Introduction

The primary health care (PHC) concept is designed to be the first contact for
health care needs for individuals in the community and a system that recognizes
health as a complete state of being rather than just an absence of disease
(Magnussen, Ehiri & Jolly, 2004). This concept also ensures that health care
needs determination and is the responsibility of all stakeholders in the
community and not just the government. Health care consumers surveyed
during a global study uniformly agree that they expect health care provision to
exceed just providing medical management but to be a holistic wellness tool
(Keckley & Coughlin, 2011).
Primary health care providers are usually the gatekeepers that direct clients to
appropriate treatment options where this is not readily available at the Primary
Health Care Clinics (PHCCs). Referral is therefore one of the fundamental
activities of PHCC health care providers, staff at the PHCCs must be able to
determine what client needs can and cannot be met at the PHC level and
institute the appropriate referrals in a timely manner to ensure that there is
continuity of care and client’s optimal health needs are met (Macdonald, 2004).
The utilization of health services by the communities it is provided for is
determined and affected by a variety of factors that have been described in
several ways. Bernstein et al (2003) characterised these factors into three broad
groups: enabling factors, predisposing factors and need determinants of care.
Enabling factors refer to factors that encourage an individual to use health
services such as good roads, newer technology or insurance; predisposing
factors looks at natural inclination of individuals towards ill health, here culture
and society expectation influence behavior and need determinants of care looks
at the assessment of need for care, the individual makes a decision on where to
seek care, this may be self-medication, use of chemists/patent medicine vendors
or other means of receiving care (Bernstein et al, 2003).
Primary Health Care is recognized in Nigeria, as a fundamental element
required in addressing the dismal health indices the country is grappling with
(NSHDP, 2010). Average life expectancy in Nigeria is 54 years compared to a
global average of 68 years; under five mortality rate is 143/1000 primarily due
to malaria, pneumonia and diarrhea compared to a global average mortality rate
of 57/1000 and maternal mortality rate is 630/100000 while the global average
is 210/100000 (WHO, 2011). The Nigerian National Strategic Health
Development Plan (NSHDP) for the period spanning 2010-2015 is
fundamentally focused on improving the systems at the PHC level. It is
anticipated that improved systems at this primary level will lead to an
improvement in the health care indices of the population in several areas such as
reduction of maternal and infant mortality, polio eradication and improved
immunization coverage (FMOH, 2010). This is because activities at the primary
care level are focused on these elements of care. If these plans are implemented,
the country will benefit from this core strategic direction, but this benefit will
only materialize when there is utilization of services provided at the PHC
centres culminating in improved health status of the citizenry.
Problem statement
Nigeria operates a three-tiered health care delivery system with a large
percentage of health care delivery vested at the primary care level. The
government has continued its efforts to decentralize health care services to the
PHCCs to ensure that health services are located closer to the people and are
also more affordable. This is expected to eventually lead to the improvement of
a wide range of health indices that affect the quantity and quality of lives of the
citizens. There has however been low utilization of health services at these
points of services defeating the fundamental aim of decentralization; evidence
of low utilization has been demonstrated by some studies in other parts of the
country as in the case of Adeyemo, 2005; Katung, 2001 and Kabiru, 2005. This
study therefore seeks to explore the the relationship between healthcare service
delivery and Health care utilization in primary health care in Mubi. (Lokuwa).
Literature Review
Primary health care
The concept of Primary Health Care was greatly publicized after the 1978
meeting of the International Conference of Primary Health in Alma Ata where a
joint decision was reached that urged all governments and the world
communities in general to take responsibility for the promotion of the health of
its people (WHO, 1978). The declaration reaffirmed the concept of health of an
individual as that of complete wellbeing and not just an absence of disease, it
also recognized the gross inequality in health when comparing the developed
and developing countries and the right of individuals to be fully be involved in
the process of planning and implementation of health care policies.
Primary health care system is designed as the first level of contact for
individuals in the community and constitutes the first element in a continuing
health care system based on practical, scientifically proven, socially acceptable
methods and technology, made accessible to all families in the community at a
cost that is affordable to the community and the country (WHO, 1978). In
developing countries, primary health care system was seen as the avenue to
achieve optimal health care for its population (Chatora & Tumusime, 2004).
Service utilization and health seeking behaviors
Utilization in the context of service delivery is the use of health services by the
individuals the service is provided for (Manzoor, Hashmi & Mukhtar, 2009).
Avan & Fatimi (2002 as cited by Manzoor et al, 2009) observes that utilization
of health services is usually a consequence of the health seeking behaviors of
individuals in a community and these behaviors are affected by several
determinants that could be physical, political, socio economic and socio
cultural.
The pre requisite for bringing about change in human behavior and improving
health practices is the understanding of human behavior which consist of
attitudes, norms and other variables and only when this is understood can health
care be provided in a manner that is acceptable to those for whom it is provided
(Hausmann- Muela, Ribera & Nyamongo, 2003). Individuals may be motivated
to seek care because of certain enablers, or demotivated due to some barriers or
act/ utilize health service based on societal expectations or norm (MacKian,
2003). The health system utilization focuses on the act of seeking health care
while the illness response process looks generally at the enablers or barriers to
seeking health care. “Health seeking behavior is not just a one off isolated
event. It is part and parcel of a person’s, a family’s or a community’s identity,
which is a result of an evolving mix of social, personal, cultural and
experiential factors” (MacKian, 2003).
Challenges with implementation of the PHC concept
Following the 1978 conference, most developing countries in the late 1970s and
early 1980s were hit with severe economic crisis that resulted in several
structural adjustments programmes thereby cutting government expenditure and
consequently affecting the process of implementation of the primary health care
system (Gilliam, 2008). In Nigeria, health facilities could not be built, drugs
were hardly available and general expenditure for health care was cut down
drastically to align with the requirement of these programmes that advocated
drastic cuts in government spending (Brunelli, 2007).
The other challenges noted with the implementation of the primary health care
system include:
a) Lack of clarity of concept: The definition proffered during the Alma Ata
conference has notable ambiguities; the conference describes primary health
care service both as a level of care as well as a holistic care system involving
health policy formulation and holistic service provision (WHO, 2003). There is
a seeming confusion with the interchange of primary care with primary health
care; certain quarters have continued to implement PHC mainly as a
primary/first level of care whereas the Alma Ata declaration is focused on an
integrated approach to create a total package of care (Bhatia & Rifkin, 2010).
Macdonald (2004; citing Tejada de Rivero, 2003) notes that a review Alma Ata
description of primary health care in totality focuses on delivery of holistic
health care, it was neither an isolated part of the health care system nor a system
targeted at the poor only. The definition also includes primary medical care
through the available cadre of staff, which could be doctors, nurses or
community health workers and the use of referral systems and should not be
seen only as a system that provides only curative services (Macdonald, 2004).
b) Selective PHC delivery and donor priority: The selective primary health
concept perpetuated by Julia Walsh and Kenneth Warren basically aims to
select specific disease intervention and focus mainly on improving the health
indices associated with that particular disease, this seemed like a viable option
at the time to tackle diseases within the ambits of dwindling resources (Cueto,
2004). Following the introduction of the selective primary health concept, the
first intervention was targeted only at women aged 15- 49 years and children
not more than 5 years and consisted only of growth monitoring, oral
rehydration, breastfeeding and immunization (GOBI), family planning, food
supplementation and female education (GOBI-FFF) were later included
(Magnussen, Ehiri & Jolly, 2004). International donors have embraced this
selective programming probably because it is easier to measure results, however
this has further eroded the PHC concept because little or no community or even
the host government participation is involved in arriving at what should or
should not be funded (Strasser, 2003).
Factors affecting health service utilization
Health service utilization is affected positively or negatively by a variety of
factors categorized in a wide range of ways.
Socio-cultural factors that affect health service utilization
Culture is generally defined as the way of life of a group of people; it is usually
an accepted code of behavior for the group of individuals or communities. This
way of living or belief will affect the individual’s attitude to health care or also
will directly affect other factors directly or remotely related to seeking care.
In most developing countries especially in the rural areas, women are given
very limited decision making roles and this affects the act of seeking care.
Pakistan is one of the many countries where women are accorded a low status in
some communities and therefore women do not have access to family finances,
cannot visit the health facility alone and are unable to make decisions regarding
the need to seek care for any ill health (Shaikh & Hatcher, 2004). Cultural
beliefs such as reduced exposure to medical care in early pregnancy; ingestion
of herbs and use of traditional birth attendants were seen as means of protecting
and preserving the unborn child in a community in South Africa (Ngomane &
Mulaudzi, 2010).
Shared culture and language facilitate information sharing and influence service
utilization within communities, sharing same language even in a multi ethnic
setting usually will affect utilization through shared experience sharing as
shown in Canada while studying some of the immigrant population (Deri,
2005). In Nigeria, ethnicity is an important determinant of utilization of health
services; certain tribes in the south, east and middle belt region are more likely
to use maternal health services than their counterparts in the northern parts of
the country (Babalola & Fatusi, 2009).
Socioeconomic determinants of health service utilization
Affordability is a very important determinant of health service utilization and in
this respect, the presence of user fees have been mentioned in several literature
sources as a de-motivating factor in health service utilization. A comprehensive
review of 25 published studies showed that removing user fees will cause an
increase in the service utilization although the reverse may not necessarily be
the case; the review observed that an increase in the user fees did not show a
decline in service utilization (Lagarde & Palmer, 2008). Health expenditure
determines the willingness of a person to seek care, this is evident in many
developing countries such as Pakistan where at least 76% of health care
expenses are out of pocket for the affected individual (Shaikh & Hatcher, 2004).
In Tshwane, South Africa where primary health care services are provided at no
cost to the individual, health services were utilized and patients reported
satisfaction with services provided (Nteta, Mokgatle-Nthabu & Oguntibeju,
2010). It has also been noted that clients are willing to pay for services if the
services are perceived to be of good quality (Habbani, Groot & Jelovac, 2006).
This is in consonance with what was discovered by Lagarde & Palmer (2004) ,
they observed that an increase in user fees may not necessarily translate to
reduced utilization.
Effect of accessibility of health services on service utilization
Accessibility can be viewed from different points of view such as availability of
services, transport costs to obtain service or the distance or state of road to be
travelled. Where there is good access, there is usually a corresponding increase
in utilization. Good access to primary health facilities in Vietnam with the
average distance from provider to client being 1.85km and a travel time of 20
minutes has encouraged utilization; distance was therefore not perceived as a
barrier to health service utilization (Duong, Binns & Lee, 2004). In Nepal, it
was observed that clients who lived greater than 2km from the primary health
clinics had low utilization of health facilities and will seek maternal health
services such as deliveries at home (Yadav, 2010). Availability will usually lead
to high utilization as seen in rural villages of Pakistan, because of the
availability of different health centres, 93% of respondents had utilized
provided services (Rehman, Khan & Abbas, 2007). Long distances, lack of
funds for transportation and lack of a transport system are reasons given by
68%, 54% and 77% of respondents for non-utilization of health care services in
a middle belt Nigerian state, Rivers state. These same reasons were cited as the
reason for non-utilization in southwestern Nigeria (Adeyemo, 2005).
Availability of Infrastructure and Staffing and its effect on utilization
Though distance and physical accessibility are critical to utilization of services,
other barriers such as infrastructure and proper staffing are critical to encourage
utilization. An effect of poor infrastructure was seen in a South African clinic
where non-functioning diagnostic equipment in a clinic with high TB client
load, had an X-ray machine that was described as forever broken down thereby
affecting patient satisfaction with provided services (Nteta, Mokgatle-Nthabu &
Oguntibeju, 2010).
Availability of staff, technical competence of available staff and the attitude of
staff to clients all have an effect on utilization of health services at the primary
health care level. A study in Guinea notes that technical competence of the
health care personnel, interpersonal relationship between patient and provider,
availability of services and effectiveness of clinic personnel are important
determinants of utilization (Haddad, Fournier, Machouf & Yatara, 1998).
Communication between the patients and the provider is an important element
in determining satisfaction with primary health care services provided
(Anderson, Weisman, Camacho, Scholle, Henderson & Farmer, 2007). Another
study in Uganda reported that poor staff attitude at the primary health care
clinics; non-availability of drugs and perceived high cost of treatment are all
barriers to utilization of health services at primary health facilities (Solome,
Wamala, Galea, State, Peterson & Pariyo, 2009). Poor staff availability due to
low staff numbers in primary health care facilities in Nigeria makes it almost
impossible for facilities to operate on a 24 hour basis and women end up
resorting to the use of traditional birth attendants or other providers even when
they had attended antenatal clinics (Babalola & Fatusi, 2009).
Other factors affecting utilization of health services
The educational status of women and their partner seems to have a direct
correlation to utilization of health services especially for childcare and antenatal
services. In the Vietnamese study, mothers who had higher educational levels
will take their children for care more readily than those with lower education
(Hong, Dibley & Tuan, 2003). In rural northern Nigeria, a positive correlation
between a higher level of education and utilization of primary health service
was observed and same was also observed in middle belt region of Nigeria
where mothers or husbands who had a primary school education will utilize
antenatal services than those who had a lower level of education or no education
at all (Kabiru, Iliyasu, Abubakar & Sani, 2005; Awusi, Anyanwu & Okeleke,
2009).
Home deliveries may be encouraged due to the belief, perceptions and culture
of certain communities. While analyzing maternal and child services in primary
health care centres in rural Vietnam; Duong, Binns & Lee (2004) observed there
was an increased tendency for persons living with extended family members to
have higher rate of home delivery, although these women would usually attend
antenatal clinics and even bring back their children for immunization but would
prefer to deliver at home.
Other factors that affect health service utilization include knowledge of the
illness, disregard for illness or an unwillingness to disclose the illness, lack of
time to seek for health service, caste discrimination, and gender of health
service provider, onset of labor at night, non-availability of hospital staff at
facilities and surprisingly, a previously uneventful delivery are all determinants
of health service utilization (World Bank, 2001; Moore, Alex-Hart & George
2011).
The literature review has revealed that there are a limited number of studies in
Nigeria especially northern Nigeria on the subject of utilization at the PHC
level. Even fewer studies are available in the last five years; available studies
have also mainly used quantitative methodology. This study expects to close the
gap with respect to focusing on northern Nigeria, the poorer region of the
country with worse health indices when compared to the rest of the country and
also will use an exploratory qualitative methodology. Some of the identified
issues will be explored for further clarification or hopefully new knowledge is
gained that can help improve primary health service delivery.

Methodology
Research design
This study adopted a descriptive survey design. This design was considered
appropriate as it describes, explain and analyze certain features of the
population related the relationship between healthcare service delivery and
healthcare utilization in primary health care.
Population of the Study: The population for the study comprised of

Sample and Sampling Technique: The sample size was a total of ----- people
using Taro Yamane
sampling technique. Taro-Yemen’s formula for calculation of sample size was
used to calculate the
sample size for the study which is shown below;
N
S = (1 + N e2)
Where = S = Sample size
N = population size
e2 = level of significance usually 0.05
Instrument for Data Collection
The instrument for data collection was the structured questionnaire designed by
the researcher.
Validation of the Instrument
Alter developing instrument, copies of the questionnaire were given to the
researchers Supervisor and three other experts in the Department of Health
Education and Promotion Studies for face, construct and content validity.
Copies of the questionnaire alongside the Objectives, research questions and
null hypotheses were given to aforementioned experts for moderation, criticism,
and correction. Contributions from the experts were incorporated in developing
the final copy of the instruments. Thus, the instrument
was found to be valid for the study.
Data Analysis: Collected data were coded and analyzed with the Statistical
Products for Service Solution (SPSS) version 25.0). Chi square at 0.05 level of
significance was used for testing the null hypotheses.