THE EFFECT OF HEALTH PROMOTION ON PRIMARY HEALTH CARE SERVICES: AN ANALYSIS OF PRIMARY HEALTH CARE POLICY

respondents revealed that there is need for active involvement of other essential sectors in formulation and implementation of PHC policy to ensure a permanent change. Conclusion: this study shows that poor health promotion in Primary health care is having negative effect on the health of children, adolescents, adults, and old ones. This study here by recommends that the policy makers and the government should eradicate corruption and embezzlement of funds in all sectors especially in primary health care


Introduction
Nigeria is a country with three tiers of governments (federal, state and local government); the other two governments are controlled by the policy made at the federal level [1]. There is a wide range of policies and guidelines that control federal, state, and local issues [2]. The most pathetic situation is that the workers at federal level are better paid than the state workers, while the state workers are also paid better than the local government workers [3]. This factor is one of the main reasons why the Primary Health Care workers are not encouraged to engage in active health promotion, and therefore they believe that they cannot be stressing themselves for nothing. Therefore, they do not follow guidelines of health promotion strictly again. Another empirical study revealed that PHC workers need to follow these sensitive steps before health promotion could be achieved and these steps are as follows: manage the planning process, conduct a situational assessment, identify goals, populations of interest and outcomes, develop indicators, review of the plans. Most primary health care centres are not doing these any longer [4]. And this attitude is the main cause of disorderliness in the society because family planning, breast feeding, nutrition, cleanliness and others are parts of health promotion. Another study discussed further that when the PHC workers do not establish all these measures in a community, of course there will be unwanted pregnancies, criminal abortions, and malnutrition disorders [5].
According to a study conducted in Nigeria showed that most Federal and State hospitals are built in the city; so nearly all the health workers want to work in the city because of their remuneration, infrastructure, other opportunities, and benefits [6]. These opportunities make most of the competent health care professionals to be working and even some are still struggling to work with the Federal and State hospitals in the cities, leaving the grass root health centres (local government hospitals) with no choice health workers [7].
Furthermore, most PHC workers working at the local government level are not competent because there is not much screening before they are employed; unlike the Federal and State Governments [8]. Concurrently, an empirical study showed that the human resources in charge of PHC recruitment find it easier to influence the recruitment processes; this shows that there is a higher level of nepotism than meritocracy at the PHC level. This action inversely has a negative effect on the productivity of the PHC workers in Nigeria [9]. Conversely, it was also revealed that most of the competent health workers want to stay in the city because of their family and other benefits associated with urban areas.
In addition to the previous findings, most of the above-mentioned factors usually cause an increase in mortality and morbidity rate that usually occur among adolescents and new-born; this is prevalent in the local government areas due to lack of competent hands, equipment, and negligence [11]. Several studies have shown that globally, Nigeria ranks second to India with the highest number of new-born deaths, with the highest reported number in Africa. Each year in Nigeria, more than a quarter million new-born die, which translates to approximately 700 neonates every day [12,13]. Neonatal mortality remains disturbingly high in Nigeria, despite the significant decline in most parts of the developing world. However, despite the considerable efforts of the country to reduce maternal mortality, numerous pregnant women continue to die every day in Nigeria [14].
The aim of the study was to examine the effect of health promotion on primary health care service through the analysis of Primary Health Care policy.

Materials and methods
A mixed method (qualitative and quantitative) approach guided this study to analyse the existing national health policies on primary health care service delivery dated as 2016. Mixed method was adopted because it provides strengths that offset the weaknesses of both quantitative and qualitative methodological approaches [15]. It is necessary for the study to adopt this method because the quantitative is weak in understanding a subjective inner context; and the voices of the respondents are not directly heard [16].
Cross-sectional survey and ethnographic method of in-depth interview were used to generate data for this study. A cross-sectional survey collects data to make inferences about a population of interest at one point in time [17]. Ethnography is the scientific understanding of peoples" cultural patterns and social processes within a socio-cultural setting. Ethnography is a type of qualitative research that gathers observations, and interviews data to produce detailed and comprehensive accounts of a social phenomenon [18]. The use of ethnographic research in medical education has produced several insight-ful accounts into its role, functions, and difficulties in the preparation of medical students for clinical practice. Ethnographic research could identify, explore, and link social phenomena that have little connection with each other. It also needs extensive time to collect data [19].

Methodology
The study was conducted in the South-Western region of Nigeria. This research was conducted in Ado-Ekiti, Ekiti State. The study was conducted in 2021.

Sample and sampling
A convenience sampling technique was utilized to recruit respondents in the quantitative section with the use of questionnaires. According to a methodological study on sample and sampling, a non-probability convenience sampling technique aids the researcher to choose the elements of the study who are available. while a nonprobability purposive sampling technique was utilized to collect the qualitative data in the study. Concurrently, discussed further that purposeful sampling is widely used in qualitative research for the identification and selection of information-rich cases related to the phenomenon of interest.

Data collection process
Data collection is the process of gathering and measuring information on variables of interest, in an established systematic fashion that enables one to answer stated research questions, test hypotheses, and evaluate outcomes [20].
A full approval ethical clearance with protocol number of HSSREC/00002401/2021 was obtained from the University of KwaZulu-Natal Research Ethics Committee before obtaining data from the respondents. The gatekeeper from Ado-Ekiti Local Government unit together with the ethical certificate from the university were submitted to the PHC coordinators to secure permission to have access to the health workers in the designated Health Centers. The coordinators of the twenty Primary Health Care Centers were also given an earlier notification before conducting the study.

Data analysis
Since the data generated from the study were both quantitative and qualitative, various descriptive and inferential methods were utilized to analyse and explain the generated data. For quantitative analytical methods, the use of Statistical Packages for Social Sciences (SPSS 25) and Chi-Square were employed to analyse generated quantitative data (Univariate and Bivariate levels of analysis were utilized at this level). While in the qualitative section, NVivo software was used for data management.

Research results
A total of 300 questionnaires were administered online, with a response rate of 100 % (n=300). The demographic data of the quantitative sample (Table 1) indicated that the PHC workers were predominantly female. The findings on Table 2 shows that there is a significant relationship between health promotion and its contribution to a successful PHC service delivery.

Discussion
The descriptive analysis of the nominal variables was presented in the Table 1 above. The quantitative findings on Table 1 showed that all the respondents are aware of health promotion while 280 (93.3 %) understand the high benefits of community participation in health promotion in PHC. In support of these findings that nearly all the health care workers are aware of the benefits of health promotion but to implement it is the problem while another study argued that most health care workers do not understand the guidelines for the implementation of health promotion in PHC any longer and this is because they are not doing it frequently, so they are not handing over the intellectual property on health promotion to the younger generations any more [21]. That is why the upcoming primary health care workers are not emphasizing on health promotion like before and hypothesis test displayed in Table 2 above revealed there is a significant relationship between health promotion and its contribution to a successful PHC service delivery. This hypothetical finding displayed in Table 2 below showed that health promotion is highly significant to the progress of PHC.
The findings of the study revealed that 152 (50.7 %) of the respondents believed that the Government is not doing anything to resolve this problem. The study emphasized more on why the Government is not helping to work on the effectiveness of health promotion in PHC and the findings showed that bad leadership is the main factor that is causing the ineffectiveness of health promotion in PHC and when the respondents were questioned on what to do to ensure a more effective health promotion in the community, majority (34.7 %) of the respondents opined that the community members should be involved actively at every stage while (33.3 %) of the respondents revealed that there is need for active involvement of other essential sectors in formulation and implementation of PHC policy.
In line with this view, when a participant was asked on what extent can leadership influence health promotion at the PHC level?
The participant stated that "Wo! Good leadership is a gift to all na-tions…unfortunately we lack leadership in Nigeria, and it has affected all areas of our economy, not only the health sector. Now coming back to your question, let me be frank, leadership has negatively influenced our health sector, and this has impacted the smooth running of our PHC across the nation…it is even better in south-west Nigeria." When the participant was probed further on whether it is possible to achieve the goals of health promotion even with bad leaders.
The participant discussed further that "It is like you don't understand what I am saying. I said: without visionary and selfless leadership, there cannot be anything like health promotion." Another participant was probed on question based on what government has been doing to improve health promotion in PHC and the participant revealed that "To be sincere I cannot see anything tangible the government is doing to improve the health promotion in the 4PHC sector. Though they always put in place health promotion policy in Nigeria, the truth is that it is not effective. For example, in 2006, the Nigerian Government developed the "National Health Promotion Policy" (NHPP) to strengthen the health promotion capacity of the National Health System, so as to deliver health care service that is restorative, promotive, protective, preventive, and rehabilitative to every citizen of the country, but they have neither analysed nor implement the welldesigned policy properly." In support of these findings, several studies have shown that Poor leadership has really contributed to the failure of primary health care in Nigeria. All the sectors of the nation are under the plague of corruption [22]. Therefore Rwanda"s health governing bodies rely solely on strong leadership [23]. However, PHC policies, politics, government, and leadership are intertwined, because without good government, politics, and leadership there can never be any successful policy development, analysis, and implementation of PHC policies locally, nationally, and globally [24]. More so PHC policy ccould only be effective through the involvement of good leadership, partnership, and other essential bodies [25].
Conclusively, the Nigeria's Federal Ministry of health found that Nigerian"s health system is filled with high level of corruption and fraud; ineffective coordination among the three levels of government; the attitude of health workers towards patients; poor health service delivery; inadequate public and private health funding; poor working environment, limited opportunities for continuing education, massive migration of health workers to greener pastures; poor implementation of guidelines, few training opportunities; poor skills for supplychain management among providers; poor location of healthcare centers; poor utilization of research findings; lack of effective leadership for the successful implementation of health promotion and community participation in PHC [6]. According to the World Health Organization, PHC could only achieve its goals, be more responsive and accountable to societal needs through the appointment of good leaders to coordinate primary health care services.
Recommendations: 1. The study recommended a careful consideration of the skills and competencies needed in the PHC system.
2. There is a crucial need for the PHC human resources department to work on how they will be appointing good and more responsible staff as leaders in the PHC system.
3. The government need to be organising workshops, trainings, and conferences for PHC workers frequently.
4. There is a need for frequent supervision, monitoring and evaluation of each Primary Health Care Centre.

Study limitations
• Nigeria had a small number of population, and the study was conducted in one region of the country. It is recommended that this same research should be conducted in other regions in Nigeria.
• The PHC Coordinators were reluctant to use their phones" data and to spend such a long minute on the interview. However, they agreed after several and financial reimbursement.
• Power failure happens to be one of the most critical problems confronting the country where the research fieldwork was conducted. Power failure was a very prominent problem encountered throughout the course of data collection for the study. The study experienced frequent incidence of epileptic supply of electricity needed to charge the phones and other electronic devices used for the interview. This adversely affected the process of data collection and almost hindered the quality of collected data. However, the researcher was able to overcome this bottleneck by making an inestimable provision for a generator; but which consumed a huge amount of money spent daily to procure petrol with which the generator was powered.
• A significant limitation of this research was lack of funding as the research was self-sponsored by the researcher without having access to any grants. This almost affected the success of the research because of the limited timeframe allotted for the research. Despite all these constraints, the study was neither in anyway adversely affected, nor was the standard lowered in any form. The researcher was faced with the burden of payment for return air tickets from South Africa to Nigeria, accommodation, food, and local transportation.
Prospects for further research • A replicate study involving all the regions of the country should be conducted to gather broader perspectives which could be generalized across the nation and globally.
• The study was focused on the 2016 National Health Policy, there is a need to conduct a comparative study on the existing PHC policies that have been established before implementing the 2016 National Health Policy.

Conclusion
Globally, policymakers and researchers must improve the "health of all" worldwide and reduce the burden of disease, ill-health, disability, inequity, health differentials and socio-economic status, amongst others. To this effect, various governments, at different capacities, need to enact their policies and reform them to tackle health inequality and its social determinants. Despite the considerable attention on socio-economic related health inequalities, striking differences in health still exist within and among nations. Furthermore, socio-economic related differences within countries are often substantial, especially in developing African countries. While most primary health care policies have been able to promote, support, and establish system orientation, financing, inputs, and service delivery mechanisms to ensure provision of quality health for all. However, PHC policies, politics, government, and leadership are intertwined, because without good government, politics, and leadership, both within and outside the government, there would not be any successful policy development, analysis and implementation of PHC policies globally.
Finally, an intensive review of relevant literature on the effectiveness of health promotion in primary health care through the analysis of PHC. For health promotion to achieve its goals in PHC, there is a need for well-established politically inclined national health policies based on good governance and leadership. From this point of view, we could believe health promotion does not achieve its goals in the well-designed Nigeria"s 2016 national health policy. Therefore, the policy has failed to accomplish its objectives of meeting the needs of the citizens in ensuring primary health care service delivery for all. There was a relatively inadequate attempt by previous research inquiries to raise constructive questions as to why the national health policies have not been effective in Nigeria to date. On this account, this study will make a scholarly attempt to systematically investigate and analyse the existing national health policies on primary health care service delivery in Nigeria. To make health promotion to be more effective in primary health care, there is need for the study to do these.

Conflict of interests
The authors declare that they have no conflicts of interest.

Financing
The study was performed without financial support.