ABSTRACT
BACKGROUND: Utilization of public health services is an important factor in the
effectiveness of national health care and achievement of Health for All. Nigeria’s population
is predominantly rural and the health needs of rural areas are numerous. For one to be able to
maintain a healthy state, the choice of health care facilities/services and predictors of the
choice are important. An individual’s choice of health facilities for healthcare is largely
determined by patient-related factors and provider-related factors and these affect patient’s
health outcomes. These choices of health care provider may also give an insight into how
these health facilities can improve on their service delivery, improve client satisfaction and
by extension ensure a healthier population.
OBJECTIVES: To determine factors (both patient-related and provider-related ) affecting
the utilization of Public health facilities by rural dwellers in Abia state south east Nigeria.
Also to elicit their health related activities and level of satisfaction with Public health
facilities.
METHODOLOGY: It was a population based cross-sectional, descriptive study, carried out
in selected rural areas of Abia state in south east geopolitical zone of Nigeria. 447 household
heads or caregivers adults permanently residing in the selected rural areas were randomly
selected and then interviewed using a pretested, semi structured questionnaire. Frequencies,
percentages and mean were calculated, tables were created and comparisons of categorical
data were done using descriptive methods. Chi square test was used to determine factors that
were significant at a p- value of 0.05 and logistic regression was used to determine the
predictors for choice of health care facility.
RESULTS: The results indicated that 282 out of 447 0f the rural study population utilized
public healthcare facilities. The patient related factors that encourage the utilization of public
health facilities included age (31-40yrs), gender (male), marital status (married) and
employment status (Government employed) There were no significant relationship between
educational level, family income, household size and duration of stay in community at pvales
of 0.05.
The provider-related variables influencing the choice of public health facility for respondents
included factors like internal organization and procedures, availability of health information,
working hours, cost of service, waiting time and availability of ancillary services matters.
This study also reported that users of government facilities were just somewhat satisfied with
services rendered, location of the facility, overall cleanliness of the center, Staff courtesy and
friendliness, skill and competency of the staff the health services they received. They are very
satisfied with the efficiency of nursing care and work schedule of care in the clinic.
CONCLUSION: This study highlighted that the utilization of public health facilities by rural-urban
dweller in Abia state is high. Choice of health care providing facility is an important
decision that involves the interplay of several factors. Understanding these factors by health
policy makers is important in the provision and the utilization of health care services . Also
satisfaction with services provided is a perception by the clients and must be considered by
managers of health institutions when decisions to improve health facility services are to be
made. A healthy population is an asset to any society. Consequently, improving the healthcare
delivery system in the public setting will in the long run improve the quality of life of the
people in the study area.
CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND
The World Health Organization (WHO) is greatly concerned with the provision of
quality health care for everyone irrespective of varying levels of living. This implies whether
the person is in the advanced or poor countries, rural or urban, poor or rich; good health
should be guaranteed by the governments of all countries. Health as defined by WHO is a
state of complete physical, mental, and social well-being and not merely the absence of
diseases or infirmity. The determinants of health of an individual at any particular time
include: the social and economic environment, the physical environment, and the person’s
individual characteristics and behaviours3. Illness or diseases is a very common thing that can
come at anytime to an individual, when this occur the in-born survival instinct in man will
want to fight back at all cost to become well again. Methods engaged to maintain and restore
healthy status is described by Health seeking behaviors. Health or care seeking behavior has
been defined as any action undertaken by individuals who perceive themselves to have a
health problem or to be ill for the purpose of finding appropriate treatment.7 Health services
utilization simply means the willingness of the would-be or potential patients to make use of
the most of the services offered at a medical establishment.4The health care utilization of a
population is dependent on their health seeking behaviour which has many determinants:
physical, political, socioeconomic and socio-cultural.
Researchers have long been interested in what facilitates the use of health services,
and what influences people to behave differently in relation to their health. Most theoretical
models view health care-seeking behavior as a result of rational individual choice.6 Although
many of these factors are similar across populations, exactly how they interact and influence
the actions of people is often unique to a population in the context of the environment they
live in.
Across the globe, no country can boast of a perfect health system that caters for the need of
the whole populace. According to Anderson and Newman, studies on the Analyses of the
determinants of medical care utilization in USA are receiving increasing attention because of
the emergence of a number of related societal values and perceptions including:
(1) A growing consensus that all people have a right to medical care regardless of their
ability to pay for this care.
(2) The general belief that certain disadvantaged population groups such as the “poor,”
blacks, Spanish-speaking Americans, American Indians, and inner city and rural residents,
are not receiving medical care which is comparable in terms of quality and quantity that is
available to the rest of the population.
(3) High expectations concerning the extent to which medical care can contribute to the
general health level of the population.
(4) Public consternation over “the crisis in medical care” stimulated by rapidly rising prices
and growing dissatisfaction about the availability of services.8
These reasons are not far from the situation in the African continent, Nigeria in this context.
Many low-income countries, Nigeria inclusive, have not been able to meet the basic
healthcare needs of their people, especially those in the rural areas.9With a population
estimate of more than 170 million, Nigeria is the most populous country in Africa and ranks
the 7th in the world. The percentage of the populace residing in the rural area is about 70% . It
has an annual population growth rate of 2.83% and the male female ratio is
50.9:49.1.10Nigeria’s overall health system performance was ranked 187th position among
the 191 Member States of the World Health Organization in 2000.11 Health status indicators
are worse than the average for sub-Saharan Africa. For example, 2013 estimates put life
expectancy in Nigeria at 55 years.12 It is assumed that improvement in health leads to
improvement in life expectancy, which is a robust indicator of human development.
Improvements in key health indicators have been slow and today Nigeria ranks among the
countries with the highest child and maternal mortality: infant mortality rate of 74 deaths per
1,000 live births, the Under-five mortality rate is 117 per 1,000 live births, and the maternal
mortality ratio is estimated at 560 per 100,000 live births.14 This is one of the highest in the
world.
Nigerian health system includes orthodox, alternative and traditional systems of
health care delivery. The Government recognizes and regulates these three systems. The
health care system in Nigeria accommodates both private and public health care providers. In
the public sector health care providers are under the three tiers of government; federal
(tertiary hospitals and some hospitals in federal institutions like universities), state (state
specialist and general hospitals) and local government areas (primary health care centers and
health posts). In the private sector, they are broadly categorized into those that provide
primary care (general practitioners), those that provide secondary care and those that provide
both primary and specialist care. There are also several non-governmental organizations and
donor- owned and operated facilities. Various Nigerian governments have made great
efforts toward the provision of healthcare facilities to its populace. Notable among these
efforts were the expansion of medical education, improvement of public health care systems,
provision of primary health care (PHC) in many rural areas.
According to the Federal Ministry of Health (2008), the total shares of public
ownership in 2004 on health facilities were 14,607 while the private sector accounted for
9,029 in Nigeria. Public and private health care facilities are sparsely provided in many rural
areas within the country. Moreover, clinics in rural areas often lack adequate equipment or
trained health personnel, and require payment before providing services. With over 70% of
inhabitants in Nigeria residing in rural communities, the overall health indices can only
improve if sufficient health facilities/projects are attracted to such areas.
Good health is a need for all and the choice of a particular healthcare system respond
to the laws of demand and supply, the demand for health care is a derived demand. Health
care is not demanded for itself but for the advantages that can be derived from being
healthy. This choice has been shown to be limited by factors such as availability,
accessibility, affordability of services of the health facilities, cultural beliefs, the situation per
time (i.e. urgency of care needed) and whether the kinds of services provided meet the need
of the user. In the health care system, patient satisfaction has emerged as an important
component that determines consumer choice of a product or service. Determining the
factors responsible for rural patient’s choice of health care providing facility cannot be
measured without considering several factors broadly grouped into Health System Related
Factors and Individual-Related Factors
1.2 STATEMENT OF PROBLEM
Health care utilisation is the use of health care services by people. Utilization of
healthcare services is an important determinant of health and has particular relevance as a
public health and development issue in low income countries. There are so many factors
that have been identified by researchers for poor utilization of modern health facilities. The
choice of health facilities for healthcare by an individual is largely determined by his/her
taste, satisfaction with service and the perceived quality of care provided. The underutilisation
of the health services in public sector has been almost a universal phenomenon in
developing countries.  While public primary health care (PHC) centers are relatively
uniformly distributed throughout local government areas (LGAs) in Nigeria, the rural people
tend to underuse the basic health services. For example, while less than half of PHC facilities
in Nigeria provide antenatal care (ANC), a reproductive health resource inventory carried out
by FMOH and WHO found that almost 60% of PHC offering ANC and delivery services had
no midwives and another 17% had neither midwives nor senior community extension
workers.
This has rendered them underutilized sometimes making the tertiary facilities
overburdened .
There seem to be higher use of private health facilities. This could be attributed mostly to
issues of easy access, shorter waiting time, longer or flexible opening hours, better
availability of staff and drugs, better attitude and more confidentiality in socially stigmatized
diseases. The utilization of private hospital was affected by the household size, the distance
of available hospital from home and the total cost of seeking health service . However, in
private hospitals, the quality of services, the responsiveness and discipline of the provider has
been questionable
1.3 JUSTIFICATION OF STUDY
In Nigeria, health care system comprises both public and private health facilities.
For one to be able to maintain a healthy state, the choice of health care services and
predictors of the choice are important. The health and health-related problems of rural people
include poverty, high endemic diseases prevalence, low level of available healthcare
facilities/infrastructures in the rural areas to mention a few. These affect their health
seeking behaviour, in this case health facility utilization compared with those individuals in
the urban setting. An assessment of these problems and needs is important to assure the
utilization of public health facilities for health care services by rural people. The behaviour of
the patient which is made evident by their choice of health care provider may also give an
insight into how these health facilities can improve on their service delivery, improve client
satisfaction and by extension ensure a healthier population. Other reasons for research of
this type includes support for consumer choice, enabling accountability, and quality
promotion on the part of health providers.
There are also arguments that the most important factors affecting an individual’s use
of health facilities in any given country may not necessarily have the same significance in
other countries because of the differences in environment, socio-cultural practices, belief
systems, the availability of health facilities and technology, differences in levels of
knowledge about illness and disease, which all differ between one country and another.
Because of such differences, caution must be exercised in generalising findings from one
country to another.
Although many policy and research initiatives have focused on the need to improve physical
access not enough is understood about what services and quality indicators affect health care
choices, and why low levels of utilization persists among certain socioeconomic groups or
geographic regions despite improved physical access. Also there is paucity of literature
specifically on factors that determine preference for the type (public or private) and the levels
of healthcare facilities visited first when ill especially when there are many options.
Furthermore, the findings of studies reporting on the use of health facilities are
inconsistent and the contributing factors vary from one study to another, perhaps because of
the varying methodologies used, differing medical care systems, different time periods and
the rhetoric of interpretation.
This study therefore intends to use state level data to showcase the impact of
recognized factors on public health facility utilization among rural dwellers in Nigeria.
Comparison will thereafter be made between the result obtained from this study and those
obtained from previous studies.
1.4 RELEVANCE TO PUBLIC HEALTH
Utilization of healthcare services is an important determinant of health and has
particular relevance as a public health and development issue in low income countries. In
fact, utilization of healthcare services for the most vulnerable and underprivileged
populations has been recommended by the World Health Organization as a basic primary
healthcare concept.
An individual’s choice of health facilities for healthcare is largely determined by
patient-related factors and provider-related factors and these affect patient’s health outcomes.
As a consequence, there is now greater emphasis on the encouragement of individual choice
and the opportunity to exercise it freely, the commitment of healthcare providers and all
stakeholders in healthcare to build mechanisms for ensuring quality of care.
Nigeria’s population is predominantly rural and the health needs of rural areas are
numerous. Public health advocates that there are the greatest burden of disease among the
poor and the underprivileged because of precarious living conditions and often inadequate
health services. Research on healthcare utilization is central to improvements in quality of
life. It is assumed that improvement in health leads to improvement in life expectancy, which
is an indicator of human development. Evidence has shown that among poor countries,
increase in life expectancy is strongly correlated with increase in productivity and income. Healthcare access and utilization are of major interest to rural development, because
they are vital elements of wellbeing and components of human capital. In rural areas, where
physical jobs tend to be more abundant, healthcare access and utilization stand to be more
important than education in determining labour productivity.
Understanding which factors are most important to health care utilization can assist in disease
prevention and treatment through creation of effective health campaigns, policies, and
promotion programs.
Health care management must discern the factors influencing health care utilization.
Identifying who will use which services and when these services will be used can help
organizations target consumers for medical contact. Importantly, this knowledge can also
help managers identify new customers, find out concerns of consumers who are rejecting
health services, and ultimately increase customer satisfaction.
1.5 AIM OF STUDY
1.5.1 GENERAL OBJECTIVE
To determine factors affecting the utilization of Public health facilities by rural dwellers in
Abia state south east Nigeria.
1.5.2 SPECIFIC OBJECTIVES
1. To determine the patient-related factors and provider-related factors affecting the use
of Public health facilities by rural dwellers in Abia state south east Nigeria.
2. To determine the health-related activities of rural dwellers in Abia state in response to
their ill-health.
3. To ascertain their level of satisfaction with the services received from the Public
health facilities.
4. To make suggestions that may improve utilization of available public health care
facilities within their communities