**2. Health infrastructure inequality**

#### **2.1 Conceptual Issues on Health Infrastructure Inequality**

According to WHO (1986), health is a state of complete physical, social and mental wellbeing, and not merely the absence of disease or infirmity. Health is considered a means to an end which can be expressed in functional terms as a resource which permits people to live an individually, socially and economically productive life. Health is also considered as a fundamental human right (WHO, 1986).

Health infrastructure (HI) has been seen from a number of perspectives. WHO (1998: 14) viewed HI as "those human and material resources, organizational and administrative structures, policies, regulations and incentives which facilitate an organized health promotion response to *public health* issues and challenges". Public Health Infrastructure (PHI), as defined by the Centers for Disease Control and Prevention (CDC) (2001), is the "underlying foundation that supports the planning, delivery and evaluation of all public health activities and practices". The three components of PHI identified by the CDC (2001) are workforce capacity and competency; information and data systems; and organizational capacity.

Turnock (2004) describes PHI as, "the systems, competencies, relationships and resources that enable performance of public health's core functions and essential services in every community." The conceptual framework for a public health system created by Handler *et al*. (2001) include structural capacity which is made up of information, organizational, physical, human and fiscal resources. In this paper, the focus is on the physical infrastructure component of HI. In Nigeria, physical infrastructure clearly indicates the presence of a HI. Most of the other components of HI are established around it.

According to WHO (1996), equity means fairness. Equity in health means that people's needs guide the distribution of opportunities for well-being. The WHO global strategy for achieving Health for All is fundamentally directed towards achieving greater equity in health between and within populations, and between countries. This implies that all people have an equal opportunity to develop and maintain their health, through fair and just access to resources for health. HI must therefore be equitably distributed in other to facilitate fair and just access to resources for health. HI is one of the socio-economic infrastructure that are considered critical for development in Nigeria. Others include education, water, electricity and transportation. The Nigeria Core Welfare Indicator study (NBS, 2006), measured Health access in terms of persons living in households with an OM health facility less than 30 minutes away. This clearly indicates the policy emphasis placed on the availability of physical HI in Nigeria.

The literature around health inequality is extensive. This literature touches on different aspects of health; HI distribution, status, access, outcomes, etc. HI distribution has been assessed from the perspective of inequality with the emphasis being on health inequality. Health inequalities

The equation is estimated by the maximum likelihood method because the procedure does not require the assumptions of normality or homoscedasticity of errors in predictor variable.

According to WHO (1986), health is a state of complete physical, social and mental wellbeing, and not merely the absence of disease or infirmity. Health is considered a means to an end which can be expressed in functional terms as a resource which permits people to live an individually, socially and economically productive life. Health is also considered as a

Health infrastructure (HI) has been seen from a number of perspectives. WHO (1998: 14) viewed HI as "those human and material resources, organizational and administrative structures, policies, regulations and incentives which facilitate an organized health promotion response to *public health* issues and challenges". Public Health Infrastructure (PHI), as defined by the Centers for Disease Control and Prevention (CDC) (2001), is the "underlying foundation that supports the planning, delivery and evaluation of all public health activities and practices". The three components of PHI identified by the CDC (2001) are workforce capacity

Turnock (2004) describes PHI as, "the systems, competencies, relationships and resources that enable performance of public health's core functions and essential services in every community." The conceptual framework for a public health system created by Handler *et al*. (2001) include structural capacity which is made up of information, organizational, physical, human and fiscal resources. In this paper, the focus is on the physical infrastructure component of HI. In Nigeria, physical infrastructure clearly indicates the presence of a HI.

According to WHO (1996), equity means fairness. Equity in health means that people's needs guide the distribution of opportunities for well-being. The WHO global strategy for achieving Health for All is fundamentally directed towards achieving greater equity in health between and within populations, and between countries. This implies that all people have an equal opportunity to develop and maintain their health, through fair and just access to resources for health. HI must therefore be equitably distributed in other to facilitate fair and just access to resources for health. HI is one of the socio-economic infrastructure that are considered critical for development in Nigeria. Others include education, water, electricity and transportation. The Nigeria Core Welfare Indicator study (NBS, 2006), measured Health access in terms of persons living in households with an OM health facility less than 30 minutes away. This clearly indicates the policy emphasis placed on the availability of physical HI in Nigeria. The literature around health inequality is extensive. This literature touches on different aspects of health; HI distribution, status, access, outcomes, etc. HI distribution has been assessed from the perspective of inequality with the emphasis being on health inequality. Health inequalities

and competency; information and data systems; and organizational capacity.

Most of the other components of HI are established around it.

<sup>3</sup> *x* = Sex of household head

<sup>7</sup> *x* = Religion (Christianity or Islam)

**2. Health infrastructure inequality** 

fundamental human right (WHO, 1986).

<sup>4</sup> *x* = Household head's number of years of formal education <sup>5</sup> *x* = Income from farm and non-farm sources (N per annum) <sup>6</sup> *x* = Number of elderly people above 60 years in the household

The model was fitted separately for rural and urban households.

**2.1 Conceptual Issues on Health Infrastructure Inequality** 

can be defined as differences in health status or in the distribution of health determinants between different population groups (WHO, 2009). They are the result of 'a complex system operating at global, national and local levels which shapes the way society, at national and local level, organizes its affairs and embodies different forms of social position and hierarchy. The place people occupy on the social hierarchy affects their level of exposure to healthdamaging factors, their vulnerability to ill health and the consequences of ill health (Marmot, 2009: 14). Health inequality refers to differences or variations in health-related quality of life and length of life profiles of different population groups in a nation (WHO, 2009).

The causes of urban health inequalities are associated primarily with socio-economic status, income, poverty, deprivation levels, unemployment, incapacity, worklessness, skills and educational level, housing conditions and social mobility as well as life chances (O'Brien *et.al*. 2010).

Inequality in health is not the same as inequity in health. Inequalities in health status between individuals and populations are inevitable consequences of genetic differences, of different social and economic conditions, or a result of personal lifestyles. Inequities occur as a consequence of differences in opportunity which result, for example in unequal access to health services, nutritious food, adequate housing and so on. In such cases, inequalities in health status arise as a consequence of inequities in opportunities in life (WHO, 1998). It should however be noted that public policy-induced inequality in HI and other socioeconomic conditions will contribute to inequities in opportunities. According to Whitehead (1992), health inequities are 'differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust'. This means that not all inequalities can be described as inequities. Whereas equality means sameness (equality of distributions), equity is *fairness* of distributions

Health status affects economic growth and sustainable development. There is evidence that investing in health brings substantial benefits to the economy (Anyanwu & Erhijakpor, 2007). According to WHO (2001), increasing life expectancy at birth by 10% will increase the economic growth rate by 0.35% a year. On the other hand, ill health is a heavy financial burden. About 50% of the growth differential between rich and poor countries is due to illhealth and life expectancy.

Harttgen & Misselhorn (2006) found that access to health infrastructure is important for child mortality which is one of the health outcomes covered by the MDGs. On the other hand, socio-economic factors, especially poverty, are often found to be strong determinants of health outcomes (Nolte & Mckee, 2004; Young, 2001; Leger, 2001). In most developing countries, health attainment indicators for the poor tend to be worse than the national average (Tandon, 2007). Also, the extent to which such health inequalities exist varies significantly across countries. Empirical evidence suggests that health inequalities have been persistent over time and, in many cases, have been growing (ADB, 2006). The rich can ignore government finance and health facilities; and access private sector health facilities on their own while the poor are more dependent on the public sector OM infrastructure and governments often do not have enough resources to expend on pro-poor health programmes and interventions (Tandon, 2007). Sachs (2004) has hence been calling for a scaling up of government health programmes in order to attain health-related MDGs.

#### **2.2 Health Infrastructure Inequality and Health Policy in Nigeria**

The MDGs had three out of eight goals directed at promoting health. These are reduction in child mortality, improvement in maternal health and combating HIV/AIDs, malaria and other diseases (UNDP, 2003). The first goal, which is the eradication of extreme poverty and

Health Infrastructure Inequality and Rural-Urban Utilization of

State Ministry of Health, Ado-Ekiti

**LGA** 

Irepodun/

State Ministry of Health, Ado-Ekiti

Irepodun/Ifelodun, a rural LGA, had 30.

**Number of Primary Healthcare Facilities** 

to the public sector while private sector accounted for 31. 22%.

Table 1. Distribution of Healthcare Facilities in Ekiti State (January 2011)

Orthodox and Traditional Medicines in Farming Households: A Case Study of Ekiti State, Nigeria 203

An overview of the available health infrastructure in Ekiti State is provided in Table 1. The table shows that there were 458 health facilities in the state. A total of 315 or 68.78% belongs

**Healthcare Facilities Number of Health Facilities Percentage**  Primary Healthcare 293 63.97 Secondary Healthcare 20 4.37 Tertiary Healthcare 2 0.44 Private Healthcare 143 31.22 **Total 458 100** 

Source: Computed based on data obtained from Planning, Research and Statistics Department, Ekiti

The distribution of the healthcare facilities by types across the LGAs is presented in Table 2. The table shows that Ado, an urban LGA, had the highest number of facilities with 75 while

> **Number of Tertiary Healthcare Facilities**

**Number of Private Healthcare Facilities** 

**Total** 

**Number of Secondary Healthcare Facilities** 

Ado 32 0 1 42 75 Efon 12 1 0 10 23 Ekiti East 14 1 0 11 26 Ekiti S/West 21 1 0 4 26 Ekiti West 25 2 0 3 30 Emure 12 1 0 15 28 Gboyin 17 2 0 6 25 Ido Osi 17 1 1 8 27 Ijero 29 1 0 5 35 Ikere 17 1 0 9 27 Ikole 22 2 0 4 28 Ilejemeje 10 1 0 2 13

Ifelodun 18 1 0 11 30 Ise/Orun 14 1 0 4 19 Moba 15 1 0 4 20 Oye 18 3 0 5 26 **Total 293 20 2 143 458** 

Table 2. Distribution of Healthcare Facilities in Ekiti State by Types

Source: Computed based on data obtained from Planning, Research and Statistics Department, Ekiti

Table 3 presents the results of the assessment of the distribution of health infrastructure in Ekiti State using the Index of Dissimilarity and Gini Coefficient. This is with a view to

hunger, is also indirectly related to health given the effect of poverty and hunger on the health status of individuals. This is an indication that the health sector requires significant public policy attention and commitment of resources. The governments of most states in South-west Nigeria, including Ekiti State, have laid emphasis over the years on free medical treatment, at least, for the vulnerable segment of the population (Ekiti State Planning Commission, 2004)) thus implying an alignment of public policy with the MGDs.

The National Health Accounts revealed that the bulk of health spending by Nigerians is on curative care, which utilizes 74% of the total healthcare. Preventive care is a distant second; this consumes only 1% of total healthcare in 2002. In some African countries, including Nigeria, government expenditure on health may have increased over the years but, it is still below the statutory recommendation (WHO 2001). WHO estimates that a minimum government expenditure of USD34 per person per year will be required to provide an essential package of public health interventions in order to achieve health related MDGs (WHO 2001). Nigeria is just striving to meet this target (NPC, 2004).

Nigeria's health policy which has identified primary healthcare as its fulcrum, defined a three tiered referral system for the management of patients. A network of primary healthcare centres in proximity to where people live, offering care of relatively low technology, is the first level of care from which patients gain entry into the healthcare system. Seriously ill patients beyond the management competence of primary healthcare workers are referred to secondary level general hospitals from where referrals are made to tertiary health facilities. The division of labour between the three complementary and easily recognizable levels seemed a rational, equitable and cost-effective way of dealing with the healthcare problems of the rural poor (Musa & Ejembi, 2004).

Health service management is decentralized at the three tier levels. In addition, some states have Health Management Board (HMB), which is responsible for direct service delivery while the Ministry of Health focuses on policy formulation, standard setting and; monitoring and evaluation. The private sector provides 65.7% of healthcare delivery in Nigeria. Efforts are on for increased public-private participation in healthcare delivery but there is yet to be a framework for collaboration (WHO, 2011). The underlying principles and values for the National Health Policy include: the principle of social justice and equity and the ideals of freedom and opportunity; health and access to quality and affordable healthcare is a human right; equity in healthcare and in health for all Nigerians is a goal to be pursued; and primary healthcare shall remain the basic philosophy and strategy for national health development (Federal Republic of Nigeria, 2004)
