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CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
The fact that there are lots of problems bedeviling the Nigeria Health Care Delivery system is not debatable. The debate, however, would rather be on the singular most important change that needs to be effected within the system, given the current trend in the system to bring about improvement. Health care delivery in Nigeria and most of its federating states have remained comatosed despite the efforts governments and individuals have made toward global best practices in the health sector and the huge sums of money sunk therein on yearly basis. Throughout the world, as Lucas and Gilles (2003:283) posit, the health sector is in crisis. They further asserted that with the United States’ annual spending of 1000–3000 US Dollars per head of the population, the developed nations of the world cannot afford to provide universal access to all modern health technologies to their citizenry. Nigeria, though a developing nation, is not isolated from this.
Ogbebulu (2009) noted that the 2003 National Demographic Health survey observed that Nigeria’s immunisation coverage was put at 13% and that led to some of the reasons why some Nigeria children were dying everyday of preventable illness. He believed that the rate at which women were dying of preventable and avoidable complications of pregnancies across the entire nation was alarming. Nigeria accounts for 10% of the global estimate of maternal death, even though the World Health Organisation assessment puts her population at about only 2% of the world population. Whereas the advances in biomedical sciences have made available many new effective technologies for the prevention, diagnosis and treatment of diseases, adequate healthcare services have remained and may still remain a mirage to many people in the country, particularly the Southeast, Nigeria; at least in the foreseeable future.
Highlighting the decadence in the Nigerian health sector, Uduji (2006: 81) writes that about twenty years ago, General Sani Abacha while broadcasting to Nigerians on 31 December 1983, following the General Ibrahim Babangida coup d’ etat, told Nigerians that their hospitals had become mere consulting clinics without drugs, water and equipment. He further asserts that at present, there is even nobody to consult again in some areas as many have fatefully taken their healthcare issues in their own hands. In the Ministry of Health (2009: 3), the Nigerian Federal Ministry of Health painted a gory picture of the health situation in the country thus:
“The Nigeria health system and the health status of its citizens are In deplorable state. Nigeria’s overall health system performance was ranked in the 187th position among the 191 Members States by the World Health Organization in 2000. Health status indicators are worse than the average for sub-Saharan Africa and a source of embarrassment to the government and people of Nigeria”.
The World Health Organization, through the Alma-Ata Declaration in Russia in 1985 recognized health to be a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. The declaration went further to note that the people have the right and duty to participate individually and collectively in the planning and implementation of their health care. It is based on this that the WHO members believed that governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures.
Consequently, in 1981, the member states of WHO (including Nigeria) pledged themselves to an ambitious target to provide health for all by the year 2000, that is attainment of a level of health that will permit all persons to lead a socially and economically productive life. Since the year 2000, up till eleven years afterwards, the situation before which the declaration was made still persists in the Nigerian health sector. Park (2009:9) puts it succinctly:
“Only 10 to 20 per cent of the population enjoy ready access to health of any kind. Death claims 60-250 of every 1,000 live births within the first year of life, and life expectancy is 30 per cent lower than in developed countries. Large numbers of people have no access to health care at all, and for many of the rest the care they receive does not answer the problems they have”.
On the other hand, the records of global healthcare delivery systems of the nations of the world as contained in the Encyclopedia of Nations (2005) add credence to Park’s position, especially about Nigeria thus:
“In 2000, 57% of the population had access to safe drinking water and 63% had adequate sanitation. As of 1999, total health care expenditure was estimated at 2.8% of GDP. Despite the receding influence of such endemic diseases as yellow fever, health problems in Nigeria remain acute. Malaria and tuberculosis are the diseases of most frequent incidence, but serious outbreaks of cerebrospinal meningitis still occur in the north. Just under half of all deaths are thought to be among children, who are especially vulnerable to malaria and account for 75% of registered malaria deaths. The prevalence of child malnutrition for children under age five as of 1999 was 46%. Goiter was present in 20% of all school-age children in 1996. Nigeria had the highest number of measles cases reported in 1995 of all African nations (95,915 cases and 12,393 deaths).
In 1995, diarrheal diseases claimed 204,400 lives. As of 2000, almost 15% of all Nigerian children did not live to their fifth birthday. Malaria and diarrheal diseases accounted for, respectively, 30% and 20% of childhood mortality. Immunization rates for 1997 for children up to one year old were as follows: tuberculosis, 53%; diphtheria, pertussis, and tetanus, 45%; polio, 45%; and measles, 69%. Only 1% of children were immunized for yellow fever in 1993.
HIV/AIDS has reached epidemic levels in Nigeria. At the end of 2001, the number of people living with HIV/AIDS was estimated at 3.5 million (including 5.8% of the adult population) and deaths from AIDS that year were estimated at 170,000. HIV prevalence in 1999 was 5.1 per 100 adults.
Only 15% of married women used contraceptives in 2000. The fertility rate in 2000 was 5.3 children per woman surviving her childbearing years. The life expectancy for the Nigerian was only 47 years in 2000. As of 2002, the crude birth rate and overall mortality rate were estimated at, respectively, 39.2 and 14.1 per 1,000 people”.
The scenario painted here is as fearful as it is dreadful. Today, a large part of the South-east populace, due to poverty and ignorance have resorted to other forms of unconventional healthcare delivery system apart from the orthodox healthcare, ignorant that adequate healthcare (at least at the primary level) is their constitutional right. Whereas some have died in this ignorance, others have been unnecessarily exploited, or maimed both clinically and psychologically. The World Health Organization (1976), is of the standpoint that the right to health was one of the last to be proclaimed in the Constitutions of most countries of the world. At the international level, Park (2009:8) agrees that the Universal Declaration of Human Rights established a breakthrough in 1948 by stating in Article 25 that everyone has the right to a standard of living adequate for the health and well-being of himself and his family. However, the Preamble to the WHO Constitution equally affirms that it is one of the fundamental rights of every human person to enjoy the highest attainable standard of health. Park further clarifies this right to include the right to health and medical care.
There is a fundamental need in many countries to reach the whole of the population with adequate health care services. The basic purpose of health care delivery, therefore, is to reach every member of the society with health facilities adequately and within affordable cost. Since the large hospitals could no longer deliver healthcare, the rising costs in the maintenance of these hospitals and their failure to deliver the health needs of the communities have led many countries to seek alternative models of health care delivery with a view to provide health care services that are reasonably inexpensive, and have basic essentials required by the rural population. One of such alternatives could be found in the area of public relations.
Public Relations (PR), of all the professions in the world, writes Okoye (1980:285) is the most used, most misunderstood and most unused. To many people, PR is publicity, to some it is giving gifts in expectation of rewards, to some others it is propaganda and the likes, while to yet others, it is advertising and/or marketing. Whereas some of these assumptions seem to be true and could be subsequently used as PR tools, none is entirely PR unto itself. According to Udeze (2010:2), PR is typified by the story of the blind men who went to see an elephant. Each of them described the elephant to match the part of the body he touched. While none of them was absolutely wrong in their analysis, yet none was wholesomely right.
Black (1989), quoted in Okoro, et al (1999: 2) sees Public Relations as the art and science of achieving harmony with the environment through mutual understanding based on truth and full information. Udeze (2005: 2) asserts that this mutual understanding is very important to both the organization and the members of its publics, if PR is to be effectually effective. However, Broom (2009: 25), looked at the concept as being the management function that establishes and maintains mutually beneficial relationships between an organization and the publics on whom its success or failure depends.
Other professionals and scholars looked at the concept of Public Relations from differing prisms. Newsom, et al (2010:2), compactly defined the term Public Relations in a way that it could suitably be adopted for this study as a management function which involves responsibility and responsiveness in policy and information to the best interests of the organization and its publics.
Whereas Public Relations has been identified as a management function, a convergent of all ideas canvassed in the definitions offered so far showcases Public Relations as reputation or image making effort, responsive and responsible interface, two-way communication and education, corporate and social responsibility among many others. This study, although agrees with the definitions of Public Relations as canvassed, but will narrowly adopt Public Relations as a social responsibility function to aid the healthcare delivery services, vis-à-vis investigating its applicative impact in the healthcare delivery in the South-east, Nigeria. According to Newsom, et al (2010:10), health maintenance organizations, hospitals, other health care agencies, pharmaceutical companies, medical clinics, health-science centers and nonprofit health agencies all employ public relations professionals. They further posit that the demand in this field is for public relations practitioners who either know or have the educational background to learn about medical science to translate that information accurately for the organization’s publics. Basically, the Public Relations profession is in high demand in the healthcare sector, especially now that the world is looking away from the normal orthodox medicine for alternatives to medicine. This, however, will create the much sought after paradigm shift in the industry and justify the need for Public Relations in the health sector. Moreso, Public Relations tools in business organizations have moved from mere attempt to maintain public goodwill to social marketing and social responsibility activities where organizations try to give back something to the society from where so much have been taken to sustain their organizations.
Public relations has been used or applied in almost all the facets of human existence. Be it the corporate world, education or health, public relations has a function to perform in the effort to achieve organizational goals, one of which is community relations or corporate social responsibility (CSR). To achieve the desired goals, public relations must be able to communicate organizations’ plans, policies and programmes to their publics, hence communication cannot be divorced from public relations.
Communication and public relations are like Siamese twins that cannot easily be separated one from the other. It, therefore, becomes imperative to ask one pertinent question: what has communication got in common with public relations vis-à-vis health care delivery? The answer is quite obvious. Public relations is a channel of communication and the support from the general public is pivotal for the mobilization and galvanization of healthcare delivery.
Communication has been given various interpretations and meanings by scholars and experts. Dance (1970) in Ndolo (2006:10) sees communication as a process by which we understand others and in turn endeavour to be understood by them. Dance further posits that it is dynamic, constantly changing and shifting in response to the total situation. But Agee et al (1988) quoted in Ndolo looked at the concept from the perspective of an act of transmitting information, ideas, and attitudes from one person to another.
Ndolo and Udeze (2008: 34), believe that communication is part of the building blocks of public relations. Communication, postulates Broom (2009: 211), affects and is affected by the social setting. It manifests as a structural process within evolving systems of related components and activities. Communication transfers information. Communication is initiated when there is information to be shared or passed from one person to another. However, information is marketable product of communication, hence perishable as well. This necessitates the sharing of health information between the PR practitioners and the publics of the health care service providers in order to enhance their health. Lucas et al (2003: 286), posit that the public often lacks information that would enable them to make informed judgements about health-care issues. They went further to suggest that this situation arises because health officials do not often present technical information in the language that would inform the lay people nor do they clearly explain the significance of the specific issues. This therefore becomes a burden which public relations should try to alleviate.
Communication and public relations, when adequately managed have the potentials to enhance sharing and dissemination of health related information to all interested parties and individuals within any given environment. Communication-related resources containing important health information and disseminated through the organized health education media and such others as newsletters, pamphlets and brochures, billboards, special publications among others have being identified as PR avenues that could be used to enhance healthcare delivery. There could still be many others.
The importance of public relations in the healthcare management and administration sub-sector is therefore, to create awareness among the citizenry of the channels that are opened in order to improve their health care and access the services therein, with the objective of making them stay healthy. Persuasive and vigorous PR campaign is therefore necessary to mobilize and educate the populace towards that direction. The application of PR in health care delivery requires the type of structural positioning, which not only facilitates communication, but stimulates interaction among those in charge of hospital administrations, health care givers and the potential patients and indeed clinical patients. This is focus of the new tools to health care delivery system which will slightly take PR away from its application of the conventional PR tools to breaking new grounds to ascertain adequate health care delivery to the people of the South-east zone of Nigeria.
All these cannot be achieved without adequate planning, which is what public relations is all about. Beaton (1974:65) observed that public health is planning, carrying out and evaluation of health measures and systems services that both maintain and improve the health of a population group and prevent and control diseases within that population group, on the other hand. This is, however, the meeting point between public relations and healthcare delivery system in any organized society.
Public healthcare necessitates the application of administrative methods and procedures that are very imperative for carrying out health services. Olewe et al (1996:188) postulate that sound health policy and its implementation is sine-qua-non for achieving efficiency in health administration. They further noted that in most countries, health policies abound but the problems had been how to communicate such to the target groups and implement the policies accordingly. It is in this area of communicating health-related education to the individuals that public relations is seen as a veritable tool for adequate healthcare delivery.
Lack of information as to know what to do, when to do so and how to do it has been the bane of healthcare delivery, especially among the rural poor of the South-east, Nigeria. A well informed people will always be better positioned to access the channels of healthcare delivery at their disposal. This is why information placed within the door-steps of the people will always continue to be a quality tool for effective healthcare delivery. However, the role of the media as the conventional information dissemination channel need not be over emphasized. However, the need for paradigm shift from the conventional or formal media to the unconventional or informal media of information dissemination suffices. This is where Public Relations comes in as a medium that could impact healthcare delivery in the South-east, Nigeria, which is the gap this study seeks to fill. This entails passing health information through unconventional socio-cultural means in a way that it will not only be public relations oriented but will enhance pubic heath care delivery.
The impoverished people of the region, by the forces of nature and the environmental factors surrounding them, directly or indirectly, lack information that could help mobilize them for efficient healthcare delivery. Even when such information are available, greater per cent of them seem elitist to the rural people who constitute a greater portion of the population. Moreso, such information may not take into cognizance their socio-cultural setting. This is where Public Relations becomes paramount in redressing the situation and filling the missing link. In recognizing this fact, the World Health Organisation (WHO), in 1980 reported a strong relationship between aggregate poor health status, poverty and underdevelopment, which could be alluded to the people of the South-east geo-political zone of Nigeria. Also Akile (1992) and Aluko (1998) quoted in Aluko (2000: 37) recognizes that:
“Most often we tend to equate poverty with lack of money or desirable income, while this may be so, there are other substantial variables of poverty apart from income. For instance, we have such as ignorance, illiteracy, inequalities in power/proportion possession as other variants of poverty. Others are unemployment, unequal movement along social structure, inability to procure necessary means of substance and lack of effective resources mobilization, are of equally very important indices of poverty that affect the health of any society”.
The importance of placing the desired information at the domains of the public who will need it cannot be over-emphasized in the contemporary setting. No wonder the Ministry of Health (2009: 3), recognized this importance in its Agenda for Health 2009 and articulated the theme “Taking health to the people with primary healthcare that works”, with emphasis on communication and Public Relations management as vital tools for achieving this.
This study, therefore, is an attempt to investigate how effective the application of Public Relations tools have been in the discharge of healthcare delivery in some selected states of the south east Nigeria. The states in focus in the study are Anambra, Ebonyi and Enugu. The findings from the states will form a prism from which to look at the use of Public Relations tools to advance healthcare delivery, not only in the South-east, Nigeria but nationally and beyond.
Consequently, the pertinent questions to ask in this study suffice: how have the three tiers of healthcare delivery system (primary, secondary and tertiary) deployed in the South East, Nigeria, been able to manage communication and PR to enhance quick and easy access to health care delivery? Have these induced behavioural change tilted towards improved healthcare? How then have the health PROs and policy makers, standing on these existing, though demanding platforms, used PR to assist the people to access quality and quantity healthcare in spite of all the prevailing challenges staring them in the face. Has it been effectively impactful? Has it been efficient? Have the people benefitted qualitatively from this application of PR? Can the application of PR in the healthcare delivery system in the South East, Nigeria, further the hope of Nigeria achieving the Millennium Development Goals (MDGs) on healthcare delivery, at least in the region? These constitute the crux of this study.
1.2 Statement of the Problem
General Sani Abacha’s wake-up call to Nigerians on 31 December 1983 invokes a deep thought into what the Nigerian healthcare delivery has been over the years. Where there is health, there is a way but when health collapses, the way could be temporarily or permanently shut out. In the milieu of issues surrounding human existence, especially in the evolving society, the issue of how to get people access quality and quantity health care delivery quickly and easily arises.
On the other hand, one wonders if hospitals, saddled with the onerous task of discharging health care to the citizenry, have any need to give public information to the populace for their improved health care. Can these information, given within the ambit of PR, help the populace access good and quality health care quickly and easily? Apart from disseminating health-related information, the health care givers need to assist the global search for alternatives to orthodox medical care.
This seems to be lacking in the South-east zone of the country.
In the zone, the health care delivery system has hinged much on the conventionally established 3layers structure of health care delivery system; viz: primary, secondary and tertiary. But a closer look at the zone and the health challenges therein shows that the socio-cultural setting of the people could be exploited for enhanced health care delivery. This, of course, could become more successful if inter-laced with the conventional public relations tools or pursued as a complement to public relations. It is the assumption of this researcher that this will enhance access to health information to promote quality healthcare as the conventional health care delivery system has not yielded the desired benefits to the people maximally. Rather, they are on daily basis being bombarded with avalanche of media information, which are elitist and has urban-oriented undertone. This has negated their health status and by extension, their social well-being, thereby hampering their contributions to national development. A popular maxim says that health is wealth (Sartwell 1973: 633), hence a healthy mind in a healthy body makes for a citizenry that is an asset for national development. To stay healthy, therefore, requires obtaining requisite information and other strategically positioned organizational efforts that could enhance healthcare quality and quantity-wise.