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TABLE OF CONTENTS
Title Page- – – – – – – – – – – i
Declaration- – – – – – – – – – – ii
Certification- – – – – – – – – – – iii
Dedication- – – – – – – – – – – iv
Acknowledgement- – – – – – – – – – v
Abstract – – – – – – – – – – – vi
List of Abbreviation – – – – – – – – – – vii
List Appendices – – – – – – – – – – xi
List of Tables- – – – – – – – – – – viii
Lists of Plates- – – – – – – – – – ix
Table of Contents- – – – – – – – – – x
CHAPTER ONE: INTRODUCTION
1.1 Background to the study – – – – – – 1
1.2 Research Problem – – – – – – – – 4
1.3 Research Questions – – – – – – – – 6
1.4 Objectives of the Study – – – – – – 6
1.5 Hypotheses of the Study – – – – – – 6
1.6 Significance of the Study – – – – – – 6
1.7 Scope and Limitation of the Study – – – – – – -9
1.8 Operational Definition – – – – – – 11
1.9 Organization of the Study – – – – – – 13
CHAPTER TWO: LITERATURE REVIEW AND THEORETICAL FRAMEWORK
2.1 Introduction—– – – – – – – – 15
2.2 Local Government———————————————————————- ——15
2.3 Service Delivery————————————————————————– —-17
2.3.1 Forms of Service Delivery—————————————————————- — 17
- Direct Service Delivery——————————————————————— -17
- Privatization Service Delivery ————————————————————- 17
- Collaborations/ Partnerships Service Delivery Model—————————– 18
| (iv) Public-Public Collaboration/ Shared Service Delivery Model—————– | 19 |
| (v) Public Not for profit making organization Collaboration———————– | 20 |
| (vi) Decentralization Service Delivery Model —————————————- | 21 |
| 2.3.2 Forms of Decentralization Service Delivery ———————————– | 22 |
| (a) Devolution—————————————————————————– | 22 |
| (b) Delegation—————————————————————————– | 23 |
| 2.3.2 Decentralization Service Delivery Model————————————– | 23 |
| 2.4 Challenges of Local Government Service Delivery————————— | 25 |
| 2.4.2 Local Government Service Delivery and prudent Management of Resources | 26 |
| 2.4.2 Local Government funding and Service Delivery —————————– | 27 |
| 2.4.3 Local Government Autonomy and Service Delivery————————- | 29 |
| 2.5 Local Government and Primary Health Care Service Delivery in Nigeria | 35 |
2.5.1 Challenges of Immunization in Nigeria—————————————- 41
| 2.5.1 Socio-cultural challenges and the success of immunization in Nigeria | 42 |
| 2.5.2 Management and Success of immunization in Nigeria——————– | 48 |
| 2.5.3 Availability of Health Personnel and success of immunization in Nigeria | 48 |
| 2.6 Immunization standard————————————————————– | 52 |
| 2.7 Experience of immunization in India———————————————- | 53 |
| 2.8 Theoretical framework ——————————————————- | 56 |
(i) Democratic school- – — – — — – – – – – – — – – — – – – – – – — – 57 (ii) Efficiency Service School————————————————— 58
(iv) Developmental school — — — — — — — — — — — 58
CHAPTER THREE: RESEACH METHODOLOGY
3.1 Introduction – – – – – – – – – 62
3.2 Research Design – – – – – – – 62
3.3 Population of the Study – – – – – – – 62
3.4 Justification for the Study – – – – – – – 65
3.5 Sampling Size – – – – – – – – 65
3.6 Sampling Plan – – – – – – – 66
3.7 Methods and Instruments of Data Collection – – – – 58
3.7.1 Questionnaires – – – – – – – 59
3.7.2 Non Participant Observation – – – – – – 59
3.7.3 Oral Interview – – – – – – – 59
3.7.4 Administration of Questionnaires – – – – – – 68
3.8 Secondary Data – – – – – – – 69
3.9 Methods of Data Analyses – – – – – – – 69
CHAPTER FOUR: EVOLUTION AND DEVELOPMENT OF LOCAL GOVERNMENT IN NIGERIA
4.1 Introduction – – – – – – – – – 62
4.1.2 Pre-colonial Local Government System in Nigeria – – – 62
4.1.3 Period between 1960-1966 – – – – – – – 67
4.1.4 Local Government between 1976-1985 – – – – – 69
4.1.5 Period between 1985 and 1991 – – – – – 72
4.1.6 Period between 1999 and 2012 – – – – – 73
4.2 Functions of the Local Government in Nigeria – – – – 4.3 Component and Objectives of PHC – – – – – – 77
4.4 Development of PHC in Nigeria – – – – – 78
4.5 History of Immunization – – – – – – 81
4.6 History of immunization in Nigeria – – – – – – 82
4.7 Previous immunization efforts by the government, religious bodies NGOs – –
– 86
4.8 National Policy on Immunization – – – – – 87
4.9 Financing Immunization in Nigeria – – – – – – 89
4.10 Policy Guide Lines on LGA Level Immunization Service Delivery – – 93
4.11 Trend of Immunization in Nigeria – – – – – – 4.12 Historical Background of Kaduna State – – – – – 99
CHAPTER FIVE: DATA PRESENTATION AND ANALYSES
5.1 Introduction – – – – – – – – – 103
5.1.1 Respondents Profile – – – – – – – – – 103
5.2 Immunization Financing in Nigeria- – – – – – – 106
5.3 Statistical Testing of Hypotheses of the Study- – – – – 124
5.4 Discussion of the Major findings- – – – – – – 130
CHAPTER SIX: FINDINGS, SUMMARY, CONCLUSION AND RECOMMENDATIONS
6.1 Introduction – – – – – – – – – 208
6.2 Summary – – – – – – – – 208
6.3 Conclusion – – – – – – – – 208
6.4 Recommendations – – – – – – – – 211 Bibliography – – – – – – – – 212
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Local Governments are essentially created to deliver services at the grassroots level so as to ensure developments across all levels of society and these services cut across all parts of the country by bringing governed closer to the government. This division of governmental power simplifies governmental activities and serves as a viable incentive for good governance and development. It also serves as an effective avenue for delivering basic goods and services to local communities in faster, easier and efficient manner (Pradeep, 2011:4; Nwosu, 2011:118).
Local Government (LG), as an institution for grassroots participation, services delivery as well as agent of development in Nigeria, has over the years passed through series of changes since the introduction of the Native Authority system by the British Colonial Administration. During the colonial era, LGs in Nigeria were basically used as instruments for maintaining laws and order through the system known as „Native Authority‟ (NA) (FGN, 1998:1). In 1921, the system became more significant all over the country and was sustained until 1950‟s when it began to take part actively in legislative functions (Hassan, 2002:1; Eboh, 2010). Throughout that period, preservation of colonial law and order was the main focus of colonial government rather than welfare service delivery.
In the Northern Nigeria, the N.A. system recorded full success partly due to the presence of highly centralized traditional authority. While in the then western region, the system recorded partial success partly due to the presence of a number of educated elites and the semi-centralized nature of the traditional institution available. The 1952, Local Government Law in the Western Nigeria adopted English multy-tier system which encouraged the participation of educated elites in the Local Government Administration (Hassan, 2002:1). However, due to absence of centralized authority in the then Eastern region of Nigeria and in spite of the introduction of the Warrant chiefs, the indirect rule system was unsuccessful which led to its abolishment in 1928.
With the attainment of Nigeria‟s independence from the colonial government in 1960; the focus of the Local Governments gradually shifted from being an instrument of perpetuating colonial dominance and exploitation of the Native people through the preservation of colonial law and order to service delivery (Igbuzor, 2007:4). This shift was necessary because the country inherited serious developmental challenges. One of such challenges was the need to expand service delivery to people. To this extent, the governments in the then three regions through the NA system embarked on social welfare delivery services including health, roads, education, and agricultural development and etc.
Nevertheless, as a result of the unsatisfactory and poor performance of local governments particularly on services delivery in the pre-1976 era, the federal government of Nigeria made effort at reforming the system so as to recognize and to place them in order to occupy its rightful position (FGN: 1976 LG Reform). The reform recognized third tier status for LGs in the country also included the reform measures in the 1979 constitution. In spite of the reform, the LG performance in terms of service delivery is still unsatisfactory (Ohiani, 2004, Malhoho, 2012). Hence, many Local Governments in the country failed to justify their existence and many people were confronted with difficulties in accessing social services such as healthcare and agricultural services. To this end, many scholars acknowledged reasons behind the poor performance of
Local Governments in service delivery. These include insufficient funding, lack of Local Governments autonomy and mismanagement (Odoh, 1998:2; Ohiani, 2004:3). This situation led
President Obasanjo in 2003 to inaugurate a committee to review the structure of the Local Governments in the country.
On the 25th of June 2003, Ciroma/Ndayako Technical Committee was inaugurated to review the structure of Local Government Councils in Nigeria. And the Committee reported that, “apart from corruption and mismanagement of public funds, Local Governments in Nigeria had not been guided by any coherent vision, principle or set of ideas in their policy formulation, implementation and even service delivery‟‟ (FGN, 2004 as cited in Abubakar, 2008:7-8). This situation has posed serious challenge to the country‟s quest for development and effective Local Government service delivery at the grassroots level.
Also, on Monday, March 3, 2006, the federal government announced the position of the National Assembly Committee report on the review of the 1999 constitution. However, the committees after collecting public views found that the majority of Nigerians were in favor of an independent system of Local Government System. In 2012, LGs in the country had received greater attention when the National Assembly embarked an effort to pass a “LG autonomy Act”, so as to ensure adequate services (including health) at the grassroots level (Okpo, 2012; Shedrack, 2012). In July 2013, the Senate of the Federal Republic of Nigeria resolved to maintain the status of LGs in the country as part of the state government and with state LGs joint account system as enshrined in the constitution.
The 1999 Constitution of the Federal Republic of Nigeria placed health care service delivery on the concurrent Legislative list. By this arrangement, each of the three tiers of Government is vested with the responsibilities of health care service delivery. The constitution further stipulated that the Federal, State and Local Governments shall support in a coordinated manner, a three-tier system of health care. They are as follows:
- Primary Health Care Local Governments
- Secondary Health Care State Governments
- Tertiary Health Care Federal Governments
The LG through the Primary Health Care system is mandated to provide general health services of preventive, curative and rehabilitative nature to the population as the entry point of the health care system. This implies that the provision of primary health care at this level (including immunization) is largely the responsibility of Local Governments with the support of state Ministries of Health and within the pivot of National health policy.
Immunization is provided mostly through the public health system with the three tiers of government (federal, state and Local Government) playing specific and sometimes duplicating functions. Among the responsibilities of the federal government include the setting up of the national health policies, coordinating and implementing of national health programs, evaluating and monitoring immunization in the country through the National Program on Immunization. The central government is also responsible for procuring vaccines and distributing them to zonal cold stores. Similarly the state government is responsible for distributing vaccines to Local Government central storage facilities and managing state health and other budgets. Based on the arrangement, the state also employs key officials responsible for immunization service provision and coordinates immunization activities within the state. While the actual implementation of routine immunization activities is done by the Local Government primary health care facilities
(Feilden Battersby Analysts, 2005).
Immunization services in Nigeria are usually delivered through two main strategies namely Routine Immunization (RI) and Supplemental Immunization Activities (SIAs). RI is the regular provision of immunization services to infants through the administration of vaccines (antigens) in a scheduled plan program. The services are usually provided at fixed post at the community hospitals, clinics or health centers. RI services are also delivered to the population through Outreach, and Mobile strategies. SIAs are mass campaigns targeting all children in a defined age group with the objective of reaching a high proportion of susceptible individuals (REW, 2007).
In Nigeria, the National Program on Immunization (formerly Expanded Program on Immunization) targets eight main childhood diseases: tuberculosis; polio; pertussis; diphtheria; tetanus; measles; hepatitis B; and yellow fever (Feilden Battersby Analysts, 2005).
1.2 Research Problem
Given the importance of Local Government (LG) as enshrined in the Nigerian constitution and designed to be part and parcel of the federation, sections two and three of the 1999 constitution of Federal Republic of Nigeria placed the LG as the third tier of government in the country. While the Fourth Schedule of the 1979, 1991, and 1999 Federal Government Constitutions and section 7(5) listed and empowered the Councils to perform essential function of service delivery. To make them functions effectively, the percentage of the LG revenue from the federation account continues to increase from 10% to in 1989 to 20% in 1992, and finally to 20.60% in 2008.
In the past, most of the usual excuses raised by the LG councils in Nigeria were lack of autonomy and inadequate funding. Hence, with the 1976 and 2003 LG reforms and the eventual increase in LGs share from the federation statutory allocation and the increase in LGs‟ revenue under the present democratic dispensation, the expectation of many people was that such excuses supposed to have been resolved. Yet health and other services were often inadequate. National
Health indicators in Nigeria are among the lowest in the world by almost all measurable indices (WHO, 2012; Jamo, 2013). Life expectancy in Nigeria as at the year 2012 was 48 years compared to 73 years in China and 83 years in Japan. Infant mortality rate was 114 per 1000, whereas less than five mortality rates were 269 per 1000 (WHO, 2012). In Nigeria, vaccinepreventable diseases account for approximately 22% of childhood deaths (amounting to over
200,000 deaths) per year. The maternal mortality rate was 1,100 deaths per 100,000 in contrast to 45 and 6 deaths per 100,000 in China and Japan respectively (WHO, 2012). One third of the world maternal death occurs in India and Nigeria with 20% and 14% respectively (WHO, 2012). In Nigeria, 52,000 women die every year and 150 pregnancy related cases with an average of death in every 10 minutes are recorded daily (UNICEP, 2012). This indicates poor performance of LGs and other tiers of government in immunization and disease prevention in the country leading to 72% of deaths due to communicable diseases. Though Nigeria is a signatory to all global immunization targets of reaching 80% DPT3 coverage in 80% districts in developing countries by the year 2005 and with MDG4 target of reducing child mortality by two-thirds by the year 2015 (NPI, 2007). Meeting this target is still questionable in spite of the series of past efforts.
Funding of immunization services is the collective responsibility of all the three tiers of government, private sector and development partners. In 2003 Nigeria expended
$12,906,678,018 to immunization and with total health expenditure from all sources to $73,764,508. The projected cost of vaccines per LGA in 2012 was $194,697. From 2010 to 2013 alone, Nigeria has received a sum of $230,168,552 from the development partners (CHEDECO, 2013; PHC Reform, 2013; Uzochukwu, 2014). However this increasing funding did not
correspond with the mortality rate and other health indicators in the country.
Everyone expected that the return of Nigeria to democratic rule would improve development through adequate healthcare services provision, yet studies have shown the contrary, Mortality rate as a result of VPDs is on the increase (WHO, 2012). The problem of the study is to examine the extent to which Local Governments in Kaduna state have been able to deliver immunization.
To achieve this, this study attempts to answer the following questions:
1.3 Research Questions
i. What are the contributions of LGs‟ funding and other support to the success of
immunization program? ii. What are the effects of availability and competence of LGs‟ health personnel to success of immunization program?
- What are the effects of LGs‟ efforts on the outcome of immunization?
- What are the contributions of effective management at the LG level to the success of immunization?
- What are the effects of socio-cultural factor to the success of LG immunization delivery?
1.4 Objectives of the Study
The main objective of the study is to review the immunization efforts of LGs in Kaduna state.
Other specific objectives include the following:
- to evaluate the contributions of LG funding and other support to the success of immunization program.
- to ascertain the contributions of the availability and competence of LG health personnel to the success of immunization.
- to examine the effects of LG efforts on the outcome of immunization program.
- Determine the contribution of LG effective management to the success of immunization
delivery
- to assess the effect of socio-cultural factor to the success of immunization delivery at the
LG level.
1.5 Hypotheses of the Study
- The higher the level of funding and other support at the LG, the more likely the success of the immunization program
- LG efforts at immunization has produced positive outcome.
- The availability and competence of personnel at the LG level affect the success of immunization program.
- LG efforts at immunization has produced positive outcome.
- Success of immunization delivery depends on effective management at the LG level.
- Success of immunization delivery at the LG level is a function of sociocultural factors.
1.5.1 Significance of study
- The study assists government to protect children from killer diseases (particularly VPDs) and also saves million lives and provides economic benefits of averting economic loss of billions of Naira and also lifts millions of Nigerians out of the vicious circle of poverty and illnesses. It serves as a policy guide to governments and international agencies with a method for mitigating poverty, poor health status in the country through effective immunization delivery.
- It guides government on cost effective strategy and health intervention to curtail mortality rate as a result of VPDs.
- It assists government, development agencies (including WHO, UNDP, UNICEF) to determine areas that require urgent attention for adequate healthcare delivery at the grassroots level.
- The work also serves as a model for assessing the impact of immunization on
development of a particular area, using health service rather than HDI,GDP, or per capital income (as used by Przeworski, 1990 ; Przeworski and Lamungi, 2007; Pel, 1990; and Ohiani, 2004) which are very abstract at the grassroots level.
- The study is also empirical using survey method including questionnaires and interviews to ascertain the extent to which LGs in Kaduna state delivers immunization services at the grassroots level. The study has filled this gap by providing empirical data in the body of existing literatures.
1.7 Scope and Limitation of the Study
At present, Kaduna state has 23 LGs; but, it will be difficult to study immunization service delivery in all the LGs in the state. To make this research easier and more representative, the scope of the study is limited to six LGs in Kaduna state. The justification behind the choice of the state is based on the reason that, the state is the second most populous state in the Northwestern Nigeria, and among the states with poor healthcare status in the country (NPC, 2006; NBS, 2008). Preliminary studies (Allo, 2008; Elah, 2012) have also indicated resistance to immunization in the state. Another reason is that even though immunization coverage in Nigeria had increased, yet Kaduna state remains one of the states in Nigeria that still recorded higher mortality rate of 74.9 per 1000 in 2014 as a result of vaccines preventable diseases.
The work covers a period of five years of the present democratic dispensation (2009-2014). The rationale behind the choice of this time frame is because the period represents the era when Local Government percentage of revenue from the federation account had risen to 20.60 percent.
Similarly, the period also corresponds to the age of high in flow of Local Government revenue from the federation account. Not only that, the period represents the democratic era when Local Government officials were enthusiastic to deliver services at the grassroots level but corresponds to the period of increasing resistance to immunization in the state. To this end, the time frame of the study (the democratic era of 2009-2014) represents period of special events on the Local Governments in the country. It is expected to have significant effect on Local Governments performance on service delivery.
Though Local Governments in Nigeria were created to perform a number of functions, this study is limited to service delivery with special reference to LGs performance in terms of immunization. Despite that, the three tiers of government and other partners are involved in delivering immunizations service, this work pay more emphasis on LG service delivery because the actual delivery of immunization service is shouldered on LG. In term of substance, the work only restricts itself in measuring performance of LG in healthcare service delivery particularly immunization. This is because healthcare service is among the indicators (eg life expectancy) for measuring presence or absence of development of modern societies and also means of achieving development (World Bank, 2012).
Study of this kind has to be conducted for a number of years and be made to cover a large area. However, we have restricted ourselves to Kaduna state in the North Western Nigeria so as to make an in depth study and to generate reliable data. Again, a research like this has to be conducted after every three or five years at interval so as to capture the annual updates of a number of facilities and strategies employed by different governments in delivering services. This work was conducted within a stipulated period lasting 2009-2014. Conducting a research especially of this type requires a lot of resources. Again, we have also faced the problem of generating primary data due to lack of information culture among our people. Usually research of this kind is perceived with suspicion especially during this time of crises and insecurity in the Nigeria.
Again, research related to finance, expenditure and executed projects are very difficult especially at the local level due to inaccurate records and at times researchers are deliberately frustrated in the name of bureaucracy and keeping the office secrets. To this extent, we faced the challenge of accessing official documents. Finally, healthcare service delivery is broad, we could not cover all. Thus, we restricted ourselves to immunization service delivery due to its importance to human survival needs and development.
1.8 Operational Definitions of the Key Variables
Introduction
The key variables in the study were operationalized below in such a way that they can be measured using measurable indicators. The theoretical framework for the study examined factors responsible for the level of service delivery. To this end, we have used government efforts, availability and competence of personnel, level of funding and other support, as independent variables while positive outcome and success of immunization program as dependent variables.
- Level of funding:
Funding has been defined by Ikya (2000) as the process of providing an institution, a project, organization e.t.c. with money to carry out its activities. Funding in this study refers to financial support for immunization at the Local Government level. “Funding” has been broken down into following measurable indicators: volume of funding of immunization, regular disbursement of fund for immunization, incentive for immunization
- Other support:
Adequate sensitization
Success of immunization: Collins English Dictionary (2014) defined “success” as the favorable or prosperous termination of attempts or endeavors; the accomplishment of one’s goals. It also implies the achieving of something desired, planned or attempted. It involves achieving what is intended to achieve. In this work “success of immunization” implies number of reported cases or outbreaks in a particular area, number of children dying in a particular area.
- Availability and Competence of health personnel:
Personnel have been defined by Adamu (2007:1) as the people who work for an organization or armed forces. It is also refers to the department in a company that concerns with recruitment and training of people. “Personnel” as used in this study refer to categories of health personnel working in Primary health care department of Local Government.Availability and Competence of health personnel have been broken down into following measurable indicators: adequacy of health personnel, adequate training of health personnel.
- Government effort :
Merriam Webster dictionary (2014) defined effort as the total work done to achieve a particular end. In this work government effort means, training, providing facilities, incentives, monitoring, advocacy, sensitization and other forms of encouragement to the people
- Positive outcome: Collins English Dictionary (2014) defined “outcome” as something that follows from an action, dispute, situation, etc; result; consequence. It implies a final product or end result; consequence; issue or a conclusion reached through a process of logical thinking. In this study “outcome” implies level of cooperation of people toward immunization
- Socio-cultural factors: Sociocultural factors are the larger scale forces within cultures and societies that affect the thoughts, feelings and behaviors. Similarly, sociocultural factors refer to the social and cultural influences in the lives of the people such as the influence of family, peers, religion and culture on an individual’s health. These factors can have a positive or negative impact on health and often determine differences between population groups. (www.hsc.csu.edu.au/…/1–1…/hoyp1_1_3_2.htm Social science). Sociocultural factors in this study implies, socially constructed belief on immunization, religious perception, cultural belief
(vi) Management: Millet (1984) defined management as the process of directing and facilitating the work of people (sic) organized in formal groups to achieve a desired goal. Nigro and Nigro (1980) defined management as determine what you want people to accomplish, to check periodically on how they are accomplishing it, and to develop methods by which they will perform more effectively. In the context of this work management implies, coordination of human and material resources, Supportive supervision, equipment calculation, budgeting and monitoring, assessment of injection and disposal safety.
1.9 Organization of the Study
Chapter one is the introduction of the whole study which contains background of the study, statement of the problem, research questions, objectives of the study, study hypotheses and operational definition.
Chapter two contains literature review and theoretical framework.
Chapter three contains historical background of LG administration in Nigeria, the chapter commenced with the Native authority system, post independent Local Government in Nigeria, Military and Local Government in Nigeria, 1976 Local Government reform, Local Governments in Nigeria in the Second Republic, Babangida Administration and Local Government in Nigeria, the chapter also covers LGs in Nigeria under the Third Republic.
Chapter four deals with method of Data collection, Sampling Technique, Population of the
Study, Instrumentation and Reliability, and finally, Method of Data Analysis.
Again, Chapter five presents data and analyzes the research findings.
Finally, chapter six is the summary of findings; conclusion and the presentation of possible recommendations. This chapter deals with the introduction. The next chapter paid more emphasis on reviewing related literatures to the study and the theoretical framework of the study.
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