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Accessibility to general hospitals in rural Bendel State, Nigeria
Sac. SC;. Med. Vol. IX. No. 8, pp. 661-666. Printed in Great Britain
1984
0277-9536/84 $3.00 + 0.00 Pergamon Press Ltd
ACCESSIBILITY TO GENERAL HOSPITALS RURAL BENDEL STATE, NIGERIA FRANCIS Department
of Geography
C.
IN
OKAFOR
and Regional Planning, University of Benin. Benin City, Nigeria
Abstract-The concern is growing in Nigeria as in many other developing countries that the rural population, in spite of its size, is the most neglected in the distribution of social facilities. Even in the rural areas the spatial disparity in the location of the few available facilities aggravates Ihe problem of some segments of the population. The case of accessibility to general hospitals in rural Bendel State of Nigeria is examined in this paper because general hospitals are crucial 10 the success of the free medical delivery system being attempted in the state. Using some surrogate measures of accessibility the study attempts a classification of all the rural Local Government Areas in the state according to their relative accessibility to general hospitals. Finally. the paper discusses some implications of the findings for social services planning in Nigeria and other developing countries.
INTRODUCTION During the last few years, emphasis on rural development in Nigeria is shifting from the traditional focus on agricultural productivity, rural income and employment towards a concern for the nature and the extent of the social difficulties experienced in many rural areas. As stated in the Third and Fourth National Development Plans 1975-l 980 and 198 l-1 985, efforts directed to providing such needs as health facilities, hygenic water supply and electricity will have to match the attempts made over the years to raise output from agriculture [l]. Among the growing interest in social problems by social scientists is a concern that economic growth and technological development should not continue to receive disproportionate attention at the expense of concerns for spatial equity in the location and allocation of social amenities [2, 31. Since every citizen of a country has a right to government amenities, the concern is that some people have an easy access to those social facilities while others experience tremendous difficulties in getting at them due to prohibitive distance and time constraints. This is the basis for the desire to assess the accessibility of general hospitals to the rural population in Bendel State one of the nineteen states in Nigeria. Official statistics provide little information about the distribution of medical facilities in this state and they conceal the disparity of access to these facilities between urban and rural communities and between different socio-economic groups in the population. But the analysis of the location of health service is as important as providing them because it is intricately related to planning for an efficient delivery of medical care. The manner in which medical facilities are distributed vis-ti-vis the population distribution has a demonstrated effect upon illness and therapeutic behaviour [4]. Geographic accessibility is, therefore, being included as a major variable in recent research in Nigeria proposed to examine and explain the utilisation of health services [S-7]. There is, however, a lack of factual research which should give insights into how much the majority if the people who live in
rural areas have ready access to government general hospitals and how frequently they utilise them. It is of particular importance to health services research and planning to know how well a particular set of health service facilities serve a group of population. It is also of major interest to measure the impact of any proposed change in the location and/or level of particular health services on the geographic accessibility of these services. This study seeks to examine the nature and extent of rural deprivation in Bendel State with specific reference to rural accessibility to general hospitals. General hospitals are singled out for examination because of the crucial place they occupy in the free health-care delivery service of the state. They are distinguished from mission or private hospitals which charge fees for their services. Since general hospitals do not charge any fees, their accessibility means a lot to a rural resident whose low income compels him to watch’cautiously his travel costs to goods and services. As such, the presence or absence of a general hospital in a rural community means much to the population. Where it is absent the population is compelled to make long trips to other general hospitals or patronise fee-charging hospitals and clinics when the need arises. Besides, general hospitals are referral units which supersede rural health clinics in importance. So, even if there are rural dispensaries, maternity homes and health clinics, referral cases still have to go to general hospitals which are supposed to have the full range of general medical and surgical facilities for psychiatry, geriatrics paediatrics and obstetrics. This means that the severe cases that would be referred to general hospitals could involve high fees. There is, however, a definite limitation of this study by limiting the survey to general hospitals only. People do make trade-offs between facilities based on distance, costs, waiting time, friendliness of staff, etc. and so a mission or private hospital close by may be very attractive and quite accessible. Also, the majority of the people might be adequately served by the lower levels of the health delivery hierarchy. In spite of this apparent shortcoming, a focus on general 661
FRANCIS C. OKAFOR
662
hospitals only has some good justification in helping to assess the effectiveness of the free health delivery practice in Bendel state. Before turning to definitions and the analysis of the research data the paper will present the background setting of the study. Finally, the general issue of social planning and access to social services in Nigeria will be examined. THE SETIING
The popular image of rural Bendel State particularly to the people outside the state is that there is an easy access to most social amenities. This popular image-or one very much like it-masks the basic issue of health care delivery in the state where general hospitals are few and far between. Although each community has got one or more of dispensaries, health centres, maternity and mobile clinics, which in
view of the paucity of full-fledged general hospitals serve a great need, easy access to general hospitals is still required for a more efficient health care delivery system. The Bendel State, with a total population of 2.5 million according to 1963 census, and an estimated population rise to 4.9 in 1980 has only 40 general hospitals with 3150 beds by 1980 (Fig. 1). This amounts to about 1500 people to one general hospital bed. Though the situation is worse in most other parts of Nigeria [8], the concern of the study is that the distribution of these general hospitals is highly skewed in favour of urban communities while the bulk of the rural population is deprived of easy access to the hospitals. Although the urban population of the state is estimated at 30% of the total, there were twenty-five hospitals located in urban centres thus representing about 63% of the total number of hospitals in the state. Locating of general hospitals mostly in urban centres not only in Bendel
4 \,
Fig.
I. Location
of general hospitdis
‘~NIOCHA
in Bendel State. Nigeria.
,
Accessibility
663
to general hospitals in Nigeria
State but throughout Nigeria seeks to perpetuate the age long imbalance in rural urban relations in Nigeria and in most developing countries [9]. This survey which is concerned primarily with identifying and measuring differentials in geographic accessibility of the rural population to general hospitals regards accessibility simply as the case of getting to a place. It is, however, a relative term and measuring it is beset with many problems. The principal types of barriers considered in this study as reducing accessibility are the distance between client and the provider and the money spent to obtain health care. Measures of these barriers include distance travelled, travel mode, travel cost and treatment cost. It may be argued that functional rather than physical measures of distance are more sensitive to the effort involved in travel for medical services. While in certain instances functional measures such as travel time are desirable, there are problems related to them also. Travel time, among other problems of computation, is often variable by time of day, direction, and of course, mode of transportation [lo]. Regardless of the type of functional measure desired they are generally much more expensive to obtain than some physical measure. This is not meant to detract from the utility of the methodology applied in this study. The methodology used here provides one procedure for a statistical comparison of accessibility appropriate for both immediate use by health planners and research to provide a more comprehensive index of accessibility. METHODOLOGY FOR ESTABLISHING ACCESSIBILITY
In a rural environment more than in other places, problems of assessing accessibility compound because of various inherent constraints. There are limited means of transportation which make movement difficult. poor social mixture to break ethnic barriers affecting accessibility, unfavourable physical terrain that increase distance cost and low income that prohibits elaborate spending on travels [1 11. Therefore, to accurately measure accessibility to particular facilities in a rural area demands an appraisal of the physical configuration of the rural area in question, the spatial distribution of the facilities and the mean of transport available [12, 131. Facilities centrally located will draw consumers from the immediate surrounding unless political and ethnic frictions compel otherwise. Where such frictions occur the catchment area of some goods and services may not be neatly defined and could intricately overlap. Thus, measuring accessibility to rural general hospitals defies neat mathematical calculations. In view of this, various factors have been taken into consideration in measuring the accessibility to genera1 hospitals by the rural population of Bendel State. On the assumption that the variation in transport fares in rural Bendel is minimal, measurement of accessibility is based on estimating the convenience of journey to the hospital by an average villager bearing in mind the principle of movement minimisation. It is further assumed that since general hospitals in Bendel State charge no fees, those rural households who spend more money on health care are less accessible to genera1 hospitals.
It remains then to aggregate the rural communities according to their relative accessibility to the available general hospitals. In an earlier work, an attempt was made to compute the index of rurality for Bendel State using the following parameters (a) analysis of the occupational structure of the inhabitants of each Local Government Area in the state, (b) distance of the local government headquarters from the state capital, (c) settlement size and (d) the provision of commercial, social and educational services in each Local Government Area [14]. Although the terms rural and urban “are more remarkable for their ability to confuse than for their power to illuminate” [15], it was possible to single out the Local Government Areas (LGAs) which are essentially rural. Out of the nineteen LGAs in the state, the following eleven show to be the most rural based on the index of rurality resulting from the analysis. They are made up of Ovia, Aniocha, Ughelli, Akoko-Edo, Etsako. Owan, Okpebho, Agbazilo, Ndokwa, Orhionmwon and Burutu (see Fig. 1). Since LGAs were the area1 unit of analysis the pattern of accessibility to the existing general hospitals in the LGAs was examined using some data. Such data include the specific location to the hospitals in each of the LGAs which forms the basis for examining how centrally located are the general hospitals with respect to the geographical extent of the LGA. In addition, a number of variables suggested by previous researchers in this field [16, 17] have been employed to produce an overall ranking of the LGAs according to their accessibility to the general hospitals located in them. Ranking was achieved based on the aggregate of standardised scores (Z-score) of each of the following variables which provides a surrogate measure of accessibility of the rural population to the general hospital; (a) Ratio of LGA’s population of the number of general hospitals in the LGA; (b) Percentage of households travelling more than 8 km to the nearest general hospital (8 km is the maximum average distance which respondents accept they can walk in a day to obtain a health service); (c) Percentage household income spent on health care (more money spent on health care means that the free health care service offered by general hospitals is not fully accessible); . (d) Transport cost to the nearest genera1 hospital. The population data utilised comprise 324 households distributed in a stratified random manner across the eleven rural LGAs. The survey was carried out from April to October 198 1. It was ensured that the households included in the study reflect the state’s cultural and linguistic heterogeneity. The interviewers were carefully selected and intensively trained. Because of linguistic variations, different interviewers were used in different parts of the state. The purpose of the survey was frankly discussed with villagers who were asked to be candid about their views freely. Anonymity and confidentiality were guaranteed. ANALYSIS
OF DATA
The data from the above surrogate measures of accessibility allow for the demonstration of
FRANCIS C. OKAFOR
664
Table I. Cluster characteristics
of accessibility indicators (mean scores on each vanable) ‘Cluster of LGAs
Variable (a) (b)
w (d)
Ratio of LGA population to general hospitals Households travelling more than 8 km to general hospitals Percentage income spent on health care Transport cost to the nearest general hospital
I
2
4
5
11.4
16.4
- 10.3
7.7
4.8
20.0
(134)’
18.7 (67)
9.1 (44)
14.6 (52)
7.4 (17)
16.7 (83) 17.3 (106)
20. I (123) 14.6 (61)
12.2 (63) 15.8 (72)
IO.1 (34) 13.2 (32)
8.5 (21) I I.6 123)
3
Total
(314)
(324) (294)
‘The number of households is in parenthesis
differential accessibility for the LGAs. A preliminary of the results the multianalysis confirm dimensionality of inaccessibility and therefore suggest a typological approach to the spatial pattern of inaccessibility to general hospitals, rather than reliance on a single diagnostic variable or the construction of an aggregate index. Such an approach has been pursued here, using a cluster analysis (Ward’s hierarchical solution) of the four variables [18]. The responses made were scored using standardised values for each of the variables. This technique of hierarchical grouping analysis combines object by a series of step decisions until all have been grouped.
Fig. 2. The spatial
pattern
of inaccessibility
One pair of groups is combined at each step, and the total with groups is the function to be minimally increased. Against the hypothesis that the scores in each of the eleven LGAs were an unstructured set, a clustering analysis was therefore carried out. A five-group classification emerged according to the relative accessibility of the LGAs to general hospitals [19]. The mean score on each variable is shown in Table 1 for each of the five groups. The spatial pattern of the groups is shown in Fig. 2. Clusters are in groups as uniform as possible in factors of accessibility to general hospitals. Thus the LGAs were grouped to identify those most deprived of the free
to general
hospitals
in rural
Bendel State by LGAs,
1981
Accessibility Table 2. Other
reasons
to general hospitals
for not gomg 10 general hospitals clusters of LGAsj
in Nigeria (responses
grouped
according
to
Number of responses (Clusters of LGAs) Reason (a) (bl (C) (d)
Preference lo mlssion and private hospitals Preference to traditional practitioners Long waiting time in general hospitals Poor standard of care in general hospitals
medical attention offered in the state’s general hospitals. The dominant characteristics of each group can be summarised as follows: Cluster
1: Ughelli. Burutu and Aniocha
These are the LGAs characterised by the presence of very few general hospitals and they score very high on nearly all the indicators of remoteness from general hospitals. Although indicators of problems of accessibility are evident for the general rural population in Bendel State, these are areas whose problems of accessibility are most striking. These three LGAs are known to suffer the most acute deprivation of health care facilities. None of the sampled households was served by a direct road route to a general hospital and only ten households travelled less than 8 km to a general hospital. On the average, the sampled households were about 25 km from the nearest general hospital. Cluster 2: Akoko-Edo
and Owan
These LGAs are distinctive for their relatively large area1 size hence the two general hospitals in each of them are not easily accessible to a majority of the population. As an alternative most of the study population indicated going more to patent medicine stores, native doctors healing homes, friends and relatives instead of travelling the long distance to general hospitals. Households in the sample were asked from whom they had last obtained treatment for an illness or injury, where they had obtained it and how much they had paid for it. Only 10% reported they had used the general hospital or any other government health services. An overwhelming 709; sought treatment from native doctors, diviners and patent medicine dealers. None of the households interviewed obtained treatment from a qualified private physician and only a small proportion went to a mission hospital (see Table 2). Cluster 3: Ouia and Agbaziio
Rural poverty in these two LGAs seems to be the major problem contributing to inaccessibility to the available general hospitals. Of those who had not used the general hospitals over 90% said they were deterred by the high cost of transport. Only a small proportion said that they had not used the general hospitals because of poor standard of care or because they had no confidence in modern medicine. The study found that attitudes towards modern medicine
I
2
3
4
5
I6
22
13
32
17
32
18
I6
13
Y
x
16
24
36
31
28
19
I2
8
Y
were generally favourable and the people in these rural LGAs actually desired greater access to general hospital and other government health services. When asked whether they would seek treatment from a native doctor (herbalist), private physician or a general hospital if all there were equally accessible, 20’% said that they would consult the private physician, only 3”/, indicated a preference for the herbalist while more than three-quarters chose the general hospital. Cluster 4: Etsako,
Okpebho
and Orhionmwon
In these LGAs other factors contributing to inaccessibility are counter-pointed by a relatively wellspaced location of the available general hospitals. Only 20% of the sampled households in these LGAs travelled more than 8 km to general hospitals. Although the presence and importance of private physicians are recognised, villagers would prefer to first visit the non-fee charging general hospital and if then necessary would go to the private physician. Cluster 5: Ndokwa
The rural population of the Ndokwa Local Government Area is the least deprived in terms of accessibility to general hospitals. The LGA is the one with the largest number of general hospital beds and the existing hospitals are centrally located. Only 5% of the respondents indicated that they travel more than 8 km to the general hospitals. The average distance for all the sampled villages is about 5 km-a distance which is quite tolerable in a rural area of any developing country. CONCLUSlONS SOCIAL
AND IMPLICATIONS SERVICES PLANNING
FOR
The findings of this study show that it is those Local Government Areas which score low on other indices of socio-economic development that are most seriously affected by inaccessibility to general hospitals. This reinforces the point made earlier that inaccessibility to general hospitals is mostly a rural problem and is only one of the syndromes of deprivation which rural areas are subjected to. These findings may also generate further research and prompt us to examine more rigorously the relationship between rurality and socio-economic deprivation. Rural deprivation, of which difficult accessibility to such services as general hospitals is just only one aspect of it, derives to a large extent from the nexus of factors associated with periph-
666
FRANCISC. OKAFOR
erality which in turn results principally from human location and allocation decisions [19]. This study also reveals the discrepancies between government social plans and the benefits people derive from these plans. The government of Bendel State has a programme of free health delivery through general hospitals and government health clinics but the achievement of this programme sharply contrasts with the official intentions. While it is assumed in official circles that health service facilities are within easy reach of a majority of the population this study reveals that the majority of the rural population is not reached by any government health service. The study has also highlighted the disparity of access even among the rural population. The reasons for the discrepancies and disparities are many and are interwoven with political, economic and social conditions in Bendel State and in Nigeria, generally. These problems are also not uncommon in other Third World countries. Nigeria because of her oil money is not a poor country relatively, but its large and ever-increasing population is straining the efficiency in the provision of social services. Domestic resources for the social services are limited and the allocation of the available resources has its own attendant problems. Problems which range from administrative inefficiency and wastage, inadequate personnel to shortage of transport and other facilities which professionals and administrators require to do their work properly. There is also a noticeable tendency to spend resources on a few expensive capital items. It is common to find that the total health development budget for a Local Government Area is to be sunk into the construction of only one hospital with expensive imported technology and building materials. The wisdom of such a decision is questionable because many more cottage hospitals could be provided if simpler buildings were constructed from local materials. The inappropriateness of such social services like the health care delivery programme is a factor which is closely related to the political realities of most countries of the Third World. Their attempt to replicate Western approaches to social service policy results in their serving the urban elite to the neglect of the bulk of the population which remains rural. Unless social planners in the Third World countries attempt to deal with the problems of limited and unequal access to social services from the rural perspective, they may continue to allocate their scanty resources in the manner which does not help to alleviate the common problems of poverty, disease and ignorance.
Acknowledgemenr-The author wishes to thank the anonymous referee who suggested some modifications on an earlier draft of this paper.
REFERENCES Development. Fourth Vol. I, p. 29. Printer, Lagos, 1981.
1. Federal Ministry of Economic National Development
Plan,
1981-85.
Government 2. Knox P. L. Social Well-Being: A Spatial Perspecrire. Oxford, 1975. 3. Smith D. M. Human Geographv: A Welfare Approach. Arnold, London, 1977. 4. Shannon G. W. et al. A method of evaluating the geographic accessibility of health services. Profess. Geogr. 27, 30, 1975. 5. Adejuyigbe D. Providing health centres in the rural areas of the Western State of Nigeria. Niger. med. J. 4. 6, 1974. 6. Onokerhoraye A. G. A suggested framework for the provision of health facilities in Nigeria. Sot. Sci. Med. 10, 565, 1976. 7. Okafor S. I. The case of medical facilities in Nigeria. Sot. Sci. Med. 16, 1971, 1982. 8. Ogunlesi T. 0. Economics of health. In Priorities in National Health Planning, pp. 99-109. Caxton, Ibadan. 1973. 9. Okafor S. I. op. cit. IO. Gowan P. Hospitals in towns: location and siting. Architect. Rev. 137, 417, 1965.
II. Sharpston M. H. Uneven geographical distribution of medical care: a Ghananian case study. J. Dec. Studies. 8, 205, 1972. 12. Shannon G. W. et al. The concept of distance as a factor in accessibility and utilization of health care. Med. Care Reu. 16, 143, 1969. 13. Girt J. The location of medical services and disease ecology-some conclusions on the effect of distance on medical consultations in a rural environment. Geographica Medica 2, 12, 1971. 14. Okafor F. C. Measuring the spatial dimensions of rural
development in Bendel State: constraints and prospects. Paper presented at the 24th Annual Conference of the Nigerian Geographicul Association, Bayer0 University. Kano, 1981. 15. Pahl R. E. The rural/urban continuum. Sociologia Ruralis 6, 299, 1966. 16. Hardman M. and Midgley J. Social planning and access
to the social services in developing cbuntries: the case of Sierra Leone. Third Wld Plan. Rev. 3. 75. 1981. 17. Shannon G. W. et al. A method for evaluating the geographic accessibility of health services. ProJkss. Geogr. 27, 1975.
18. Ward J. H. Hierarchical grouping to optimize an objective function. J. Am. Siarist. Ass. 58, 236, 1963. 19. Everett B. Cluster Analyis. Social Science Research Council, Heinemann, London, 1974.
1984
0277-9536/84 $3.00 + 0.00 Pergamon Press Ltd
ACCESSIBILITY TO GENERAL HOSPITALS RURAL BENDEL STATE, NIGERIA FRANCIS Department
of Geography
C.
IN
OKAFOR
and Regional Planning, University of Benin. Benin City, Nigeria
Abstract-The concern is growing in Nigeria as in many other developing countries that the rural population, in spite of its size, is the most neglected in the distribution of social facilities. Even in the rural areas the spatial disparity in the location of the few available facilities aggravates Ihe problem of some segments of the population. The case of accessibility to general hospitals in rural Bendel State of Nigeria is examined in this paper because general hospitals are crucial 10 the success of the free medical delivery system being attempted in the state. Using some surrogate measures of accessibility the study attempts a classification of all the rural Local Government Areas in the state according to their relative accessibility to general hospitals. Finally. the paper discusses some implications of the findings for social services planning in Nigeria and other developing countries.
INTRODUCTION During the last few years, emphasis on rural development in Nigeria is shifting from the traditional focus on agricultural productivity, rural income and employment towards a concern for the nature and the extent of the social difficulties experienced in many rural areas. As stated in the Third and Fourth National Development Plans 1975-l 980 and 198 l-1 985, efforts directed to providing such needs as health facilities, hygenic water supply and electricity will have to match the attempts made over the years to raise output from agriculture [l]. Among the growing interest in social problems by social scientists is a concern that economic growth and technological development should not continue to receive disproportionate attention at the expense of concerns for spatial equity in the location and allocation of social amenities [2, 31. Since every citizen of a country has a right to government amenities, the concern is that some people have an easy access to those social facilities while others experience tremendous difficulties in getting at them due to prohibitive distance and time constraints. This is the basis for the desire to assess the accessibility of general hospitals to the rural population in Bendel State one of the nineteen states in Nigeria. Official statistics provide little information about the distribution of medical facilities in this state and they conceal the disparity of access to these facilities between urban and rural communities and between different socio-economic groups in the population. But the analysis of the location of health service is as important as providing them because it is intricately related to planning for an efficient delivery of medical care. The manner in which medical facilities are distributed vis-ti-vis the population distribution has a demonstrated effect upon illness and therapeutic behaviour [4]. Geographic accessibility is, therefore, being included as a major variable in recent research in Nigeria proposed to examine and explain the utilisation of health services [S-7]. There is, however, a lack of factual research which should give insights into how much the majority if the people who live in
rural areas have ready access to government general hospitals and how frequently they utilise them. It is of particular importance to health services research and planning to know how well a particular set of health service facilities serve a group of population. It is also of major interest to measure the impact of any proposed change in the location and/or level of particular health services on the geographic accessibility of these services. This study seeks to examine the nature and extent of rural deprivation in Bendel State with specific reference to rural accessibility to general hospitals. General hospitals are singled out for examination because of the crucial place they occupy in the free health-care delivery service of the state. They are distinguished from mission or private hospitals which charge fees for their services. Since general hospitals do not charge any fees, their accessibility means a lot to a rural resident whose low income compels him to watch’cautiously his travel costs to goods and services. As such, the presence or absence of a general hospital in a rural community means much to the population. Where it is absent the population is compelled to make long trips to other general hospitals or patronise fee-charging hospitals and clinics when the need arises. Besides, general hospitals are referral units which supersede rural health clinics in importance. So, even if there are rural dispensaries, maternity homes and health clinics, referral cases still have to go to general hospitals which are supposed to have the full range of general medical and surgical facilities for psychiatry, geriatrics paediatrics and obstetrics. This means that the severe cases that would be referred to general hospitals could involve high fees. There is, however, a definite limitation of this study by limiting the survey to general hospitals only. People do make trade-offs between facilities based on distance, costs, waiting time, friendliness of staff, etc. and so a mission or private hospital close by may be very attractive and quite accessible. Also, the majority of the people might be adequately served by the lower levels of the health delivery hierarchy. In spite of this apparent shortcoming, a focus on general 661
FRANCIS C. OKAFOR
662
hospitals only has some good justification in helping to assess the effectiveness of the free health delivery practice in Bendel state. Before turning to definitions and the analysis of the research data the paper will present the background setting of the study. Finally, the general issue of social planning and access to social services in Nigeria will be examined. THE SETIING
The popular image of rural Bendel State particularly to the people outside the state is that there is an easy access to most social amenities. This popular image-or one very much like it-masks the basic issue of health care delivery in the state where general hospitals are few and far between. Although each community has got one or more of dispensaries, health centres, maternity and mobile clinics, which in
view of the paucity of full-fledged general hospitals serve a great need, easy access to general hospitals is still required for a more efficient health care delivery system. The Bendel State, with a total population of 2.5 million according to 1963 census, and an estimated population rise to 4.9 in 1980 has only 40 general hospitals with 3150 beds by 1980 (Fig. 1). This amounts to about 1500 people to one general hospital bed. Though the situation is worse in most other parts of Nigeria [8], the concern of the study is that the distribution of these general hospitals is highly skewed in favour of urban communities while the bulk of the rural population is deprived of easy access to the hospitals. Although the urban population of the state is estimated at 30% of the total, there were twenty-five hospitals located in urban centres thus representing about 63% of the total number of hospitals in the state. Locating of general hospitals mostly in urban centres not only in Bendel
4 \,
Fig.
I. Location
of general hospitdis
‘~NIOCHA
in Bendel State. Nigeria.
,
Accessibility
663
to general hospitals in Nigeria
State but throughout Nigeria seeks to perpetuate the age long imbalance in rural urban relations in Nigeria and in most developing countries [9]. This survey which is concerned primarily with identifying and measuring differentials in geographic accessibility of the rural population to general hospitals regards accessibility simply as the case of getting to a place. It is, however, a relative term and measuring it is beset with many problems. The principal types of barriers considered in this study as reducing accessibility are the distance between client and the provider and the money spent to obtain health care. Measures of these barriers include distance travelled, travel mode, travel cost and treatment cost. It may be argued that functional rather than physical measures of distance are more sensitive to the effort involved in travel for medical services. While in certain instances functional measures such as travel time are desirable, there are problems related to them also. Travel time, among other problems of computation, is often variable by time of day, direction, and of course, mode of transportation [lo]. Regardless of the type of functional measure desired they are generally much more expensive to obtain than some physical measure. This is not meant to detract from the utility of the methodology applied in this study. The methodology used here provides one procedure for a statistical comparison of accessibility appropriate for both immediate use by health planners and research to provide a more comprehensive index of accessibility. METHODOLOGY FOR ESTABLISHING ACCESSIBILITY
In a rural environment more than in other places, problems of assessing accessibility compound because of various inherent constraints. There are limited means of transportation which make movement difficult. poor social mixture to break ethnic barriers affecting accessibility, unfavourable physical terrain that increase distance cost and low income that prohibits elaborate spending on travels [1 11. Therefore, to accurately measure accessibility to particular facilities in a rural area demands an appraisal of the physical configuration of the rural area in question, the spatial distribution of the facilities and the mean of transport available [12, 131. Facilities centrally located will draw consumers from the immediate surrounding unless political and ethnic frictions compel otherwise. Where such frictions occur the catchment area of some goods and services may not be neatly defined and could intricately overlap. Thus, measuring accessibility to rural general hospitals defies neat mathematical calculations. In view of this, various factors have been taken into consideration in measuring the accessibility to genera1 hospitals by the rural population of Bendel State. On the assumption that the variation in transport fares in rural Bendel is minimal, measurement of accessibility is based on estimating the convenience of journey to the hospital by an average villager bearing in mind the principle of movement minimisation. It is further assumed that since general hospitals in Bendel State charge no fees, those rural households who spend more money on health care are less accessible to genera1 hospitals.
It remains then to aggregate the rural communities according to their relative accessibility to the available general hospitals. In an earlier work, an attempt was made to compute the index of rurality for Bendel State using the following parameters (a) analysis of the occupational structure of the inhabitants of each Local Government Area in the state, (b) distance of the local government headquarters from the state capital, (c) settlement size and (d) the provision of commercial, social and educational services in each Local Government Area [14]. Although the terms rural and urban “are more remarkable for their ability to confuse than for their power to illuminate” [15], it was possible to single out the Local Government Areas (LGAs) which are essentially rural. Out of the nineteen LGAs in the state, the following eleven show to be the most rural based on the index of rurality resulting from the analysis. They are made up of Ovia, Aniocha, Ughelli, Akoko-Edo, Etsako. Owan, Okpebho, Agbazilo, Ndokwa, Orhionmwon and Burutu (see Fig. 1). Since LGAs were the area1 unit of analysis the pattern of accessibility to the existing general hospitals in the LGAs was examined using some data. Such data include the specific location to the hospitals in each of the LGAs which forms the basis for examining how centrally located are the general hospitals with respect to the geographical extent of the LGA. In addition, a number of variables suggested by previous researchers in this field [16, 17] have been employed to produce an overall ranking of the LGAs according to their accessibility to the general hospitals located in them. Ranking was achieved based on the aggregate of standardised scores (Z-score) of each of the following variables which provides a surrogate measure of accessibility of the rural population to the general hospital; (a) Ratio of LGA’s population of the number of general hospitals in the LGA; (b) Percentage of households travelling more than 8 km to the nearest general hospital (8 km is the maximum average distance which respondents accept they can walk in a day to obtain a health service); (c) Percentage household income spent on health care (more money spent on health care means that the free health care service offered by general hospitals is not fully accessible); . (d) Transport cost to the nearest genera1 hospital. The population data utilised comprise 324 households distributed in a stratified random manner across the eleven rural LGAs. The survey was carried out from April to October 198 1. It was ensured that the households included in the study reflect the state’s cultural and linguistic heterogeneity. The interviewers were carefully selected and intensively trained. Because of linguistic variations, different interviewers were used in different parts of the state. The purpose of the survey was frankly discussed with villagers who were asked to be candid about their views freely. Anonymity and confidentiality were guaranteed. ANALYSIS
OF DATA
The data from the above surrogate measures of accessibility allow for the demonstration of
FRANCIS C. OKAFOR
664
Table I. Cluster characteristics
of accessibility indicators (mean scores on each vanable) ‘Cluster of LGAs
Variable (a) (b)
w (d)
Ratio of LGA population to general hospitals Households travelling more than 8 km to general hospitals Percentage income spent on health care Transport cost to the nearest general hospital
I
2
4
5
11.4
16.4
- 10.3
7.7
4.8
20.0
(134)’
18.7 (67)
9.1 (44)
14.6 (52)
7.4 (17)
16.7 (83) 17.3 (106)
20. I (123) 14.6 (61)
12.2 (63) 15.8 (72)
IO.1 (34) 13.2 (32)
8.5 (21) I I.6 123)
3
Total
(314)
(324) (294)
‘The number of households is in parenthesis
differential accessibility for the LGAs. A preliminary of the results the multianalysis confirm dimensionality of inaccessibility and therefore suggest a typological approach to the spatial pattern of inaccessibility to general hospitals, rather than reliance on a single diagnostic variable or the construction of an aggregate index. Such an approach has been pursued here, using a cluster analysis (Ward’s hierarchical solution) of the four variables [18]. The responses made were scored using standardised values for each of the variables. This technique of hierarchical grouping analysis combines object by a series of step decisions until all have been grouped.
Fig. 2. The spatial
pattern
of inaccessibility
One pair of groups is combined at each step, and the total with groups is the function to be minimally increased. Against the hypothesis that the scores in each of the eleven LGAs were an unstructured set, a clustering analysis was therefore carried out. A five-group classification emerged according to the relative accessibility of the LGAs to general hospitals [19]. The mean score on each variable is shown in Table 1 for each of the five groups. The spatial pattern of the groups is shown in Fig. 2. Clusters are in groups as uniform as possible in factors of accessibility to general hospitals. Thus the LGAs were grouped to identify those most deprived of the free
to general
hospitals
in rural
Bendel State by LGAs,
1981
Accessibility Table 2. Other
reasons
to general hospitals
for not gomg 10 general hospitals clusters of LGAsj
in Nigeria (responses
grouped
according
to
Number of responses (Clusters of LGAs) Reason (a) (bl (C) (d)
Preference lo mlssion and private hospitals Preference to traditional practitioners Long waiting time in general hospitals Poor standard of care in general hospitals
medical attention offered in the state’s general hospitals. The dominant characteristics of each group can be summarised as follows: Cluster
1: Ughelli. Burutu and Aniocha
These are the LGAs characterised by the presence of very few general hospitals and they score very high on nearly all the indicators of remoteness from general hospitals. Although indicators of problems of accessibility are evident for the general rural population in Bendel State, these are areas whose problems of accessibility are most striking. These three LGAs are known to suffer the most acute deprivation of health care facilities. None of the sampled households was served by a direct road route to a general hospital and only ten households travelled less than 8 km to a general hospital. On the average, the sampled households were about 25 km from the nearest general hospital. Cluster 2: Akoko-Edo
and Owan
These LGAs are distinctive for their relatively large area1 size hence the two general hospitals in each of them are not easily accessible to a majority of the population. As an alternative most of the study population indicated going more to patent medicine stores, native doctors healing homes, friends and relatives instead of travelling the long distance to general hospitals. Households in the sample were asked from whom they had last obtained treatment for an illness or injury, where they had obtained it and how much they had paid for it. Only 10% reported they had used the general hospital or any other government health services. An overwhelming 709; sought treatment from native doctors, diviners and patent medicine dealers. None of the households interviewed obtained treatment from a qualified private physician and only a small proportion went to a mission hospital (see Table 2). Cluster 3: Ouia and Agbaziio
Rural poverty in these two LGAs seems to be the major problem contributing to inaccessibility to the available general hospitals. Of those who had not used the general hospitals over 90% said they were deterred by the high cost of transport. Only a small proportion said that they had not used the general hospitals because of poor standard of care or because they had no confidence in modern medicine. The study found that attitudes towards modern medicine
I
2
3
4
5
I6
22
13
32
17
32
18
I6
13
Y
x
16
24
36
31
28
19
I2
8
Y
were generally favourable and the people in these rural LGAs actually desired greater access to general hospital and other government health services. When asked whether they would seek treatment from a native doctor (herbalist), private physician or a general hospital if all there were equally accessible, 20’% said that they would consult the private physician, only 3”/, indicated a preference for the herbalist while more than three-quarters chose the general hospital. Cluster 4: Etsako,
Okpebho
and Orhionmwon
In these LGAs other factors contributing to inaccessibility are counter-pointed by a relatively wellspaced location of the available general hospitals. Only 20% of the sampled households in these LGAs travelled more than 8 km to general hospitals. Although the presence and importance of private physicians are recognised, villagers would prefer to first visit the non-fee charging general hospital and if then necessary would go to the private physician. Cluster 5: Ndokwa
The rural population of the Ndokwa Local Government Area is the least deprived in terms of accessibility to general hospitals. The LGA is the one with the largest number of general hospital beds and the existing hospitals are centrally located. Only 5% of the respondents indicated that they travel more than 8 km to the general hospitals. The average distance for all the sampled villages is about 5 km-a distance which is quite tolerable in a rural area of any developing country. CONCLUSlONS SOCIAL
AND IMPLICATIONS SERVICES PLANNING
FOR
The findings of this study show that it is those Local Government Areas which score low on other indices of socio-economic development that are most seriously affected by inaccessibility to general hospitals. This reinforces the point made earlier that inaccessibility to general hospitals is mostly a rural problem and is only one of the syndromes of deprivation which rural areas are subjected to. These findings may also generate further research and prompt us to examine more rigorously the relationship between rurality and socio-economic deprivation. Rural deprivation, of which difficult accessibility to such services as general hospitals is just only one aspect of it, derives to a large extent from the nexus of factors associated with periph-
666
FRANCISC. OKAFOR
erality which in turn results principally from human location and allocation decisions [19]. This study also reveals the discrepancies between government social plans and the benefits people derive from these plans. The government of Bendel State has a programme of free health delivery through general hospitals and government health clinics but the achievement of this programme sharply contrasts with the official intentions. While it is assumed in official circles that health service facilities are within easy reach of a majority of the population this study reveals that the majority of the rural population is not reached by any government health service. The study has also highlighted the disparity of access even among the rural population. The reasons for the discrepancies and disparities are many and are interwoven with political, economic and social conditions in Bendel State and in Nigeria, generally. These problems are also not uncommon in other Third World countries. Nigeria because of her oil money is not a poor country relatively, but its large and ever-increasing population is straining the efficiency in the provision of social services. Domestic resources for the social services are limited and the allocation of the available resources has its own attendant problems. Problems which range from administrative inefficiency and wastage, inadequate personnel to shortage of transport and other facilities which professionals and administrators require to do their work properly. There is also a noticeable tendency to spend resources on a few expensive capital items. It is common to find that the total health development budget for a Local Government Area is to be sunk into the construction of only one hospital with expensive imported technology and building materials. The wisdom of such a decision is questionable because many more cottage hospitals could be provided if simpler buildings were constructed from local materials. The inappropriateness of such social services like the health care delivery programme is a factor which is closely related to the political realities of most countries of the Third World. Their attempt to replicate Western approaches to social service policy results in their serving the urban elite to the neglect of the bulk of the population which remains rural. Unless social planners in the Third World countries attempt to deal with the problems of limited and unequal access to social services from the rural perspective, they may continue to allocate their scanty resources in the manner which does not help to alleviate the common problems of poverty, disease and ignorance.
Acknowledgemenr-The author wishes to thank the anonymous referee who suggested some modifications on an earlier draft of this paper.
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