Analysis of distribution, capacity and utilization of public health facilities in Borno, North-Eastern Nigeria

Introduction This study aimed to analyze the spatial distribution and capacities of public health facilities and assess utilization of the facilities in Biu area of Borno State, Nigeria. Methods A descriptive survey of health facilities and households were conducted by stratifying the area into 11 electoral wards. Data collection instruments include a hand-held GPS (Garmin 76CSx) and 2 sets of structured questionnaires (facility and household). The hand-held GPS was used in taking the coordinates of each health facility in the area. Twenty-five facility-based and 400 household-based questionnaires were administered. Results It was identified that 138 public health personnel serve the area’s population of 240,838. Medical professionals (doctors/nurses/midwives) to patient ratio is 1:2973, about 7 times less than the minimum WHO recommendation of 2.5 medical personal per 1000 population. Uneven distribution of facilities exists, which impact on utilisation. For instance, a ward (Mandaragrau) with a population of 18,732 have 5 facilities (4 dispensaries and 1 primary health care) in comparison to a ward (Miringa) with a population of 21,343 with only one Dispensary. Income level and distance were significant socio-economic factors affecting service utilisation (p < 0.001). Area’s households Gini index was 26.7, most of which (49.7%) survive on less than USD2/day and majority (33.6%) spend an average cost of treatment of ₦2,750 (approx. $8) per clinic visit. Conclusion It was concluded that insufficiency and inequity in distribution of healthcare services exist in Borno State. It is thus recommended that future policies be directed toward improving healthcare in under-served areas.


Introduction
Healthcare is central to community well-being as well as a fundamental aspect of life. Lack of basic health facilities and services in any community is significantly associated with poor productivity, reduced life expectancy and increased mortality rates [1][2][3][4][5]. This therefore necessitate the need for equity in distribution of health facilities. Both accessibility and utilization are important aspects of equitable distribution of health resources, which is based on needs of the population rather than equal distribution. Health System as an organizational set-up is charged with the responsibility of distributing and servicing the health care needs of a given population [3,6], thereby achieving positive health outcomes. In developed nations, a tangible proportion of its wealth is budgeted to healthcare provision and sustainability, thus there is a better health outcome. In most developing countries on the other hand, there is need for increased expenditure on healthcare provision and parameters need to be put in place to ensure its sustainability. Awoyemi et al. [4] opined that, improvement in healthcare leads to improvement in life expectancy, which serves as a robust indicator of human development.
Evidences have also shown that among the least developed countries, increase in life expectancy is strongly correlated with increase in income/productivity [2,[7][8][9]. Therefore, there is need for adequate and equitable distribution of healthcare services in any given country, particularly in sub-Saharan Africa, where health outcome is poorest.
Healthcare provision in Nigeria is the responsibility of the three tiers of government; the Local, State and the Federal Governments, which handles the primary, secondary and tertiary health facilities respectively. The Federal Government's role is majorly limited to coordinating the affairs of university teaching hospitals and federal medical centers (tertiary healthcare) while the State Government manages the various general/specialists hospitals (secondary healthcare). The local government on the other hand focus on Primary Health Care (PHC), which is regulated by the Federal Government, through the National Primary Health Care Development Authority (NPHCDA) [10]. Utilization of health services among the Nigerian population is directly associated with accessibility and several socioeconomic variables [9,11,12].
Where N = Total population (240,838), n = sub-population size (population of each ward). Hence, 400 copies of questionnaires were administered across the 11 wards of the area (Table 1). A systematic sampling technique was employed by selecting one household after every 5 households in a ward, until the total number of participants is reached in every ward.
Data collection: data was collected using a hand-held Global Positioning System (GPS) and two sets of questionnaires (facility and household). The GPS (Garmin 76CSx) was used to obtain and record the geographic locations of the health facilities in the area. The GPS instrument was validated by three independent experts in the field of GIS and remote sensing from University of Maiduguri, Nigeria. It was further checked for reliability by taking several readings of some coordinates, which gives similar readings. At each health facility, the GPS was used to take the geo-location (coordinate) of the health facility. The reading from the GPS was taken after three repeated readings to avoid calibration error from the recording. The facilitybased questionnaire was used to obtain information about the facility´s capacity in terms of number of health personnel and bed space. The facility-based questionnaire was administered to each health facility and was filled-in by the head/record officer of each health facility. The household questionnaire was used to assess utilization of health facilities by the population of the area. Head of each household was chosen to fill the questionnaire. The participants´ questionnaire was pilot tested among 30 respondents and modified accordingly, before it was administered to the sampled population.
Literate respondents fill the questionnaires themselves, while those that are not English-literates were assisted by research assistants, all of which were health personnel from the surveyed facilities.

Results
Socio-demographic characteristics of respondents: majority of the respondents that participated in the study are male (72.5%) between the ages of 20 to 30 years (43.5%). This indicates that Biu LGA is largely inhabited by youths in comparison to those over 40 years of age (13.6%). Most participants are married (64%) with secondary and diploma education accounting for 29.8 % and 25.9 % respectively. This shows that majority of Biu population have acquired basic education, although about one-quarter (23.6%) have no formal education. About half are self-employed and have monthly income less than ₦20,000 (USD1 approx. ₦350). In other words, most of the respondents in the study area, including those with family, live on less than $2/day, of which more than 2/5 of those with the low monthly income (<₦20,000) survive on less than $1 per day ( Table 2) (Table 3). This indicates the extent to which socioeconomic status impact on utilization of healthcare in Biu.
Similarly, a significant association exists between utilization of the health facilities and distance travelled to reach a facility (χ2 = 55.4, p < 0.001). It was identified that majority of the respondents that prefer public health facilities traveled 10km or less to reach a facility, as compared to those travelling above 10km (Table 3). This indicates how distance of health facilities affect access and utilization of the facilities. Furthermore, less than half (48%) of the respondents can transport themselves to health facilities with a vehicle (car/bus/motorcycle), compared to those using other means of transport (Table 3). However, there is no significant relationship between use of the facilities and mode of transportation (χ2 = 8.1, p = 0.148). Common sickness affecting participants in the study area, which requires them to attend a health facility, include malaria (50.33%), diarrhea (23.3%) or typhoid fever (19.4%), all of which are preventable diseases. Accordingly, most of the respondents (33.6 %) claimed to be spending an average cost of treatment of ₦2,750 per visit, while 23.3% spend as low as ₦500 and 9.3% spend as high as ₦5000 or above. Although, based on these figures, about half (50.3%) are likely to afford the basic cost of treatment as they have a monthly average income of at least ₦20000 (above country´s minimum wage).
However, those with monthly income of less than ₦20000 (49.7%), otherwise known as those below the 50th percentile on the Lorenz curve ( Figure 1) are likely to find it difficult to cope with the average cost of treatment. Moreover, these costs of treatment are mostly found in government-owned facilities and it exclude specialist services like surgery, dental care, scanning or x-rays as revealed by some respondents.

Discussion
The study explored how public health facilities were distributed and utilized in a densely populated area in North-Eastern Nigeria. A major strength of this study is its focus on a major semi-urban population with its surrounding communities, as opposed to majority of studies that focus on urban/capital cities. Similarly, it is likely to shape future State´s healthcare policies and planning, to focus more on equity between different communities within an area, rather than just equality approach. The finding of the study indicates that youths form most of the population (43.5%) and the population are educated at least to secondary level (56%), which enables them to be selfemployed rather than relying on government employment. Although about half of these population largely depend on small scale businesses and farming but earn a monthly income above the national minimum wage of ₦18,000 ($51). However, the other half survive on less than the minimum wage, sharing less than 15% of the wealth (Figure 1), out of which more than two-fifth were below the poverty line i.e. live on less than $1 per day. People in the latter category are likely to find it difficult to cater for their basic life expenses, let alone covering healthcare expenses. This is in line with other studies, which put majority of the Nigerian population as living below the poverty line, leading to poor health outcomes [20][21][22]. The finding of this study further shows majority of the respondents´ preference to government (public) health facilities due to affordability. Preference to government health facilities were also reported in other parts of Nigeria despite providing less quality services, which many literatures associated it with less cost of treatment [5,9,11,23]. Distance travelled to access a health facility is a major determining factor in utilizing care according to the finding of this study. While some respondents travel within a 5km radius to access health services, others need to travel 10km or more to access health services. The uneven distribution of health services is common in many Nigerian regions, particularly in rural areas, where health outcomes are generally poor [4]. Delay in reaching a facility complicates the matter as more than half of respondents (51.2%) were unable to transport themselves to a health facility with a reliable vehicle (car/motorcycle) coupled with lack of functional ambulance services, which could lead to high incidence of preventable deaths in emergency situations.
Delay in reaching a health facility is one of the major delays that affect healthcare in Nigeria [5,24] and many sub-Saharan African countries [25], most of which complicate maternal and child health  (Table 4). On the other hand, one secondary health facility exists in the study area, which is in line with the minimum requirement for an LGA in Nigeria, to serve as a referral center for primary health facilities in the LGA [26].
Looking at the facilities´ capacity in-terms of manpower, the finding of this study revealed that medical personnel (doctors/nurses/midwives) were concentrated in the secondary health facility (69%), leaving the primary health facilities staffed with less skilled personnel. Ujoh and Kwaghsende [15] opined that quality of services rendered is directly affected by manpower availability. This indicates that even if there is equity in distribution of health facilities, lack of skilled personnel could lead to poor delivery of the services.
The WHO 2006 Global workforce and the 2016 estimate for achieving Sustainable Development Goals (SDGs), respectively indicated a minimum of 2.5 and 4.45 medical staff (physician/nurse/midwife) per 1,000 populations, which is required to provide adequate coverage of primary healthcare [27]. Comparing this standard with the population of this study (240,838), it can be inferred that at least 602 medical staff are required to provide adequate primary care services in Biu LGA of Borno State. However, only 81 medical staff exist in the study area, which is less than 1/7 of the WHO minimum recommendation.
A major limitation of this study is its focus on government owned health facilities, which neglect impact of private facilities, hence ratio of facility distribution and patient-professional ratio are likely to be underestimated. However, the proportion of the population that utilize private health facilities were only about one-tenth, indicating a minor difference in-terms of facility distribution or patient-professional ratio.

Conclusion
Based on the findings of this study, it was concluded that health facilities in the study area were unevenly distributed and the number

What is known about this topic
• Spatial distribution and utilization of health facilities is well documented in many southern Nigerian States, particularly in the urban areas.

What this study adds
• Unfold a story in a major semi-urban area with its rural communities in Northern Nigeria; • Impact of socio-economic status on utilization of health services in an area characterized by conflict for a decade; • The need for health policies to focus not just on equal distribution of health resources, but equity in the distribution.