Triple A Research Journal of Social Science and Humanity (ISSN: 2636-5472)

Vol.2(2): xxx - xxx, July 2018

Available online: http://www.triplearesjournal.org/jssh
Copyright ©2018 Triple A Research Journal

Full Length Research Paper

Economic Evaluation of The Effectiveness of Primary

Health Care Services in Cross River State
Opue, Job Agba1*, Otu Chris and Ekpe1 and Augustine Nyong2
1Department of Economics, University of Calabar, Cross River State, Nigeria
2Department of Economics, University of Ibadan, Oyo State, Nigeria
Phone: +2347062522700; Email: ngaji74@yahoo.com

ABSTRACT

This study examined the effectiveness of primary health care services

in Cross River State (CRS). The total number of 450 respondents was
sampled from the three senatorial districts of the state using a well-
structured questionnaire. The data collected were analysed using the
t-test of mean difference and the confidence interval analysis with the
aid of MINITAB statistical software. The results obtained showed that
there is disparity in accessibility to healthcare facilities between
Northern and Central Cross River State, while there is no disparity in
the effectiveness of primary health care services between the
Northern and Southern and between Central and Southern district of
Cross River State. The results also showed that there is no disparity
in government funding of health care services in the three senatorial
districts of Cross River State. Further analysis showed that there is
no disparity in the management of primary health care services
among the three senatorial districts in the State. Lastly, there is
disparity in the level of infrastructural amenities among the three
senatorial districts in Cross River State. On the basis of this, we
recommended in section 5.1.2 that CRS government should increase
her budgetary allocation for health care in line with the World health
Organization’s 15 percent of the total budget benchmark so as to
cater for motorable roads to health centres, employment of health
experts, provision of modern health care facilities, and above all, for
Corresponding Author:
the creation of more health care centres in CRS so as boost the
Opue, Job Agba effectiveness of primary health care services.
Department of Economics, University of Calabar,
Cross River State, Nigeria
Keywords: Evaluation, Effectiveness, Primary-health-care-services
Email address:
ngaji74@yahoo.com JEL CLASSIFICATION: C81, I18

BACKGROUND

Health is wealth. Nations are only as healthy as their
citizens. Health according to the World Health Organisation
(WHO) is not only the absence of illness or infirmity but
complete physical and mental wellbeing. Health is a basic
human right. Article 25 of the Universal Declaration of
Human Rights, states that every individual has the right to a
standard of living adequate for the health and well-being of
himself and of his family, including food, clothing, housing
and medical care. In pursuit of achieving this right, nations
and communities set up mechanisms of providing
healthcare for their citizens and members. Nigeria
established its National Health Policy in 1988, which aims to

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achieve health for all Nigerians by the year 2000. Primary
health care was adopted as the strategy to achieving the
goal of the policy. To assess the impact of PHC on the health
status of the country, it is important to take a brief look at the
health service pre-PHC.
The following problems were noticeable in the health
services prior to the adoption of PHC:
• Inadequate coverage: Coverage was very low often
below 35% with limited access for the rural communities
and the urban poor.
• Disproportionate high investment on curative service to
the detriment of preventive services.
• Weak management resulting in waste and inefficiency.
• Minimal community participation
• The lack of basic health statistics a major constraint at
major stages of planning, monitoring and evaluation of
health services.
• Inadequate funding which acts as constraints to
performance.
• Defective, poorly maintained infrastructure, equipment
and logistic supports.
• The World Health Community in Alma Ata in 1978
adopted Primary Health Care as the key to providing
health for all by the year 2000.
Primary Health Care is essential health care based on
practical, scientifically sound and socially acceptable
methods and technology made universally accessible to
individual and families in the communities and through their
full participation and at a cost that the community and
country can afford to maintain at every stage of their
development in the spirit of self-reliance and self-
determination.
Primary Health Care snowball into Cross River State
through the Ministry of Health, with the aim of providing and
managing a comprehensive and integrated quality
healthcare delivery to the people of Cross River State, with
emphasis on meeting the needs of the poor particularly
those in rural communities. The mission objectives of the
ministry were:
• Integration of disease prevention and control
programmes into routine healthcare provision.
• Establishment of a medical emergency response
programme to cater for the needs of the injured and
critically ill supported by the provision of an ambulance
and paramedical service, accessible 24 hours.
• Establishing teams of primary health care providers to
enhance health care services available to rural
communities. These teams will be led by NYSC doctors
and will work in collaboration with Local Government
Primary Health Care Providers.
• Upgrading health care facilities and equipment and
enhancing of professional skills of health care providers
through continual training.
• Building linkages and encouraging partnerships with
private sector health providers as a means of increasing
access to timely and quality health for the people of
Cross River State.
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It is in this light that this study seeks to investigate and
assess the service/ organizational factors and client’s
perceptions that influenced the utilization of Primary Health
Care (PHC) facilities and its implementation in Cross River
State of Nigeria.
Despite huge government spending, coupled with
bilateral and multilateral assistance in the health sector, the
patterns of health status in Cross River State mirror many
states in Nigeria, but are worse than would be expected
given the state level of per capita Gross State Product. The
health system is in shambles, policy somersault and
reversals tend to have undermined several reforms in the
health sector over the years. Poor human resources and
policy management have led to unprecedented brain drain
in the health sector as health professionals in search for
better conditions of service in other states often vote with
their feet in droves.
Cross River State health system is in comatose, few
hospitals with few drugs, inadequate and substandard
technology and a lack of infrastructural support, including
electricity, water and diagnostic laboratories resulting in
misdiagnosis. Medical record keeping, and diseases
surveillance is very poor. Delivery of primary health care
becomes a personal affair and dependent on ability to pay
for basic laboratory and physician services. Health care
financing is worse hit especially in the poor communities
where healthcare faces serious problem of acceptability with
out-of-pocket expenditure due to high disease burden on
most poverty-stricken households has kept them in the
vicious cycle of the poverty trap.
There has been too much concentration of medical
personnel at the urban to the neglect of the rural areas.
Another significant problem in the management of PHC is
transportation. It has been reported in LGA PHCs that there
are not enough vehicles for workers to perform their task
especially to the rural areas. Immunization outreach
services are inadequately conducted. The maintenance
culture of the existing vehicles is poor while PHC vehicles
were used for other purposes other than health-related
activities.
Lack of adequate integrated system for disease
prevention, surveillance and treatment has manifested into
lack of targeted effort at outreach, health promotion and
disease prevention activities designed to reach the people
where they are. This has resulted in low immunization
coverage, pre-national care and screening public health,
where it exists, is in a passive mode, with little activity
designed to motivate people to change their behaviour or to
adopt attitudes and practices that reduce their risk to
disease. The result is that many children are still not
immunized, pregnant mothers do not receive the pre-natal
care they need, older men and women do not have the
regular screening they need for blood sugar and cholesterol,
for breast and cervical cancer. When health professionals
refer to low incidence rate for cancer in Cross River State,
they forget that what is not screened for is not reported.
Given the extremely low screening rates for cancer,
diabetes, hypertension and other chronic and
communicable diseases, no wonder the reported incidence
and prevalence rate are low too! It is against this backdrop
that this study seeks to evaluate economically the
effectiveness of Primary Health Care Services in Cross
River State.
OBJECTIVES
The broad objective of this study is to evaluate from an
economic perspective the effectiveness of Primary Health
Care Services in Cross River State of Nigeria. The specific
objectives are as follows:
• To evaluate the level of accessibility to Primary Health
Care Services in Cross River State.
• To evaluate the level of funding of Primary Health c\are
Services in Cross River State.
• To evaluate governance/administrative/management
leadership in the discharge of Primary Health Care
Services in Cross River State.
• To assess the level of infrastructural amenities available
in the provision of Primary Health Care Services in
Cross River State.
LITERATURE REVIEW
Some studies have been made on the effectiveness and
implementation of primary health care in Nigeria. Oyegbite
(1989) postulated that a decision was taken by the Federal
Government to build a basic health care centre in every local
government headquarters to enhance a model health
service to the rural dwellers with community involvement
and participation. It was also observed by Metiboba (2005)
that the scheme still suffers from inadequate awareness for
mass mobilization for increased involvement of the citizenry
in primary health care services. A greater proportion of rural
population in many communities do not seem to know what
PHC all about is, nor are they aware of the various services
under PHC scheme. Rural dwellers are isolated from the
local government headquarters where the services and
activities of PHC are well felt and enjoyed. The rural dwellers
therefore need a wide range of information to access the
services of PHC in order to improve in their health education.
Onyejiaku (1990) argued that despite international
prestige accorded primary health care (PHC) as evidenced
by the numerous philosophical papers, workshops and
projects carried out in its name, the impact of PHC is still
relatively unknown. In many cases, the effectiveness of a
PHC project is difficult to assess, particularly when it
involves multisectoral interventions and different health
outcomes. Cross Sectional studies often falter when trying
to gauge the long-term effects of specific interventions. The
reasons were poorly kept or that the PHC success is
evaluated in terms of rural clinics constructed rather than in
population health parameters.
Zeitz et al. (1993) asserted that management of primary
health care (PHC) system in less developed countries is
often impeded by factors such as poorly trained personnel,
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limited financial resources, and poor work morale. The study
explored the ability of local level PHC supervisors in rural
Nigeria to use quality assurance (QA) management
methods to improve the quality of PHC system. PHC
supervisors from Bama Local Government Area were
trained for three days in the use of QA methods and tools.
The supervisors targeted the supervisory system and the
health information system (HIS) for improvement. Health
worker performance in diarrhea case management was
assessed, using a simulated case to measure the impact of
supervision. A HIS audit assessed data collection forms
used by seventeen PHC facilities. Gaps in quality were
monitored over a 2-month study period and flaws in work
processes were modified. PHC supervisors introduced a
checklist during monthly visits to facilities to monitor how
workers managed case of diarrhea. Performance in history
taking, physical examination, disease classification,
treatment and counselling improved over the evaluation
period. The HIS audit found that a variety of reporting was
standardized, the number of health facilities using a daily
disease registry significantly improved during the period.
Conclusively, QA management method were used by PHC
supervisors in Nigeria to improve supervision and the HIS.
QA management methods are appropriate for improving the
quality of PHC in Nigeria and in other less developed
countries where at least a minimal PHC infrastructure exists.
Uzochukwu (2002) compared the level of availability
and rational use of drugs in primary health care (PHC)
facilities where the Bamako Initiative (BI) drug revolving fund
programme has been operational, with PHC centres where
the BI-type of drug revolving fund programme is not yet
operational. The study was undertaken in twenty-one PHC
centres with BI drug revolving funds all in Enugu State of
Nigeria. Data were collected on the essential and non-
essential drugs stocked by the facilities. Drug use was
determined through analysis of prescriptions in each health
centre. The proportion of consumers that were able to
remember their dosing schedules was determined. An
average of 35.4 essential drugs was available in the BI
health centres compared with 15.3 in the non-BI health
centres (P < 0.05). The average drug stock was adequate
for 6.3 weeks in the BI health centres, but for 1.1 weeks in
the non-BI health centres (P < 0.05). More injections (64.7 v
25.6%) and more antibiotics (72.8 v 38%) were prescribed
in BI health centres than in the non-BI health centres (p <
0.05). the BI health centres had an average of 5.3 drugs per
prescription against 2.1 in the non-BI health centres. But the
drugs prescribed by generic name and from essential drug
list were higher in the BI health centres (80 and 93%) than
the non-BI health centres (15.5 and 21%, respectively) (P <
0.05). It was observed that the BI facilities had a better
availability of essential drugs both in number and in average
stock. The BI has given rise to more drug prescribing, which
could be irrational. The findings call for strategies to ensure
more availability of essential drugs especially in the non-BI
PHC centres as a strategy to decrease medical costs and
improve the quality of PHC services, while promoting
rational drug use in all PHC centres. More detailed studies
(for example, by focus group discussion or structured
interviews) should be undertaken to find out reasons for the
over-prescription and to develop future interventions to
correct this.
Asuzume (2004) used the history of primary health care
in Fiji to find out the present PHC policy situation at all the
management levels as well as the dynamics of community
mobilization and PHC service extension. Findings were to
be used to propose the strengthening of the implementation
of PHC in the country. This is a mail questionnaire study of
managers at all three levels of the health services for the
historical study and those at the district health system for the
PHC implementation. Fiji has had a very active primary
health care programme. Community mobilization and health
services extension was initially very active and health status
indices improved greatly. But this momentum has dropped
due to reduction in following the initial directives for his
purpose as at the early part of the programme. It was
recommended that the programme of community health
service extension be restored as a matter of a national
written policy. The medical officers in charge of PHC should
be trained in community medicine as before, in order to
regain the lost momentum.
Chukwuani (2006) took a survey to audit PHC
operations and determine community perception and
expectations of PHC service delivery in Enugu State. An
expectation of PHC service delivery was conducted in 72
communities in Enugu State, southeastern Nigeria. The
study was intended to facilitate the development of
intermediate performance indicators for monitoring the
progress of an ongoing health sector reform and to gather
baseline data for planning and policy formulation. The tools
used for the operations audit assessed indicators for
evaluating stewardship, service provision and administrative
and financial management, while the community survey was
assessed by utilization of health services, perception of
service delivery and healthcare financing. One hundred and
sixteen respondents from each of the facilities in the sample
frame were interviewed using a structured self-assessment
questionnaire and a qualitative assessment was undertaken
in 53 of the facilities using an audit guide. Focus group
discussions (FGD) were conducted with the policy makers
and planners in each of the 17 LGAs in the state. A total of
832 respondents were interviewed in the communities
(using a structured questionnaire) and 42 community FGDs
were conducted. The results indicate a lack of operational
deficiency in the majority of the facilities audited. It was also
observed that majority of the facilities do not provide all
services required of it, are poorly maintained, do not have
enough skilled health workers and operate without a budget.
There appears to be no formal financial management
system in place and no policy on financial resource
generation. The community survey identified two major
problems: low utilization of PHCs and poor service
provision. The key indicator identified by the community for
evaluating performance of the PHCs remains “Access to
essential drugs.” The major prospect was the willingness of
an appreciable number of respondents to invest in health
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financing through insurance schemes and payment of health
tax among others. It was evident that poor funding, bad
management practices and infrastructural decay is the bane
of efficient PHC delivery. Consequently, he proposed that
cost determination studies, to establish implication of the
minimum package for provision of primary health care
services, should be an essential prerequisite to the reform
process. Some critical cross-cutting issues identified from
the data obtained which could form the basis for major policy
thrust include, development of strategies for sustainable
promotion of public-private partnership for enhanced
community involvement in health care management,
ensuring that interventional investment is proportional to the
felt health needs of the populace and funding of healthcare
through equitable integration of user fees/charges.
Sule (2008) assessed service/organisational factors
and clients’ perceptions that influenced utilization of primary
health care (PHC) facilities in a rural community in Nigeria.
A cross-sectional household survey in the community as
well as key-informant interviews of opinion leaders and
healthcare providers and participants observations for
health facilities and utilization pattern was used to collect
data. Forty-four percent of respondents to the survey who
were ill in the preceding six months visited a PHC facility for
treatment, while others relied on self-medication/self-
treatment. Education was positively associated with
utilization of PHC services (P <0.05). Maternal and child
health (45.4%), prompt attention (23.0%) and appropriate
outpatient (20.5%) services attracted respondents to use
PHC services. Poor education about when to seek care,
poverty, perceived high cost of PHC services, lack of drugs
and basic laboratory services, and a regular physician on
site at the facility were identified barriers to utilization. He
finally concluded that community perceptions of poor quality
and inadequate available services was responsible for low
use of PHC services.
Lawan (2009) provides a review of studies on primary
health care prior to his. That health care system in Nigeria
has been developed at three levels, the extension of health
care to all people has been an objective of all National
Health Systems for many years since the Alma Ata
Conference on Primary Health Care (PHC) in 1978.
Decades after the take-off of PHC in all parts of this country,
the goals of health for all and beyond is still far from being
attained. The management activities of primary health care
facilities in plateau state were investigated. A multistage
sampling method was used to select 30 PH facilities from 10
randomly selected LGAs out of the 17 local government
areas (LGAs) of plateau state. All the heads, the secretaries
and the chief matrons of the selected facilities were
interviewed using self-administered structured
questionnaires. Responses were scored using a
dichotomous scale and categorized into poor, fair, good and
excellent performances, and analysed using Epi info 23.05
2003 statistical software. Out of 90 workers interviewed
68.9% were female and 85.6% were married. 74.4 percent
of the respondents were between 30-44 years of age, 43.3%
of the workers worked at the Basic Health Clinic (BHCs)
while 20% of them worked in Comprehensive Health Centre
(CHCs). A statistically significant difference in scores of
management activities between the various types of PHC
facilities was observed (F = 2.81, P<0.05). The management
staff in most of the primary healthcare facilities lack
resources at their disposal and this hinders the efficient and
effective running of the facilities. Lack of transportation and
poor maintenance of those available would seem to be
major constraints to the effective running of the health
facilities.
Wakerman (2009) describes the factors and processes
that facilitates or inhibit implementation, sustainability and
generation of effective models of primary health care (PHC)
service delivery in rural and remote Australia. Six PHC
services in small communities across rural and remote
Australia were selected based on results of a previous
systematic review; they reflected diverse rural and remote
settings and PHC models, and the multidisciplinary nature
of PHC site were visited, and 55 individuals associated with
the establishment and operation of these services were
interviewed between July 2006 and December 2007.
Independent and template analysis confirmed the
usefulness of a conceptual framework, which identified three
key “environmental enablers” – supportive policy; federal
and state/territory relations; and community readiness and
five essential service requirements – governance,
management and leadership; funding, linkages;
infrastructure; and workforce supply. Systematically
addressing each of these factors improve effectiveness and
lessens the threat to service sustainability. Evidence from
existing effective rural and remote PHC services can inform
the health care reform agenda, in Australia and other
countries. The evidence highlights the need for improved
governance, management and community involvement, as
well as strong visionary political leadership to achieve a
more responsive and better coordinated health system
which could help eliminate existing health status differentials
between cities and rural areas.
THEORETICAL FRAMEWORK
Attribution Theory
Attribution theory as applied to health care management, is
a way of assessing the successes and failures of a health
care system or program. According to Patrick Palmieri and
Lori Peterson (2009), attribution theory is described as one
possible health care management theory that can be used
to create a safer environment for patients. Although not fully
developed as a healthcare management theory, the authors
suggest that attribution theory can be used as a conceptual
framework to foster a positive and safe work environment for
both health care workers and patients. Attribution theory
assumes health care management can be improved by
understanding that error in health care can sometimes
occur. When it does it can lead to feelings of cynicism and
“organisational inertia” in the health care system. By
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understanding where these feeling arises, health care
managers can learn to foster a positive work environment
that will improve employee response to errors in health care.
By learning to recognize these mistakes as simply “human”
errors, health care workers can learn to focus on continuing
to provide a positive environment for patient recovery rather
than focusing on what they have not done successfully.
Evidence-based Management
A second health care management theory is the evidence-
based management theory. A 2001 report by K. Walshe and
T. G. Rundall at the University of Birmingham suggests that
health care managers have been slow to accept and apply
the same theories to which they often hold health care
workers, an evidence-based approach that requires doctors,
nurses and other health care professionals to make
decisions based on the best available evidence. Some
researchers like Walshe and Rundall suggest that there is a
need to impose these same standards on the decision-
making process of health care managers. Doing so will bring
a level of uniformity to the decisions of health care officials.
Practical considerations such as time constraints and
deadlines often make the transition from evidence-based
theory to practice somewhat difficult.
Utilisation Management
Utilisation management is a third health care management
theory, one that has received wider application in the health
industry than the more theoretical attribution and evidence-
based theories. Utilisation management is a proactive
approach to managing health care through present
guidelines. The American College of Medical Quality
identifies several tasks in utilization management that are
essential to effective management of a health care
organisation. Fist it is essential to determine the
organisation’s priorities. This is followed by research and a
determination of who will benefit from the major decisions
that are made. From this information, health care managers
then determine what goals to set and how to go about
implementing further research. Once data is collected and
evaluated, policies, guidelines and procedures can be
developed and implemented.
Bureaucratic Theory
The bureaucratic theory of management is one of the oldest
in use today. Organisations of all sizes and in many
industries use it. Bureaucratic management involves a few
people at the top making decisions and a chain of middle
managers and lower-level people below them carrying out
specific functions with limited authority. Orders come from
the top down in a manner mimicking the military. Health care
organisations – especially hospitals and insurance
companies – have traditionally used bureaucratic
management because it creates consistency and precision.
Through specialization, each member of the organisation
does a limited number of things frequently and ostensibly
very well. For example, nurses take care of their patients
and don’t consider larger organisational issues. Similarly,
nurse managers oversee their nurses, but don’t concern
themselves with issues involving the medical staff.
Patient-Centered Management
Both changing attitude toward patient care and the
healthcare business environment have led many
organisations to adopt a patient-centered approach to
management. Instead of developing systems that top
managers consider easiest to oversee or the most cost-
efficient hospitals and healthcare providers organize
themselves in a way that enables them to deliver the best
patient care possible. The idea is that through medical and
service excellence, organisations will achieve the best
financial results. Often top managers promote collaboration
between departments and interdisciplinary approaches to
medicine not seen in the traditional bureaucratic
management style.
Scientific Management
Management who wants specific results often rely on
scientific management theory to guide their operations.
Scientific management designs organisational structure to
achieve particular benchmarks and outcomes. Authority is
typically delegated to a larger degree than in a bureaucratic
system, although departments are designed and staffed with
specific purposes in mind. For example, a hospital using
scientific management structure, staffing and number of
beds allocated to a post-anesthesia care unit to care for a
specific number of patients per year. In its approach to
managing staff, a scientific-management-driven facility will
typically evaluate nurses based on several objective
performance indicators including productivity, number of
patients seen, days absent and documentation detail.
Contingency and Resource Theories
Health care is an industry in constant flux. Besides changes
in medical practice itself, insurance, medicare and
regulations change regularly. Contingency management
theory says management should stay flexible and remain
capable of reorganizing structurally and procedurally as
needed to keep up with demands and requirements.
Resource theory compliments contingency theory by
positing that organisations sometimes need to manage
based on available resources in their environments. That
means as costs, labour, supplies and specialists on staff
change, so much health care organisations. Both theories
carry the idea that, rather than allow outside forces to create
organisational panic, organisations can adopt management
approaches rooted in change.
Triple A Research Journal of Social Science and Humanity (JSSH) | Vol.2 No.2 | July 2018
An Overview of Primary Health Care Programme in
Cross River State
To sustain and be effective in delivering Primary Health Care
services to the people in Cross River State, especially
among rural dwellers and hard-to-reach communities, Cross
River State initiated a partnership with Tulsi Chenrai
Foundation (TCF) in 2009 to improve the status of Primary
Health Care program in the state.
The baseline survey conducted in 2010 indicated that the
Infant Mortality Rate was 75/1000. Under 5 years-mortality
was 157/1000, material mortality rate was 545/1000, Ante-
natal coverage was only 55 per cent, skill birth attendance
by health workers was 39 percent and only 74% of one-year
old children were fully immunized.
Goals of partnership with Tulsi Chenrai Foundation and
Cross River State are to achieve the following:
Infant Mortality Rate – 30/1000 live births; Under-5 Mortality
Rate – 75/1000 live births; Maternal Mortality Rate –
250/1000 live births; Antenatal Coverage – one visit: 95%,
four visits: 85%; Skilled Birth Attendance by health workers
85%; One-year child fully immunized – 90%
Targeted Population and Reach
The beneficiaries of the program are population dwelling in
the remote areas of Cross River State. The Cross-River
State is divided into 18 local government areas (LGAs). The
program will cover all 18 LGAs in a phased manner. 2 LGAs
covered in 2010, 6 LGAs in 2011, another 6 LGAs were
covered in 2012 and 4 LGAs in the final phase will be
covered this year.
The Scope of work in CRS includes:
1. Establishment of health facilities for every 500 families
with community participation
2. Training of health workers in basic midwifery skills.
3. Establishment of a viable health management
information system.
4. Provision of drugs with a functional revolving fund
mechanism.
5. Monitoring, supervision of the health facilities.
6. Ensuring community participation to create ownership at
the grassroots.
Work in Progress
• TCF so far has covered 14 LGAs namely Abi,
Akpabuyo, Bekwarra, Biase, Ikom, Obubra, Obudu,
Odukpani, Obanliku, Yala, Boki, Etung, Yakurr, Bakassi.
• For supporting the implementation of the program and
for monitoring and supervision TCF has appointed two
program managers for South and North Senatorial
Districts of the State in addition to Director – Primary
Health Care and General Manager –Administration
• In 14 LGAs, a total of 621 health facilities are operational
and managed by TCF, benefiting 1027 communities
with a population 2,460,820.
• Essential equipment and instruments have been
supplied to all health facilities after taking existing
inventory.
• A fresh baseline survey in 14 LGAs has been initiated to
take stock of the health situation of the population.
• Under the project, 8 ambulances and 9 pickup vehicles
have been made available by the Government to enable
doctors to reach out to remote areas and to quickly
transport serious patients to primary health centres or to
the general hospital in Calabar.
• Health workers have also been provided 102
motorcycles for their outreach programs.
• Identified 94 health facilities with erratic power supply
are provided with generators.
• In 14 LGAs, 13 local doctors have been appointed; one
vacancy will be shortly filled.
• Drugs stores with essential medicines have been
refurbished in 8 LGAs. Seed drugs are supplied to 8
LGAs.
• Health staff appointed by Local Government Service
Commission: Community Health Extension Workers –
618, Nurse Midwives – 167, Laboratory Technicians –
98, Pharmacy Technicians – 98, Drivers – 28.
• 980 CHEWS have been trained in Basic Midwifery Skills
and Basic Eye Care.
• Refurnished Drug Stores with Drugs supplied by DRF
Committee.
• Central Drug Revolving Fund (DRF) Committee and
LGA DRF Committee have been constituted to monitor
the supply and consumption of essential drugs in health
facilities.
• Task forces consisting of TCF representatives, LGAs
representatives and government officials have been
constituted in 8 LGAs to monitor the effective functioning
of health facilities. Joint review meetings are being
conducted at regular interval with community leaders to
assess the impact on the ground.
• Mostly performance reports are collated from the health
facilities, which are being reviewed by Taskforces,
community leaders and TCF representatives and
feedback is sent back to the health facilities.
Impact: January 2012 – March 2013
While TCF has reached out to 14 LGAs till date, health
facilities in 8 LGAs (Abi, Akpabuyo, Bekwarra, Biase, Ikom,
Obubra, Obudu and Odukpani) are fully operational. Health
reporting is fully functional in these 8 LGAs from January
2013.
• 28,679 people have been provided primary healthcare
service by trained community health workers and
doctors.
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• Community health workers have registered 5953
pregnant women (12 weeks above) and ante-natal care
has been provided.
• A total of 3304 deliveries have been registered out of
which 3123 have been performed by health workers.
• 2,789 infant’s weights were recorded at the time of the
birth out of which 1,527 infants were between 2.5 –
3.0kgs and 1104 infants were above 3kgs only 158
infants were below 2.5kgs.
• A total of 14,206 infants have been registered in health
facilities out of which 6133 infants are fully immunized
against BCG, DPT, measles, hepatitis, yellow fever and
7421 have been partially immunized, their immunization
will be completed in due course of time.
• 34349 children under 5 years of age have been weighed
at the health facilities. Out of which 341 children were
identified as malnourished. 303 children were put on
supplementary feeding out of which 196 have been
graduated to normal weight.
• Pregnant women and under-5 children are given drugs
free of cost by the government under the free health
scheme called project HOPE and this program is
coordinated by Tulso Chenrai Foundation.
RESEARCH METHODOLOGY
Research Design
The research design used in this study is both qualitative
and quantitative in nature. The qualitative design adopted
the survey method. According to Asika (2002), a survey is a
scientific experiment conducted on a large scale on a
defined population to determine some desirable
characteristics of a designed population. For the purpose of
this study, the sample survey adopted is aimed at collecting
sample from the population in order to evaluate the
effectiveness of primary health care services in Cross River
state. The quantitative design employed was empirical in
nature through the use of MINITAB software package. The
relevant data for this study were obtained from
questionnaire administered during the sampling process.
Area of Study
The research area of study is Cross River State which is one
of the thirty-six States in Nigeria with eighteen local
governments (LGAs). Located in the Niger Delta, Cross
River State occupies 20,156 square kilometres. The State
shares boundaries with Benue State in the North, Ebonyi
State in the North West, Akwa Ibom State in the South West,
Cameroon republic in the East and Cross River in the South.
The state is ethnically diverse, including Efiks, Bekwara, and
Ejagham inhabitants. Efik is very widely spoken in Cross
River State because it used to be a language of trade and
commerce in the 19th and early 20th centuries. Other
languages spoken are Ekoi, Etung, Boki and Becheve. The
Becheve people have linguistic affinity with the Tiv of Benue
State. The people's wood carving, stone sculpture, raffia and
cane works, pottery and silver works are highly valued in and
outside Nigeria. The State is mainly rural. Even the State
capital Calabar, can best be described as sub-urban town.
The state has an estimated population of 2.89million
according to 2011 census. The topography of the state is
essentially that of a typical rainforest with creeks and rivers
of significance including Cross River from where the name
of the state is derived.
The Cross-River State economy is predominantly
agricultural and is sub-divided into two sectors - the public
and the private sectors. The private sector is dominated by
local subsistence farmers while the public sector is run by
the Government and features large plantations and
demonstration farms. The main crops are cassava, yams,
rice, plantain, banana, cocoyam, maize, cocoa, rubber,
groundnut and palm produce. The State government places
emphasis on fish farming as a measure to diversify its
economy. To this end, it took measures to boost fish
production in areas including: fish farming, processing,
storage, marketing, in-shore fishing and monitoring of fish
resources. Major livestock in the State are cattle; goats and
sheep. Rearing activities are mainly undertaken by local
farmers and nomadic Fulanis, except in Obanliku at the
Obudu Cattle Ranch where organised cattle ranching takes
place. The raising of poultry, pigs, rabbits and turkeys is
carried out on a commercial scale in some parts of the State
but mainly in Calabar Municipality. Mineral resources in
Cross River State include limestone, titanium, tin ore,
ceramic raw materials and hard stone. The people are
predominantly fisher men, farmers and service renders. A
few are also civil servants. There are few industries in the
state despite its oil production status.
As regards tourism, Cross River State offers both its
visitors and interested indigenes many centres of attraction.
The outstanding ones are Obudu Cattle Ranch, Obudu, Old
Residency Museum, Calabar, Agbokin Waterfalls, Ikom,
Etanpim Cave, in Odukpani local government area and Mary
Slessor's Tomb, Calabar, Cross River National Park and
Kwa Falls in Akamkpa local government area, Obubra Lake,
Obubra and the Calabar Cenotaph, Calabar, Beaded works
which are a peculiarity of Cross River State are sold in crafts
shops. Common works are beaded bags, beaded wall
hangings, and shoes, Ekpe masquerade made with rafia,
cane chairs, brass trays, raffia clocks, motif work and a lot
more.
Population Sample
The required population for this study is taken from sample
respondents taken from the selected villages in the local
government area. The targeted population for this study
include the various primary health care centres spread
across the 18 local government areas in the state. The total
population sample for this study is made up of 450
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respondents, which will be selected based on the probability
sampling method used by the researcher. Of the total
population of 450, 150 respondents are sampled from each
of the three senatorial districts of the state. The sampled
population included both the primary health care providers
and members of the public who selected during the process
of sampling.
The above sample is a representative of the entire
population of the local government area, whose responses
are used as a representation of a wider view.
Sampling techniques
The sampling technique adopted for this study is a stratified
random sampling technique. In this technique, the study
area is sub-divided into Strata and members are selected
which form the variables for the study (Ndiyo, 2005). Here,
one first identifies the Strata of interest and then draws a
specified number of subjects from each stratum.
For the purpose of this study, the various primary health
care centres in each of the local government across the
three senatorial districts are the required strata and each
stratum represents the respective sampled population
identified and visited by the researcher during the survey
process. One advantage of this sampling technique is that
the researcher can determine to what extent each stratum
in the population is represented in the sample. Also, the
technique allows the diversification of opinions.
Instrumentation and data collection procedure
To collect data for this study, a carefully structured
questionnaire was designed and administered by
researcher personally with the help of some assistants. The
measuring instrument used by the researcher for this
research study is a four–point Likert scale–type
questionnaire. The questionnaire is divided into two
sections. Section one contains information regarding
respondent’s personal details. Sections two contains
information pertaining to our subject of study based on the
hypothesis to be tested.
Each response was given a degree of scores which
range from one to four as shown below;
Strongly agree SA 4Points
Agree A 3Pionts
Disagree D 2Pionts
Strongly disagree SD 1Point
Reliability of the Instrument
A pilot test exercise was carried out by the researcher on 50
respondents from the sampled population for the purpose of
establishing test-retest reliability. The respondents were
asked to complete the questionnaire and then asked to
complete it again after two weeks. The Pearson Product-
Moment Correlation Coefficient was then computed for the
two sets of responses for the reliability of the overall score.
The high value of the Pearson Product Moment Correlation
Coefficient indicates that there is a correlation between the
two pre-test responses, and hence the reliability of the
instrument.
Methods of Data Analysis
The analysis is carried out using the t-test of mean
difference and the confidence interval analysis. The purpose
of the test is to validate or invalidate the formulated
hypotheses.
PRESENTATION AND ANALYSIS OF RESULTS
Presentation of Results
This section presents the test results on the hypotheses
formulated in this study.
• Primary Health Care Accessibility: The results of
primary healthcare accessibility in Cross River State are
presented in tables 1, 2 and 3.
• Government funding of healthcare in Cross River State:
Tables 4, 5 and 6.
• Management of Health Care in Cross River State:
Tables 7, 8 and 9.
• Health Care Infrastructures in Cross River State: tables
10, 11 and 12.
Analysis of Results
The empirical results as presented in table 1 above showed
that the calculated t-statistical value of 10.37 is greater than
the critical t-statistic of 1.96 at five percent of significance.
Since the t-value falls in the critical region, the null
hypothesis is rejected while the alternate hypothesis is
accepted. Hence, there is significant difference in the
accessibility to healthcare services in the Northern and
Central Cross River State. There is therefore a 95 percent
confidence that the difference lies between -6.492 and -
9.548.
The results as presented in table 2 showed that the
calculated t-value (0.23) is less than the critical t-value (1.96)
at five percent level of significance. Since the calculated t-
value is less than the critical value, the null hypothesis is
accepted while the alternative hypothesis is rejected and
hence there is no significant difference in the level of
accessibility to healthcare services in the Northern and
Southern Cross River State. Thus, there is 95 percent
confidence that the mean difference in accessibility lies
between -1.074 and 0.848.
Lastly, the result as shown in table 3 indicates that the
calculated t-value of 0.86 is less than the critical value of
1.96 at five percent level of significance. Therefore, the null
hypothesis cannot be rejected; hence there is no significant
difference between accessibility and effectiveness of health
care services in the Central and Southern Cross River State.
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From the analysis above, we can conclude that there is
disparity in accessibility to healthcare facilities between
Northern and Central Cross River State, while there is no
disparity in the effectiveness of primary health care services
between the Northern and Southern and between Central
and Southern Cross River State.
The results as presented in table 4 showed that the t-
value of 1.96 at five percent level of significance. Since the
t-value calculated is less than the critical value, we do not
have evidence to reject the null hypothesis. Thus, there is
no difference in government funding of health care services
in the Northern and Southern Cross River State.
Similarly, the results as presented in table 5 showed that
the t-statistics value calculated of 0.87 is less than the critical
value of 1.96 at five percent level of significance. Since the
calculated t-value is less than the critical value, we accept
the null hypothesis and reject the alternate hypothesis and
conclude that there is no significant difference in funding of
healthcare services in the Central and Southern Cross River
State.
Further examination of the results as presented in table
6 showed that the calculated t-value of 0.74 is less than the
critical value of 1.96 at five percent level of significance.
Therefore, there is no significant evidence to reject the null
hypothesis and hence conclude that there is no difference in
government funding of health care services in Northern and
Central Cross River State.
Further examination of the results as presented in table
6 showed that the calculated t-value of 0.74 is less than the
critical value of 1.96 at five percent level of significance.
Therefore, there is no significant evidence to reject the null
hypothesis and hence conclude that there is no difference in
government funding of health care services in Northern and
Central Cross River State.
In conclusion, the results revealed that there is no
significant difference in government funding of health care
services in the three senatorial districts of Cross River State.
This means that government funding of health care system
has been fairly distributed across the three senatorial
districts.
The results as presented in table 7 showed that the t-
statistic value calculated of 0.36 is less than the critical value
of 1.96 at five percent level of significance. Therefore, there
is no evidence to reject the null hypothesis that management
leadership does not have significant impact on health care
services in the state. Hence, there is no significant impact of
management leadership on primary health care services in
the Northern and Central Cross River State.
In the same vein, the results as presented in table 8
showed that the t-statistics value calculated of 0.32 is less
than the critical value of 1.96 at five percent level of
significance. The null hypothesis is therefore accepted,
while the alternative hypothesis is rejected. We conclude
that there is no significant difference in management
leadership on primary health care services between
Northern and Southern Cross River State.
Further examination of the results showed that there is
Table 1: Primary Health Care Accessibility in Northern and Central Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Northern CRS -10.37 ± 1.96 -9.548
Central CRS -10.37 ± 1.96 -6.492
Level of significance = 0.05

Table 2: Primary Health Care Accessibility in Northern and Southern Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Northern CRS -0.23 ± 1.96 -1.074
Southern CRS -0.23 ± 1.96 0.848
Level of significance = 0.05

Table 3: Primary Health Care Accessibility in Central and Southern Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Central CRS -0.86 ± 1.96 -1.514
Southern CRS -0.86 ± 1.96 0.594
Level of significance = 0.05

Table 4: Government Funding of Health Care in Northern and Southern Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Northern CRS -0.47 ± 1.96 -0.602
Southern CRS -0.47 ± 1.96 0.976
Level of significance = 0.05

Table 5: Government Funding of Health Care in Central and Southern Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Central CRS 0.87 ± 1.96 -1.22
Southern CRS 0.87 ± 1.96 3.14
Level of significance = 0.05

Table 6: Government Funding of Health Care in Northern and Central Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Northern CRS - 0.74 ± 1.96 -2.85
Central CRS -0.74 ± 1.96 1.30
Level of significance = 0.05

Table 7: Health Care Management in Northern and Central Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Northern CRS -0.36 ± 1.96 -1.375
Central CRS -0.36 ± 1.96 0.948
Level of significance = 0.05

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 Table 8: Health Care Management in Northern and Southern Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Northern CRS -0.32 ± 1.96 -1.575
Southern CRS -0.32 ± 1.96 1.135
Level of significance = 0.05

Table 9: Health Care Management in Central and Southern Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Central CRS -0.01 ± 1.96 -1.796
Southern CRS -0.01 ± 1.96 1.756
Level of significance = 0.05

Table 10: Health Care Infrastructures in Northern and Central Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Northern CRS -10.37 ± 1.96 -9.548
Central CRS -10.37 ± 1.96 -6.492
Level of significance = 0.05

Table 11: Health Care Infrastructures in Northern and Southern Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Northern CRS -2.29 ± 1.96 -2.635
Southern CRS -2.29 ± 1.96 -0.192
Level of significance = 0.05

Table 12: Primary Health Care Accessibility in Central and Southern Cross River State

Senatorial Districts Calculated t-value Critical value Confidence interval

Central CRS 7.58 ± 1.96 4.884
Southern CRS 7.58 ± 1.96 8.330
Level of significance = 0.05

no significant difference in the management of healthcare
services between the Central and Southern Cross River
State. This is so because the t-value calculated of 0.01 is
less than the critical value of 1.96 at five percent level of
significance.
From the results obtained, we can conclude that there
is no significant difference in management of health care
services among the three senatorial districts in the state.
Hence, we accept the null hypothesis and conclude that
there is no significant impact of management leadership on
primary health care services in Cross River State.
The results as presented in table 10 showed that the t-
value calculated of 10.37 is greater than the critical value of
1.96 at five percent level of significance. This means that
there is significant evidence to reject the null hypothesis and
accept the alternative hypothesis. Thus, there is significant
difference in the level of infrastructural amenities available
in Northern and Central Cross River State.
In the same manner, the results as presented in table
11 showed that the calculated t-value of 2.29 is greater than
the critical value of 1.96 at five percent level of significance.
And since the t-value of 2.29 falls in the critical region, we
reject the null hypothesis and accept the alternative
hypothesis and conclude that there is significant difference
in the level of infrastructural facilities available in the
Northern and Southern Cross River State.
Further analysis of the results as shown in table 12
revealed that the t-value of 7.58 is greater than the critical
value of 1.96 at five percent level of significance. Based on
the results, the null hypothesis is rejected while the
alternative hypothesis is accepted. Therefore, it can be
concluded that there is a significant difference in the level of
infrastructural amenities in the Central and Southern Cross
River State.
From the results, it can be revealed that there is
significant difference in the level of infrastructural amenities

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among the three senatorial districts in Cross River State.
Based on these results, we can conclude that the level of
infrastructural amenities available significantly influences
the effectiveness of primary healthcare services in Cross
River State.
SUMMARY, RECOMMENDATIONS AND CONCLUSIONS
Summary of major findings
From the results in section four it was found that:
• There is disparity in accessibility to healthcare facilities
between Northern and Central senatorial district of
Cross River State, while there is no disparity in the
effectiveness of primary health care services between
the Northern and Southern and between Central and
Southern district of Cross River State.
• There is no significant difference in government funding
of healthcare services in the three senatorial districts of
Cross River State. This implies that government funding
of healthcare system is equitably distributed across the
three senatorial districts of the state.
• There is no significant difference in the management of
healthcare services in the three senatorial districts in the
state. Therefore, there is no significant impact of
management leadership on primary health care
services in Cross River State.
• There is significant difference in the level of
infrastructural amenities among the three senatorial
districts in Cross River State. Thus, the level of
infrastructural amenities available significantly
influences the effectiveness of primary health care
services in Cross River State.
Policy recommendations
Based on the results obtained, the following policy
recommendations are made.
• There is urgent need for the government to implement
policies that will increase accessibility to health care
facilities in the state. To achieve this, there is need for
the government to provide motorable roads and also
increase the number of healthcare facilities in the three
senatorial districts so as to make it easier for
accessibility.
• There is also need for the government to increase the
funding of health care in the state. This can be done by
increasing budgetary allocation to the health sector to
bring it in line with the World Health organisation’s 15
percent of the total budget benchmark.
• It is equally important that steps should be taken to
restructure the management of healthcare system in the
state. Health experts and practitioners should be made
to manage health sector in the state so as to achieve
optimum performance and efficiency in health care
delivery.
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• Lastly, the government should do more to provide
infrastructural amenities in various health centres in the
state. The provision of modern health care facilities will
help improve the quality of health care in the state.
CONCLUSION
This study was carried out to examine the effectiveness of
primary health care services in Cross River State of Nigeria.
The extant literature in human capital development has
considered health as a vital ingredient in economic growth
and development of any nation. However, for this to happen,
the health care system must be organized in such a way that
it performs effectively the function of delivering efficient and
affordable health care services to the people.
The results obtained showed that there is disparity in
accessibility to healthcare facilities between Northern and
Central Cross River State, while there is no disparity in the
effectiveness of primary health care services between the
Northern and Southern and between Central and Southern
Cross River State. The results also showed that there is no
disparity in government funding of health care services in
the three senatorial districts of Cross River State.
Further analysis showed that there is no disparity in the
management of primary health care services among the
three senatorial districts in the State. Lastly, there is disparity
in the level of infrastructural amenities among the three
senatorial districts in Cross River State. On the basis of this
we recommend in section 5.1.2 that government should
increase her budgetary allocation for health care in line with
the World health Organization’s 15 percent of the total
budget benchmark so as to cater for motorable roads to
health centres, employment of health experts, provision of
modern health care facilities, and above all, for the creation
of more health care centres in CRS.
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APPENDIX: QUESTIONNAIRE

SECTION A: PERSONAL CHARACTERISTICS OF RESPONDENTS

1. Sex of respondents:
Male

Female

2. Age composition of respondents:

Below 29 years

30 – 39 years

40 – 49 years

50 – 59 years

60 and above

3. Marital status:
Single

Married

Divorced

Others (please specify) …………………………………………………………

4. Educational qualification
First School Leaving Certificate (FSLC)

Senior School Certificate of Education (SSCE)

NCE/ND

B.Sc./HND

M.Sc./PhD

Others (please specify) …………………………………………………………

5. Occupation of respondents:
Public servant

Clergyman

Traders

Student

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 Others (specify) ……………………………………………………………….

6. I often go for malaria treatment:

Once a year

Twice a year

Three times a year

Every month

7. I often go for typhoid treatment:

Once a year

Twice a year

Three times a year

Every month

8. I often go for Diarrhoea treatment:

Once a year

Twice a year

Three times a year

Every month

9. I often go for eye check-up:

Once a year

Twice a year

Three times a year

Every month

10. Other treatments:

Once a year

Twice a year

Three times a year

Every month

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11. I spend this amount per annum on health alone:
Below 5,000

6,000 – 20,000

21,000 – 40,000

41,000 – 60,000

61,000 and above

SECTION B

Questionnaire on the Accessibility of Primary Health Care Services in Cross River State

Responses
S/N Variables SA A D SD
1 Patients pay transport to complain about their health status
2 Health workers usually come to homes for immunization once in a while
3 The drugs administered to patients by health workers are very effective
4 Patients are often attended to for treatments without delay
5 The nurses who attend to patients really know their jobs and patients
always respond to treatment
6 Health workers often organize maternity, environmental, family planning
and child health programmes

Questionnaire on Infrastructural Amenities

Responses
S/N Variables SA A D SD
1 There are fans and air conditioners in our primary health care centre
2 Drugs/medical equipment’s available are adequate to boost primary health
care services
3 There are adequate computers in primary health care centre
4 There are adequate number of ambulances in primary health care centres
5 There are houses for primary health care staff
6 There is constant power supply in our primary health care centre
7 There are sufficient generators/plants in our primary health care centres
8 There is constant water supply in our primary health care centre
9 There are Hilux vehicles for primary healthcare delivery
10 There are recreational facilities in our primary health care centre

Questionnaire on the Effectiveness of Primary Health Care Services in Cross River State

Responses
S/N Variables SA A D SD
1 We have sufficient nurses in our primary health care centre
2 We have sufficient midwives in our primary health care centre
3 We have sufficient community health officers in our primary health care
centre
4 We have sufficient health technicians in our primary healthcare centre
5 We have sufficient community health extension workers in our primary
health care centre
6 We have sufficient medical doctors in our primary health care centre
7 We have a primary health care coordinator assisted by a deputy
coordinator
8 The management structure is adequate for efficient healthcare delivery

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 9 The staff available are sufficiently trained in the delivery of primary health
care services in Cross River State
10 There is adequate community participation within the environment

Questionnaire on Government Funding

Responses
S/N Variables SA A D SD
1 The primary health care centre is adequately funded
2 The staff are well paid
3 Government makes financial provision to train staff
4 Government offers staff bonuses during public holidays

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