ANALYSIS OF INEQUALITY IN HEALTH CARE UTILIZATION AMONG PREGNANT WOMEN IN NIGERIA EVIDENCE FROM SURVEY DATA

ABSTRACT

Currently, inequalities in health care utilization in  developing countries receive a lot of Attention, from both researchers and policy makers. Since measuring inequality in health care utilization in Nigeria is often problematic, different indicators of health are used in different studies. However, there exists inadequate evidence on the extent of disparity to health care utilization among pregnant women in Nigeria. This study provides this empirical evidence for a  sample  of  pregnant  women  within  the  Nigeria  country,  using  the  General  Household Surveys data-set. The study employed the concentration index by making use of the convenient covariance and  the logit  estimation  model to  estimate the disparity level  in  health  care utilization among pregnant women in Nigeria.  The study found    huge disparities to health care utilization among pregnant women in Nigeria as shown by the CIF coefficients which indicates total inequality as the results indicate concentration of women deprived to receive adequate, maternal care among the poorest quintile of economic status. The research also observed  that    wealth  in  quintile  level,  education  level  of  pregnant  women  and  age  of pregnant women were significantly associated with access to the minimum three antenatal care visits, showing that significant relationship between being poor and access to less utilization of ANC services independent of caste category or residence, and  that 19%, 29%, and  25% of  the services  of  the trained  health personnel  and  medical  doctors  are more consumed  during  delivery  as  associated  with  the  high  income  pregnant  women  during delivery. And 13% of untrained personnel and 14% traditional health care personnel are consulted by the low income pregnant women in Nigeria. Researchers and policy makers should include measures that could include the non-literate and the non-federal civil pregnant women residing in some rural areas in to the national health insurance scheme so that the scheme can help reduce inequality in health care found as obstacles among the poor class of pregnant women. Since economic status can influences the observed magnitude of health care inequalities.

CHAPTER ONE INTRODUCTION

Maternal and child mortality remain one of the most significant negative health Outcomes in the world and is predominant in developing countries with huge proportions of poverty and inequality. Considering a patriarchal society as Nigeria in which pregnant women are discriminated against as evident in the rural setting, gender disparity has been observed with women generally receiving less attention than men. Common among this situations is the Poor access  to  medical  services  which  is  compounded  by  socio-  cultural,  economic  and demographic factors including the behavior of families and communities, social status, education, culture, income, health, decision making power, age, access to health facilities, and availability of health services which has played a vital role in causing maternal mortality as identified by (Yahaya, 2004)

But then, the broad aim of achieving equitable access to healthcare across pregnant and adolescent mothers is to reduce, or at least not exacerbate, existing health inequalities found among vulnerable population groups, evidence in the progressive policy of achieving the fifth UN Millennium Development Goal (MDG 5), which is to reduce maternal mortality by 2015, by  three quarters  from  the level  of 1990.  This  effort  has  been  demonstrated by  several developing nations. For example Nigeria government has shown commitment in policy objectives since 2009, across the country, to improve on the proportion of births attended by skilled  health  workers  which  is  necessary  in  improving  maternal  health  (Nigeria  Health System Assessment, 2008).

However, this commitment by the Government appears not to be reflecting much in the health sector  as  the  nation’s  poor  health  care  delivery  has  been  experiencing  rising  cost  in medication and unequal opportunities in healthcare, limited resources, inefficient health systems as well as the huge burden of diseases among pregnant women in Nigeria. Studies have showed that some Countries have succeeded in improving maternal health and reducing maternal mortality, yet huge inequalities exist between different segments of the populations. Disadvantaged groups of women tend to have higher rates of both morbidity and mortality,

and less access to safe, affordable and acceptable health care services enabling safe pregnancy and childbirth as revealed by Irwin et al (2006). This “hidden” ill-health further adds to the challenge of reaching MDG 5, not only for an average but for all.

Attempts   have   been   made   to   reduce   health   inequalities   between   advantaged   and disadvantaged populations, on global, national and sub-national levels, and ensure opportunities to all members of a society to achieve good health (Culyer, 2001). Most health systems are, however, inequitable, benefiting the well-off more than the disadvantaged (Gwatkin et al., 2004). This led to the conclusion by World Health Organization (WHO,

2009) that there is still a need to better understand determinants of reproductive health in order to improve access to health services for disadvantaged groups.

Report by the Nigeria Health System Assessment (NHSA) (2008) revealed that health inequalities are increasingly recognized as an important public-health issue throughout developing countries. As a result of the growing recognition of the problem, many countries are responding by developing public policies in a wide variety of ways that could reduce what appears to be a serious gap in the area of health care utilizations especially among pregnant women in less developed countries.

In an attempt to buttress this, the study by the Nigeria Human Development Report 2008-2009 published by the UNDP (2013) showed that Nigeria seems to have a systemic structure of inequity where just 20 per cent of the population owns 65 per cent of national assets while as much as 70 per cent are peasant rural workers and artisans that may not be opportune to access healthcare utilization. This correlate with the findings by (Awoyemi et al., 2011) that huge inequalities exist among the low income adolescent mothers in the rural areas of Kogi state Nigeria, which also was demonstrated by Eboh (2008) that there is nothing national in the  National  Health  Insurance  Scheme  (NHIS)  and  that  the  implementation  grossly undermines the right of every citizen of Nigeria to the essential social good under the social contract. His findings indicates that such policy in a country like Nigeria where the society is diverse, multicultural, overpopulated and undergoing rapid but unequal opportunities among pregnant women in the rural areas could  create certain failures in the health sectors.

A Report by World Health Organization (2009) indicates that each year, 500,000 women die due to complications from childbirth. Of these, 10% comes from Nigeria, where, for every woman who dies in childbirth, another 30 percent of women suffer debilitating complications and  chronic  ill  health.  The  infant  mortality  rate  mirrors  the  maternal  statistics,  with  71 neonatal deaths per 1000 live births. Interestingly, this statistics appears to be high in rural areas in Nigeria where evidence of common diseases like malaria, guinea worm, pneumonia, measles, gonorrhea, schistosomiasis, typhoid, tuberculosis, chicken pox, and diarrhea and, more recently, AIDS are much more found. In fact, reported cases from noticeable diseases were about 1.78 million in 1991, the figure rose to some 2.06 million by 1995 (WHO,2006).

A Report by the NHSA (2008) has actually shown that the Nigeria health care system has provided evidence of inequalities in health care utilization, though not much could account for pregnant women. For instance the Federal Ministry of health revealed that distribution imbalances persist across all the zones indicating that rural areas are systematically under- resourced compared with urban areas, even in cases where the majority of the state population resides in rural areas (as is the case in the central and northern parts of the country) as shown in the two diagrams below:

Table 1.1: Number of health professionals by cadre and geographical zones (FMOH,

2007)

Zone	Nurses and Midwives	Medical Laboratory Scientists	Pharmac   ists	Doctors	Women who   received antenatal care  from  a skilled provider   in the   past   5 yrs (%)	Births   assisted by         a skilled provider (%)
North	3,398	96	245	675	43	16
East
North	3,941	201	502	1,388	31	10
West
North	5,778	434	1,342	1,841	65	43
Central
South	4,914	2,110	841	3,210	87	82
East
South	4,487	1,603	2,859	7,300	87	77
West
South	7,097	1,281	743	2,168	70	56
South
Source: Nigeria health system assessment 2008

However, to depict this information clearly, a pie chat was illustrated to present the statistics as shown below:

Figure 1.1

With  the  growing  Nigeria  population  it  may  be  difficult  to  reconcile  the  distribution imbalances in health care utilization in rural areas as compared to urban areas with these level of health care providers as shown by the NHSA (2008), The chat shows that North East and South South appeared to be among the disadvantaged population in the six geopolitical zones in Nigeria given that greater percentage of Nigerians reside in rural areas. This diagram is evidenced to show why women die in Nigeria from complications during pregnancy and delivery related to the access of quality health care services.  And when health care facilities and personnel are inadequate, occurrences like excessive bleeding, infections, pregnancy induced high blood pressure leading to Convulsions, Unsafe abortion, Anemia, Malaria, and Obstructed labor will become common among pregnant women as supported by   (WHO,

2009).The study infers   that this can create a   gap among health consumers   which   may restricts most of them from having direct access to health care utilization when they need it or where some are even forced to sell their assets or go into debt in order to pay for health care costs as observed by Riman and Apkan (2010).

Ichoku (2006) in a study revealed that the healthcare system is not income redistributive. For this, people generally purchase their healthcare needs in proportion to their income or ability to pay. And there is high level of horizontal inequity and re ranking arising from the current

method of healthcare utilization. Interestingly, years after his findings, statistics showed that death among women due to pregnancy and childbirth is still a current challenge in the nation health sector.  This finding is also supported to some extent by Adamu (2011), as his finding showed that utilization of maternal healthcare services is a proximate determinant of maternal morbidities and mortalities leading to more deaths.

1.2 Statements of the Problem

Studies have investigated various dimensions of healthcare inequalities especially within the countries where early efforts were made to gather relevant data. Despite several research efforts and policy recommendations from several literatures reviewed, there are still wide variations in health outcomes and related issues both within and across countries. Even so, despite the Nigerian 1999 constitutions effort to create equitable distribution of welfare yet with only two percent of the world’s population, Nigeria contributes ten percent of the world’s maternal death (Abouzahr, 2003). Each year as many as 60,000 Nigerian women die due to pregnancy related complications (Ladipo, 2006; USAID, 2008; WHO 2005).

Nigeria has made insufficient progress over the past two decades on maternal health and is not yet on track to achieve 2015 targets (NHSA, 2008). This is because over half of women who indicated having  problems in accessing healthcare cited concerns regarding inability to afford the service, and more so is unavailability of service providers as main barriers in accessing healthcare evidenced by DHS final report, Nigeria (2008). Yet,   section 17, subsection 3, article ‘d’ of the 1999 Nigerian constitution states that every citizen of Nigeria shall have access to adequate medical and health facilities.

World Bank Report, (2008) showed that the high maternal mortality ratio at 840 maternal deaths per 100,000 live births indicates that access to and qualities of emergency obstetric and neonatal care remain a challenge. However, these could be possible as a result of the statistics that showed   that human resource for maternal health in Nigeria are limited with only 0.4 physicians per 1,000 population but nurses and midwives are slightly more common, at 1.6 per 1,000 population which is also revealed by World Bank and UNICEF (2010).

Furthermore, reports by National Population Commission (NPC, 2008), showed that about

36.9 percent of all women who had live births in the five years preceding the 2003 NDHS, did so without any antenatal care. About 50.5 percent attended antenatal care at most three times before delivery, more than two percent started ANC when their pregnancies were at least eight months, while about 18.7 percent started when their pregnancies were at least six months old. Say and Raine (2007) supported this evidences as their findings showed that within countries, urban or wealthier women were usually more likely to deliver with the help of a skilled health worker than were rural or poor women. Other studies also agree with this evidence, that urban women were more likely to use medical settings for delivery than were rural women in Nigeria as revealed by Uguru et al (2007), Adamu (2011) and Ochi (2012).

For example, the diagram below shows the percentage of pregnant women receiving prenatal care in Nigeria form 1990 to 2008. The chart shows that about 63% of pregnant women receive prenatal care in Nigeria in 1999 and this declined to about 57% in 2008.  The diagram further shows that the married women who were not using a contraceptive method, traditional or modern, as at the time of the survey were about 21 percent and the  Total  Fertility  Rate (TFR)  in  Nigeria  stands  at  5.7%  while the  Contraceptive  Prevalence  Rate  (CPR)  was estimated  at 15%.

Figure 1.2

Source: National Population Commission (2009)

The 2008 Nigeria Demographic and Health report (NDHS, 2008),  also showed that 25.3% of the births were attended to by midwives, 9.1% by doctors and 19.3% of the women were not attended to by anyone even though no possible reasons could account for such. However, it could be inferred that the lack of prenatal care is due to the lack of income amongst other possible reasons. This means that the rich can afford and the poor cannot again re-iterate the significance of re-addressing the inequality that lies in health care utilization. Thereby, agreeing with the finding by Adamu (2011) that there exist huge inequalities among pregnant women in the six geopolitical regions in Nigeria.

Despite various reforms put forward by the government to address the wide range of issues in the health care system in Nigeria, health facilities (health centers, personnel, and medical equipment) are inadequate, especially in the rural areas (NHSA2008). Nigeria spends only 6.5 percent of its budget on health care as against the World Health Organization’s recommendation of 15 percent. And this may pose a serious problem especially to achieving health MDGs, and sustainable economic development as it was the view of Abdulraheem et al. (2011) that spending and implementation have not matched policies. With the level of disparity shown by several studies, it can be inferred that the system is geared toward making

the rich and educated access better health care services than the poorly educated and poverty stricken that need it most since the 1999 Nigerian constitution provides evidence of equal opportunities for all citizens.

Efforts have been made by several researchers to bring to tone the differences in the quality of health and health care across different populations, such as the aged, women and children (Ichoku 2009),(Bywood et al 2011), (Umukoro 2012). This may include differences in the “presence of disease, health outcomes, or access to health care across racial, ethnic, sexual orientation, and socioeconomic groups. Based on this backdrop, this study is geared toward examining the proportion of disparities to health care utilization among the high and the low income pregnant women in Nigeria due to the dangers it poses on the life of pregnant women in Nigeria.

1.3 Research Questions

The specific research questions of the study are therefore outlined below;

1.   What are the levels of disparities to healthcare utilization among pregnant women in

Nigeria?

2.   What are the demographic and socio-economic factors that may contribute to low utilization of health care service among pregnant women in Nigeria?

3.   What  type of healthcare services  is  being  utilized  by  different  income classes  of pregnant women in Nigeria?

1.4        Objectives of the Study

The broad objective of this study is to analyze the inequality in healthcare utilization that  exists  among  pregnant  women  in  Nigeria.  Based  on  this  background  the  specific objectives are therefore;

1     To examine the levels  of disparities to healthcare utilization among pregnant women in Nigeria.

2     To determine the demographic and socio-economic factors that may contribute to low utilization of health care service among pregnant women in Nigeria.

3     To investigate what type of healthcare services are being utilized by different income classes of pregnant women in Nigeria.

1.5.       Scope of the study

This study covers all the six geopolitical zones in Nigeria (urban and rural) namely, the South- South, South-East, South-West, North-Central, North-East and North-West. The major focus of the study is inequality in healthcare utilization among pregnant women and the indicators of pregnant women used in this study are: namely at least four antenatal care(ANC) visits, safe delivery, and postnatal care within 42 days of delivery.

Other demographic indicators include; maternal age, women’s education (no education, primary but below middle, secondary and above), husband’s education (no education, primary but below middle, secondary and above), place of residence (rural, and urban), wealth quintile (poorest, poorer, middle, richer, and richest), religion (Christian and Islam), birth order and interval (first birth order, birth order second or third and interval 24 months, and birth order second or third and interval 24 months).

1.6.       Significance of the Study

This study analyses the inequality in healthcare utilization, focusing on pregnant women in the six geopolitical zones in Nigeria. Healthcare utilization is one of the major contests faced by many developing countries especially in the sub-Saharan Africa and Nigeria cannot be left out of this trend. Therefore, the focus on pregnant mothers’ health is important for two reasons. First, adolescent mothers’ health is worsening in Nigeria with high malnutrition, infant and under5 mortality rates with little efforts policy wise to address these issues. Second, maternal mortality advocacy is one of the main goals of Millennium Development Goals and as we approach the deadline of 2015 more policy prescriptions will be important on how to move towards realizing the MDG health targets for Nigeria. Hence, this study has a lot of potential implications for policy in Nigeria in the following areas:

1.         This study was informative in predicting how inequality will change if policymakers are to uncover certain healthcare services utilized by different income classes.

2.         Understanding if inequality in healthcare utilization among adolescent mothers across geopolitical regions is due to differences in income is important in designing effective policy interventions that address specific health needs of those regions.

3.         Understanding  if  certain  indicators  explain  the  factors  that  determine  healthcare utilization among low and high income pregnant women in knowing priority areas policy should be designed to target.

4.         The outcome of this study will shape policies that aim at realizing the goal 4 of the

MDG for Nigeria or at least moving closer to it as we approach 2015.

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