i REFORMING THE NIGERIAN HEALTH SECTOR: EQUITY AND RESOURCE ALLOCATION AT THE LOCAL LEVEL (A CASE STUDY OF EKITI STATE) 1 Dare o. o, Yisa I.O, Faleye K. I, Osegie H 1 The research unit of CHESTRAD International implemented the study with support from the Alliance for Health Policy and Systems Research, Geneva – Switzerland. All Correspondence should be addressed to Dr. Lola Dare, Center for Health Sciences Training, Rtesearch and Development ( CHESTRAD ) International –29, Aare Avenue, New Bodija Estate, UIPO Box 21633, Ibadan, NIGERIA. chestrad @yahoo.com
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i
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