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REFORMING THE NIGERIAN HEALTH SECTOR:EQUITY AND RESOURCE ALLOCATION AT THE
LOCAL LEVEL
(A CASE STUDY OF EKITI STATE)
1Dare o. o, Yisa I.O, Faleye K. I, Osegie H
1 The research unit of CHESTRAD International implemented the study with support from theAlliance for Health Policy and Systems Research, Geneva – Switzerland. All Correspondenceshould be addressed to Dr. Lola Dare, Center for Health Sciences Training, Rtesearch andDevelopment ( CHESTRAD ) International –29, Aare Avenue, New Bodija Estate, UIPO Box21633, Ibadan, NIGERIA. chestrad @yahoo.com
ii
ContentsPage
Outline of Contents i - iiList of Tables iiiList of figures ivList of Maps vAcronyms and abbreviations vi
EXECUTIVE SUMMARY 1 - 7
1.0 Introduction 8 - 92.0 Conceptual Frame 9 - 103.0 General Objectives 114.0 Specific objectives 115.0 Purpose of the Study 11
6.0 Methodology 126.1 Study Design 126.2 Study Area 126.3 Study Population 126.4 Sample Size 126.5 Assumptions 12
7.0 Data Management And Analysis 137.1 Data Collection Instruments 137.2 Data Quality 137.3 Data Collation 147.4 Data Analysis 14
8.0 Findings 15
8.1 Resource Inflows Into The Local Governments 15
8.2 Financial Inflows 15
8.3 Total Public Sector Budget Per Capita 16
8.4 Health Infrastructural Facilities 20
8.5 Human Resources For Health 21
iii
8.6 Population Based Surveys 25
8.6.1 Demographic Characteristics 25
8.6.2 Assessment of Poverty 26
8.6.3 Income and Education 27
8.6.4 Income and Gender 28
8.6.5 Education and Gender 29
8.7 Survival Assets 30
8.7.1 Access to Water Supply 30
8.7.2 Income and Access to Water 31
8.7.3 Access to Sanitary Disposal of Sewage 32
8.7.4 Access to Safe Refuse Disposal Methods 32
8.7.5 Income and Access to Refuse Disposal Methods 33
8.7.6 Access to Acceptable Shelter 34
8.7.7Access to Health Care Facility 35
8.8 Health Status Indicators 38
8.8.1 Child Survival 38
8.8.2 Health Of The General Population 42
8.8.3 Health Status 43
8.8.4 Equity In Health 43
9.0 A Public Health Policy Dialogue 47
CONCLUSION 48
iv
List of Tables
Tables : Page
1 Distribution of CHOs : Population Ratio by LGA 23
2 Population Distribution of Ekiti State by Local LGAs 25
3 Average Income by level of Education 28
4 Average Income by Gender 28
5 Educational level by Gender 29
6 Average Income and Access to Water 31
7 Educational Level and Access to Water 31
8 Average Income and Refuse Disposal Methods 33
9 Educational Status and Access to Refuse Disposal
Methods 34
v
List of Figures:
Page1 Sources of Financial Inflows to the LGAs 32 Relationship between Health Status, Socio-economic
Status and Resource Allocation 103 Sources of Financial Inflows to the LGAs 154 Financial Inflows by LGAs 165 Total Budget Per Capita 176 Existing Channels For Health Resource Allocation
In Nigeria 187 Percentage Distribution of Primary Health Care
Facilities By LGAs 208 Percentage Distribution of Nurses/Midwives by LGAs 219 Percentage Distribution of Total Primary Healthcare
Workers by LGAs 2210 Distribution of Poverty by LGAs 2711 Percentage Distribution of Access to Safe Water
Supply by LGAs 3012 Percentage Distribution of Access to Sanitary
Sewage Disposal by LGAs 3213 Percentage Distribution of Access to Sanitary
Disposal of Refuse by LGAs 3314 Percentage Distribution of Access to Acceptable
Shelter by LGAs 3415 Percentage Distribution of Access to Health
Care Facilities by LGAs 3616 Percentage Distribution of BCG Coverage by LGAs 3817 Percentage Distribution of OPV coverage by LGAs 3918 Distribution of Percentage Under 5 with DPT
Coverage by LGAs 3919 Incidence of Childhood Diarrhoea by LGAs 4020 Percentage Distribution of ANC by LGAs 4121 Percentage Distribution of Pregnant Women
Who did not receive TT in Last Pregnancy by LGA 4222 Distribution of Malaria Prevalence by LGAs 42
vi
List Of Map
PageMap 1: Map of Ekiti State Showing its 16 Local Government Areas in 2002
vii
Acronyms and Abbreviations
ACOSHED African Council for Sustainable Health DevelopmentAIDS Acquired Immunodeficiency SyndromeARI Acute Respiratory Tract InfectionBCG Baccille Calmette GuerinBHA Better Health in AfricaCHESTRAD Center for Health Sciences Training, Research & DevelopmentCHO Community health OfficerCPAS Composite Poverty AssessmentDFID British Department for International DevelopmentDPT Diphtheria, Pertusis and TetanusFMOH Federal Ministry of HealthHSR Health System ReformISEqH International Society for Equity in HealthN NairaNDHS National Demographic Health SurveyNHMIS National Health Management information SystemsNISH National Integrated Survey of HouseholdsNMDS Nigerian Micronutrient Deficiency SurveyNPC National Planning CommissionLGA Local Government AreaHIV Human Immunodeficiency VirusOPV Oral Polio VaccinePHC Primary Health CareSMOH State Ministry of HealthSPSS Statistical Package for Social ScientistTT Tetanus ToxoidWHO World Health OrganizationWHR World Health ReportUNICEF United Nations Children’s FundUSD United States Dollars
viii
EXECUTIVE SUMMARY
There has been global concern about the performance of public health
systems. Patients and the public are dissatisfied by the quality of care,
politicians complain about spiraling costs of providing health care, health
professionals are concerned with equity and value for money. Given these
concerns, economic pressure for health reform is being felt in nearly all
countries.
Studies have observed that health services and programmes in many
developing countries have been designed and implemented without
establishing an adequate policy framework. Similarly, reform efforts are being
undertaken in situations of gross inadequacy of information. Various
arrangements are forged to improve access to health services with very little
consideration for levels of inequities in health status, socio-economic conditions
and resource allocation. The situation in Nigeria is not different. Health reports
from various sources in Nigeria suggest poor documentation of the distribution
of health resources and that it is largely perceived that these do not relate to
the health status and needs in the geo-political zones and at the local level.
This is against the background of an absence in an equity-based resource
allocation formula especially at the local level that recognizes these differences
in health outcomes and status. Furthermore, there are no guidelines for
monitoring the fairness and responsiveness of health resource allocation to
health status and service utilization. This seemingly chaotic situation was
manifested in the dismal performance of Nigeria’s health system as revealed
by WHO in its year 2000 report on the assessment of health systems of
member nations. The purpose of this exploratory study was to analyze the
fairness in the distribution of health resource allocation and its relationship
with socio-economic conditions and health status in Ekiti State. The study
aimed to:
ix
(1) Use evidence and stakeholder review to support equity oriented
outcomes in the public budget allocation to and within health.
(2) Develop consensus amongst key stakeholders on the goals,
mechanisms, principles and factors used in developing a transparent,
equity oriented resource allocation formula to be used for the
allocation of resources to and within the health sector and for
monitoring the use of those resources
(3) Hold a review meeting by key stakeholders (Government, local
authorities, funding agencies, communities and others) to review the
technical information and processes involved, and to widen
understanding on equity oriented resource allocation processes.
The study was descriptive, cross sectional in design and implemented in
two (2) arms. A desk review for secondary data focused on current allocation
and distribution of health data resources in the participating LGAs. The primary
data was on household survey of socio-demographic characteristics and health
indicators using prevalent figures provided by NDHS 1999, NMS 1994 and
NISH 1994 with a final size of 400 households in each LGA. A systematic
random sampling technique was applied with the updated sampling frame
developed by the NPHCDA.
The findings from the study showed that there were no identifiable
criteria for the allocation and distribution of health resources to all the LGAs.
Over 98% of the financial inflows into the LGAs were from outside sources with
less than 2% generated from within. This is shown in Figure 1.
Figure 1: Sources of Financial Inflows to the LGAs
92.9
1.9 5.1
102030405060708090
100
x
Figure 1 shows that 92.9% of the revenue was from statutory budgetary
allocation while 5.1% represented grants and 1.9% as internally generated.
The average public expenditure on health per capita was N53.00, a far
cry from the national average of N693.2 (US$6) and the WHO recommended
minimum of N1,690 (US$13). The average monthly income of the study
population was N5, 000.00 amounting to N178.57k daily income which is
slightly above the World Bank standard rate of N140.00 (US$1) poverty line.
Eighty percent of the population was relatively poor, indicating a high
prevalence of poverty in the state. This compares unfavourably with the
national figure of 70%. These observations are consistent with the World Bank
documented GNP per capita of N110.23k (US$290) for Nigeria, which is
grouped among the World’s poor nations
The socio – economic conditions and other determinants of health as
observed in this study showed that income and education were strongly related
(P=0.00000). For those with no formal education, 532 (41.6%) earned less
than N5,000 compared with 746 (58.4%) of those earning more than N5,000.
Four hundred and fourty (41.0%) of the respondents with primary education
earned less than N5,000 compared with 632 (59.0%) of those with similar
education who earned more than N5,000. For those with secondary education,
395(31.4%) earned less than N5,000 compared with 862(68.6%) who earned
more than N5,000 while 184 (11.2%) of those with post secondary education
xi
earned less than N5,000 compared with 1452(88.8%) who earned more than
N5,000. Higher levels of education enhanced income earning capacities.
A significant gender disparity with respect to income was observed, with
543(25.0%) of males compared with 1058(33.1%) of females earning less
than N5,000 while 1625(75.0%) of males compared with 2141(66.9%) of
females earned more than N5,000. Gender disparity was also observed in
educational attainments. Of those with no formal education, 385 (30.3%) were
males compared with 886(69.7%) females. Of those with only primary
education, 407(38.1%) were males compared with 660(61.9%) females while
479 (38.3%) males compared with 772 (61.7%) females had only secondary
education. However, at post secondary level, there were more males
811(50.2%) compared with 803 (49.8%) females.
The relationship between income and access to water showed that for
those who earn less than N5,000, 721(45.9%) had no access to acceptable
source of water compared with 85 (54.6%) who had while among those who
earned more than N5,000, 1510(41.4%) had no access compared with
2140(58.6%) with access to acceptable source of water. Similarly, 1303
(82.7%) of those earning less than N5,000 had no access to acceptable refuse
disposal method compared with 273(17.3%) who had. For those who earned
more than N5,000 2788(76.6%) had no access compared with 850(23.4%)
who had access to acceptable refuse disposal method.
Current malaria episode was reported by 1452 (40.7%). Of this, Seven
hundred and four (63.0%) of those who earned less than N5,000 reported
current episodes of malaria compared with 414(37.0%) who did not report any
current episode, while 1414(57.7%) of those who earned more than N5,000
reported current episode compared with 1038 (42.3%) who did not report
current episode.
Higher educational status showed improved access to water. with
707(57.2%), 709 (58.2%), 958(62.3%) of the respondents with no formal
xii
education, secondary and post secondary education respectively having access
to water. It was however observed that 512(48.7%) of those with primary
education had access which was lower than what was reported for those with
no formal education. A similar trend was observed with educational status and
refuse disposal. One hundred and sixty four (13.2%), 168(16.0%), 274
(22.5%) and 465(30.4%) of those with no formal education, primary,
secondary and post secondary education respectfully had access to acceptable
refuse disposal methods.
For educational status and malaria episode, 377(50.0%) of those with no
formal education reported current episode of malaria. Of those with primary
education, 428 (62.8%) did not report any episode compared with 254(37.2%)
that reported malaria episodes. Five hundred and sixty four(65.4%) of those
with secondary education did not report episodes compared with 298 (34.6%)
who reported malaria episodes while 696 of those with post secondary
education reported having malaria compare with 451(39.3%) who did not
report any episode.
The distribution of health infrastructure varied significantly from one LGA
to the other. On the average, there was 1 primary health care facility to a
population of 175,864 in the state. For the manpower distribution, there was I
nurse/midwife to a population of 15,025 while CHO/population ratio was
1:7,750. These were generally lower than the national averages and the WHO
recommended figures. Health status indicators measured through proxies
showed that immunization coverage for infants were BCG, 98%; Polio3,
75.3%% and DPT3, 72% on the average. The percentage of pregnant women
who had access to ante natal care was 94.3% with 84.5% having had TT in
their last pregnancies. Except for acceptable shelter with a State average of
99.5%, accesses to survival assets were generally low with water 47.6% and
sanitation 45%. These observations are consistent with the unfavourable
health status as reflected in the high point prevalence (40.0%) of malaria in
xiii
the entire population as well as diarrhoeal diseases among the under fives in
the state.
The result of this study shows that factors such as personality, political
and others appear to have played major roles than rationality in resource
allocation and distribution. The resulting disparities and inequities in the socio-
economic and health status in the State provide enough evidence for major
policy change towards a credible health reform process. It is imperative that a
review of suitable indicators with appropriate weightings be undertaken and a
consensus reached by all the stakeholders to arrive at a formula for equitable
health resource distribution. The reform process as agreed by all the
Stakeholders, would involve capacity building at local level to identify suitable
indicators and equity based criteria for resource distribution. Such indicators
should be based on:
(a) Health needs in relation to priority health goals.
(b) Ability to meet health needs.
(c) Performance of health services.
This would address equity issues in health, taking into consideration
other social determinants, for the overall socio-economic development of
the Ekiti State.
xiv
1.0 INTRODUCTION
A health system includes all activities whose primary purpose is to
promote, restore or maintain health. Health systems have a responsibility not
just to improve people’s health but to protect them against the financial cost of
illness and to treat them with dignity (The World Health Report, 2000). Health
systems have three fundamental objectives namely:
a. Improving the health of the population they serve.
b. Responding to people’s expectations.
c. Providing financial protection against the costs of ill – health.
Health Sector Reform (HSR) involves a sustained process of fundamental
change in policy and institutional arrangements, guided by governments and
designed to improve the functioning and performance of the health sector and
ultimately to the health status of populations i.e. meeting the above stated
objectives of a health system. A major thrust of a health sector reform is the
elimination of inequities in health status and resource allocation at all levels of
the health system. Nigeria, like many other countries has been involved in
health reform processes. These have seen largely carried out as components of
her National Development Plans up to the time it adopted the Primary Health
Care (PHC) as the cornerstone of health care development in the country. In
1995, a National Health Summit was organized to re-appraise the Health
System of Nigeria and the relationship to its health status; with a view to
carrying out a reform process that would address identified deficiencies.
Among factors making health sector reform process imperative in Nigeria,
include:
(a) Increase in the burden of disease
xv
(b) Deteriorating health outcomes, particularly among the vulnerable
groups (women & children) in the population.
(c) Threats of emerging and re-emerging diseases including HIV/AIDS
and tuberculosis among others.
(d) A rapidly dwindling resource allocations to the health sector.
(e) Lack of synchronization between planning and implementation of
health programmes on one hand and inadequate responsible to the
health needs and demands of the people on the other hand,
through rationally gathered information from research and health
data.
(f) The need to acknowledge the role and involvement of the end user
through carefully designed and culturally sensitive co-financing and
management schemes.
(g) The need to acknowledge the role and involvement of the private
sector in the planning, implementation and evaluation of health
programmes and development efforts in Nigeria.
2.0 CONCEPTUAL FRAMEWORK
Several studies have observed that health services and programmes in
many developing countries have been designed and implemented without
adequate policy framework. Similarly, reform process particularly in developing
countries are undertaken in situations of gross inadequacy of relevant
information. While many equity studies have shown inequities in health status
and outcome, studies on criteria and mechanism for health resource allocation
to address such inequities have been generally lacking. This situation describes
what obtains in many African countries including Nigeria.
xvi
There is a relationship between health needs (identified and defined by
indicators of health status), health resource (defined as all inputs into the
health system) and socio-economic status, Figure 2.
This relationship is dynamic and mutually reinforcing and interruption of this
relatedness results in disparities i.e. inequities in the distribution of each of
these variables
As a prelude towards contributing to the Health Sector Reform process in
Nigeria, this study was undertaken to examine the role of equity consideration
in resource allocation, health planning and service delivery in Ekiti State. If
sought further, to identify criteria for the allocation of health resources at local
government levels in the state.
3.0 (GENERAL OBJECTIVE)
Figure 2: Relationship between Health Status, Socio-economic Status and Resource Allocation.
Socio-economic Status
Resource Allocation
Health Status
xvii
The aim of this study was to identify criteria for health resource
allocation in relation to socio-economic status and health needs at local
government authorities (LGA) i.e. district level in Ekiti State of Nigeria, making
appropriate recommendations.
4.0 SPECIFIC OBJECTIVES
The specific objectives of the study were to:
a. Document and describe existing health resource allocation
mechanism in Ekiti State.
b. Describe the distribution by size, demographic and socio-economic
characteristics as well as the health status of the population in the
communities of the selected local government areas.
c. Identify criteria for equity based health resource allocation at LGA
level taking into consideration, population distribution,
demographic and socio-economic characteristics and health status
and
d. Base on the findings, recommend appropriate strategies to identify
and monitor inequities in health as well as differentials in health
needs at district level in Ekiti State.
5.0 PURPOSE OF THE STUDY
The purpose of the study was to document and contribute relevant
information for the Health Sector Reform in Nigeria.
6.0 METHODOLOGY
6.1 STUDY DESIGN
xviii
The study was descriptive and principally cross-sectional in design.
Implementation was 2 arms involving primary and secondary data. The
primary data collection was on a household survey on socio-demographic
characteristics and health status indicators. The secondary data collection was
a desk review which focused on current distribution of health resources in the
participating local governments.
6.2 Study Area. The study was conducted in all the 16 local government
areas of Ekiti State.
6.3 Study Population. The study population was made up of communities
in all the 16 local government areas in Ekiti State.
6.4 Sample Size. For the collection of the primary data in the household
health and socio – economic and development profile survey, sample size
estimates were based on the assumptions stated below. No sample size
determination was required for the collection of the secondary data (the desk
review).
6.5 Assumptions.
a) Twenty five percent of households in the study LGA have access to safe
water supplies (289 households per community).
b) Fifteen percent of households in the study LGA have access to acceptable
methods of refuse disposal (139 household per community).
c) Twenty three percent of children under 5 years old are stunted (289
children under five per community).
Estimates were computed based on 95% precision and a confidence
interval of + 5%. Reference prevalent figures were as obtained from the
National Demographic and Health Survey (NDHS) 1991, National Micronutrient
Deficiency Survey (NMDS) 1994, National Integrated Survey of Households
xix
(NISH) 1994. With an estimated prevalence of 15% non-response, the
estimated sample size per LGA was 332 households. For this investigation, 400
households were recruited per local government. Sampling was conducted by
systematic random sampling technique using the updated sampling frame
developed by the Primary Health Care Development Agency (NPHCDA).
7.0 DATA MANAGEMENT AND ANALYSIS
7.1 Data Collection Instruments. The data collection instruments included
in this report were used for the analysis. These had been previously, developed
and tested. The field testing was carried out by the Research Unit of
CHESTRAD and supported by the World Bank as part of the Health Systems
Funds activity in Oyo State and the Better Health in Africa Secretariat of the
same organization.
7.2 Data Quality. Data quality was ensured through the use of
internationally conducted and or supervised surveys in Nigeria, including the
NDHS, population census of 1997 and the National Health Management
Information System (NHMIS). Other sources of data included the National
Planning Commission (NPC), the NPHDA, state departments for local
government affairs and local government offices of NPC. Health resources from
donor agencies to all participating LGAs were also collated from the local
government offices and validated from records of the relevant donor agencies.
Data collection was done with trained interviewers, principally by trained
community extension workers in the participating local governments. These
extension workers had earlier been trained for community mobilization and
conduct of community level registration exercises. Supervision was carried out
by research assistants from CHESTRAD International.
7.3 Data Collation. Collation of primary data was by double entry using Epi
Info version 6.04b. A check file was designed for interactive data checking.
xx
Entries of both clerks were validated as true entries of questionnaire records
using VALIDATE module of Epi Info.
7.4 Data Analysis: Data analysis was computer based, using Epi Info
version 6.04b. Presentation of data was by Microsoft Power Point and as maps
by Epi Map and Atlas GIS. Advanced analysis was by SPSS version 10. The
descriptive maps related allocation of health resources i.e. staff, health
facilities and supplies to demographic composition of the community and
health status parameters (indicators) from the household development profile
survey. It also identified key determinants of inequities in resource allocation
and the impact of different health allocation criteria on health status. Potential
criteria for health resource allocation in response to health needs were also
explored.
xxi
8.0 FINDINGS
The findings have been presented in the following sections:
a. Resource inflows into the local governments.
b. Population Based Surveys.
SECTION A
8.1 RESOURCE INFLOWS INTO THE LOCAL GOVERNMENTS
Resources on this study include the inflows and distribution of financial
resources, health infrastructure (health centres etc.) and human resource. The
analysis of resource inflows is however limited by the inability of the survey
team to access information on expenditure patterns. The study was not able to
report on allocational efficiency of the financial resources reported in this
section. In addition, the study is unable to report on disparities between
budgeted and actual releases. The figures reported in this section refer to the
actual amount available to the State and each local government during the
period covered by the report.
8.2 Financial Inflows. The sources of financial inflows to the various local
government areas were investigated and the result shown in Fig 3.
Figure 3: Sources of Financial Inflows to the LGAs
Figure 3 showed that budgetary allocations represented 92.9%, while
revenue generation was 1.9% and grants received from other sources
92,9
1,9 5,1
0
20
40
60
80
100
Budgetary Allocation Revenue Grants
xxii
accounted for 5.1% of the total. The dis-aggregation by local governments is
shown in Figure 4.
Figure 4: Financial Inflows by LGAs
Figure 4 shows financial inflows by local government distribution. It was
quite apparent that budgetary allocations from government to the LGAs were
their main sources of income, ranging from 86.2% for Ido Osi local
government to over 97% of inflows to Efon Alaye and Ilejemeje, local
governments. Other sources combined, accounted for very little of the financial
inflows into the local governments, ranging from 2.7% with Efon Alaye and
Ilejemeje LGAs to the highest level of over 11% for Gboyin and Irepodun
LGAs.
8.3 Total Public Sector Budget Per Capita. The total budget (Public
Sector Expenditure) per capita is shown in figure 5.
92.3
6.7
97.3
2.7
93.5
6.5
95.1
4.8
94.2
5.8
96.1
3.9
88.2
11.8
86.2
13.8
92.2
7.8
92.9
6.1
91.9
8.1
97.3
2.7
94.2
5.8
88.8
11.2
94.9
5.1
94.3
5.7
94.9
5.2
0
10
20
30
40
50
60
70
80
90
100
Ad. Ef.Ek.
E
Ek.SW EK
.W Em Gb.
Ido. O Ij. Ik Ek Ile Ise Ire
p.Mob
aOye
Total
% from Govt. % from other Sources
xxiii
Figure 5: Total Budget Per Capita
Gboyin LGA had the highest budget of N75.4 per capita as compared
with the other LGAs, while Ado Ekiti LGA had the lowest budget of N37.4 per
capita. Per capita budget for the other local governments vary greatly as
shown in Figure 4 with an overall State aggregate of N53.0. Fundamentally,
the State average per capita budget for health is a far cry from the national
average of N693.2 (US $6.0) and the WHO amount of $13 (USD) amounting to
N1690 (one thousand six hundred and ninety naira(Erinosho, 1991), (Annual
Report Statement of Account, CBN, 2000). The implication of this finding is
that the health needs of the people are met from other sources such as out of
pocket expenses or seek care from alternative sources outside the formal
health sector which may have grave consequences. Furthermore, the
distribution of the per capita health budget between the local governments is
not based on any identified criteria. The general variations would no doubt
contribute to avoidable mal-distribution of health resources which invariably
results in inequities in health.
This finding provides evidence for alternative methods and mechanisms
for health care financing in Ekiti State. Policy on social health insurance such as
community co-financing is worth considering in this regard. The success of
37.4
54.9
67.3
38.940.8
66.7
75.4
58.354.4
38.8
45.8
68.1 66.2
46.443.4
45.6
0
10
20
30
40
50
60
70
80
Ad. Ef.Ek.
E
Ek.SW EK.W Em Gb.
Ido. O Ij. Ik Ek Ile Ise Ire
p.Mob
aOye
xxiv
such schemes as the Oriade Initiative provides a good model for Ekiti State to
explore.
The existing channels for health resource allocation in Nigeria is shown
in Figure 6.
Figure 6: Existing Channels For Health Resource Allocation In Nigeria.
The diagram shows the flow of health resource allocation in Nigeria from
and between all levels of the Health System, including stakeholders. It is
observed that the flow of information and planning is top-down from federal to
all levels of the health system with little or no regards for local perception of
health needs. Resource flow from development and donor agencies follow a
similar pattern. This lack of clarity and co-ordination at all levels of the system
affects communication and effective planning process between the local
government health authorities and the communities they serve. This situation
NATIONAL PLANNINGCOMMISSION
NATIONAL PRIMARYHEALTH CAREDEVELOPMENT
AGENCY
FEDERALMINISTRY OF
FINANCE
HEALTHDEVELOPMENTPARTNERS /
DONORS
FEDERALMINISTRY OF
HEALTH
STATEMINISTRY OF
HEALTH
LOCALGOVERNMENT
HEALTH AUTHORITY
xxv
is totally at variance with the national health policy provision which states
inter-alia that “implementation of all activities particularly health related
activities should be undertaken at the local government level to ensure access
to communities and their disadvantaged group. A study carried out in
Zimbabwe found that equity in health has been a priority policy issue to the
government since 1980 at independence. It also observed that while progress
was made in the extension of health care programs and facilities to all
segments of the population including rural and urban, the health sector had
witnessed decline in public expenditure on health. Allocations to the health
sector and within the health sector have become an issue of public debate. This
situation raised the pressure to increase effectiveness and equity in the use of
the limited resources for health. The strategy proposed to address the problem
presented the following:
• Analysis of policy documents to identify key factors for inclusion in equity
dimensions of resource allocation and dis-aggregations used.
• An outline of the current budget allocation process within health.
• A proposal for stakeholder interview to identify their priority factors for
equity based resource allocation and the stakeholders to be interviewed.
This strategy has implications for studies on health equity in Nigeria.
8.4 HEALTH INFRASTRUCTURAL FACILITIES
Primary Health Care Facilities. The percentage distribution of primary
health care facilities by local governments in Ekiti State is shown in figure 7.
Figure 7: Percentage Distribution of Primary Health Care Facilities By
LGAs
xxvi
8
5.3
3.7
6.9
9.6
4.8 5.
3 6.4
11.2
2.7
6.4
3.7
6.4
5.9 6.
4 7.4
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
LGAs
02
46
810
1214
Per
cent
age
of T
otal
PH
C
PHC Fac
PHC Fac 8 5.3 3.7 6.9 9.6 4.8 5.3 6.4 11.2 2.7 6.4 3.7 6.4 5.9 6.4 7.4
Ikere LGA had the lowest percentage (2.7 %) of the total number of PHC
facilities in the State as compared with the other LGAs. Ekiti East and Ilejemeje
LGAs each have 3.7% while Ijero had the highest percentage of the total
number of PHC facilities in the State. Details are shown in figure 7. The
distribution varied across the LGAs without any identifiable criteria. However,
there are possibilities that the LGAs with very low distribution of facilities could
be among those carved out of the existing old LGAs with most of the facilities
having been retained by their mother LGAs.
Primary health care, being the cornerstone of health reform process in
Nigeria is considered very crucial to the performance of the health system. The
great disparity in the distribution of the primary health care facilities therefore,
raises major questions of equity with respect to access to health care in the
various local governments.
8.5 HUMAN RESOURCES FOR HEALTH
xxvii
The distribution of nurses and midwives as well as primary care workers
at the LGA was investigated as proxies for the overall health manpower. The
result is shown in figure 8.
Figure 8: Percentage Distribution of Nurses/Midwives by LGAs
Figure 8 indicates a wide variation in the distribution of this category of
health manpower in all the local government areas in the State. Ado Ekiti LGA
had the highest percentage (14.5%) followed by Ekiti West (13.3%) and Ikere
(13.2%) of the total number of Nurses/Midwives in the State. Ijero LGA had
the lowest with 1.8%. The distribution across the other LGAs are shown in
figure 8. For the total primary health workers which includes the community
health officers (CHOs), senior community health extension workers (SCHEWs)
and the junior community health extension workers (JCHEWs), the distribution
is shown in figure 9.
Figure 9: Percentage Distribution of Total Primary Healthcare Workers
by LGAs
14.5
2.73.6
3.2
13.6
6.8
3.64.5
1.8
13.2
3.2
4.5
7.3
6.4
3.6
7.2
0
2
4
6
8
10
12
14
16
Ad. Ef.Ek
. E
Ek.SW EK
.W Em Gb.
Ed. Ij. Ik Ek Ile Ise Ire
p.Mob
aOye
8.2
7.2
10.3
8.3 8.17.6
6.9 6.77.6
6
8
10
12
xxviii
From figure 9 Ekiti West LGA had the highest percentage (10.3%) of
primary health workers while Emure and Ijero LGAs had the lowest
percentages of 2.9% each while the distribution in the other local governments
vary between these extremes. However, the distribution of CHOs showed a
glaring inequity as the variations between the LGS were significant. The ratio
of CHOs to the population and by LGAs is shown in Table 1.
xxix
Table 1: Distribution of CHOs : Population Ratio by LGA
Name of LGA (CHO) Population Facility/ Popn. Ratio.
1 Ado 5 249,868 1: 49,974
2 Efon 1 122,458 1: 122,458
3 Ekiti East 2 105,270 1: 5,635
4 Ekiti South West 1 213,922 1: 213,922
5 Ekiti West 1 212,322 1: 212,322
6 Emure 0 96,767 1:3,4478
7 Gbonyin 3 103,435 1: 6,0936
8 Ido Osi 3 150,421 1: 4,4081
9 Ijero 0 144,529 0: 144,529
10 Ikere 3 182,809 1: 6,0936
11 Ikole 2 88,162 1: 4,4081
12 Ilejemeje 0 78,492 0: 78,492
13 Irepodun/Ifelodun 4 117,506 1: 2,9377
14 Ise / Orun 2 168,258 1: 8,4129
15 Moba 1 193,980 1: 193,980
16 Oye 3 175,864 1 :5862
Total 31 2,404,063 1: 77,550
It was observed from the distribution that Emure, Ijero and Ilejemeje
had no CHOs. Irepodun /Ifelodun was the best served LGA with CHOs having a
ratio of 1 CHO to a population of 29,377. Efon, Ekiti South West, and Ekiti
West LGAs had only 1 CHO to populations of 122,458; 213,922 and 212,322
respectively.
Health resource allocation to the local governments from various sources
including the State and the federal government, development partners, donor
agencies and other stake holders neither showed any clear pattern nor based
xxx
on any identifiable criteria. Furthermore, the distribution of such resources is
not based on any rationally gathered information from research and health
data. The variations and disparities in the distribution of health resources as
observed in Ekiti State constitute inequity as factors responsible are avoidable.
The local government level is a credible avenue where all health resources can
be captured and therefore offers a unique advantage for initiating a health
resource allocation mechanism that is bottom up, involving all stakeholders
which include local community development committees.
xxxi
SECTION B
8.6 POPULATION BASED SURVEYS
8.6.1 Demographic Characteristics
Ekiti State with a total population of 1,879,826 by the 1991 election
(NPC, 1991) and by projection was 2,404,063 (NPC, 2000) is one of the 36
political divisions in Nigeria. This study was based on the year 2000 population
projection. The population as disaggregated by the 16 local governments in the
state shows that Ado LGA had the highest percentage (10.39%) while
Ilejemeje had the lowest (3.26%) of the total population. Details are shown in
table 2.
Table 2: Population Distribution of Ekiti State by Local LGAs.
S/N LGA NAMES YEAR 2000Male Female Under 5 Total %
Total1 Ado 104,855 103,444 41,569 249,868 10.392 Efon 49,981 52,068 20,409 122,458 5.093 Ekiti East 46,526 42,199 16,545 105,270 4.374 Ekiti South West 88,108 90,161 35,653 213,922 8.895 Ekiti West 87,668 89,267 35,387 212,322 8.836 Emure 40,131 40,508 16,128 96,767 4.027 Gboyin 43,332 42,858 17,245 103,435 4.308 Ido Osi 61,883 63,485 25,053 150,421 6.259 Ijero 58,347 61,927 24,255 144,529 6.1010 Ikole 75,671 76,670 30,468 182,809 7.6011 Ikere 36,992 36,143 15,027 88,162 3.6612 Ilejemeje 12,831 13,333 52,328 78,492 3.2613 Ise Orun 48,011 49,911 19,584 117,506 4.8814 Irepodun/Ifelodun 69,245 70,970 28,043 168,258 6.9915 Moba 80,763 80,554 32,663 193,980 8.0616 Oye 72,324 72,229 29,311 175,864 7.31Total 976,668 987,727 439,668 2,404,063 100
The mean age of the population of the State is 43.2(SD 17.83) years
with little variations across the 16 LGAs. Ekiti State is predominantly Yoruba (…
xxxii
%), a major ethnic tribe in Nigeria. Majority of the citizens, 89.3% practice
Christianity as their religious faith while 9.3% practice Islam and 1.5%
practices others, including the traditional religions. The literacy level in the
state shows that 59% of the population could read easily, while those who
could read with difficulty constituted 19.5% and the percentage of those who
could not read at all was 21.1. The distribution by local governments shows
that there was a significant variation (p-value =0.000) in all the local
governments across the State. Four thousand three hundred and fifty eight
(85%) of the respondents had acceptable occupation while 770 (15%) had
unacceptable occupation. The income distribution was highly skewed and
therefore the median income of N5000 (Five thousand naira) of the
respondents was a more acceptable measure of the average monthly income
and this varied significantly (X2 value of 3359.47, p-value <0.000) between
the local governments across the state. An average monthly income of N5000
translates into an average daily income of N178.57K. This is consistent with
the World Bank standard rate of $1(N140) per day poverty line, indicating that
an average person in Ekiti State is poor. Furthermore, it also agrees with the
classification of Nigeria among the poor countries of the World with her GNP
per capita of $290 (N110.00), (UNICEF, 2003). The level of poverty in the
State was investigated.
8.6.2 Assessment of Poverty: Poverty assessment was based on a
binary score of 0 or 1 for some selected social variables namely: mean monthly
income, literacy status, occupational status, shelter, access to potable water,
access to sanitation, access to health facilities, access to legal services,
employment status, educational status.
A score of (0) indicated that the individual was not poor while a score of
1 indicated that he or she is poor with respect to a particular
variable. The minimum aggregate score was (0) while the
maximum score was 12, which was the total and maximum
xxxiii
number of variables considered. An aggregate score of (0)
indicated no poverty, aggregate score of 1-6 indicated relative
poverty while an aggregate score of 7-12 indicated absolute
poverty. Details are shown in Figure 10.
Figure 10: Distribution of Poverty by LGAs
Figure 10 shows the distribution of poverty across the local governments
in Ekiti State. It was observed that in Ilejemeje LGA, the proportion of the
population in absolute poverty was 52.1% while of 47.9% of it’s population
were in relative poverty and zero percent as not poor. The poverty level varied
widely across the State with an overall State aggregate of only 1.7% not poor,
80% in relative and 18.3% in absolute poverty.
8.6.3 Income and Education
Educational status was found to be strongly related to income level
(P=0.0000), table 3.
Table 3: Average Income by level of Education
EDUCATIONAL STATUS
AverageIncome
No formalEducation
PrimaryEducation
SecondaryEducation
PostSecondaryEducation Total
88,6
4,5
86,3
12,6
56,9
38,3
90,5
8,8
66,8
33
91
8,2
83,7
15,8
66,9
29,6
81
19
76,5
21,5
88,6
10,4
47,952,1
81,6
16,3
77,7
22,1
88,2
11,4
94,7
2,8
80
18,3
0
10
20
30
40
50
60
70
80
90
100
Ad. Ef.
Ek. E
Ek.SW EK
.W Em Gb.Ido
O Ij. Ik Ek Ile Ise Irep.
Moba Oye
State A
gg.
% Relative % Absolute % not poor
xxxiv
<N5, 000 532(41.6%)
440(41.0%)
395(31.4%)
184(11.2%)
1551(29.6%)
>N5, 000 746(58.4%)
632(59.0%)
862(68.6%)
1452(88.8%)
3692(70.4%)
Total 1278(100.0%)
1072(100.0%)
1257(100.0%)
1636(100.0%)
5243(100.0%)
(P = 0.0000)
For those with no formal education, 532(41.6%) earned less than N5,
000 compared with 746 (58.4%) of those earning more than N5,000. Four
hundred and forty (41.0%) of the respondents with primary education earned
less than N5,000 compared with 632(59.0%) of those with similar education
who earned more than N5,000 while 184 (11.2%) of those with post secondary
education earned less than N5,000 compared with 1452(88.8%) who earned
more than N5,000.
8.6.4 Income and Gender
A significant gender disparity with respect to income was observed, table
4.
Table 4: Average Income by Gender
Average IncomeGender <N5, 000 >N5, 000 TotalMale 543(33.9%) 1626(43.2%) 2169(40.4%)
Female 2058(66.1%) 2141(56.8%) 3199(59.6%)
Total 2601(100.0%) 3767(100.0%) 5368(100.0%)
(p=0.0000)
Five hundred and forty three (25.0%) of males compared with
1058(33.1%) of females earning less than N5, 000 while 1625(75.0%) of
males compared with 2141(66.9%) of females earned more than N5, 000.
8.6.5 Education and Gender
Gender disparity was also observed in educational attainments.
As shown in table 5.
xxxv
Table 5: Educational level by Gender
EDUCATIONAL STATUS
GenderNo formalEducation
PrimaryEducation
SecondaryEducation
PostSecondaryEducation Total
Male 385(30.3%)
407(38.1%)
479(38.3%)
811(50.2%)
2082(40.0%)
Female 886(69.7%)
660(69.9%)
772(61.7%)
803(49.8%)
3121(60.0%)
Total 1271(100.0%)
1067(100.0%)
1251(100.0%)
1614(100.0%)
5203(100.0%)
(p=0.000)
Of those with no formal education, 385(30.3%) were males compared
with 886(69.7%) females. Of those with only primary education, 407(38.1%)
were males compared with 660(61.7%) females had only secondary education.
However, at post secondary level, there were more males 811(50.2%)
compared with 803(49.8%) females. Higher levels of education enhanced
income-earning capacities. In addressing poverty issue in Ekiti State therefore,
educational empowerment particularly female education would be crucial.
This finding provides evidence to address poverty issue in the state.
Poverty alleviation is part of a comprehensive socio-economic projects, being
undertaken by CHESTRAD International through its Oriade Initiative
Programme and would need to be considered by Ekiti State.
8.7 SURVIVAL ASSETS
A number of social services indicators that impact directly on health were
investigated. These include; access to safe water supply, sanitary sewage and
refuse disposal methods as well as shelter. The results are stated below:
8.7.1 Access to Water Supply. The proportion of the population with
access to safe water varied widely across the local government areas. The
distribution of this social indicator by LGA is shown in figure 11.
Figure 11: Percentage Distribution of Access to Safe Water Supplyby LGAs.
xxxvi
Ilejemeje LGA had the highest proportion (95.5%) of it’s population with
access to safe water supply while Ekiti East LGA had the lowest
(43%) of Its population having access to safe water. The
distribution for the other LGAs and the State aggregate of 47.6%
are shown in figure 10. The observed high accesses of Ilejemeje
and Moba LGAs to safe water are consequent upon the location of a
drain and irrigation projects within and around these LGAs.
8.7.2 Income and Access to Water
Accessibility to water was found to be strongly related to income and
level of education as shown in tables 6 and 7.
Table 6: Average Income and Access to Water
Average IncomeAccess to water <N5, 000 >N5, 000 TotalUnacceptable 721(45.9%) 1510(41.4%) 2231(42.7%)
Acceptable 851(54.1%) 2140(58.6%) 2991(57.3%)
Total 1572(100.0%) 3650(100.0%) 5222(100.0%)
(p=0.000)
91,2
38,8
4,3
54,4
14,1
58,6
41
75,4
31,239,5
78,3
95,5
30,7
46,4
95,1
16,7
47,6
0
10
20
30
40
50
60
70
80
90
100
Ad. Ef.
Ek. E
Ek.SW EK
.W Em Gb.Ido
O Ij. Ik Ek Ile Ise Irep.
Moba Oye
State A
gg.
xxxvii
Table 7: Educational Level and Access to Water
Educational Status
Access towater
No formalEducation
PrimaryEducation
SecondaryEducation
PostSecondaryEducation Total
Unacceptable 530(42.85) 539(51.3%) 510(41.8%) 580(37.7%) 2159(42.8%)
Acceptable 707(57.2%) 512(48.7%) 709(58.2%) 958(62.3%) 2886(57.2%)
Total 1237(100.0%) 1051(100.0%) 1219(100.0%) 1538(100.0%) 5045(100.0%)
(p=0.000)
The relationship between income and access to water showed that for
those who earn less than N5, 000, 721(45.9%) had no access to acceptable
source of water compared with 85 (54.6%) who had while among those who
earned more than N5, 000, 1510(41.4%) had no access compared with
2140(58.6%) with access to acceptable source of water. Higher educational
status showed improved access to water with 707(57.2%), 709 (58.2%),
958(62.3%) of the respondents with no formal and primary education,
secondary and post secondary education respectively having access to water.
8.7.3 Access to Sanitary Disposal of Sewage. The percentage
distribution of access to acceptable (sanitary) method of sewage disposal is
shown in figure 12.
Figure 12: Percentage Distribution of Access to Sanitary SewageDisposal by LGAs.
90,483,1
79,8
60,8
68,1 65,8
42,5
86,9
61,5
80,6 78,7
3,8
73,7
93,6
59,353,2
68,7
0
10
20
30
40
50
60
70
80
90
100
Ad. Ef.
Ek. E
Ek.SW EK
.W Em Gb.Ido
O Ij. Ik Ek Ile Ise Irep.
Moba Oye
State A
gg.
xxxviii
Figure 12 shows that Irepodun LGA had the highest percentage access of
93.6% with Ilejemeje LGA having the lowest percentage of 3.8% while the
State aggregate was 68.7% and the distributions in other LGAs observed to
vary greatly.
8.7.4 Access to Safe Refuse Disposal Methods. The access to safe
refuse disposal method in Ekiti State was generally low across all the local
governments. The distribution across the LGAs is shown in figure 13.
Figure 13: Percentage Distribution of Access to Sanitary Disposal of
Refuse by LGAs
Figure 13 shows that Ilejemeje LGA had the lowest access with only
1.4% of its population having access to sanitary disposal method
while Ado Ekiti LGA had 54.2% which was the highest, followed by
54,2
25,7
11,216,3
5,8
17,413,6
3,6
41,2
23,2 24,7
1,4
22,928,6
4,9
18,7 21,5
0
10
20
30
40
50
60
Ad. Ef.
Ek. E
Ek.SW EK
.W Em Gb.Ido
O Ij. Ik Ek Ile Ise Irep.
Moba
Oye
State
Agg.
xxxix
Ijero with 41.2% among all the LGAs. The distribution in the other
LGA’s shows a general low trend with a State aggregate of only
21.5%. Compared with the national average of 54% (UNICEF,
2003), only Ado Ekiti LGA had an acceptable level of access to
adequate sanitation facilities.
8.7.5 Income and Access to Refuse Disposal Methods
Education and level of income of income were found to be strongly
related to access to refuse disposal methods as shown in tables 8 and 9.
Table 8: Average Income and Refuse Disposal Methods
Average IncomeRefuse Disposal Method<N5, 000 >N5, 000 Total
Unacceptable 1303(82.7%) 2788(76.6%) 4091(78.5%)
Acceptable 273(17.3%) 850(23.4%) 1123(21.5%)
Total 1576(100.0%) 3638(100.0%) 5214(100.0%)
(p=0.000)
Table 9: Educational Status and Access to Refuse Disposal Methods
Educational StatusRefuse
DisposalMethod
No formalEducation
PrimaryEducation
SecondaryEducation
PostSecondaryEducation Total
Unacceptable 1080(86.8%) 880(84.0%) 944(77.5%) 1063(69.6%) 3967(78.7%)
Acceptable 164(13.2%) 168(16.0%) 274(22.5%) 465(30.4%) 1071(21.3%)
Total 1244(100.0%) 1048(100.0%) 1218(100.0%) 1528(100.0%) 5038(100.0%)
(p=0.000)
For refuse disposal methods, 1303 (82.7%) of those earning less than
N5, 000 had no access to acceptable refuse disposal method compared with
273(17.3%) who had access while those who earned more than N5,000
2788(76.6%) had no access compared with 850(23.4%) who had access to
acceptable refuse disposal method. Increasing levels of education was related
to improved access to refuse disposal with 64(13.2%), 168(16.0%),
274(22.5%) and 465(30.4%) of those with no formal education, primary,
xl
secondary and post secondary education respectively having access to
acceptable refuse disposal method. Income level and education therefore, have
direct implication on the health of the people with respect to access to water
and sanitation. The general low level of sanitation in the state has grave
consequences for health. This finding provides enough evidence for policy
towards the provision of this social amenity to the people.
8.7.6 Access to Acceptable Shelter: The findings with respect to shelter
showed that almost the entire population lived in one form of acceptable
shelter or the other, Figure 14.
Figure 14: Percentage Distribution of Access to Acceptable Shelter by
LGAs
The entire communities in Ekiti State do not seem to have shelter
problems as indicated in Figure 14. Ijero LGA with 96.5% of its population
living in acceptable shelter had the lowest while several other LGAs had as
much as 100% with a State aggregate of 99.5%. The predominance of rural
communities compared the urban and the cultural background explains the
state of shelter in the State. However, as the State becomes more urbanized,
99,6
10099,7
10099,7 99,7
100
97,1
96,5
99,7 99,7100
99,799,5
100 100
99,5
94
95
96
97
98
99
100
Ad. Ef.Ek.
EEk
.SW EK.W Em Gb.
Ido O Ij. Ik Ek Ile Ise Ire
p.Mob
a Oye
State
Agg.
xli
shelter issues are bound to arise. There is need therefore, to consider in the
overall development plan of the State.
8.7.7 Access to Health Care Facility. Health Care Facilities were
expected to provide the medium of contact between the population and the
health system. The percentage of the population having access to health
facilities would therefore have direct impact on the health status of the
population. For the purpose of this study, only the proportion of the population
with physical access to a healthcare facility (distance from living area to the
nearest health facility) was investigated. Figure 15 shows the distribution
across the State.
Figure 15: Percentage Distribution of Access to Health Care Facilities
by LGAs
Access to health facilities was investigated by determining the
percentage of the population within 1km or 10 minutes walk to a health
facility. The result which is shown in figure 15 indicate that Ado Ekiti LGA had
the highest proportion (74.3%) of it’s population with physical access to health
care facility as compared with the other LGAs while Ilejemeje had the lowest
with only 3.3% of it’s population having physical access to health care
facilities. The State aggregate of 46.3% is below the national average of 53%
74,3
50,9
70,6
52,6
39,3
56,759,7 58,4
42,5
20,824,7
3,3
63,8
36,1
63,2
21,5
46,3
0
10
20
30
40
50
60
70
80
Ad. Ef.
Ek. E
Ek.SW EK.W Em Gb.
Ido O Ij. Ik Ek Ile Ise Irep
.Mob
a Oye
State A
gg.
xlii
(Osibogun A, 1999). Generally, there is a reasonable and acceptable level of
physical access to health facility in the state except for Ikole, (20.8%) EK
(24.7%), Ilejemeje (3.3%) and Oye (21.5%) LGAs with relatively low access.
This may be accounted for by non-uniform spatial distribution of health
facilities and or poor road network in those LGAs. The role of inter-sect oral
cooperation and co-ordination is therefore relevant in this regard.
According to Norman D, Bruce K and Ichirok I (1999), safe water supply,
sanitation, shelter, education and a country’s prosperity as indicated by its GNP
per capita are vital social determinants of health. They stated further that
political participation as a means of power in decision making is also a social
determinant of health and that such determinants offer a distinctive angle on
how to think about justice, public health and the reform of the health system.
If social factors play a large role in determining health, then efforts to ensure
greater justice and equity in health should not focus simply on the traditional
health sector. Health is produced not merely by having access to medical
prevention and treatment, but also to a measurably greater extent, by the
cumulative experience of social conditions over the course of one’s life. The
results of this study showed the inequitable distribution of these determinants
across the LGAs in Ekiti State, as they do not follow any rational or consistent
pattern.
xliii
8.8 HEALTH STATUS INDICATORS
The health status of a population is an outcome of the effect of the
resource inputs and the performance of the health system. In order to
determine this outcome measure, some selected health services and point
prevalent measures of common diseases were used as proxies to actual health
status indicators. The results were as follows:
8.8.1 CHILD SURVIVAL
BCG Coverage. The BCG coverage was generally high across the local
government areas, ranging from 88.2% in Ekiti South West to 100% in 10
other local government areas as shown in Figure 16.
Figure 16: Percentage Distribution of BCG Coverage by LGAs
Figure 16 shows the distribution of BCG coverage in all the local government
areas with a State aggregate of 98.3%.
a. Oral Polio Vaccine Coverage. The Oral Polio Vaccine
(OPV) coverage was generally impressive. This assessment was based on
those who have had at least 2 doses of the OPV.
Figure 17: Percentage Distribution of OPV coverage by LGAs
100 100
95
88.2
100
98.199.2
100
92.3
100
96.5
100 100 100 100 100
98.3
82
84
86
88
90
92
94
96
98
100
Ad. Ef.
Ek. E
Ek.SW EK.W Em Gb.
Ido O Ij. Ik Ek Ile Ise Ire
p.Mob
a Oye
State
Agg.
xliv
From figure 17, it was observed that records from Ekiti East and Ekiti
South West local governments areas were not available. It was also observed
that Gboyin LGA had a very low coverage of o.8%. The State aggregate for
the OPV coverage was 75.3%.
b. DPT Coverage . The DPT coverage was based on those who have had at
least 2 of the 3 doses of the vaccine. From the local government areas
where records were available, the DPT coverage was generally high as
shown in Figure 18.
Figure 18: Distribution of Percentage Under 5 with DPT Coverage byLGAs
97.4100
0
10094.5
0.8
100 100 100 100 100 100 100 100
75.3
0
10
20
30
40
50
60
70
80
90
100
Ad. Ef.
Ek. E
Ek.SW EK
.W Em Gb.
Ido O Ij. Ik Ek Ile Ise Ire
p.
Moba Oye
State A
gg.
97.7100
94100
78.2
100 100 100
83.3
100 100
72.1
0
10
20
30
40
50
60
70
80
90
100
Ad. Ef.Ek
. EEk
.SW EK.W Em Gb.
Ido O Ij. Ik Ek Ile Ise Ire
p.Mob
aOye
State
Agg.
xlv
Figure 18 shows that many of the local governments had full coverage of
100% while the State aggregate was 72.1%. There were no records available
for Efon Alaye, Ekiti East, Ekiti South West, Gboyin and Ise Osi.
Childhood Diarrhoea. The incidence of childhood diarrhoea varied greatly
from one local government area to the other as shown in figure 19.
Figure 19: Incidence of Childhood Diarrhoea by LGAs.
From figure 19, it was observed that 10% of the respondents in Ekiti
East local government area reported episodes of diarrhoea in the past 3
months. This incidence was as high as 95.5% of the respondents, reporting
episode of childhood diarrhea in Efon Alaye Local government area. The
incidence for the other local governments, fall between these extremes while
the state aggregate was 32.6%. Records were not available for Ado Ekiti, Ido
Osi, Ise and Oye local government areas with respect to the incidence of
diarrahoea in their areas.
Women’s Health. For the measurement of women’s health, some indicators
were used as proxies. These include the percentage of women who had ANC in
their last pregnancies, percentage who did not receive tetanus toxoid in their
0
95.5
1017.6
50
29
48.8
0
20.328.9
79.2
19.3
0
80
16.7
0
32.6
0
10
20
30
40
50
60
70
80
90
100
Ad. Ef.Ek.
E
Ek.SW EK
.W Em Gb.Ido
O Ij. Ik Ek Ile Ise Irep.
Moba
Oye
State A
gg.
xlvi
last pregnancies and percentage who had abortion or miscarriage in their last
pregnancies. The results were as follows:
a. Ante – Natal Care. Ante-natal care was provided at an acceptable level
and was observed to be generally high across all the local governments in the
state. Figure 20 shows the detail distribution.
Figure 20: Percentage Distribution of ANC by LGAs
For those who had ante-natal care during their last pregnancies, the
state recorded an overall aggregate of 94.3%. When dis-aggregated to local
government level, this ranged from 89.8% for Ijero local government to 100%
for Ekiti East and Ise LGA, details for all the local governments are shown in
figure 20.
a. Tetanus Toxoid in Pregnancy. For the provision of this service, the
percentage of the pregnant women who did not receive the vaccine
was determined for each LGA. The result is shown in Figure 21.
Figure 21: Percentage Distribution of Pregnant Women who did notreceive TT in Last Pregnancy by LGA
97.998.3
100
90.8
95.996.4
92.1
98.3
89.8
93.4 93.8 93.1
100
94.2
96.1
93.3 94.3
84
86
88
90
92
94
96
98
100
Ad. Ef.
Ek. E
Ek.SW EK.W Em Gb.
Ido O Ij. Ik Ek Ile Ise Ire
p.Mob
a Oye
State
Agg.
612.5
04.8 1.1
15.3 16.7
0 1.7
36.5
12.6
2.5 06.3
89.7
80
14.6
0
10
20
30
40
50
60
70
80
90
xlvii
With the exception of Moba LGA with 89.7% and Oye LGA with 80% of
their pregnant women population who did not receive tetanus toxoid in their
last pregnancies, majority of women in other LGAs were provided with this
service as indicated in figure 16. The overall state aggregate of those deprived
of this service was 14.5%.
8.8.2 HEALTH OF THE GENERAL POPULATION:
The prevalence of malaria as measured by the detection of malarial parasites
in the blood of the respondents was used to assess the state of health of the
general population. The distribution across the State is shown in figure 22.
Figure 22: Distribution of Malaria Prevalence by LGAs.
Figure 22 shows that malaria was highly prevalent in the State with an
overall aggregate of 49.8% of the respondents having malarial parasites in
their blood at the time of measurement (point prevalence). However, there
were wide variations across the local governments in respect of malaria
prevalence. Efon Alaye LGA had the lowest prevalence of 25.3% while
45,1
25,3
43,1
53,1
29,931,9
55,2 56,1
64,568,9
29,6
75,7
50,7
67,3
59,254,7
49,8
0
10
20
30
40
50
60
70
80
Ad. Ef.
Ek. E
Ek.SW EK
.W Em Gb.Ido
O Ij. Ik Ek Ile Ise Irep.
Moba Oy
e
State A
gg.
xlviii
Ilejemeje had as much as 75.7%. The prevalence varied across the other
LGAs.
8.8.3 Health Status: Health status is conventionally measured by such
indicators as life expectancy, infant Mortality Rates, Maternal Mortality Rates,
Disability Rates, GNP per capita among others. These rates are not
disaggregated to states and local governments in Nigeria. Proxy measures
were therefore used as shown in the report. The immunization coverage for
pregnant women and infants were observed to show an impressive
performance. However, these findings were not consistent with a more recent
country assessment in which the ANC coverage was 64%, immunization status
at age one were; TB 54%, DPT3 26%, POLIO3 25%, and Measles 40%. These
observations in the national figures may be accountable for by the general
view that the aggressive drive on polio eradication in Nigeria tend to have
compromised the routine immunization programme in the recent past. Malaria
in the general population and childhood diarrhoea were still very prevalent in
the State. The trend of health status shows a lot of disparities across the
States and cannot be related rationally with the distribution of resources and
social amenities.
8.8.4 EQUITY IN HEALTH
Equity in health as defined by the International Society of Equity in
Health (ISEqH), is “the absence of potentially remediable, systemic differences
in one or more aspects of health across socially, economically, demographically
or geographically defined population or subgroups. Margaret whitehead and
Goran Dhalgren (1991) suggested that health inequalities count as inequities
when they are avoidable, unnecessary and unfair. The distribution of financial,
health infrastructure and manpower social determinants of health with the
observed disparities do not follow any discernible pattern. No criteria for these
distributions could be identified. Such considerations as personality or political
xlix
factors, may appear to have played major roles in decision making. Against
this background, the inequalities in health resource allocation and distribution
of social determinants of health constitute inequities. The factors responsible
for these are largely avoidable and therefore subject to remedies. The
relationship between social determinants of health such as income, education,
high level of poverty and gender disparities in them as observed in this study
show that major policy re-direction towards addressing them are imperative.
A study in Zimbabwe in 2001 reviewed the existing resource allocation
mechanisms. In Zimbabwe, the Ministry of Health and Child Welfare (MOHCW)
was responsible for allocating resources for health care at Provincial (State)
and District (Local) levels. Three methods namely; incremental, workload and
demand methods had been used to allocate resources. Each of these methods
have weaknesses. A new formula based on weights from selected indicators of
which had been agreed upon by all the stakeholders was proposed. In Nigeria,
local governments obtain their funds and directly from stationary budgetary
allocations while each LGA chairman allocation to each of the sectors including
health. Unlike the Zimbabwe situation, there are usually no stated criteria for
the allocation. Bearing in mind the need to address equity through an objective
allocation mechanism, the following parameters as adopted in Zimbabwe may
need to be considered:
(a) HEALTH NEEDS IN RELATION TO PRIORITY HEALTH GOALS
• Total fertility rate
• Population growth rate
• Households with access to safe water
• Households with access to adequate toilets
• Mortality rate of children under one years
• Mortality rate of children under five years
• Malnutrition in under five years olds
• Mortality rate of women in pregnancy and childbirth
l
• Percent of women attending antenatal care who are HIV positive
• Prevalence of tuberculosis
• Prevalence of respiratory infection
• Prevalence of malaria
(b) ABILITY TO MEET HEALTH NEEDS
• Household income
• Household poverty
• Household education levels
• Employment opportunities
• Food security
• Access to adequate housing
• Family separation
• Community organization and participation in social institutions.
(c) PERFORMANCE OF HEALTH SERVICES
• Immunization of under one year olds
• Pregnant women attending antenatal care
• Women delivering attended by a trained attendant
• Women vaccinated against tetanus
• Married women using contraceptives
• Coverage by community health cadres
• Coverage of clinics
• Access to ambulances
• Health facilities with potable water and safe toilets
• Health facilities with adequate health personnel
• Health facilities with adequate essential drugs
li
• Establishment and functioning of health centre committees
• Share of district funds that go to primary health care.
It is proposed that stakeholder perceptions be obtained for priority factors
that need to be taken account of in resource allocation systems in order to
achieve equity goals. The priorities obtained will be used as one input in
identifying the strongest factors required for equitable resource allocation.
Stakeholders should include:
PRIMARY STAKEHOLDERS
(i) Communities and their representatives
(ii) Health providers
(iii) Health purchasers
SECONDARY STAKEHOLDERS
(i) Public finance institutions
(ii) Legislators, Regulators, Parliamentary committee on health,Parliamentary budget committee
(iii) Policy advisory fora.
9. A PUBLIC HEALTH POLICY DIALOGUE
A stakeholders’ Seminar was held on the presentation of the preliminary
findings of the equity studies in Ekiti State. The Seminar which
was attended by the State government represented by its Hon.
Commissioner for Health, chairmen of LGAs in Ekiti State, the
Grand Alliance, development partners, donor agencies and others
Stakeholders as well as CHESTRAD demonstrated a strong
commitment on the part of the political leadership in the State.
The seminar acknowledged the unjustifiable disparities in resource
allocation, distribution of social amenities, level of poverty and
their implication on the health status as well as the overall socio-
lii
economic development of the state. The stakeholders’ meeting
resolved to put in place, necessary strategies that would.
a. Improve evidence base for primary care policy reforms and systemsdevelopment.
b. Strengthen community roles and participation.
c. Reduce inequities in access to survival assets.
d. Strengthen the primary care systems and catalyze community activityagainst the challenges of prevalent and endemic diseases.
e. Assess the impact of on-going reforms on the delivery of maternaland adolescent health care services.
f. To make equity in health a major policy goal.
g. The development of a State health plan.
liii
CONCLUSION
Local governments in Ekiti State depend almost entirely on external
sources for their health resources. There is a near absence of any rational
criteria for the distribution of financial allocations, health infrastructure and
health manpower. The study also provides evidence on the inequalities in the
distributions of other social determinants of health including household income,
access to education, water and sanitation as well as gender disparities in
almost all socio-economic conditions. Together with high prevalence (80%) of
relative poverty and low government expenditure on health, the inadequacies
of these social factors accounted for the poor health status in the State.
The lack of any rational or discernible criteria and the uncoordinated top-
bottom flow of resources with no feedback mechanism create problems of
communication and effective planning process between higher authorities and
the local governments as well as the communities they serve. These findings
present enough evidence for a health sector reform with particular emphasis
on addressing the problems of inequity in health, involving all the stakeholders
towards achieving the overall goal of socio-economic development in the State.
