Charging fees for medical treatment can bring in desperately needed revenue and may discourage people from using health services unnecessarily. However, it can also prevent the poorest members of society, particularly in rural areas, from seeking treatment.  Are Nigerians on low incomes willing to pay for health care when they need it?

Doctors’ fees were introduced in Nigeria in the 1980s as part of its structural adjustment programme. The London School of Hygiene and Tropical Medicine, together with the University of Nigeria, carried out a survey in two communities, one urban and one rural, in Enugu State, south east Nigeria, to look at their different experiences of primary health service use.

652 households were asked about their health problems during the month before the study. Households were asked a number of questions, including how much money they had spent on food in the past week and whether they possessed items such as a car, television, or refrigerator. Households were divided into four socio-economic groups: 'poorest', 'very poor', 'poor', and 'least poor'.

The study found that:

• The urban dwellers were much better off than those living in the countryside.  Many more of them owned a fridge, a television and a car than their rural counterparts.
• Most of the urban households fell into the top two socio-economic groups, while the vast majority of the villagers fell into the categories ‘poorest’ and ‘very poor’.
• Rural households suffered more from respiratory diseases, diarrhoea and hypertension than those in the city.
• Nevertheless more than 90 percent of the city folk sought health care in the preceding month compared with only 58 percent of the villagers.
• The average monthly cost of treatment was US$ 15 in the city and US$ 4.40 for the villagers.
• The most common way of paying for care was payment upon treatment. The second most used method (used much less frequently) was payment by instalments.

The poorest people living in the city and those living in rural community experienced the greatest inequality. They spent the least amount of money on health care and were more likely to turn to traditional healers. The lower costs for treatment in the rural community may well have been caused by an inability to pay for the tests and treatment recommended by doctors.

The Government's policy of investing in and building primary health care centres across Nigeria is a step in the right direction. However, if genuine equality access to health care is to be reached:

• primary health care services in rural areas should be improved so that people see them as attractive places to go for treatment
• public-private partnerships need to be set up to provide funding for improvements
• schemes, such as fee exemptions, subsidies, and vouchers, should be introduced for the poorest members of society
• funding should be provided for training in the private sector to improve the quality of health services
• primary health care services must be shaped to meet the needs of the communities they serve
• the quality of health services used by poorer sections of communities must be as high as those used by the more well-off
• regulation and supervision of health services needs to be improved.

Source(s):
'Socio-economic and geographic differentials in costs and payment strategies for primary health care services in south east Nigeria', Health Policy 71(3): 383-397, by O. Onwujekwe and B. Uzochukwu, 2005
HINARI subscribers can access the full-text article here. Full document.

Funded by: Alliance for Health Policy and Systems Research

id21 Research Highlight: 19 April 2005

Further Information:
Obinna Onwujekwe
Health Policy Research Unit
Department of Pharmacology and Therapeutics
College of Medicine
University of Nigeria
PMB 01129, Enugu
Nigeria

Tel: +234 42 259569
Fax: +234 42 259569
Contact the contributor: onwujekwe@yahoo.co.uk

London School of Hygiene and Tropical Medicine, UK

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