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AN ASSESSMENT OF THE SPATIAL DISTRIBUTION OF PRIMARY HEALTH CENTRES IN GIWA, KUDAN AND SABON GARI LOCAL GOVERNMENT AREAS OF KADUNA STATE

  1. INTRODUCTION

Primary health care has been defined by the World Health Organisation (WHO) as a universally accessible health care that is socially acceptable, affordable and requires individuals to be more self reliant with their health care needs. Primary health care according to Wikipedia, the free online Encyclopedia (www.wikipaedia.org), is  based on practical, scientifically sound and socially acceptable methods and technology made universally accessibleto individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination".

Health is a fundamental human right. The human rights covenants that underpin the rights of people originates principally from the UN Declaration of Human Rights formulated in 1948 (Article 12 of the International Covenant of Economic, Social and Cultural Rights deals with the right of citizens to the highest attainable standard of health).Health care provision in many countries including Nigeria is structured along three major levels of Primary, Secondary and Tertiary. Primary health care is vital to many individuals in order to receive necessary health care services as it is closer and makes services to be accessible to all individuals who require various health services. Primary health care is meant to be community based and this has been the practice in many developing countries, Nigeria inclusive. This is supposed to make health care available and accessible to the vast majority of the population. Poor accessibility to primary health brings adverse effects that may lead to prevalence of certain diseases that commonly affect the common man like Malaria, Child mortality and Tuberculosis among others. The successful provision of Primary health care takes care of at least three of the United Nations Millennium Development Goals (MDGs) viz: i. reduce child mortality, ii. improve maternal health and iii. combat HIV/AIDS, malaria and other diseases.

An ideal model of health care was adopted in the declaration of the International Conference on Primary Health Care held in Alma Atain 1978 (known as the "Alma Ata Declaration"), and became a core concept of the World Health Organization's goal of Health for all.The Alma-Ata Conference mobilized a “Primary Health Care movement” of professionals and institutions, governments and civil society organizations, researchers and grassroots organizations that undertook to tackle the “politically, socially and economically unacceptable” health inequalitiesin all countries.

The provision of Primary health care is hinged on certain goals and principles which were spelt out at Alma Ata. The main goal being a better health for all, the WHO identified five key elements to achieving this goal:

  • reducing exclusion and social disparities in health (universal coverage reforms);
  • organizing health services around people's needs and expectations (service delivery reforms);
  • integrating health into all sectors (public policy reforms);
  • pursuing collaborative models of policy dialogue (leadership reforms); and
  • increasing stakeholder participation.

The principles, which are expected to be formulated within national policies of countries and to help launch and sustain PHC as part of a comprehensive health system in coordination with other sectors include:

  • Equitabledistribution of health care - according to this principle, primary careand other services to meet the main health problems in a community must be provided equally to all individuals irrespective of their gender, age, caste, color, urban/rural location and social class.
  • Community participation - in order to make the fullest use of local, national and other available resources.
  • Health workforcedevelopment - comprehensive health care relies on adequate numbers and distribution of trained physicians, nurses, allied health professionscommunity health workersand others working as a health team and supported at the local and referrallevels.
  • Use of appropriate technology- medical technology should be provided that is accessible, affordable, feasible and culturally acceptable to the community (e.g. the use of refrigerators for vaccinecold storage).

The dispensation of primary health care is carried out through Primary health Centers. Primary Health Centre (PHC) is the basic structural and functional unit of the public health services in developing countries. PHCs were established to provide accessible, affordable and available primary health care to people, in accordance with the Alma Ata Declaration of 1978 by the member nations of the World Health Organisation  (WHO). The concern for accessibility through equitable distribution of Primary Health Facilities is of much concern as it is reflected in the elements and principles.  In Nigeria, it is estimated that there are     numbers of Primary Health Centres. According to Asuzu (2004), ‘the neglect of the primary health care system, its misdistribution as well as the secondary health care, will result in an inverted health care pyramid. This will not produce any health for the people but will always have the threat to collapse on itself’.

  1. RATIONALE FOR THE STUDY

Demand for public services is usuallyunevenly spread across space, broadly in accordance with the distribution of population, but these services are only provided at discrete locations. Inevitably therefore, there will be inequalities of access in terms of the practicality of using services, transport costs, travel times and so on. Although health care is a public good, it is not equally available to all individuals. There is therefore the need to know about how they are located and distributed

 According to Wikipedia (http://en.wikipedia.org/wiki/Health_care_in_Nigeria), “Health care in Nigeria is influenced by different local and regional factors that impact the quality or quantity present in one location. Due to the aforementioned, the health care system in Nigeria has shown spatial variation in terms of availability and quality of facilities in relation to need. However, this is largely as a result of the level of state and local governmentinvolvement and investment in health care programs…”.  Also that the Nigerian ministry of health usually spend about 70% of its budget in urban areas where only 30% of the population resides”. This spatial variation is a matter of concern.

The low level in the development of Local Spatial Data Infrastructure (LSDI) in Nigeria according to Olomo (Olomo, 2003)), is another reason for the interest of the researcher in this direction. Local Spatial Data Infrastructure has to do with the availability of spatial data at the local government level. This was found to be true also for State, National, Regional and Global Spatial Data Infrastructures (SSDI, NSDI, RSDI & GSDI). According to him, spatial data can be generated through Remote Sensing techniques, Global Positioning Systems (GPS) and conventional land surveys.

  1. AIM AND OBJECTIVES

The aim of this study is to investigate and describe in spatial terms, using spatial statistical formular, the distribution of Primary Health Centres in Giwa, Kudan and Sabon Gari local government areas. This is hoped, will add up to the spatial data base specifically for the primary health sector of the three local government areas that can serve as a reference material for administrators and decision makers and generally add to the spatial data infrastructure of the state and country. In pursuance of this, the following objectives will be pursued:

  • Determine the number of Primary health centre in each of the three local government areas,
  • Measure the coordinate of each primary health centre using GPS, to determine their geographic location on the world map,
  • Geographically position every primary health centre on a geo-referenced map of the local government,
  • Statistically describe the observed spatial distribution pattern..
  1. METHODOLOGY

Research Questions

The location of these Primary health care facilities largely depend on different factors but access to primary careis a very significant component of access to the whole health system, and we should note that there is a likely pattern of utilisationwhich increases with access, i.e. people who have easier access to health careuse it more often. The researcher found it pertinent to ask the following questions in the case of these three local governments in particular:

  • Where is the location and how is the distribution of health centres in the three local government areas?
  • Does the distribution encourage accessibility to the health centres?
  • What factors were responsible for the observed distribution?
  • How can future siting be rationally done?

Data Need

Since the study is more of spatial than social, much of the data needed will be about the environment and the health facilities. Therefore, these data will be sourced through:

  1. Field work: the researcher will visit every primary health centre in the three local government areas to measure with a GPS equipment, the coordinates (i.e. Longitude and Latitude) of each centre.
  2. Statistical records as kept by the local government authority for place names, number of health centres and other related data needed for this study,
  3. Maps, both from atlases, archives, records and the internet, especially Google maps.       

Tools to Employ

Analytical Tools:

  1. Spatial Measures of Central Tendency e.g. Mean Centre (equivalent of Mean) to determine the Mean of the Spatial distribution.
  2. Spatial Measure of Dispersion e.g. Standard Distance (equivalent of Standard Deviation), Relative Distance (equivalent of Standard Deviation, which is Standard Deviation divided by the Mean) and Average Distances between facilities,
  3. Spatial Random test,
  4. Nearest neighbor Analysis of distribution,
  5. Quadrat Test of distribution,
  6. Density Measurement of Distribution,

Geographical Tools:

  1. Remote sensing tools, e.g. Google earth
  2. Geographic Information System (GIS) tools, e.g. ArcGis                          
  1. SCOPE OF RESEARCH

Geographical or 'locational' factors (e.g. physical proximity, travel time) are not the only aspects which influence the location and access to health care. Other types (or dimensions) of accessibility to health care apart from geographical (or spatial) are social, financial and functional.Socialaccessibility to health care could depends on literacy status, age, sex tribe, religion and other social characteristics of individuals; important here is also relationship between patient and the doctor. Financial depends upon the price of a particular health care and functional reflects the amount and structure of provided services. This can vary among different countries or regions of the world. Access to health care is influenced also by factors such as opening times and waiting lists that play an important part in determining whether individuals or population sub-groups can access health care – this type of accessibility is termed 'effective accessibility', this research is limited to only assessing the spatial characteristics of Primary Health Centres especially those characteristics with potentials of affecting the physical accessibility to the health facilities.

THE STUDY AREA

During the 1979 Local Government reforms in Nigeria, the old Zaria province was divided into 6 local government areas with Zaria Local Government as one of the six. Then Zaria local government has its headquarters at Zaria and comprises of five districts namely; Giwa, Sabon Gari, Igabi, Soba and Zaria districts. In 1991, Giwa, Kudan and Sabon Gari Local Government Areas were created out of the former districts of Zaria. The area is predominantly rural with population density lower than the recommended threshold of 50,000 per square km (US Population Department). The study area comprises the three local government areas of Giwa, Kudan and Sabon Gari which are located within the Zaria Emirate, covering part of Zaria city and areas along the Zaria­-Sokoto and Zaria-Kano roads. Giwa local government area has now eleven Districts and twelve political wards, Kudan has five districts and ten wards and Sabon Gari local government has six Districts and eleven wards. The area lies within the Northern Guinea Savannah between latitudes 7 deg. 14’and 7 deg. 86’E and longitudes 10 deg. 88’ and 11 deg. 37’ N. The study area occupies a total of 2, 835.116 sq km of land (Giwa-2145.579 sq km, Kudan-415.758 sq km and Sabon Gari-273.779 sq km; NPC, 2006), lying at the Northern border of Kaduna state. It is bordered by Zaria, Igabi and Soba local government areas in the Southern part, Makarfi local government area in the East, Birnin Gwari local government area in the West and in the north by Katsina and Kano states.

The population of the study area which according to the 2006 census is as follow: Giwa LGA-292, 384, Kudan LGA-138, 956 and Sabon Gari LGA 291, 358, is made up indigenously by the Hausa/Fulani tribe with a mixture, in varying degrees, of other tribes from other parts of the state and country. The population of Sabon Gari local government area can be said to be more diverse as it is predominantly made up of settlers and non-indigenes that came to settle in Zaria over the years for different reasons and could not be accommodated within the walls of Zaria city. This group includes military personnel, as there are located within the local government, many military institutions and barracks; others include students of the various higher institutions within the local government among which are the Ahmadu Bello University and the School of Aviation; railway workers and traders in assorted items. Several ethnic groups can be distinguished including Yorubas, Igbos, Bajju, Jebba, Tiv, Idoma, Igala, and many others. The major religions of the people in the study area are Islam and Christianity with Islam being the major religious group.

The study area is part of the extreme pen plain developed on crystalline metamorphic rocks of the Nigerian basement complex. The interior is a mass of very old rocks belonging to the Precambrian period while the surface of these underlying blocks of older rock is covered by later formations of materials. [Including sediments deposited by winds Aeolian deposits. Harmattan winds blowing over the Saharan may have carried these materials eroded and later deposited in this part of Nigeria (Barbair, 1982)]. The study area is situated in the Northern Guinea Savannah ecological zone, a designation which implies a woodland vegetation characterized by the presence Isobeslina doka, isobellinia tomentosa and also a well developed grass layer of tofted Angroporeae.

The study area lies in the northern part of Nigeria which is usually invaded by two distinct air masses: one from the North-dry and continental in origin, the Sahara air mass and the other from over the Atlantic in the South-moist, cool and equatorial maritime in nature. The weather in these three local government areas depends to a large extent on the air mass, which covers the area and its depth at a particular period in the year (Mortimore, 1970). On the basis of the influence of the dry continental North Easterly airmass and the humid South-Westerly airmass, the year in the study area can be divided into the following seasons: Dry (cold winter) season, which starts from November to February, a Hot season from March to April, a season of thunderstorm and squalls from May to June and a wet raining season from July to October (Barbair, 1982).

The study area is generally characterized by two seasons: the rainy season which averagely lasts for five months duration and a dry season of seven months duration. Annual rainfall varies from 800mm to 1,300mm and a long term average of 100mm, most of which fall from late April to early October, with average temperature of 37°c at the beginning of the rainy season. Rainfall are usually torrential and are accompanied by tornadoes. Air temperature is high most part of the year with the mean monthly rising from January (at minimum of 12°c) and attaining maximum in April at an average of 35°c; April is the hottest month and August the month of the mildest climate. The relative humidity drops from an average of 60% in October to about 25% in November. The relative humidity is very high in August, reaching as high as 85% (Barbair, 1982).

The main economic activity in the study area is agriculture in which about 90% of the people are peasant farmers, operating at a small scale both for subsistence and commercial purposes. Application of implements such as fertilizers, hoe and animal tractor is a common practice. In the three local government areas, family labour is mainly employed, though few cases of hired labour exist for commercial prospects. On a whole, the males takes up the commercial aspect of growing cash crops and food crops such as Yam, Cassava, Maize, Soyabeans, Millet, Sorghum, Cocoyam, and vegetables are grown mainly for domestic uses. Cash crops serve as sources of income to the farmers and means of improving the standard of living in the study area. In addition, quite a considerable proportion of the population is involved in petty trading of varied items. Most of these items are gotten from the large commercial towns like Kaduna, Zaria, Sokoto and Kano). The farm products are constantly taken to the periodic markets. The women also shell and extract groundnut oil using local methods for sale while the Fulanis extract milk from cows also for local sales within the neighbourhood and at the nearly markets. Trading in crafts and tailoring are some economic activities engaged in by the people of the study area. Livestock .keeping is .relatively lesser within the area, either for local consumption or for trade

Map. 1: Kaduna State in the context of Nigeria

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 States

                  Map 2: The Study Area in the context of Kaduna State

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 Local Government Areas

7.       CONCEPTUAL FRAMEWORK AND LITERATURE REVIEW

Spatial Data Analysis

Spatial analysis or spatial statistics includes any of the formal techniques which study entities using their topologicalgeometric, or geographic properties  (Wikipedia 2012). Spatial data analysis aims at extracting implicit knowledge such as spatial relations and patterns that is not explicitly stored in spatial databases. It distinguishes itself from classical data analysis in that it associates with each object the attributes under consideration including both non-spatial and spatial attributes.

There are three basic spatial data types defined by the topology of the entity to which the recorded information refers. These are point, lines and area. Features having a specific location, but without extent in any direction are considered as points. A pair of coordinates represents a point. Village locations, industrial locations, cities etc. are the examples of the point data. Lines features consist of series of x, y coordinate pairs with discrete beginning and ending points. Features like rivers, road networks, represents lines. Features defined by a series of linked lines enclosing an area are known as polygons. Polygons are characterized by area and perimeter. Administrative boundaries, land use, soil map etc. are the polygon features. Statistical analysis which deals with such spatial data is termed Spatial statistics.

Spatial statistics span many disciplines, with methods varying in relation to the specific research questions being addressed, whether predicting ore quality in mining, examining suspiciously high frequencies of disease events, or handling the vast data volumes being generated by GPS (Global Positioning System) and satellite remote sensing. A unique feature of spatial data is that geographical location provides a key that is shared either exactly or approximately between data sets of different origins. Descriptive spatial statistics that are areal or locational are equivalents to the non-spatial measures as is shown in the Table below:

Table1: Spatial and Non-spatial Descriptive Statistics

Statistic

Central tendency

Absolute Dispersion

Relative Dispersion

Nonspatial

Mean

Standard Deviation

Coefficient of Variation

Spatial

Mean Center or

Standard Distance

Relative Distance

Median Center or

Euclidean Median

The Concept of Health

Health has been defined by the World Health Organisation (WHO) as: ‘A state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity’ (WHO 1948). It is the level of functional or metabolic efficiency of a living being. Inhumans, it is the general condition of aperson's mind, body and spirit, usually meaning to be free from illness,injuryorpain. The spiritual dimension of health is increasingly being recognized.

The WHO emphasizes certain pre-requisites for health which include peace, adequate economic resources, food and shelter, and a stable eco-system and sustainable resource use. Recognition of these pre-requisites highlights the inextricable links between social and economic conditions, the physical environment, individual lifestyles and health. These links provide the key to an holistic understanding of health which is central to the definition of health promotion.

Within the context of health promotion, health has been considered less as an abstract state and more as a means to an end which can be expressed in functional terms as a resource which permits people to lead an individually, socially and economically productive life. Health is a resource for everyday life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities.

Health is regarded by WHO as a fundamental human right, and correspondingly, all people should have access to basic resources for health.

Health System

Health system refers to a conglomeration of elements that work together simultaneously in a coordinated manner to bring about all activities whose primary purpose is to promote, restore or maintain health (WHO). Commenting on the necessity of a health system reform in Nigeria, Asuzu m. c. (Journal of Community Medicine & Primary Health Care. 16 (1) 1-3, June 2004) defines a health system as ‘an organizational framework for the distribution or servicing of the health care needs of a given community. It is a fairly complex system of inter-related elements that contribute to the health of people - in their homes, educational institutions, in work places, the public (social or recreational) and the psychological environments as well as the directly health and health-related sectors’. He observed that in Nigeria, health care is structured along the now universal three levels of the primary, secondary and tertiary levels of care. The system is run concurrently such that all the three levels of government - local, regional/state and national/federal, even though they hold primary responsibility for only one level of the system each, can exceed it and provide services at any of the other two levels of care.

Primary Health Care (PHC)

The concept of PHC was formulated by the 134 countries that met at the Alma Ata conference in Russia on 12th September 1978, organized under the auspices of the World Health Organization (WHO) and the United Nations Childrens Fund (UNICEF). The World Health Organization (1978) defines health care as ‘essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and the country can afford. It forms an integral part of the countries health system. Primary health care system, is the nucleus, and of the overall socio-economic development of the community’.

Primary Health Care Is the essential care based on practical, scientifically sound and socially acceptable method and technology made universally accessible to individuals and families in the community through their full participation and at a cost they and the country can afford to maintain in the spirit of self reliance and self determination. As an element of the national health system, it is an integral part of the country’s health system. It is the first level of contact of individuals, the family and the community with the national health system bringing health care as close as possible to where people live and work.

It is a scientifically based health system which focuses on priorities. Primary Health Care is to be culture sensitive and expected to be equitably distributed by being made made universally accessible to individuals and families in the community. Primary Health Care is to carry the community along in its operations while being able to sustain itself and make the community self reliant medically.

Summarily, Primary Health Care operates as follows:

  • Primary health care reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities.
  • Addresses the main health problems in the community providing promotive, preventive, curative and rehabilitative services.
  • It includes education concerning prevailing health problems and the methods of preventing and controlling them.
  • It involves, in addition to the health sector, all related sectors and aspects of national and community development example, Agriculture, education ,housing etc.

The Alma Ata Declaration

The international conference on primary health care, met in Alma Ata on 12th Sept 1978 and made some declaration summarized as foolow:

  1. Health is a fundamental human right and that the attainment of the highest possible level of health is a most important world wide social goal.
  2. The existing gross inequality in the health status of the people particularly between developed and developing countries is politically, socially and economically unacceptable.
  3. Economic and social development, based on a new international economic order is of basic importance to the fullest attainment of health for all.
  4. The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.
  5. Government have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social; measures.
  6. All government should formulate national policies, strategies and plans of action to launch and sustain primary health care.
  7. All countries should cooperate in a spirit of partnership and service to ensure PHC for all people.
  8. An acceptable level of health for all the people of the world by the year 2000 can be attained through a further and better use of the world’s resources.

The Components of Primary Health Care

There are eight components (elements) of primary health care.

  1. Immunization:  An increasing number of infectious diseases can be prevented by vaccinations example-measles, Meningitis, Pertusis, tuberculosis, yellow fever etc
  2. Maternal and child care:  Pregnant women and women of child bearing age (15-49 years) are the target group for special care. Children under 5yrs of age are also vulnerable to childhood killer disease. Maternal and child health clinics are established in Nigeria to take care of these groups.
  3. Essential drugs:  The most vital drugs should be available and affordable at all levels.
  4. Food and Nutrition:  The family’s food should be adequate, affordable and balanced in nutrients.
  5. Education:  The community should be informed of health problem and methods of prevention and control.
  6. Illness and injury:  Adequate provision of curative services for common ailments and injuries should be made by the community.
  7. Water and sanitation:  A safe water supply and the clean disposal of wastes are vital for health.
  8. Vector and reservoirs:  Endemic infection diseases can be regulated through the control or eradication of vectors and animal reservoir.

Standards in health care

In the final draft for the minimum standard expected of any Primary Health Centre (Asuzu et al, 2007), the necessity of standard setting in the health services was observed to have become widely recognized in the recent times. That, according to the World Health Organization (WHO), the purpose of setting health standards as a tool in health services management is to strive to achieve the highest quality of care possible within the resources available. Standards provide degrees of excellence to be pursued in a given exercise or exercises. They provide the basis for monitoring, comparison, supervision and regulation of the given services.

The draft observed that since the development and use of standards in health care, two levels of standards have come to be recognized – minimum standards to be achieved by all involved in the exercise as well as optimal (ideal or desirable) standards to which all concerned should be striving at. It was also noted that optimal standards, after a period of time has elapsed and significant effort has been exercised to meet them, may, in fact, become the minimum standards. Types of standards recognized include standards directed toward structure, process or outcome. Structural standards apply to the things used for services such as human, financial and physical resources (men, money and physical matters). Process standards apply to what is done (such as activities that constitute care, service or management). Outcome standards address the results (both clinical and non-clinical) of what is done with the resources available.

The Alma-Ata conference (WHO, 1988) specified eight (8) minimum health service areas that can be referred to as the minimum service components (standards) of PHC. These consist of:

  • Education on prevailing health problems and how to prevent them (health education)
  • Provision of adequate water and basic sanitation (environmental health)
  • Adequate food supply and good nutrition (public health nutrition)
  • Maternal and child health including family planning (reproductive and family health)
  • Immunization against the common diseases
  • Control of common endemic diseases (epidemiology and disease control)
  • Treatment of common diseases and injury (primary medical care)
  • Provision of essential drugs (community pharmacy practice)

Primary Care versus Primary Health Care

Writing on ‘Why Primary Health Care offers a more comprehensive approach for tackling health inequities than Primary Care’, Keleher (2001) described Primary health care as “a strategy of public health, derived from the social model of health and sustained by the Alma Ata Declaration, which was jointly sponsored by the World Health Organisation and UNICEF (WHO, 1978, 1986)” . Primary Care was described as “commonly considered to be a client’s first point of entry into the health system if some sort of active assistance is sought”. That “…drawn from the biomedical model, primary care is practised widely in nursing and allied health but general practice is the heart of the primary care sector. It involves a single service or intermittent management of a person’s specific illness or disease condition in a service that is typically contained to a time-limited appointment, with or without follow-up and monitoring or an expectation of provider-client interaction beyond that visit. However, primary care can also provide continuity of care. Primary care providers are focused on early diagnosis and timely, effective treatment but have greater potential for referral to secondary, non-medical services than has been realised to date (Ham, 2000)”

He observed that as governments attempt to focus more intently on how to deal with alarming measures of health disadvantage and inequities, a reformist gaze seems to have settled on the primary care sector. And that simultaneously, in literature about this area, whether intended or not, primary health care and primary care are terms that are increasingly interchanged. He argued that this slippage in language is counter-productive, first because it disguises the transformative potential of strategies and approaches that can make the fundamental changes necessary to improve health status and secondly because the structures and practices of primary care sector are not necessarily compatible with notions of comprehensive primary health care. That, there is much to be lost, if primary health care and health promotion are disguised as primary care and not understood for their capacity to make a difference to health inequities; although of course, comprehensive primary health care is interdependent with services provided by primary care.

Further in his article, the characteristics of primary care and primary health care are juxtaposed to show that if the strengths and limitations of each model are understood, they can be mobilised in collaborative partnerships to deal more effectively with health inequities than current system has so far been able to do.

Primary Health Care in Nigeria

The Nigerian PHC system which evolved from the Nigerian Basic Health Service (BHS) Scheme (articulated in the Third National Development Plan of 1975 – 1980), sets its health facilities standards such that approximately one LGA was to have 1 comprehensive health centre at its apex, 4 primary health centres at what may appear to be the LGA districts (Wards) and each PHC serving as referral centre for a further four health centres/clinics each. Each comprehensive and PHC was to have one mobile clinic attached to it for its outreach services to communities not adequately served by the physical health facilities.

In August 1987, the Nigeria Federal government launched its Primary Health Care (PHC) plan, which the president announced then as the cornerstone of any health policy. Intended to affect the entire national population, its main stated objectives included accelerated health care personnel development, improved collection and monitoring of health data, ensured availability of essential drugs in all areas of the country, implementation of an Expanded Program on Immunization (EPI), improved nutrition throughout the country; promotion of health awareness; development of a national family health program; and widespread promotion of oral rehydration therapy for treatment of diarrheal disease in infants and children. Implementation of these programs was intended to take place mainly through collaboration between the Ministry of Health and participating local government councils, which received direct grants from the federal government.

To achieve primary health care in Nigeria, Nigeria was divided into wards of  approximately 10,000 people. This ward is the same as political ward that makes up district and then the local government.According to Asuzu et al, current situation is that each higher level of government is generally expected to provide public health facilities for the immediate lower level as follow:

  • the Federal Government is expected to provide at least one tertiary health facility  in every State:
  • the state government is expected to provide at least one general hospital in every  LGA;
  • the local government is expected to  provide at least one primary health centre in every district/political ward;
  • the political ward committee (WDC) is expected to provide/support at least one health clinic for a group of villages/communities with about 1000-2000 inhabitants; and
  • the community development committee (CDC) is expected to provide/support at least one health post  for villages, settlements or neighbourhoods of about 200-500 inhabitants.

According to the Midwives Service Scheme (MSS) scheme (2006) document, the goal of the National Health Policy is to establish a comprehensive health care system based on primary health care that is promotive, preventive, restorative and rehabilitative to every citizen of the country, within the available resources, so that individuals and communities are assured of productivity, social well being and enjoyment of living.

The Nigerian National Health Policy recommended strategies for effective primary health care implementation. One of these strategies includes ‘Equity’. Equity means the distribution of health services without bias for or against any segment of the community. Service coverage equity can be ensured by making services universally accessible to individuals and families in a community. Health services should be available in every community and where static families or clinics are used, they should be sited within the stipulated PHC radius of 5 kilometers from every member of the community. For curative services, people are willing to travel up to 5 kilometers or even more, but for preventive services, e.g. immunization, people will travel less than two kilometers. That facilities are available does not totally predict accessibility coverage. Respect for the cultural values of the community is important otherwise, the services will not be patronized and coverage will be poor. A health facility or service may be close enough to the people but not acceptable because of cultural taboos. There is also no equity where only a few are able to pay the cost of services.

Problems of Primary Health Care in Nigeria

Writing under the heading: ‘The Weaknesses in the Data Collection Systems at the PHC Levels’, Bamigboye (2009) wrote: ‘It is sad to note that the PHC system is weak in data generation partially because there are no strict penalties for poor implementation of our health data management system. It is generally known that the data generated are seldom used for planning purposes and allocation of resources. The location of some of the PHCs like most social facilities in Nigeria could have been dictated by political consideration rather than evidence-based information of need and potential use. The country is yet to disengage itself from the politics interwoven with empirical data. Hence, rather than plan health services on available facts and figures, the planning and policy formulation have largely been influenced by the strength of our political powers.

Ado (1993), wrote on the ‘problems of Primary Health Care delivery system in Markudi local government area of Benue state as they affect the mortality, morbidity and health status of the people’, defined health and primary health care as a mean of providing the essential health care of the society; the first level of contact of individuals, families and society with the national health system, bringing healthcare as close as possible. He thereafter came up identifying the following problems which is identical to what is obtainable in any local government in Nigeria:


1. Shortage of funds

2. Lack of materials and equipment

3. Shortage of appropriate stuff

4. Lack of commitment which can be at the  individual or government level.

5. Lack of incentive

6. Lack of information

7. Inadequate community participation

8. Inadequate intersectoral collaboration

9 .  Rapid turnover of policy makers

10. Lack of manpower training and

      development

11. Inadequate utilization of services

12. In appropriate staff recruitment

13. Ill defined responsilities, that is, poor  job description

14. Ill defined authority.


Appraising Health Care services and utilization of Health Centres in Yewa North local government of Ogun state Adepoju (1998), discovered that there were no enough personnel in all the health centres, insufficient drugs and vaccines in all the sampled centres, insufficient facilities to cater for maternal and child care services and that ambulances and other necessary transport means were inadequate and called on the government as part of his recommendations to take urgent steps in providing adequate infrastructures for a speedy recovery, from comatose, of the Health care services of the local government.

Danlami (1994), researched into the problem of primary health care delivery in Jabba local government area of Kaduna state. From the seven villages specially selected for study in the local government, he discovered among other problems:

  • Inadequacy of facilities in the Primary Health Centres
  • Low satisfaction of respondents in the area of dugs supply,
  • Lack of qualified staff at centres and
  • Unequal distribution of health facilities

and recommended:

  • More rational distribution of health facilities,
  • Training of more health personnel and
  • Intensive campaign on environmental sanitation.

While looking at the ‘Impact of Primary Health Care Delivery system in Shika District of Kaduna state’, Ayogu (2009), observed that ‘the lack of good clinics, hospitals…makes the people in the study area to go as far as 50km into Zaria town before they get good clinics and specialized hospitals’ and also has led to increase in maternal and infant mortality. He opined that Primary Health Care as an institution for rural development is expected to decentralize services for socio-cultural, economic and physical transformation.

Haruna (1995) examined Community participation in Primary Health Care programme in Suleja local government of Niger state. The research attempted to determine the level of community involvement in primary health care programme in the local government which also led him to discover some problems with health care provision in the local government. He suggested as solutions to his findings the following: educating and mobilizing the community towards greater participation in community health development, extensive study of peoples culture, believe and attitude towards diseases and different methods of cure, involvement of the community in the planning and making of strategic decisions concerning health issues in the local government.

REFERENCES

Asuzu M. C. & Ogundeji M. O. (2007):MINIMUM STANDARDS FOR PRIMARY HEALTH CARE SERVICES NATIONWIDE IN NIGERIA-Report of a consultancy assignment, Novenber, 2007

Command Secondary School, 1999: Student Handbook

Federal Ministry of Health (1988) The NationalHealth Policy & Strategy to Achieve Healthfor All Nigerians, Lagos: Federal Ministryof Health.

Federal Ministry of Health (2004) Revised NationalHealth Policy, September, Abuja:FMOH

http://en.wikipedia.org/wiki/Health

http://wiki.answers.com/Q/What_are_the_primary_health_care_principles#ixzz1fKAGYfWb

http://www.definitionofwellness.com/dictionary/health.html

Kaduna. (2011). Encyclopædia Britannica. Ultimate Reference Suite. Computer Software. Chicago

Keleher, H. (2001): ‘Why primary health care offers a more comprehensive approach for tackling health inequities than primary care’. Australian Journal of Primary Health, vol 7 (2), 57-61.

Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

Olomo, R.O.(2003): The need for National Spatial Data Infrastructure in Nigeria. Proceedings of the 21st International Cartographic Conference (ICC)               Durban, South Africa, 10-16 August, 2003

Prachi M. S.: Statistical Technique for spatial Analysis, Indian Agricultural statistics Research Institute, New Delhi

WHO (1978) Declaration of Alma Ata. Reportof the International Conference on  PrimaryHealth Care. Alma Ata, 6-12 September 1978,USSR. WHO, Geneva

  1. STUDY AREA

Kaduna State & Kaduna

Kaduna is the name of both the state and its capital, a name which took its root from the Hausa word ‘Kada’ for Crocodile; Kaduna being the plural. Literally, Kaduna is a town of Crocodiles. As a town, Kaduna has a long history. During the Colonial administration, Kaduna became the Headquarters of the protectorate of Northern Nigeria after it was moved from Zungeru, in the present Niger state, by Lord Lugard in 1956. Kaduna was the Capital territory of the defunct Northern Region until 1966. It became the capital of the then North Central state untill more states were created in 1967 when it became the capital of Kaduna state.

Kaduna state, with an area of 45, 567 sq km is located between Lat. 11deg North and Long. 7 deg East. It shares boundaries with 7 states and the Federal Capital Terriotary (FCT). It is bounded in the North by Katsina state, Kano by the North East, Bauchi and Plateau on the East, Zamfara on the North-West, Niger on the West and the FCT on the South. The state has a population of    according to 2006 Census.

The state has a fairly moderate weather condition compared to other Northern states such as Sokoto, Adamawa and Borno States. That notwithstanding, during the hot season (around March to May), temperatures could be as high as 23 deg C - 32 deg C while it could range between 25 deg C and 32 deg C during the harmattan, which is usually from November to February. The raining season usually sets in around June and lasts till October. The vegetation is typical of of the Savannah just like most or all the states bordering it. The terrain is generally flat and suitable for agriculture which is the main occupation of the people. Kaduna state is divided into 23 LGAs among which is Giwa, Kudan and Sabon Gari LGAs which are located at the northern part of the state.

PHYSICAL FEATURES OF THE STUDY AREA

RELIEF AND DRAINAGE

Shika lies on the Galma Plain, the high elevated part rising from above sea level within the confines of Shika, two (2) land scales can be recognized which are distinct in land form soil vegetation and land use (Mortimu 1970) in the East the terrain is gently undulating with long slope towards the broad valleys of the Shika River with Mayo, Kebbi and Turo as provincial tributaries, in the West, the land rises to a series of Iron stone plateau quantize ridges that is dissected by the occasionally extend into bad lands (Kawa, 1998).

GEOLOGY

Shika

CLIMATE

SOIL AND VEGETATION

In the East, the soils are deep grey-grown sandy loams which become heavier at depth. These are imperfectly drain and subject to surface sealing because of them high salt content. On the top slopes, the water table is high result to poor drainage'and temporary holding at the end of the rainy. In some places along the rivers, bands of shallow soil cover the outcrops of secondary iron pan. In the west, on the higher portions, the soil have greatly influenced the vegetation on the better soil land has been framed for many decades prior to the establishment of Shika station.

The predominance of grass over any other vegetation type is evident in Shika. Most of the species of plants in Shika were ephemeral in nature; notable among these species are the grasses. Along the roads, cattle trail and are overgrazed paddock sprobulus pyramid ales becomes the dominant On the land that is not formed, herbaceous, fallows develop with pioneer communities of grasses like Brachiereie Strigmetisete cileur and many herbs, which over the year are gradually invaded by perennial. In the valley there are several grass communities in which Hyparrhems rufe and Andropogen Condeulatus may be dominant depending on the depth of the water table and the duration of flooding in the western part, the vegetation is much less disturbed. Although repeated burning and cutting have reduced the above cover to an open

2.3m tall shrub savannah. Some hundred trees and shrub have been identified in this savannah, but Isobnerlina doka and terminalta are the most prominent. The grass cover consists primarily of up to 1.5m tall tussock grasses (Kaura 1998).

ECONOMY

POPULATION

The establishment of NAPRI (National Animal Production Research Institute) has led to the migration of people from remote areas of Guva to occupy the vast area of Galma plain North-East of Zaria in the Northern province of the "country Between "1928-1976, the total number of migrants has increased greatly over the years.

According to the demographic census of 1952; the area had a total population or about 502 people of which 258 were males and 245 females. 63males and 19 females accounted for the age group between 15-49, in the 1963 census population of he area rose to 1,888 According to the 1991 'population census in Nigeria, the population of Shika was 8,316 with males comprising of 4,421 and females 3,895, with a projection of9,719 people by the year 1996.

The indigenous Shika village are Hausa/Fulani but other tribes from all over the federation have migrated there to work with Ahmadu Bello University of NAPRI. They include,

HISTORICAL GROWTH

Fig i: Map of Nigeria showing Kaduna State

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Fig ii:Map of Kaduna State showing Giwa, Kudan and Sabon Gari LGAs

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The Concept of Health

Financing Of Primary Health Care System In Nigeria: ByDr. Victor Inem

Health is a fundamental human right. The human rights covenants that underpin the rights of people originates principally from the UN Declaration of Human Rights formulated in 1948 (Article 12 of the International Covenant of Economic, Social and Cultural Rights deals with the right of citizens to the highest attainable standard of health).

According to the Midwives Service Scheme (MSS) scheme (2006) document, the goal of the National Health Policy is to establish a comprehensive health care system, based on primary health care that is promotive, preventive, restorative and rehabilitative to every citizen of the country, within the available resources, so that individuals and communities are assured of productivity, social well being and enjoyment of living. The Nigerian National Health Policy recommended strategies for effective primary health care implementation. One of these strategies includes ‘Equity’. Equity means the distribution of health services without bias for or against any segment of the community. Service coverage equity can be ensured by making services universally accessible to individuals and families in a community health services should be available in every community and where static families or clinics are used, they should be sited within the stipulated PHC radius of 5 kilometers from every member of the community. For curative services, people are willing to travel up to 5 kilometers or even more, but for preventive services, e.g. immunization, people will travel less than two kilometers. That facilities are available does not totally predict accessibility coverage. Respect for the cultural values of the community is important otherwise, the services will not be patronized and coverage will be poor. A health facility or service may beclose enough to the people but not acceptable because of cultural taboos. There is also no equity where only a few are able to pay the cost of services.

Health System

Health system refers to a conglomeration of elements that work together simultaneously in a coordinated manner to bring about all activities whose primary purpose is to promote, restore or maintain health (WHO).

Commenting on the necessity of a health system reform in Nigeria, Asuzu m. c. (Journal of Community Medicine & Primary Health Care. 16 (1) 1-3, June 2004) defines a health system as ‘an organizational framework for the distribution or servicing of the health care needs of a given community. It is a fairly complex system of inter-related elements that contribute to the health of people - in their homes, educational institutions, in work places, the public (social or recreational) and the psychological environments as well as the directly health and health-related sectors’.

He observed that in Nigeria, health care is structured along the now universal three levels of the primary, secondary and tertiary levels of care. The system is run

concurrently such that all the three levels of government - local, regional/state and

national/federal, even though they hold primary responsibility for only one level of the system each, can exceed it and provide services at any of the other two levels of care.

The World Health Organization (1978) defines health care as essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and the country can afford. It forms an integral part of the countries health system. Primary health care system, is the nucleus, and of the overall socio-economic development of the community,’

The Concept of Primary Health Care

Is the essential care based on practical, scientifically sound and socially acceptable method and technology made universally accessible to individuals and families in the community through their full participation and at a cost they and the country can afford to maintain in the spirit of self reliance and self determination. As an element of the national health system, it is an integral part of the country’s health system. It is the first level of contact of individuals, the family and the community with the national health system bringing health care as close as possible to where people live and work.

It is a scientifically based health system which focuses on priorities. Primary Health Care is to be culture sensitive and expected to be equitably distributed by being made made universally accessible to individuals and families in the community. Primary Health Care is to carry the community along in its operations while being able to sustain itself and make the community self reliant medically.

Summarily, Primary Health Care operates as follows:

  • Primary health care reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities.
  • Addresses the main health problems in the community providing promotive, preventive, curative and rehabilitative services.
  • It includes education concerning prevailing health problems and the methods of preventing and controlling them.
  • It involves, in addition to the health sector, all related sectors and aspects of national and community development example, Agriculture, education ,housing etc.

In August 1987, the Nigeria Federal government launched its Primary Health Care (PHC) plan, which the president announced as the cornerstone any of health policy. Intended to affect the entire national population, its main stated objectives included accelerated health care personnel development, improved collection and monitoring of health data, ensured availability of essential drugs in all areas of the country, implementation of an Expanded Program on Immunization (EPI), improved nutrition throughout the country; promotion of health awareness; development of a national family health program; and widespread promotion of oral rehydration therapy for treatment of diarrheal disease in infants and children. Implementation of these programs was intended to take place mainly through collaboration between the Ministry of Health and participating local government councils, which received direct grants from the federal government.

THE ALMA ATA DECLARATION

The international conference on primary health care, met in Alma Ata on 12th Sept 1978 and made the following declaration:

  1. Health is a fundamental human right and that the attainment of the highest possible level of health is a most important world wide social goal.
  2. The existing gross inequality in the health status of the people particularly between developed and developing countries is politically, socially and economically unacceptable.
  3. Economic and social development, based on a new international economic order is of basic importance to the fullest attainment of health for all.
  4. The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.
  5. Government have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social; measures.
  6. All government should formulate national policies, strategies and plans of action to launch and sustain primary health care.
  7. All countries should cooperate in a spirit of partnership and service to ensure PHC for all people.
  8. An acceptable level of health for all the people of the world by the year 2000 can be attained through a further and better use of the world’s resources.

THE COMPONENTS OF PRIMRY HEALTH CARE

There are 8 components (elements)of primary health care.

  1. Immunization

An increasing number of infectious diseases can be prevented by vaccinations example-measles, Meningitis, Pertusis, tuberculosis, yellow fever etc

  1. Maternal and child care

Pregnant women and women of child bearing age (15-49 years) are the target group for special care. Children under 5yrs of age are also vulnerable to childhood killer disease. Maternal and child health clinics are established in Nigeria to take care of these groups.

  1. Essential drugs

The most vital drugs should be available and affordable at all levels.

  1. Food and Nutrition

The family’s food should be adequate, affordable and balanced in nutrients.

  1. Education

The community should be informed of health problem and methods of prevention and control.

  1. Illness and injury

Adequate provision of curative services for common ailments and injuries should be made by the community.

  1. Water and sanitation

A safe water supply and the clean disposal of wastes are vital for health.

  1. Vector and reservoirs

Endemic infection diseases can be regulated through the control or eradication of vectors and animal reservoir.

PROBLEMS OF IMPLEMENTATION OF PRIMARY HEALTH CARE PROGRAMME AT LGA LEVEL IN NIGERIA.

To achieve primary health care in Nigeria, Nigeria was divided into wards of 10.000 people. This ward is the same as political ward that makes up district and then local government. However problems experienced during implementation of primary health care in Nigeria include the following:

1. Shortage of funds

2 Lack of materials and equipment

3. Shortage of appropriate stuff

4. Lack of commitment which can be at the individual or government level.

5. Lack of incentive

6. Lack of information

7. Inadequate community participation

8. Inadequate intersectoral collaboration

9 .Rapid turnover of policy makers

10. Lack of manpower training and development

11. Inadequate utilization of services

12. In appropriate staff recruitment

13. Ill defined responsilities that is poor job description

14. Ill defined authority.

Keleher, H. (2001): ‘Why primary health care offers a more comprehensive approach for tackling health inequities than primary care’. Australian Journal of Primary Health, vol 7 (2), 57-61.

Writing on ‘why Primary Health Care offers a more comprehensive approach for tackling health inequities than Primary Care, Keleher (2001) described Primary health care as “a strategy of public health, derived from the social model of health and sustained by the Alma Ata Declaration, which was jointly sponsored by the World Health Organisation and UNICEF (WHO, 1978, 1986)”  Primary Care was described as “commonly considered to be a client’s first point of entry into thehealth system if some sort of active assistance is sought”. That “…drawn from the biomedical model, primary care is practised widely in nursing and allied health but general practice is the heart of the primary care sector. It involves a single service or intermittent management of a person’s specific illness or disease condition in a service that is typically contained to a time-limited appointment, with or without follow-up and monitoring or an expectation of provider-client interaction beyond that visit. However, primary care can also provide continuity of care. Primary care providers are focused on early diagnosis and timely, effective treatment but have greater potential for referral to secondary, non-medical services than has been realised to date (Ham, 2000)”

He observed that as governments attempt to focus more intently on how to deal with alarming measures of health disadvantage and inequities, a reformist gaze seems to have settled on the primary care sector. And that simultaneously, in literature about this area, whether intended or not, primary health care and primary care are terms that are increasingly interchanged. He argued that this slippage in language is counter-productive, first because it disguises the transformative potential of strategies and approaches that can make the fundamental changes necessary to improve health status and secondly because the structures and practices of primary care sector are not necessarily compatible with notions of comprehensive primary health care. That there is much to be lost if primary health care and health promotion are disguised as primary care, and not understood for their capacity to make a difference to health inequities although of course, comprehensive primary health care is interdependent with services provided by primary care.

Further in his article, the characteristics of primary care and primary health care are juxtaposed to show that if the strengths and limitations of each model are understood, they can be mobilised in collaborative partnerships to deal more effectively with health inequities than current system has so far been able to do.

EFFECTIVE PRIMARY HEALTH CARE DELIVERY IN NIGERIA. FORUM ON EVIDENCE-BASED HEALTH POLICY MAKING

WORKSHOP SUMMARY

The Nigerian Academy of Science, June 2009.

Editors:

M. Oladoyin Odubanjo

Adedamola Badejo

Temitayo Shokunbi, FAS

STRENGTHENING DATA MANAGEMENT: BOTTOM-TOP APPROACH

Prof Afolabi Bamgboye, Department of Epidemiology, Medical Statistics

and Environmental Health, University of Ibadan

The Weaknesses in the Data Collection Systems at the PHC Levels

It is sad to note that the PHC system is weak in data generation partially because there are no strict penalties for poor implementation of our health data management system. It is generally known that the data generated are seldom used for planning purposes and allocation of resources. The location of some of the PHC like most social facilities in Nigeria could have been dictated by political consideration rather than evidence-based information of need and potential use. The country is yet to disengage itself from the politics interwoven with empirical data. Hence, rather than plan health services, on available facts and figures, the planning and policy formulation have largely been influenced by the strength of our political powers.

Final Report on Evaluation of Kachia PHC Project

The National Primary Health Care Development Agency was established by Decree 29 of 1992 A.D. to guide the development of primary health care in Nigeria

MC Asuzu & Dr. MO Ogundeji-MINIMUM STANDARDS FOR PRIMARY HEALTH CARE SERVICES NATIONWIDE IN NIGERIA-Report of a consultancy assignment, Novenber, 2007

Standards in health care

In the final draft for the minimum standard expected of any Primary Health Centre (Asuzu et al, 2007), the necessity of standard setting in the health services was observed to have become widely recognized in the recent times. That, according to the World Health Organization (WHO), the purpose of setting health standards as a tool in health services management is to strive to achieve the highest quality of care possible within the resources available. Standards provide degrees of excellence to be pursued in a given exercise or exercises. They provide the basis for monitoring, comparison, supervision and regulation of the given services.

The draft observed that since the development and use of standards in health care, two levels of standards have come to be recognized – minimum standards to be achieved by all involved in the exercise as well as optimal (ideal or desirable) standards to which all concerned should be striving at. It was also noted that optimal standards, after a period of time has elapsed and significant effort has been exercised to meet them, may, in fact, become the minimum standards. Types of standards recognized include standards directed toward structure, process or outcome. Structural standards apply to the things used for services such as human, financial and physical resources (men, money and physical matters). Process standards apply to what is done (such as activities that constitute care, service or management). Outcome standards address the results (both clinical and non-clinical) of what is done with the resources available.

The Alma-Ata conference (WHO, 1988) specified 8 minimum health service areas that can be referred to as the minimum service components (standards) of PHC. These consist of:

  • Education on prevailing health problems and how to prevent them (health education)
  • Provision of adequate water and basic sanitation (environmental health)
  • Adequate food supply and good nutrition (public health nutrition)
  • Maternal and child health including family planning (reproductive and family health)
  • Immunization against the common diseases
  • Control of common endemic diseases (epidemiology and disease control)
  • Treatment of common diseases and injury (primary medical care)
  • Provision of essential drugs (community pharmacy practice)

The Nigerian PHC system which evolved from the Nigerian Basic Health Service (BHS) Scheme (articulated in the Third National Development Plan of 1975 – 1980), sets its health facilities standards such that approximately one LGA was to have 1 comprehensive health centre at its apex, 4 primary health centres at what may appear to be the LGA districts (Wards) and each PHC serving as referral centre for a further four health centres/clinics each. Each comprehensive and PHC was to have one mobile clinic attached to it for its outreach services to communities not adequately served by the physical health facilities. These has since proved difficult to achieve.

According to Asuzu et al, current situation is that each higher level of government is generally expected to provide public health facilities for the immediate lower level as follow:

-        the Federal Government is expected to provide at least one tertiary health facility  in every State;

-        the state government is expected to provide at least one general hospital in every  LGA;

-        the local government is expected to  provide at least one primary health centre in every district/political ward;

-        the political ward committee (WDC) is expected to provide/support at least one health clinic for a group of villages/communities with about 1000-2000 inhabitants; and

-        the community development committee (CDC) is expected to provide/support at least one health post  for villages, settlements or neighbourhoods of about 200-500 inhabitants.

Definition of Health

http://www.definitionofwellness.com/dictionary/health.html

Health is defined in the WHO constitution of 1948 as: A state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.

Within the context of health promotion, health has been considered less as an abstract state and more as a means to an end which can be expressed in functional terms as a resource which permits people to lead an individually, socially and economically productive life.

Health is a resource for everyday life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities.

In keeping with the concept of health as a fundamental human right, the Ottawa Charter emphasizes certain pre-requisites for health which include peace, adequate economic resources, food and shelter, and a stable eco-system and sustainable resource use. Recognition of these pre-requisites highlights the inextricable links between social and economic conditions, the physical environment, individual lifestyles and health. These links provide the key to an holistic understanding of health which is central to the definition of health promotion.

Today the spiritual dimension of health is increasingly recognized. Health is regarded by WHO as a fundamental human right, and correspondingly, all people should have access to basic resources for health.

A comprehensive understanding of health implies that all systems and structures which govern social and economic conditions and the physical environment should take account of the implications of their activities in relation to their impact on individual and collective health and well-being.

http://en.wikipedia.org/wiki/Health

Healthis the level of functional or metabolic efficiency of a living being. In humans, it is the general condition of a person's mind, body and spirit, usually meaning to be free from illnessinjuryor pain(as in “good health” or “healthy”).[1]The World Health Organization(WHO) defined health in its broader sense in 1946 as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

a relative state in which one is able to function well physically, mentally, socially, and spiritually in order to express the full range of one's unique potentialities within the environment in which one is living. In the words of René Dubos, “health is primarily a measure of each person's ability to do and become what he wants to become.”

Current views of health and illness recognize health as more than the absence of disease. Realizing that humans are dynamic beings whose state of health can change from day to day or even from hour to hour, leaders in the health field suggest that it is better to think of each person as being located on a graduated scale or continuous spectrum (continuum) ranging from obvious dire illness through the absence of discernible disease to a state of optimal functioning in every aspect of one's life. High-levelwellness is described as a dynamic process in which the individual is actively engaged in moving toward fulfillment of his or her potential.

health care system,

the complete network of agencies, facilities, and all providers of health care in a specified geographic area. Nursing services are integral to all levels and patterns of care, and nurses form the largest number of providers in a health care system.

Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.