|Year : 2017 | Volume
| Issue : 8 | Page : 1027-1035
Effects of health-care services and commodities cost on the patients at the primary health facilities in Zaria Metropolis, North Western Nigeria
O Adegboyega1, K Abioye2
1 Department of Community Medicine, Kaduna State University, Kaduna, Nigeria
2 Department of Community Health, Obafemi Awolowo University, Ile-Ife, Nigeria
|Date of Acceptance||24-Apr-2017|
|Date of Web Publication||11-Sep-2017|
Department of Community Medicine, College of Health Sciences, Kaduna State University, Kaduna
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: The payment for health-care services is a major problem for many poor patients in developing nations. The aim of the study was to examine the cost of services and commodities and how these affect the patients who utilizes the primary health-care centers in Zaria, North western Nigeria. Methodology: A descriptive cross-sectional survey of six primary health-care facilities in Zaria metropolis, namely Baban dodo, Tudun Wada, Magajiya PHCs from Zaria local government areas (LGA) and Samaru, Kwata, and Dogarawa PHCs from Sabon Gari LGA, was carried out. Result: The mean age of the respondents was 28.87± 8.63 years, most of them were married (53.3%), Hausa (63.3%), and Muslims (85.7%); also, they were unemployed housewives with daily stipends from their husbands less than 1 dollar/day. The major method for payment for health-care services was out of pocket (98.3%). More than one-third of the clients were not aware of the National Health Insurance Scheme (NHIS) (39%). There was a significant inverse relationship between the monthly income of the clients and the experience of financial stress and a positive association between patients' monthly income and awareness of the NHIS (P < 0.05). Conclusion: The respondents were paying user fees for essential health-care services at the primary health-care centers and this was not convenient for them. Recommendation: There is a need for the LGA health department to intensify the supervision of the activities at the PHCs. Standardization of prices of services and commodities and the implementation of the National Health Act may alleviate the burdens of the poor community members who access PHCs in Nigeria.
Keywords: Commodities, National Health Act, primary health care, regulation, services
|How to cite this article:|
Adegboyega O, Abioye K. Effects of health-care services and commodities cost on the patients at the primary health facilities in Zaria Metropolis, North Western Nigeria. Niger J Clin Pract 2017;20:1027-35
|How to cite this URL:|
Adegboyega O, Abioye K. Effects of health-care services and commodities cost on the patients at the primary health facilities in Zaria Metropolis, North Western Nigeria. Niger J Clin Pract [serial online] 2017 [cited 2020 Nov 23];20:1027-35. Available from: https://www.njcponline.com/text.asp?2017/20/8/1027/214373
| Introduction|| |
Despite enormous developmental partners and government interventions, the payment for health-care services is a major problem in many developing nations including Nigeria., The cost of the health-care services at tertiary centers is considered exorbitant by many poor patients in Nigeria. The privately owned clinics are no-go areas for many poor Nigerians whose earnings are less than 1 dollar per day. Therefore, the majority of the poor patients crowd themselves at the Primary and Comprehensive Health centers, forming a congregation during clinic days to be attended by very few doctors, nurses, and other health-care providers at these levels of the national health system, though majority of these facilities are not adequately equipped to cater for the health needs of the clients patronizing them.,,
There is a popular saying “Health is wealth.” A healthy nation is a wealthy nation because the populace will be at a better advantage to contribute immensely to the growth of the national economy. Most developed nations today attained their present status by the enormous contributions of their healthy citizens. Financial difficulties, on the other hand, render accessibility to basic health-care services difficult, worsening the cycle of poverty, ignorance, and disease in developing nations.
To help alleviate the burden of the health-care cost, the Federal Government of Nigeria introduced the National Health Insurance Scheme (NHIS) in 2005.
This is a social security system that guarantees the provision of needed health services to persons on the payment of token contributions at regular intervals. The beneficiaries are mostly civil servants in Federal employment. The NHIS also proposed the concept of Community Health Insurance Scheme (CHIS), but the challenge of nonregular sources of income for the informal sectors has limited the community acceptability of this scheme. Many Nigerians have to resort to out of pocket expenditures to pay for their health-care services. This has led to a growing concern about the economic impact of health-care expenditure on families and individuals clients at the community level.,
The primary health-care centers located in many communities are the first contact this group of the populace have with the national health system in Nigeria.
These facilities are the backbones of the country's health-care delivery system. The services at these centers should be accessible to all at affordable cost. This calls for urgent need to do more researches at the PHCs to ascertain the ability of the community members to afford the cost of the services at this level of the health-care system because of the current decline in the Nigeria economy and the attendant negative impact on the populace. There are also scarcity of researches in Zaria metropolis, North western, Nigeria, on this subject matter. This current study intends to bridge this gap. It will also explore the sources of the health-care funds and the effects of payment for health-care services and commodities on the study community.
| Materials and Methods|| |
Background of the study area
Zaria is a guinea savannah region in the north western Nigeria. It is the home of the famous Ahmadu Bello University, Zaria, with a temperature range of 22.7 December-January during the harmattan as high as 28–30o in April. Rainfall is between April and October. Maximum rainfall occurs in August. The Zaria metropolis consists of two local government areas (LGAs): Sabon Gari and Zaria. The Sabon Gari LGA was carved out of Zaria LGA in 1996. The LGA is boarded by Giwa on the western part, Soba in the East, Kudan in the North and South with Zaria LGAs. Sabon Gari LGA has a total projected population of census of 338, 510 with 11 political wards: Bomo, Jama'a, Hanwa, Jushi, UngwanGabas, Chikaji, Muchiya, Dogarawa, Zabi, Basawa, and Samaru. It has 1 tertiary health center, 3 secondary health centers, and 25 PHCs.
The Zaria LGA has an estimated population of 548,584. It is bounded by Sabon Gari in the West, Soba LGA in the East, and Igabi LGA in the South. The administrative headquarter is Zaria city, which have 13 political wards 7 in the northern and 6 in the southern division of the LGA namely Kufena, TukurTukur, Tudunwada, Gyellesu, Dambo, Fatika and Kwarabai B in the north, and AngwaJuma,, Babandodo, Kaura and Kwarabai A, Dutse Abba and Wuciciri. The major ethnic group is Hausa. There are people from different parts of Nigeria and other parts of the world resident in Zaria. The residents are predominantly farmers, artisans, traders, health workers, civil servants, students, and higher institution lecturers.
A descriptive cross-sectional survey of six primary health facilities in Zaria metropolis was carried out. Three PHCs, namely Samaru, Kwata, and Dogarawa, were selected by the simple random sampling technique from the list of 25 PHCs in Sabon Gari LGA and 3 PHC Babandodo, Tudun Wada, and Magajiya were also selected from the 45 PHCs in Zaria LGA.
The patients who came for health-care services at these PHCs during the period of the study constituted the study population. Patients' relatives, except the caregivers of sick children, and those who came for screening for employment or for school enrolment screening tests were not included in this study. The minimum sample size was 293 clients calculated using the proportion of out-of-pocket expenditures in Nigeria to be 74.4% as reported in a previous study. For more accurate result, the sample size was increased to 300. We did not include nonresponse in the calculation of the sample size. This was because the study was clinic based, and we had planned to replace any client who declined interview with another willing client. No respondent, however, declined the interview.
A multistage sampling technique was used. In the first stage, Zaria metropolis was stratified to Zaria and Sabon Gari LGAs. Three PHCs each in Zaria and Sabon Gari LGAs were then selected by the simple random sampling technique: Baban dodo, Tudun Wada and Magajiya PHCs from Zaria LGA and Samaru, Kwata, and Dogarawa PHCs from Sabo LGA. A minimum of 50 clients were interviewed at each selected health facility. Structured interviewer administered questionnaires were used as the instruments for data collection. A total of 300 questionnaires were administered to the respondents. The researcher was assisted by six Community Health Extension Workers (CHEWs). They were trained on how to administer the questionnaires prior to data collection. The data collected were collated and cleaned immediately after data collection. Data entries were done with the IBM SPSS Version 20, whereas Statacorp SE12 was used for both descriptive and inferential analysis. The level of statistical significance was set at P value ≤0.05 Appendix 3.[Additional file 1]
The ethical approval to conduct the research was sought from the Kaduna State Ministry of Health. The permission of the supervising heads of the study facilities and the individual verbal consents were obtained before data collection.
This research has some limitations. It was based on the oral reports given by the clients who were liable to recall bias. It was a clinic-based study, therefore, limited by the concept of the ice berg phenomenon.
| Results|| |
Majority of the respondents in this study were aged 24–33 years (39%) with a mean age of 28.87 ± 8.63 years, most of them were married (53.3%), Hausa (63.3%), majority were Muslims (85.7%) housewives, with monthly household allowances from their husbands less than 1 dollar/day (<5000 per month) [Table 1]. The major reason for visiting the health facilities was common endemic illnesses (39.3%), such as malaria, respiratory tract infections, and gastro intestinal diseases. A large proportion of the respondents were at the health facilities for the antenatal care (30.7%), family planning (13%), delivery (4.7%), and immunization services (6.7%) [Table 2].
|Table 2: Main reasons for respondents visit to the primary health-care centers|
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This study was conducted when a dollar was exchanged for approximately N200 in Nigeria. The respondents paid an average of 107(0.5 USD) for immunization, 250(1.25USD) for family planning services, and 263.71(1.3 USD) to access antenatal care services. Cost of delivery at the PHCs in Zaria ranges from 1500 to 2500 ($7.5–12.5). The average cost of a blood test in most of the PHCs was N 202.17 (1 USD). The cost of IV fluid at the PHC could be up to N400.00 ($2). The various routine ANC laboratory tests, such as the PCV, malaria parasite test (MP), urine analysis, random blood glucose, HIV, and VDRL tests, cost between 1000 ($5) and 12,000 ($6). Postabortion care services were reported to cost N1000 ($5) [Table 3].
|Table 3: Cost of services and commodities reported by the study subjects|
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The total out-of-pocket pay in this study was 73.3.3%. The husbands paid for most of the clients' health-care services (47%), whereas 26.3% of the clients had to pay out of pockets. Some of the clients had to source for fund from thrifts (4.7%), religious organizations (3.7%), and community donations (2.3%), only 1.7% used the NHIS for payment for their health-care services [Table 4].
The payments for health-care bill were not convenient for 26.3% of the clients, whereas 67 (22.3%) could not access the required health services due to the financial cost. Some families (3.7%) had to borrow money to pay for the primary health-care services. These expenses also affect the payment of school fees (3.3%), affect family feeding (2.0%), and resulted in marital disharmony (1.7%) [Table 5].
|Table 5: Immediate effects of the out of pocket health-care expenditures on respondents' household (n = 300)|
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More than a quarter (27.6%) of the clients spent above than N500 ($2.5) at the PHC per visit [Figure 1] and [Figure 2]. [Table 6] shows that the medical expenses were significantly more stressful, awareness lower, and the unmet need for the NHIS significantly higher for those with monthly income P< 0.05).
|Figure 1: Total amount spent by the clients for essential health-care services per visit|
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|Table 6: Association between Medical expenses, Awareness of NHIS and monthly income of the respondents|
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| Discussion|| |
Majority of the respondents in this study were aged 25–34 years (39%) with a mean age of 28.9 ± 8.63 years; they were within the reproductive and working age group, but they were extremely poor with majority earning less than 1 dollar per day. The “Megidas” (husband) gave the household maintenance allowance, paid for the clients health-care services (47%), others paid through thrifts (4.7%), religious organization (3.7%), community donations (2.3%), only 1.7% used the NHIS to pay for the health-care delivery services [Table 3]. The clients could not pay for health-care services without external intervention due to their poor financial state. The cycle of poverty, ignorance, and disease persists in this type of setting resulting in catastrophic health expenditures. Previous studies have shown that some clients discharge themselves from the hospital against medical advice when they could not afford to pay. Some of these clients sometimes expect financial assistance from the health workers to help purchase the prescribed drugs and pay medical expenses.
Various studies have shown that the people from the high socio-economic background would not come to such primary health-care centers because they believe that these facilities were for the poor masses only and not well equipped enough to meet the health needs of the affluent and the enlightened. The high-class Nigeria citizens will prefer to seek medical help at the tertiary centers where they will meet with the specialist doctors even for the management of an ailment, such as simple malaria, that can be handled by the community health workers at the PHCs. This abuse of the health-care facilities in Nigeria and most other developing countries is basically due to the lack of trust in the primary and secondary health-care facilities to deliver quality health-care services. This lack of trust may not be misplaced because most of these PHCs are poorly situated, constructed, structured, financed, and equipped. Therefore, the middle-class Nigerians patronize the tertiary centers mostly and occasionally the secondary facilities but rarely the primary centers, whereas the politicians, influential government executives, managing directors, and chief executive officers habitually engage in medical tourism to India, Dubai, London, America, and even to some other African countries for any ailment usually at the expense of the government or their employers. This is what is responsible for the socio demographic pattern of the respondents in this study which reflect mainly the less privilege community members especially women with low socio-economic conditions.
In this current study, majority of the clients earned less than 5000 per month [Table 1] which is about $25 monthly or $0.83 per day. An income of less than 1 dollar per day has been described as extreme poverty. The payment for health-care services was stressful to the family of 30% of the respondents, whereas only 26.3% reported that the cost were convenient for them to afford. Some families (3.7%) had to borrow money to pay for the health-care services at the PHCs. The expenses also affected the payment of school fees (3.3%), family feeding (2.0%), and caused marital disharmony (1.7%) [Table 4]. More than one-fifth (22%) of the clients spent more than N500 ($ 2.5) at the PHC per visit [Table 5]. This study therefore corroborates the report of other studies that it is the poorest among the poor who patronize the PHCs mostly.
Majority of the respondents paid for immunization and family planning services. They were charged more than $1 to access ANC services (45.7%). These services especially the immunization and family planning were supposed to be rendered to the clients free of charge. However, the researchers discovered that the patients paid for these services due to various reasons such as logistic, scarcity of the commodities, maintaining the revolving funds, and illegal charges by the health-care workers. The demand for an essential service might be low not necessarily because of apathy for the service, but because of unaffordable cost. For example, there was poor supply of vaccines and family planning commodities to the PHCs in Zaria metropolis during this study and this affected the cost of vaccine. These health commodities usually come to the facilities from the cold room of the local government health departments, which also got their supply from the state Ministry of Health. The Ministry gets vaccine supply from the National cold room. They sell this vaccine to willing health-care workers who also have to sell them to clients at a higher selling price to make some profits. This is one of the major factors affecting the vaccine coverage rate and other essential services, such as the contraceptive prevalence rate in Nigeria. The uptake of these services were better in facilities that could overcome this challenge. The inability to pay user fee for family planning might have contributed severely to the poor utility rate and the poor contraceptive prevalent rate in Nigeria. In this current study, only 4.3% of the clients were able to access the family planning services [Table 2].
The average cost for ANC services in this study is about N300 ($1.5) [Table 3] and about 1500 ($ 7.5) for a delivery service in a PHC, though lesser than user fees at the secondary, and tertiary facilities in Nigeria, but still very much unaffordable for most of these poor women. This might also be a major contributor to high prevalence of home deliveries reported in several studies in the Northern Nigeria., The high cost of the postabortion care reported in this study may prevent women from seeking this service., It should be noted that it was only one person who accessed this service at a PHC out of the 300 women that were involved in this current study. This low turnout for postabortion care may contribute to the already worsened statistics for the maternal mortality not only in the north but in the nation at large. This cost need to be reviewed if the patient will continue to patronize these facilities for essential care. The principle of Ward Health Minimum package and the SURE P MCH need to be extended to all the PHCs in Nigeria. Report from other part of Africa have shown improvement in health seeking behavior when subsidy was introduced 
It was also noted in this study that the majority of the clients (27.3%) were not aware of the NHIS, and 39% did not use the NHIS because they could not access the service since they were not civil servants. This has brought to the fore the urgent need to implement the informal sector health insurance scheme and the speedy implementation of the National Health Act which address the issues of primary health-care funding.
| Conclusion|| |
The cost of primary health-care services was unaffordable by the majority of the participants in this study resulting in catastrophic health expenditures which negates the principles of primary health care. There is an urgent need for regular supervision of the activities of all the PHC workers by the health department of the LGAs and the primary health care development agencies. Standardization of prices of services and commodities at the PHCs is recommended. Government poverty reduction programs, if extended to the community people, and the implementation of the National Health Act may alleviate the burdens of the community members who access primary health-care services.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Soyibo A. National Health Accounts of Nigeria, 1998-2002. Ibadan: University of Ibadan; 2004.
Witter S. An Unnecessary Evil? User fees for healthcare in low-income countries. London: Save the Children; 2005.
Uzochukwu BSC, Onwujekwe OE, Akpala CO. Effect of the Bamako-Initiative drug revolving fund on availability and rational use of essential drugs in primary health care facilities in Southeast Nigeria. Health Policy and Plan 2002;17:378-83.doi: 10.1093/heapol/17.4.378.
Wag staff A. Poverty and health sector inequalities. Bull World Health Organ 2002;80:97-105.
Federal Ministry of Health. The National health policy of Nigeria. Abuja: Federal Ministry of Health (FMOH).
Litvack JI, Bodart C. User fees plus quality equals improved access to health care: results of a field experiment in Cameroon. Soc Sci Med 1993;37:369-83.doi: 10.1016/0277-9536(93)90267-8.
World Bank. World Development Indicators. Washington: World Bank; 2003.
Federal Office of Statistics. Core Welfare Indicators Questionnaire Survey: Combined 6-States Main Report. Abuja, FOS, State Statistical Agencies of Abia, Cross River, Gombe, Kebbi, Osun, and Plateau states. Abuja: Federal Office of Statistics; 2004.
Shaw R, Griffin C. Financing Health Care in Sub-Saharan Africa through user fees and insurance. Washington DC: World Bank; 1995.
Ibiwoye A, Adeleke IA. Does national health insurance promote access to quality health care? Evidence from Nigeria. Geneva Pap Risk Insur: Issues Pract 2008;12:219-33.doi: 10.1057/gpp.2008.6.
Onwujekwe OE. Inequities in healthcare seeking in the treatment of communicable endemic diseases in Southeast Nigeria. Soc Sci Med 2005;61:455-63.doi: 10.1016/j.socscimed.2004.11.066.
Metiboba S. Nigeria's national health insurance scheme: The need for beneficiary participation. Res J Int Stud 2011;12:51-6.
PG Oyibo. Out-of-pocket payment for health services: constraints and implications for government employees in Abakaliki, Ebonyi state, south east Nigeria. Afr Health Sci 2011;11:481-5.
World Bank. Financing health services in developing countries: An agenda for reform. Washington: World Bank; 1987.
Ezeoke OP, Onwujekwe OE, Uzochukwu BS. Towards universal coverage: Examining costs of illness, payment, and coping strategies to different population groups in Southeast Nigeria. Am J Trop Med Hyg 2012;12:52-7.doi: 10.4269/ajtmh.2012.11-0090.
Christopher O. Primary health care for developing countries. 2nd ed. 2007. pp 88–9.
Uzochukwu BS, Akpala CO, Onwujekwe OE. How do health workers and community members perceive and practice community participation in the Bamako Initiative programme in Nigeria? A case study of Oji River local government area. Soc Sci Med 2004;59:157-62.
National population commission. National census facts and figures. Abuja; 2006.
National Population Commission Nigeria and ORC Macro, Nigeria Demographic and Health Survey. Calverton Maryland: National Population Commission and ORC Macro; 2008.
Mohindra KS, Haddad S, Narayana D. Women's health in a rural community in Kerala, India: Do caste and socioeconomic position matter? J Epidemiol Community Health 2006;60:1020-6.doi: 10.1136/jech.2006.047647.
Ke Xu. Understanding the impact of eliminating user fees: Utilization and catastrophic health expenditures in Uganda. Soc Sci Med 2006;62:866-76.
Roland ChidiIbekwe, Vivan U Muoneke, Uche H Nnebe-Agumadu, Mary-Ann U Amadife. Factors influencing discharge against medical advice among pediatrics patients in Abakaliki, Southeastern Nigeria. J Trop Pediatr 2009;55:39-41.
Whitehead M. The concepts and principles of equity and health. Int J Health Serv 1992:22-429-45.
National Primary Health Care Development Agency. Integrating primary health care governance-primary health care under one roof-implementation manual. Abuja, Nigeria: NPHCDA; 2013.
Mohindra KS, Haddad S, Narayana D. Women's health in a rural community in Kerala, India: Do caste and socioeconomic position matter?. J Epidemiol Community Health 2006;60:1020-6. Doi: 10.1136/jech.2006.047647.
Igbuzor O. The millennium development goals: Can Nigeria meet the goals in 2015. A Symposium on Millennium Development Goals and Nigeria: Issues, Challenges and Prospects, organized by the Institute of Chartered Accountants of Nigeria (ICAN), Abuja District on. 27:2006.
Akin JS, Guilkey DK, Hazel E. Quality of services and demand for health care in Nigeria: A multinomial probit estimation. Soc Sci Med 1995;40:1527-37.
Abdulraheem IS. Reasons for incomplete vaccination and factors for missed opportunities among rural Nigerian children. J Public Health Epidemiol 2011;3:194-203.
Fatiregun AA, Etukiren EE. Determinants of uptake of third doses of oral polio and DTP vaccines in the Ibadan North Local Government Area of Nigeria. Int Health 2014;6:213-24.
Huber SC, Harvey PD. Family planning programmes in ten developing countries: Cost effectiveness by mode of service delivery. J Biosoc Sci 1989;21:267-77.
Adamu YM, Salihu HM. Barriers to the use of antenatal and obstetric care services in rural Kano, Nigeria. J Obstet Gynecol 2002;22:600-3.
Idris SH, Gwarzo UMD, Shehu AU. Determinants of place of delivery among women in a semi-urban settlement in Zaria, northern Nigeria. Ann African Med 2007;5:68-72.
Lagarde M, Palmer N. The impact of health financing strategies on access to health services in low and middle income countries. Cochrane Database Syst Rev 2008;In press.
De Bethune XAS, Lahaye JP. The influence of abrupt price increase on health service utilization: evidence from Zaire. Health Policy Plan 1989;4:76-81.REF
Adewole Isaac F. Trends in postabortal mortality and morbidity in Ibadan, Nigeria. Int J Gynecol Obstet 1992;38:115-8.
Mudyarabikwa O. An examination of public sector subsidies to the private health sector: A Zimbabwe case study. Equinet Policy Series 2000;3:1-27.
National Health Insurance Scheme. Guidelines for the operation of the formal sector social health insurance programme. Abuja; 2005. 1 pg.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]