EVALUATION OF CHILD HEALTH CARE SERVICES IN HEALTH FACILITIES IN NSUKKA URBAN OF ENUGU STATE

Abstract

Evaluation of child health care services in health facilities in Nsukka Urban is the main focus of this work. To achieve the purpose of this work, 430 mothers and 156 health care providers were used to collect quantitative data for the establishment of the baseline data. The instrument for data collection was the evaluation  of child health care questionnaire  comprised  of two questionnaires,  which  helped  to  gain  responses  from  mothers  and  health  care  providers respectively. The data collected was analyzed using arithmetic mean and percentages for the research questions and t-test statistics for the hypotheses. The findings of the study showed that the  components  of  child  health  care  services  proved  supportive  in  the  improvement  of children’s health status in Nsukka urban and staff were reasonably commended as competent in their effort ensure quality care for children in health facilities. The findings of the study also showed that the investigated administrative problems and strategies for improvement in child health care services were considerable and should constitute part of the established standard protect providers in their practice in order to avoid obstacles and uphold high quality care for children.

CHAPTER ONE

Background to the Study

Introduction

Child health was once part of adult medicine, but emerged in the 19th and early 20th century as a medical specialty because of the gradual awareness that the health problems of children are different from those of grown ups and that response to illness  and medication depends upon the age of the child (Hetch & Shiel, 2006). Children are the promise and future of every nation and the core of development which made World  Health Organization-WHO (2004) observe that investing in children’s health and development means investing in future of a nation. Children are vulnerable group whose needs and rights must be protected including the right to health and development.  Paediatricts  (2004) also reported that advances in prenatal intensive care have been associated with improved survival of high risk neonates, but have not resulted  in  decreased  morbidity  in children.  This  helped  to  bring  about  child  health  care services.

Child health care services according to Turmen (2006) are provisions made to improve optimal growth and development in infancy and childhood through disease prevention, good nutrition and health supervision. Hetch and Shiel (2006) defined child health care as services which focus on the well-being of children from conception and is concerned with all aspects of children’s growth and development and with the unique opportunities that each child has to achieve his or her full potential as a healthy adult. According to Onuzulike (2005), child care services are total care and services rendered to children 0 – 5 years in order to maintain their healthy living. Therefore, child health care services are efficient strategies provided by health workers in order to promote health  and prevent diseases,  disabilities  and death in children through simple cost effective measures. Hetch and Shiel (2006) observed that a healthy child’s development actually begins from the parents, and once the baby is delivered other matters such as breastfeeding, newborn screening tests, sleeping safety, health care appointments for check ups and immunizations are considered. As services are provisions made for the public to use as much as they need in order to benefit from them, the purpose of child  health care in health  facilities  is  to  promote  the  health  of children,  provide  support  in  maintaining  and improving   children’s   health   through   counseling,   medical   examination,   treatment   and immunization.

Child health is a critical issue of concern to everyone, and at the level of the family, the community, the nation and the international community. This is because successful societies safeguard their future by continually striving to improve the well being of their children. They understand  that  healthy,  well developed  educated  and respected  progeny  ensures  that  past

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achievements  serve as the foundation  for continuing  progress  (Turmen,  2006). In order  to improve health outcomes of children there should be more effective organization of preventive services and more coordination between practices. Intervention to achieve an effect on children and to overcome specific barriers in the process of care delivery needs to be adopted so that preventive services could be effectively delivered.

Therefore, Changes in the organization of the delivery system that concerns children

will lead  to improvement  in preventive  health outcomes  for them  (Margolis  et al.,  2005). International  communities  and individual  countries  are repeatedly  committed  to  improving child health. WHO (2004) however stated that this commitment  needs to be  translated  into stronger  action  if the  silent  tragedy  of preventable  death,  illness,  disability  and  impaired psychosocial development among children are to be avoided, and if children’s quality of life is to be improved.

Improving  child  health development  relies,  to  a great  extent,  on understanding  the causes of child morbidity and mortality with programmes and policies aimed at improving the health of children. Moy (1998) reported that twelve million children under five years of age in developing countries die every year before their fifth birthday and  seventy per cent of these deaths are due to five common preventable and easily treated childhood diseases namely: acute respiratory infections, diarrhea, measles, malaria, and  malnutrition or the combination of all five which also account for three quarter of all childhood morbidity. Schor (2004) observed that historically, the field of paediatrics has been concerned with promoting children’s health and development as with treating children’s diseases, and the trend in children’s health status showed that their physical health is better than it has ever been. This is as result of scientific progress which has led to substantial reduction in many of the acute morbidities of the early

20th century and increasing survival from acute illness and premature births.

Various interventions for the prevention and management of childhood illnesses have been established to be provided through health services. According to Moy (1998), Expanded Programme on Immunization (EPI) was founded by WHO in 1977, the control of Diarrhoeal Diseases  Programme  (CDD)  was  established  in  1980,  and  in  1985  the  control  of  Acute Respiratory Infection Programme  (ARI) was added to these vertical  strategies.  With WHO technical  support  and UNICEF  (United  Nations  Children’s  Fund)  sponsorship,  these  three programmes  have been put in place  and health workers  are trained  through  workshops  to recognize  key signs of illnesses and to implement  correct treatment  and follow-up  actions. Also,  a  strategy  known  as  integrated   management  of  childhood  illnesses  (IMCI)  was formulated by WHO and UNICEF in 1996 as an additional and principal strategy to improve

child health, which concentrates on their overall health status by integrating all intervention for prevention, treatment and health promotion (Healthy Children Goal, 2002).

However,  the potential policy option for reducing  the burden of children’s  diseases would be to utilize the public and private sector health resources in a coordinated fashion with options for health sector reform to achieve its goal of providing quality health care to members of the population (Thind, 2004). Evaluation of child health care services is one of the strategies that can be used to provide for this reform, to encourage improvement in the quality of care provided for children.

Trochim  (2006)  defined  evaluation  as the systematic  acquisition  and assessment  of information  to provide useful feedback about some object.  Evaluation as it concerns  child health care in hospitals can be defined as the assessment of the features or attributes of hospital provisions for children’s care in order to determine their influence on children’s health, and the extent to which they are meeting the objectives of child health care. The goal of evaluation is to  provide  useful  feedback  to  clients,  groups,  administrators,   staff  and  other  relevant constituencies  and  to  influence  decision  making  or  policy  formulation.  It  strengthens  or improves the object being evaluated by examining the delivery of the programme, the quality of its implementation, the organizational context, personnel, procedures and inputs.

Evaluation helps to emphasize the importance of evaluation participants, especially the client or users of a programme and stake holders. Agency for Health Care Research and quality

– AHRQ (2007) observed that potential audiences for quality measurement  report for  child health care services are the providers and the consumers. This is because providers are more familiar with their methods and problems they encounter in care delivery.  Also  parents are useful observers of the pattern of services provided for their children.   In this case, several parental and health care providers’ perception measures, as well as several measures of the delivery of preventive care may be used to assess the quality of the health plan or programme for children in hospitals and health centres in Nsukka Urban. WHO (2004) observed that the main providers of health care and their role in child health includes the two main categories of government  and  public  sector  players.  Thind  (2004)  added  that  the  quality  of  the  public facilities and quality of the private facilities were variables based on drug availability and ORS (Oral rehydration  solution). This is  because provisions  for child health care in government hospitals may differ from provisions for child health care in private hospitals in both coverage and quality.

However,  AHRQ  (2007)  emphasized  that  regular  measurement  of  quality  is  an important programme management tool because it;

1.   promotes the effective use of scarce resources and delivery of needed services;

2.   provides information needed to manage health plans and providers;

3.   provides basis for offering incentives to them;

4.   allows programme managers to access the extent of their own accomplishments;

5.   allows  comparison  of  plan  or  programme  performance  with  that  of  other  plan  or programmes in the state;

6.   allows the tracking of trends over time; and

7.   provides an objective basis for ongoing quality improvement programme.

AHRQ (2007) also noted that health care should have the following qualities:

1.   effectiveness which relates to providing care process and achieving outcomes;

2.   efficiency  which  relates  to  maximizing  the  quality  of  health  care  delivered  or  health benefits achieved for a given unit of health care resources used;

3.   equity  which  relates  to  providing  health  care  of  equal  quality  for  the  same  clinical condition to those who differ in personal characteristics;

4.   patient centeredness which relates to meeting patient’s needs and preferences;

5.   safety which relates to precaution for avoidance of actual or potential bodily harm, and

6.   timeliness which relates to obtaining needed care while minimizing delay.

Therefore, increased attention to performance monitoring is essential for ensuring, the delivery of  quality  services  for  children’s  health  and  development,  because  quality  measurement provides one of the tools needed for effective quality improvement  initiatives, especially in hospitals.

Hospital standard for child health care involves: the quality and safety of care; child- centered care which addresses the broader needs of children, and the hospital  environment. Improvement in the training of staff, appropriate emergency cover and organization of services are also emphasized (Commission, for Health Care Audit and Inspection, 2007). Specifically, hospital standard states that the care of children in hospitals should be provided in building that are  accessible,  safe,  suitable,  and  child-and-family-friendly  with  separate  facilities  for  the treatment of children wherever possible. In out-patient departments there should be partitioned waiting areas for children, or appointments organized so that all children are seen at the start of a clinic. Also, children receiving in-patient care should be treated in child-only ward separate from adults. This will enable children to benefit more appropriately from cares put in place for

them.

However, it is not surprising that preventive care services for children as they are being provided currently may not be meeting the needs of children and many families with children.

Schor (2004)  observed  that the  quality of child  health care services  varies  greatly  among physician  practices  and  parents  are  signaling  their  dissatisfaction   by  failing   to  obtain approximately one half of recommended preventive care services. It is not possible in the time available,  to provide even the few preventive services most highly recommended,  nor is it possible to respond effectively to the myriad recommendations for the content of well-child care (Yarnall, Pollak, Ostbye, Krause & Michener, 2003) and the current care system cannot do the work except if there is change in the system of care (Committee on Quality of Health Care in America, 2001). Commission for Health Care Audit and Inspection (2007) found that hospitals have made poor progress  in  meeting the broader needs of children which reflects more widely across different services in hospitals. Insufficient number of staff is trained in the management of pain in children, and to deliver resuscitation and initiate treatment in serious emergencies, especially at night.

Radolph, Fried, Loeding,  Margolis  and Lannon (2005) discovered  that few  hospital practices  have  evidence  of  comprehensive  system  of  prevention  and  some  organizational characteristics  were at level that  might  impede  delivery of high quality  care for children. Furthermore,  under  immunization  and  inadequate  screening  were  observed  as  significant problems in private paediatric practices and some physicians are not always aware of the rates of under immunization  in their hospitals. Many experts in  the field of preventive  care for children know that the current system of preventive care for children may not be very scientific and they also know that only a few of the recommendations for the contents and processes of well-child care are supported by evidence of effectiveness. The current quality of preventive care for children is quite variable and the need of many children and parents are not being met because the existing guidance and approaches to well-child care are inadequate to the task and stand as barriers to effective and efficient care as is the case below.

The Kennedy report into events surrounding  the deaths of children who  underwent heart surgery at the Bristol Royal Infirmary found that the quality of care  was less than it should  have been, services  were fragmented,  the rights and  vulnerability  of children were overlooked,  and  open  and  honest  relationship  with  children  and  parents  were  lacking (Commission  for Health Care Audit and Inspection,  2007). According to their observations service  providers  treated  children  as if they  were  mini-adults  who  need  smaller  beds and smaller portion of food. Staff were skilled  in treating adults but had no specific training in treating children and facilities  were  designed  with  little acknowledgement  of the  needs of children. These should be considered in response to the rights and vulnerability of children.

McGlynn and Halfon (1998) stated that child care quality has not received the kind of attention  that  has  been  given  to  adult  health  care,  and  children’s  issues  have  not  been

emphasized  in  many  national  quality  measurement  and  improvement  efforts.  Health  care quality in some hospitals is focused on early detection and management of diseases in adults rather than on the promotion of healthy development and prevention of illness and injury in children. The broader needs of children were not being recognized or given priority in many hospitals. Therefore, Safeguarding children remains a major area of risk and many children are having  worse  experience  of  hospital  than  they  should  because  of  lack  of  training  in communication,  and staff who specialize  in child care. Level of training in child protection were often  not up to standard  and there  were  particular  problems  relating  to the  level of intermediate  training  in emergency  care  with  significant  and  unexplained  variation  in the delivery  of child  health  care  across  hospitals.  WHO  (2005)  observed  that  radiology,  and laboratory services are minimal or non-existent in first level facilities in low income countries, and drugs and equipment are often scarce. These factors leave doctors with few opportunities to practise complicated clinical procedures. Practitioners often rely on signs and symptoms to determine the course of treatment that makes the best use of available resources.

A  list  of  barriers  to  providing   the  preventive   and  curative   services   that   are recommended for children which urgently need to be addressed as provided by Schor (2004), includes: time constraint; too much work-load; low level of reimbursement for preventive child care;  lack  of  training  in child  development;  lack  of  trained-non-physician  staff  members; limited  access  to  community  services  to  support  families  and  children,  and  few  external incentives. These barriers may be factors that lead to poor performance and may be the reasons why the needs of children for preventive care are not fully met. Therefore, consideration has broad implications for the organization, and provision of child health care and there is need for clinicians to improve the efficiency of their practices.

This suggests a growing need for research that examines the impact of organizational characteristics on the quality of care for children especially as it concerns health facilities in Nsukka Urban. Evaluation of child health care services in health  facilities is considered  an effective quality measurement initiative for care provided for children because it will help to access  whether  hospitals  were  meeting  or  making  progress  towards  key requirements  of hospital standard with regard to the objectives of child health care. Bethal, Reuland, Halfon, and Schor (2004) also suggested  effective  evaluation research as a means that will help to improve  effective  child  health  interventions.  Lucas  and  Gilles  (2003)  observed  that  the objectives of child health care services are to promote and protect the health of children in order  to  prevent  diseases  and  ensure  that  they  achieve  optimal  growth  and  development physically and mentally. Child heath care also aims at the early treatment of childhood diseases to avoid dangerous complications. As there may be need for major revision of well-child care

taking into  account  the objectives  of child  health care and the varying  needs of  children, prompting  a re-examination  of child  health care  will  help  in reducing  medical  errors and improving quality relying on evidence-based medical approaches.

Health care for children needs to be rationalized and the rationale must be apparent in the documents guiding the provision of child health care. Hospital directorates must accept that they have to meet the hospital standard, and improving the provision of services for children must be integral to the plans. All services accessed by children need to be scrutinized and staff influenced to ensure the management of the performance of all relevant services, with respect to quality of care provided for children. With consideration of the child health care objectives, hospitals can be held responsible to account for improvement in managing performance and planning in child health care (Schor, 2004). This translates to the need for health care providers to be adequately informed of their responsibilities towards child health care and development.

Margolis et al. (2004) observed that better office system can improve the delivery of preventive care for children. They defined office system as an organized series of interrelated activities carried out by several members of staff to achieve a specific purpose. The focus of office system for preventive care is on interactions of patients, staff, and clinicians to ensure that each step of preventive care is carried out for every eligible patient at every encounter. This involves practices that receive continuous medical education and process. The elements of governance  are  extremely  important  because  they  are  the  first  steps  to  ensuring  that  the requirements  of hospital standard are met.  The review of the Commission  for Health Care Audit and Inspection (2007) found that the needs of children were better met when they were, cared for in services managed by paediatric directorates. However, leaders in other directorates such as general practitioners need to ensure that improving the care of children is integral to their  plans. Improvement  in methods  used  for implementing  office  systems  of health care interventions would ensure higher rate of core preventive services, than practices that do not undergo improvement. The provision of tools and materials allow practices to concentrate on improving care, and emphasis on measurement  encourages  practitioners to learn from  their data (Margolis et al., 2004).

Circle  of  research  action  and  evaluation  has  provided  remarkable  achievements  in

global health as it concerns decline in child mortality, but there are many infants and children who have not benefited from the progress in research for whom the fruits of research remain inaccessible. Therefore research is essential to ensure that effective interventions for children’s health are made available to those in need of them in order to improve the survival, health and development of infants and children especially as it concerns health facilities in Nsukka urban. From the foregoing, this study will attempt to determine the extent in which public and private

health facilities are striving to improve child health care and the effectiveness of their services and care towards the achievement of the objectives of child health care services. It is believed that adequate provision of quality child health care in hospitals is imperative, because it would greatly help to improve the quality of children’s health.

Although, it is the responsibility of parents and guardians to take children to hospitals for essential health services which will be beneficial to their health, health care providers also play major role of keeping appointments for immunizations, check-ups, and ensuring readiness for  preventive,  curative  and  emergency  care.  Therefore,  parents  and  hospital  staff  were involved in this study.

Statement of the Problem

In developed countries, the under-five mortality rate has been reduced below 10  per

1000 live births, but many developing countries still record rates that are over 100 per 1000 (Lucas & Gilles, 2003). Campbell, Sow, Levine and Kottloff (2004) also observed  that the burden of mortality from infectious diseases weighed most heavily on children living in the developing world where seventy per cent of all childhood deaths are  attributed  to the five diseases of clinical syndromes: acute respiratory infection (ARI),  diarrhea, measles, malaria and  malnutrition.  This  fact  is most  disturbing  given  the  existence,  in many  instances,  of effective methods of prevention and intervention.

According to Turmen (2006), mortality rates among newborn infants remain stubbornly high in many countries because mothers lack care during pregnancy and child birth and babies do not receive essential newborn care. The aftermath of survival in weakened children who do not receive necessary care is worse because, they may be  stunted or live in blindness. Such children may drag out painful lives crippled by polio or be mentally retarded because of poorly managed  delivery  in  health  care  systems  which  often  fail to  meet  the  needs  of the most vulnerable  group  (children  and  child  bearing  mothers)  in the  society  (Belsey,  1984).  All children and pregnant women have a right to comprehensive health care that is fully portable and ensures continuous coverage.

Therefore, much remains to be done in reducing the avoidable mortality and morbidity rates by making the services reach all children. The importance of children receiving well-child and  other  primary care services  in their  early years  is well  established.  Even  for  healthy children  obtaining  routine  preventive  care  during  the  first  year  of  life  can  be  critical  to development. For those who experience acute or chronic conditions, or who have special health needs,   obtaining   regular   medical   attention   is   even   more   important   (Delone,   2006). Consequently, initiative to improve child health can have an enormous impact in reducing the

global burden of disease. Postnatal care requires further assessment as to the quality of services and their outcome.

In children’s  preventive  care for  which the  healthy development  and  avoidance  of injury and illness are the desired outcomes and for which guidelines are more consensus based than evidence based, special challenges  in both accurately and efficiently measuring health care performance exists (Bethel, Reuland, Halfon & Schor, 2004).  Bethel et al. (2004) also observed that health care performance assessment effort at the  national, state, health system, and  medical  practice  levels  all  face  real  constraints  in  the  amount  of  information  about performance that can be collected, included or reasonably absorbed in performance report to or about health systems or providers. Care for children is largely composed of routine services to promote their healthy development, prevent injuries, and screen for illness and other threat to

health.

Therefore, health system in general are being required to be assessed for improvement in the quality of care that they provide for children in order to make performance information available to their patients and stakeholders of health services.  Since the goal of evaluations is to provide useful feedback to relevant constituencies such as client groups, administrators and staff, feedback is perceived as useful if it aids in decision-making or policy formulation. The CIPP  evaluation  model  of  evaluation  which  was  adopted  in  this  study  is  among  the management oriented systems model where the C stands for context the I for input, the first P for  process  and  the  second  P  for  product.  This  modal  emphasized  comprehensiveness  in evaluation,   playing   evaluation   within   a   larger   framework   of   organizational   activities (Stufflebeam,  2000).  It is focused  on programme  evaluation  aimed  at affecting  long-term, sustainable improvements with questions such as, what needs to be done? How should it be done? and Did it succeed? In this case the concept of evaluation is to assess and report merits, worth and significance and present lessons learned to encourage improvement in child health care services  in health facilities.       The evaluation  of child  health care services  in health facilities in Nsukka urban in necessary because designing and conducting effective evaluation research will contribute to maximizing effective child health interventions.

Purpose of the Study

The purpose of this study is to evaluate child health care services in health facilities in

Nuskka urban of Enugu State. Specifically, the objectives of the study are to:

1.   determine  the  efficiency  of  components  of  immunization  services  provided  in public and private  health facilities  in Nsukka urban;

2.   determine the reliability of the growth monitoring and screening services carried out in public and private health facilities.

3.   assess  the effectiveness  of the curative  health services  provided  in these  health facilities  for children;

4.   assess  the reliability  of the emergency  health  services  provided  in these  health facilities for children;

5.   determine  the  usefulness  of  the  nutritional  services  provided  in  these   health facilities for children;

6.   assess the consistency of the health education components provided in these health facilities for children;

7.   determine the competency of staff who are responsible for the provision of child health care in these health facilities;

8.   determine administrative  problems that affect child health care services in public and private health facilities.

9.   determine administrative strategies used for improving child health care services in public and private health facilities.

Research Questions

The following research questions have been formulated to guide the study:

1.   How efficient are the immunization services provided in public and private health facilities in Nsukka urban?

2.   How reliable are the growth monitoring services and screening tests provided  in these health facilities for children?

3.   How effective are the curative health care services available for children in these health facilities?

4.   How reliable are the emergency care services available for children in these health facilities?

5.   How  useful  are  the  nutritional  services  provided  in  these  health  facilities  for children?

6.   How consistent are the health education services provided in the health facilities for children?

7.   How competent is the staff that provides child health care services in these health facilities?

8.   What administrative  problems affect provisions  for child  health care services  in these health facilities?

9.   What administrative  strategies are used for improving child health care in  these health facilities?

Hypotheses

To provide direction to the study each of the following three hypotheses are formulated to be tested at .05 level of significance.

1.   There is no statistically significant  difference  between private  and public  health facilities in relation to the quality of services provided for children.

2.   There is no statistically significant  difference  between public  and private  health facilities in relation to the competency of staff that provide care for children.

3.   There is no statistically significant  difference  between public  and private  health facilities in the administrative problems encountered in the provision of child health care services.

Significance of the Study

Health workers and parents will find the information on evaluation of child health care services useful to check whether their local hospitals provide a safe child friendly services and to press for improvement in line with the recommendations that was made for the benefit of children.  The  information  will  also  help  administrators  of  health  facilities  reorganize  the services provided for children in their hospitals in realizing their responsibilities in health care provision for children and in managing performance and planning in child health care

This study generated information on efficiency of immunization services which  will help health workers and parents to know if government  and private health facilities  ensure quality and coverage of this service. This will help to ensure improvement  in  immunization services which form an important aspect of children’s preventive  medicine  against diseases that cause disabilities and death in children.

The information  that was be obtained  on the reliability of growth monitoring  (e.g., height and weight measurement) and screening tests will help health care providers to ascertain if these services are ignored in their hospitals or health centers. With the information that is be provided, the knowledge of parents and health care givers on growth monitoring and screening tests  as  important  indicators  for  children’s  health  and   development  can  be  improved. Observations  and  screening  tests  can provide  the  bases for  teaching  parents  the  need  for improvement in the nutritional status of their children.

By providing information on the effectiveness of curative services in public and private health facilities the attention of health care providers will be drawn in integrated management

of childhood illness (ARI), with combination of therapies for several conditions. Data collected will help health care providers in planning and improvement on multiple approaches to help children who often present in hospitals with multiple symptoms.  Parents and health workers will use the information on curative services to check  whether hospitals provide safe child friendly care by meeting the broader needs of children (e.g., play to reduce fear), that helps to ensure effectiveness in child health care provisions.

The findings on the reliability of emergency services in health facilities will hopefully encourage  health  care  providers  in the  establishment  and  sustenance  of  strategies  to  help prioritize sick children. This will help to reduce morbidity mortality and permanent disability in  children  and  ensure  that  parents  are  confident  in  the  ability of  staff  to  place  special consideration for children in health facilities.

The information on the usefulness of the nutritional services in these hospitals will help to provide bases for the education of parents to place emphasis on the nutritional needs of their children and for health workers to ensure quality of child health care by making  necessary provisions  (e.g.,  Vitamin  A and  micronutrient  supplementation).  With the  confirmation  of parents, health workers will use the information to note if they have  considerations  for this important aspect in child health care.

Information generated on the consistency of health education services provided in these health facilities for children will provide bases for health workers to appreciate and improve on this important aspect in services for children. The information will help to ensure that health education is integrated with other services to enhance improvement in child health care quality. Parents will also benefit from improvement in health education that will help to enhance their children’s  health  status  through  knowledge  consequently,  provided  for  them  on  disease prevention and simple remedies for common diseases (e.g., oral rehydration therapy, accident prevention and sleeping positioning).

By providing information on the competency of staff who provide care for children in these  hospitals,  this study will hopefully  help  health care providers  to be clear  about the minimum requirement in the care of children. They will use the information to understand and appreciate  what is required  for professionals  to  improve and maintain  their competence  in working  with  children.  The  information  can also  provide  bases  for  in service  training  of auxiliary hospital staff members to improve their performance in the care of children.

In this study, data was generated on problems that affect child health care services in government and private health facilities. By addressing all areas of weakness identified, health care providers can be helped to press for improvement of services for children in line with the recommendations  in  this  project  report.  The  information  can  help  hospital  trusts  in  the

development of plans based on the areas of weakness identified by this report and to  ensure that these plans are achieved through incentives for improvement in child health care.

The  study hopes  to  generate  data on strategies  for  improving  child  health  care  in government and private health facilities through which guidelines can be provided to facilitate improvement  in  services  for  children’s  welfare.  The  information  will  help  to  encourage providers to continually improve their services and the way they work  and  to improve the coordination  of  child  health  care  services  which  will  lead  to  changes  in  the  process  of preventive services delivery in practice. They will use the information in decision making and in carrying out their responsibilities in multiple practice organization for children.

Scope of the Study

The study was delimited to health facilities in Nsukka Urban. Therefore, hospitals and health centres in Nsukka urban was used for this study with special consideration for public and private sectors as providers of health care services for children (WHO, 2004). The study was guided by the programme area of child health care services prescribed by WHO (2004) for children.  These  services  include:  immunization  services,  growth  monitoring  and  screening tests, nutritional  services,  health education,  emergency and  curative  services as well as the functions of health facilities and personnel. All the health personnel in these health facilities that are involved in the provision of child health care services were used as respondents for the study. This is because they are more  knowledgeable  in the pattern of health services they provide. Parents (especially mothers) as useful observers of health care services provided for their children were also involved.

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