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Primary health centres are an effective means of achieving access to primary healthcare (PHC) in low- and middle-income countries. We assessed service availability, service readiness and factors influencing service delivery at public PHC centres in Enugu State, Nigeria. We conducted a cross-sectional study of 60 randomly selected public health centres in Enugu using the World Health Organization’s Service Availability and Readiness Assessment (SARA) survey. The most senior health worker available was interviewed using the SARA questionnaire, and an observational checklist was used for the facility assessment. None of the PHC centres surveyed had all the recommended service domains, but 52 (87%) offered at least half of the recommended service domains. Newborn care and immunization (98.3%) were the most available services across facilities, while mental health was the least available service (36.7%). None of the surveyed facilities had a functional ambulance or access to a computer on the day of the assessment. The specific-service readiness score was lowest in the non-communicable disease (NCD) area (33% in the rural health centres and 29% in the urban health centres) and NCD medicines and supplies. Availability of medicine and supplies was also low in rural PHC centres for the communicable disease area (36%) and maternal health services (38%). Basic equipment was significantly more available in urban health centres (P = 0.02). Urban location of facilities and the presence of a medical officer were found to be associated with having at least 50% of the recommended infrastructure / basic amenities and equipment. Continuing medical education, funding and security were identified by the health workers as key enablers of service delivery. In conclusion, despite a focus on expanding primary care in Enugu State, significant gaps exist that need to be closed for PHC to make significant contributions towards achieving universal healthcare, core to achieving the health-related Sustainable Development Goal agenda.
Enugu State is one of the 36 Nigerian states, located in the eastern part of Nigeria. The state has 17 LGAs, of which 12 (70%) are rural. The state has an estimated population of 3 267 837 (National Bureau of Statistics, 2006), divided into seven health districts. It has a total of 443 public health facilities, of which 250 are primary health centres, described as comprehensive health centres, each serving a catchment population of 10 000–20 000 people. We conducted a descriptive cross-sectional study of the service availability of PHC centres in Enugu State and their readiness to provide core PHC functions, within the context of the DHS policy implementation. The study sites were primary health centres selected by simple random sampling from a sampling frame of centres in each of the seven health districts (see paragraph below for details) to achieve the minimum sample size required. The most senior health worker available at each health facility was interviewed in each sampled facility, because PHC centres may differ in staff cadre availability or distribution. The sample size was determined statistically using the formula for estimation of proportion with a specified precision (Kirkwood, 2003). The required sample size, n, is given as p [1−p]/e2, where p is the proportion of primary health centres (21.9%) that met the stipulated service coverage in an assessment of PHC services in five Nigerian states (Christian Aid, 2015) and e is the standard error (5%). Accounting for non-response and losses with an expected response of 90%, an adjustment formula was applied as well as a correction formula for study populations <10 000 (Araoye, 2004), to give a total of 58.87 health facilities. This was rounded up to 60 primary health centres. The survey instruments were adapted from WHO’s SARA (WHO, 2015a,b) to reflect the Ward Minimum Health Care Package of the National Primary Health Care Development Agency. The questionnaire had structured sections for the data collection on general and specific service availability and on qualifications and continuous medical training. Services assessed included health education and promotion; nutrition; community outreach; reproductive, maternal, newborn and childcare; communicable diseases; and selected NCDs. The questionnaire had an open-ended section for health workers to note the factors that enable and constrain service delivery in the areas of funding, continuing medical education, maintenance of equipment and any other area. An observation checklist was used to collect data on communications, ambulance/transport for emergencies, power supply, basic client amenities, infection control, processing of equipment for reuse, healthcare waste management, supervision and basic equipment. The tools were pre-tested at a PHC centre which was not included in the final sample, to ensure they captured the correct range of services according to the national guidelines and were understandable by the respondent. Data were collected from July to December 2017 by the investigator (AE) and by two university undergraduates trained by the investigator in the administration of the study tools. The following domains were reported: staff, training, services, infrastructure or basic amenities, equipment, essential medicines and commodities (Table 1; Supplementary Appendix SA1 and SA2). Basic equipment was assessed in the following areas: infection control items, sterilization equipment, laboratory items and equipment in the wards, labour and consulting rooms. One point was given for each basic amenity/infrastructure, equipment and essential medicine if it was available, functional and not expired. A score of one was given to a facility with staff who had received pre- or in-service training in each of the four purposively specified (maximum score of four) interventions during the two years preceding the survey. Ward Minimum Healthcare Package recommendations for primary health centres Service-specific readiness refers to the capacity of a facility to provide a service that it offers (measured through consideration of tracer items that include trained staff, equipment, diagnostic capacity, medicines and commodities). Descriptive statistics were used for mean scores for PHC centre readiness in the SARA methodology specific-service areas (PHC staff training, maternal health services, child health services, communicable diseases and NCDs). Specific-service readiness and domain scores were calculated according to the SARA guidelines (WHO, 2015a). The specific-service readiness score was calculated as the mean availability score of tracer items across all domains in each facility calculated for the different specific-service areas in percentage. For each domain of equipment, diagnostics, medicines and commodities, we calculated a domain score as the mean availability of noted tracer items in each domain for the selected service-specific areas (maternal health, child health, communicable diseases and NCD). We compared mean availability between urban and rural PHC centres using the T-test. Fischer’s exact test was used to assess the association between availability of a medical officer in a facility and that PHC centre meeting at least half of the Ward Minimum Service Package, as well as the association between PHC centre locations (urban or rural) and meeting at least half of the Ward Minimum Service Package. A binomial logistic regression model was used to identify the independent factors influencing the availability of at least half of the Minimum Service Package in PHC centres. All statistical analysis was done at 5% level of significance. All analysis was done using SPSS version 20.0. The open-ended data were analysed using manual content analysis (Kumar, 2014). Ethical approval was obtained from the Ethics Committee of the authors’ institute. All participants gave written informed consent before responding to the questionnaire.
