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Open Access Journal of Public Health

www.scientonline.org Open Access J Public HealthVolume 1 • Issue 1 • 003

Research Article

Strategies of Community-Based Programmes and Home-Based Care in Primary Health Care Implementation in Nigeria: Can we make a

Difference in Universal Health Coverage?

Asiton-a Solomon Ibama1* and Pauline Dennis 2

1Public Health Department, School of Health Technology, Federal University of Technology, Owerri, Imo State, Nigeria2Community Health Services Department, Rivers State Primary Health Care Management Board, Port Harcourt, Nigeria

IntroductionCommunity-Based Programmes (CBPs) and Home-Based Care (HBC) concepts are

strategies of Primary Health Care, designed to making essential health care services available, accessible and acceptable to the majority of the people, where ever they live and earn a living.

Community is an integral whole of the homes usually defined in terms of households living in houses. Health care delivery services and intervention programmes under the auspices of Community-Based Programme are more often than not carried out at communal gathering points and at intervals. Such gathering points may or may not be acceptable to every member of the affected community for various reasons associated with individual differences among others.

This implies that such services may not get to all the target population of the programme over time and most of the times the missed populations are the most vulnerable group that needed the services more. Such barrier to utilization of available health care services is capable of creating a gate way to poor access to quality health

*Corresponding author: Asiton-a Solomon Ibama, Community Health Services Department, Rivers State Primary Health Care Management Board, Port Harcourt, Nigeria, Email: [email protected]

AbstractThis is a review and operational research paper seeking to x-ray the strategies

of Community-Based Programmes and Home-Based Care in Primary Health Care implementation in Nigeria as it may influence Universal Health Coverage. The objective is to determine to what extent either each or collectively can impact on the health status of the population. The methodology applied was traditional review of published literatures concerning the subject and findings of operational research of programmes implemented by Health Care Providers at the communities and households levels. The paper looked at basic interfacing issues and challenges in health care delivery that could be addressed via strategies of Community-Based Programmes and Home-Based Care to ensure reasonable reduction in barriers to access to quality health care, to attain the fundamental goal of Universal Health Coverage. The 2013 Nigeria Demographic and Health Survey showed that 23% of pregnant women received antimalarial drug for prevention of malaria for their last live birth in the two years preceding the survey. Among them, 15% received the recommended two doses of Sulphadoxine-Pyrimethamine (SP) with at least one dose administered during an antenatal care visit. Higher proportion of pregnant women in urban areas than rural areas received two or more doses of SP (19% and 12% respectively). The proportion was highest in South East zone (18%) and lowest in the South-South zone (10%). Studies had also shown that home visits can reduce deaths of newborns in high mortality developing country settings by 30 to 61 percent. Nigeria health policy on Universal Health Coverage should be strengthened with focus on Community-Based Programmes and identification of interventions that would be effectively carried out under Home-Based Care Strategies in the implementation of Primary Health Care Services. In conclusion, Home-based care in its strategy has an edge over Community-Based programme to ensure eliminating perceived socio-economic and cultural barriers to access to available quality health care by taking interventions directly to the homes of target population in a continuum of care approach, thereby creating opportunity for commonly occurring diseases/health conditions to be effectively managed at home towards ownership over time, therefore capable of making reasonable difference in Universal Health Coverage.

Keywords: Community-based programme, Home-based care, Primary Health Care, Access to Care, Utilization of available care, Universal health Coverage

This article was published in the following Scient Open Access Journal:Open Access Journal of Public HealthReceived November 19, 2017; Accepted November 29, 2017; Published December 06, 2017

Citation: Asiton-a Solomon Ibama, Pauline Dennis (2017) Strategies of Community-Based Programmes and Home-Based Care in Primary Health Care Implementation in Nigeria: Can we make a Difference in Universal Health Coverage?

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Figure 1. Conceptual framework for fast tracking the attainment of Universal Health Coverage based

Static PHC Facilities

Community-Based Programmes (CBPs)

Home-Based Care (HBC)

Complements Routine PHC Services

Fast Track the attainment of Universal Health Coverage

Routine Services covering the 8-12 components of PHC

Targeted Population based Interventions for Targeted Diseases/Health conditions of Public Health Importance at Intervals at Communal gathering point/s

Targeted Population based Interventions for Targeted Diseases/Health conditions of Public Health Importance at household level in a continuum of care approach

Eliminates Socio-economic and Cultural barriers to access to health services/population coverage

Complements CBPs

Figure 1. Conceptual framework for fast tracking the attainment of Universal Health Coverage based on Primary Health Care Services in Nigeria.

care and therefore, may impact negatively on the indicators of health status of the population.

It is in this regards the Home-Based Care in its concept is seen as a strategy or vehicle for conveying health care services and interventions to the households as a day-to-day activity in a continuum of care approach and as integral part of the health system in a comprehensive manner. By so doing, capable of addressing perceived socio-economically and culturally influenced poor access to quality health care services.

Strategies in view of this presentation implies range of activities involved in Community Based Programmes and Home-Based Care aimed at achieving set goals and or objectives about identified health problem/s of public health importance within the context of Primary Health Care services.

Primary Health Care (PHC) is an essential health care of holistic approach to all, based on simple but sound scientific methods and technology that is acceptable, affordable, appropriate and sustained at every stage of development of the people and nation. Primary Health Care services in view of this paper are range of activities within the 8-12 components/elements of PHC aimed at solving about 70% of Nigeria’s health problems. These components include: education concerning prevailing health problems and the methods of preventing and controlling them; maternal and child health care, including family planning; promotion of food supply and proper nutrition;

immunization against the major infectious diseases; adequate water supply and basic sanitation; prevention and control of locally endemic and epidemic diseases; treatment of common ailments and injuries; provision of essential drugs and supplies; provision of community mental health programme; community dental health care; as well as primary eye care and geriatric care (care of the elderly).

Universal Health Coverage in its concept seeks to ensure improved access to preventive, curative, rehabilitative and palliative services to the population in need… meaning opening the coast of quality health care delivery services to all, in particular the underserved for whom the necessary services are unavailable or unaffordable. It is a policy framework for strengthening the health care delivery system of which PHC is the cornerstone.

Figure 1 gives the conceptual framework of Community based programmes and Home based care within the purview of Primary Health Care services as it could fast track the attainment of Universal Health Coverage in Nigeria.

For better understanding of the subject of this paper, we shall also look at the key words such as Community in Health Care Delivery; Natural History of Disease and Intervention Strategies; overview of policy thrust of Primary Health Care implementation in Nigeria and Universal Health Coverage; Community-Based Programme/Care as well as Home-Based Care concept, and to draw up conclusion based on obvious benefits.


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Community in Health Care DeliveryNo one definition can give meaning and understanding

of community in health care delivery, because of its diversity and complexity. However, we shall give an explanation of what Community implies in the present context of our discussion. Community is the centre of action for population based health care research, teaching and intervention/s that could translate to evidence-based attainment of Universal Health Coverage. Nevertheless, such attainment in the concept of Community in health care delivery is not necessarily a standalone venture but must function via interacting structures, systems, policies, and politics among others.

The idea of the community as the centre of health services delivery was conceived in the 60s, making the principle of health care services in relation to availability, accessibility, acceptability and appropriateness (the 4 “A” in health care services concept) an important considerations in WHO health policy from the late 60s and into the 70s.

In Nigeria, the first attempt at application of concept of Community in health care delivery was in the third National Development plan period from 1975-1980 that gave birth to the Basic Health Services Scheme (BHSS)- a system of providing health care at the Community level with the intent of achieving wider population coverage. The BHSS was necessitated by the fact that the previous system of health care was hospital based and comprised of curative care. The scheme was therefore, based on the establishment of health centres at the community level to work with the community members. The care applied holistic approach to health care covering among others;

a. The whole field of human biology including sociological and attitudinally influenced health problems such as the HIV/AIDS pandemic as well as other diseases/health condition/s which is more of socio-behavioural context.

b. Health services utilization etc. [1].

WHO/UNICEF Alma-Ata Conference of 6th-12th September, 1978, gave a universal endorsement of the idea of community involvement in health care as provided by the Conference declaration, clause “iv” of which reads, “The people have the right and duty to participate individually and collectively in the planning and implementation of health care”. It is equally interesting to note that the 1978 WHO, definition of primary health care focuses community participation as one of its main pillars.

From these indications, it is very glaring that community as individuals or group is an essential component of effective health care towards universal health coverage, revolving round;

• Planning (initial assessment of the situation, defining the main health problems, setting the priorities for the programme aimed at addressing the problems).

• Implementation of activities designed to addressing the problems.

• Monitoring and evaluating the programmes/activities.

• Sustainability of resources that enhances provision of health care services.

Involving people from the community in planning the health services will make them understand how the services will help them and they will utilize the services because they will see it as their own. They will also feel more responsible for the success of the services and its sustainability and be more interested in identifying other health projects which the community can undertake.

However, the role of the community in making choices and decisions with regards to priorities and strategies should be adequately supported by health education. This health education component is the bedrock and cardinal focus of Community-Based Programme/Care.

Natural History of Disease and Intervention Strategies

Natural history of a disease is a description of the behaviour of such disease and the factors affecting its incidence and distribution. Knowledge of natural history of diseases of public health importance is key in any public health programme. This is because, every disease condition has its peculiar natural history which can be examined or observed epidemiologically as it moves from unaffected well persons to cases of asymptomatic disease or preclinical phase through to clinical manifestations characteristic, then to the disease. In the process, affected individuals may develop disabling complications and some will die.

The concern of the health care system, more so primary health care is the putting in place appropriate and adequate measures geared towards the prevention and amelioration of the disease condition at different stages of its evolution. The strategies of such interventions include; general health promotion (health education, environmental modifications, nutritional interventions, lifestyle and behavioural changes), specific prophylaxis/protection (immunization, and seroprophylaxis, chemoprophylaxis, use of specific nutrients or supplementations, protection against occupational hazards, drug and food safety, control of environmental hazards e.g. air pollution), early diagnosis and treatment (case finding, screening, contact tracing & chemotherapy), limitation of damage (minor surgery, chemotherapy) through to rehabilitation (physiotherapy, social integration, occupational support framework etc) see schematic view in Figure 2. According to [2], the interventions would prevent the occurrence of the disease or limit and reverse pathological changes before irreversible damage occurs.

Concept of Primary Health Care The concept of Primary Health Care was an offshoot of Alma-

Ata Conference in U.S.S.R in September, 1978, as a new concept of health care delivery of the time. Nigeria launched a National Health Policy in October 1988; the mainstay of the policy was Primary Health Care as cornerstone of the National Health Care system. The key entities of the Primary Health Care definition is as illustrated in figures 3 and 4.

It is the first level of contact of individuals, the family and community with the National Health system bringing health care as close as possible to where people live and work and constitutes the first element of continuing health care process.

The concept of Primary Health Care is explained in the following perspective:


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1. Integration of preventive, promotive and curative services using the type of technology the community will accept at the level it can afford with an efficient and effective system of supervision and referral.

2. Involving all health sections, all health related sectors. Any aspect of National and Community development in

particular, the agriculture, animal husbandry, food and industry, Education, Housing, Public utility and works, Communications and other sectors and demand the coordinated efforts of all these sectors.

3. Fostering close partnership between the community and government in the development of resources and health care.

Minor Surgery

Figure 2. Strategies of Interventions at different stages of Disease evolution Adapted from [3].

Figure 3. Segmented meaning/focus of Primary Health Care Definition.


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The cardinal focus of the primary health care system is that:

1. Health care should trickle down to the grass-root. This means that there should be better coverage of the population with health care services.

2. There should be more emphasis on preventive as well as basic curative services to the majority of the population.

3. Appropriate technology is being used thereby reducing cost and therefore making health care affordable, for instance use of oral rehydration salt in management of dehydration.

4. Appropriate and essential health care is being provided since community diagnosis as a major component of the primary health care is carried out in the local government areas and communities to ensure solving specific prevalent health problems in the context of such communities.

5. The primary health care system is being co-managed by various health development committees which are made up mainly of the local population, therefore, encouraging community participation which pave way for self-reliance and self-determination.

6. Emphasis is laid on inter-sectoral collaboration, therefore, avoiding duplication of efforts that enabled fund to be reserved.

7. From (table 1), which reflects the current realities in PHC services in Nigeria, there is no doubt that there is the dire need to strengthen the PHC system with strategies that will effectively create demand for health care services in our country, Nigeria. In our consideration, this can easily come by through the strategies as discussed in this paper.

Universal Health Coverage and the Primary Health Care System

Universal Health Coverage (UHC) seeks to ensure improved access to preventive, curative, rehabilitative and palliative services to the population… providing unrestricted platform for quality health care delivery services to all, the underserved in particular. It is not a new global health concept, just think about, “Health for all by the year 2000”.

The attainment of UHC is only made feasible on realization of the value or importance of Primary Health Care. This means making progress towards attainment of UHC is based on effective

Figure 4. Criteria for Universal Health Coverage in a Health Care System, Adapted from [5].

1. ACCESS to CARE

Financial access

Geographic access

Legal and protection

access Absence of cultural and

social barriers to care

2. POPULATION COVERAGE

100% coverage

under a given health plan

Or Comprehensive coverage without user

fees

3. PACKAGE of SERVICES

Guaranteed benefits

Set of cost-effective essential

services

Source: Adapted from [4]

Ideal Reality

Forms first level of contact of patients with the national health service delivery Patent Medicine Vendors, Secondary, Tertiary & Private Hospitals, Traditional Birth Attendants (TBAs)

Provides the general health service of preventive, curative and rehabilitative nature Immunization, Ante-Natal Care (ANC)Responsibility of local government authority with support from the federal and state governments No one takes real responsibility

Services rendered by PHC workers (Community Health Officers (CHOs), Community Health Extension Workers (CHEWs), Public Health Nurses (PHNs) Junior Community Health Extension Workers (JCHEWs) etc.)

Yes* but largely without tools and motivation

Services delivered at the health centres (Comprehensive Health Centre, Primary Health Centre, Basic Health Clinic, Health Post) Empty facilities

Not a rural health care service Rural Health Care ServiceNot just basic health care services Very basic serviceNot low level health care Low level careNot low quality care Poor qualityNot just for developing countries Developing country model

Table 1. Current Realities in PHC Services in Nigeria.


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and efficient operational capacity of the PHC system in any way not below the critical components of it.

According to [5], a health care system with features of UHC should meet the following criteria:

In view of the foregoing criteria, the strategies discussed in this presentation is basically a leeway towards meeting criteria 1 and 2 (access to care and population coverage respectively) much more than the 3rd criterion. The question is does our Nigeria health care delivery system able to satisfy these criteria? The answer from available evidence based reports is No.

This is because we are aware about the 2013 Nigeria Demographic & Health Survey (NDHS) report which indicated that common preventable diseases such as malaria, diarrhoea and malnutrition are major causes of morbidity and mortality in children; maternal mortality is 576/100,000; and the under-five mortality rate is 69/1000 live births. Antenatal care attendance and delivery by skilled health providers are 61% and 38% respectively; and only about a quarter of children are fully vaccinated. Nigerians have an average life expectancy of 52.6 years among other poor community health indicators. Economic indicators show that as at 2013, total health expenditure as a proportion of Gross Domestic Product (GDP) was 3.7%, and out-of-pocket payments represent over two thirds of health expenditure.

In our consideration, these were basically so because, the health care system in Nigeria is seen to be skewed towards the rich, noting that the primary health facilities were not functioning well, thereby unable to solve at least 70% of Nigeria’s health problems. This prompted measures for Relaunching Primary Health Care in Nigeria with a view to revitalizing the health care system to ensure quality basic health care services to be delivered to majority of Nigerians, irrespective of their location in the country.

It is on this premise we are commending the present administration in taking steps in making Primary Health Facilities functional across the country, Nigeria, as well as putting mechanism on ground to convene National Primary health Care Submit to provide the forum for all stakeholders to discuss on the issue to proffer direction for enduring policy focus for the attainment of Universal Health Coverage.

Strategies of Community-Based Care/Programme Community-based care is the care that the consumer can

access nearest to the home, which encourages participation by people, responds to the needs of people, encourages traditional community life and creates responsibilities [6].

The service provision point/s should more often than not within a trekking distance of 5km radius/30minutes [7]. However, this standard had in some cases compromised by political expediencies making sitting of health facilities/services provision point away from nucleus of target population. These cares include; any health care delivery services and/or intervention programmes rendered in static primary health facilities and/or static outreach post/communal gathering point in the communities just as we do have during National Immunization Programmes; Maternal, Newborn and Child Health Week Programmes; School Health Driven Deworming Programme; Maternal and Neonatal

Tetanus Elimination Programme; Community-Based Ivermectin Distribution Programme for the Control of Onchocerciasis; Community-based Long Lasting Insecticide Treated Net (LLITN) Distribution Programme in the Control of Malaria; and such other programmes with the intent of invoking high impact coverage of target population in support of routine health services activities.

One of more recent applications of Community-Based approach to addressing health conditions of public health significance is the Community management of acute malnutrition among under 5years children, wherein most children with severe acute malnutrition (SAM) without medical complication can be treated as outpatients at accessible, decentralized health centres, while children with SAM and medical complication treated as inpatients, whereas community outreaches conducted to ensure community participation and involvement, early detection and referral of cases.

In Figure 5, measurement that falls on the green coloured section of the tape indicate nourished child; measurement that falls on the yellow coloured section of the tape indicate moderately malnourished child, while measurement that falls on the red coloured section of the tape indicate severely malnourished child.

Community-based programmes are usually targeted population care in response to identified prevalent health conditions/diseases among the population or community in reference. Our concern here is not necessarily argument about the immediate workability or efficacy of the care in solving the health problem of the population, but the extent to which the population can access such care over time that will impact positively on the health status of the population to satisfy the overall goal of Universal Health Coverage.

According to [8] official documents only an estimated 54% of Nigerians have access to modern health services. The document also recognizes that “rural communities and the urban poor are not well served”. This implies that 46% of the population was without access to modern health, probably medical care. This inequity in service provision in our health care delivery system in Nigeria has not been so different.

For instance, the Federal Ministry of Health in Nigeria, in 2001, recommended that pregnant women receive intermittent

Figure 5. Screening and referral of cases of Malnutrition Using Mid-Upper Arm Circumference tape by Community Health Workers (CHEWs) in a Community-Based Programme.


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preventive treatment (IPT) of malaria during pregnancy using two (2) doses of Sulphadoxine-Pyrimethamine (SP). IPT is offered through the focused antenatal care strategy in Nigeria in public health facilities and Non Governmental Organization (NGO) facilities free of charge. However, recent recommendation emphasizes the importance of three (3) doses of SP during pregnancy for all women [9]. According to the Nigeria Demographic and Health Survey 2013 report, 23% of women received an antimalarial drug for prevention of malaria during pregnancy for their last live birth in the two years preceding the survey. In the overall, 15% of pregnant women reported receiving the recommended two doses of SP with at least one dose administered during an antenatal care (ANC) visit. A higher proportion of women in urban areas than rural areas received two or more doses of SP (19% and 12% respectively). Among the six (6) zones, the proportion was highest in South East (18%) and lowest in the South-South (10%).

These are typical issues of poor access and utilization of available health care services, even when such services by policy are free. This situation can improve reasonably via Home-based

care as complementary strategy to Community-based programme which is discussed in this paper. Figures 6 and 7 are pictorial illustration of some activities of community-based programmes activities.

Generic Stepwise Approach to Community Based Inter-vention Programme’s

1. Identification of a public health problem/s from evidence-based report/s and or survey of affected or vulnerable population group/s as well as community or communities in reference.

2. Plan for advocacy and sensitization visits to appropriate authorities in connection with the health problem.

3. Gain entry into the community by meeting with Local Government Officials/Health Authority and Community Leaders based on prior agreed date and time for the purpose.

4. Identification of various groups, influential persons, boundaries of community, wards and to engage in dialogue sessions about approach to the problem.

5. Identification of cultural, social and occupational orientation among others in the community in relation to health, health care delivery and utilization.

6. Identification of resources available in the community e.g. industries, markets, churches, mosque, health facilities, schools etc.

7. Identification of infrastructure in the community e.g. electricity, water supply, means of transportation.

8. Identification of health team for implementation of activities of intervention programme to addressing identified health problem/s.

9. Identification of community linkage structure or activation/promoting the formation of one.

10. Plan and conduct training on strategies for implementation of activities of intervention to addressing identified health problem/s

11. Putting in place monitoring and supportive supervision framework/team.

Figure 6. Rally on the Road in the Community Creating Awareness for National Immunization Plus Days (NIPDS).

Figure 7. Screening of Mothers and Children for Targeted Service Provision during Maternal & Child Health Week in Primary Health Facility .


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12. Putting in place framework for timeliness and completeness of data collection and integrated reporting system.

13. Communicate affected authorities and community/communities as reminder on commencement date for implementation of interventions.

14. Implementation of programme intervention activities as planned and budgeted.

15. Review of mechanisms of activities and set objectives.

16. Evaluation of programme output, outcome and impact.

Benefits of Community-Based ProgrammesReduction of pressure on hospital beds and other

resources at different levels of service.

Reduction and sharing of cost of care within the system.

Invoking feelings of ownership and accountability.

Enabling family members to gain access to support services.

Promotion of holistic approach to care and ensuring that health needs are met.

Creation of awareness on health issues in the community

Bringing care providers in touch with potential beneficiaries.

Decision making is inclusive.

Ensuring that caregivers and all key role players are well informed (knowledgeable) and received adequate skills training and utilizes other partners in care.

Home-Based Care StratrgiesHome-Based Care is defined as the provision of health

services/care by formal and informal caregivers in the home in order to promote, restore and maintain a person’s maximum level of comfort, function and health including care towards a dignified death [10]. The care is classified into preventive, promotive, therapeutic, rehabilitative, long-term maintenance and palliative care categories. It is an integral part of community-based care.

Home-Based Care hinges on two strengths that exist anywhere in the world, namely: families and communities. Families are the central focus of care and form the nucleus of the Home-Based Care team. The community is a source of support and care to individuals and families in need.

According to [10] about 70 to 90 percent of illness care takes place within the home. Research evidence clearly demonstrates that most people would rather be cared for at home and that effective home care improves the quality of life for ill people and their family caregivers. Home-Based Care is seen as the best way for most people to be cared for and to die, probably considering its cost-effective mechanism (mainly cost of stay in health facility and transportation). Throughout the world, most caregivers are family members (usually women and young girls) and these caregivers are valued as the main source of care for ill people.

One significant thing is that, people in many resource-limited

countries and communities and especially poor people have to pay for health care out of their own pockets at the very time they are sick and very few are able to pay. As a result, poor people often avoid attending health facilities for care when sick or for promotion of their health. It is therefore, imperative in our consideration that strategies are being developed to practically integrate Home-Based Care in Primary Health Care to making it more available, affordable and accessible to everyone who needs it. However, such strategies will require creativity in financing and commitment to providing sufficient funds.

The goal of Home-Based Care is to provide hope through high quality and appropriate care that helps ill people and families to maintain their independence and achieve the best possible quality of life [11].

Home-based care calls upon the resources, skills, time, energy and funds of communities and governments. It is implicit that “health” is the outcome of the overall social and economic development of the community. Therefore, no single entity is able to meet the total requirements and challenges of home-based care. A collaborative effort is fundamental to success. Care in the Community must become care by the community [10].

Home-based care will provide back-up for people, who need extended care, not necessarily hospital care or patients that are discharged early from hospital. However, Home-based Care is not intended to be “second class care” or “cheap care” for those who cannot afford hospital care.

Commonly occurring diseases/conditions can be effectively managed at home

Institutionalized care is not the most appropriate care for many problems [10].

Whom does HBC programme assist?People who need basic support services to continue to live

and/or die in their community and without which they would have been; prematurely, inappropriately or unavoidably moved to institutional care. Such categories of persons, qualified for assistance from HBC programme is as indicated in (Table 2).

Where and where home-based care strategies adopted as an innovative health care delivery practice

[12]. reports that studies conducted in Bangladesh, India, and Pakistan showed that home visits can reduce deaths of newborns in high mortality developing country settings by 30 to 61 percent.

In figure 8, as adapted from [12] it may be explained that reduction in neonatal deaths by HBC strategy accounts for an average of 45.5% while other methods of health care delivery put together in such setting can only account for 54.5%.

In a setting in Nepal where referral to hospital was not possible for most families, a study showed that recognition of severe illness and administration of oral antibiotics by Community Health Workers and referral to facility-based health workers for provision of daily antibiotic injections substantially improved access to treatment [13].

Similarly, research studies conducted in Bangladesh and India in areas with poor access to health facilities had successfully used appropriately trained and well supervised Community Health


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1. These group of persons 2. The caregivers of the group of persons in (1)Healthy Persons FamiliesAt risk or frail older persons Caregivers from the formal system e.g. health professionals

At risk people with moderate to severe functional disabilities Caregivers from the non-formal system e.g. NGOs, Community Based Organizations (CBOs).

People recovering from illness, in need of assistance e.g. post deliveries or after specific treatment.

Caregivers from the informal system e.g. village health worker (VHW), volunteers, other community caregivers and church groups.

Terminally ill personsPersons living with HIV/AIDS or any other debilitating disease and/or conditions e.g. mental illness, substance abusers.Any other disadvantaged group/person in need of such care e.g. people in crisis.

Table 2. Range of Persons that could be assisted by HBC Programme.

Figure 8. Reduction of Neonatal Mortality in High Mortality Developing Country Setting by Average Percentage.

45.5% 54.5%

Reduction of Neonatal Mortality in High Mortality Developing Country

Setting by Average % Reduction of neonatal deaths by HBC strategy Reduction of neonatal deaths from other methods of Health Care Delivery

Source: [10].

Source: Adapted from [12].Figure 9. Comparism of HBC Strategy and Other Methods of Health Care Delivery and Setting in Annual Target Population Coverage in Piloted 3 LGAs.

26 27 14

74 73 86

Utilization of Maternal and Newborn Health

Services by Average %

Reduction in Maternal Malnutrition Status by

Average %

Improvement in U5yrs Malnutrition Status by

Average %

Comparism of HBC Strategy & Other Methods of Health Care

Delivery & Setting HBC Stategy Other methods of Health Care Delivery

Source: [14]

Figure 10. Home-Based Care Team Members on their way to homes of target population for Home-Based Care in Ahoada West LGA, Rivers State, Nigeria.

Workers to give antibiotic injections at home [13]. Again, Health Workers in Ethiopia, deliver a basic package of care, supported by Community Volunteers for many health promotional activities. Interestingly, these frontline health workers and volunteers were being used to provide Home-Based maternal and newborn care after appropriate training [13].

Home-Based Care Strategy for Integrated Maternal, Newborn and Child Health was adopted in 2012 in Rivers State, Nigeria and piloted in three (3) local government areas (Ahoada West, Etche and Oyigbo), targeting about 189,913 population, aimed at fast tracking the reduction in maternal, newborn and child morbidity and mortality by 20% by 2015 in line with the United Nations (UN) Millennium Development Goals 4 and 5. It was shown to achieve an average of 26% improvement in utilization of maternal and newborn health services, an average of 27% overall reduction in maternal malnutrition status, an average of 14% overall improvement in under 5 years malnutrition status among others in 2013 on comparing with baseline indicators, etc. [14].

We can adduce from Figure 9 that, HBC strategy actually fast tracked utilization of maternal and newborn health services and reduction in maternal malnutrition status by exceeding the 3 years 20% target in just one year of implementation. Also, the 14% improvement in 5 years malnutrition status in one year of implementation is quite within the domain of fast tracking the attainment of set goal in comparism with other health care delivery methods and setting (Public and Private sectors). Figures 10-16 are pictorial illustration of activities and tools of the HBC.

Also, the new service delivery models for fast tracking the

achievement of Vision-90-90-90 by 2020 target on antiretroviral treatment services in Nigeria, targeting about 3.4 million estimated HIV infected persons has brought in the concept of home-based care strategies within the framework of Task Shifting and Task Sharing Policy. This implies that by three (3) years to the target year, 90% of all people living with human immunodeficiency virus (HIV) should know their HIV status; 90% of all persons diagnosed with HIV will receive sustained antiretroviral treatment and 90% of all persons receiving antiretroviral treatment will have durable suppression of the viral load.

The illustrated instances are aggressive disease prevention and control strategy as well as high impact population coverage approach to an identified health problem which primary health care and universal health coverage stood for, could easily come by via the home-based care strategies.

Generic Stepwise Approach to Home-Based Care1. Identification of a public health problem/s from evidence-


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based report/s and or survey of affected or vulnerable population group/s as well as community or communities in reference.

Figure 13. Home-Based Care Emphasizes Supportive Supervision to Home-Based Care Team Members at Upatabo Community in Okogbe HBC District in Ahoada West LGA, Rivers State, Nigeria.

Figure 14. Home-Based Care also Emphasizes Community Participation & Access to Maternal & Child Health Services in Okpontu Community in Oyigbo LGA, Rivers State, Nigeria.

Figure 15. Home-Based Care Team Members on Household Based Hand Washing With Soap and Water Practice and Promotion in Odagwa Community in Etche LGA, Rivers State, Nigeria.

Figure 16a. Pictorial View of Data Collection and Monitoring ToolSource: [15].

Figure 16b. Pictorial View of Data Collection and Monitoring Tool by Danger Signs. Source: [15].

Figure 11. Home-Based Care Monitor/Supervisor with a Pregnant Woman at Household level in Odhiogbokor Community in Odioku HBC District in Ahoada West LGA, Rivers State, Nigeria.

Figure 12. A Community Health Practitioner on Home Based Growth Monitoring and Promotion in Umuadagu (Umulorji) Community in Egwi in Etche LGA, Rivers State, Nigeria.


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2. Plan for advocacy and sensitization visits to appropriate authorities in connection with the health problem.

3. Gain entry into the community by meeting with Local Government Officials/Health Authority and Paramount rulers based on prior agreed date and time for the purpose.

4. Identification of various groups, influential persons, boundaries of community, wards in the Local Government Area.

5. Determination of home-based care (HBC) operational districts of 20, 000 – 30,000 target population.

6. Identification of human resource and conducting training on HBC strategies for implementing intervention/s activities.

7. Listing of villages/settlements/communities as per HBC operational districts making up the target population.

8. Plan and to engage in community dialogue sessions to gain support and entry into the settlements/villages/communities at household level with minimal hindrances.

9. Conducting village/community mapping for identification and location of community resources associated with identified health problem/s.

10. Conducting house numbering for identification/registration of target population for the intervention per households, locations and number.

11. Orientation of professional stakeholders on strategies and modalities for integration of data into the health care delivery system.

12. Putting in place monitoring and supportive supervision framework/team.

13. Putting in place framework for timeliness and completeness of data collection and integrated reporting system.

14. Communicate affected authorities and community/communities as reminder on commencement date for implementation of interventions at household level.

15. Implementation of programme intervention activities as planned and budgeted.

16. Review of mechanisms of activities and set objectives.

17. Evaluation of programme output, outcome and impact.

Benefits of Home-Based CareReduction and sharing the cost of care within the system.

Allowing people to spend their days in familiar surroundings and reduce isolation.

Enabling family members to gain access to support services.

Promotion of holistic approach to care and ensure that health needs are met.

Intervention is pro-active rather than reactive.

Ensuring right to decide about care within own environment.

Commonly occurring diseases/conditions can be effectively managed at home.

Decision making is more inclusive.

Beneficial to family and friends as it allows more direct time with clients and involvement in care giving.

Care will be individualistic and person centered.

Avoiding unnecessary referrals to and from higher levels.

Avoiding unnecessary and/or prolonged admission to health care facilities or institutions.

Ensuring that partners in care-giving know and play their roles to avoid duplication.

Ensuring that caregivers are fully involved and informed about the individual care plans.

Ensuring adequate documentation and encouraging proper use of recorded information.

Ensuring continuity and consistency in service, quality assurance and management.

Broad Objective of Community-Based Programmes and Home-Based Care Strategies

The broad objective is to establish an effective referral system at all levels, including hospital, clinic and community and/or home by reaching out to the population in the perspective of their peculiar environment and circumstance concerning health care.

Figure 17 illustrates a two-way referral system model for community-based programmes and home-based care showing arrows indicating normal route of referral for less serious conditions and emergency route for serious/severe conditions from and to the community/household levels. Two-Way Referral System is a process of transferring the care of a patient/client of more serious conditions from a less skilled person to more skilled personnel with a feedback. It also involves the transfer of patient/client from lower health care system to higher health care system with superior facilities and staff with a feedback.

The responsibilities of the referring facility/Care provider are to:

Discussing with client and family on home-based care/community-based care as an alternative and obtain consent/agreement and acceptability based on informed decisions.

Assessing clients’ readiness for referral.

Informing the home care provider/health facility to which the client is being referred to, to allow notification and preparation to receive the client.

Providing written or pictographic instructions on medication, purpose for use and dosage.

Observing the understanding of the caregiver and/or client of the usage of medication.

Sending a referral form to the primary care site/higher facility that will take over the care of the patient.


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Figure 17. A Model for Two-Way Referral System based on Community-Based Programme and HBC Strategies.

Hospitals

& Diagnostic Centres

Household/ Community

HC

Health Centres

Comprehensive Health Centres (CHC)/ Model Primary Health Centres (MPHC)

Emergency Path (Route)

Normal Path (Route)

Informing client and/or caregiver of follow-up care, appointments, details on patient-retained card, etc.

Advising client on any specific care, e.g. nutrition, hygiene, oral health, pain control, infection control, mobility, wound care etc.

Giving contact details of the referral role-players as well as primary role-players.

Providing assistive devices, e.g. mobility and/or self-care aids as required.

Providing pharmaceutical supplies and dietary supplements as required.

Providing sick leave certificates, social assistance forms.

Arranging transport for patient to home on discharge and for referrals.

Defining formal/informal/non-formal partnership and lines of communication by contract or agreement.

Ensuring that referral from community/household level is accepted by the recognized referral facility.

The figure18 is an illustration of a typical operational model for community-based programmes and home-based care in which a number of JCHEWs working with CHEWs take intervention packages into the community and household levels, while monitored and supervised by the health care team, covering indicated estimated annual population that is translated into workable daily population coverage. The estimation was based on the annual population served by these cadres, ranging from; 2,000 to 5,000 for JCHEWs; 5,000 to 10,000 for CHEWs and 10,000 to 30,000 for CHOs. However, convenient population coverage of 10,000 in relation to the target population of programmes may be considered, to obtain the operational teams, noting that communities/settlements are not of equal population/target population. It is also worthy of note that team composition is not restricted to Three (3) per HBC District, but just for illustration of the operational structure of the programme.

Population within 5km radius/30 minutes trekking distance,

are planned for utilization of services/interventions at static PHC facilities that are within that distance; population within 5-10km distance to static PHC facilities, are planned for mobile team (HBC) intervention packages while population that are 10km and above to static PHC facilities are planned for outreaches/home-based care approach for intervention packages which will reasonably link and complement services/interventions of static PHC facilities to ensure improved population coverage.

Figure 19 reflects a typical scene for rural community interactive sessions that avail opportunity to explain and discuss basic operational methods, benefits and challenges of community-based programmes and home-based care to gain more support at the implementation levels.

Recommendation1. It is quite auspicious and necessary that Nigeria Health

policy on Universal Health Coverage is strengthened with focus on Community-based programmes and identification of interventions that would be effectively carried out under Home-Based Care Strategies in the implementation of Primary Health Care Services.

2. Policy makers and implementers as well as Development Partners should ensure development of strategies to practically integrating Home-Based Care as a cardinal focus in making Primary Health Care more available, affordable and accessible to everyone who needs it (equity).

3. Judicious implementation of the Task Shifting and Task Sharing Policy in Nigeria should be given needed attention to making more meaning to availability, affordability and accessibility of PHC to majority of Nigerians irrespective of their location via the strategies of community-based programmes and home-based care in Primary Health Care Services implementation.

ConclusionIt has been clearly shown that, both community-based

programmes and home-based care have similar approaches and the intent is to evoke improved access to care, community involvement and participation towards ownership and effective


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Figure 18. A Typical Community-Based Programmes and Home-Based Care Operational Model.

HEALTH FACILITY DESK OFFICER/ HBC

DISTRICT COORDINATOR

TEAMS ( 4

CHEWs EACH) 5,000 – 10,000 POPULATION

5 JCHEWS 2,000 -5,000

POPULATION EACh

TEAMS ( 4


5 JCHEWS 2,000 -5,000

POPULATION EACH

TEAMS ( 4


5 JCHEWS 2,000 -5,000

POPULATION EACH

HBC DISTRICT 3 CHOs

(10,000 - 30,000) POPULATION

Ideal Reality

Community/Household levels



Figure 19. Home-Based Care Team members in Community Interactive Sessions to gain more support for Community-Based Programme/Home-Based Care in Etche LGA, Rivers State, Nigeria.

system support. However, Home-based care in its strategy goes further to in-cooperate additional mechanism or methodology to eliminating perceived socio-economic and cultural barriers to access to available quality health care by taking such health care services and or intervention packages directly to the homes of the target population in a continuum of care approach, thereby creating opportunity for commonly occurring diseases/health conditions to be effectively managed at home towards ownership over time and so, capable of making reasonable difference in Universal Health Coverage in our context, Nigeria.

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Practice in The Domain of Public Health. Internal Journal of Innovative Research and Advanced Studies (IJIRAS) Volume 4 Issue 6. June 2017.www.ijiras.com

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9. National Population Commission (NPC) and ICF International (2014). Nigeria Demographic and Health Survey, 2013. Abuja, Nigeria, and Rockville, Maryland, USA:NPC and ICF International.

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Retrieved 28th March, 2012 from 101article.timesofindia.indiatimes.com/2012-02-16/india/31066263-1-neonatal-mortality-newborn.

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Copyright: © 2017 Asiton-a Solomon Ibama, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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