This document is a thesis submitted by Azanui Clifford Aluofuh to the University of Bamenda exploring community perception of primary healthcare services in Nkwen Health District, Cameroon. It includes an introduction outlining the study background, objectives to identify available services, utilization frequency, and factors influencing accessibility, quality and affordability. The methods section describes the descriptive cross-sectional study of 360 respondents using questionnaires. Key results found most services were available but underutilized, with top factors influencing accessibility being resource availability and cost. Factors for quality included increased professionals, proper planning and effective resource management. The study aims to improve healthcare in the region.

1. REPUBLIQUE DU CAMEROUN
……………………………………………
Paix- Travail- Patrie
……………………………………
UNIVERSITE DU BAMENDA
…………………………………..
FACULTE DES SCIENCES DE LA SANTE
……………………………………...
BAMBILI, BAMENDA
REPUBLIC OF CAMEROON
……………………………………………
Peace- Work- Fatherland
……………………………………
THE UNIVERSITY OF BAMENDA
…………………………………..
FACULTY OF HEALTH SCIENCES
……………………………………...
BAMBILI, BAMENDA
DEPARTMENT OF PUBLIC HEALTH
OPTION: COMMUNITY HEALTH
COMMUNITY PERCEPTION ON ACCESSIBILITY,
QUALITY AND AFFORDABILITY OF PRIMARY HEALTH
CARE SERVICES IN NKWEN HEALTH DISTRICT
PRESENTED BY
AZANUI CLIFORD ALUOFUH (B.Sc. in Nursing)
Registration number UBa20HP022
SUPERVISOR
PROF. GERALD NGO TEKE
Associate Professor of Pharmacology, UBa
OCTOBER 2022
1

2. 2
PRESENTATION OUTLINE
 INTRODUCTION
 STATEMENT OF THE PROBLEM
 RESEARCH QUESTIONS
 RESEARCH OBJECTIVES
 MATERIALS AND METHODS
 RESULTS AND DISCUSSION
 CONCLUSIONS
 RECOMMENDATIONS
 LIMITATIONS OF THE STUDY
 ACKNOWLEDGMENT
 REFERENCES
 SIGNIFICANCE OF THE STUDY

3. 3 INTRODUCTION
The WHO defines primary health care as essential health care based
on practically, scientifically, and socially accepted method and
technologically made universally accessible to the individual and
families in the community through their full participation and at a
cost that the community and the country can afford to maintain at
every stage of their development in the spirit of self-reliance and self-
determination. Globally, more than half the world’s population
already lacked access to essential health services before the COVID-
19 pandemic[1].

4. 4 INTRODUCTION CONT.
Research indicates that patients’ perception of quality is influenced by
a variety of factors, such as features of the national health system,
practice type and the providers’ personal and clinical skills. It seems
that patients value immediate comfort while physicians addressing
quality of care are concerned more about resources. A large body of
research addressing different aspects of quality of care from the
perspective of patients and providers exists. However, these studies
mostly cover a single country and/or one health problem. There is a
lack of data about the perception of quality of care by patients and
health providers in an international context.

5. 5 STATEMENT OF THE PROBLEM
A key message of the World Health Report 2010 is that “...millions
of people cannot use health services because they have to pay for
them at the time they receive them. And many of those who do not
use these services suffer financial hardship, or are even
impoverished, because they have to pay.[1] To date, much of the
focus has been on the implications of out-of-pocket payments
(OOPs), including user fees for individuals and households in
relation to socio-economic status.

6. STATEMENT OF THE PROBLEM CONT.
In Cameroon, little is known about the perception rates of PHC
services and factors influencing community perception especially
with the advent of the COVID-19 pandemic. The socio-political
unrest in the North West region of the country has caused an
increase in internally Displaced population (IDP population), an
increase in the rate of poverty and decrease in levels of education
among the community. With all these changes, there is little or no
knowledge on the perception rates of PHC services in this region.
6

7. RESEARCH QUESTIONS
• What are the available primary health care services in Nkwen Health
District?
• How frequent is the utilization of these primary health care services
in Nkwen Health District?
• What are the factors that influence accessibility, quality and
affordability of primary health care services by inhabitants in Nkwen
Health District?
• What are the ways of improving accessibility, quality and
affordability of these primary health services in Nkwen Health
Districts?
7

8. RESEARCH OBJECTIVES
Main Research Objective
The general objective of this study is to explore community perception on accessibility,
quality and affordability of primary health care services in Nkwen Health District.
Specific Research Objectives
• To identify the available primary health care services in Nkwen Health District.
• To determine the frequency of utilization of these primary health services in Nkwen
Health District.
• To identify the factors that influence accessibility, quality and affordability of
primary health care services by inhabitants in Nkwen Health District.
• To determine the ways of improving accessibility, quality and affordability of
primary health care services in Nkwen Health District.

9. 9
Access to primary healthcare services expressively improves productivity,
increase life expectancy and reduces both morbidity and mortality rates
among citizens. Hence, investigating the factors that affect access to
healthcare, and also child mortality, will help to guide the policy makers to
improve on their interventions, with respect to issues concerning
improvement in access to primary healthcare services.
Significance of the Study

10. 10
MATERIALS AND METHODS
STUDY DESIGN
The study was a community
based descriptive cross-sectional
study
STUDY PERIOD
This study covered a period of 3 months from
March to July 2022
STUDY AREAAND SETTING
 This research is limited to households within the Nkwen Health Area of the
Nkwen Health District in the North-West Region of Cameroon.

11. 11 MATERIALS AND METHOD CONT
TARGET POPULATION
This study will be a community-based study, to be carried out in randomly selected
households within the Nkwen Health Area of the in North-West Region
INCLUSION CRITERIA
All households randomly selected
and consent to the study will be
included in the survey.
EXCLUSION CRITERIA
All unoccupied households
All household that refused/opted out from
the survey.
All Red (highly insecure) zones vis a vis the
sociopolitical crisis

12. 12
MATERIALS AND METHODS CONT.
Sampling Method
A simple random sampling
will be use to select the
households of the study
The sample size was calculated using Taro
Yamane `s formula
A total of 360 respondents were
enrolled in the study.
Sample Size Determination
Ethical Considerations
• Ethical clearance was obtained from the Institutional Review Board (IRB) of the University of
Bamenda.
• Administrative authorization was gotten from the regional delegate of public health.
• Informed consent form from the school was signed by the participants.

13. 13
MATERIALS AND METHODS CONT.
• Data for this study was analyzed using SPSS for version 26.
• The results were presented in the form of tables and charts, in
representation of frequencies and percentages according to the various
objectives of the study.
• Association between categorical variables was done using Bivariate
logistic regression analysis technique. A P-value of <0.05 was
considered as statistically significant.

14. 14
RESULTS AND DISCUSSION
Demographic Data
Gender of Respondents
Frequency
Percen
t
Variables Male 97 26.9
Female 263 73.1
Total 360 100.0
Employment status
Frequency
Percen
t
Variables Unemployed 260 72.2
Private sector 56 15.6
Public sector 30 8.3
Retired 13 3.6
Informal sector 1 .3
Total 360 100.0
73.1% females and 26.9% males during the study majority of our respondents were unemployed, that is 72.2%
(260), 15.6% (56) worked in the private sector while 8.3% (30)
were civil servants

15. 15
RESULTS AND DISCUSSION CONT.
Demographic Data cont.
0.83% had no education, 75.56% had attended
university studies. 18.06% had attended
secondary school closely followed by 5.56% for
primary scholars.
most of our respondents, 63.3% (228) were 21 – 40 years,
followed by those of the age of 41 – 60 years, 21.1% (76). The
minority were those of both <= 20 years and 60+ years with a
percentage of 7.8% and frequency being 28.

16. 16
RESULTS AND DISCUSSION CONT.
Demographic Data cont.
Marital status
Frequency Valid Percent
Variables single 152 42.2
Married 136 37.8
Divorced 2 .6
Widow/Widower 70 19.4
Total 360 100.0
Religion
42.2% (152) were married, closely followed by 37.8% (136).
We had 19.4%(70) widowed/widowers with 0.6% (2) divorced
respondents
87.22% Christians, 10.83% Muslims and 1.94%
respondents from other faiths.

17. 17
RESULTS AND DISCUSSION CONT.
PHC services available
PHC services available yes no Total
N % N % N %
Mother and child care including family planning 244 67.9 116 32.1 360 100
Provision of adequate nutrition 321 89.3 39 10.7 360 100
Provision of safe drinking water and sanitation 334 92.9 26 7.1 360 100
Health education on the prevention of prevailing illnesses 320 89 40 11 360 100
Control and prevention of communicable diseases and injuries 241 67 119 33 360 100
Vaccination against the major infectious diseases(E.P.I) 360 100 0 0 360 100
Treatment of injuries and minor ailments 219 61.1 141 38.9 360 100
Provision of essential drugs 299 83.3 61 17.7 360 100

18. 18
RESULTS AND DISCUSSION CONT.
PHC services available
Generally, there was a general acceptance of public health services being
available in the area in the following proportion. 67.9% indicated the
availability of mother and child health care including family planning. The
demographics indicates more females than males in the study area, who use
the mother and child care public health service, and are open to becoming
housewives than the male counterpart. This is in line with a study by Marko,
2020 which shows that the female are much more open to becoming mothers if
idle than when employed. (Marko,2020) Regarding the availability of
adequate nutrition, 10.7% said there was no provision of accurate nutrition.
This is inline with a study carried out by FNG, 2021 which shows that, about
48% of Cameroonians cannot afford a diet that meet their nutritional
requirements.

19. 19
RESULTS AND DISCUSSION CONT.
PHC services available
Moreover, 24% cannot afford a diet that meets just their energy needs.
However, the World Food Programme (WFP) in collaboration with the
Cameroon government is now providing food to the IDPs of the study area as
of the time of this study. The study found out that regarding the provision of
safe drinking water and sanitation, 92.9% agreed while the remaining 7.1%
said no. This high percentage is due to the fact that community water is
provided in most areas of Bamenda community by the policy makers of the
town. In 1968 Cameroon created the National Water Supply Company of
Cameroon (SNEC, Société Nationale des Eaux du Cameroun) to provide water
supply across the country This is in line with a study by Goudge, 2016 where
he stated that water was the most available public health care resource to the
people of South Africa according to the BMC health services.

20. 20
RESULTS AND DISCUSSION CONT.
PHC services available
89% said there was the availability of health education on the prevention of
communicable diseases and injuries, with a 100% record on the availability of
vaccination against the major infectious diseases. This goes to support the fact that
what Onyeneho,2016 about vaccines is true. The researcher stated that Vaccines reduce
risks of getting a disease by working with your body's natural defences to build
protection. When you get a vaccine, your immune system responds. Given that
Cameroon government does door to door vaccination campaigns, the research study is
in confirmation of this act. As per the treatment of injuries and minor ailments, 38.9%
said it was not available and 83.3% said there was the provision of essential drugs as a
public health service in the area. This shows that sensitization is needed in the area as
many people records shows education on PHC is lacking in the area.

21. 21 RESULTS AND DISCUSSION CONT.
Frequency of utilization of
PHC services
V. frequent Frequent I don’t know Not frequent Never used
N % N % N % N % N %
Mother and child care
including family planning
9 2.6 53 14.9 103 28.2 51 14.3 144 40.0
Provision of adequate
nutrition
19 5.3 64 17.9 15 3.8 44 12.3 218 60.7
Provision of safe drinking water and
sanitation
259 72.1 38 10.8 30 7.1 36 10.0 0 0
Health education on the
prevention of prevailing illnesses
215 59.9 41 11.4 40 10.7 14 4.1 50 13.9
Control and prevention of
communicable diseases and injuries
252 70.0 49 13.8 6 1.3 53 14.9 0 0
Vaccination against the major
infectious diseases(E.P.I)
328 91.3 10 2.8 0 0 22 5.9 0 0
Treatment of injuries and minor
ailments
32 8.9 58 16.3 16 3.9 252 70.1 2 0.8
Provision of essential drugs 197 54.8 44 12.4 77 20.7 30 8.6 12 3.5
Frequency of utilization ofPHC services

22. 22 RESULTS AND DISCUSSION CONT.
Frequency of utilization of PHC services in Nkwen Health District.
The respondents data was collected, and regarding how frequent the health
services available are being used, we had the following results. 40.0% said they
don’t know about mother and child care while 2.6% said they use it very
frequent. This however shows that even though mother and child care is being
provided, most of our respondents do not use it as they ought to. Most
mothers are preoccupied with house works and farming, that services such as
clinical visits are often neglected by mothers in the study area. When it came to
adequate nutrition, 60.7% said they had never used it as a public health
service, and a few, 5.3% actually indicated they use it very frequently. Even
though the World Food Program in association with the Cameroon
government provides food to households in the study area, there are
procedures to be followed, such as registration which most of them skip, and
as a result they do not receive the benefit of nutritional provision as a public
health care service

23. 23 RESULTS CONT
Frequency of utilization of PHC services in Nkwen Health District.
Regarding safe drinking water and sanitation, 72.1% indicated they use it very
frequently, and there was no case of any individual who does not use this particular
public health service in the district. Audrey Hepburn,1993 said Water is life, and clean
water means health. Therefore, it is not surprising that 72.1% of the study population
use safe drinking water provided, and as per sanitation, the HYSACAM company
carries the trash in the neighborhood to the appropriate location. This then prevents
dirt related diseases in the area. 59.9% of respondents use health education on the
prevention of illnesses, and there was no case of those who have never used control
and prevention of communicable diseases and injuries. The study showed that 91.3%
have used the vaccination service before, and 54.8% have frequently used the
provision of essential drugs to the public. The government of Cameroon provides
vaccination for children and adults in hospitals, as well as during doorto-door
campaigns. The results shows most of our respondents do use the vaccination services
provided by the government. The most recent being the COVID-19 vaccine which was
provided by the Public Health Ministry to the population.

24. 24
Sub factors N %
Factors influencing accessibility of PHC
service
Availability resources of health
care
310 86.2
Low cost of care 230 64.0
Transportation system 72 20.0
Health insurance coverage 38 10.8
Factors influencing quality of PHC services
Increase in health professionals 284 79.1
Collaboration 73 20.5
Proper planning 283 78.8
Effective management of resources 230 64.0
Availability of resources 111 30.9
Factors influencing affordability of PHC
service
knowledge and skills 353 98.1
Income
Transportation cost
360
165
100
45.9
Price or cost of use 353 98.2
Waiting time 118 32.9
Quality of care 46 12.9
Factors influencing accessibility, quality and affordability of PHC in Nkwen Health District.

25. 25
Factors influencing accessibility, quality and affordability of PHC in Nkwen
Health District.
Accessibility was generally positive as most of the PHC services could be easily
accessible especially health care resources, (86.2%). (310) of them ticked availability of
health care resources as a factor influencing accessibility, with 64.0% indicating the
percentage of low cost of care being a factor affecting accessibility of health care
services. Government hospitals in Cameroon give out health care services at very low
cost, and also during campaigns and other community outreach programs. As per
transportation system, 20% agreed and health insurance coverage recorded 10.8 of
respondents. The ambulance with the number 119 is accessible to each member of the
study population, as such accessibility of the health care service is facilitated upon
during emergency cases. As per health professionals, 79.1% accepted that an increase
in health professionals will actually influence accessibility of health care services. It is
but normal that professionalism means a good impact on the accessibility of health
care services. This is in line with the division of labour theory which shows that
many hands can reach out to more people than few hands.

26. 26
Factors influencing accessibility, quality and affordability of PHC in Nkwen
Health District.
As per the factors affecting the quality of the health care services delivered, it shows
that proper planning (78.8%) and effective management of resources (64.0%) will go a
long way as shown by the agreed population. One of the major objectives of the
health sector third and fourth five years plans (1980-90) was to improve the quality
and to increase the coverage of the health care delivery system (GOB 1990). As per
resource management, it is advisable for the government to also implement
maintenance policies in order to deliver quality health care services. Rani et al. (2015)
advises that government should do three types of maintenance, namely unplanned
(corrective) or planned (preventive), and predictive maintenance approaches.
Corrective maintenance (CM) occurs when a component is going out of function and
needs intervention in the form of repair or replacement (Higgins et al., 2002). On the
other hand, Preventive maintenance (PM) includes planning of periodical repairs or
replacements at specified time intervals (Gross, 2002) such as monthly, quarterly or
annually. Looking at the factors influencing affordability, there was a 100% agreed on
income, and 98% on cost of use

27. 27
Sub factors N %
Ways of improving accessibility of PHC services
Increase efficiency of the workforce
Ensure adequate funding of children’s health insurance
program and retain Medicaid expansion
162
85
45
23.6
Stabilize individual insurance 37 10.3
Ways of improving the
quality of PHC services
Address physician shortage 243 67.7
Collaboration
Proper planning
113
301
31.8
83.7
Effective management of resources 324 90
Availability of resources 3 0.9
Ways of improving
affordability of PHC services
Education and training 270 75
Promote virtual healthcare
Poor sections of society must be provided free medicines
20
287
20.4
79.9
Regulate the prices of drugs 295 82.1
People should be allowed to buy health insurance from
company
46.44 12.9
Door to door distribution should be encouraged
276 76.9
Ways of improving accessibility, quality and affordability of Primary Health Care services.

28. 28
Ways of improving accessibility, quality and affordability of Primary Health Care
services.
The responses to the various suggestions to improve affordability, quality and
accessibility of primary health care services indicates that, as per improving
affordability, a lot of emphasize was laid on price regulation on drugs (82.1%). This
was closely followed by poor sections of society having free medicines, 79.9%. The
least percentage came from insurance, with 12.9% ticking to allowing people to buy
insurance from other companies. According to Kessler, 2014, the primary goal of
drug price regulation is to reduce expenditures by cutting prices. This will intend
make the drugs very much affordable to the general public. Boiling down to ways of
improving quality of public health services, proper planning, 83.7% and effective
management of resources, 90% was highest. Availability of resources recorded a
0.9%. Talking about ways of improving accessibility, hiring more people or
addressing physician shortage scored 67.7%, followed by increasing the efficiency of
workforce

29. 29 CONCLUSION
Every citizen has a right to have access to healthcare services
(Cameroon constitution, 1960). This discussion has shown how
affordability and accessibility can influence the usage of healthcare
services. Accessibility is not only the distance an individual must
travel to reach the health service point but more so the utilization of
these services.
As per the availability of the Public health care services, generally,
there was a general acceptance of public health services being
available in the area with the most being vaccination, then safe
drinking water, closely followed by mother and child care. The least
available public health service in the area was the treatment of
ailments.

30. 30 CONCLUSION CONT
Regarding the Frequency of utilization of these services, most of
our respondents use safe drinking water frequently which is
provided by CAMWATER, and the sanitation taken care of by
HYSACAM. Even though mother and child care is available, its
frequency of utilization is rather low.
Looking at the factors influencing accessibility, quality and
affordability of PHC in Nkwen District Area availability of health
care resources, transportation system, and an increase in health
professionals will actually influence accessibility of health care
services. Regarding the quality, it shows that proper planning and
effective management of resources are the main factors affecting the
quality of public health care services in the area.

31. 31 CONCLUSION CONT
Looking at the factors influencing affordability, there was a 100%
agreed on income, and 98% on cost of use. Most of the users of the
health care services were housewives, and especially the mother and
child services. Given they are housewives, the challenge of income is
but understandable in this study, and the cost of usage can also be
burdensome
Looking at ways of improving affordability, a lot of emphasize was
laid on price regulation on drugs. The least percentage came from
insurance. And in order to improve quality, proper planning, and
effective management of resources, should be taken into
consideration. Talking about ways of improving accessibility, hiring
more people will be increasing the efficiency of workforce

32. 32 RECOMMENDATIONS
The government should provide medication for free especially
to the low and middle class residents of her country.
At present doctors who fail to fulfill their duties have little fear
of any penalties, and enjoying higher income from
government practice. There are no direct financial incentives to
provide higher quality services. As such provision of
incentives for better performance and disincentives for
irresponsibility need to be introduced effectively.

33. 33
Electricity problems disturbed the realization of this study during
the report writing, and printing phases
Most households were scared of receiving the researcher due to the
insecurity issues in the area which is as a result of the Anglophone
crises
Poor roads especially in the quarters where the research is carried
out was a hindrance to the study
LIMITATION OF STUDY

34. 34
Economic impact of public health services on the country
Evaluation of the performance of public health practitioners in the
community
SUGGESTIONS FOR FURTHER STUDIES

35. 35
AKNOWLEDMENTS
I would like to express my gratitude to my supervisor Prof. Gerald Ngo Teke for the
time and dedication he put to ensure the best out of this work.
The Dean, administrative staffs and lecturers of the Faculty of Health Sciences of the
University of Bamenda, for the training for these two years.
Much thanks to the department of Public Health, Faculty of Health Science and
University of Bamenda for granting me the opportunity to bring out this piece of
work.
To all the participants of this study, thank you for accepting to take part in this study.
This piece of work would not have been realized without the support of my friends,
brother and sisters, classmates and family members. Your input is deeply
appreciated.

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Poor Live on $2 a Day; Princeton University Press: Princeton, NJ, USA, 2009.

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38. 38