Healthcare Services in Nigeria

The Nigerian health care system is organised into primary, secondary and tertiary health care levels (Onilude 2017). Primary Healthcare (PHC) delivery (or level) is the sole responsibility of the Local Government Areas (LGAs); the provision of secondary care is attached to the State Governments, while the Federal Government is responsible for policy development and implementation. The establishment of PHC was to provide accessible healthcare services for all by the year 2000 and beyond. Unfortunately, this is yet to be achieved in Nigeria and seems to be unrealistic in the next decade (Abdulraheem, Olapipo and Amodu 2012). Primary healthcare which provides healthcare services through health centres is the base for the healthcare system in Nigeria as it directly services rural communities within LGAs. However, PHC is catering for less than 20% of the potential patients (Gupta, Gauri and Khemani 2004).

Moreover, the demography of Nigeria shows that of the total population of over 180 million in 2016, about 51.4% live in rural areas while about 48.6% live in urban areas (World Bank Data Report 2017). The Nigerian people are greatly underserved regarding healthcare delivery, especially the rural populations (Abdulraheem, Olapipo and Amodu 2012). Although various reforms have been put forward by the Nigerian government to address wide-ranging issues in the healthcare system, they are yet to be implemented at the state and LGAs levels (Onilude 2017). For example, the combined budgets allocation of the federal and

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state government on the public health sector is less than 5% of the 13.5 trillion naira in 2017⁵. This is despite the poor infrastructure in the sector and the government's declaration to discourage medical tourism. This poor funding of the health sector means that primary healthcare is least funded in every state (Onilude 2017) because the LGAs are the least organised level of government in Nigeria and depend on the state to finance its healthcare services.

The Nigerian Medical Association (NMA) estimates there are about 25 consultant oncologists, 7 radiotherapy machines to about 180 million Nigerians, and cancer patients can access specialist care only in 7 out of the 36 states – Lagos, Oyo, Kaduna, Edo, Ondo, Sokoto, and Abuja⁶. The ratio of hospital beds per 1,000 Nigerians is 5 (World Bank Data Report 2017). Despite lack of up-to-date data on the number and growth rate of hospitals in rural Nigeria, there has been a visible increase in the number of private health facilities in urban areas rather than government-owned facilities (Onah and Govender 2014). Despite the increase in private hospitals, the healthcare system in Nigeria remains weak and characterised by inadequate and decaying healthcare infrastructure. These state and private-owned health facilities are not within the reach of rural citizens as they are predominately in urban areas and provide expensive services which many rural people cannot afford and the cost of travel (Umezinwa 2016). This affordability and proximity constraints call for the need to have a functional primary healthcare system.

The primary health care system has been extensively hampered by poor allocation and utilisation of funds, and lack of health infrastructures thereby affecting its coverage and quality of care. For example, there are limited health care centres, gross dilapidation of available healthcare infrastructure, poorly trained staff and health workers. The failure of the primary healthcare system means that citizens, especially those in the rural communities, lack access to both health information from qualified health workers and healthcare centres and thus suffer health issues which should have been managed at the primary care level with adequate health information.

5 https://www.thisdaylive.com/index.php/2017/02/09/nigerias-grossly-inadequate-2017-health-budget/

6 http://www.thisdaylive.com/index.php/2016/09/29/at-56-nigeria-still-lacks-functioning-radiotherapy-machines/

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In South-East Nigeria, access to and use of healthcare services is limited (Onah and Govender 2014), and many rural residents do not have access to quality healthcare, and this has been attributed to many factors (Onyeneho et al. 2016).

For example, unavailability of healthcare services and proximity to healthcare facilities, are barriers to accessing health services (Kadobera et al. 2012) and have long been attributed to poor utilisation of health services in rural Nigeria. As a result, many rural residents in south-east Nigeria do not have health care centres located in their communities and are not aware of the services they provide (Onyeneho et al. 2016). On the contrary, Musoke et al. (2014) found that most of the population (89%) in rural Uganda knew mobile clinic services, chemist shops (91%) and health centres (100%) existed in their local communities.

Healthcare centres in rural communities in South-East Nigeria are predominantly managed by nurses because there are no resident doctors. In addition, the breadth of services and facilities vary. This is due to years of neglect, inequitable distribution of resources, the absence of medication and poor funding in the primary healthcare system (Efe 2013) which has led to the absence of key health workers who do not have the necessary facilities and incentives to provide the needed healthcare services in rural areas. Subsequently, primary healthcare centres have only one visiting head nurse who oversees the management of the centres, visits the healthcare centres from the city during specific days, and schedules patients in need only of attending the service on those days.

Consequently, primary healthcare services lack sufficient resources to provide quality of care and restrict access to healthcare as and when needed, increasing waiting time, and weakening the healthcare system through lack of coordination and quality of services. Consequently, there is a loss of confidence of the public in the primary healthcare system in rural Nigeria (Abdulraheem, Olapipo and Amodu 2012; Jaro and Ibrahim 2012). As a result of these inefficiencies around primary healthcare delivery, rural people may have a greater reliance on cultural beliefs and seem to be reverting to the traditional care providers when managing health issues because of problems of access and affordability (Emmanuel 2014;

Abdulraheem, Olapipo and Amodu 2012; Jaro and Ibrahim 2012). Furthermore, cultural appropriateness of health services plays an important role in stimulating the acceptability and utilisation of health information (Onyeneho et al. 2016), especially among rural residents.

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Many health-related cultural practices in Nigeria as discussed in previous chapters, oppose conventional medicine and inhibit access to healthcare delivery. Therefore, recognition of culture in the provision of healthcare services cannot be overstressed as there are cultural boundaries in attitudes, disease definition and diagnosis (Ibeneme et al. 2017). The specific characteristics of individuals and their cultural orientations are critical to understanding, classifying, and interpreting diseases and treatment options. Understanding the culture of the Igbos helps to outline reality about the practice and delivery of health services rather than some unexplained assumptions which have been advocated for non-Western societies through non-Western intervention programs. Healthcare-related activities cannot be performed or effective outside a cultural context (Ibeneme et al. 2017). The associated interpretation, experience or behaviour by individuals about health-related issues depends on social norms, cultural values and beliefs of the society in which they exist (Ibeneme et al. 2017). Simply put, two different cultures are most likely to have two different interpretations or meanings to the same health-related issue. For example, in the Western culture, obesity is viewed as a precursor to adverse health condition meanwhile, in African culture especially Nigeria, among the Igbos, Ibibios and Efiks, unmarried women are deliberately fattened in seclusion to ensure fertility before going into marriage. This exemplifies the variability across cultural boundaries and reflects the need to pay attention to target the specific audience’s culture when designing or providing any health-related intervention.

This study aims to offer recommendations for improving access to health information by proposing strategies which aim to reduce potential barriers in reaching out to rural communities with the health information they require to manage their health better. The provision of timely information aimed at combating possible health issues is an important function of the healthcare service. Inadequate healthcare centres and lack of health information in the public health sector can lead to health insecurity among citizens. Therefore, sufficient health information provision and effective health intervention aligned to the cultural beliefs and practices of the targeted audience may stimulate participation in healthcare services in Nigeria (Amidu, Harrison and Olphert 2016).

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