Out-of-Pocket Payments, Health Care Access and Utilisation in South-Eastern Nigeria: A Gender Perspective

Citation: Onah MN, Govender V ( Out-of-Pocket Payments, Health Care Access and Utilisation in South-Eastern Nigeria: A Gender Perspective Michael N. Onah 0 1 Veloshnee Govender 0 1 Sassy Molyneux, University of Oxford, Kenya 0 1 STRIVE Research Consortium, Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of Witwatersrand , Johannesburg, South Africa, 2 Health Economics Unit (HEU) , School of Public Health, Faculty of Health Sciences, University of Cape Town , Cape Town , South Africa 1 Gender, OOPs , Healthcare Access/Utilisation , Nigeria Out-of-pocket (OOP) payments have severe consequences for health care access and utilisation and are especially catastrophic for the poor. Although women comprise the majority of the poor in Nigeria and globally, the implications of OOP payments for health care access from a gender perspective have received little attention. This study seeks to fill this gap by using a combination of quantitative and qualitative analysis to investigate the gendered impact of OOPs on healthcare utilisation in south-eastern Nigeria. 411 households were surveyed and six single-sex Focus Group Discussions conducted. This study confirmed the socioeconomic and demographic vulnerability of female-headed households (FHHs), which contributed to gender-based inter-household differences in healthcare access, cost burden, choices of healthcare providers, methods of funding healthcare and coping strategies. FHHs had higher cost burdens from seeking care and untreated morbidity than male-headed households (MHHs) with affordability as a reason for not seeking care. There is also a high utilisation of patent medicine vendors (PMVs) by both households (PMVs are drug vendors that are unregulated, likely to offer very low-quality treatment and do not have trained personnel). OOP payment was predominantly the means of healthcare payment for both households, and households spoke of the difficulties associated with repaying health-related debt with implications for the medical poverty trap. It is recommended that the removal of user fees, introduction of prepayment schemes, and regulating PMVs be considered to improve access and provide protection against debt for FHHs and MHHs. The vulnerability of widows is of special concern and efforts to improve their healthcare access and broader efforts to empower should be encouraged for them and other poor households. Gender, Out-of-Pocket Payments and Health Care Access A key message of the World Health Report 2010 is that millions of people cannot use health services because they have to pay for them at the time they receive them. And many of those who do use services suffer financial hardship, or are even impoverished, because they have to pay.([1] p:113). To date, much of the focus has been on the implications of out-of-pocket payments (OOPs), including user fees for individuals and households in relation to socio-economic status [2,3]. While this is clearly important and warranted, other researchers have been pointing to the barriers that other vulnerable groups (i.e., women, children, ethnic minorities) face [48]. Considering that women represent 70 per cent of the worlds poor [9], the influence of gender on access in the context of out-of-pocket payments is important. Research has shown important differentials in financial access between men and women. For example, women incur more out-of pocket expenditure than men, paying for health care and other reproductive health services places a high financial burden on women and out-of-pocket expenditure may prevent more women than men from utilising essential health services([10] p:650). Research on gender and health care access has also broadened to consider implications for access from the perspective of femaleheaded households (FHHs). This has been prompted by the growing number of FHHs globally [11]. In 1998, almost a fifth of households worldwide and in sub-Saharan Africa was femaleheaded [12]. In both developed and developing countries, studies have revealed that FHHs are likely to have different demographic, sociological, and economic characteristics from MHHs and that these differences have major implications for health care access and utilisation [13,14].While data are inconclusive on whether FHHs are poorer than their male counterparts [15], data from across different settings suggest that they have higher dependency ratios and are typically headed by older women, who are often widows [9]. Research from Ghana indicated that widows and single women are especially vulnerable and that particularly those from poor households found direct costs of care an access barrier [16]. Nigeria Since the fall in oil prices in Nigeria in the 1980s, economic growth has slowed, with adverse implications for government budgetary allocations towards health care and other social sectors [17]. In 2010, it was found that the share of government expenditure on health care was merely 3.5%; this is considerably below the 2001 Abuja commitment which called on all signatory governments (including Nigeria) to allocate 15% of government expenditure to health care [18]. In Nigeria, public spending per capita for health is less than USD 5 and can be as low as USD 2 in some parts; a far cry from the USD 34 recommended by WHO for LMICs [1]. Private health expenditure as a percentage of total health expenditure is almost 64%. Households contribute almost 96% of total health care expenditure through OOP payments [1]. This is important in the context that 34.1% of the population lives below the poverty line (i.e. less than USD1 per day) [19]. Clearly, the burden of paying for health care is especially regressive for poor households. In Nigeria formal and informal user fees are charged in health care facilities with fees differing according to the type of care sought and the level of facility utilised [20]. The under-resourcing, poor provision and delivery of public health services and the burden of user fees for roughly every treatment item has encouraged the growth of and demand for private health care [20]. Private health care accounts for almost 66 per cent of total health care in Nigeria [18] and covers a wide range of providers, including patent medicine vendors (PMVs), pharmacy shops, traditional medicine sellers, maternity homes, clinics, and private tertiary hospitals, many of which are unregulated (e.g. PMVs). Women lag behind men in education and employment. Women have lower levels of literacy compared to men (44% vs. 67%) [21]. This has implications for the type of employment opportunities that women have. Data from the NBS (2009) show that women had a higher unemployment rate (42%) compared to men (22%), 55% of the employed were low-grade staff in the formal sector and those employed in the farming sector were predominantly employed as unpaid (family) labour. In the rural communities, controls of income from farm proceeds are in the hands of (...truncated)