ABSTRACT
People in poor countries tend to have less access to health services than those in better-off countries, and within countries, the poor have less access to health services. This article documents disparities in access to health services in low- and middle-income countries (LMICs), using a framework incorporating quality, geographic accessibility, availability, financial accessibility, and acceptability of services. Whereas the poor in LMICs are consistently at a disadvantage in each of the dimensions of access and their determinants, this need not be the case. Many different approaches are shown to improve access to the poor, using targeted or universal approaches, engaging government, nongovernmental, or commercial organizations, and pursuing a wide variety of strategies to finance and organize services. Key ingredients of success include concerted efforts to reach the poor, engaging communities and disadvantaged people, encouraging local adaptation and careful monitoring of effects on the poor. Yet governments in LMICs rarely focus on the poor in their policies or the implementation or monitoring of health service strategies. There are also new innovations in financing, delivery, and regulation of health services that hold promise for improving access to the poor, such as the use of health equity funds, conditional cash transfers, and coproduction and regulation of health services. The challenge remains to find ways to ensure that vulnerable populations have a say in how strategies are developed, implemented, and accounted for in ways that demonstrate improvements in access by the poor.
CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND OF STUDY
The imperative of the association between poverty and health have long been recognized. Until recently the primary focus for social scientists has been on examining the relationships between income (or consumption) poverty and key indicators of health status, such as mortality, morbidity and nutrition. However, the pressure for ‘multidimensional’ and ‘people centred’ understandings of poverty, fueled by the work of Sen (1984), has critiqued such utilitarian measures of poverty and welfare and encouraged a focus on individual capabilities (the means which enable people to function) and more nuanced conceptualisations of poverty. From such perspectives, preventable deaths and ill-health are not merely outcomes of poverty but integral components of poverty itself. Such conceptualisations are reflected in the increasing use of broader measures such as the UNDP’s human development index (HDI) and human poverty index (HPI) that incorporate health indicators in their computation. Health is also measured by a number of indicators with the most common being life expectancy, infant mortality rate and the fertility rate.
In Sub-Saharan Africa, it is estimated that almost (50) per cent of the population live in absolute poverty (Avery, 2016; Rowson, 2011; WHO, 2009). It is significant, however, to mention that the estimate of poverty incidence in sub-Saharan Africa would increase if poverty was seen beyond income poverty (Sahn and Stifel, 2012). The problem of faltering social progress is especially acute in Africa in contrast with other regions that have witnessed more sustained improvements in living standards (World Bank, 2011). Social exclusion, human right abuse and gender inequalities are major dimensions of poverty that deprive most people in Africa of their human dignity other than income differentials. Klasen (2010), Carter and May (2011) attribute South Africa’s poverty situation to apartheid policies and its aftermath that denied equal access to education, employment, social services and resources to the black population in the country. Poverty thus has strong racial, social and
political dimensions with high concentration among African population.
The increase in poverty rate across Nigeria has been coupled with a correspondent increase in the incidence of diseases and deaths. A life expectancy of 51 years has been recorded (Sindiga, 2015). Mortality rate is high especially for children below five years of age. Data from the World Development Indicators show that life expectancy at birth for Nigeria has declined over the past 15 years from 49 years in 1990 to 47 in 2015, and infant mortality rates increased in many sub-Saharan countries where poverty remains pervasive (World Bank,2016). According to Sindiga, (2015) some 14.5 million children die every year in developing countries; while (10) per cent of all births end up in death by the first birthday and (20) per cent by the fifth birthday. It is emphasized that the relatively high mortality rate in Nigeria is as a result of parasitic infectious diseases.
Diseases such as malaria, schistosomiasis, trypanosomiasis are endemic in many parts of Nigeria which affect productivity.
The specific causes of morbidity and mortality are respiratory infections such as pneumonia, tuberculosis and whooping cough and water-borne diseases such as dysentery, typhoid and cholera. With regard to the major causes of poor health conditions in Africa, especially Northern Nigeria, Sindiga (2015) explains that, most of the
Tropical diseases are related to poor housing with little ventilation as well as sanitation; clean water supplies are often unavailable and waste disposal is a problem. As regards human waste, many people do not have pit latrines and thus help themselves in the bush. This is often collected by rain water and taken to rivers where people water
their livestocks and also fetch water for domestic use. The diseases that account for (50¬90) per cent of illness and death among the poor. These, according to Sanders (2015), are nutritional deficiencies and communicable diseases which sometimes act separately but more often act together and aggravate each other (GHD, 2014).
Thus, the high spate of mortality and morbidity in relatively Nigeria are associated with nutritional deficiencies, defective hygiene and lack of certain basic needs of life.
1.2 STATEMENT OF PROBLEM
The cost of health care service in both public and private health facilities has sky rocketed in the recent past and it seems this will continue in years to come except an urgent intervention is put in place. While the ability to purchase health care is diminishing there is increasing poverty in the country (Nigeria), as it is the case with most developing nations. Therefore there is the need for urgent intervention at all levels and quarters to bring about access to all, no matter their position or where they live.
The continuous inability of the sick and households to pay for health services is a common phenomenon in many health facilities across the length and breadth of Nigeria. This is, however, more common among the poor rural households and semi-urban dwellers. The situation may be so precarious that the sick‟s relation may have to sell some properties of the sick or of the household in order to pay for medical bills. In other instances loans with high interest rates may be obtained on behalf of the sick and this are usually not devoid of the consequence of impoverish of both the sick and the household. In extreme cases of poverty the sick are often left at home without treatment or if already on treatment at a health center she/ he is taken home and left at the mercy of death. These unfortunate happenings could be attributed to lack of commitment on part of government at the three levels, federal, state and local governments. For example, the financial contribution of all level of government was only about 36% between 2002 and 2004
while household have a share of an average of 64% within the same period1,5. This has been the pattern over the last 15 to 20 years. The lack of health insurance for the poor is another major contributing factor. The National Health Insurance Scheme that is meant to alleviate the burden of high household expenditure on health is yet to reach the poor who need it most urgently, and the probability of reaching them in the near feature is almost not feasible because of the slow phase of attempt at implementation and for the lack of commitment on the part of government at all levels. The almost nonexistence of Private health insurance has further compounded the problem. As at the end of 2006 not many health insurance organization were in existence, even the mutual health organizations that were operating in early 1990s are almost in nonexistence today, except a few in Lagos State, e.g. Jas Medical Service in Mushin and Lawanson in surulere, Lagos.16 The other contributing factor and probably the most crucial for now is the lack of savings for Health (or illness) by households. It could be said that two factors are responsible for the failure to save for health. First, the high level of poverty in the country, where 60% of its citizens live below poverty line and secondly, there is significant level of lack of awareness among Nigerians and it‟s households that they and the community could come together and save for their health care and thereby minimize the ugly, incessant and unnecessary incidence of catastrophic expenditure on health care and its impoverishment.
It’s intended that this study will determine the level and frequency of household expenditure on health care and also explore the resources available to households in Lapai Local Government Area of Niger State that could improve access to health care that are affordable, feasible, and sustainable.