Geographical and socioeconomic inequalities in the utilization of maternal healthcare services in Nigeria: 2003–2017

Background Maternal mortality has remained a challenge in many low income countries, especially in Africa and in Nigeria in particular. This study examines the geographical and socioeconomic inequalities in maternal healthcare utilization in Nigeria over the period between 2003 and 2017. Methods The study used four rounds of Nigeria Demographic Health Surveys (DHS, 2003, 2008, 2013, and 2018) for women aged 15–49 years old. The rate ratios and differences (RR and RD) were used to measure differences between urban and rural areas in terms of the utilization of the three maternal healthcare services including antenatal care (ANC), facility-based delivery (FBD), and skilled-birth attendance (SBA). The Theil index (T), between group variance (BGV) were used to measure relative and absolute inequalities in the utilization of maternal healthcare across the six geopolitical zones in Nigeria. The relative and absolute concentration index (RC and AC) were used to measure education-and wealth-related inequalities in the utilization of maternal healthcare services. Results The RD shows that the gap in the utilization of FBD between urban and rural areas significantly increased by 0.3% per year over the study period. The Theil index suggests a decline in relative inequalities in ANC and FBD across the six geopolitical zones by 7, and 1.8% per year, respectively. The BGV results do not suggest any changes in absolute inequalities in ANC, FBD, and SBA utilization across the geopolitical zones over time. The results of the RC and the AC suggest a persistently higher concentration of maternal healthcare use among well-educated and wealthier mothers in Nigeria over the study period. Conclusion We found that the utilization of maternal healthcare is lower among poorer and less-educated women, as well as those living in rural areas and North West and North East geopolitical zones. Thus, the focus should be on implementing strategies that increase the uptake of maternal healthcare services among these groups

The Challenges of Establishing Universal Health Coverage in Enugu State, South East Nigeria

This research was supported by UNN TETFUND Committee through TETFUND Institution Based Research Fund. Abstract Background: Financial risk protection for healthcare is deficient in Enugu state, Southeast Nigeria and the worst affected are the rural dwellers and the poorest, thus creating both socioeconomic and geographic inequity in access and use of services. The study aimed at eliciting the level of awareness and use of pre-payment mechanisms, and more importantly, determining the economic and political factors that facilitate or constrain achievement of Universal Health Coverage in Enugu state, Southeast Nigeria. Methods: Study was conducted in two purposively chosen urban and rural local government areas(LGA) of Enugu state with mixed method study design. Cross-sectional household questionnaire survey was conducted on 802 sample size from the two LGAs and 12 key informants participated in In-depth interviews (IDIs). The quantitative data was analysed with STATA using descriptive statistics while the qualitative IDI data was organized into nodes and sub-nodes using Nvivo: political and economic factors, corruption, communication/Awareness, capacity development / Infrastructure, policy development, leadership and referral system. Later, findings were thematically analysed. Results: The survey results showed that 84% of the study sample have secondary school education and 83% are engaged in employment or petty business. About 56% are aware of prepayment mechanism for healthcare bills but only 10% of them have used prepayment mechanisms. Out of pocket payment (85%) is the main source of payment at health facilities. Major political constraining factors to UHC revealed by the IDI include lack of political will backed with financial commitment from the political leaders, lack of legislative framework for UHC, lack of trust on the political leaders/government by the citizenry and inactive civil society organizations. Also, the poor fiscal space for health and the poverty level in the populace are big threats to sustainable UHC in Enugu state. Other economic challenges include corruption, poor health capacity development and poorly paid healthcare workers leading to poor quality of health care delivery. There is need for comprehensive health system development in the state to accommodate UHC. Conclusions: Establishment of sustainable UHC in Enugu state faces considerable political and economic challenges. There is need for increased government budgetary allocation for UHC to ensure coverage for the poor and vulnerable members. The lack of legislative framework for UHC could be resolved by legislative arm of the government. The government should invest in health system development to improve the quality of health care services to compliment the FRP component of UHC. Keywords: Universal Health Coverage, Health Insurance, Financial Risk Protection DOI: 10.7176/DCS/9-4-07 Publication date: April 30th 201

Are there geographic and socio-economic differences in incidence, burden and prevention of malaria? A study in southeast Nigeria

<p>Abstract</p> <p>Rationale</p> <p>It is not clearly evident whether malaria affects the poor more although it has been argued that the poor bear a very high burden of the disease. This study explored the socioeconomic and geographic differences in incidence and burden of malaria as well as ownership of mosquito nets.</p> <p>Methods</p> <p>Structured questionnaires were used to collect information from 1657 respondents from rural and urban communities in southeast Nigeria on: incidence of malaria, number of days lost to malaria; actions to treat malaria and household ownership of insecticide treated and untreated mosquito nets. Data was compared across socio-economic status (SES) quartiles and between urban and rural dwellers.</p> <p>Results</p> <p>There was statistically significant urban-rural difference in malaria occurrence with malaria occurring more amongst urban dwellers. There was more reported occurrence of malaria amongst children and other adult household members in better-off SES groups compared to worse-off SES groups, but not amongst respondents. The average number of days that people delayed before seeking treatment was two days, and both adults and children were ill with malaria for about six days. Better-off SES quartile and urban dwellers owned more mosquito nets (p < 0.05) (treated and untreated).</p> <p>Conclusion</p> <p>Malaria occurs more amongst better-off SES groups and urban dwellers in southeast Nigeria. Deployment of malaria control interventions should ensure universal access since targeting the poor and other supposedly vulnerable groups may exclude people that really require malaria control services.</p

Decomposition of socioeconomic inequalities in the uptake of intermittent preventive treatment of malaria in pregnancy in Nigeria: evidence from Demographic Health Survey

Background: Although malaria in pregnancy is preventable with the use of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP), it still causes maternal morbidity and mortality, in sub-Saharan Africa and Nigeria in particular. Socioeconomic inequality leads to limited uptake of IPTp-SP by pregnant women and is, therefore, a public health challenge in Nigeria. This study aimed to measure and identify factors explaining socioeconomic inequality in the uptake of IPTp-SP in Nigeria. Methods: The study re-analysed dataset of 12,294 women aged 15-49 years from 2018 Nigeria Demographic Health Survey (DHS). The normalized concentration index (Cn) and concentration curve were used to quantify and graphically present socioeconomic inequalities in the uptake of IPTp-SP among pregnant women in Nigeria. The Cn was decomposed to identify key factors contributing to the observed socioeconomic inequality in the uptake of adequate (≥3) IPTp-SP. Results: The study showed a higher concentration of the adequate uptake of IPTp-SP among socioeconomically advantaged women (Cn = 0.062; 95% confidence interval [CI] = 0.048 to 0.076) in Nigeria. There is a pro-rich inequality in the uptake of IPTp-SP in urban areas (Cn = 0.283; 95%CI = 0.279 to 0.288). In contrast, a pro-poor inequality in the uptake of IPTp-SP was observed in rural areas (Cn = -0.238; 95%CI = -0.242 to -0.235). The result of the decomposition analysis indicated that geographic zone of residence and antenatal visits were the two main drivers for the concentration of the uptake of IPTp-SP among wealthier pregnant women in Nigeria. Conclusion: The pro-rich inequalities in the uptake of IPTp-SP among pregnant women in Nigeria, particularly in urban areas, warrant further attention. Strategies to improve the uptake of IPTp-SP among women residing in socioeconomically disadvantaged geographic zones (North-East and North-West) and improving antenatal visits among the poor women may reduce pro-rich inequality in the uptake of IPTp-SP among pregnant women in Nigeria

Does expanding fiscal space lead to improved funding of the health sector in developing countries?: lessons from Kenya, Lagos State (Nigeria) and South Africa

This article examines whether increased tax revenue in the three territories of Kenya, Lagos State (Nigeria) and South Africa was accompanied by improved resource allocation to their public health sectors, and explores the reasons underlying the observed trends.CW201

Socioeconomic inequalities in teenage pregnancy in Nigeria: evidence from Demographic Health Survey

Background: Despite the high rate of teenage pregnancy in Nigeria and host of negative medical, social and economic consequences that are associated with the problem, relatively few studies have examined socioeconomic inequality in teenage pregnancy. Understanding the key factors associated with socioeconomic inequality in teenage pregnancy is essential in designing effective policies for teenage pregnancy reduction. This study focuses on measuring inequality and identifying factors explaining socioeconomic inequality in teenage pregnancy in Nigeria. Methods: This is a cross sectional study using individual recode (data) file from the 2018 Nigeria Demographic Health Survey. The dataset comprises a representative sample of 8,423 women of reproductive age 15 – 19 years in Nigeria. The normalized Concentration index (Cn) was used to determine the magnitude of inequalities in teenage pregnancy. The Cn was decomposed to determine the contribution of explanatory factors to socioeconomic inequalities in teenage pregnancy in Nigeria. Results: The negative value of the Cn (-0.354; 95% confidence interval [CI] = -0.400 to -0.308) suggests that pregnancy is more concentrated among the poor teenagers. The decomposition analysis identified marital status, wealth index of households, exposure to information and communication technology, and religion as the most important predictors contributing to observed concentration of teenage pregnancy in Nigeria. Conclusion: There is a need for targeted intervention to reduce teenage pregnancy among low socioeconomic status women in Nigeria. The intervention should break the intergenerational cycle of low socioeconomic status that make teenagers’ susceptible to unintended pregnancy. Economic empowerment is recommended, as empowered girls are better prepared to handle reproductive health issues. Moreover, religious bodies, parents and schools should provide counselling, and guidance that will promote positive reproductive and sexual health behaviours to teenagers

Improving equity in malaria treatment: Relationship of socio-economic status with health seeking as well as with perceptions of ease of using the services of different providers for the treatment of malaria in Nigeria

<p>Abstract</p> <p>Background</p> <p>Equitable improvement of treatment-seeking for malaria will depend partly on how different socio-economic groups perceive the ease of accessing and utilizing malaria treatment services from different healthcare providers. Hence, it was important to investigate the link between socioeconomic status (SES) with differences in perceptions of ease of accessing and receiving treatment as well as with actual health seeking for treatment of malaria from different providers.</p> <p>Methods</p> <p>Structured questionnaires were used to collect data from 1,351 health providers in four malaria-endemic communities in Enugu state, southeast Nigeria. Data was collected on the peoples' perceptions of ease of accessibility and utilization of different providers of malaria treatment using a pre-tested questionnaire. A SES index was used to examine inequities in perceptions and health seeking.</p> <p>Results</p> <p>Patent medicine dealers (vendors) were the most perceived easily accessible providers, followed by private hospitals/clinics in two communities with full complement of healthcare providers: public hospital in the community with such a health provider and traditional healers in a community that is devoid of public healthcare facilities. There were inequities in perception of accessibility and use of different providers. There were also inequity in treatment-seeking for malaria and the poor spend proportionally more to treat the disease.</p> <p>Conclusion</p> <p>Inequities exist in how different SES groups perceive the levels of ease of accessibility and utilization of different providers for malaria treatment. The differentials in perceptions of ease of access and use as well as health seeking for different malaria treatment providers among SES groups could be decreased by reducing barriers such as the cost of treatment by making health services accessible, available and at reduced cost for all groups.</p

Investigating determinants of out-of-pocket spending and strategies for coping with payments for healthcare in southeast Nigeria

<p>Abstract</p> <p>Background</p> <p>Out-of-pocket spending (OOPS) is the major payment strategy for healthcare in Nigeria. Hence, the paper assessed the determinants socio-economic status (SES) of OOPS and strategies for coping with payments for healthcare in urban, semi-urban and rural areas of southeast Nigeria. This paper provides information that would be required to improve financial accessibility and equity in financing within the public health care system.</p> <p>Methods</p> <p>The study areas were three rural and three urban areas from Ebonyi and Enugu states in South-east Nigeria. Cross-sectional survey using interviewer-administered questionnaires to randomly selected householders was the study tool. A socio-economic status (SES) index that was developed using principal components analysis was used to examine levels of inequity in OOPS and regression analysis was used to examine the determinants of use of OOPS.</p> <p>Results</p> <p>All the SES groups equally sought healthcare when they needed to. However, the poorest households were most likely to use low level and informal providers such as traditional healers, whilst the least poor households were more likely to use the services of higher level and formal providers such as health centres and hospitals. The better-off SES more than worse-off SES groups used OOPS to pay for healthcare. The use of own money was the commonest payment-coping mechanism in the three communities. The sales of movable household assets or land were not commonly used as payment-coping mechanisms. Decreasing SES was associated with increased sale of household assets to cope with payment for healthcare in one of the communities. Fee exemptions and subsidies were almost non-existent as coping mechanisms in this study</p> <p>Conclusions</p> <p>There is the need to reduce OOPS and channel and improve equity in healthcare financing by designing and implementing payment strategies that will assure financial risk protection of the poor such pre-payment mechanisms with government paying for the poor.</p

Is community-based health insurance an equitable strategy for paying for healthcare? Experiences from southeast Nigeria.

OBJECTIVES: To determine how equitable enrolment and utilization of community-based health insurance is in two communities with varying levels of success in implementing the scheme. METHODS: The study was undertaken in two communities in Anambra state, southeast Nigeria. Data was collected using a questionnaire that was administered to 971 respondents in two communities selected by simple random sampling. Data analysis examined socio-economic status (SES) differences in enrolment levels, utilization, willingness to renew registration and payments. RESULTS: Enrolment level was 15.5% in the non-successful community and 48.4% in the successful community (p<0.0001). However, there was no inequity in enrolment, willingness to renew registration and utilization of services. Equal amounts of money were paid as registration fee and premium by all SES quartiles. There were no exemptions and no subsidies. CONCLUSION: Enrolment was generally low and contributions were retrogressive. The average premiums were also small. However, there was equitable enrolment and utilization of services. Efforts need to be made to increase the number of enrolees, so as to increase the pool of funds and risks. Payments by enrolees especially in poor and rural communities should be supplemented by subsidies from government and donors in order to ensure equitable financial risk protection

Commentary article: reducing anticancer drug toxicities

No Abstract