 2000). Gibben (1992) has established that, poorly perceived health is associated with decreased utilization, whilst London and Bachman (1997) observed that user’s choice of service appears to be a rational decision on health care services and perceptions of the quality of these services. In a study of self-treatment of malaria in a rural area of western Kenya, Reuben et. al (1995) established that the people’s perception of malaria as a relatively mild illness, much less severe than Acquired Immunodeficiency Syndrome (AIDS) and measles, encouraged them to embark upon self-treatment. Thus the utilization of intervening therapeutic options is the function of perception of health and disease. Yamey (2000) and 11 University of Ghana http://ugspace.ug.edu.gh Jeppsson et al, (2000) confirm this situation in their studies. Others have attempted to draw a tacit relationship between the nature of health care and the social systems. To Hours (1986) it is impossible to separate the nature of health care systems from the societies that thoy seek to serve. The systems are created within specific social, cultural and economic structures, and, even if the health care is “improved’’ potentially, it has to adapt to local expectations, beliefs and norms if it is to have any popular relevance. These factors are linked with perception. It is for this reason that WHO (1978) recommended that traditional healing be integrated where possible with modern medicine, and stressed the need to ensure respect, recognition and collaboration among the practitioners of the various systems concerned. Scientific health services come under the umbrella of the professional sector. In most advanced countries, they are the only one legally recognized under the professional sector. A feature of Western health service in the developing nations is the inadequacy and scarcity of facilities. The scarcity of the facilities is due to lack of funds for the health sector. On the issue of funds for health services, Ron (2000), Buor (1988) and Mensah (1997) have found that they are woefully inadequate. 1.4.3 Accessibility to and Utilization of Health Services Forbes (1964) defines accessibility as implying the ease of getting to a place. It is a variable quality oflocation, and in a technical sense, refers to a relative quality accruing to a piece of land by virtue of its relationship to a system of transport. It can be reduced in simple terms lo mean the ability to reach a facility from a defined location. The concept means in general that something is “get-at-able” (Moseley, 1979). 12 University of Ghana http://ugspace.ug.edu.gh Phillips (1990) discussed issues related to access to health care by drawing distinctions between physical (potential) accessibility and revealed accessibility (utilization); equity and equality of provision, and between quantity and quality of services. People in a community are supposed to be potential users. Even though people in a community may have physical (potential) access to a facility, it may not necessarily lead to revealed or effective accessibility (utilization). Factors such as patient’s preferences and tastes, financial ability and time - space variables may affect utilization. Phillips also introduced locational accessibility that is a function of proximity, and related to physical accessibility. The potential accessibility factors that impinge on utilization are distance and time, both travel and waiting times. Some studies have identified a negative relationship between distance and hospital utilization: the longer thp distance, the lower the attendance rate (Phillips, 1986; Stock, 1987). This relationship may, however, vary according to the nature of illness, nature of road, and the quality of transport service. In developing countries, distance is only one variable that may interact more or less strongly with others to influence utilization. Mesa-Lago (1985) points out in his survey that a middle-class state employee living in San Jose, Costa Rica, obviously has a much better opportunity of receiving quick, efficient and appropriate health care than a poor peasant living 30 kilometres from the nearest health centre or rural post in the same country. A pattern of hospital use in developing countries is that most patients visiting health facilities come from the immediate vicinity (Meise et.al, 1996). In-patients are drawn largely from the community in which a health facility is located. In Ghana, 80 percent of the in-patients at the live major hospitals, came from the urban 13 University of Ghana http://ugspace.ug.edu.gh district in which the hospital was located (Buor,2001). About 35 percent of rural households cover a distance of between 1 and 9 kms to travel the nearest hospital, whilst over 20 per cent cover over 30 kms to get to the nearest hospital (Ghana Statistical Service, 1993). The phenomenon of distance decay features prominently in health service utilization. It is a well-recognised spatial phenomenon that as a service or facility becomes more distant, fewer people will patronize it. Distance decay thrives largely in a pluralistic health care. In Nigeria, Stock (1987) found that at a distance of 5 kilometres from a dispensary, per capita utilization fell to less than one-third of the 0-km rate. Writing on distance and health care utilization among the elderly in Zambia, Jeppsson et.al (2000) observed that increased distance from provider does reduce utilization. Oppong and Hodgson (1994) and Fendall(1995) confirm the great impact distance has on utilization of health, services. Phillips (1990) noted some socio-economic differentials in distance decay in Kingston, Jamaica, where residents from the high status sites often travel considerable distances to reach expensive private clinics in the business area, whilst by contrast, poorer residents in many sites use locally available public health centres or one of the two public emergency rooms at the University Hospital or Kingston Public Hospital. Oilier factors that violate the distance - decay mechanism include tire quality of care provided, and the nature of the illness. In rural Nigeria for instance, Stock (1983) found out that people were willing to travel further for more specialized services, or better quality care. Girt (1973), Wolinsky (1983) and Mays el al (1990) also confirmed that gradients o f distances patients travel to seek health care are relative to the nature of illness. 14 University of Ghana http://ugspace.ug.edu.gh A patient is prepared U> cover a long distance, depending upon the gravity of his health problem (Sharpson,1972). Time accessibility and utilization could be examined in three perspectives, namely travel time, waiting time at the hospital, and waiting time with respect to appointments. In developing nations, travel and waiting times are more important in examining utilization. Waiting time through appointments is not a regular feature of the health system. Meise et.al (1996) saw time distance as a major obstacle to hospital attendance, and that waiting time, defined as the length of time a patient spends waiting at a physician’s office, is an important time price that determines utilization levels (Acton, 1975). Aday and Andersen (1974) also note that this negative effect on utilization is greater for rural farm residents than for the urban dwellers because they have been found to have the highest traits o f seeing a physician. This may be based on their low socio-economic status. Time, as a barrier to utilization could be influenced by the season of the year, and the nature of a patient’s business activities. During the farming season, it would be expected that the rural farmers would not like to waste much time travelling long distances for health care, whilst a very busy entrepreneur may care during peak seasons such as Christmas. He may prefer using intervening alternatives. Apart IVom physical accessibility, sucio-cconomic, demographic, and political factors influence the use of health services. These factors are income, education, age, sex, government policy and ethnicity, place of residence, quality management and affective behaviour. Mensch (1985) in a household survey in rural Iraq found that the use of 15 University of Ghana http://ugspace.ug.edu.gh higher-level government health services and private clinics did increase substantially with increasing income. In Indonesia, Chernichovsky and Meesook (1986) in a household survey found low income to be a strong barrier to the utilization of modem medical facilities, even when publicly provided. Pickett and Hanlon (1990); Ensor and Pham- Bich-San (1996); and Wyss, K, et al. (1996) conclude in separate studies that poverty is a strong barrier to the utilization of health services. In a study of user satisfaction with health services in government health facilities in the Eastern Region of Ghana, code-named, “What does the public want from us?”, Dovlo, et.al (1992) identified high cost of services, among others, as a major cause of user dissatisfaction. Writing on strategies for regional welfare planning, Aase (1996) had emphasized the link between education and health - related behaviour. The situation in the Ashanti Region (Buor, 2001) confirms Aase’s position. The educated are more cautious and conscious of their health, and tend to use health services more. The educational levels o f mothers are generally strongly related to levels o f infant mortality, effective feeding, and good use of health services. Improved education of women is associated with increased use of modern pre-natal care (Wong et.al, 1987). The education of mothers in Ghana is a determinant of child immunization, which constitutes a significaift aspect of preventive health care. Whereas 42.2 percent of mothers without formal education immunized their children against BCG, DPT, polio and measles between 1989 and 1993, 86.7 percent of mothers with secondary education and above did (Ghana Statistical Service, 1994). Education and demand for health care are positively related (Grossman 1975). The education of the mother is a strong factor in determining the use of health services (Caldwell, 1986; Caldwell, 1989; Swenson, et.al, 1993; Mensch, et al. 16 University of Ghana http://ugspace.ug.edu.gh 1985; Raghupathy, 1996; Wong et.al. 1987). Educated women tend to use health facilities more than the uneducated, and the level o f education of a woman and the number of living children also has an effect on her use of pre-natal and antenatal services. Demographic factors of age and sex show some correlation with the use of health services. In (ural India, rural Nigeria and rural Ethiopia, Kroeger (1983) observed that children are important clients o f Traditional Medical Practitioners (TMPs), whilst Good (1987) found that in India, women consulted TMPs most, accounting for 55 to 60 percent of consultations. The two situations could stem from poverty, ignorance and cultural practices. Ethno medicine is intrinsically embedded in the rural economies of developing countries where poor access to scientific medicine exists. In an empirical research on accessibility and utilization of health services in a rural district in Ghana, Abugri (1995) observed that, the youth made use of health services more than the aged. Persons aged below 20 years shared an increasing tendency to visit the clinic more than those above that age. The elderly above 51 years used the clinic very seldomly. The explanation is that the elderly are generally dependent on the middle age group for support, hence their decisions to visit clinics, were restrained by either lack of financial or physical support. This “gate-keeper” model (Buor, 2001) is very crucial in the accessibility and utilization problem, especially in the rural areas that are deprived of adequate health services. Gender disparities also impact negatively on use of health services. Ojanuga and Gilbert (1992) in a work on women’s access to health care in developing countries established the premise that myriad socio-cultural factors negatively impinge upon the physical well­ 17 University of Ghana http://ugspace.ug.edu.gh being and accessibility of appropriate health care facilities of women. Santow (1995) believed that in developing countries, women’s roles affect their use of health services, since health as a good is allocated, but men monopolise family decisions. Women’s views are not respected, and decision-making tends to favour men. The political, economic and1 social structures internally and nationally decide who is going to get what, where and how (Smith, 1979), and this finds expression in the impact o f the Structural Adjustment Programme (SAP). Some of the features of the SAP are the devaluation of the local currencies, removal of subsidies from social services, trade liberalization, and labour retrenchment. The cost of health services is therefore unbearable for the unemployed and the low-income earners. Delvin and Yap (1993) have emphasized the fact that moderated levels of poverty are not consistent with SAP’s basic prescription. The growing poverty has led to a significant decline in hospital use in Ghana ( Sowa,1993; Abugri,4995 and Waddington and Enyimayew,1990). Abugri( 1995) concluded that the introduction of the SAP affected the utilization of health facilities of the rural people, and led to the reduction of medical staff, with negative effects on the quality of services. Waddington and Enyimayew(1990) found that, in the Volta Region of Ghana, there were significant cuts in outpatient attendance, with the introduction of hospital fees (user charges) that was a by - product o f the SAP. The issue of ethnicity in accessibility and utilization is very important. Certain ethnic groups show bias to the utilization of certain types of healers or medical providers. In developing nations, Hyma and Ramesh (1994) have found that preferences for health 18 University of Ghana http://ugspace.ug.edu.gh facilities may be based on a common language or religion that leads to the utilization of certain types of healers or medial providers. The residence in certain locations especially in the urban areas, can affect accessibility and utilization of health facilities. Membership of religious groups can be associated with access to superior or inferior health care. In Western countries, Philips (1990) has found that residence in less desirable urban locations and socio-economic deprivation can lead to poorer physical and social access to health care. There is also the concept of social accessibility (social distance) in which patients in a community consulted doctors with whom they felt comfortable. In a study of factors of general practice in rural Australia, Caldwell (1986), found that social accessibility considerations were more important than geographical proximity in the choices of rural residents to consult a particular doctor. Finally, the application of Total Quality Management (TQM) has been found to enhance accessibility (Miller and Milakovich, 1991; Donabedian, 1980; Dhungel and Dias, 1988)). Sira (1996) stressed the manner of professional presentation (affective behaviour) as influencing utilization whilst Sintonen and Maljanen (1995) use the supplier - inducement model to access utilization. 1.4.4. Distribution of Health Facilities It has been found that equality of provision implies the arithmetic division of available facility resources equally among the population by a formula adopted for demographic criteria such as local age structure. On the other hand, equity implies justice in distribution in which those who, for some reason, require more of a service, will be 19 University of Ghana http://ugspace.ug.edu.gh provided with more than their equal share, because of their relatively high requirements (Phillips, 1990). The distribution of modem health care facilities, especially public hospitals, tends to favour disproportionately urban centres. The differences in provision between rural and urban areas are often so great as to make national averages of population facilities almost meaningless. The Annual Report of WHO drew attention to the concentration of physicians in urban centres and the development of health services predominantly in towns (WHO, 1998). The Metro-Manila region in the Philippines, for instance, though contains 25 per cent of the country’s population, has 43 per cent o f total hospital beds (Phillips, 1986). In Kenya, it is estimated that only 10 per cent of the country’s doctors serve rural areas, and that some 70 per cent o f all doctors are in urban private practice. Doctor-to-population ratios ranee^ftom 1:990 in the cities to 1:7000 in rural areas (Good, 1987). Such disparity also exists in urban areas ( Harpan,1988; Bailey & Phillips, 1990). Variations have also been \ found to exist in spatial provision of health facilities between rural local government areas in Nigeria (Okafor, 1984). In the Ashanti Region of Ghana about 34 per cent of all health facilities are concentrated in Kumasi, the capital, (Ghana. MOH, Ashanti, 2000); and, above all, health facilities are concentrated within the Central Business District (CBD), (Town and Country Planning Department, 1996/Kumasi Metropolitan Health Directorate, 1995). Such imbalance in the distribution of health facilities and personnel makes rural dwellers for remote from, and virtually inaccessible to modem health facilities (Buor, 2001). 20 University of Ghana http://ugspace.ug.edu.gh This unequal distribution of health facilities in urban settings in developing countries has serious health implications. Rural people tend to rely on intervening options such as se lf­ medication using orthodox and traditional medicine, and resorting to “quack doctors” and pharmacy shops that can result in serious health implications. 1.4.S Traditional Health Services Traditiorial medicine is a serious defying factor of utilization of scientific medicine in developing countries. In Ghana, as in most African countries, the rising cost of Western medicine means that individuals and, to a lesser extent, governments are increasingly turning to traditional medicine as an affordable alternative (Tsey, 1997). Traditional medicine is also being actively promoted by the WHO and other international agencies throughout the Third World (WHO, 1978; Leslie, 1980; Launs, 1989; Chavanduka, 1994). Traditional healers are a group of persons recognized by the community in which they live as being competent to provide health by using vegetable, animal and mineral substances and other methods based on social, cultural and religious backgrounds as well as on the knowledge, attitudes and beliefs that are prevalent in the community regarding physical, mental and social well-being and the causation of disease and disability. As an acceptable definition, we can group Ghanaian traditional healers into four main types o f specialities (Twumasi 1998): 1. Traditional birth attendants (TBAs) 2. Faith healers 3. Herbalists 4. Spiritualists 21 University of Ghana http://ugspace.ug.edu.gh These traditional health care providers play a very important role in the whole health care situation in the country. They have a large number of patients and are busy all year round. Traditional Birth Attendants (TBAs) focus on pregnancy problems and have a special role to play at birth and puberty ceremonies. In childbirth, they are midwives and are also recognized at times as good mothers to young children. Throughout Ghana, especially in the rural areas they are known as specialists in obstetrics. Their range of activities extend into the field o f sex education and contraceptive counseling. Besides taking on the responsibility in delivering babies, they also see to the health of the child and the mother (Gaisie, 1989). Faith healers are representatives and leaders of religious movements, especially the new, unorthodox, charismatic, pentecostal churches. Common among the faith healers are the leaders o f sectarian religious movements. Included in this group are also the Muslim healers who are generally referred to as “mallams” in the country. The most numerous among the traditional healers are the herbalists. They are the healers whose approach to healing is often related to the use and application of herbs. Their methods of treatment and operational procedures are often similar to modem medicine though their principles are quite different (Twumasi, 1998; Gaisie, 1989). Spiritualists include fetish priests, fetish priestesses, ritual leaders and others who are specialists in divination. At times, it is difficult to make a clear-cut distinction between faith healers and spiritual healers. For analytical purposes, faith healers operate from a religious movement whereas spiritualists are intermediates between a particular god or spirit and the public. 22 University of Ghana http://ugspace.ug.edu.gh In 2002, Medi-Moses medicine, a potent herbal beverage for hypertension, stroke, heart diseases and aphrodisiac for sexual enhancement manufactured by Duganco Pharmaceutical Ltd, won a Drugs and Chemicals (Small-Scale Category) Award at the National Quality Awards held in Accra(Daily Graphic,2003). Medi-Moses medicine, which comes in three categories namely gastro-intestinal tract, and respiratory tract infections, waist and rheumatoid arthritic pains and lumbago and slimmer for obesity, has been commended by the Ghana Federation of Traditional Practitioners (GHAFTRAM), GAR, for being national quality award winner in herbal medicine. Dr. Moses Kofi Amuzu Dogbatsey, Managing Director of the Company, promised to assist other herbal manufacturers to attain best quality in herbal medicine preparations. He received his award from Mr. Taylor of the Ghana Standard Board. Generally, the traditional healers are reputed to be skilful in dealing with social and psychological ailments. Studies conducted in Ghana and Zambia show that physical cases are almost invariably referred to the modem health clinics. The findings of a study conducted by Twumasi (1998) are summarized below: Clients of traditional healers were of the opinion that due to the non-availability of modem hospitals and clinics, the only alternative left for them was to go to traditional healers. This conclusion was expressed frequently by rural people. They also stated that there were certain types of problems and illnesses which modem practitioners were not able to deal with, especially those of social and psychological origins. For those problems and illnesses they felt satisfied consulting the traditional healers (Twumasi, 1998). There is a strong belief that sickness is caused mostly by supernatural forces, especially witchcraft, and not just physical and environmental situations. Sickness attributed to personal attack is a cause for alarm (Stock, 1981). 23 University of Ghana http://ugspace.ug.edu.gh It is a commonly and easily observed fact that some of the most “detribalised” and “modernized” Christians, scholars, scientists, and entrepreneurs among the African bourgeoisie today still consult African divinities, diviners, and healers when their health or other affairs are in serious trouble (Airhihenbuwa, 1995). Many have been known to sneak away from their church pews, discard their three-piece suits, steal away by night to some healer in his forest shrine, and carry out all manner o f ritual sacrifices when these are demanded. Infact, even among those with Ph.Ds, D.Sc.s, LL.D.s, and other assorted strings of Western bourgeois academic degrees, the going attitude is still that Western medicines and the Western Christian God are fine in their place, but when things get tough one runs back to one’s roots and ancestral ways (Chinweizu, Jenier, Madubuike, 1983, p.21). Illiteracy, superstition, religion and general underdevelopment has a very important role to play in the perception of sickness in our rural areas. 1.4.6: Health Insurance in developing Countries Health insurance can be interpreted broadly as an ongoing activity, which secures health status, or narrowly in terms of the institutions, which secure (financial) access to health care. According to Supakankunti (2000), health insurance is a means of financial protection against the risk of unexpected and expensive health care. In countries like Taiwan and Thailand, where the use of public health services is heavily subsidized, governments are implicitly covering the risk of incurring high-cost care (Kutzin, 1995; Tangcharoensathien et.al, 1999; Liu et al, 2002). In-poor rural communities, access to basic health care is often severely limited by inadequate supply as well as financial barriers to seeking care. National policies may introduce social health insurance, but these are likely to begin with the salaried public and 24 University of Ghana http://ugspace.ug.edu.gh private sector workers while the informal sector population may be the last to be covered. Studies by Ron (1999) show that community initiatives, in Guatemala and the Philippines, to generate health care financing required a complex development process. Non­ government organizations came to the rescue of some of the rural populations of the above mentioned countries. The scheme of the Association poor Salud de Barillas (ASSABA) in Guatemala, however, was not sufficiently established as an administrative body at the initial stage and there was no clear national policy on health care financing. By the time the necessary action was taken, local conflicts hindered progress. In the Philippines, on the other hand, the Health Plus Scheme was implemented during the period o f registration of a national health insurance act. The appraisal after three years operation shows that OPAS had made health care affordable and accessible to the target population, composing mainly of low and often unstable income families in rural areas. The major success factors are probably the administrative structure provided by cooperation and controls in the delivery system and in expenditures, through the salaried primary health care team, referral process and the capitation agreement for hospital - based services. The proliferation of such schemes could benefit from national guidelines, a formal accreditation process and an umbrella organization to provide assistance in design, training and information services, involving government, non-government and academic institutions as an integral part of the development process. Studies in Bangladesh by Desmet et al (1999), Bloom et.al (1999) in China and Chen et al (2001) in Taiwan confirm Ron’s findings. Empirical evidence from the Bwamanda hospital (Zaire) insurance scheme established that hospital utilization was significantly higher among the insured population (Criel, et al, 25 University of Ghana http://ugspace.ug.edu.gh 1999). Case studies by Atim (1999) in Ghana and Cameroon, however concluded that there were not enough evidence to confirm that the presenfce or absence of a social movement dynamic per se accounted for the perceived performance of either of the schemes. However, it is also argued that the dynamic of social movement could enhance the design and performance of a scheme, especially the efficiency and quality of health care. Such enhancement is possible provided that the scheme is set up in such a way as to benefit from the specific contribution of a movement component, in particular, if the scheme engages in direct negotiations with providers over the price and quality of care and makes direct payment contracts with such providers. A good scheme design is therefore one of the real keys to success. Studies in Asia by Ensor (1999) confirm these findings by Atim. Atim (1999) is also not clear how insurance will develop in the future, but he agrees with Carrin et al (1999), Musgrove (2002), and Supakantunti (2002) that a non­ social movement based scheme can incorporate elements o f a social movement (such as greater community participation, accountability and autonomy) in the course of time. It is argued that this process would enhance the success of a non-movement based scheme. Like many low-income countries, Ghana finds itself on the eve of the introduction of a national health insurance scheme. In the context of its national health policy framework, health insurance is seen as one option of obtaining additional resources for the financing of health care without deterring the poor and vulnerable group from seeking care when they need it. It is a way of improving the quality and access to health care as well as managing resources more efficiently. 26 University of Ghana http://ugspace.ug.edu.gh Arhinful (2001) observed numerous obstacles which need to be overcome. Among the complexities and problems of implementing a scheme of insurance include the background o f Ghana’s low economic base, a relatively poor population, unplanned spending on health care, and lack of expertise on socialized health insurance. Besides, there are other crucial issues of social and cultural nature that need to be considered in the design and implementation but which have not yet received adequate attention. As in most Third World communities, social security arrangements have been and still are largely based on primary relationship within and between relatively small- scale units, such as kinship, parenthood and gender, neighbourhood, friendship, patron^ client ties and common village membership. The underlying principle of exchange in these arrangements is reciprocity. The proposed insurance system, however, is based on an entirely different principle: that of state authority (Arhinful, 2001). The question that needs to be answered is how traditional mechanisms o f reciprocal moral obligation can be “scaled up” or extended to an anonymous more formalized state centred solid insurance scheme. Particularly crucial is the question of how the concept of “universalistic solidarity” translates in the behaviour of the population in a social health insurance scheme based on their past experience on traditional social security mechanisms. To date, it is not clear to what extent the policy objectives o f increasing the provision of and raising the quality of primary health care reconcile with what individuals and informal groups such as the 'abusua’ (family) know, do and want in health insurance. Mass and individual education is needed to inform and discuss with the people about socio-cultural challenges of social health insurance in Ghana. 27 University of Ghana http://ugspace.ug.edu.gh 1.5 CONCEPTUAL FRAMEWORK 1.5.1 Aday and Andersen’s Accessibility Framework This model takes into consideration the factors of accessibility and utilization and health policy in the relationships in the access and utilization variables. Aday and Andersen (1974) use the input - output approach, with the characteristics of the delivery system, and the population at risk, constituting the inputs, whilst the utilization of health services and consumer satisfaction constitute the outputs ( Figure 1.1). The health policy factors o f Fig. 1.1: A Framework for the Study of Access to Health Services Source: Aday and Andersen, 1974. 28 University of Ghana http://ugspace.ug.edu.gh financing, education, manpower, and organization directly affect both the characteristics of the delivery system, and the population at risk. This suits the situation in developing nations, where the central government controls health decisions. The characteristics of the delivery system, resources sand organization, affect the characteristics of the population. The predisposing and enabling factors as well as need, perceived and evaluated, can influence utilization. The model also shows a two-way direct relationship between utilization and consumer satisfaction. The model nonetheless has some deficiencies. First, location, which is a very important factor in accessibility, is absent from health policy. Second, health policy can have a direct effect on utilization and consumer satisfaction; but this is not considered by the model. Third, demographic factors of age and sex, which are important factors in utilization were not included in the characteristics of the population. Fourth, utilization o f health services and consumer satisfacticm can also have direct effects on the characteristics of the delivery system, but this is not reflected in the model. In a user payment system for instance, effective utilization that will result in consumer satisfaction will improve the financial capabilities of the delivery system which can produce greater efficiency (Buor, 2001). 1.5.2 The Andersen-Newman Model This model focuses on utilization and accessibility of health care in the United States of America. Andersen and Newman (1973) looked at the individual as well as the society’s determinants of medical care utilization. Consumer satisfaction is of prime importance. The Medicare and Medicaid programmes were, at least in part, by products of the civil rights struggle. The strong, sustained economic growth in the United States during the 29 University of Ghana http://ugspace.ug.edu.gh 1960s raised expectations for expanded social services. Improvements in access to health care for blacks had begun to take place well before the implementation of the Medicare and Medicaid programmes. In the developing world, the introduction of the National Health Insurance Scheme would go a long way to boost the accessibility and utilization of health care facilities. 1.5.3 The Mathematical Models Gross (1972) and Kon-Kyun (1972) have developed complex mathematical models. Gross identifies the components of patients’ behaviour as the major determinants of, utilization. It is a model that incorporates accessibility, which has generally been omitted in earlier models. His model is represented in an equation: U = F (E, P,A, A, X)e Where, U = Utilization of various services reported by the individual or family E = Enabling factors such as income, family size, education P = Predisposing factors such as attitudes to health care, knowledge of sources of care. A = accessibility factors such as distance and /or time from facility and service availability H = perceived health level X = individual and area - wide exogenous variables E = residual error term. Gross’s model is a significant improvement upon Andersen’s (1968), Aday et. al’s (1980) and Stock’s (1980). It goes beyond predisposing and enabling factors to include 30 University of Ghana http://ugspace.ug.edu.gh accessibility, and also individual'variables instead of the aggregate. It thus incorporates a wide range of variables. These notwithstanding, the model has some set backs. Their numerical expression and measurement can constitute a problem. It is difficult to determine the parameters. Pyle (1974) uses a modified gravity model to determine hospital service areas. This model confirms Shannon’s model of 1969. In Pyle’s model, he shows the relationship between distance, a dependent variable and parameters such as income, education and employment status. Distance is supposed to be a function of the socio-economic parameters. The model can help compute the volume of hospital attendance based upon the distance. Gould and Leinbach (1966) developed a locational model which was used to locate three regional hospitals in Western Guatemala, whilst Kon-kyun’s model proposes four determinants of the amount and type of hospital services provided, including the responses of physicians to the medical conditions of patients, the socio-economic characteristics of patients, institutional environment of individual hospitals, and the interaction between patient characteristics and hospital characteristics. 1.5.4 Dutton’s Utilization Model Dutton’s (1986) model views the use of health services as a result o f patient characteristics, and the provider and the system characteristics as represented diagrammatically in Figure 1.2. Her diagrammatic representation shows the interrelationships between patient characteristics, use of health services, and provider and system features. In the model, utilization is the product o f patient characteristics and 31 University of Ghana http://ugspace.ug.edu.gh FIG. 1.3: A HYPOTHETICAL MODEL OF ACCESSIBILITY AND UTILISATION O l HEALTH SERVICES PATIENT CHARACTERISTICS USE OF HEALTH SERVICES PROVIDER AND Source: Buor, 2001; Dutton, 1986; Aday and Anderson, 1974 In a hypothetical model by Buor (2001), the main factors of interaction are patient characteristics, use of health services, and provider and system features and levels of accessibility. Levels of accessibility was introduced to show the other factors of potential 37 University of Ghana http://ugspace.ug.edu.gh accessibility that had been introdqped to show the other fatctors of potential accessibility that, had not been introduced in tlje Dutton and Aday and Andersen models. Structural barriers here indicate the barriers created by the institutions providing health care. They do not necessarily imply government policies. The time under structural barriers refers to waiting time at the hospital. Need and physician characteristics have direct impact on patient-controlled factors, whilst resources available and predisposing and enabling factors have direct effect on the levels of accessibility. Factors under the levels of accessibility are distance, rural settings and transport facility. The volume of resources available and the distribution would influence the patterns of accessibility, whilst predisposing and enabling factors would influence such barriers to health facilities. The key independent variables for the study are income, employment, age, sex, education, distance to health institution, time taken to get to a health institution, waiting time at the health institution, transport cost, quality of the road and service cost. The main dependent (outcome) variable is utilization. The variables that come under patient characteristics are income, education, age and sex. These come under predisposing - enabling need factors. The level o f income will determine the level at which are could be accessible to a health facility. Where the accessibility factor is distance, transport cost or cost of service, the wealth status is a strong determinant of utilization. Education will also predispose a patient to the need to access health service, whilst age and sex will affect the need that is patient- 38 University of Ghana http://ugspace.ug.edu.gh controlled: The education and income factors* can influence patient-controlled factors of preventive check-ups and initiation of illness care. The factors of education and income will also influence physician - controlled factors of follow up visit and medication. Physician’s follow-up visits that are expensive would require financial capacity of the patient to pay for the services. The levels o f accessibility of distance and travel time would depend upon the volume; of resources and their distribution pattern. Patients nearer health facilities, given a quality road network and availability of transport facilities, will pay less than those further away. The provider, the state or private institutions, will determine the cost factor. This is a factor o f government policy. Where the cost is high, the poor segment of the society cannot afford die services. 1.6 STATEMENT OF HYPOTHESES a) There is an inverse relationship between physical distance, travel and waiting times and utilization of Primary Health care facilities in the Greater Accra Region. b) There is a positive relationship between the socio-economic factors of income and education and utilization of health services. 1.7 ORGANIZATION OF THE STUDY The thesis has nine chapters. Chapter one begins with an introduction, followed by the problem, the study’s objectives, literature review and conceptual framework. It concludes with the organization of the study. Chapter two concentrates on the research methodology. Methods of data collection, analysis and limitations of the data are also 39 University of Ghana http://ugspace.ug.edu.gh discussed. Chapter three focuses on the study area. Details on administrative divisions, physical conditions, population and health issues as well as socio-economic issues are delved into. Chapter four examines the primary health care system in the Ga, Dangme East and Dangme West Districts. Spatial distribution of the health facilities and components PHC are assessed. Chapter five looks at the health status of the people. Household disease patterns as well as differences in health by place of residence are examined. Chapter six gives the factors of physical accessibility and utilization. Distance, travel and waiting times are very important factors. Chapter seven examines other factors affecting utilization. Service cost, transport cost, age and sex, employment education and income are salient issues discussed. Chapter eight focuses on synthesis o f utilization of primary health care. The Variables for the study are examined as well as the use of multiple regression in the study. Chapter nine summarises the findings, and offers some conclusions and recommendations to ensure effective use of health facilities, and to promote sound health that is a goal and an end of development. 40 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO RESEARCH METHODOLOGY 2.1 INTRODUCTION Methods o f data collection include four different enquiry schedules including questionnaire, focus group discussion guides, in-depth interviews, non-informal schedules and participant observation. Targets of the enquiry range from heads of households, users of health institutions, providers of health services including doctors, nurses, drug sellers and drug peddlers. Statistics from health institutions are also o f great importance to the study. Spatial dimensions such as rural- urban situations show up in the provision and spread of health care facilities and the hierarchy of settlements within and across districts. 2.2 TYPES AND SOURCES OF DATA Primary sources of data included questionnaires, focus group discussions, interview schedules and personal observations from field survey. Secondary sources of data included population census reports on socio-economic and demographic characteristics of the population of the three rural districts o f the Greater Accra Region, books, journals and periodicals. Other sources included survey reports on accessibility and health service utilization in the developing countries, and specific ones on. Ghana; Ghana Demographic and Health Surveys; health situation in the selected health institutions from the biostatistics department of the Ministry of Health; the Ghana Living Standards Survey (GLSS) of the Ghana Statistical Services and Annual Reports of the Greater Accra Region, Ga, Dangmp East and Dangme West Districts. Quantitative data were the main data collected. These were supplemented with qualitative data. 41 University of Ghana http://ugspace.ug.edu.gh 2.3 RESEARCH INSTRUM ENTS The units o f enquiry were selected heads o f households (non-patient respondents), outpatients in health institutions, district directors o f health services, medical assistants, nurses, assembly persons, licensed chemical sellers and drug peddlers; and the research instruments being formal questionnaire schedule, interview schedules, focus group discussions, in-depth interviews and observations. Ten interviewers (research assistants), graduates, administered the questionnaires. They had knowledge o f the health conditions in the study area, and were conversant with the languages so very little interpretation was needed. For household respondents and patients, structured questionnaire schedules were administered to the educated in the entire sampled health institution and towns and villages. The same set o f questions was used as interview schedules for the illiterate population. To limit the problem o f call-backs associated with the questionnaire instrument,- interview schedules were applied on some educated respondents who, for pressure o f time, would not be able to fill the questionnaire on schedule. Copies o f the questionnaires for household respondents and patients are indicated in appendices 1 and 2. Formal questionnaire was also structured for health administrators in the sampled health institutions. The directors o f district health management teams filled the questionnaire for; the district level whilst, the medical assistants and /or clinic attendants who were trained nurses; filled the questionnaires for the rural health centres and clinics. For the health institutions, the questionnaire involved hospital statistics and opinions on accessibility and health reform. The schedule also covered the utilization patterns as 42 University of Ghana http://ugspace.ug.edu.gh reflected in outpatient attendances, health conditions in their catchment areas, health resources, health financing, and the impact o f government policy on health care issifes. The questions schedule for the health institutions is indicated in Appendix 3. Interview guides were structured for drug and chemical sellers, as well as community leaders (traditional and religious opinion on issues o f accessibility to and utilization o f primary health care). These can be found in Appendices 4 and 5. Focus group discussions were held in the health centres at Amasaman, Dodowa and Ada Health Centres; at 3 separate MCH/FP sessions. Details on their attenatal attendance, immunizations, breast-feeding practices and nutrition for the babies and children were discussed. Habits like washing o f hands before feeding the child, keeping a clean environment were also looked at. Attitudes o f the nurses, quality o f health care were all important features o f the discussions. Indepth interviews also helped the researcher get details about the crisis respondents personally faced as a result o f poverty and their inability to enjoy the available health services because o f the financial difficulties they experienced under the cash and carry system. The health conditions o f selected settlements as well as .their ability to utilize health services were observed. The motorability o f minor roads and the walking distances by the people to the health facilities were all observed. Some patients and non-patients were asked informal ubiquitous questions relating to their accessibility to health institutions, and their ability to utilize them. Indepth interviews gave detailed information on some o f these important health issues/ 43 University of Ghana http://ugspace.ug.edu.gh 2.4 SAMPLING DESIGN 2.4.1 Sample frame Greater Accra region was selected for the study. Its capital, Accra is the administrative and political capital o f Ghana. This region has the largest urban centre in the country, as well as some o f the least developed areas in Ghana (the Ga, Dangme East and Dangme West Districts). There are extremes o f wealth and poverty; high quality health service with specialists at the Korle Bu Teaching Hospital, Police and 37 Military Hospitals, Tema General Hospital, polyclinics, private hospitals and clinics in both Accra and Tema, whilst at the extreme end, some rural dwellers, just a few kilometers away, are depending mostly on self-medication and untested traditional medicine during periods o f ill-health. There are varieties in transport system, educational and income levels in these districts. The frame from which the districts, settlements and primary health care institutions were selected is indicated in Table 2.1 Out o f the five administrative districts, three districts namely the Ga, Dangme East and Dangme West representing the bulk o f the rural sector o f Greater Accra, were selected for critical study (Table 2.1). These three districts made for comparative analysis o f rural-rural dichotomies. The district capitals show some urban tendencies, whilst the smaller settlements exhibit typical rural characteristics such as the inhabitants engaging in primary economic activities. They also have very poor road networks and poor health facilities that are physically inaccessible to a significant proportion o f the population. 44 University of Ghana http://ugspace.ug.edu.gh TABLE 2.1: Sample frame 1. A ccra M etropo litan A rea 2. T em a M etropo litan A rea D ISTR ICTS . 3. G a 4. D angm e East 5. D angm e W est H IE R A R C H Y O F S E T T L E M E N T S 1. H am let 2. C o ttage 3. V illage 4. Sem i-U rban . 5. Peri-U rban 6. U rban C ore HIERARCHY OF HEALTH Ministry o f Health District Hospitals INSTITUTIONS Ministry o f Health Health Centres Ministry of Health Community Clinics Source: C o n stru c t o f th e icsearclier, 2 0 0 1. As at the lime o f the field work (2001), there was no district hospital (Level C o f the primary health care facilities) in any o f these three rural districts. Each district capital had one health centre with a medical assistant in charge. This is the highest in the hierarchy o f Ministry o f Health primary health care facilities available in the districts. Selecting o f the health centres was done purposefully, by hierarchical order. The spatial spread o f the health institutions and the level o f accessibility to them will help in comparing utilization based upon physical accessibility. Each district is well represented. Major and minor roads and the use o f footpaths, and river transport are also o f interest to this study. The selection o f the various localities portray this important component in the accessibility and utilization o f the available PHC. The sampled settlements included settlements where the health institutions are situated and those without primary health care facilities. The former was done purposively while the 45 University of Ghana http://ugspace.ug.edu.gh ensured that every group was represented. The sub-groups were also homogeneous enough to warrant such a sample size. Added to the financial and logistics constraints, the sample size was reasonable. 2.4.3 Sampling Methods The multi-stage non-probability approach was used in the allocation o f the respondents to the districts and health institutions; total, and by age and sex. Total sample allocations were made to the districts, then to the health institutions. There after, allocation was made by age and sex, which are variables that are common in almost every locality. It was not possible to pre-determine the samples for the variables o f education, employment and income, since there are no current statistics on them. Disproportionate and proportionate sampling, stratified random, simple random and systematic random sampling were used at various stages. The sample allocation to the districts was done purposefully. Table 2.2 shows the allocation o f respondents to settlements and health institutions in sampled districts. Table 2.2 - Allocation o f respondents to settlements and health institutions in sampled districts. District Respondents sampled in Respondents sampled in Total settlements health institutions Ga 200 60 260 Dangme West 100 60 160 Dangme West 100 60 160 Total 400 180 580 Source: Autnor’s Construct, 2001, Population was used as a basis for the various settlement allocation. (Refer to Table 2.3). The Ga District had an allocation o f 260, whilst the Dangme East and Dangme West districts had 160 each. The details for the health institutions are given in Table 2.4. Table 2.3 shows the sample proportion o f the households in the districts University of Ghana http://ugspace.ug.edu.gh T able 2.3 ■> Sam >le proportion o f households in the selected districts District Population Percentage of Actual sample Rationalized Census 2000 Total Sample size size Ga 556,581 74.5 298 200 Dangme West 96,776 13.0 . 52 100 Dangme East 93,193 12.5 50 100 Total 746,550 100 400 400 Source: Construct o f the researcher, 2001. Table 2.4 gives the sample allocation to health institutions. Table 2.4 - Sample allocation to health institutions District Name and type of health Location Number of Number of institution patients workers interviewed interviewed 1. Ga Amasaman Health Amasaman 40 7 Centre 2. Ga Ngleshie Amanfrom Ngleshie Community Clinic Amanfrom 20 3 3. Dangme Ada Health 7 East Centre Ada 40 4. Dangme Pediatorkope Pediatorkope 20 3 East Community Clinic 5. Dangme Dodowa Health Centre Dodowa 40 7 West 6. Dangme Agomeda Community Agomeda 20 3 West Clinic Total 6 6 180 30 Source: Construct o f tne researcher, 2001. Amasaman, the Ga District capital had the largest proportion bf samples in the settlements because o f its relatively bigger population size and its importance in terms o f its closeness to Accra (23 kms away) and also its peculiar situation o f having more city dwellers flocKing there because o f the relatively lower rent cost compared to the Accra Metropolitan area. Ada and Dodowa, district capitals for Dangme East and Dangme West respectively, had the second largest proportion o f household heads or their spouses/representatives because o f their special positions as district capitals thus having a 48 University of Ghana http://ugspace.ug.edu.gh higher population and more urban tendencies compared to the more rural dwelling places such as Medie, Tuanikope and Yakubukope. There was an allocation by sex in the health institution o f sampled districts. Out o f a total o f 180 respondents in the health institutions (patients), 64 o f them making 36 percent were males, whilst 116 making 64 percent were females. Females are more than males in the communities as well as the patients. No allocations were made for the households since most household heads are males any way and one can never tell who would be available to be interviewed per time. The allocation by sex and age (patients) is indicated in Tables 2.5 and 2.6 respectively. Table 2.5 - Allocation o f respondents (patients) to the districts by sex H ealth Institu tion (P atien ts) Total D istrict M ale Fem ale Sam ple % Sam ple % Sam ple % Ga 18 28.1 42 36.2 60 33.3 D angm e W est 22 34.3 38 32.8 60 33.3 D angm e East 24 37.6 36 31.0 60 33.3 Total 64 100 116 100.0 180 99.9 •Source: A u tn o r’s C onstruct, 2001. Table 2.6 - Allocation o f respondents (patients) to the districts by Age. (H ealth Institution Patients) Total D istrict 18-59 601 Sam ple % Sam ple % Sam ple % % Ga 49 42.9 11 16.7 60 33.3 D angm e W est 34 29.9 26 39.3 60 33.3 D angm e East 31 27.2 29 44.0 60 33.3 Total 114 100.0 66 100 180 99.9 Source: A u th o r’s C onstruct, 2001. Allocation o f respondents (patients) was arbitrarily done by quota sampling for the districts (Table 2.6). For the age group 18-59, the proportion was 114, making 63 percent of the sample, whilst 60+ formed 37 percent o f the patients. 49 University of Ghana http://ugspace.ug.edu.gh For the selection o f the respondents in the communities, systematic random sampling was used to select the houses from which respondents were located. In each house, the head of household or his/her spouse, or representative, o f 18 years and above, were interviewed if they were illiterate, or given a questionnaire if literate. Couples were not interviewed. Either the man or woman was interviewed to avoid duplication. Care was taken to ensure that the other variables, that is education, income and employment were adequately covered. In view o f this, discretion was applied to discriminate in the selection o f samples when it was realized that some groups were under represented. For the final selection o f respondents in the communities, the district capitals (urban) and the smaller settlements (rural) were divided into zones (area sampling). One zone was selected and the houses listed. Systematic random sampling was used to select the ‘Nth’ value based upon the sample size and the number o f houses in an area. The selection o f the respondents was by random (chance) selection initially. However, when the process of data collection advanced and some sub-variables were found to be under-represented, purposive technique was applied. This was to ensure a fair representation o f the various groups. Education, income and employment and occupational status formed the basis of the socio-economic categorization. Income status was stratified into income quintile, from very low to high income, as stated in Table 2.7. Table 2:7: Income categorization by income quintile Level o f Income Income per month (in cedis) 1. Very Low Below 100,000 2. Low 101,000-200,000 3. Medium 201,000 300,-000 4. High 301,000- 400,000 5. Very High Above 400,000 Source: Author s Construct, 2001. 50 University of Ghana http://ugspace.ug.edu.gh The collection o f data on income was guided by the methods used in the Ghana Living Standards Surveys. The components were wage income from employment, household agricultural income, non-farm self employment income, rental income and net remittance and other minor sources (Ghana Statistical Service 2000). Household agricultural income featured more in these three rural districts. Educational status was categorized into three, namely, no formal education, basic education and secondary education and above. 2.5 TECHNIQUES OF DATA ANALYSIS The data were audited, summarized coded and classified: Descriptive, and multivariate methods were used in the data analysis. Maps and charts have also been used. The survey is mainly correlational and cross - sectional. The independent variables that have been related to effective accessibility (utilization) are income, education and employment status, age, sex waiting time, travel time, distance, service cost and transport cost. The outcome (dependent) variable in the study is utilization, which is measured by the number of times a person attends the health centre or community clinic when he falls sick consecutively for a certain number o f times. The data have been analysed on the district levels and also by health status, that is patients and non-patients. Apart from maps and graphical presentations, statistical tools have been used for the analysis o f data. Buor (2001) has successfully used multivariate techniques in analyzing his study on accessibility and utilization o f health services in the Ashanti Region, specifically the Kumasi Metropolitan and Ejusu Juaben District. To measure the relative impact o f the selected variables, multiple linear regression technique was used. 51 University of Ghana http://ugspace.ug.edu.gh Multiple linear regression is used when additional independent variables are introduced into a regression model (Yeomans, 1979), and also when the dependent is continuously distributed (Hennekins and Buring, 1987). In the regression analysis, variables with interaction terms o f .05 and less (P<.05) were considered significant so used for explanation. Correlation coefficients o f the independent - dependent variables have been used to assess the strength o f relationships, whilst regression values have been used to measure variations, in the dependent variables. Continuous, ranked and dummy data were used for the multiple regression model. Distance, income, travel time, waiting time, service cost, transport cost and age were entered as continuous variables, whilst educational status was ranked and entered as such. There were three categories o f educational status namely, “no formal education”, “basic education”, and “secondary education and above”, given quantitative codes o f 0,1, and 2 respectively. Sex and employment status, which could not be entered as continuous variables, were entered as dummies. In the coding o f the variables, the ranking scale was used and values assigned to some of the variables like utilization and education. Data entered as a dummy could enter the regression model (Buor, 2001). Human behaviour is subject to change based upon certain prevailing circumstances. Codes were therefore used in a ranked order. In this instance, the appropriate measure o f central tendency is the median. The various forms o f the variables were given codes that reflected their strengths o f relationship with utilization, as indicated in Table 2.8. 52 University of Ghana http://ugspace.ug.edu.gh Table 2.8 - Quantitative Codes for Selected variables Independen t/D ependen t Param eters C odes V ariab le U tilization Scarcely 1 M oderately 2 R egularly 3 E ducational S tatus N o form al Education 0 B asic Education 1 S econdary Education+ 2 E m ploym ent status U nem ployed 0 Em ployed 1 Sex M ale 0 Fem ale 1 Source: Author’s Construct, 2001. The assigning o f quantitative values to the parameters o f the various variables was based on assumptions and results o f other surveys. With regard to education, it was assumed that the educated were more likely to utilize health services than the illiterate. Phillips (1981) has noted that, in both developing and developed countries, poorer education, among other factors, place families and children in multiple jeopardy, whilst Wong, et. al ( Table 2.9 - Codes for grouped data Variable Group Code Income <100,000 1 (in cedis) 101,000-200,000 2 201,000-300,000 3 301,000-400,000 4 >400,000 5 Waiting Time 3 0 - 6 0 1 (in minutes) 61 - 120 2 > 120 3 Travel Time <15 1 (in minutes) 1 5 -3 0 2 31 60 3 61 - 120 4 > 120 5 Service Cost <20,000 1 (in cedis) 21 ,000-40,000 2 41 ,000-60,000 3 60,000 - 80,000 4 >80,000 5 Transport cost <1,000 1 (in cedis) 1 ,000-2 ,000 2 2 ,100-3 ,000 3 3 ,100-4 ,000 4 1 >4,000 5 Sour_c__e_:_ AA ut1.h1__o__r__’_s__ _C___o__n_struct, 2001 53 University of Ghana http://ugspace.ug.edu.gh 1987) have discovered that improved education o f women is associated with increased use o f modem pre-natal care. Continuous variables o f income, waiting time, travel time, service cost and transport cost were grouped (Table 2.9) for the sake o f comparison o f the groiips with utilization behaviour. The groups were not used for the multiple regression analysis. 2.6 LIMITATIONS OF THE DATA The quality o f data could generally be ascertained, and found to be a fair representation o f what obtained in the study area, certain deficiencies notwithstanding. For the macrodata, like that derived by DHS,it is most likely that the problem o f age misreporting would be encountered (Awusabo Asare, 1980). The health institutions face the problem o f data keeping. The records sections o f all the health centres and community clinics in the study area faced great challenges in terms o f good record keeping o f data. Computation o f data is manual. Statistics on attendances had not been compiled for years. Statistics for some years could not be obtained. This affected the determination o f trends for most o f them. There were problems with respondents’ determination o f certain quantitative data like income per month, frequency o f attendance at health centres, distance to the nearest health . institution, time taken to cover distance, and waiting time. This was particularly so with the illiterate respondents who constituted a greater proportion o f the sample than the educated. There were problems with determining qualitative data like quality o f health services, and the state o f health. There was also a problem with deriving personal information like marital status. There were some respondents who are in cohabitation who initially responded married. Some 54 University of Ghana http://ugspace.ug.edu.gh women felt that it was a stigma for a women to be in cohabitation. It is most likely that some who are not legally married may have responded, “married”. There was also the problem o f not getting respondents for all categories o f the sampled houses. This called for minor changes o f the “11th” values in the process o f systematic sampling. There was thus an element o f bias in the sampling process. 2.7 Conclusion This chapter has outlined the methodological approaches employed by this study to examine the accessibility to and utilization o f PHC in these three rural districts o f the Greater Accra Region. Multi-stage sampling involving stratified, simple random and systematic random samplings were used for the collection o f data. Basically, quantitative data were collected on the field with the use o f questionnaires. Apart from the administration o f indepth interview in selected settlements with health institutions and others without health institutions within the study area, Focus Group Discussion (FGDs) were used to collect additional qualitative data. The multiple regression model was appropriately used for the analysis o f data. The limitations o f the study and pfoblems encountered in the field have also been provided. 55 University of Ghana http://ugspace.ug.edu.gh SOURCE ACCRA METROPOLITAN ASSEMBLY 2 0 0 3 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE - THE STUDY AREA 3.1 INTRODUCTION This chapter is on the background o f the study area and the key physical and human conditions that relate to the theme o f research. The physical conditions have a bearing on the nature o f roads, the major transport network in the region. The economic activities like agriculture could be affected by the nature o f the soil, hence income and nutrition o f the people could show a reflection. The status o f employment and income would affect utilization o f primary health care services. 3.2 BACKGROUND TO THE STUDY AREA 3.2.1 Administrative Divisions The Greater Accra region is divided into five administrative districts (Fig. 3.1), each with a director for health services responsible for health administration in the districts. There is a District Health Management Team (DHMT), under the chairmanship o f the district director o f health services, which is responsible for the operation o f the Primary Health Care (PHC) programme. Each District Assembly, the political authority in a district, has a health committee that takes technical decisions on health issues in a district. There is also a regional director for health services who oversees the administration o f health institutions owned by the Ministry o f Health (MOH). He chairs the Regional Health Management Team (RHMT). In principle, the district and regional health administrations in consultation with the District Assemblies and Regional Co-ordinating Councils, make recommendations for the location o f health facilities in the respective areas o f jurisdiction. 57 University of Ghana http://ugspace.ug.edu.gh 3.2.2 Physical Conditions Hie south-east coastal plains, mostly covered by the Dangme East and Dangme West districts o f the Greater Accra Region, are very flat and contain only a few isolated hills, for example Shai, Krobo, Ningo and Osudoku hills, which rise abruptly from the surrounding plains. The hills have been likened to islands standing clearly and abruptly above the sea; hence they have been called inselbergs, literally “island mountains” (Dickson and Benneh, 1988). The general elevation of the land, except in the case of the inselbergs is not more than 75 metres above sea level, and at some places on the coast the land is even below sea level and is subject to periodic invasions by the sea. Between Accra and about the Songaw Lagoon, the coastline is fairly smooth, without cliffs, and is marked by sand bars, the Volia delta, the only one of its kind in the country and by numerous lagoons. West of Accra, the plains show different characteristics. The land is not undulating since the hills, especially o f the Ga District, show steep sides and rise almost abruptly from the surrounding plains. Various types of rock are found here, but the most widespread are the granite which also forms most of the hills (Dickson and Benneh, 1988). Road construction in such areas are very expensive. The driest area in Ghana is found in the south-east coastal plains where the mean annual rainfall is less than 75 centimeters. The area experiences dry equatorial climatic conditions with two rainfall maxima with marked dry season. The mean annual rainfall is between 74-89cm. The highest mean monthly temperature of about 30°C occurs between March and April, and the lowest, about 26°C in August. Highest average monthly relative humidity does not exceed’75%, and the lowest is about 60% (Dickson and Benneh 1988). There are variations in rainfall from year to year, for example Accra records from nothing to as much as 6.32 cms. of rain in different 58 University of Ghana http://ugspace.ug.edu.gh years for the month o f August. These fluctuations, which cannot be predicted, can create problems for the farmers. Ungravelled roads become very muddy during the rainy season, and it is common for vehicles to get stuck in the mud. Roads adjacent to streams are flooded during the rainy season. 3.2.3 Population According to the 1960,1970, 1984 and 2000 Population Census Reports, the population of all three districts has increased, but at different rates. The population increase in the Ga District from 31,308 in 1960 to 556,581 in 2000, that is 1678% is astronomical compared with that o f the Dangme East District (129.8%, that is from 40,543 to 93,193) and Dangme West District(125.9%, that is from 42,543 to 96,193) rate o f growth respectively (table 3.1). Table 3.1 - Basic Population Statistics o f the Ga, Dangme East and Dangme West districts District/Year 1960 1970 1984 2000 Ga 31,308 58,674 136,358 556,581 Dangme East 40,543 62,730 69,550 93,193 Dangme West 42,837 63,125 70,369 96,776 Source: Population Census Reports (1960,1970,1984, 2000). High population density in the Ga District is found along the border with the Accra Metropolitan Area (AMA) and along its southern border where settlements such as Bortianor and Oshie can be found. This depicts the expansion o f the metropolitan area into the hitherto rural districts. This is basically the result o f high income inhabitants o f Accra putting up new houses away from the AMA area, in the peri-urban sections. Low income dwellers in central Accra are flocking to the rural sections to avoid paying the relatively higher rents for accommodation. The rates at Amasaman and the other rural parts o f the region are far cheaper. The relatively large settlements in the Ga district 59 University of Ghana http://ugspace.ug.edu.gh include Madina, Mallam, Bortianor, Pokuase, Weija, Dome, Kwashieman, Ofankor and Adzen Kotoku. The Dangme East and the Dangme West Districts, on the other hand, have experienced lower growth levels. The intercensal growth rate for 1970 and 1984, for example was below the national average estimated for the same period as 2.6%, underlying the fact that these two districts are losing their historical importance as commercial centers and thus becoming less attractive and so out migration is quite high. The Dangme West District has a slightly lower population density than the average for the countiy (55.3) persons per sq.km as against the national average o f 63 persons per sq.km. The population is concentrated along the coast especially in the larger settlements like Prampram, Great Ningo and Lekpongunor. Oilier areas o f concentration o f population are Dodowa in the West and Asutsuare in the north o f the district. A significant feature o f the district is that the central area is virtually empty with hardly any settlements in it. The bulk o f the population is scattered in relatively small settlements with populations under a thousand. The Dangme East District capital, Ada has a large concentration of people. The islands are isolated and generally have fewer inhabitants. The largest island, Pediatorkope has a relatively higher number o f people dwelling there, in comparison to the other isolated islands, accessible only by canoe. Large portions o f the district are virtually empty, like its neighbour district, Dangme West. There is a big problem of out-migration in these rural parts o f the Greater Accra Region. 3.2.4 Health Conditions The health situation o f the people is not very encouraging, judging from the reported cases of endemic diseases such as malaria, diarrhoea, and skin diseases. The study has also 60 University of Ghana http://ugspace.ug.edu.gh recorded a considerable number o f HIV/AIDS cases as well as the Buruli Ulcer, which are fatal diseases. Details o f the health conditions o f the people can be found in Chapter 5 o f this study. 3.2.5 Transportation Network The chief means o f transport in the Ga District is by roads, footpaths and railways, whilst in the Dangme East district, people travel by roads and footpaths. Canoes are used to and fro the islands in the Dangme East district. There are no railways in the Dangme East and Dangme West districts. Major roads connect the urban and sub-urban settlements. Dodowa, Amasaman and Ada are linked to Accra by bitumen/asphalt - surfaced class I (major) roads. The peripheries are devoid o f major roads. Rural settlements are poorly served with major roads. Some o f the secondary and minor roads, which connect them to the urban and senior urban centes, are in such a bad state that drivers are discouraged from plying them. During the rainy season, such roads become almost unusable. Potholes and gullies are common features found on them. The rural areas make use o f footpaths, especially where they have access no roads and transport facility. Footpaths defy relief obstruction. They go through all forms o f relief. 3.2.6 Employment, Income and Educational Status Poverty has been identified as a factor which hinders the utilization o f health services. Poverty is the condition o f being poor, not having sufficient money or means to live comfortably (Chambers, 1997). It means the lack o f the basic necessities o f life (Tulloch,1993). Berman et al (1987), showed that the utilization o f all types o f care, 61 University of Ghana http://ugspace.ug.edu.gh except traditional care, increased with level o f income. Dutton’s (1986) studies portray the fact that overall, low economic status o f patients was the most significant obstacle to utilization o f health services. Financial and economic challenges in the study area hinders the utilization o f health services in the rural districts. Table 3.2 shows occupations o f 5.80 respondents (non-patients and patients) in the study area. Over 50 per cent o f them are unemployed (that is 299 out o f 580). A total o f 80 out o f 580 o f them are farmers, that is 13.8 per cent o f all the heads o f households/spouses and patients). The Dangme West Districts had the highest percentage o f its respondents working as farmers that is 16.9 per cent), compared with 13.7 per cent from the Dangme East District and 11.9 percent from the Ga District). The proportion o f fisherfolks is higher in the Dangme East District (11.9 per cent), Trading activities take place in all the districts. Ga District and Dangme West District had 8.1 per cent of its respondents working as traders, compared with 7.5 percent from the Dangme East District. Table 3.2 - Non-patient and patient respondents and their occupations in the study area. D istrict G a D istrict D angm e W est D istric t D angm e East D istrict O ccupat-i.n F requency Percentage Frequency Percentage Frequency Percentage Farm ing 31 11.9 27 16.9 22 13.7 Fishing 3 1.2 2 1.3 19 11.9 T rad ing 21 8.1 13 8.1 12 7.5 C attle ranch ing 5 1.9 9 5.6 2 1.3 Service Providers 9 3.5 6 3.8 3 1.9 Teachers 13 5.0 7 4.4 5 3.1 A rtisans 14 5.4 5 3.1 4 2.5 Drivers 10 3.9 3 1.8 4 2.5 C onstruction 5 1.9 - - - - Stone Q uarry ing 8 3.1 - - - - Sand W inning 5 >.9 1 6 - - U nem ployed 127 48.8 87 54.4 85 53.1 Pastor 5 1.9 - - 1 .6 Salt m aking - - - - 3 1 9 Civil Servant 4 1.5 - - - 1.9 Total 260 100.0 160 100.0 160 100.0 • Based on Field Data; 2001. 62 University of Ghana http://ugspace.ug.edu.gh A higher percentage o f Dangme West respondents are’cattle ranchers that is 5.6 per cent, compared with 1.9 per cent from the Ga District and 1.3 per cent from the Dangme East Districts, respectively. Other typical rural activities included construction, storm quarrying, sand winning and salt making. Construction work, store quarrying and sand winning activities are more concentrated in the Ga District than in the 2 other rural districts. Infact, no respondent in the Dangme East District was involved in the above mentioned activities. Salt making takes place in the Dangme East District, and not the Ga and Dangme West Districts. More drivers were interviewed in the Ga Districts (10) than in the Dangme West (3) and Dangme East (4) districts, showing the presence o f more vehicles in the former than in the latter. Income plays a veiy important role in the lives o f all human beings. It is the most important socio-economic variable that influences access to health facilities. According to Agyepong (1999), the population in the Dangme West District is generally poor with the main income generating activities being subsistence farming and fishing along the coast and the Volta River. The predominance o f rural population reflects in the occupational distribution in the district. Agriculture dominates the occupation in the district. Table 3.3 shows the distribution o f small-scale industries in the districts. Table 3.3 Distribution o f small-scale industries in the Dangme West district by their type and number Kind o f Industry Total N um ber Percentage A G R O -B A S E D Bakery, gari p rocessing , m illing , 207 57.5 Fish sm oking D istilla tion C LO TH IN G D ressm aking, tex tile , 35 9.7 mat w eav ing ~ W O OD BASHD C arpentry, C harcoal burning , 29 8.1 Boat bu ild ing M ETA L B lacksm ith ing , fitting 14 3.9 OTH ERS 75 20.8 Total 360 100.0 Source: District Planning Coordination Unit, 19% 63 University of Ghana http://ugspace.ug.edu.gh The Baseline survey shows that agriculture (crop farming, livestock and fisheries) is the major activity in the district, employing 58.6% of«the people. About 22.1% o f the people are involved in trading activities. Processing o f agriculture products such as bakery, gari processing, milling, fish smoking and distillation is also very important in the area of industry (57.5%). Fishing employs about 6.4% of the labour force. More people could be employed in this sector if the people appreciated it better. Its labour intensive nature puts people off. Compared to the Dangme East district, where fishing is a more lucrative job and employs 45% o f the people (Dangme East Assembly Report, 1998), some o f the fishermen obtain a good income from the harvest o f oyster, crabs and fish from the Volta River. The women sell these items in the markets in the surrounding villages and settlements. Some are also sent to Accra anti other big towns for sale. Demand for these products are high and so fetch a good price. Ada salt is another important product on the Ghanaian and even international market- in the neighbouring countries like Togo, La Cote D ’Ivoire and Burkina Fasso. The Ga District lias the highest number o f civil servants in the formal sector. The Dangme West District records only 8.4% o f its adult inhabitants as workers in the tertiary services. Majority o f the dwellers in these three rural districts o f the Greater Accra therefore depend on flie land, through farming, sandwinning and other primary forms o f production for their livelihoods. The farms are generally small and crop yields are low. This results in low income and grgai .difficulty in paying school fees, health center bills and medicaments they may be requested to purchase in times o f ill health. Rural dwellers depend mainly on subsistence or small scale agricultural-related income. The vagaries o f the weather, the 64 University of Ghana http://ugspace.ug.edu.gh marginal soils, the high cost o f agricultural inputs, the lack o f post harvest handling facilities and so on makes income levels quite low. The whole nation is in serious economic crisis. Ghana gained independence from Britain in 1957. The per capita income o f Ghana at independence stood at a comparable level to that o f Mexico and. South Korea and was classified as a medium-income country. Growth slowed in the following two decades and by the beginning o f the 1980s, Ghana’s economy was in crisis. The economy has been fragile, and remained dependent on a few primary exports, especially cocoa and timber. Like many developing countries, unstable commodity prices on the international market make these unreliable sources o f earnings (Anyinam,1989; Boateng,1990). Gross mismanagement, corruption and political instability have also contributed greatly to the economy’s decline. Many policies simply remained on paper or failed to be implemented because o f coup de’tat or other changes in governments. One can only lament over the fact that the country has. had at least four development plans drawn up since independence, but none has been implemented fully (Boateng, 1990). The net effect o f this economic crisis was a continuous decline in most sectors o f the economy. Problems ranging from high unemployment,' low industrial performance, declining health services and increasing poverty became the hall mark o f the day. In April 1983, Ghana accepted an International Monetary Fund (IMF) programme for economic recovery and structural adjustment. The programme has so far benefited fhe tradable sectors at the macro-economic level. These gains at the macro level, however, have not trickled down to the micro level. It has been observed that the adjustment process by its very nature inflicts severe hardships on certain vulnerable groups (Key, 1987). 65 University of Ghana http://ugspace.ug.edu.gh Ghana’s experience has not been an exception. The programme has improved the export o f most primary products by making them relatively cheap externally due to the devaluation o f the cedi relative to the dollar (US), but at the same time limiting the productivity o f the peasant farmers because o f low prices paid to them by private middlemen or state companies like the Cocoa Marketing Board (CMB). The industrial sector has also seen some improvement but this has had little impact on the low-income group since they do not have the requisite capital to participate in this sector (Anyinam, 1992). flence, despite the impressive macro-level growth statistics, both the absolute and relative levels o f poverty increased among both the urban and rural populations during the adjustment period (Sowa, 1993). The main cause o f poverty is in most cases structural. The political, economic and social structure internationally and nationally decides who is going to get what, where and how (Smith, 1979). Rehabilitation o f health infrastructure and improved management o f health resources are proceeding under the SAP. But inasmuch as a larger percentage o f the poor have no access to medical facilities whatsoever, subsidies provided for health care benefit mainly the non-poor. Employment, income and educational status have an effect on patronage o f health services. These variables are the principal enabling factors in the utilization o f health services. The unemployed would not eam income to be able to patronize health services, and the level o f income determined the level o f health service one can patronize, whilst education connotes enlightenment, modernization, and hence effective utilization o f health services. It could also connote a job with good pay, therefore the financial accessibility to health services. 66 University of Ghana http://ugspace.ug.edu.gh Students, homemakers, vocational trainees, disabled people and children depend on the employed to cater for them. There is a high dependence ratio o f 123 where a hundred employed labour had to cater for the needs o f 123 economically inactive and unemployed. The situation might be worse today with mass retrenchments due to the introduction o f the Structural Adjustment Programme (SAP) and the failure o f the government to create more jobs. The worker receives a minimum wage o f eleven thousand cedis (11,000). Large sections o f the mass workers can not afford the cost o f health services. The introduction o f the cash and carry (CC) scheme in 1992,'and government’s removal o f subsidy on health, have aggravated the health utilization situation. The illiteracy problem o f the population in the study area is not encouraging. Taking Ghana as a whole, 43.5 percent o f the totar population o f school age have never been to school; and, whilst 35 percent o f llic male population have never been to school, 51.7 percent o f the female have not (Ghana Statistical Service, 1987). The high illiteracy rate has implications for the patronage ol' health services. The educated are more likely to get employment with good pay which will give them greater access to health services. Secondly, the educated are more aware and conscious o f their health conditions, so they will patronize health services more than the uneducated. The socio-economic and environmental diversity in the study area makes the theme an interesting study in the selected areas. Results o f such a study would be o f keen interest to policy markers, since . they will cover the broad spectrum of human resource development, which is a pre­ requisite to socio-economic development. 67 University of Ghana http://ugspace.ug.edu.gh 3.3 Conclusion The Dangme East District and Dangme West Districts are losing their historical importance as commercial centres and thus becoming less attractive and so out migration is quite high, compared to the Ga District which is attracting more people, in fact population increased 1678% from 31,308 in 1960 to 556,581. in 2000, compared to 40,543 to 93,193 that is 125.8% for the Dangme East District and 42,837 to 96,776 (125.9%) for the Dangme West District respectively (Population Census Reports, 1960,2000). Preventable diseases1 such as malaria, diarrhoea, respiratory tract infections are the main health challenges in these rural districts. Poor drinking water and insatiitary environments compound the challenges in the area. Low income from primary occupations such as farming, fishing, huntng, sand-winning, as well as no or low formal educational backgrounds o f most inhabitants further complicates the challenging issues at stake. Access to transportation is best in Amasaman, Dodowa and Ada, the districts capitals. Outside these communities inhabitants are confronted with transportation problems and move around more on foot using footpaths and untarred roads in the various local communities. 68 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR PRIMARY HEALTH CARE SYSTEM IN THE GA; DANGME EAST AND DANGME WEST DISTRICTS 4.1 INTRODUCTION Primary Health Care is a comprehensive system o f care, prevention, treatment, community development, management and organization. It is a shift from curative to preventive health care. It is based on-a three-tier delivery system, the community level (A), the health institutional level (B) and district level (C). Each level B health Centre is to serve people with is 8 km radius (Agyei, 1984). Adibo (1986) notes that Primary health care is a tool for integrated community development. For the success o f the PHC programme, there shall be certain basic facilities such as good housing, potable water, increased food production, as well as adequate food and nutrition. It is, therefore, important for all institutions which provide these services to work together with the MOH in the planning and implementation o f PHC. For example, the provision of potable water in adequate quantities to all communities is one o f the main components o f the PHC. According to Adibo, many o f the diseases found in our communities are related to the provision o f unsafe drinking water. Diseases such as diarrhoea, guinea worm and bilharzia are basically due to lack o f adequate supply o f potable water. Similarly, roads and transport play a critical role in access to and utilization o f health facilities in general. 4.2 OBJECTIVES OF PRIMARY HEALTH CARE The main objective o f PHC is to re-orientate the health service delivery system for the benefit o f the people in rural areas. They form the majority o f the nation’s population, yet are neglected in terms o f health facilities. The high rate o f mortality is attributed 69 University of Ghana http://ugspace.ug.edu.gh to inadequate and poor services for pregnant women and lack o f doctors, trained midwives, public health nurses and other health workers. There is the need to shift from curative to preventive health care, from an urban-oriented, lopsided health care delivery system to a rural, community-based form o f health care (MOH Report, 1977). The Ministry o f Health in 1977 had this policy “Every Ghanaian shall have ready access to basic and primary health care. A primary health system including environmental and personal health components built on the principle o f direct community participation will serve as the base for all health care” (MOH, 1977). .PHC is an integrated approach to health care delivery system aimed at meeting the needs o f the people, especially in the rpral areas. It has its health component, agriculture, water supply, building o f a sanitary environment and the education o f the public. The auxiliary health personnel is recruited from the community. A health development committee is set up within the local council to play an essential role in community development. Specific objectives o f the Primary Health Care in the Ga, Dangme West and Dangme East Districts is to achieve basic primary health care for 80 percent o f the people. Also to effectively attack the disease problems that contribute to 80 percent o f the unnecessary death and disability afflicting the people (MOH, 1977). Preventive health care means as much caring as possible should take place at the community level, not in the hospitals and health centers. The provision o f simple appropriate care under PHC prevents or controls diseases which kill many people. The use o f immunization, for example has reduced deaths caused by measles, poliomyelitis, tuberculosis, tetanus, whooping cough, yellow fever and diphtheria (Mensah, 1997). Simple medications, keeping a clean environment and health education go a long way to reduce the morbidity and mortality rates in the various communities (Twumasi, 1981). Primary Health Care aims specifically at reducing the 70 University of Ghana http://ugspace.ug.edu.gh high rates o f blindness, lameness, deafness and dumbness and other disability through its programmes at the community level. It does not require highly trained personnel and expensive equipment. Preventable conditions such as parasitic diseases, nutritional disorders, common infectious illnesses o f childhood are made possible long before the illness occurs, not after they have taken place. It is cheaper and more effective to prevent diseases rather than to cure them (Mensah, 1997; Acheampong, 1998). The MOH’s strong desire to reach the majority o f people in the Ga, Dangme East and Dangme West districts, as . well as all the other districts in Ghana with health services, preventing diseases responsible for much ill-health (morbidity as well as disability) and mortality has brought about a mobilization o f resources and health personnel working with the various local communities to achieve health for all the people. There is a reduction in the rates o f mortality and morbidity caused by conditions for which prevention, easy treatment and control exist. Through immunization and maternal and child health programmes some communicable diseases, nutritional deficiencies and management o f complications in pregnancy are being solved. Trained TBAs, supervised by the Public health nurses are helping to solve problems o f health at the community level. Simple tasks are being carried out daily by people without sophisticated training using simple equipment. This new approach to health care provision is seen as part o f the national effort in social and economic development with community involvement at each level and support from health centers and hospitals. Together they make up the system for Primary Health Care (MOH, 2000). 71 University of Ghana http://ugspace.ug.edu.gh 4.3 SPATIAL DISTRIBUTION OF HEALTH FACILITIES IN THE STUDY AREA There are no hospitals (Level C) in the three districts. Each o f the district capitals (Amasaman, Ada and Dodowa), however has a health centre (Levels B) manned by a medical assistant, and public nurses/m id wives, environmental health workers and pharmacists/dispensers. Rural medical and nursing aides and midwifery aides are available in some o f the smaller towns and settlements. Community clinics are available for the smaller communities o f about 500-1000 people. Village health workers and traditional birth attendants, especially the trained TBAS are o f great importance in this level (A). Services provided are mainly in the fields o f prevention, hygiene, sanitation, first aid, simple diagnosis and treatment, antenatal and post natal care, child care and control o f communicable diseases. Most communities, unfortunately have lost most, if not all, o f their village health workers to the now popular job o f drug peddling in all parts o f the three rural districts, selling .simple drugs like APC, paracetamol, capsules (“abombelt”) and local herbs in solution, powder or tablet forms. Popular herbal drugs supplied by TV and radio advertised companies such as Top Herbal Centre and Apico Centre include drugs curing malaria such as class malaquin; typhoid drugs; Apico Blood Tonic. Others include Madam Catherine Blood tonic; Fama Nyame Herbal medicine for body pain, lumago; Mercy cream for all skin diseases; “Aberewa Bebo bool” (ball) for stronger bones for old men and women, athletes, especially foot ball players; Top Blood Tonic for malaria; Akobalm for body pains; mala herb for malaria, Alafia bitters, tonic, Dr. Alhaji Harwa Special Power herbal drugs and Adorn Strong by Dr. Bediako. 72 University of Ghana http://ugspace.ug.edu.gh There are aggressive adverts on all television and radio stations, as well as loud speakers at the various lorry parks all over the three rural districts and even in Accra, the capital town o f Ghana. These big herbal centres based in Accra have a fleet o f vans/vehicles which distribme the traditional herbal medicine among others, to all parts o f the rural districts. There is brisk business going on there. They have agents all over the districts and some clients buy direct from the distributing vans. Some o f the drug vendors are based in the lorry parks, others travel on board passenger buses selling their drugs in a very humorous way, backing their advertisements with interactive stories and testimonies. The researcher interviewed 10 o f these drug peddlers and it is interesting to hear that a bottle o f a particular herbal concoction selling between 4,000-12,000 cedis (in different sizes) can cure piles, menstrual disorders, asthma, fever, weakness in the male organ, among others. Atta Mensah, a drug vendor at the Amasaman lorry park told the researcher his drug, A.dom Strong" produced by Dr. Bediako treats menstrual problems, waist pains, eye troubles, piles and onchocerciasis!! Incidentally, the manufacturers, mostly called “doctor”, have not attended formal school o f pharmacy!! The belief that traditional herbal medicine is used only by illiterates in the rural area is a big myth. Well-educated university trained professionals are also using some o f these drugs, especially where orthodox medicine has not been able to cure them o f their peculiar ailments. Figure 4.1 shows the spatial distribution o f the health facilities in the three rural districts o f the Greater Aecra Region. There is a high concentration o f health facilities in the urban 73 University of Ghana http://ugspace.ug.edu.gh FIG.4.1 SPATIAL DISTRIBUTION OF PRIMARY HEALTH CARE FACILITIES IN THE GA, DANGME EAST AND DANGME WEST D I ST R IC T S . Sourca : Survey of Ghana — A c c r a University of Ghana http://ugspace.ug.edu.gh areas. In the Ga District, Maternal and Child Health (MCH) and Family Planning (FP) services are provided by 3 rural health centers , the communicable Disease Centre and the five purely MCH clinics. In addition, growth monitoring and immunization services are offered on outreach basis (Ga District Assembly, 1988). Major health problems are catered for in hospitals and polyclinics in the Accra Metropolitan Assembly (AMA) or in the hospital at Nsawam in the Akwapim South District. The Ga district has ten Ministry o f Health facilities and these form the basis upon which the district has be'en divided for health planning and administration. Table 4.1 shows the distribution o f health institutions in the Ga District. Table 4.1 - The distribution of health institutions in the Ga District Sub districts Type of health institution Location 1. Amasaman Health centre Amasaman 2. Danfa Health Centre Danfa 3. Madina Reproductive and Child Health Madina 4. Obom Health Centre Obom 5. Weija Health Centre Weija 6. Oduman Community Clinic Oduman (Under Amasaman) 7. Abokobi Community Clinic Abokobi (Under Danfa) 8. Pantang Reproductive and Child Health Pantang (Under Danfa) 9. Kokrobite Community Clinic Kokrobite (Under Weija) 10. Amanfro Community Clinic Ngleshie (Under Weija) Source: MOH Amasaman, 1998 Studies show that the district suffers from low patronage or usage o f health facilities (Ga District Assembly, 1998). Even though several factors account for, this phenomenon, it has been explained that distance and the nature o f communication/road network pose 75 University of Ghana http://ugspace.ug.edu.gh o tc 0% o f respondents confessed practising open defecation since they did not have their own places o f convenience. An outbreak o f cholera in these rural areas would be very disastrous indeed. Flies and mosquitoes breed freely, bringing diseases to the people in the various communities. These components o f PHC need urgent attention. No amount o f health education given by the nurses would be o f benefit to the people if they continue to have poor sanitation and hygiene practices. 90 University of Ghana http://ugspace.ug.edu.gh 4.4.5 Prevention and control of locally endemic diseases PHC has the main aim o f preventing diseases rather than curing them. The doctors and nurses in the various districts are working hard at this through health education. There are serious difficulties because o f illiteracy and ignorance on the point o f the people. Most people practise self-medication and the use o f herbs and consult medical personnel only when the disease gets out o f hand. Most parts o f the districts are inaccessible to the district capitals and the health centers because o f bad roads, especially outside the Amasaman, Ada and Dodowa areas. Transport fares are high and people cannot afford to pay for prescribed drugs. Poverty is a big hindrance to utilization o f health facilities. Altogether, 75 per cent o f the 580 respondents at the communities and health facilities said the cost o f drugs and treatment was too high. About 21 percent said it was reasonable; only 4 percent said the expenses were just enough. Table 4.7 gives the opinions o f respondents in the various health institutions and communities in the study area. Sister Mama, is 28 years old, a mother o f two. She is a single mother and earns very little from her table-top petty trading activity. She told me, “The cost o f drugs and treatment is high. I am not able to afford it. I just buy drugs from the chemical shop or from the itinerant drug vendors who come to the area. I have no other alternative”. Table 4.7 : Opinions o f respondents, concerning the cost o f drugs in the various communities and health institutions in the Ga, Dangme East and Dangme West districts Responses Frequency Percentage 1. Cost o f drugs and treatment is too high 435 75 2. Cost o f drugs and treatment is reasonable 121 21 3. Cost o f drugs and treatment is just enough 24 4 Total 580 100 Source: Field Survey, 2001. 91 University of Ghana http://ugspace.ug.edu.gh The most reported disease in all the districts is malaria (over 50 per cent o f O.P.D. cases). This has been the case for decades. There is some education going on in the districts on the use o f drug-impregnated mosquito nets, weeding o f the environments, desilting gutters and drains in order to destroy the breeding places o f the mosquitoes. These should be intensified. The government must subsidize the cost o f these special mosquito nets since the poor rural dwellers said they cannot afford to buy these nets for between 80,000 - 100,000 cedis each. Wofa Yaw, a 33 year old teacher who had brought his 7 year old son to the Dodowa Health Centre for treatment added that, “The cost o f the drug-impregnated mosquito net is too expensive. Government must subsidize it so that we, the poor in society can also buy it for our use. Mosquitoes are “chewing” us too much”. Most o f the health problems in these districts, like other districts in Ghana, are preventable (See Table 4.12). With effective health education and general cleaning o f the environment as well as good sanitation, all these can be solved by a determined group o f people. The role o f the CDRs and other groups during the period o f the Revolution (Late 1979 till about 1985) was very important indeed; especially clearing o f gutters, streets and rubbish dumps. A fully motivated people can do all that work once again as a preventive measure . against the attack o f diseases in these rural parts o f the Greater Accra Region. 4.4.6 M anagem ent o f common illnesses and injuries Immunization o f infants and children has helped to reduce morbidity and mortality cases caused by measles, tuberculosis, poliomyelitis, whooping cough, diphtheria, tetanus and yellow fever. Urban dwellers have more access to health facilities than the rural dwellers. 92 University of Ghana http://ugspace.ug.edu.gh Under PHC, trained TBAs are able to manage common illnesses like headaches, rising temperature, cold, swellings on thighs or arms from injections, dressing o f sores and first aid for injuries. There are few village workers and community dispensaries in the Ga, Dangme East and Dangme West districts. Most o f the trained village workers have vacated their posts and are now peddling herbal and orthodox drugs in remote parts o f the districts (Agycpong, 1992). The trained TBAs are o f great importance to the various communities. They screen pregnant women and refer all complicated cases to the health centers. Accidents occur from time to time on the busy high ways (Kumasi-Nsawam-Amasaman road; Dodowa-Accra; Ada-Aflao). Occupational hazards on farms, rivers, sea, in the store, at home, or the market also bring about accidents. These are preventable and can be avoided by one being extra careful. Care must be taken to eliminate this problem. 4.4.7 Provision of essential drugs Drug are needed both for curative and preventive proposes. Under the PHC system, drugs play a very important role. The concept o f an essential drug list as proposed by WHO, is that the list should comprise drugs corresponding to the needs o f the majority o f the people. Essenliiil drug lists have been embraced by many countries, which have adapted the WHO model list to their needs (Fasehun, 1999). However, in many instances, “lack of availability o f essential drugs foims a problem for the treatment o f diseases that predominantly affect the developing world” (Pecoul et al, 1999). The availability o f drugs is one o f the most visible symbols o f quality care to consumers in the Ga, Dangme West and Dangme East Districts. The most commonly used drugs in 93 University of Ghana http://ugspace.ug.edu.gh the health centres included chloroquine, metronidazole, cotrimoxcide, procain benzyl penicillin injection, acetyl salicylic acid, oral rehydration salts, tetracycline eye ointment, benzyl benzoate, whitefield ointment, intravenous fluid, antacid and iron/folic acid (MOH, GAR 2002). The health workers confirmed the fact that shortages occurred more often than not. Drugs were sometimes apparently prescribed according to which drugs were available at the health centre or community clinic and not necessarily according to patient needs. Excessive prescription o f drugs is sometimes a serious problem, especially the inappropriate use o f antibiotics that can predispose to the development o f drug - resistance by micro-organisms. The abuse o f injections by itinerant injectionists in the districts causes concern ;ibout the transmission o f infectious disease such as HIV, hepatitis and poliomyelitis. Pre-packaging o f drugs in easily understandable doses is a possibility for improving both compliance and dispensing practices (Ansah et al. 2001). Over 75% o f the respondents found drugs to be too expensive, especially where they have to buy them on the open market (Refer to Table 4.7). Table 4:8 shows the respondents’ opinion o f improved services in the health sector. Opinions on drugs alone accounted for a total o f 73.3 per cent o f the respondent’s ideas o f improving the health care delivery system. About 44 percent wanted to have more drugs; 16.5 per cent wanted the Table 4.8: Opinion of respondents on ways to improve health services Attributes Frequency Percentage 1. More drugs 79 4 4 2. More equipments 33 18.3 3. G o v e rn m e n t s n l is 'd y n e e d e d lo r d ru g s 30 16.5 4. Abolish the cash-and- carry system 23 12 .8 5. Build a district hospital 2 0 11.0 6. Reduce formalities and hospital procedures 18 10 .0 7. All drugs must be available in the dispensary 17 9 .4 8. Rude nurses must be sent home 15 8.3 9. Doctors must he available to see to patients 15 8 .3 10. In-service training for all staff 14 7 .7 11 . More beds and wards are needed 14 7 .7 Source: Field Survey. 2 0 0 1 94 University of Ghana http://ugspace.ug.edu.gh government to subsidize the cost o f drugs; 12.8 per cent wanted the cash and carry system abolished and 0.4 per cent wanted all drugs to be available in the dispensary. Low income earners are most times unable to provide balanced meals for themselves and their families. This leads to nutritional diseases, and makes them vulnerable to environmental infections (Mensah, 1997). There is also the psychological pain associated with poverty. This is a potential health hazard. Higher income earners are able to afford the high charges o f private medical practitioners where they receive prompt attention when they, or a member o f the family, reports sick. The low income group tends to direct attention to self-medication and “quack doctors”, drug peddlers and dispensers. They tend to. use more herbal medicine because it is relatively cheaper and sometimes even readily available in the rural areas. The higher income earners usually use herbal medicine as a last, resort, where orthodox medicine somehow does not seem to.heal their afflictions such as stroke, hypertension and other chronic sicknesses. 4.4.8 Community mobilization and awareness The greatest potential asset o f any people lies in the people’s resourcefulness and their will to work for the improvement o f their living conditions. To work well, people need to be healthy. This means that health services have a crucial part to play in the over-all development programme. (More o f this analysis in chapters 7 and 8). The whole community needs to get involved in building toilet facilities, schools, roads and work on .community farms to make some revenue available for community projects. People’s morale is generally low. Few people would volunteer to clean gutters and clear rubbish heaps. During the early years o f the 1979 and 1981 revolutions, the CDRs and 95 University of Ghana http://ugspace.ug.edu.gh PDCs and various organizations would organize clean up campaigns almost every weekend to keep the environment neat. Today, all the gutters in the district capitals and towns are choked with rubbish. No one cares about what happens. Floods occur whenever it rains since the water is not able to flow freely in the communities. Table 4.9 focuses on respondents’ attitude to clean up campaigns. Table 4:9: Respondents’ attitudes to clean up campaigns Responses Frequency Percentage 1. Individual, cleaning is more important than 85 21.3 group cleaning 2. No interest in clean up campaign 166 41.5 3. Clean up campaigns are tedious for us 52 13.0 4. We are too hungry to clean up the community 97 24.2 Total 400 100 Source: Field Survey, 2001 About 41.5 per cent o f the respondents acknowledged that sometime ago, everyone in the society, especially the young men helped clean up the community. About 24.2 per cent said they were too hungry to do such tedious work. Atta Nii, a 48 year old, father o f 6, living at Amas .man said,” I used to drive a commercial bus but the owner collected it. I have no job now and no money. I have not eaten the whole day. I have no energy to clean this dirty environment”. Twenty one percent said they cleaned their individual homes and surroundings and so campaigns to clean the whole community was not really necessary. Thirteen per cent o f the respondents said clean up campaigns were too tedious. 96 University of Ghana http://ugspace.ug.edu.gh Table 4: 10 - Respondents ideas on whose responsibility it is to clean the environment Responses Frequency Percentage 1. The government must hire people to do so 196 49.0 2. I he assemblymen must organize such campaigns 63 15.8 3- Young 80 20.0 men must do that 4. Women must clean their own areas as usual 61 15.2 Total 400 100 Source: Based on Field Data, 2001. Table 4.10 shows the respondents’ ideas on whose responsibility it is to clean the environment. Majority o f llie respondents (49.0 percent) believe the government must hire people to clean the environment. Awoyoe, a 34 year old mother o f 3 in Ada insisted that, “Government collects money from us so he must see to it that people clean the environment for us. It is his job to keep the area clean”. 4.5 LEVEL OF ACHIEVEMENTS OF THE PRIMARY HEALTH CARE SYSTEM PHC has achieved a lot in the Ga, Dangme. West and Dangme East districts. The most significant achievement is in the area o f the reduction in morbidity and mortality rates in the thomy issue o f the six childhood killer diseases. All mothers interviewed pointed this fact out. They said there has been a significant reduction in the number o f children killed by measles, diarrhoea and jaundice. Table 4.11 shows the major causes o f infant mortality before serious immunization was started. Measles was a major killer followed by malaria. Pneumonia and anaemia were 97 University of Ghana http://ugspace.ug.edu.gh leading causes o f death. Malnutrition tends to be a contributory factor underlying all these diseases. This is true o f anaemia which is often nutritionally related or haemolytic as a result o f repeated malarial attacks or sickle cell disease. Comparing these figures with that o f the summary o f MOH report for the Ga, Dangme East and Dangme West districts under the top ten causes o f death in children under 2 years old, and under 5 years old is helpful for the study. Infant and child mortality and morbidity has declined. ■Table 4.11: The major causes o f death o f under 5 years old children before serious Immunization was started. C auses o f death Percentage Low birth w eight (Prem aturity) 21.8 Pneum onia 9.7 M easles 8.5 D iarrhoea 8.4 A naem ia 5.4 M alaria 5.3 M arasm us 3.3 K w ashiorkor 2.6 Tuberculosis 2.3 All other causes 31.7 1'otal 100 Source: Ministry o f Health, Death Certificate from the Centre for Health Statistics (1979-1983), Greater Accra Region. 98 University of Ghana http://ugspace.ug.edu.gh Table 4.12: Major Causes o f Child Mortality (1979-83^ in the Greater Accra Region D iseases A ges 1 -4 years D iseases killing Percentage (Percentage death) children under 5 years M easles 21.3 M easles 16.6 M iliaria 14.8 Pneum onia 13.1 Pneum onia 10.2 Low birth w eight 10.2 A naem ia 9.5 M alaria 9.2 D iarrhoea 6.8 A naem ia 8 8 K w ashiorkor 5.6 Diarrhoea 8.6 M arasm us 3.7 K w ashiorkor 5.4 T uberculosis 2.8 M arasm us 4.8 All o ther causes 25.3 All other causes 23.3 Total 100.0 100.0 Source: MOH, Death Certificate from the Center for Health Statistics (1979-1983), Accra Tabic 4.13 Top Ten Causes o f death in children (1-23 months)(1999). Diseases_______________ Percentages 1. Severe A naem ia 22.6 2. C erebral M alaria 14.7 3. Septicaem ia 11.7 4. C ardio-respiralory failure 6.6 5. M eningitis 5.9 6. R espiratory failure 5.3 7. Pneum onia 5.3 8. Protein C alorie deficiency 4.5 9. HIV 4.7 10. N eonatal jaund ice 4.2 Total 100.0 Source: Ministry o f Health, GAR, 2000. 99 University of Ghana http://ugspace.ug.edu.gh Table 4:14 - Top 10 Causes o f Death in children (2-5 years) in the Greater Accra Region in 1999 ___________■_________________ Diseases Percentage o f death 1. Cerebral Malaria 24.6 2. Severe anaemia 22.9 3. Septicaemia 14.7 4. Renal failure 11.5 5. Enteritis dysentery 6.6 6. Pneumonia 4.9 7. Meningitis 4.9 8. HIV 3.3 9. Brain abscess 3.3 10.Measles 3.3 Total 100 Source: Ministry o f Health, GAR, 2000. Measles, one o f the major killer o f children according to the 1979-1983 data obtained from death certificates, is at a low bottom in 2000. Malaria, anaemia and pneumonia still occupy a high position before and alter the introduction o f EPI. This clearly shows that the component o f immunization to a large extent has been successful. Problems o f malnutrition, especially protein calorie malnutrition, kwashiorkor and marasmus are still significant. The same problems were observed in the New Juaben district study (Merisah, 1997). Immunization has been successful bccause it is one o f the best health interventions that show a success picture within a short period. Solving the other preventable and parasitic diseases is more complex and difficult. Poverty is a big issue. As already stated, 67.1 per cent o f all the respondents said they could not afford enough protein in their diet. Even the fisher folks confessed selling most o f their catches because they needed money for their other needs. More carbohydrates are therefore consumed compared to the other food 100 University of Ghana http://ugspace.ug.edu.gh Kwashiorkor. Micro-nutrient deficiencies are another problem in the study area. Vitamin A and iodine deficiencies are auite widespread. Fertility rates have reduced from 6.71 in 1980 to 6.4 in 1988 and 6.1 in 1992. There are wide regional variations in this, from a level o f 4.64 in Accra to the relatively high levels o f 6.80 and 6.86 in the rural parts o f the Greater Accra region and (GSS, 1998). The risks involved in high fertility affect not only the mother but also the health o f her child. It implies short birth intervals and failure o f repletion o f nutrients, often leading to the maternal depletion syndome which contributes to early aging and death. Children are affected by low birth weight and increased risks o f death. Water and sanitation programmes have also not been very successful in the Ga, Dangme East and Dangme West districts (the rural parts) o f the Greater Accra Region. About 70­ 80% o f the people continue to drink untreated river and stream water. Some o f these sources o f water are polluted with faeces and chemicals. The World Vision International and other NGOs are working hard at providing some areas with boreholes. Sanitation is poor and o f critical concern. Disposal o f excreta or human waste, garbage disposal and liquid household waste and storm water disposal are a big problem. Available data indicate that only 50 per cent o f the urban and 15 percent o f the rural population have adequate sanitation installations (Amonoo-Lartson, 1991). This yields a national figure of 27 per cent, a situation which is veiy alarming. Reports o f Ghana Living Standards survey (GSS, 1999) show a sharp contrast between rural and urban areas in terms o f availability o f human excrota disposal facilities.. For example Table 4:15, reveals that urban areas rely on a range o f toilet facilities including 102 University of Ghana http://ugspace.ug.edu.gh flush toilets while rural areas primarily depend upon pit latrines and other types of toilets (which are not defined in the GLSS). On a country wide basis, the pit latrine is the most common type of facility, whilst the “open defecation” is the most widespread. It actually i torms the bulk of the “other types” of toilets. Table 4:15. Distribution of households by locality and type of toilet used (percentage) ly p e s o f toilet A ccra O ther urban Rural C ountry F lush toilet 16.2 12.6 0.8 5.6 P it latrine 27.3 37.4 64.8 53.4 Pan/bucket 19.6 34.0 5.7 14.7 O ther (1) 36,9 16.0 28.7 26.2 All sam ple size 100 100 100 100 Total 352 827 1956 3135 '1) Otner includes anyone wno said ne oid not nave-a tonet facility or hano one different from those listed above. Source: GLSS, 2002 Access to human excreta disposal facilities is related to household income. There is a strong correlation between households with potable water supply and those with good sanitation facilities especially excreta disposal system, the best o f which depend on the availability o f potable water supply. The poorer social groups face serious sanitation problems with children playing around refuse dumps and pits o f open faeces. Black polythene bags filled with faeces are dumped in gutters, streets, bushes uncompleted houses and rubbish dumps. These can be observed in some of the settlements. Amasaman had some serious examples. The preventive component of PHC includes health education by health providers. There is room for improvement in this direction. Better methods of reaching out to the populace 103 University of Ghana http://ugspace.ug.edu.gh must be adopted. Locally endemic diseases like malaria, buruli ulcer, and skin diseases are still spreading in the various districts. Common ailments like headache, malaria and temperature are being handled quite successfully by the retrained TBAs, community nurses and other health providers. Some essential drugs are also being made available. A good example is the free supply of drugs to all leprous and tuberculosis patients. Community mobilization and awareness also needs to be encouraged. Some people are indifferent to what is happening around them. The zeal to work hard in terms of communal work and participation in community development needs to be rekindled once again like the days of the Revolution when volunteers from the Committee for the Defence of the Revolution (CDRs) and People’s Defence Committee (PDCs) were all ready and willing to work real hard. Immunization is the most successful of child survival interventions. Immunization services are effective in preventing specific diseases which might otherwise precipitate malnutrition, blindness, or death (Pillsbury, 1990). These services are relatively inexpensive and are effective entry points for other PHC activities. The relatively high coverage of BCG in the Dangme West and Dangme East Districts (82%, .90%, 113%) then (75.3%, 77.3%) in the Ga District, especially in big towns like Ada, Dodowa, Amasaman, Prampram and Old Ningo, means that majority of the children are saved from attacks of tuberculosis. However, there are pockets of low coverage in isolated places such as the Osudoku sub-district of the Dangme West District and the islands in the Volta River in the Dangme East districts where low coverage such as 38% are recorded for HCG, and 24% for measles. 104 University of Ghana http://ugspace.ug.edu.gh Coverage for DPT3, OPV3, yellow fever are quite high for the districts (94%, 88%, 83% etc) but the isolated settlements record low coverage once again (20%, 15%). Focusing on just district totals can therefore be very deceptive (87%, 83%, 71%, 61%). Tables 4.16, 4.17 and 4.18 help us observe the details of immunization coverages. On the whole, the records in the health centers and community clinics show reduction in morbidity of infants and children from whooping cough, measles, yellow fever, diphtheria and poliomyelitis. Records from the OPD however show morbidity caused by malaria, diarrhoea,, upper respiratory infection, accidents, skin disease, acute eye infection, rheumatism, ear infection, anaemia and Intestinal worms. (Refer to Table 5.2). Table 4.16: Health Services Coverage by Sub-district (based on actual population) A ntigen Dodovva Pram pi am ■ O ld N ingo O sudoku D istric t Total BCG 82% 90% 113% 38% 87% DPT3 80% 88% 94% 39% 83% O PV 3 89% 88% 91% 39% 81% M easles 74% 83% 83% 24% 71% Y ellow Fever 53% 79% 75% 20% 61% TT2 45% 81% 40% 15% 47% Table 4.17: Immunization Coverage in the Dangme West District. Y ear • BCG M easles OPV3 DPT3 Y ellow fever TT2 1996 89% 84% 80% 80% 34% 9% 1997 79% 72% 72% 64% 51% 31% 1998 82% 73% 74% 75% 49% 47% 1999 75% 62% 73% 73% 54% 39% 2000 87% 71% 81% 83% 61% 47% 105 University of Ghana http://ugspace.ug.edu.gh Table 4.18 shows the trend in immunization coverage in the Ga District, 1998-2000. Children under live years have many challenges as far as health is concerned. Health problems facing this group are communicable, infectious and preventable diseases, and diseases due to poor environmental sanitation, malnutrition, ignorance and poverty (Ababio, 1986 and UNICEF, 2003). Immunization is only one component of PHC. It has helped reduce the morbidity rate of children, especially in the area of measles, tuberculosis and the other 4 killer disease but the other components of PIIC have to be in place for the health of children in the rural areas to get better and stronger. Village health workers are needed to help the trained TBAs, as well as Public/Community Health nurses to see to the health needs of children at the grassroots level. Dr. Kwegyir Aggrey’s wise saying, “Educate a man and you educate an individual; educate a woman and you educate a nation”, is so apt in health education. Serious PHC activities such as health’education of women especially, concerning issues on food supply and nutrition, water and sanitation, prevention and control of locally endemic diseases, management of common illnesses and injuries, provision of essential drugs and community mobilization and awareness will go a long way to help improve the health of children in the study area. EPI is a strong preventive component of PHC and has helped . reduce severe attacks of measles, poliomyelitis, whooping cough and tuberculosis. Mothers see and comment on the difference in growth and development between immunized, exclusively breastfed children and non-immunized, formulae, non-breastfed children. 106 University of Ghana http://ugspace.ug.edu.gh VO OO o OO 4^ 4^- OO U> OO VO oo 00 OO OO U \ o 4^ 4^ OO 4^ o L/i O 09 % % %COVERAGE % TARGET Number o f % New Antigen COVERAGE COVERAGE 1998 523,687 COVERAGE Set for Children COVERAGE Target 1998 (Pop 1999 (Pop (Projected) 1999-Pop 2000 Immunized 2000 (Pop for 2001 239,370 246,552) 539,883 in 2000 556,581) Projected) BCG 75.3 77.3 32.4 35.3 10241 46.0 DPT3 90.1 39.5 41.1 85 11032 48.6 150 OPV3 90.4 91.4 39.6 41.1 85 10717 49.5 MEALSES 81.1 35.5 50 YF 61 0 86.6 18.3 18.3 85 10658 48.0 50 TT2 BY (EXPREGNCIES) 32.1 28.4 85 4837 21.7 50 University of Ghana http://ugspace.ug.edu.gh Pregnancy and child birth are a natural, physiological phenomenon, but they are often fraught with problems leading to serious illness and even death. There are great demands on the health of women. This is especially so in terms of severe manual work on farms and at home. Inadequate nutrition has a predisposing factor which adds to factors such as inadequate health facilities (Amonoo-Lartson, 1991). Factors that limit access to health care facilities include the lack of roads and bad roads which are impassable during raining periods and inability to afford the costs involved in seeking health care. Most of the inhabitants in the Ga, Dangme West and Dangme East Districts of. the Greater Accra region experience these problems, especially those in the. p la te d settlements like Fulanikope, Tuanikope, Asutsuare, Atikpe, Dogoban, Konkon, Adzen Kotoku, Weija, Oduman, Lutenya, Osudoku, Okwebieku and Lumuor. The people also experience cultural attitudes, beliefs and practices which propound the desperate situation. The Maternal and Child Health Clinics of the PHC, together with EPI in these rural parts of the GAR have helped to reducc the number of sick women in the study area. Some preventive care is taking place in the various communities through health education, better food supply and nutritional knowledge. The trained TBAs are especially helpful in some villages where locally recruited health workers are not available. Instead of attributing all diseases and di faculties to witches, the women are fast learning about the importance of preventing rather than curing preventable diseases such as measles, malaria, tuberculosis and tetanus. 108 University of Ghana http://ugspace.ug.edu.gh Table 4.5 and Table 4.6 show the level of knowledge and use of contraceptives in the study area. There is a high knowledge about contraceptives, {95.5%). Out of the 87 women who used a form of contraceptive, 39.5% of them used pills. This shows a reduction in the large number of women in the child bearing age who are in constant danger of becoming ill or losing their lives in the course of performing their physiological function of pregnancy and child bearing. Spacing of pregnancies preserved some of the women’s limited energies that would have been used up in pregnancies. Indepth interviews helped the researcher obtain detailed information on sensitive issues. For example concerning the spacing of children, Daavi Ama of Pediatorkope said, “Those days of having 10-13 children by our grandmothers are gone. Now we have doctors and nurses to help us give medicine to our children to prevent them from dying young from measles and other diseases so having 3-4 children is okay. Using pills help us limit our pregnancies and also live longer”. Table 4.19: Main source of information on HTV/Ains in the three districts. M ain source o f Frequency Percentage Inform ation Friends/R elatives 219 37.8 H ealth W orker 125 21.6 R adio" . 80 13.8 Television 54 9.3 C om m unity m eeting 52 8.9 N ew spaper 50 8.6 Total . • 580 100 Source: Field Survey, 2001. The HIV/AIDS is a dreadful disease. All the respondents had interesting ideas about it. Knowledge of IIIV/AIDs is widespread (97 per cent of the respondents knew about it). 109 University of Ghana http://ugspace.ug.edu.gh The main source of information on HIV/AIDs is that of friends and relatives 37.5 per cent), followed by health worker (21.6 per cent) and radio (13.8 per cent), TV (9.3 per cent), community meetings (8.9 per cent) and finally newspaper (8.6 per cent). Information through one to one contact tends to spread faster than through newspapers, TV and the radio. Health education is important in primary health care. Children are the future leaders of tomorrow. The death of a child brings great pain and sorrow to the family. The EPI operating under PHC has helped in a very significant way in reducing the death of children in the rural parts of GAR. In the past, more than a third of deaths among children under five was due to preventable and infective causes like malaria, measles, diarrhoea! and respiratory problem (MOI1, 1979). One out often were due to nutrition-related causes with a little less than one out o f ten due to low birth weight. Children no longer die from measles, tuberculosis and the other four childhood killer diseases (Refer to Tables 4:12). Great emphasis placed by the District Health Management teams on having 80% of children immunized against the six killer diseases and the control of diarrhoeal diseases through the use of oral rehydration therapy has reduced deaths by measles, tuberculosis, diphtheria, whooping cough, as well as diarrhoea among the children in the districts. Malaria stands out as the main cause of morbidity and death (Refer to Tables 5.1 and 5.2). TBAs (the trained ones, especially) and the nurses are helping in this aspect of preventive health care. According to the health workers, all pregnant women with potential complications or instrumental delivery and history of still births who consult the TBAs and nurses are referred to the Level B Health Centres and the available hospitals outside the study area. 110 University of Ghana http://ugspace.ug.edu.gh On the whole, there has been a reduction in the morbidity situation among others, as a result of their coniact with the public health nurses, through health education concerning nutrition, child-rearing, immunization and fertility problems and family planning. De- worming, use of simple medicines and food supplements, as well as contraceptives have helped reduce morbidity levels of women in the study area. The problem of malnutrition has also reduced as a result of the serious health education sessions the community health nurses kept having with the mothers. They were encouraged to use local food such as anchovies, beans, ground nuts and other nutrition food items to prepare food for the children. The incidence of kwashiorkor and marasmus has also reduced because of the good health education taking place in various communities. Mortality risk factors are attributes or conditions that increase the probability of death. Thdse involved with infant and child mortality include the age of the mother, the socio­ economic status-ol' the household and environmental conditions. The minimum mortality rates pertain to mothers in the 20-24 and 25-29 age groups. Rates at maternal age below 20 are generally higher as are rates at maternal ages 35 and over, implying that children bom to very young mothers (under 20) and very old mothers (over 35) have increased risk of death during infancy and childhood. 62% of the mothers in this study were between the ages of 16-35 years. The weight of the babies at birth is increasing thus improving their chances of survival. Women with no formal educational experience generally have higher risk of infant and child mortality compared to those with some formal education. Between the ages of one and four, the 111 University of Ghana http://ugspace.ug.edu.gh probability of dying is far less for children of mothers who have more than middle school education. Children of mothers who have at least primary school education are 40% less likely to die between ages one and five than those of mothers with no education. 67 per cent of the women interviewed at the health institutions in this study area had no formal education. Only .1 ' per cent had primary/middle up lo the tertiary level (Field survey, 2001). Education brings enlightenment and promotes the good healths f men, women and children. Prevention is always better than cure. The re-activation of EPI in 1985 helped the preventive component of health care to push forward in a positive way. Both health care users and providers realized that it is far cheaper and easier to prevent diseases such as measles, tuberculosis, poliomyelitis, blindness and deafness, than to cure them after they had taken root in the life of people. No case of diphtheria has been Recorded in the three districts for years (MOH, 2001). The health providers, especially the outreach teams and MCH/FP public health nurses, are seriously educating mothers concerning food nutrition. Mothers who cannot afford expensive sources of protein such as meat, fish, eggs and milk are being encouraged to use cheaper but nutritious local substitutes such as anchovies, beans, agusi, groundnuts, and soya bean powder to prepare food for their children (Mensah, 1997). The problem of malnutrition has therefore reduced considerably. Maternal and Child Health (MCH) services in the Ga, Dangme East and Dangme West districts have helped in spreading health education to many mothers. Their services include antenatal and delivery care (maternity services). In the Dangme West district, between 73% 95% of pregnant women attended ante-natal care. However, only 35%-48% of them, between years 1996- 112 University of Ghana http://ugspace.ug.edu.gh 2000 actually delivered in the Ada Health centre and the other health centers and community clinics available. Majority of rural women (65%-52%) continue to deliver at TBAs or at home. Table 4.20 also shows that in 1999 only 7% - 13% of the pregnant women actually accepted and practised family planning. MCH services include the growth monitoring of babies, nutrition, health education, food supplementation immunization and diarrhoeal disease control. Family planning, management of infertility and improvement of reproductive health and school health services are all being seen to by the health care providers. Table 4.20: Trends in some MCH/FP indices over time Jan-Dee. 2000 Y ear A ntenatal C overage % D elivery C overage % Fam ily P lanning A cceptor Rate ' 1996 95% 40% 13% 1997 82% 36% 12% 1998 73.0% 35% 10% 1999 80% 39% 7% 2000 (A ctual) 87% 48% 11% 2000 (Projected) 74% 41% 11% i ' Source: DHMT, MOH, DODOW a, 2001 . There is a good coverage for the district capitals (Amasaman, Ada and Dodowa) compared to the neglected rural communities in the Osudoku, Yakubukope and other isolated settlements. The nurses try to reach these far away places from time to time (quarterly, annually), but for most times they simply focus on the accessible settlements with good roads and amenities (Field survey,2001). 113 University of Ghana http://ugspace.ug.edu.gh Trained TBAs at the community levels and other traditional healers serve as the first contact of spme form of PHC and treatment on the Level A (that is the community level). Some of them have also been very helpful in spreading the good news of immunization, family planning, food and nutrition as well as hygiene practices such as washing of hands before eating, and after visiting the toilet. They assist with first aid in times of emergencies and give treatment of simple ailments such as diarrhoea and convulsions. The good health education going on in the various communities have thus helped lower the incidence of kwashiorkor and marasmus in children. During our focus group discussions at the Amasaman, Dodowa and Ada Health centers, most of the women (10 from each session) said they attended antenatal and received the tetanus toxoid injection, and also immunized their children against the 6 killer diseases. About 7-8 women in each group testified of breast feeding their babies for 1-2 years. Only 4 out of the total of 30 fyomen stopped exclusive breast feeding at 3-4 months because they had to report back to work after exhausting their maternity leaves. According to a respondent, Auntie Jane (Amasaman Health Centre) “Exclusive breast feeding builds up my baby so much. He is very strong and healthy. He never falls sick and he is so alert. I experience a great bond with him. He is so content sucking my breast and we look into each other’s eyes with great love, peace and joy. It is also cheap!!! SMA, Lactogen and other formulae are too expensive and not even ,good for babies. I highly recommend exclusive breastfeeding”. Only 5 women out of 30 gave artificial baby food formulae to their babies. They said the nurses had instructed them not to give such foods to the babies because of unhygienic practices in keeping the bottles, which 114 University of Ghana http://ugspace.ug.edu.gh leads to diarrhoea and other complications. They testified that exclusive breast feeding made the babies more Healthy, strong and happy. Most o f them used soya bean powder, groundnut and fish powder to enrich their children’s food, especially weaning foods. Below are a summary of findings of some of the issues examined in discussions with 10 women in 3 separate MCH/FP clinics at Ada, Amasaman and Dodowa. 1. All the women attended antenatal clinic 2. All o f them received the tetanus toxoid injection 3. All the women immunized their children fully against the 6 killer diseases 4. Almost all the women'breas.t fed their babies for 1-2 years. 5. Only 4 women stopped exclusive breastfeeding after 3-4 months because they had to report back to work when their maternity leave had been exhausted. 6. Only 5 women gave artificial baby food formulae to their babies. 7. The women testified to the better growth and development of the children they exclusively breastfed for 6 months, before introducing them to porridge, “mpotompoto” and other foods. 8. Their knowledge of PHC and EPI was quite high. a) On the method of preventing diarrhoea, 10 of the 30 women said giving liquid food like “koko” maize or “rice water”, (porridge) was a solution to diarrhoea b) Six women said washing of hands before feeding the child prevented diarrhoea c) Six more women added that keeping a clean environment also prevented diarrhoea 115 University of Ghana http://ugspace.ug.edu.gh d) Four women said washing of hands after toilet was also very important e) They all agreed that the safe disposal of human solid waste helped prevent diarrhoea. f) Three women said exclusive breast feeding, without water for the first four months would prevent the baby from experiencing diarrhoea. g) Only one women (at Ada) said she had no idea at all about preventing diarrhoea in children. The other women in the group rebuked her saying, “Maame Nurse has been teaching us on these important issues. You don’t attend these sessions so you can never know anything”. The women are very much aware of the benefits of health education programmes. The MCH/FP staff, especially the community health nurses are doing a very good job. They work hard under very difficult and cramped up conditions. Yet their morale and spirit is quite high. They, are rendering a very valuable service to the rural people. They cheerfully go about their duties and interact nicely with the mothers and their babies. The patients/mothers on their part were also very pleasant and willing to share their ideas and problems with (lie researcher and her assistants. The health education and counselling opportunities the PHC offers through its staff has helped to improve maternal and child care in the rural districts, especially about the dwellers in the district capitals and their surrounding settlements. Special mention is made of exclusive breastfeeding among many mothers in the rural districts. Research on brcasl milk has shown that it is the best food for an infant (Amonoo-Lartson, 1991). Not only are the nutrients in the right proportions but it actually alters in 116 University of Ghana http://ugspace.ug.edu.gh composition to meet the child’s changing nutritional needs. The infant needs nothing but breastmilk alone for the first six months of his life, unless medically indicated otherwise (Brakohiapa, 2001). During antenatal and post natal sessions at the health institutions, the nurses kept impressing it on the mothers the fact that anti-infective properties of breast milk help protect'the child against diseases and also maximizes a child’s physical and intellectual potential (Brakohiapa, 2001). Mothers are made aware of the fact that children breastfed for longer periods show higher scores on mental ability tests than those not breastfed. Some of the mothers told the researcher that babies who do not receive breast milk were more likely to die from diarrhoea because of the use of unsterilized bottles, poor preparation and use of contaminated water. Only 9 per cent of the 180 mothers interviewed exclusively breastfed their babies for 0-3 months. About 27 per cent of the mothers exclusively breastfed their bab ies^or 4 -6 months. About 64 percent of the mothers were not able to exclusively breast feed the babies for six months. Mothers are being encouraged to eat nutritious food, especially palm nut soup with beans, green leaves, fish added to help them obtain good health and also breast feed their babies well. Some women were confused because some years ago the nurses said it was alright to give the baby boiled then cooled drinking water. Now they said the nurses instructed that no water at all was to be given to the babies for six months. Maame Mansa (Amasaman Health Centre) lamented, “My baby gets very thirsty and cries for water. I can’t just sit and do nothing about it. I give him the boiled then cooled water. 117 University of Ghana http://ugspace.ug.edu.gh I don’t want him to die of thirst. Babies are miniature adults. They must also drink water like we do” . The Senior Nursing Officer at the Amasaman Health Centre advised the pregnant women at antenatal session to give colostrum (the yellow liquid which is the first to conic out of the mother’s breast after birth) to the babies because it was very important. She added that more suckling makes more milk, and that early supplements depress the production of milk. Breastfeeding also reduces the risk of premenopausal breast cancer by half and also reduces ovarian cancer by 25 per cent. Exclusive breast feeding also helps with the spacing of babies. The women in the rural districts of the Greater Accra Region, like all others in Ghana, have always had some knowledge of birth spacing and control, both traditional and modem ways. Out of 249 women interviewed 95.8% of said they had some knowledge about birth control spacing methods, but only 33.5% of them actually used a form of contraceptive. Table 4.5 and Table 4.6 show that out of 87 women (33.5%) who used contraceptives, 41.4% used pills; 28.7% used foaming tablets; 19.5% used injection; whilst 20.4% used intrauterine device. None of them had been sterilized. Others had periodic abstinence. Most men said they used condoms from time to lime, and that some of their wives used pills, traditional methods, periodic abstinence, foaming tablets and sterilization to prevent pregnancy from occurring/ With the high cost of living, couples want only 2-4 children. As the nurses continue with their talks and discussions on family planning, more women will also opt for contraceptives to help reduce the number of children bom, and also help space them for 118 University of Ghana http://ugspace.ug.edu.gh better health and care of both mothers and children. “When you educate a man, (a boy) you cducatc an individual, but when you ed u ca te a woman (a girl), you cducatc a nation”, by Dr. Kwegyir Aggrey. This is a great adage, which is really important in the lives of all mothers, women in Ghana. There is an increasing incidence of female-headed households in both urban and rural areas in Ghana (Ardayfio-Schandorf, 1994). For many years, and especially during the prevailing economic crisis, many homes are maintained by women. As more parents get educated, they also gain knowledge that help them look at the world more critically. Education helps women to obtain paid work and to acquire self­ confidence, additional skills and some measure of autonomy. Women with high educational levels are expected to have lower fertility rates (Agyei-Mensah, 1997). If more women in the study area get formal education the emphasis on traditionally getting only male children formally educated at the expense of the girl child, would reduce more and more. The economic independence being enjoyed, especially amongst the traders, teachers, seamstresses, hairdressers, ‘chopbar’ keepers and other self-employed women in the study area has encouraged them to send their girls to school so they get good education. Auntie Leticia (Dodowa), a "trader in plastic ware told the researcher, “My parents were farmers and did not send m y sister and I to school. Our 4 brothers all went to school, even to the secondary level. Fortunately, our aunt took us to her place where she trained us to trade in beads and other wares. ‘ She also sent us to Sunday school so we learnt how to read and write in the Dangme language. My sister and I have sent all our children (5) to school so that both boys and girls can study hard and be doctors, accountants and engineers in future to earn more money and to be able to take care of us in our old age”. 119 University of Ghana http://ugspace.ug.edu.gh The use of the mass media, especially radio, television has gone a long way to help parents grasp the importance of educating the girl child as well as the boy child. Indirectly, the counselling from health workers in the various communities has also helped raise the consciousness and the importance of formal education. Knowledge is power. The more educated a people become, the more receptive they become to innovations and better way of living and taking excellent care of their health and families. 4.6 BOTTfeENKCKS IN THE IM PLEM ENTATION OF PRIMARY HEALTH CARE The whole idea of PHC is to make basic health care available to rural areas and urban areas in their local communities. Disadvantaged members of the general population are still facing health problems, especially diseases which are preventable. The three District Directors of Health Services (heads of the DHMT) were asked specifically to list the persistent problems affecting the full implementation of PHC in their various districts. The following is a summary of what they mentioned. According to Dr. Emestina Mensah- Quainoo (Amasaman); Dr. Irene Agyepong (DHMT, Dodowa) and Dr. Yao Yarbani (DHMT, Ada), persistent problems affecting the full implementation of PHC include the following^ 1. High illiteracy among the people thus preventing them from following the instructions given by the health providers. 2. Inadequate transport and Communication for outreach programmes. 3. Insufficient funding. 4. Poor organization and delivery at peripheral levels. 5. Lack of logistical support. 6. Staff unavailability. 7. Improper referrals. 120 University of Ghana http://ugspace.ug.edu.gh 8. Scarcity o f necessary equipm ents and supplies 9. Paucity of data to serve as the basis for further planning. The big problem is that, even though the official policy of PHC is rural based, health coverage still remains below 50 per cent with only 10 per cent of smaller communities benefiting from the services of trained health workers. The introduction of PHC resulted in extensive training of voluntary community based health workers in the 1980s. Supervision and close monitoring could not be maintained, due to the deteriorating situations of the health delivery structures. The various communities could not motivate these voluntary workers monetary-wise. This resulted in the collapse of the community- based system. A good portion of drug peddlers (itinerant drug vendors) are trained village health workers, some even now operating as injectionists in remote parts of the rural districts of thfi^Greater Accra Region. The Ministry of Health (MOll) emphasized the decentralized delivery of health care services through the strengthening of the district health system and the basic unit of health care delivery The District Health Management Teams in the Ga, Dangme East and Dangme West districts are working on strategies to help cover all the isolated portions of the districts with community health clinics. The PHC system in the rural parts of the Greater Accra Region has had some success, especially in the area of immunizing children against the six child killer diseases. Some components forming the essential elements of PHC have ran into serious trouble, especially the collapse of the community-based system. Curative practices with limited preventative services continue to take place under the health care dclivviv system. Trained Traditional Birth Attendants in level A and outreach . teams from the health centers (Lewi B) are helping with work in these remote areas. 121 University of Ghana http://ugspace.ug.edu.gh Health information and services, especially the Expanded Programme on Immunization reach the rural poor and not just the socially and economically powerful in urban areas only (Amonoo-Lartson, 1984). EPI is a very important component of PHC (Mensah, 1997). PHC in the Ga, Dangme East and Dangme West Districts has upgraded the quality of EPI and MCH. It has helped reduce the occurrence of diarrhoeal diseases using Oral Rehydration Therapy (ORT) and other locally prepared liquids and foods. Maternal and child care, family planning and nutrition have all been pushed to a higher level than ■ before (Agyepong, 1992). Fig. 4.4: The Role of Traditional Healers in the Ga, Dangme West and Dangme East Districts Source: Field Data, 2001 Traditional healers are available in all parts of the districts, especially the remote parts the trained PHC worker is unwilling to go. They comprise herbalists, fetish priests/priestesses, faith healers, circumcisionists, bone setters and TBAs. Fig 4.4 shows the respondents’ 122 University of Ghana http://ugspace.ug.edu.gh ideas on the role of traditional healers in the study area. Out of 580 respondents responses, herbalists were seen to play the greatest role of 52 per cent of all traditional medicine, fol©Wed 24 per cent by TBAs, 14 per cent by fetish priest/priestesses. Faith healers were placed at 10 per cent. In most of the villages and small towns, traditional healers are the only first level of contact for the population. Most mothers are illiterate and tend to patronize traditional healers, if modern services are not available. They use them as first aid before getting to the nearby health center or distant hospital, when the health problem gets almost out o f hand. Delayed patients tend to die enroute to the health facility, or on admission. Use of traditional health service also depends on the type of illness and the perceived effectiveness of the service (Twumasi, 1981; Acheampong) 1992. The main problems with traditional healing and the services of drug peddlers and injection in its operating in these rural districts are the unhygienic methods in the preparation and preservation of herbs as well as the absence of standardized procedures. There is also a problem with dosage and storage. The big herbal centers with factories in Accra are trying to reduce these above mentioned inadequacies in the production of herbal medicine in bottles and tablets (capsules). Traditional medicine must be integrated into the primary health care system; it cannot be ignored. The cost for such an attitude is too high. 4.7 Conclusion Primary Health Care has eight component parts - food supply and nutrition, water and sanitation, mother and child health, immunization prevention and control of local endemic diseases, management of common illnesses and injuries, provision of essential drugs and community mobilization and awareness. All these components need to be strengthened in 123 University of Ghana http://ugspace.ug.edu.gh all the three districts forming the study area. The back-up referral service for training ol PHC workers, especially the TBAs, is of prime importance to the smooth running of this grass-root health system. Chapter five focuses on the health status of the people. 124 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE: HEALTH STATUS OF THE PEOPLE 5.1 INTRODUCTION Being in good health is a fundamental human right and it is one of the basic requirements for a socially and economically productive life. The health status of people in the study area is discussed in this chapter. Preventable diseases such as malaria, diarrhoea and skin rashes are ranked high on the list of health challenges confronting the people in the study area. 5.2 HOUSEHOLD DISEASE PATTERNS The outpatient registration in the Dangme East District(Table 5.1) clearly reveals the health status o f the people in the study area. Table 5.1: Top ten diseases seen at QPD, DangmeEast District DISEASES 1997 1998 1999 • tim # OF % tt OF % # OF % CASES TOTAL CASES TOTAL CASES TOTAL Malaria 7237 58.3 8256 57.0 8815 56.7 Diarrhoea 1259 10.1 1789 12.4 1860 12.0 Upper Respiratory 1420 11.4 1606 11.1 1382 8 9 Infection Accident 1232 9.9 1413 9.8 1632 10.5 Skin Diseases 638 5.1 723 5.0 886 5.7 Acute Eye Inf. 117 0.9 185 1.3 272 1.7 Rheumatism 118 1.0 136 0.9 196 1.3 Hypertension 153 1.2 187 1.3 181 1.2 Ear Infection 104 0.8 115 0.8 143 0.9 Anaemia 129 1.0 71 0.5 176 1.1 Total 12407 100 0 14481 100.0 15543 100.0 Source: DHMT/DCU, MOh. A' >A, 2000 125 University of Ghana http://ugspace.ug.edu.gh Table 5.2: Top ten diseases recorded at OPD in the Ga, Dangme past and __________ Dangme West Districts, 1999_______ _____ ____________ D iseases Ga D istrict D angm e-E ast D angm e-W est D istrict D istrict M alaria 1 1 1 Skin D iseases/U lcers 2 5 4 D iarrhoea 3 2 3 A cute Eye Infection 4 6 10 U pper R espiratory Infection 5 3 2 A ccidents/bum s 6 4 5 R heum atism 7 7 6 G astritis/E ar Infection 8 9 8 A naem ia 9 10 9 H ypertension/In testinal 10 8 7 W orm s Source: MOH, GAR, ACCRA, 2000 Table 5.2 shows the top ten diseases seen at OPD, in the Ga, Dangme West and Dangme East Districts. The population of the districts are heavily affected by malaria, which is still the leading cause of mortality. The chief sources of the diseases are inadequate potable water, environmental pollution, lack of personal hygiene and overcrowding. Poor access roads and careless driving are the main causes of road motor accidents. The pattern o f reported cases in the districts shows some similarities and differences. All the districts recorded malaria as the number one reported disease. Skin diseases (including Buruli Ulcer) feature as the second reported disease in the Ga District, whilst the OPD in Dangme East District has it as fifth on its list, with Dangme West District having it as fourth. Diarrhoea has a high third and second position respectively in all three rural districts. Acute eye infection, upper respiratory diseases and all other preventable/chronic diseases follow in that order. 126 University of Ghana http://ugspace.ug.edu.gh The treatment of Buruli Ulcer, especially in the Ga District, is very expensive so patients cannot afford it. It affects residents of rural areas where poverty is endemic. The MOH is finding it difficult to continue with intervention measures in view of the high expenses involved. The Amasaman Health Centre that deals with the patients complain about the financial burden the treatment has brought to bear upon them. The National Health Insurance policy will help patients lo obtain some help in this area. There is a dearth of data on the rural districts’ mortality situation. The nutritional status needs some improvement. Major micronutrient deficient disorders in Ghana are related to iodine, iron and vitamin A deficiencies. Infant mortality rate, child mortality rates as well as maternal mortality rates for these rural districts are not available. Quoting the Greater Accra Region rates are a big deception, since the situation in the rural sectors are totally different (GSS, 1999). Curative health service and certain aspects of preventive health care have not been able to reach the goal of Health for all by the year 2000. The next target set is for 2020. The health institutions and their distribution pattern, the personnel and equipment situation and the budgetary allocation are inadequate. The administration of the MOH, Greater Accra Region has noted that among the problems facing health delivery services in the Ga, Dangme East and Dangme West districts are poor quality services, lack of basic equipment, and lack of trained personnel to man key positions (MOH, Greater Accra Region, 2000). Poor physical accessibility to the available facilities makes some portions of the population unable to patronize health services. Table 5.3 shows the primary health care facilities in the study area. 127 University of Ghana http://ugspace.ug.edu.gh Table 5.3 The Primary Health Care facilities in the Ga, Dangme East and Dangme '-..'.st Districts. D istricts/Institu tion D istrict Health C om m unity C linics H ospitals Centres Ga - 5 5 D angm e East - 3 4 D angm e W est - 3 7 Total 0 11 16 Source: MOH, GAR, 2000 The new Dangme East District Hospital was commissioned in 2002 and opened to the public in year, 2003. Ga District has a population of 548,001 and is serviced by only 5 health centres and 5 community clinics, whilst Dangme East with a population of 93,193 has only 3 health centres and 4 community clinics and Dangme West District with a population o f 96,776 (Population Census Report, 2000) has 3 health centres and 7 community clinics (MOH, 2000). This is a clear situation of inadequate supplies of primary health care services in the rural portions of the Greater Accra Region. All the big health facilities with specialist services are situated in the Accra and Tema Metropolitan areas. The inadequacy of the. health services is clear when the institutions are related to the population. Every district is to have a hospital with the district hospital - population ratio at 1:200,000 as recommended by the MOH in 1995. Yet as at the beginning of this study, none of these 3 rural districts of Greater Accra Region had a district hospital (MOH, 2000). The situation in the Ga District is even worse since the population is over half a million, to be precise it is about 548,011 (Population Census, 2000). The Dangme East 128 University of Ghana http://ugspace.ug.edu.gh District Hospital was commissioned in 2002, but opened to public use in 2003. The Dangme West and Ga District Hospitals are yet to be completed and commissioned. Access to safe water is still a big problem in these rural areas. The people in the Ga District have no pipe borne water. Inhabitants depend on untreated water from streams and rivers as well as water tanker services. These sources of water get contaminated. World Vision International has however provided some bore holes for a few communities. Portions of Dangme East and Dangme West Districts, especially the capitals, Ada and Dodowa have some pipe borne waver, but the villages and islands use untreated water (Agyepong, 1999). Excreta disposal leaves much to be desired. Open defecation was observed in all 3 rural districts. Such a situation has serious implications for health status. Diseases like diarrhoea, cholera and malaria could have a high prevalent rate. Respondents were asked specifically to mention common diseases afflicting members of their households. Malaria was the number one disease (45.5 percent). This confirms the situation recorded in the various OPDs in the study area (Refer to Table 5.2). It was followed by acute headache (24.8 per cent), then diarrhoea (6.4 per cent), gynaecological problems (5.8 per cent), followed by skin diseases (2.6) per cent), accidents (2.4 per cent), rheumatism (2.2 per cent). Table 5.4 gives the details of the common diseases found in households in the study area. The health status of the people does not look good at all. Most of the diseases mentioned can be prevented. Stressful living, poor eating habits lead to diarrhoea, diabetes, hypertension, headaches and other diseases. Prevention is always better than cure. Some 129 University of Ghana http://ugspace.ug.edu.gh women experience serious gynaecological problems, thus 5.8 percent o f the diseases mentioned in the study area. Specialist care is needed to address this sensitive situation. Table 5.4 — Common household diseases as reported by respondents in the Ga, __________ Dangme East and Dangme West Districts_______________ _________ Disease Frequency Percentage Malaria 264 45.5 Acute Headache 144 24.8 Diarrhoea 37 6.4 Gynaecological problems 33 5.8 Skin diseases 15 2.6 Accidents 14 2.4 13 2.2 Rheumatism Body pains 11 1.9 Cough 10 1.7 Diabetes 8 1.4 Hypertension 8 1.4 Ear infection 7 1.2 Heart bums 6 1.0 Intestinal worms 5 0.9 Gastritis 3 0.5 Anaemia 2 0.3 Total 580 100.0 Source: Based on Field Data, 2001 Manual work plus over work, especially for the women also accounts for the 1.9 percent problem o f body pains. Working hard to earn some money to help take care of the family, plus extra hours seeing to domestic activities at home accounts for this problem. Some of the men also work extra hard to provide for the needs of the family. Skin rashes (2.6 per cent) is a problem because of the poor sanitary conditions in the environment. Ga District, especially has a big problem of buruli ulcer. Treatment of this horrifying disease is very expensive and a big financial problem to the patients. The introduction of the National Health Insurance Scheme will help the poor obtain better health care. Upper respiratory diseases, especially coughs (1.7 percent) are brought about by environmental challenges. Heart bums (1.0 per cent) are also reported. Intestinal worms 130 University of Ghana http://ugspace.ug.edu.gh (0.9 per cent), gastritis (0.5), as well as anaemia (0.3 per cent) are all diseases affecting the intestines, then blood levels due to nutritional challenges. Poverty prevents people from eating properly balanced meals leading to excellent health and sufficient blood flowing through the veins. Low counts of white corpuscles in the blood lowers the immunity levels, opening the door to worse health problems. Fear, doubts, debts all lead to more stressful living and psychologically many people are sick and cannot cope with the numerous crisis and challenges in life as families and then as individuals. Malaria, acute headache and diarrhoea accounted for 76.7 per cent of all the diseases afflicting the households. 5.3 DISEASE PATTERNS OF RESPONDENTS Respondents were also asked to mention common diseases afflicting them as individuals, not their households collectively. Malaria accounted for 40.2 per cent of the diseases afflicting individual respondents (Table 5.5). The mosquito is public enemy number one. Malaria is preventable. Detail discussions on malaria can be read in chapter 7 of this thesis. Great effort is needed in eliminating this health menace once and for all. Acute headaches accounted for 21.9 per cent of the individual health challenges respondents battle with. Some put it as, “Too many issues to settle in our minds concerning providing food for the family, school fees, clothes. Health problems cause us to think too much leading to serious headaches such as migraine”. Diarrhoea accounted for 9.3 percent of the diseases disturbing individual respondents in the study area. Sleeplessness that is insomnia accounted for 6.0 percent of the health challenges afflicting respondents 131 University of Ghana http://ugspace.ug.edu.gh Table 5.5: Common diseases affecting individual respondents in the Ga, Dangme __________ East and Dangme West Districts___________ _________ _ _________ Disease Frequency Percentage Acute Malaria 233 40.2 Headache 127 21.9 Diarrhoea 54 9.3 Insomnia 35 6.0 Piles 26 4.5 Chest pains 22 3.8 Body pains 18 3.1 Accidents 14 2.4 Gynaecological problems 12 2.2 Diabetes ' 10 1.7 Skin Diseases 8 1.4 Hypertension 5 0.8 Gastritis 4 0.7 Anaemia 3 0.5 Bilharzia 3 0.5 Nervousness 2 0.3 Intestinal Worms 2 0.3 Heart bums 1 0.2 Rheumatism 1 0.2 Total 580 100.0 Source: Based on Field Data, 2001. in the study area. Some respondents actually linked it up with acute headaches, putting the two challenges as a big ordeal on them psychologically leading to physical ailments such as hypertension. One woman in the Ga District said, “ I find il difficult sleeping’, especially at night because of financial challenges. I owe people money and I do not know where I can even get money to pay them. I am a widow. My husband is not alive to help me so I have a big burden providing for my 5 children. God help me”. The four top diseases afflicting individual respondents in the study area accounted for 77.4 per cent o f all the diseases mentioned. The four top diseases are malaria, acute headache, diarrhoea and insomnia. These are all diseases that can be prevented. Malaria is still the most important problem facing the people. The environment is basically a malarial ecology; a breeding ground for 132 University of Ghana http://ugspace.ug.edu.gh the anopheline mosquito. In the urban milieu, wastes keep mounting at refuse collection points, and with the onset o f the rains, these become breeding grounds for mosquitoes. The drains are also poor, causing stagnant water at various points within the drains. Bushes in the rural areas are also important breeding grounds for mosquitoes. Control programmes have been negligible. In most rural and urban communities, the communities fail to take the initiative to carry out spraying and environmental maintenance programmes. It is in a few cases that community labour is carried out to desilt drains and drain stagnant water at irregular intervals. In the urban areas, unlike the rural communities, more individuals protect themselves with mosquito nets; whilst others contend with mosquito coils that have the potential of inducing respiratory tract infections that rank high among the endemic health problems. Poverty is the underlying enemy of the health of the people in this area. Mosquito nets, specially treated to prevent mosquitoes from biting the people, are too expensive. Under the primary health care system, pregnant women are allowed to buy highly subsidized mosquito nets at 40,000 cedis. The current market price is between 80,000 - 120,000 cedis, depending on the size and quality of the mosquito net. The pollution of the environment brings in its wake respiratory tract infections as well as diarrhoeal infections. Harbingers sometimes go to the homes of residents living near refuse grounds to contaminate dishes. Children who play in such areas face the risk of contracting diarrhoeal infections. It is therefore not a surprise that the incidence rates of such diseases are quite high, yet there are no adequate health facilities to deal effectively with them. 133 University of Ghana http://ugspace.ug.edu.gh Piles accounted for 4.5 per cent of the diseases affecting individual respondents. The researcher’s discussions with some respondents brought out the fact that eating of fruits will solve a lot of this problem with piles since the eating of fruits help people obtain lree bowls instead of constipation. The high price of fruits, especially when specific fruits are not in season prevents people from patronizing them. Respondents believed it was a good idea to consume great quantities of fruits according to their season of availability due to harvest times. Chest pains (3.8 per cent), body pains (3.1 per cent), accidcnts (2.4 percent), gynaecological problems (2.2 per cent), diabetes (1.7 per cent), skin diseases (1.4 percent), hypertension (0.8 percent) and gastritis, anaemia, bilharzia, nervousness, intestinal worms, heart bums and rheumatism follow in that order. The health status of the people is not encouraging. The preventive aspect of primary health care needs to be enforced in the study area. People are still focusing on curative health care rather than preventive health care. 5.4 DIFFERENCES BY PLAC E OF R ESIDENCE Spatial differences exist in the Ga, Dangme East and Dangme West Districts. Table 5.6 gives details of the differences in common household diseases in the various districts. Malaria ranks high in all the districts (51.9 per cent in the Ga District; 40.6 per cent in the Dangme East District and 40.0 per cent in the Dangme West). Over half of the respondents in the Ga District mentioned malaria as the top disease afflicting them, compared to 40 per cent in the other two districts. Acute headache featured as the second disease mentioned by the respondents. In the Dangme West district, 30 per cent of the respondents said it was a big challenge to their health whilst 27.5 per cent in the Dangme East and 20 per cent in the Ga District, acknowledged the same challenge. 134 University of Ghana http://ugspace.ug.edu.gh Higher percentages of diarrhea and skin diseases were mentioned in the Dangme West and Dangme East Districts, compared to the 1.8 per cent figure given for the other two districts. Dangme West Districts respondents had a total of 2.5 per cent of them mentioning body pains as an affliction, compared to 1.9 per cent by the Ga District respondents and 1.3 per cent by the Dangme East district respondents. Cough levels were higher in the Dangme East district (2.5 per cent ) compared to 1.5 per cent in the Ga District and 1.3 per cent in the Dangme West District Ga District had a higher case of diabetes compared to 1.3 per cent in both Dangme East and Dangme West Districts. Hypertension cases also featured higher on the scale at the Ga District (1.5 per cent) compared with 1.3 per cent in both the Dangme East and Dangme West Districts. The problem of heart bums was higher in both Dangme East and Dangme West districts (1.3) compared to 1.2 per cenl in the G a District. Intestinal worm percentage came to 1.2 in the Ga District, but recorded 0.6 per cent in the Dangme East District and 0.9 per cent in the Dangme East District, and 0.9 per cent in the Dangme West Districts respectively. More of the respondents in the Ga District mentioned gastritis as a health problem in his/her household. On the other hand, 1.3 percent of the respondents in the Dangme East District and 0.6 percent in the Dangme West Districts complained of this disease afflicting their households. In the Ga district, 0.8 percent of the respondents mentioned anaemia as a disease afflicting their households. On the other hand, no respondent in the Dangme East, nor the Dangme West Districts mentioned anaemia as a health challenge. 135 University of Ghana http://ugspace.ug.edu.gh Table 5.6: Differences in Common household diseases in the Ga, Dangme East and Dangme West Districts Disease Ga Dangme East Dangme East Total Freq. % Freq. % Freq. % Freq. % Acute 135 51.9 65 40.6 64 40.0 264 45.5 Malaria Headache 52 20.0 44 27.5 48 30.0 144 24.8 Diarrhoea 16 6.2 10 6.3 11 6.8 37 6.4 Gynaecologi 13 5.0 11 6.8 9 5.6 33 5.8 cal problems Skin 5 1.9 5 3.1 5 3.1 15 2.6 Diseases Accidents 8 3.1 3 1.8 3 1.8 14 2.4 Rheumatism 5 1.9 4 2.5 4 2.5 13 2.2 Body Pains 5 1.5 2 1.3 4 2.5 11 1.9 Cough 4 1.5 4 2.5 2 1.3 10 1.7 Diabetes 4 1.5 2 1.3 2 1.3 8 1.4 Hyperten­ 4 1.5 4 1.3 2 1.3 8 1.4 sion Ear 2 0.8 3 1.8 2 1.3 7 1.2 Infection Heart Bums 2 0.8 2 1.3 2 1.3 6 1.0 Intestinal 3 1.2 1 0.6 1 13.6 5 0.0 Worms Gastritis 2 1.3 1 0.6 3 0.5 Anaemia 2 0.8 - - 2 0.3 Total 260 100.0 160 100.0 160 100.0 580 100.0 Source: Based on field Data, 2001. 5.5 VARIATIONS BY DEMOGRAPHIC AND SOCIO-ECONOMIC VARIABLES The Ga District has a total population of 556,581 (Population Census Report, 2000). The sample of respondents from this district was 260. The Dangme East and Dangme West districts with a population of 93,193 and 96,776 respectively, had samples of 160 each, making a total of 320. 136 University of Ghana http://ugspace.ug.edu.gh The income, education, employment and marital status of the respondents are indicated in Table 5.7 to 5.10 respectively. Table 5.7 -Classification of respondents bv income (per month in ‘000s cedis). Ga Dangme West Dangme Ei 1st Total Income Sample % Sample % Sample Sample So <100 79 30.4 66 41.3 62 38.8 207 35.7 <101-200 67 25.8 52 32.5 36 22.5 155 26.7 201-300 63 24.2 31 19.3 41 25.6 135 23.3 >300 51 19.6 11 6.9 21 13.1 83 14.3 Total 260 100.0 160 100.0 160 100.0 580 100.0 Source: Basea on field Data, 2001. Table 5.8: Classification of respondents by Education Educational Ga Dangme West Dangme East Total Status Sample % Sample % Sample % Sample % No formal 124 47.7 82 51.2 88 55.0 294 50.7 Education Basic 77 29.6 43 26.9 45 28.1 165 28.4 Education Secondary 59 22.7 35 21.9 27 16.9 121 20.9 Education+ Total 260 100.0 160 100.0 160 100.0 580 100.0 Source: Based on field Data, 2001 Table 5.9 - Classification of respondents by employment Employment Ga Dangme West Dangme East Total Status Sample % Sample % Sample % Sample % Employed 133 51.2 73 45.6 75 46.9 281 48.4 Unemployed 127 48.8 87 54.4 85 53.1 299 51.6 Total 260 100.0 160 100.0 160 100.0 580 100.0 Source: Based on field Dala, 2001. 137 University of Ghana http://ugspace.ug.edu.gh Table 5.10- Classification o f respondents by marital statutf M a rita l G a D a n g m e W est D a n g m e E a s t T o ta l S ta tu s S a m p le % S a m p le % S a m p le % S a m p le % M a rr ie d 192 7 3 .8 121 7 5 .6 126 7 8 .7 4 3 9 7 5 .7 U n m a rr ie d 68 2 6 .2 39 2 4 .4 34 2 1 .3 141 2 4 .3 T o ta l 2 6 0 100 .0 160 100 .0 160 1 0 0 .0 5 5 0 100 .0 Source: Basea on field Data, 2001. Incomes are low, an indication of the predominance of poverty in the area. Over 35 percent of the sample earn less than 100,000 cedis a month. Only 14.3 percent of the sample earn above 300,000 cedis a month. There is a disparity by place of residence. There are more low income earners in the Dangme East and Dangme West Districts than ■in the Ga District. A higher proportion of those earning above 300,000 cedis can be found in the Ga District than the other two districts. Poverty is more likely to affect ■ utilization of health services. Over half of the total sample have had no formal education. A higher percentage of the sample from the Ga District had had secondary education and above, compared with the lower levels at the Dangme West and Dangme East Districts. With education making a positive impact on utilization, the rural-urban differential in utilization need not be overemphasized. A little over half of the sample are unemployed. There is a disparity by place of residence. There are more employed respondents in the Ga District than in the Dangme West and Dangme East Districts. With regard to marital status, greater part of the respondents are married. The Dangme East and Dangme West Districts had higher percentages of married respondents than the Ga District sample.* 138 University of Ghana http://ugspace.ug.edu.gh Demographic factors of age and sex have an impact on utilization. The aged have health problems such as body pains, joint pains, hypertension, gastritis, chest pains, heart bums, diabetes, which are experienced more than that of the youth and economic active. Table 5.7 shows the respondents in the districts by age. The Ga District had 51.4 percent of all household heads or their spouses, or representatives between the ages of 59. Table 5.11 - Respondents in the districts by age. Household heads/Spouses Patients Total Districts 18-59 60+ 18-59 60+ No % No. % No. % No. % No. % No. % Ga 143 51.4 57 46.7 49 42.9 11 16.7 260 44.8 Dangme 71 25.6 29 23.8 34 28.9 26 29.9 160 27.6 West Dangme 23.0 36 29.5 31 27.2 29 27.2 160 27.6 East 64 Total 278 100.0 122 100.0 114 100.0 66 100.00 580 100.0 Source: Based on Field Data, 2001. On the other hand, 25.6 per cent and 23.0 per cent of the 18-59 age bracket originated from the Dangme West and Dangme East Districts, respectively. Out of the total household heads or their spouses/representatives (400) in the three districts, a total of 278 of them, making 69.5 per cent were between 18-59 years, whilst 122 of them, making 30.5 per cent of the household sample, were 60+. Among the patients sampled, in the health centres and community clinics, 114 out of 180, that is 63 per cent of them were between 18-59 years, whilst 37 per cent were 60 years and above. More details would be given in chapter 6 as we focus among others, on the utilization of health services by the various age groups. Sex is another important demographic variable in the utilization of health services. Females suffer peculiar ailments such as gynecological problems as well as greater stress leading to psychological challenges compared to the males. Table 5.8 shows the respondents in the districts by sex. 139 University of Ghana http://ugspace.ug.edu.gh Out of 400 heads of households/spouses, 292, forming 73 per cent were males, with 108, making 27 per cent as females. Taken as a whole, together with the example of patients in the health centres and community clinics, out of 580 respondents, 356 of Table 5.12 =- Respondents in the districts by sex H ousehold heads/Spouses Patients Total D istricts M ale Fem ale M ale Fem ale No. % No. % No. % No. % No. % Ga 145 49.7 55 50.9 18 28.1 42 36.2 260 44.8 Dangm e 73 25.0 27 25.0 22 34.3 38 32.8 160 27.6 W est Dangm e 25.3 26 24.1 24 37.6 36 31.0 160 27.6 East 74 Total 292 100.0 108 100.0 64 100.0 116 100.00 580 100.0 . Source: Based on Field Data, 2001. them (61.4 are males, whilst 224, making 38.6 per cent of the respondents are male. Ga District had 49.7 per cent of the 292 male respondents at the household level, whilst Dangme West and Dangme East Districts had 25.0 and 25.3 per cents, respectively. The proportion of female patients at the health centres and community clinics was higher at the Ga Districts, that is 36.2 per cent, compared to 28.1 per for the males. The proportion for male patients was higher in both the Dangme East and Dangme West Districts, 37.6 per cent and 34.3, compared to 32.8 and 31.0 per cents for female patients. More details will be given in Chapter 6 as greater focus is given on the role of sex and also important socio-economic variables such as income and education in the utilization of health services in the Ga, Dangme East and Dangme West District. 5.6 FACTORS AFFECTING THE HEALTH OF THE PEOPLE 5.6.1 Housing Over 70% of the houses in the three rural districts, especially those outside the district capitals, are of poor quality. They are made of mud and slicks, and roofed with thatch. 140 University of Ghana http://ugspace.ug.edu.gh A bout 30% o f the houses are m ade w ith concrete or sandcrete. A m asam an had som e o f these rural build ings as did D odow a and Ada. A m asam an incidentally is closer to A ccra, the capital city o f G hana, than all the other d istrict capitals .T he researcher expected the buildings w ould be m ostly concrete or sandcrete. O ne finds a fam ily o f 5-8 people living in one or two sm all room s. M ost roofs leak so w henever it rains w ater pours or seeps (depending on the seriousness o f the situation), into the room s. M ildew and m ould can be found on the w alls o f the room s. It is not surprising upper respiratory infections are the third and second top d iseases recorded in the D angm e E ast and D angm e W est districts. In the G a D istrict, it is the fifth top recorded O PD case (R efer to Table 5.1). Poor housing and environm ental conditions encourage a very h igh transm ission o f com m unicable d iseases such as tuberculosis. Poor ventilation is a lso a b ig problem because o f the barred w indow s, or a tiny w indow in the room. The sleeping room is crow ded in som e o f the villages and even the poor sections o f the d istrict capitals. 5.6.2 Electricity and Power Supply T uanikope, Pediatorkope, and m any o f the villages in these rural districts do not have electricity. K erosene is used for lighting lanterns. The sm oke em itted from these lanterns are not healthy. They lead to upper respiratory diseases. (See T able 5.2). In the big tow ns like A m asam an, D odow a and Ada, som e people have access to electricity. People w ho use gas and electricity as fuel have less problem s w ith fum es from kerosene and fuel wood. O nly 7.8 percen t o f the respondents use gas for their cooking. M ajority o f the rural dw ellers cannot afford the direct connection to the electricity even w hen it is available in their area. Fum es from the fuelwood used for cooking is a health hazard. There are a lot 141 University of Ghana http://ugspace.ug.edu.gh of diarrhoea problems in the areas. Table 5.9 shows the availability of electricity and pipe borne water supply in the Ga, Dangme East and Dangme West Districts. Table 5.13 Availability of electricity and water supply in the selected settlement in the Ga, Dangme East and Danqm e W est District. Selected settlements District Electricity Supply Pipe borne water supply Amasaman Ga Partial No Ngleshie Aman from Ga Partial Partial Medie Ga No Partial Dodowa Dangme West Partial Partial Agomeda Dangme West No Partial Yakubukope Dangme West No No Ada Dangme East Partial Partial Pediutorkope Dangme East No No Tuanikope Dangme East No No Source: Based on field Data 2001. 5.6.3 Water Supply Most of the inhabitants in these rural areas fetch drinking water directly from rivers, streams, wells and other water ways. Communities such as Agomeda, Dodowa, Ada, Sege have good drinking water. Ironically, Amasaman, the Ga district capital has no pipe bome water. According to the opinion leaders, the pipe lines were destroyed during the construction of the Accra-Nsawam road in the 1970s. Amasaman relies on water delivered by tankers, stored in concrete tanks and dispensed to poor households in buckets and other receptacles. Sometimes these concrete tankers are connected to roof tops to harvest rain water to supplement household supplies (Kofie, 2001). There are serious water shortages in all the districts during the dry season. Water based, water borne and insect vector mechanisms disturb the people leading to water related diseases such as 142 University of Ghana http://ugspace.ug.edu.gh scabies, diarrhoea, typhoid, bilharzia, schistosom iasis, m alaria and even cholera. Records in the out-patient departm ent in all the districts show skin d iseases/u lcer, acute eye infections, intestinal w orm s all occupying high levels (R efer to Table 5.2). C ontam inated w ater sources by infected persons w ashing dow n in rivers and stream s pose health hazards to com m unities that rely on rivers or stream s as sources o f household w ater supply. Poor environm ental sanitation, plus indiscrim inate spitting and em ission o f nasal and throat secretions could spread m easles and other com m unicable d iseases in the various com m unities (B enneh et al, 1993). C hem ical pollu tion o f w ater through the use o f harm ful pestic ides like D D T is also a health hazard. Few people filter or boil their drinking w ater. 5.6.4 Solid W aste disposal Solid w aste d isposal has an effect on the health o f people (B enneh et al, 1993). O pen storage o f solid w aste is practised by m ost households (73 per cent). This brings about a high prevalence o f flies and rodents, leading to poor health, especially diarrhoea. The refuse dum ping sites in all the com m unities, are a n ightm are and eyesore. The stench from the site near M allam is especially sickening. The accum ulation o f the w aste within the neighbourhood are the m ost visible problem in this sector. C ollection points and official dum ps becom e environm ental hazards. The sites are unsightly and unpleasant, health problem s follow , especially am ong children. G utters and w aterw ays are blocked with rubbish from these areas (A w um bila, and M om sen, 1995). T able 5.10 show s the ideas o f household heads concerning environm ental pollution. Im proper disposal o f rubbish and sew erage w as the top problem (24 per cent o f 400) facing the people. It was 143 University of Ghana http://ugspace.ug.edu.gh followed by indiscriminating toilet habits in the communities (22 per cent). Urinating everywhere was also' seen as a bad source of pollution (12 per cent). Table 5.14 - Respondents’ responses to the source of environmental pollution in the studv ares Problem N o o f Percentage o f responden ts respondents 1. Im proper disposal o f rubbish and sew erage 96 74.0 2. Ind iscrim inate to ile t hab its in the area 88 22.0 3. U rina ting everyw here 48 12.0 4. S p itting around 41 10.3 5. W eedy areas harbou r snakes 37 9.2 6. Em pty tin s b reed m osquitoes 29 7.3 7. C hild ren defeca te on rubbish dum ps 26 6.5 8. S tench from d irty gu tte rs and dum ping sites 18 4.5 9. D angerous chem ica ls used in fish ing /farm ing 10 2.5 10. Poly thene bags co n ta in in g faeces 7 1 7 Total 400 100.0 Source: Based on Field Data, 2001 5.6.5 Toilet Facilities This is a big problem in the study area, especially Amasaman. Open defecation coupled with pit latrines are sources of viruses and bacteria, leading to skin infections. All the districts have high records of this infection. It is the second OPD recorded disease in the top ten cases in the Ga District. It places fourth and fifth in the Dangme West and Dangme East districts respectively. There are no available public places of convenience. They are all broken down. The filth in such places leaves much to be desired. Faeces found along the streams and rivers pollute the environment. The air is all fouled and disease — carrying insects, especially flies, can be seen. 32% have their private toilets. About 36% of the respondents confessed using open defecation (beaches, bushes, field). Table 5.11 shows the human excreta disposal situation in the various communities. 144 University of Ghana http://ugspace.ug.edu.gh Table 5.15 - Human excreta disposal in the various communities. Facility No. o f respondents Percentage o f respondents 1. O pen defecation (beaches, bushes, field) 144 36 2. Private toilets (K V IP, Pit and Pan latrines) 128 32 3. Polythene bag 92 23 4. R efuse dum ps 36 ' 9 Total 400 100.0 Source: Field Data, 2001 Improper disposal o f human excreta has very serious unhygienic and healthy connotations since it contaminates water leading to cholera, diarrhoea, worm infestation, typhoid and other health problems. Insufficient water means very little water is available for washing hands after going to the toilet. The public health nurses have a big job educating the people on issues o f personal hygiene and environmental sanitation. Buruli ulcer is a mycobacterial infection associated with humid environments. It destroys tissues causing horrifying lesions to the limbs of affected persons and seem to be on its way to replacing leprosy as a social scourge (WHO, 1997). According to WHO, buruli ulcer is the 3rd most widespread mycobacterial disease in the world after tuberculosis and leprosy. The researcher observed patients suffering from it. Buruli ulcer has assumed alarming proportions in the Ga District. Surveillance mounted in 1993 by the Regional Health Management Team (RHMT) in the Greater Accra Region showed that, out of 100 cases of Buruli Ulcer identified, 98 percent came from Ga District. The disease causes marked debilitation in sufferers and often leads to deformities and disability and may result in complications such as septicaemia (blood poisoning) and death (Mensah-Quainoo, 1997). She indicated in her work on buruli ulcer that the disease 145 University of Ghana http://ugspace.ug.edu.gh causes h igh dropout rates from schools. It leaves in its trail social sligm a such as severe deform ity including total loss o f arm s, crippling, im paired grip and lim ping. R esearching on the d isease is very im portant bccausc o f the econom ic losses due to inactivity and the corresponding stress that this brings to already poor fam ilies and com m unities. A total o f 378 cases o f the d isease from 33 com m unities w ere reported betw een the period o f O ctober 1997 and Septem ber 1998 A m asam an alone had 94 percen t (357) o f the cases o f bunili u lcer, m aking it the m ost endem ic sub-district in the G a D istric t (K ofie, 2000). A peculiar feature o f the d isease is that its causative agent is know n, bu t the exact m ode o f infection and spread has yet to be established (M ensah-Q uainoo, 1997). Endemic com m unities are located in the basins o f the follow ing rivers, D ensu, N saki, N tafrafra, D obro, A daiso and Honi. D esp ite vast im provem ents in health globally over the past several decades, environm ental factors rem ain a m ajor cause o f sickness and death in m any regions o f the world (A w usabo-A sare, et al, 1997). In the poorest areas, one in five children do not live to see their fifth birthday, largely because o f environm entally re lated and preventable diseases. H ealth is affected by the environm ent in w hich one lives. Rural areas, especially , are facing big challenges in this area. The urban poor also suffer from these challenges. 5.7 CONCLUSION The m ost frequently reported diseases for the three districts include m alaria, diarrhoea, acute headaches and upper respiratory tract diseases. Factors im peding the health o f the people included poor housing and environm ental conditions and the use o f K erosene and fuclwood (fum es are a health hazard). C ontam inated w ater sources as well as poor 146 University of Ghana http://ugspace.ug.edu.gh disposal of solid and liquid waste also have a negative effect on the health of the people. Good drinking water and clean environments promote better health lor the people. 147 University of Ghana http://ugspace.ug.edu.gh CHAPTER 6: FACTORS OF PHYSICAL ACCESSIBILITY AND UTILIZATION 6.1 INTRODUCTION This chapter focuses on the impact of physical accessibility variables of distance, travel time and Waiting time and utilization of primary health care services, using descriptive statistics. Distance has a relatively higher impact on the use of primary health care services than all-the other variables. Data have been analysed at the total sample, health status, that is, patient non-patient and district levels. 6.2 GENERAL UTILIZATION OF PRIMARY HEALTH CARE SERVICES Utilization is at three levels, namely regularly, moderately and scarcely. Two attendances at a health centre or community clinic for two illnesses within a year before the survey were defined as “regularly”, whilst one attendance was “defined as “ moderately’'. No attendance was defined “scarcely’'. The general utilization of primary health care services indicjiJjing the frequencies and percentages by total sample, district and health status, that is patient and non-patient is indicated in Tables 6.1 and 6.2. Table 6.1: General utilization of Primary Health Care services for total sample and districts U tilization G a D angm e W est D angm e East Total No. % No. % No. % No. % R egularly 67 25.8 31 19.4 19 11.9 117 20.2 M oderately 132 50.7 64 40.0 53 33.1 249 42.9 Scarcely 61 23.5 65 40.6 88 55.0 214 36.9 Total 260 100.0 160 100.0 160 100.0 580 100.0 ■Source: Based on Field Daia, 2001 148 University of Ghana http://ugspace.ug.edu.gh •Table 6.2 — General utilization of Primary Health Care Services for patients and non­ ___________patients __ Utilization Health Status Patient Non-Patient Total Regularly 53 29.4 83 20.7 117 20.2 Moderately 79 43.9 20.7 51.8 249 42.9 Scarcely 48 26.7 .110 27.5 214 36.9 Total 180 100.0 400 100.0 580 100.0 Source: Based on Field Data, 2001. Utilisation levels in all three districts are very low. An average of 20.2 per cent of all 580 respondents patronize the primary health care services regularly. Only 11.9 per cent 160 respondents in the Dangme East districts patronized the health centres and community clinics regularly. A slightly higher percentage of 19.4 patronized the primary health care services in the Dangme West District. The highest per cent of a mere 25.8 per of regular users of the health services was obtained from the Ga District. Only 42.9 per cent of the total respondents in the study area used the services moderately. In the Dangme West District 40.0 per cent patronized the health centres and community clinics moderately, whilst 50.7 per cent did so at the Ga District and 33.1 per cent at the Dangme East districts respectively. In all, 36.9 per cent of the respondents scarcely patronized the health services. In the Dangme West District, 40.6 per cent o f the respondents scarcely used the facilities, compared to 23.5 per cent in the Ga District and 55.0 per cent in the Dangme East District. This may be explained by poverty situation. Poverty in the rural areas prevents residents from using health services regularly. The poverty factor contributes to a worsening health 149 University of Ghana http://ugspace.ug.edu.gh situation through malnutrition and exposure to environmental hazards such as insect vectors, pollution and overcrowding. Generally, inhabitants of the Ga District utilise health facilities more than the people in the Dangme West and Dangme East Districts. Data analysis show higher incomes, higher levels of formal education, and higher awareness of health conditions and their significance for personal and national development in the Ga District. The inflow of workers from Accra to Amasaman because of its comparatively lower rent costs and its closeness to Accra also helps in increasing its general status. 6.3 DISTANCE TO HEALTH FACILITIES About 73% the respondents, live within 5 - kilometre radius of the primary health care facilities (health centres and community clinics). The proportions of the sample living within certain radi from the nearest health centres and community clinics are indicated in Table 6.3. Table 6.3 - Distances from respondents’ homes to the nearest health centre and __________ community clinic.___________________________________________ Radius from health facility Frequency Percentage (%) Less than 1 km 304 52.4 1 - 4 .9km 118 20.4 5 - 9.9km 92 15.8 10 km and above 66 11.4 Total 580 100.0 Source: Based on Field Data, 2001. More than half of the respondents (52.4 per cent) live less than one kilometre away from the nearest primary health care facility (health centre or community clinic). Another 36.2 150 University of Ghana http://ugspace.ug.edu.gh per cent live within l-9.9.km away from the nearest primary health care facility, whilst 11.4 per cent live beyond 10 kilometres away. There are disparities between the dwellers in the Ga, Dangme East and Dangme West Districts, as indicated in Table 6.4. T able 6.4 — D istances from respondents’ hom es to the nearest health centre and community clinics by place of residence D istrict R a d i u s f r o m PHC f a c i l i t y D a n u m e E a s t Less than 1km 1-4.9 km 5-9.9 km 10km> Total N o % No. % No % No % No % Ga 163 62.7 49 18.8 23 8.8 25 9.7 260 100 D angm e East 85 53.1 33 20.6 22 13.8 20 12.5 160 100 D angm e W est 56 35 36 22.5 47 29.4 21 13.1 160 100 Source: Based on field data, 2001 More than 60% o f the respondents in the Ga District live within I-km radius of health centres/community clinics compared to 53.1% in the Dangme West District and 35% in the Dangme East District. In the Ga District, 18.8% of the respondents lived within 1­ 4.9km. from the nearest health centre or community clinic compared with 20.6% and 22.5% respectively from the Dangme West and Dangme East Districts. The Ga District had 8.8%, whilst Dangme West had 13.8% per cent for the 5-9.9 km radius. Dangme East District recorded a higher percentage of 29.4% for this level, showing the distance islanders in the Volta Lake travel to the Ada Health Centre or Pediatorkope Community Clinic for their primary health care services. Respondents travel over 10km to reach some of these services (9.7% for Ga District, 12.5% for Dangme West and 13.1% for Dangme East). The average distance of a settlement to a health facility is smaller in the Ga District than in the Dangme East and Dangme West Districts. The geographical contiguity of the Ga District makes health institutions in the area and in Accra potentially and locationally more accessible to the population than in the Dangme West and Dangme East Districts wlieic public transport is also not as easily available, especially on the main 151 University of Ghana http://ugspace.ug.edu.gh road to and from Accra and Nsawam, and Accra to Kasoa roads. There are differences by health status, (patient and non-patient), as indicated in Table 6.5. Table 6.5 — Distances from respondents’ homes to the nearest Primary Health Centre/Clinics by health status in the Ga, Dangme West and Dangme East Districts. ■___________" Distance Patients Non-Patients Total km) No % No % No % Less than 5 150 83.3 272 68.0 422 72.8 5-9.9 22 12.2 70 17.5 94 15.8 10 and above 8 4.5 58 14.5 66 11.4 Total 180 100.0 400 100.0 580 100.0 Source: Based on Field Data, 2001 The largest proportion of both patients and non-patients live within 5-kilometre distance of health facilities (83.3% and 68.0%). There is however a smaller proportion of patients(12.2%) than non-patients( 17.5%) living within 5 -10 kilometer radius of health facilities, whilst a greater proportion of non-patients (14.5%) than patients lives 10 kilometres (4.5% ) and further from health facilities. What this implies is that non- patients have better potential accessibility than patients. 6.4 RESPONDENTS’ DISTANCE PREFERENCE TO HEALTH FACILITIES Respondents were asked to indicate their preferred distance by foot and motorized transport to health centres. Respondents’ distance preferences for footing and by • motorized transport are indicated in figures 6.1 and 6.2 respectively. 152 University of Ghana http://ugspace.ug.edu.gh Fig. 6.1: Percentage D is trib u tio n o f R espondents ' d is tan ce preference fo r tra ve lling on fo o t to health fa c ilitie s 35 ' 30 25 o Qi/l.O 20a o 21ns. 0 0.0 9 29.0 5 26.3 Total 67 100.0 31 100.0 19 100.0 Source: Based on field data, 2001 155 University of Ghana http://ugspace.ug.edu.gh Generally travel time has very little impact on utilization. Distances to some health centre and community clinics are short so some patients do not travel for long hours in vehicles. Variations, however, exist in the study area. No regular user of health facilities in the Ga District actually travelled over 2 hours to get to the health facility. Over 70 percent of the regular users of health facilities travelled within 30 minutes to get to the health facility. This contrast sharply with the situation in the Dangme West district where more than half fif the regular users of the health facilities said they had to travel over 30 mins and even over 2 hours to get to the health center. The situation in the Dangme East District is more challenging since 73.7 percent actually travelled more than 30 mins, and even over 2 hours to get to the Ada health center, some coming from the isolated islands in the Volta Lake. These findings in the Dangme East and Dangme West Districts confirm findings on travel time and attendance pattern in the developing countries. Meise et al. (1996) saw time distance as a major impediment to hospital attendance. It is not surprising some islanders prefer to stay at home when they are sick and self medicate and use traditional herbal medicine and only try to travel long distances by canoe when the illness worsens or takes a turn for the worse. Waiting times at the health centers and community clinics have an impact on utilization patterns (Table 6.8). Table 6.8 - Percentage distribution of respondents who use the health facility __________ regularly by waiting time at the health center by total sample and district. Waiting Time District/Utilization (min). Ga Dangme West Dangme East No. % No. % No. % 3 0 - 6 0 8 12.0 10 32.3 5 26.3 61 - 120 11 16.4 9 29.0 4 21.1 < 120 48 71.6 12 38.7 10 52.6 lo la l Sam ple 6"? 100.0 31 100.0 19 100.0 Source: Based on field data, 2001. 156 University of Ghana http://ugspace.ug.edu.gh Over 70% of the respondents spend over 2 hours waiting to be attended to by the medical assistant or nurse in charge of the health facility. In the Ga District, 71.6 per cent of the regular users of the health facilities actually waited for over 2 hours because of the presence ol man patients especially in the Amasaman Health Centre. Dangme East District responde its (52.6 per cent) also go through this same problem because of many patients at the A ia Health Centre, the main primary health care referral point in the district, as at thi year 2002/2003, before the opening of the new district hospital at Faithkope. Waiti ig time has a greater effect on utilization in the Ga district more than in the Dangme East ind Dangme West districts. Once again, people are tempted to stay at home, and contii tie with their self-medication and traditional medicine therapies for “minor” sicknessi ; like headache and piles. 6.7 CONCLL^ION Regularity o f attendance to PIIC centres and community clinics is rather low with an observed spatial disparity in the use of these facilities within the three districts. Distance in the most important physical accessibility problem that affects the use of primary health care services in all the districts, especially the Dangme East in Dangme West ones. Ga District, especially is closer to Accra and tends to benefit from the use of vehicles plying the main Accra-Nsawam route. Travelling and waiting time are also important factors in the study. Chapter seven looks at the role of other factors such as income and service cost, in utilization of PHC services. 157 University of Ghana http://ugspace.ug.edu.gh CHAPTER SEVEN: OTHER FACTORS AFFECTING UTILIZATION 7.1 INTRODUCTION Apart from physical accessibility factors, demographic, socio-economic and morbidity factors also affect utilization patterns. These factors include service cost, transport cost, age, sex, employment, education and income status, type of disease and type of facility. The analyses are at 2 levels, total sample and district. There are differences as well as similarities in the various districts concerning the factors affecting utilization of primary health care in the Ga, Dangme East and Dangme West Districts. 7.2 SERVICE COST The literature survey on utilization patterns in Africa indicates a strong inverse association between service cost and use of health services. Table 7.1: Percentage distribution of respondents who use the health facilities regularly by service cost by total sample and district. Service C ost D istric t/U tiliza tion (((000s) Ga D angm e W est D angm e East No. % No. % No. % <20 14 21.0 23 74.2 9 47.4 20 - -10 39 58.2 3 9.6 4 21.1 41 - 6 0 8 12.0 2 6.5 3 15.8 61 - 8 0 3 4.4 2 6.5 2 10.5 8H 3 4.4 1 3.2 1 5.2 Touil 67 100.0 31 100.0 19 100.0 Source: I3;iscd on •! iclcl Dula, 2001. Service costs for the entire sample and by district are indicated by Table 7.1. A sizeable proportion of respondents utilize health services regularly for service cost less than 20,000 to 60,000, cedis. The Ga District had 91.2 percent, compared to 90.3 per cent for 158 University of Ghana http://ugspace.ug.edu.gh Dangme West, and 84.3 per cent for Dangme East Districts, respectively, of the respondents paying, within the above mentioned range for simple services. Altogether 89.7 per cent of the 117 respondents who said they regularly attended health services paid up to 60,000 cedis for services received. Only 10.3 per cent of them paid 61,000 cedis and above for their treatment. In general, service cost has a negative effect on the utilization of health services. The cash and carry system is a disincentive for the poor people. Family members sometimes come to the aid of patients who are unable to bear the cost o f treatment A relationship has been drawn between the use of alternative curative devices and service cost. An attempt has been made to find out the alternative used due to financial constraints. Fig. 7.1: Responses of Respondents to their use of alternatives to P.H.C. Services. 1 1\m i n , . Hiiii - iiiii Self M edication Traditional Chemical O th e r H ealth Medicine Sellers Services Prescription Source: Based on Field Data, 2001. Responses to the use of alternatives in the event of not going to the health centres and clinics are indicated in figure 7.1. 159 ♦ ♦ ♦ ♦ ♦ ♦ ♦ -1 ♦ • « • • • ♦ i • • • • • • « i University of Ghana http://ugspace.ug.edu.gh Self-medication, use of traditional medicinc, and chemic'il seller* proscription play a major role in the curative service, in the absence of health services. This is as a result of certain fundamental factors. First is the problem of physical accessibility. People living far away from health facilities will choose such methods instead of travelling or walking long distances. Second is the factor of education that reinforces the need for scientific medicine. The well educated is more conscious of the negative implications of unscientific medicine. The well educated are more likely to be employed, so have the financial means to pay for service and transport costs. Third is the factor of cost. Ability to pay is very fundamental to utilizing health services. Finally is the lack of confidence in .scientific medicine that is a function of education and culture. 7.3 • TRANSPORT COST The percentage distribution of respondents who use the health facility regularly by transport cost by regional total sample and district is indicated by Table 7.2. Table 7.2 - Percentage distribution of respondents who use the health facility __________regularly by transport cost by total sample and district. Transport Cost District/Utilization (*) Ga Dangme West Dangme East No. % No. % No. % <1000 32 47.8 4 12.9 3 15.9 1,100-2 ,000 14 20.9 3 9.7 5 26.3 2 ,100 -3000 8 11.9 7 22.6 2 10.5 3 ,100-4 ,000 6 8.9 9 29.0 4 21.0 4,000 7 10.5 8 25.8 5 26.3 lotal Sample 67 100.0 31 100.0 19 100.0 Source: Based on Field Data Work, 2001. Transport cost does not have serious negative effect on the total sample since most users of the primary health care facilities live within walking distances. Ordinary trotro, taxi and boat rides within the districts are reasonable (300 1,500 cedis). 160 University of Ghana http://ugspace.ug.edu.gh The big problem is those travelling by hired canoe from Jhe Volta Lake islands in the Dangme East District, to the mainland, Ada for treatment and health care. Sometimes canoes are hired, costing 3,000 - 6,000 cedis. Where the sick person is unable to walk from the banks of the Volta River/Lake to the Ada Health Centre, a taxi is hired for 3,000 — 4,000 cedis in addition to the earlier canoe cost. The same situation occurs at the } _ Dodowa Health Centre, a referral point, where patients from distant and isolated villages like Yakubokope and Osudoku arrive at the health centre in chartered taxis costing 10,000 - 40,000 cedis. 7.4 AGE AND SEX Survey results for age and utilization for total sample and district are indicated by Table 7.3. Table 7.3 - Percentage distribution of respondents who use the health __________facility regularly by age by total sample and district._____ Age District/Utilization Ga Dangme West Dangme Fast No. % No. % No. % 1 8 -5 9 43 61.1 21 67.7 15 78.9 60+ 24 35.9 10 32.3 4 21.1 Total Sample 67 100.0 31 100.0 19 100.0 Source: Based on Field Data Work, 2001. Tt is evident that the- youth and economically active utilize health services more than the aged. The first explanation that can be offered is the fact that old people, especially the illiterates are set in their old way of doing things so they prefer to use traditional medicine and also selfrmedicate at home rather than health centers/clinics. Secondly, most of the aged are economically challenged and do not have money to pay for the drugs even where consultation fees are not charged for the aged. The cash and cany system prevents the 161 University of Ghana http://ugspace.ug.edu.gh poor from seek in g m ed ica l care. T hey are too poor to pay for health serv ices. Thirdly, m o st o f the aged in these rural districts have no p ension benefits. T his coupled w ith the .lack o f a national health insurance schem e p laces the aged in a serious predicam ent upon retirement.: T he w elfare status o f a retired public w orker is better than the aged w h o have, not been p ublicly em ployed . M ost aged people depend on their children and extended fam ily m em bers for all their finances. In the m idst o f poverty in the liv e s o f these relatives, the aged su ffer financia lly . There are d ifferen ces by place o f residence. A greater percentage o f the youth and eco n o m ica lly a ctive in the D angm e W est and D an gm e E ast D istricts u tilize health serv ices m ore regularly than their counterparts in the G a D istrict. In the G a District^ better em ploym ent opportunities w ith better pay arc availab le to the able bodied and strong residents w h o w ork in A ccra and com m ute daily for their live lih ood . M o st o f them attend hospitals ou tsid e the district. Percentage distribution o f respondents w h o u tilize health serv ices regularly b y total sam ple, and district by sex are indicated by T able 7.4. Table 7 .4 - P ercentage distribution o f respondents w h o u se the health care ____________facilities regularly by se x by total sam ple and d istrict. Sex District/Utilization Ga Dangme West Dangme East No. % No. % No. % Male 38 56.7 22 70.9 13 68.4 Female 29 43.3 9 29.1 6 31.6 Total Sample 67 100.0 31 100.0 19 100.0 Source: B ased on F ield D ata, 2001 . 162 University of Ghana http://ugspace.ug.edu.gh M ales u tilize health serv ices m ore regularly than fem a lts for the total sam ple. This situation is. inconsistent w ith equity in health care, g iven that w om en need m ore health serv ices than m en. B eca u se o f their childbearing role and the com plica tions associated w ith it, w o m en require sp ec ia list serv ices (Buor, 200 3 ). In G hana, m ost hou seholds are headed by m ales w h o take m ost household d ec ision s, e sp ec ia lly in the rural areas. A good num ber o f w o m en do not earn cash incom es even w h en they w ork hard on the fam ily farm s and at hom e. W ith the m en dom inating d ec is io n m aking, the utilization o f w om en m ay be d ec id ed by m en. Greater percentage o f both fem ales and m ales u tilize health serv ices m ore regularly in the Ga District than their counterparts in the D an gm e W est and D an gm e E ast districts. Greater autonom y o f fem ales in the “urban’' centres (A m asam an) in this case than the typical rural (D an gm e W est and D angm e Liasl D istricts, including llioir capitals, D od ow a and A da) cou ld b e said to be a factor. In the urban centres, w om en tend to b e less dependent on their husbands and share fam ily d ec is ion w ith them . In the urban centres, w om en en joy so m e financia l autonom y so could m ore ea sily a c ce ss health fa c ilities 7.5 EM PLOYM ENT E m ploym ent a lso has an im pact on utilization o f health serv ices. T he percentage distribution o f respondents w h o utilize health serv ices regularly by total sam ple and district by type o f em ploym en t is indicated in Table 7 .5 . T he em ployed u tilize health services m ore regularly than the unem ployed. In G hana, there is no support schem e for the unem ployed, and there is also no national health insurance schem e so the em ployed has very little a c ce ss to health services. In all the districts, the em ployed u tilize health facilities m ore regularly than the unem ployed; the proportions in the Ga D istrict are higher 163 University of Ghana http://ugspace.ug.edu.gh T able 7 .5 - P ercentage distribution o f respondents w h o u se the health fac ilities ____________ regularly by em ploym en t by total sam ple and district._______________ Employment District/Utilization Ga Dangme West Dangme East No. % No. % No. % Employed 51 76.1 18 58.1 12 63.2 Unemployed 16 23.9 13 41.9 7 36..8 Total Sample 67 100.0 31 100.0 19 100.0 Source: Based on Field Data, 2001. becau se o f the greater opportunities for em ploym ent in the nearby A ccra m etropolis, com pare to the D an gm e E ast and D angm e W est districts, w h ich are farther aw ay. 7.7 FORMAL EDUCATION There is so m e relationsh ip betw een formal education and utilization . D ifferen ces by educational status for the enlire sam ple, and district are indicated in T able 7 .6 . T able 7 .6 - P ercentage distribution o f respondents w h o u se health facilities ____________regularly b y educational status by total sam p le and district. Educational District/Utilization Status Ga Dangme West Dangme East No. % No. % No. % No formal 15 22.4 6 19.4 5 26,4 education Basic Education 21 31.3 12 38.7 7 36.8 Secondary 31 46.3 13 41.9 7 36.8 Education+ Total Sample 67 100.0 31 100.0 19 100.0 Source: B a sed on F ie ld D ata, 2001 . Form al education has a strong im pact on utilization o f health serv ices for the total sam ple. T he educated u tilize health serv ices m ore regularly than the illiterates and the rate o f utilization increases w ith increase in the level o f education . R espondents w ith secondary education and above in the Ga D istrict u tilize health serv ices m ore than those in the D angm e W est and D an gm e E ast districts. 164 University of Ghana http://ugspace.ug.edu.gh 7.7 INCOME T he in com es o f respondents w ere related to their utilization patterns by total sam ple and district (Table 7.7). Table 7 .7 - P ercentage distribution o f respondents w ho use health facilities regularly by incom e status and district. Income Quintile Dislrict/lJlilizalion (cedis) Ga Dangme West Danj>me East Very Low 8 11.9 3 9.7 2 10.5 (<100,000) Low(101,00- 11 16.4 5 16.1 2 10 5 200,000) M edium(201,000 - 15 22.4 4 12.9 5 26.3 300,000) High(301,000- 20 29.9 12 38.7 7 36.8 400,000) Highest(>400,000) 13 19.4 7 22.6 3 15.9 Total Sample 67 100.0 31 100.0 19 100 0 Source: B ased on F ield Data, 2001. It is evident in the total sam ple and district that, there are w ide disparities betw een the low est and the h igh est qu intiles (< 1 0 0 ,0 0 0 ced is a month to over 4 0 0 ,0 0 0 ced is a month). Incom e has greater im pact on Ga District than on D angm e W est and D angm e East Districts. 7.8 DISEASE TYPE A ttendance patterns are related to the type o f d isease . For the d iseases that affect respondents m ost, eight, w h ich are reported m ore regularly, are indicated in Table 7.8. Malaria is still the m ost im portant problem facing health providers. The environm ent is basically a m alarial eco logy; breeding ground for the anopheline m osquito. In the Ga District, for exam ple, w astes keep m ounting at refuse co llection points, and w ith the onset o f the rains, these b ecom e breeding grounds for m osquitoes. T he drains are a lso poor, causing stagnant w ater at various points w ithin the drains. P otholes are also prevalent in 165 University of Ghana http://ugspace.ug.edu.gh T able 7 .8 - M ost prevalent d iseases w ith high regularity o f reporting at health facilities. D isea se District Ga D angm e W est D angm e Last Proportion (%) Proportion (%) Proportion (%) M alaria 83.3 84.1 85.2 A cute H eadaches 53.3 52.3 51.7 Respiratory Tract 25.4 33.3 24.8 Infection Diarrhoea 45.5 48.8 31.7 G ynaecolog ica l 22 .2 24.5 27.0 problem s Skin D isea ses 2 3 .4 28.6 37.7 B od ily pains 33.3 47 .7 51.3 H ypertension 20 .6 31.1 42 .0 Source: B ased on field Data, 2001 . several areas, e sp ec ia lly at the urban margins o f Accra w here developm ent o f lands are taking p lace. T he rural areas w ith uncleared bushes and stagnant water, are potential grounds for the breed ing o f m osquitoes. The D angm e East district with its fam ous Volta delta/estuary at A da is a b ig exam ple o f these breeding grounds for m osquitoes. Control program m es have been negligib le. C om m unities have failed to take the initiative to carry out spraying and environm ental m aintenance program m es. C om m unity labour is hardly carried out to desilt drains and drain stagnant w ater at irregular intervals. M ost individuals do not protect them selves w ith m osquito nets b ecause the bed ones especia lly cost 8 0 ,0 0 0 - 120 ,000 ced is , depending on the quality and size . The rural dw ellers find this price to be to o expensive; they sim ply cannot afford it. D w ellers contend w ith m osquito c o ils w ith a h igh potential o f inducing respiratory tract in fections and chest pains. Stress and ch a llen ges o f life brings in its w ake severe headaches, a top d isease in the study area. The pollution o f the environm ent brings in its w ake respiratory tract infections as w ell as diarrhoeal in fections. Harbingers som etim es go to the hom es o f residents living 166 University of Ghana http://ugspace.ug.edu.gh near refuse grounds to contam inate dishes. Children w ho play in such areas face the risk o f contracting diarrhoea! infections. It is therefore not a surprise that the incidence rates o f such d isea ses are quite high, yet there are no adequate health facilities to deal e ffec tiv e ly w ith them . In addition to this, those w ho face such a health trauma may face the problem o f co st accessib ility . 7 .9 T Y P E O F H E A L T H F A C IL IT Y U tilization varies by the type o f health facility. P rivate/M ission hospitals enjoy higher patronage than the other health facilities (Table 7 .9 ). The private/m ission hospitals (Battor C atholic H osp ita l and the N saw am C atholic H ospita l) and the K orle Bu T eaching H ospitals have the h igh est patronage. These are referral leve ls o f health service so they autom atically attract large users. They also provide sp ecia list serv ices that are not available in the health centres and clin ics. Table 7 .9 - P ercentage distribution o f respondents w ho utilize health facilities __________ regularly by type o f facility._________________________________________ Facility Frequency % Korle Bu T each ing H ospital 121 20 .9 Public H ospital 61 10.5 Private/M ission H ospital 162 27 .9 Public P o lyclin ic 40 6.9 Public H ealth Centre 81 14.0 Public C linic 40 6.9 Private C linic 29 5.0 Traditional Birth Attendant 46 7.9 Total 580 100.0 Source: B ased on field Data, 2001. 167 University of Ghana http://ugspace.ug.edu.gh K orle Bu T each ing H ospital has radiological, chem otherapy, physiotherapy and other sp ec ia list departm ents. The private/m ission hospitals have the h ighest patronage because o f the better quality o f treatment and warm, pleasant behaviour o f the staff. 1 he responses o f respondents to w hether public hospitals are better than private/m ission hospitals are as indicated in T able 7 .10. Table 7:10: R esp on ses o f respondents to w hether public hospitals are better than District Yes No Uncertain Same Total No. % No. % No. % No. % No. % Ga 104 40.0 128 49.2 26 10.0 2 0.8 260 100.0 Dangme 41 25.6 83 51.9 32 20.0 4 2.5 160 100.0 West Dangme 59 36.9 72 45.0 24 15.0 5 3.1 160 100.0 East Source: B ased on F ield D ata, 2001 . Forty-nine percent o f the respondents in the Ga D istrict said the public hospitals w ere not better than the private m issio n hospitals. F ifty tw o percent o f the respondents in the Dangm e W est district gave that sam e answer, com pared to 45% in the D angm e East District. Forty percent is the Ga D istrict and 25.6% percent and 36.9% from the D angm e W est and D an gm e E ast D istricts respectively answ ered “Y e s ” to the fact that the latter w as better than the former. T he reasons given by the respondents w h o consider private/m ission hosp ita ls to b e better than public hospita ls are indicated in Table 7.11. Responses District Quality Service Less time spent Better diagnosis Availability o f drugs No % No % No % No % Ga 42 32.8 5 3.9 13 10.2 12 9.4 Dangme West 28 33.7 4 4.8 9 10.9 8 9 6 Dangme East 23 32.0 2 2.8 6 8.3 7 9.7 168 University of Ghana http://ugspace.ug.edu.gh Table 7.11 contd. Responses Low Service Less No Bribery Better staff Total District Cost expensive attitude drugs No % No. No % No % No. % Ga 8 6.3 3 2.3 4 3.1 41 32.0 260 100.0 Dangme 6 7.2 3 3.6 4 4.9 21 25.3 160 100.0 West Dangme 5 7.0 2 2.7 3 4.2 24 33.3 160 100.0 East Source: B ased on F ie ld D ata, 2001. Thirty tw o percent o f the Ga D istrict respondents said they preferred the private m ission hospitals becau se o f quality service, com pared w ith 33.7% from the D angm e W est and 32% from the D an gm e East respectively. 7.10: CONCLUSION Incom e is the m o st im portant soc io -econ om ic factor w h ich affects the use o f primary health care serv ices. F inancial challenges im pede the use o f these important facilities in and outside the districts. This has given rise to a situation w hereby 50% o f the population o f the study area u se self-m ed ication , a very dangerous health care strategy and a serious act o f drug abuse. T hirty-one percent use traditional or herbal m edicine. Transport and service co st as w e ll as education, sex and age are a lso important factors in the accessib ility and utilization o f PHC serv ices. Preventable d iseases such as malaria an diarrhoea top the list o f d iseases in the districts. 169 University of Ghana http://ugspace.ug.edu.gh C H A PT E R 8: SYNTH ESIS OF UTILIZATIO N O F PRIM ARY HEALTH CARE 8.1: INTRODUCTION This chapter attem pts a m ultivariate analysis, using the linear regression m odel, to assess the relative im pacts o f the independent (predictor) variables on the dependent (outcom e) variable o f utilization. D istan ce and incom e are key variables in the utilization o f health serv ices in all the districts. Education and em ploym ent are also important variables affecting the u se o f the facilities available in the various settlem ents. 8.2 THE VARIABLES The dependent (ou tcom e) variable is the utilization o f primary health care services. The independent (predictor) variables are grouped into ph ysica l, soc ia l, spatial, econ om ic and dem ographic. T he ph ysica l variables are distance from hom e to health facilities, w aiting tim e at the health centre or com m unity c lin ic , and travel tim e to the facility. D istance has been identified as a very crucial factor in utilization o f health serv ices since it involves transport cost. W aiting tim e can also discourage attendance in a d evelop in g country where health is y e t to be recognized as a crucial factor in developm ent. The socia l variab les inclu de education and em ploym ent. In predom inantly illiterate com m unities, education is a very important variable. There are com plete illiterates, school dropouts, primary sch o o l leavers, secondary school leavers and tertiary graduates. The educational categories w ere, “no formal education”, “basic education, and “secondary education and a b ove” Education, w hich is p o sitiv e ly associated w ith enlightenm ent, em ploym ent and incom e, has a sign ificant im pact on utilization. E m ploym ent w ill ensure incom e, hence ability to pay for health care services. The type o f em ploym ent w ill also 170 University of Ghana http://ugspace.ug.edu.gh ind icate the ease w ith w h ich a patient can secure perm ission to m ove to the hospital, health centre or com m unity clin ic. The spatial factor, p lace o f residence, that is, rural-urban is very important in access and utilization o f health facilities in develop ing countries. The distribution o f health facilities tends to favour the urban areas; therefore an assessm ent o f utilization by residence is very im portant for p o licy in itiatives. Incom e, an econ om ic factor, is about the m ost important so c io -eco n o m ic variable that in fluences access to health studies. In a lm ost every study o f access and u tilization o f health services in develop in g countries, poverty has been found to be the m o st inh ib iting factor. A person m ay be k n ow led geab le enough to see the need to attend hosp ita ls but w ithout the financial capability, utilization cannot be effected . D em ographic factors o f age and sex have an im pact on utilization. The aged have health problem s that m ay differ from the youth and econ om ic active, w hich m ay call for various lev e ls o f health care use. T he econ om ica lly active have access to m ore financial resources, so m ay have greater access to health care use. There could be d ifferences by sex. F em ales tend to have m ultiple health problem s so m ay need greater use o f health services. On the other hand, m ales m ay have greater access to financial resources so may have greater revealed a c ce ss to health facilities. The variables w ith interaction terms that are sign ificant at the selected probabilities are entered into the m ultip le regression m odel for each o f the sam ples, that is total sam ple, patient and non-patient and districts. A m ultip le regression m odel is as indicated: Y = A + (3 i X, + (32 X 2+ ..... (3n Xnt + 171 University of Ghana http://ugspace.ug.edu.gh W here, Y = D ependent or R esponse Variable A = C onstant or Intercept in S im ple Linear - Regression X I , ............, Xn are the Independent variables or factor on w hich Y depends and estim ates based upon this m odel (Y eom ans, 1979). To determ ine what percentage o f the variation in the sam pled dependent variable has been explained by the independent (predictor) variables in the regression (predictor) variables in the R egression equation, w e determ ine the co effic ien t o f determ ination, R 2 (K vanli, et al, 1992). The independent variables used for the study are Sex = Xl A ge = X 2 E m ploym ent = X3 Education = X 4 D istance = X 5 W aiting T im e X* Travel T im e = X 7 Incom e = X 8 Transport C ost = x9 Service C ost = X , 0 172 University of Ghana http://ugspace.ug.edu.gh p. ...... ,p n are the co effic ien ts o f the independent variable. T hey indicate the c lfec ts on Y. = R esidual or error term. The independent variables are the predictor variables, w h ilst the dependent variable is the outcom e or response variable. In effect, the independent variables determ ine the response (ou tcom e) variable. The dependent variable is estim ated from tw o, three or more independent variab les, the m ain justification being the appearance o f higher co effic ien t o f determ ination. The coeffic ien ts o f the independent variables ( P i .......... Pn ) indicate the influence o f the factors on the response variable, that is utilization. T he greater the variation o f the dependent variable w h ich the regression equation can explain , the m ore reliable w ill be the predictions. The dependent (outcom e) variable Y , is utilization o f health services. The m ultiple regression factors that w ere sign ifican t w ere used to build m ultiple regression m odels o f utilization o f health services for districts (total sam ple), patient and non-patient and for each o f the districts. The non-physical accessib ility variables that statistically m ake a great im pact on utilization for the total sam ple are incom e and service cost. The im pact o f education, though, statistica lly sign ificant, is not strong, as depicted by the low coefficien t. The m ultiple regression m odel m akes a m eaningful contribution to research on accessib ility and utilization, deviating from the predom inantly bivariate approach. H ealth conditions are not favourable in the rural parts o f the Greater Accra R egion , especia lly areas like the D angm e E ast and D angm e W est D istricts, w hich are further away from Accra, than the Ga District. 173 University of Ghana http://ugspace.ug.edu.gh 8.3 MULTIPLE REGRESSION MODELLING C ross-tabulations fail to sh ow clear differences am ong sets o l data, especia lly where differen ces are not clearly distinct. The linear regression depicts the impact independent variab les have on dependent (outcom e) variables; so regression factors arte used to explain relative im pacts. The rationale for introducing m ultiple regression m odel as an important contribution to the study o f accessib ility and utilization o f health serv ices is that, m ost studies have used the bivariate analysis. M ost studies have attem pted sing le variable studies instead o f m ultivariate analysis. Buor (2001) su ccessfu lly used the m ultivariate approach in h is studies in the Ashanti Region. H e saw that the m ultivariate approach could help identify the relative strengths o f the variables that affect utilization. The single variable study approach fa ils to analyse the broader d im ensions o f the access - utilization problem . The regression factors for the total sam ple and health status (patient and non-patient) and districts w ith their probability values, are indicated in T ables 8 .1 , 8 .2 and 8.3 respectively. T able 8.1: M ultip le R egression C oeffic ien ts o f independent variables on utilization for total sam p le V ariables B eta C oeffic ien t S ign ifican ce Sex - .045 .087 A ge .038 .298 E m ploym ent status .024 .329 Educational Status .087 .002 D istance -.3 1 7 .000 W aiting T im e -.128 .000 Travel T im e .036 .387 Incom e .454 .000 Transport C ost .089 .009 Service C ost -.145 r.ooo A djusted R2 .552 Source: B a sed on F ield D ata, 2001 . 174 University of Ghana http://ugspace.ug.edu.gh Table 8.2 - M ultip le R egression C oeffic ien ts o f independent variables on utilization for ____________ patients and n on -D atien ts__________________________ ________________ ___ Patient N on-Patient V ariables B eta Co Sig. Beta Co Sig. Sex -.124 .017 -.017 .649 A ge -.142 .006 .068 .026 E m ploym ent .039 .414 .035 .268 Status Educational .016 .668 .103 .004 Status D istance -.223 .000 -.376 .000 W aiting T im e -.167 .004 .089 .000 Travel T im e .085 .105 -.15 .578 Incom e .532 .000 .440 .023 Transport C ost .032 .538 .077 .046 Service C ost .093 .071 -.259 .000 A aiusted .662 .549 Source: B ased on F ield Data, 2001. O f the a ccessib ility variables, incom e exhibits the h ighest co effic ien t w ith utilization. For the entire study area, the beta coeffic ien t is 0 .454 at a sign ifican ce o f 0 .000 , indicating a high p ositive correlation. This is fo llow ed by distance w ith a beta coeffic ien t o f -0 .317 at a sign ifican ce o f 0 .0 0 0 . W aiting tim e has a beta co effic ien t o f - 0 .128 , w h ich is significant at 0 .000 , w h ilst serv ice co st is at -0 .145. For patients, incom e once again is the top co effic ien t at 0 .5 3 2 , com pared w ith 0 .440 for non-patients. D istan ce affects non-patients m ore than the patients and is at 0 .376 and 0.223 respectively . Service co st has a higher beta coeffic ien t for the non-patients, at - 0 .2598 w h ilst the patients have a beta coeffic ien t o f .093. 175 University of Ghana http://ugspace.ug.edu.gh Table 8.3 - M ultip le R egression C oeffic ien t o f independent variables on utilization for districts Ga Dangme West Dangme East Variables Beta Co. Sig. Beta C o Sig. Beta Co. Sex -.031 .236 -.019 .631 .020 .018 Age .024 .348 .023 .433 .022 0.562 Employment Status .038 .154 .017 .582 .014 .573 Educational Status .074 .138 .061 .091 .063 .92 Distance .347 .000 -.463 .000 489 000 Waiting Time .173 .534 -.194 .000 .215 .000 Travel Time .008 .637 .016 771 .019 745 Income .454 .000 .335 000 .348 .000 Transport Cost .083 .539 .157 .041 186 053 Service Cost .161 .241 .239 .000 245 .000 Adjusted R2 .486 624 .638 Source: B ased on F ield D ata, 2001. For the entire sam ple the variables that are sign ificant at the selected probabilities are incom e, distance, serv ice cost, w aiting tim e, transport co st and education in order o f im portance. In com e is predom inant in all the districts. (0 .4 5 4 ,0 .3 3 5 and 0 .348). It how ever has a greater im pact on the D angm e East and the D angm e W est D istricts than the Ga D istrict. Poverty is both a rural and urban phenom enon, but the rural d im ension is greater than the urban situation. Service cost is greater at the D angm e East and D angm e W est D istricts, than the Ga District. (0 .2 4 5 ,0 .2 3 9 and 0 .161). Poverty is en em y num ber one. The em ergence o f incom e and distance as the m ost important factors a ffectin g utilization could be explained by the fact that m ost respondents in the Ga, D an gm e E ast and D angm e W est D istricts, are poor. T hose liv ing in the V olta islands, and Shai H ills for exam ple travel long distances to get to the m ain health centres at A da and D od ow a respectively . The situation is even w orse at the D angm e East District w here very s ick p eo p le are put into hired canoes and brought to the banks o f the Volta R iver, and w here the patient is too w eak or sick to w alk or be carried on the back o f a relative, a taxi is hired to transport them to the health centre. In the Ga District, the 176 University of Ghana http://ugspace.ug.edu.gh distance factor is less critical than the situation in the tw o other rural districts. The problem o f distance, once again is critical in the Ga District w hen ever patients delay in com in g to the A m asam an H ealth Centre, for exam ple, and so are too sick to w alk and end up being transported in a taxi. W aiting tim e is a challenge confronting the people. T he respondents are generally busy with their farm ing, fish ing and other business activities and so do not look forward to spending lon g hours w aiting to be attended to by the m edical assistant at health centres. Incom e, distance, serv ice cost and w aiting tim e challenges delay them at hom e, with them applying traditional therapies and self-m edication till the situation gets very serious and som etim es ev en fatal. T his situation o f long w aiting hours is m ore serious in the Ga District then in the D angm e W est and D angm e East D istricts. Transport co st is not a b ig deal where patients are able to w alk to the health centre or com m unity c lin ic c lo se by. The problem is where taxis or canoes are hired because patients are too sick to w alk or travel by m inibuses (trotros). Transport charges are higher in the D angm e East and D angm e W est D istricts where respondents travel longer distances than they do in the Ga District. The poor nature o f roads also lengthens travel time. Storms and strong currents in the V olta lake som etim es increase travel tim e in the D angm e East D istrict, esp ec ia lly am ong the islanders w ho travel to A da for their health care services. T he im pact o f education on utilization is low . Incom e and distance are clearly the m ain issu es in utilization o f health care in the study area. T he im pact o f education is significant for non-patients, but not patients. 177 University of Ghana http://ugspace.ug.edu.gh T he im pact o f sex and age for health status (patient and non-patient) has been exem plified by the survey. U tilization has a negative im pact on fem ale patients, w h ilst for non­ patients, the im pact is statistically not significant. The im pact o f age on utilization is statistically significant. There is a negative effect; the higher the age, the low er the utilization b y patients, w h ilst for non-patients, age has a p ositive im pact on utilization. The im pact o f em ploym en t on utilization is not statistically sign ifican t for all categories o f data. A separate study in the near future is needed to establish possib le hypotheses that shall form the basis for further research into these interesting health issues. 8.4 CONCLUSION D istance is a very crucial factor in utilization o f health serv ices. It involves transport cost. Incom e is another im portant variable since it affects o n e ’s ability to pay for the service in the first p lace. S oc ia l variables like education and em ploym ent a lso play their important roles in the u tilization o f health care services. T he econ om ica lly active have access to more financial resources, so have greater access to health care. M ales have an advantage over fem ales b eca u se o f better econ om ic pow er for the former. The elderly are disadvantaged com pared to the youth w h o are able to work and m ake m ore m oney. 178 University of Ghana http://ugspace.ug.edu.gh CHAPTER 9: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 9.1 INTRODUCTION The results o f the research have been sum m arized, fo llow ed by recom m endations aim ed at im proving a ccessib ility and utilization o f primary health care serv ices in the Ga, D angm e W est and D an gm e E ast D istricts o f the Greater A ccra R elig ion . The validation o f the hypotheses and the fram ew ork has also been stated. 9.2 SUMMARY OF FINDINGS The study represents an original p iece o f work carried out on accessib ility and utilization o f Primary H ealth Care in the Ga, D angm e East and D angm e W est D istricts o f the Greater Accra R egion. A s such , it provides a basis for com paring the health care facilities and outcom e w ith sim ilar ex istin g studies in other regions like A shanti. The research set out to exam ine the factors o f a ccessib ility and how they relate to the utilization o f primary health care serv ices in the three rural districts in the Greater A ccra R egion. The physical accessib ility factors exam ined w ere distance, travel tim e and w aiting tim e. The dem ographic and so c io -so c io -eco n o m ic factors, nam ely incom e, transport cost, service cost, education, and em ploym en t status w ere a lso regressed on utilization. The research aim ed at either confirm ing or invalidating ex istin g research findings. This project confirm ed and a lso rejected ex istin g research findings in Ghana and also elsew here in A frica. There is a general paucity o f health fac ilities throughout the districts. This has put the health centers under great pressure w ith irregular attendance o f patients. This is m ore ev id en t in the D angm e East D istrict w here people utilize the serv ices far less than those in the G a D istrict w ith distance being one o f the major influential factors. The 179 University of Ghana http://ugspace.ug.edu.gh ev id en ce further supports the key findings that incom e and distance show the highest im pact on utilization o f services. The study also had the additional advantage o f exam in in g the variables in their spatial dim ension (rural-urban) in a sim ultaneous perspective. This is a major contribution to know ledge in the area o f accessib ility and utilization o f primary health care services. B oth qualitative and quantitative data w ere collected . The main research instruments w ere questionnaire, interview , focus group d iscussions and personal observation. Three districts, the Ga D istrict, esp ecia lly , its capital, A m asam an, representing urban and the Dangm e W est and D an gm e East D istricts representing the typical rural settings, w ere used. T his has afforded a basis for spatial analysis. Sam pling too ls included system atic, stratification and sim ple random. The m ain findings o f the research are indicated as: (a) The health cond itions o f the study area are only a reflection o f the conditions in sub- Saharan A frica. O ver 45 per cent o f the health problem s in all the three districts w as due to malaria. T he m o st frequently reported d iseases for the Ga D istrict are malaria, acute headaches, diarrhoea and upper respiratory tract in fections, w h ilst for D angm e W est District, m alaria, diarrhoea, acute headaches and bod ily pains rheum atism , and for the D angm e E ast D istr icts, m alaria, diarrhoea, acute headaches, bod ily pains/rheum atism and hypertension w ere m entioned. H ealth facilities are generally inadequate, w ith a high concentration in the A ccra-T em a m etropolis, outside the study area. The Ga District, especia lly A m asam an, w h ich is 23 kilom etrres aw ay from A ccra has a better access to specialist care in the K orle Bu T eaching H ospital, 37 M ilitary H ospital, and other public/private hospitals and clin ics in Accra, outside the study area. The three districts 180 University of Ghana http://ugspace.ug.edu.gh have a health centre in each district capital w ith a m edical assistant in attendant. Each D istrict H ealth M anagem ent Team has a m edical officer heading it. A s at the tim e ol the fie ld survey, 2 0 0 1 , no district had a district hospital (L evel C o f the primary health care hierarchy). V illa g e H ealth W orkers, trained sp ecifica lly to take care o f com m unity c lin ics at lev e l A o f the Primary H ealth Care services had vacated their post and w ere operating as itinerant in jection ists/q uack doctors (A gyepon g, 1999). O ut o f 20 V H W s for exam ple trained in the D an gm e W est D istrict, only 2 o f them are still serving in their local com m unities. A health Centre built by W orld V ision in Pediatorkope to cater for the islanders in the V olta Lake area is operating as a com m unity c lin ic because no m edical assistant/officer is ready to stay on the island to man the health centre. b) The w ork load factor is quite high for health providers in all the three districts. The m edical assistants, nurses and attendants, esp ec ia lly in the district health centres at A m asam an, D o d o w a and A da are overworked. c) In all three d istricts, the capitals have a health centre each w hich is under great pressure and congestion . In the G a District, A m asam an is the centre for health activities in the district. A da and D o d o w a play such a role in their respective districts. d) The regularity o f attendance to the primary health centres and com m unity c lin ics is rather low . A b out 2 0 .2 per cent o f respondents attend health centres for attention regularly. There is a spatial disparity, w ith 25 .8 per cent o f respondents in the Ga District attend regularly, as against 19.4 per cent o f those in the D angm e W est District and 11.9 .percent o f those in the D an gm e East D istrict, respectively . M ore m ales than fem ales attend regularly. A greater proportion o f patients than non-patients utilize health services more regularly. e) Incom e and d istance w ere the variables that show ed the h ighest in fluence on utilization o f health serv ices. T he e ffec ts o f travel tim e, age and em ploym ent w ere statistically not 181 University of Ghana http://ugspace.ug.edu.gh sign ificant. Transport co st exhibited a positive relationship w ith utilization o f health serv ices for the total sam ple. f) T hough w aiting tim e and service cost have negative e ffec ts on utilization, their impact w as low er than incom e and distance. g) The im pact o f d istance is stronger for the D angm e East D istrict than for the D angm e W est and Ga D istricts. Serv ice cost had an im pact on all three districts, esp ecia lly the D angm e E ast D istrict. h) Incom e and distance have relatively high im pact on utilization than all other variables for all respondents, patients and non-patients. The im pact o f incom e and distance was greater on patients than non-patients in the utilization o f primary health services, esp ec ia lly the health centres at the district capitals (A m asam an, A da and D odow a). Service co st had a greater im pact on non-patients than patients in the use o f health facilities. E ducation m ade a w eak positive im pact on non-patients, but m ade no im pact on patients in the u se o f health services. W hereas age has a negative im pact on patients in utilization, it had a p ositive e ffec t on non-patients. For all the groups studied for this survey, it is on patients that sex statistically has a negative e ffec t in utilization. i) R espondents w h o fail to attend the health centres and com m unity c lin ics w hen sick use X- herbal m ed icine m ost o f the tim e. F ifty percent o f the population in the study area resort to self-m ed ication , a very dangerous health care strategy and a serious act o f drug abuse. Thirty one percent u se traditional or herbal m edicine. j) Private/M ission hosp ita ls such as the Battor C atholic H ospital receive the greatest patronage by respondents in the D angm e W est and D an gm e East D istricts, especia lly because o f quality o f serv ice and pleasant attitude o f the m edical and param edical staff. 182 University of Ghana http://ugspace.ug.edu.gh T his study has sh ow n that incom e and distance are the m ost important physical a ccessib ility problem affecting utilization. Incom e and cost o f service rank high am ong the obstacles o f utilization o f health services. M ost respondents use the nearest com m unity c lin ic or health centres in their p lace o f residence, e sp ecia lly after attem pts at usin g traditional herbal m ed icine or self-m edication w ith orthodox m edicine had failed in ■ curing them o f their ailm ent. The Pediatorkope case (a health center actually operating as a com m unity c lin ic) is exceptional because o f the absence o f a m edical assistant there. Hypotheses Validation Incom e sh o w s a p o sitiv e relationship w ith utilization, w h ilst service cost exhibits a negative relationsh ip to validate the hypotheses. Incom e m akes a stronger im pact than distance, serv ice co st and w aiting tim e. Education exhibits a w eak association w ith utilization. Justification o f the Framework The results ju s tify the conceptual fram ework used for the study (F ig 1.3). Patients’ predisposing and enabling characteristics affect their use o f health services. The poor use the serv ices le s s than the rich, w h ile the educated utilize serv ices more than the illiterate. The sign ifican t d ifference am ong the leve ls o f education w as how ever, not as significant as for incom e, distance, serv ice co st and w aiting tim e. Financial constraints have been identified as a m ajor so c io -eco n o m ic obstacle to utilization. Initiation o f health care is influenced b y the status o f education and incom e. Structural barriers like governm ent policy on co st o f serv ice a lso affect the patient - controlled factor o f initiation and use o f health care. 183 University of Ghana http://ugspace.ug.edu.gh The so c io -eco n o m ic factor o f incom e has em erged as the m ost important factor aflectin g utilization. Incom e has been observed as the m ost important factor, a longside distance and co st o f service. This study confirm s studies by several researchers in the develop ing w orld. R espondents responded that the status o f a d isease w ould determ ine the sw iftness w ith w h ich they m ove to the health facility for treatment, and that serious cases w ill be taken to hospitals outside the districts, irrespective o f the a ccessib ility hindrance. The volum e and distribution o f resources influence the level o f accessib ility . The level o f e ffec tiv e accessib ility in the Ga District where its c lo sen ess to Accra, the national capital, gives it an advantage o f a greater volum e o f health facilities than at the D angm e W est and D angm e E ast D istricts w here Battor in the Volta R egion, and Tem a are c loser but have less health fa c ilitie s , com pared w ith Accra. This is reflected in the higher utilization o f health fac ilities by the dw ellers in the Ga District, e sp ecia lly Am asam an, com pared with those liv in g in the D an gm e W est and D angm e East D istricts, respectively. 9.3 CONCLUSIONS Health is a prerequisite for developm ent. It is an end o f developm ent and a veh icle for achieving developm ent. Rural residents utilize health serv ices m ore regularly than their urban counterparts, w h ilst patients utilize health serv ices m ore than non-patients. The poor a ccessib ility o f the p eo p le to health serv ices is a factor that has affected their health. The factors that have a ffected the services are poverty, long distances, high service cost, long w aiting tim e at the health facilities, transport co st and lo w education, fo llo w in g in an order o f im portance. W here as poverty (incom e), d istance and w aiting tim e are predom inant factors in the rural-urban Ga D istrict, long d istan ces, poverty (incom e), service co st and lon g w aiting tim e are the predom inant factors in the pure rural D angm e W est and D an gm e E ast D istricts. W hilst patients are m ore affected by the factor o f 184 University of Ghana http://ugspace.ug.edu.gh w aiting tim e m ore than non-patients, non-patients are a ffected by the incom e factoi m oie than patients. To reduce the problem o f poor accessib ility and utilization ca lls for pragramatic and aggressive p o lic ie s o f poverty alleviation, the eradication o f ignorance in terms o f aw areness o f health conditions and the eradication o f illiteracy, and im provem ent in health fac ilities. H ealth facilities and access roads in the rural areas w here utilization is low m ust be im proved. Credit facilities m ust be m ade available to private and m ission health system s, w h ich have higher patronage, to develop their health institutions. Three factors how ever co m e out clearly in the rural urban utilization problem s. T hese are poverty and tim e for the urban area, and poverty and distance for the rural. Therefore im provem ent in the fac ilities and personnel o f the health centres to reduce w aiting tim e and m easures to reduce poverty to ensure the financial capacity to utilize health facilities should be the main concerns o f p o licy m akers and health providers. M easures to reduce the distance factor and im provem ent in formal education should be considered in ensuring effective utilize o f health serv ices. Finally, in addressing the problem o f access and utilization o f primary health care services, an integrated approach to developm ent is called for. This should not be seen as an isolated problem , but should interrelate w ith other developm ent issu es such as good drinking water, good nutrition, good hygien ic practices, a sound healthy environm ent so as to ensure a balanced and sustainable developm ent. Such m easures would ensure vibrant health, through adequate patronage o f primary health care serv ices, and the enjoym ent o f a better standard o f living. 185 University of Ghana http://ugspace.ug.edu.gh 9.4 RECOMMENDATIONS G iven the status o f the econom y and the financial constraints, the fo llow in g recom m endations are m ade to ensure e ffective use o f health facilities, and to prom ote sound health that is a goal and an end o f developm ent: (a) Prim ary H ealth Care m ust be em phasized, esp ecia lly in deprived rural areas. M ore funds for basic health serv ices m eans better health care could reach greater proportion o f the population. Primary health care facilities, under the care o f trained nurses, m ust be provided w ithin 10-kilom etre radius. M ost patients are prepared to cover 5 kilom etres to hospital b y m otorized transport. A t this level, the com m unity m ust be fu lly involved. (b) H ealth education program m es m ust be intensified . C om m unities m ust be educated to ■ em brace preven tive m ed icine, have access to prom otive facilities like potable water, ensure personal and environm ental hygiene. (c) F acilities in ex istin g health facilities and access roads m ust be im proved, rather than putting up n ew hosp ita ls and clin ics that are m ore expensive, and that the econ om y cannot bear in the short run. (d) Efforts m ust b e m ade to integrate scien tific m ed icine w ith traditional m edicine that is readily available. (e) G irl-child education m ust be intensified , g iven that w om en bear the greater burden o f caring for their children in health facilities, and g iven that education , as a factor, im proves access to hospitals. (f) D istrict A ssem b lie s m ust m ake consc ious efforts to apply the poverty alleviation funds effective ly to ensure poverty reduction, hence em pow er the population to utilize health facilities. (g) A dequate personnel m ust be em ployed at the health fac ilities to ensure speedy rendering o f health serv ices, to reduce the tim e patients spend in health centers. D iscip line 186 University of Ghana http://ugspace.ug.edu.gh m ust be enforced, e sp ec ia lly in public hospitals, to ensure that personnel discharge their duties creditably. (h) S in ce high co st o f service has been a burning factor in utilization, a N ational Health Insurance Schem e, w ith governm ent subsidy, must be structured The fo llo w in g research areas are recom m ended, in efforts to have greater insight into the access - u tilization problem: a) H ealth Insurance and utilization pattern. Health Insurance has been found to have a positive im pact on utilization o f health services. An exam ination o f the health insurance and utilization can help in the developm ent o f G hana’s H ealth Insurance Schem e. b) A sse ss in g the im pact o f traditional m edicine on utilization am ong rural com m unities. S in ce traditional m edicine is em bedded in the rural culture, its utilization is more lik ely to be m uch higher. It can pivot a p o licy on herbal m edicine. 187 University of Ghana http://ugspace.ug.edu.gh r e f e r e n c e s A a se, A , (1 9 9 6 ). T owards a m ethodology for regional w elfare planning. In N o rsk G eografisk Tidskrift V ol. 45, N o .4 , 213-221 . A babio , B. (1 9 8 6 ). N ational C onference on Population and N ational Reconstruction. U n iversity o f Ghana, L egon. V ol. 2: Contributed Papers. M aternal and Child Health F am ily P lanning S erv ices and the PHC programme in Ghana, A bugri, B .A (19 9 5 ). 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Statistics for the Socia l Scien tist, N e w York: Penguin P. 1991. Zwart, S. and V ooerh oeve W .A . (1990). Com m unity Health and H ospital Attendance: A Case Study o f Rural Ghana. Social Science and M edicine 3 1 (7), pp. 771-718 . 204 University of Ghana http://ugspace.ug.edu.gh APPENDIX I DEPARTMENT OF GEOGRAPHY UNIVERSITY OF GHANA - LEGON C onfidential inform ation to be used for research purposes only. Individual questionnaire for indepth interview on the a ccessib ility and utilization of Primary H ealth care in the Greater Accra Region. H eads o f H ousehold s or their sp ouses District: .............................................................. T o w n /V illa g e .................................................. Interviewer: .............................................................. Date: .................................................. Section A: Personal Information 1. Sex: 1. M ale 2. Fem ale ■3. Age: ................................................................................................................................ 4. Marital Status: a. Single b. M am ed c C onsensual union D. Divorced e. Separated f. W idow ed. 5. R elig ious A ffiliation , a. Catholic b. M ethodist c. A nglican d. Presbyterian e. Pentecostal f. Spiritualist g. Other Christian h. M oslem i. Traditionalist j. N o religion. 6. Ethnicity: a. Ga Adangbe b. Akan c. Ewe d. Guan e. G russi f. M ole-D agbani g. Hausa h. other, p lease sp ec ify ......................... 7. E ducational attainm ent. A. N on e b. Primary. C. M iddle/JSS d. SS S/C om m ercia l/V ocation al/T ech n ica l e. Postsec/N ursing/Polytechn ic e. U n iversity f. Others s p e c i f y ...................................................................................... 8. E ducation attainm ent o f your spouse. A. N on e b. Primary cc. M iddle/JSS e. SSS /C om m ercia l/V ocation /T echn ica l e. P ostsec/N ursing/P olytechn ic e. U n iversity f. Others sp ec ify ........................................................................................................ 205 University of Ghana http://ugspace.ug.edu.gh 9. W hat are your m ain and m inor profession? Profession Main Minor a. Farmer b. F isherfolk c. T eacher d. N urse e. T ailor/Seam stress f. C lerk/T ypist/Secretary g- Trading h. H om em aker/H ousew ife i. N o O ccupation j- O thers, P lease sp ecify 9b. W hat is the occupation o f your spouse? (S ee 8) 10. State the approxim ate num ber o f years you have in this main p rofession .................... 11. H ave you changed your job /profession or lost your job w ithin the past 10-15 years? 1. Y es 2. N o 12. I f you have ever lo st your job indicate how long you have rem ained unem ployed and h o w you m anaged to su rvive.................................................................................................... 13. I f you have changed your jobs, w hy did you do so? 14. Total incom e per d ay/w eek /m onth ............... 15. D o es your hou sehold use the fo llow item s. a. E lectricity b. R adio c. T e lev isio n d. V id eo 206 University of Ghana http://ugspace.ug.edu.gh 16. D o you or any m em ber o f your household ow n the fo llow in g ilcnis ’ j House b. Car. C. F ishing boat. D. F ishing Net e. Tractor I Motorcycle g. B icy c le . 17. W hen you are old and no longer working, how do you intend to support yoursell a. Personal savings b. Rem ittances from children c. Socia l Security and Pension d. End o f service award e. Cannot tell f. God w ill provide. G. Others, P lease sp e c ify ........ 18. A re there any se lf-h e lp or developm ent program m es (co-operatives) going on in your com m unity? 1. Y es. 2. No. 18b. If yes, are you involved in any o f these program m es? l .Y e s 2. No. Section B: H ousin g and Environm ental Situation 19. W hat type o f h ou se do you live in now ? a. C om pound b. Flat c. Q uarters/B ungalow . D . Others, P lease s p e c i f y ................................................................... 20. W ho o w n s the house? A. O wn house b. Fam ily house c. Rented H ouse d. O thers, P lea se s p e c i f y ................................................................................................................ 21. G ive the total num ber o f people w ho usually live in w ith you now? (Include your h ou se-help i f an y)............................................................................................... 22. H ow m any room s do you use in your house (exclud e kitchen, store, bathroom) 23. T ype o f bu ild ing m aterials used for the house in w h ich you are staying? a. C em ent (sandcrete) b. Land crete c. Ata K pam e (mud) d. Other, P lease s p e c i f y .................................................................................................. 24. M ain m aterials used for roofing the house. A. Grass or thatch b. Sheets or asbestos c. T ilesd . C oncrete e. Other, p lease sp e c ify ..................................................................... 207 University of Ghana http://ugspace.ug.edu.gh 25. T ype o f lighting. A. Electricity b. Lamps c. Candle d. N o Electricity e. Other, p lease sp e c ify .................................................................................................................. 26. T ype o f w ater supply used for drinking. a. P ipe water piped into residence b. Pipe water piped into yaid com pound. c. P ublic tap/neighbour’s house pipe water d. W ell water (public) e. B orehole f. Surface water (spring, river, stream) g. rain water h. Tanker water i. B ottle water j. Other, sp ec ify ............................................................................. 27. H o w do you store your drinking water? a. Open containers b. Barrels c. Storage tanks d. Refrigerators. e. Other, p lease s p e c i f y ................................................................................................... 28. W hat problem do you face with your water supply system ? .................................... 29. T ype o f toilet/latrine. A . Flush toilet ow n W C b. Shared W C c. Pit latrine d. K um asi V entilated Im proved pit (K VIP) e. B ucket/pan latrine f . N o. facility (bush /field /beach). 30. Presence o f flie s in Kitchen and toilets 1. Y es 2. No. 31. R odent problem l .Y e s 2. N o 32. D o you use in sectic id es for controlling household insects, eg. Mosquitoes'.' 1. Y e s N o N o. 33. I f yes, nam e the in sectic ide u sed ........................................................................................ 34. L ocation o f coo k in g place. A O pen kitchen b. Private Kitchen 35. W hat type o f fuel/energy do you household use for cooking? a. Gas b. E lectricity c. Charcoal d. Firewood. 208 University of Ghana http://ugspace.ug.edu.gh Section C: Health Seeking Behaviours 36. W here do you norm ally go for treatment when you are unwell ’ ........................ 37. W ho takes the decision to take a child to the health center? ......................................... 38 .a W ho im m unization/vaccination did your chi ld/chi ldren receive Irom the muses . 38b. W hat d iseases disturb your c h ild ren ? ........................................................................................ 39. H ave you ever been hospitalized before? l .Y e s 2 .No 40. I f Y es, w hen , for what ailm ent and for how long? D ate (year)...................................a ilm ent.............................. Duration ........................................ 41. W hat other d isea ses disturb y o u ? ............................................................................................... 42. W hat do you consider to be the major health problem in your area and why? 43. H ave you heard o f the d isease called A ID S? 1. Y es 2. N o 44. From w h ich sources o f inform ation or persons have you heard about A ID S in the last six m onths? a. R adio b. TV. C. N ew spaper d. Health worker c. C om m unity m eetings f. Pam phlets/Posters g. Friends/relatives h. Other, p lease sp e c ify ........................................................................................................................ 45. H as the p resence o f A ID S affected your sexual relations? 1. Y es 2. N o. 45b. I f Y e s , in w hat w a y s ? .......................................................................................................................... 46a. D o you u se contraceptives? 1. Y es 2. N o 46b. I f yes, m ention the m ethod you u se ............................................................................................. Section E: Accessibility and Utilisation of Health Service 47. H o w far is the nearest health facility from you house? a. L ess than one m ile 1-12 m iles c. 3-4 m iles d. 5 or m ore m iles. 48. H ow do you rate the cost o f health sen d ees at the facility? a. V ery exp en sive b. M oderate c. R easonable d. Cheap 209 University of Ghana http://ugspace.ug.edu.gh 49. W hat is the m ajor factor that constitute a constraint to you as far as the utilization o f fac ilities at the health center is concerned.a. D istance b. fin a n ce c. Ignorance d. W aiting for lon g hours to receive care e. Cultural be lie fs. f. Other, p lease s p e c i f y .............................................................................................................. 50. H ow m uch m oney has your household spent on health scrviec chem ical/drug spiritualist, prayer groups in the past m onth?......................................................................... 51. H as there been a v isit to the center this past six m onths? 1. Y e s 2. N o. 52. H o w do you get to the health center? a. B y w alking b. By b icycle c. boat d. B y taxi e. B y trotro. f. Other please specify ............................................................................................. 53. H ow long does it take you go get to the health center? a .........................................M inutes b ........................................... hours 54. H ow long do you have to wait before you see the doctor/m edical assistant? 55. D o health serv ice providers honour their schedule to your com m unity? 1. Y es 2. N o. 56. D o often do the health service providers v isit your com m unity? a. O nce a w eek b. tw ice a w eek c. once a month. d. Other, p lease s p e c i f y ........................................................................................................ 57. H ow is inform ation on health program mes com m unicated to the com munity? B y ...................................a. M obile van b. Pos ter c. Radio d. Go ng - go n g better e. T V f. Other, p lease specify). Thank you. 210 University of Ghana http://ugspace.ug.edu.gh APPENDIX II C onfidential inform ation to be used for research purposes only Individual questionnaire for indepth interview on the A ccess ib ility and utilization o f Primary H ealth Care in the Greater Accra Region. Patients at the H ealth F acilities D is tr ic t ......................................................... T o w n /V illa g e .................................................................. Interviewer: ........................................................................ Date: ................................................................ Section A: Personal Information 1. Sex: 1. M ale 2. Fem ale 3. Age: ...................................................................................... 4. M arital Status: a. Single b. Married c. C onsensual union. D. Divorced e. Separated f. W idow ed. 5. R elig iou s A ffilia tion , a. Catholic b. M ethodist c. A nglican d. Presbyterian e. Pentecostal f. Spiritualist g. Other Christian h. M oslem i. Traditionalist j. N o religion. 6. Ethnicity: a. Ga A dangbe b. Akan c. E w e d. Guan e. G russi f. M ole-D agbani g. Hausa h. other, p lease sp ec ify ...................... 7. Educational attainment. A . N on e b. Primary. C. M iddle/JSS d. SSS/C om m ercial/V ocational/T echnical e. Postsec/N ursing/Polytechnic e. U n iversity f. Others s p e c i f y ...................................................................................... 8. Education attainm ent o f your spouse. A. N on e b. Primary cc. M iddle/JSS e. SSS/C om m ercial/V ocation /T echn ical e. Postsec/N ursing/Polytechn ic e. U n iversity f. Others sp ec ify ......................................................................................................... 211 University of Ghana http://ugspace.ug.edu.gh 9. W hat are your m ain and m inor profession? Profession Main Minor k. Farmer 1. Fisherfolk m. Teacher n. Nurse 0. Tailor/Seamstress p. Clerk/Typist/Secretary q. Trading r. H om em ak er/H ou sew ife s. N o O ccupation t. O thers, P lease sp ec ify .............................................................................................................. 9b. W hat is the occupation o f your spouse? (S ee 8) 9b. W hat is your total incom e per d ay/w eek/m onth?......................................................................... Section B: Health Seeking Behaviour 10. Apart from this p lace w here e lse do you go for treatm ent w hen you are unwell. 1. G overnm ent hosp ita ls/clin ic 2. Private hosp ita l/clin ic 3. M issio n hospital 4. health center 5. Church 6. Prayer Group or garden. 7. Traditional herbalist. 11. D o you som etim es practice self-m edication? 1. Y es. 2. N o. l ib . I f Y e s , w hat ex a ctly do you d o ? ................................................................................................. 12. D o you consu lt chem ical or drug sellers and herbalist w hen you or your spouse/ch ildren is sick? 1. Y es. 2. No. 12b. I f Y e s , w hat do they do before they g ive you som e d ru g s/h erb s? ..................................... 212 University of Ghana http://ugspace.ug.edu.gh 13. W hat a ilm ent brought you to this p la c e ? ................................................................................. 14. H ow long has this ailm ent persisted?............................................................................................. 15. W hat other a ilm ents disturb you? ................................................................................................. 16. A t hom e, w hat type o f water do you drink? 1. Piped water 2. W ell water 3. bore hole 4. river/stream 5. tanker water. 6. Other, p lease s p e c i f y ..................................................................................................................... 17. T ype o f toilet/latrine. 1. Flush to ilet/ow n W C 2. Shared W C 3 . Pit latrine 4. K um asi V entilated im proved pit (K V ID ) 5. B ucket/pan latrine 6. B ush /F ie ld /B each 8. Other, p lease s p e c i f y ....................................................................... 18. W hat type o f fuel/energy do your household use for cooking? 1. G as 2. E lectricity 3. Charcoal 4. F irew ood 19. W hat do you consider to be the major health problem in your area and why? 20. H ave you heard o f the d isease called A ID S? 1. Y es 2. N o 21. From w h ich sources o f inform ation or persons have you heard about A ID S in the last six m onths? 1. R adio 2. T V . N ew spaper 4. H ealth w orker 5 .C om m unity m eetings. 6. P am phlets/Posters 7. Friends/relatives 8. O thers, p lea se s p e c i f y ......................................................................................................... 22. Has the presence o f A ID S affected your sexual relations? l .Y e s 2. No 22b. I f Y es, in w hat w a y s ? ....................................................................................................................... 23. D o you use contraceptives? l .Y e s 2. N o. 24. I f Y e s , m ention the m ethod you use? 213 University of Ghana http://ugspace.ug.edu.gh Section C. A ccessib ility and Utilization of Health Services 25. H ow far is the nearest health facility from youi house? I Less than one km 2. 1-2 km 3. 3-4 km 4. or m ore km 26. H ow do you rate the cost o f health services at the facility? 1. V ery ex p en sive 2. M oderate 3. R easonable 4. Cheap 27. W hat am ounts have you paid so far for the fo llo w in g services? 1. R e c o r d s ........................... 2. Consultation 2. L a b o ra to ry ...................... 4. D r u g s ................................................ 28. W hat is the major factor that constitutes a constraint to you as far as the utilization o f fa c ilities at the health center is concerned? 1. D istance Finance 2. Ignorance 4. W aiting for lon g hours to receive care. 5. Cultural beliefs. 6. Other, p lease s p e c i f y ........................................................................................................... 29. H ow much m oney have you spent on health service chem ical/drug sellers, spiritualist, prayer groups in the past m onth?............................................................................ 30. H ow do you get to this health center? 1. B y w alking 2. B y b icycle 3. B y boat 4. B y taxi 5. B y trotro. 6. Other, p lease s p e c i f y ............................................................................................................. 31. W hat is the approxim ate transport cost from here too your h o u s e ? ............................... 32. H ow m any children do you have? ............................................................................................... 33. W hat are their ages? ............................................................................................................................ 34. W ere they bom : 1. at hom e 2. health center 3. TBA 4. Hospital 35. W hat d iseases affected your children w hen they w ere very young? 36. W hat d isease affects them now? 37. D id you im m unize all your children against the six killer disease" 1. Y es 2. No 214 University of Ghana http://ugspace.ug.edu.gh 38. I f N o , w h y did you not do so? ................................................................................. 39. W hat cau ses you to fall sick? 1. germ s 2. poor food 3. pover ty 4. w itch es 5. other, p lease s p e c i f y ................................................................................... 40. W hich 3 o f the fo llo w in g do you norm ally consult? 1. health center 2. se lf-m ed ica tion 3. drug peddler 4. spiritualist 5. chem ical sellci 6 pharm acist 7. local herbalist 41. D o the doctors and nurses here treat you nicely? 1. Y es 2. N o 42. G ive reasons for your answer in 4 1 ............................................................ .......... 215 University of Ghana http://ugspace.ug.edu.gh 38. I f N o , w h y did you not do so? ........................................................................ 39. W hat cau ses you to fall sick? 1. germ s 2. poor lood 3. poverty 4. w itches 5. other, p lease s p e c i f y .................................................................................. 40. W hich 3 o f the fo llow in g do you normally consult? I ■ health centei 2. self-m ed ication 3. drug peddler 4. spiritualist 5. chem ical sellci <> pharm acist 7. local herbalist 41. D o the doctors and nurses here treat you nicely? 1. Y es 2. N o 42. G ive reasons for your answer in 4 1............................................................................... 215 University of Ghana http://ugspace.ug.edu.gh (b) P lea se explain your a n s w e r ..................................................................... 15. W hat type o f d iseases do patients norm ally report at this heal th facility ' ............. 16. W hat is average daily attendance? ................................................................... 17. W h a t kind o f people normally patronize this placc? I High income group 2. M edium incom e group 3. Low incom e group 18. Rank the category o f patients (A -D ) 1. M en. 2 W om en 3. Children 4. Y ou th /A d olescen ts 19. In your estim ation w hich o f the fo llow in g influence the patronage o f the facility? (Rank them a-f) 1. E asily accessib le (In terms o f distance and transportation). 2. A ffordability (eg. Cost). 3. Q uality and prompt services 4. C our teous staff 5. A vailab ility o f drugs 6. Other, p lease s p e c i f y ......................................................... 19b. D o you incorporate the use o f traditional m edicine in your work? 1. Y e s 2. N o 20 H ow does tradition, ignorance and values conflict w ith PHC in this com m unity0 21. W hich o f the fo llo w in g needs im m ediate attention? Rehabilitation o f infrastructure 2. M ode o f operation. 3. Equipment. 4. Transport and Com m unication. 5. Other, p lease sp ec ify ................................................................................. 22. W hat log istic support do you need u r g e n tly ? .......................................................................... 23. W hat do you think w ill m ake your station a better place? 24. D o you have in-service training and refresher courses from tim e to time? 1. Y es 2. N o 24b. P lease explain your answer 21" University of Ghana http://ugspace.ug.edu.gh A P P E N D I X IV C onfidential Inform ation to be used for research purposes only Interview schedu le for Drug and Chem ical Sellers1' 1. W hat exactly is the nature o f your work? 2. H ave you had any formal o f training? a. Y es b. No 3. I f yes, w here did you have the formal tra in in g ? ......................................................... 4. H ow long have you been sellin g drugs?.......................................................................... 5b. W hat is the e ffica cy o f the drug (ie does it heal very w ell) 6. D o you enjoy your work? a. Y es b. N o P lease explain your answ er further................................................................................. 7. W hat are som e o f the d ifficu lties you face in your work'’ ...................................... 8. H ow m uch incom e do you generate in a day/w eek/m onlh? ................................. 9. D o you go on outreach programmes? .............................................................................. 10. W hat form o f transportation do you norm ally use? .................................................. 11. D o you sell traditional m edicine (herbs, liquid form)? l .Y e s . 2. N o. 12. W hy do people patronize your drugs? ............................................................................ 13. H ow can you com pare your work to that o f the worker at the health center? 14. D o you receive any help from the governm ent? 1. Y es 2. N o 15. Are you in any association? l .Y e s 2. N o. 16. I f Y es, what is the n a m e ? ...................................................................................................... 17. W hen w as it fo r m e d ? ............................................................................................................... 18. W ho are the le a d e r s? ............................................................................................................... Thank you. 218 University of Ghana http://ugspace.ug.edu.gh APPENDIX VI C onfidential Inform ation to be used for research pur poses only Interview schedu le tor C om m unity Leaders? (Traditional and R elig iou s O pinion). 1. W hat are your opin ions about the orthodox health care in your com m unity? 2. W hat alternative sources o f health care do you have in your locality? 3. W hich on es do you patronize and why? ........................................................... 4. W hich on es do the m ajority o f the people patronize and w hy? 5. W hat is the e ffic a cy o f treatment for orthodox m edicine and also local traditional m e d ic in e? ................................................................................................................................................ 6. W hat do you think about user fees at the health fac ilities in your locality? 7. H ow can you describe the attitude o f the health workers in your locality? 8. Are there any se lf-h e lp or developm ent program m es (cooperatives) go ing on in your area? a. Y es b. N o. 9. If Y es, are you involved in any o f these program m es? 10. H ow can the access to health service and their utilization be improved' . ’ 11. W hat do you think about this issue o f H ealth Insurance? ..................................... 12. H ow can the poor benefit from m edical treatment? .................................................. 2 1 9 University of Ghana http://ugspace.ug.edu.gh 13. Can the rich help set up a fund to help the poor? 1 Y es No. 14. D o peop le patronize tradition m edicine more than sc icn lific m cdicinc.' 1. Y e s 2. N o. P lease explain your answ er.................................................................................................. 15. W hat can you personally do to help enhance the work o f PHC in youi co m m u n ity? ........................................................................................................................................... 220 University of Ghana http://ugspace.ug.edu.gh A P P E N D I X VII D ecem ber 5, 20 0 2 , Thursday. D aily Graphic H ospital C om p lex not functioning A lot o f concerns have been raised over the long delay in opening the newl y buill Da ngm e East D istrict H ospital for public use at Faithkope, Ada. The 60 bed ultra-modern facility w hich w as com pleted in April this year by China N ational Cooperation for O verseas E conom ic C o-operation is not operating despite the procurem ent o f drugs and other accessories . The D angm e East D istrict C h ie f E xecutive, Mr. , Kofi Plahar explained that the award o f the contract for the construction o f the hospital did not include sta ff accom m odation. H e said the district assem bly has entered into negotiations with som e landlords in the B ig -A d a tow nship to secure a temporary place for the sta ff and as and w hen they fin a lise the deal, the hospital w ill be com m issioned . The M P o f the area, Mr. A m os B uertey w a s reticent to com m ent on the issue. B ut inform ation gathered at the site revealed that the m achines are deteriorating at a fast rate 221 University of Ghana http://ugspace.ug.edu.gh A P P E N D I X V III Thursday D ecem ber 5, 2002. Fight against m easles launched D aily Graphic A national m ass m easles im m unization cam paign w as launched at G baw c in Accra on D ecem ber 4 lh w ith a call on parents to support the cam paign to prom ote the health/growth o f children. President J.A . K ufuor said although significant progress has been m ade in the fight against m easles , occasion al outbreaks o f he d isease still leads to con sequ en ces such as blindness, malnutrition, and even death am ong children. The number o f reported cases has reduced from 140 ,000 children cases in 1975 to 12,500 in 2001. W e have m ade som e progress in controlling the d isease . Y et m easles is still the leading cause o f illness in Ghana am ong the diseases that can be prevented by vaccination. Children are the future leaders o f Ghana and bring so m uch jo y into the lives o f parents, for w h ich reason the im m unization o f children against d iseases is som ething that ought to receive the enthusiastic support o f every body in our so c iety ” The M inistry o f Health, Dr K waku A friy ie , appealed to adult m ales to lend a hand in this year’s im m unization by taking their children to the centers to be im m unized. Dr. A friy ie expressed his gratitude to the W H O , U N IC E F, the Red Cross, the UN Foundation, the Japanese G overnm ent and the Centre for D iseases Control, U SA for supporting the program m e fighting hard to eradicate m easles from Ghana. 222