CHAPTER ONE INTRODUCTION

            Background to the study

Community Health Nurses are the frontline health providers in Ghana‟s health care system and the world over. Largely they provide Primary Health Care services to the door step of the client or citizenry in communities through health promotion and education, while referring complicated cases.

The Alma Ata conference of 1978 in the United Soviet Socialist Republics (USSR) stated that Primary Health Care Services should be the focus of health-related projects in the developing world. The emphasis was placed on the use of appropriate technology and allied health personnel such as Community Health Nurses, while rejecting the orthodox medical model of disease diagnosis and providing cure to such illnesses diagnosed (Alma-Ata, 1978), report of the International Conference on Primary Health Care.

Since the Alma Ata conference, there have been diversified efforts by countries to improve access to Primary Health Care (PHC) in order to attain a minimum standard quality of life.  There have been several coordinated PHC programme improvement efforts; however, the expansion and adaptation of PHC services to serve vulnerable populations such as the poor and rural dwellers remain ineffective.

Community Health Nurses (CHNs) have become the primary providers of health care across the world, since the Alma Ata declaration of 1978. There have been an expansion over the century of the CHNs working force, just as there have been an increase in the populations they serve (Bovbjerg & Ormond, 2013). According to them, the principal factor responsible for this expansion is the population boom in the mid-20th century. During the population explosion, the human clientele health demands started out stepping the medical provider capacity to extend the needed health care services as cited by Health Resources and Services Administration, HRSA, (2007). The United States of America Census Bureau (2012), also reports of an increase in families living in poverty, with one in five families at or near poverty level incomes. It is a fact that there exist a positive correlation between increased poverty and increase in poverty-related diseases but a negative correlation at the same time in access to health care. This therefore demands a need of change in service approach.

Paired with the need for change in health care delivery is also a strong push in the medical system to provide efficient care delivery through various means such as the use of care teams. The change in approach coupled with the use of teams is driven by shortages in the primary medical care working personnel, however, with a simultaneous increase in demand for care.

Meanwhile, the orthodox physician or medical model approach to Primary Health Care leads to high costs, thereby hindering access to primary medical care. These constraints are pushing government and other providers to reconfigure how health services are delivered. The use of Community Health Nurses (CHNs) is therefore seen as the best approach to increase access to health services to reduce costs. It is also seen as the best approach to solve the problem of increasing population with its attendant health problems such as; (1) programme design and sustainability, (2) management of integration , (3) management of primary health facilities and

(4) management of intermediary health care facilities. For instance, Liu, Sullivan, Khan, Sachs  & Singh (2011) posited that during the twenty first century, many developing countries were deploying Community Health Nurses programmes because these Community Health Nurses have the ability to identify, refer, and treat illnesses at the household level. They further added that there were however many hindrances in programme design and sustainability as far as management and integration with primary health facilities were concerned.

Confirming the findings of Liu, Sullivan, Khan, Sachs & Singh (2011) about increasing population with its attendant management and integration problems, (Wanjau, Muiruri & Ayodo, 2012) cited over 4,700 health facilities that provide health services in Kenya with the public sector accounting for slightly more than 51 percent of these facilities. According to (Wanjau, Muiruri & Ayodo, 2012), there is a hierarchy for public health facilities, namely:  national referral hospitals, provincial general hospitals, district hospitals, and health centres with dispensaries at the lowest end. The provincial health care facilities are intermediaries between the central level agencies and the district level agencies. In Nigeria, they have oversight responsibilities of policy implementation at the district level (Omoleke, 2005). The district hospitals in turn concentrate on the delivery of health care services based on guidelines from the headquarters; while the Health Centres provide preventive and curative services of local needs.

Primary Health Care (PHC) services in Nigeria are composed of the education on existing health problems and their preventive and control measures (Afolabi & Mayowa, 2015). Some of these health promotion measures have to do with food supply and quality nutrition, the provision of good maternal and child health care, and not excluding methods to plan families for better development.