Out-of-pocket health-care spending and its determinants among households in Nigeria: a national study

"I am the one taking care of her and donating blood": lived experiences of role-routines of hospital-based informal caregiving in Nigeria

PURPOSE

Informal caregivers (ICs) in Africa perform a long list of tasks to support hospitalization care. However, available studies are weak in accounting for the experiences of everyday role-routines of hospital-based informal caregiving (HIC) in under-resourced settings. This article explored the experiences of role-routines among informal caregivers in a Nigerian tertiary health facility.

METHODS

The ethnographic exploratory study relied on primary data collected from 75 participants, including 21 ICs, 15 inpatients, 36 hospital staff, and 3 ad-hoc/paid carers in a tertiary health facility in Southwestern Nigeria.

RESULTS

ICs perform several essential roles for hospitalized relatives, with each role characterized by a range of tasks. An integrative narrative of everyday routines of HIC as experienced by ICs showed critical complexities and complications involved in seemingly simple tasks of assisting hospitalized relatives with hygiene maintenance, medical investigations, blood donation, resource mobilization, errand-running, patient- and self-care and others. The role-routines are burdensome and ICs' experiences of them revealed the undercurrents of how health systems dysfunctions condition family members to support hospitalization care in Nigeria.

CONCLUSION

The intensity and repetitive nature of role-routines is suggestive of "routinization of suffering". We recommend the closing of gaps driving hospital-based informal caregiving in Africa's under-resourced settings.

Feasibility and Safety of Implementing Volumetric Arc Therapy (VMAT) for Pediatric Craniospinal Irradiation in a Low-Middle-Income Region: The Nigerian Experience

Purpose

Volumetric modulated arc therapy (VMAT) is a relatively new treatment technique in sub-Saharan Africa. Although craniospinal irradiation (CSI) in the pediatric population has been practiced in Nigeria for many years, the use of VMAT to deliver this treatment is previously undocumented. We reviewed the first set of patients to undergo CSI at a cancer center in Nigeria, detailing the treatment technique, the progress experienced, dose statistics achieved, treatment toxicities, and cancer outcomes to date.

Methods and Materials

This was a prospective case series of 5 children with histologically diagnosed cancers requiring CSI whose parents consented to the study. They were recruited at evaluation and followed through the process of their therapy. Toxicity was monitored at weekly review appointments using the Common Terminology Criteria for Adverse Events version 5.0. Follow-up of the children will continue in the long-term effects clinic.

Results

Five patients with a median age of 6 were recruited. Diagnoses were intracranial germ cell tumor (n = 2), medulloblastoma (n = 1), pineoblastoma (n = 1), and ependymoma (n = 1). For all patients, a dose of 36.0 Gy in 1.8 Gy daily fractions was prescribed to the entire neuraxis. A subsequent boost of 18 Gy (n = 4) to 19.8 Gy (n = 1) in 10 daily fractions to the primary tumor bed (n = 2) and posterior fossa (n = 2) was delivered. Four patients had chemotherapy before, during, or after radiation therapy. No patient experienced grade 3 or greater toxicity.

Conclusions

Our results indicate great progress has been made in the delivery of CSI in Nigeria, demonstrating tolerable acute side effects using VMAT. This series suggests the feasibility of implementing VMAT technology in low- or middle-income countries. Additional follow-up will be needed to determine whether survival rates and chronic toxicity rates are similar to those reported in the literature.

Assessing the inequality in out-of-pocket health expenditure among the chronically and non-chronically ill in Saudi Arabia: a Blinder-Oaxaca decomposition analysis

BACKGROUND

Many high-income countries have made significant progress towards achieving universal health coverage. Nevertheless, out-of-pocket (OOP) health expenditure continues to undermine the effectiveness of the universal healthcare system. In Saudi Arabia, due to the overburdened free public health services, many people opt for alternative healthcare services, risking high OOP payments. The presence of chronic illness further exacerbates this situation. However, there is limited evidence on the extent of the gap in OOP health expenditure between the chronically and non-chronically ill and the associated drivers contributing to this gap. The aim of this study was to assess inequalities in relative OOP health expenditure, estimated as the percentage of income spent on healthcare, between the chronically and non-chronically ill in Saudi Arabia and their associated drivers.

METHODS

Data from 10,785 respondents were obtained from a national cross-sectional survey conducted in Saudi Arabia as part of the 2018 Family Health Survey. Inequalities in relative OOP health expenditure were measured using concentration indices and curves. A Blinder-Oaxaca decomposition analysis was used to assess the differences in relative OOP health expenditure between the chronically and non-chronically ill.

RESULTS

The results showed that the chronically ill experience a higher financial burden due to healthcare services in absolute costs and relative to their income compared to the non-chronically ill. In addition, there was higher pro-poor inequality (-0.1985) in relative OOP health expenditure among the chronically ill compared to that (-0.1195) among the non-chronically ill. There was a 2.6% gap in relative OOP health expenditure among the chronically and non-chronically ill, of which 53.8% was attributable to unexplained factors, with explained factors accounting for the 46.2% difference. Factors that significantly contributed to the overall gap (i.e. both explained and non-explained factors) included employment status, insurance status, self-rated health, and periodic check-ups.

CONCLUSION

This study underscores the high financial burden due to OOP payments among the chronically ill and the existence of pro-poor inequalities. In addition, there is a significant gap in relative OOP health expenditure between the chronically and non-chronically ill, which is mainly attributable to differences in socio-economic characteristics. This indicates that the existing financial mechanisms have not been sufficient in cushioning the chronically ill and less well off in Saudi Arabia. This situation calls for health policymakers to integrate a social safety net into the health financing system and to prioritize the disadvantaged population, thereby ensuring access to health services without experiencing financial hardship.

Stakeholders' perspectives and willingness to institutionalize linkages between the formal health system and informal healthcare providers in urban slums in southeast, Nigeria

BACKGROUND

The widely available informal healthcare providers (IHPs) present opportunities to improve access to appropriate essential health services in underserved urban areas in many low- and middle-income countries (LMICs). However, they are not formally linked to the formal health system. This study was conducted to explore the perspectives of key stakeholders about institutionalizing linkages between the formal health systems and IHPs, as a strategy for improving access to appropriate healthcare services in Nigeria.

METHODS

Data was collected from key stakeholders in the formal and informal health systems, whose functions cover the major slums in Enugu and Onitsha cities in southeast Nigeria. Key informant interviews (n = 43) were conducted using semi-structured interview guides among representatives from the formal and informal health sectors. Interview transcripts were read severally, and using thematic content analysis, recurrent themes were identified and used for a narrative synthesis.

RESULTS

Although the dominant view among respondents is that formalization of linkages between IHPs and the formal health system will likely create synergy and quality improvement in health service delivery, anxieties and defensive pessimism were equally expressed. On the one hand, formal sector respondents are pessimistic about limited skills, poor quality of care, questionable recognition, and the enormous challenges of managing a pluralistic health system. Conversely, the informal sector pessimists expressed uncertainty about the outcomes of a government-led supervision and the potential negative impact on their practice. Some of the proposed strategies for institutionalizing linkages between the two health sub-systems include: sensitizing relevant policymakers and gatekeepers to the necessity of pluralistic healthcare; mapping and documenting of informal providers and respective service their areas for registration and accreditation, among others. Perceived threats to institutionalizing these linkages include: weak supervision and monitoring of informal providers by the State Ministry of Health due to lack of funds for logistics; poor data reporting and late referrals from informal providers; lack of referral feedback from formal to informal providers, among others.

CONCLUSIONS

Opportunities and constraints to institutionalize linkages between the formal health system and IHPs exist in Nigeria. However, there is a need to design an inclusive system that ensures tolerance, dignity, and mutual learning for all stakeholders in the country and in other LMICs.

Determinants of Turkish households' out-of-pocket expenditures on three categories of health care services: A multivariate probit approach

This study identifies the driving forces that contribute to the probabilities of incidence of out-of-pocket (OOP) expenditures by households in Turkey. Factors affecting the probability of OOP expenditures on medical products/devices/supplies (MP), outpatient services (OTS), and inpatient services (ITS) are examined using the Household Budget Survey data gathered by the Turkish Statistical Institute in 2018. The study applies the multivariate probit model. The incidence of OOP spending varied with 48.9% of the households reporting OOP expenditure on MP, 22.4% on OTS, and 25.4% on ITS. The largest probability changes were associated with household disposable annual income, household type and size, age category, and having private health insurance. Gender and marital status also influenced expenditures in some categories. Lifestyle choices had small and mixed effects, with smoking and alcohol consumption lowering the probability of OOP spending. From a policy standpoint, households with the lowest incomes, large households, and those where the household head was 'others' (retiree, student, housewife, not actively working, etc.) or had a condition preventing employment seemed to report OOP expenditures less frequently and may have chosen not to receive healthcare services, leading to the need for more healthcare services later.

Challenges faced by healthcare workers at a central hospital in Zimbabwe after contracting COVID-19: An interpretive phenomenological analysis study

Background

Healthcare workers play a critical role in the delivery of healthcare services. Because of the high risk of exposure to healthcare workers, the emergence of coronavirus disease 2019 (COVID-19) has had a significant impact as they struggled to contain the pandemic. The purpose of this study was to explore and describe the challenges they faced after contracting COVID-19.

Methods

An interpretative phenomenological analysis (IPA) design was employed to gain insight into the lived experiences of healthcare workers who contracted COVID-19 in the course of their duties. This study involved participants who were healthcare workers based at a central hospital in Bulawayo, Zimbabwe. Data were collected through in-depth interviews that were audio recorded. A sample size of ten was reached based on data saturation.

Results

The study showed that healthcare workers lacked psychosocial support, experienced economic challenges as they incurred diagnostic and treatment costs. The study also found that the healthcare workers experienced stigma and discrimination both at work and in the community. Findings also indicate that healthcare workers did not receive institutional support. The study demonstrated lack of preparedness at the institution evidenced by inadequate testing for COVID-19 and shortage of personal protective equipment.

Conclusion

This study’s findings will be critical for health authorities, programmers and policymakers to facilitate planning and preparedness for pandemics. The researchers recommend setting up a differentiated service delivery support system for healthcare workers to cater for their mental health and well-being and that of their families.

A contextual exploration of healthcare service use in urban slums in Nigeria

Introduction

Many urban residents in low- and middle-income countries live in unfavorable conditions with few healthcare facilities, calling to question the long-held view of urban advantage in health, healthcare access and utilization. We explore the patterns of healthcare utilization in these deprived neighborhoods by studying three such settlements in Nigeria.

Methods

The study was conducted in three slums in Southwestern Nigeria, categorized as migrant, indigenous or cosmopolitan, based on their characteristics. Using observational data of those who needed healthcare and used in-patient or out-patient services in the 12 months preceding the survey, frequencies, percentages and odds-ratios were used to show the study participants’ environmental and population characteristics, relative to their patterns of healthcare use.

Results

A total of 1,634 residents from the three slums participated, distributed as 763 (migrant), 459 (indigenous) and 412 (cosmopolitan). Residents from the migrant (OR = 0.70, 95%CI: 0.51 to 0.97) and indigenous (OR = 0.65, 95%CI: 0.45 to 0.93) slums were less likely to have used formal healthcare facilities than those from the cosmopolitan slum. Slum residents were more likely to use formal healthcare facilities for maternal and perinatal conditions, and generalized pains, than for communicable (OR = 0.50, 95%CI: 0.34 to 0.72) and non-communicable diseases (OR = 0.61, 95%CI: 0.41 to 0.91). The unemployed had higher odds (OR = 1.45, 95%CI: 1.08 to 1.93) of using formal healthcare facilities than those currently employed.

Conclusion

The cosmopolitan slum, situated in a major financial center and national economic hub, had a higher proportion of formal healthcare facility usage than the migrant and indigenous slums where about half of families were classified as poor. The urban advantage premise and Anderson behavioral model remain a practical explanatory framework, although they may not explain healthcare use in all possible slum types in Africa. A context-within-context approach is important for addressing healthcare utilization challenges in slums in sub-Saharan Africa.

Factors Associated with Out-of-Pocket Health Expenditure in Polish Regions

Out-of-pocket (OOP) payments are perceived as the most regressive means of health financing. Using the panel-data approach and region-aggregated data from Statistics Poland, this research investigated associations between socio-economic factors and OOP health spending in 16 Polish regions for the period 1999–2019. The dependent variable was real (inflation-adjusted) monthly OOP health expenditure per person in Polish households. Potential independent variables included economic, labour, demographic, educational, health, environmental, and lifestyle measures based on previous research. A set of panel-data estimators was used in regression models. The factors that were positively associated with OOP health spending were disposable income, the proportions of children (aged 0–9) and elderly (70+ years) in the population, healthcare supply (proxied by physicians’ density), air pollution, and tobacco and alcohol expenditure. On the other hand, the increased unemployment rate, life expectancy at age 65, mortality rate, and higher sports participation were all related to lower OOP health spending. The results may guide national strategies to improve health-care allocations and offer additional financial protection for vulnerable groups, such as households with children and elderly members.

Stakeholders' Perspectives on the Unmet Needs and Health Priorities of the Urban Poor in South-East Nigeria

Relatively little is known about readiness of urban health systems to address health needs of the poor. This study explored stakeholders' perception of health needs and strategies for improving health of the urban poor using qualitative analysis. Focus group discussions (n = 5) were held with 26 stakeholders drawn from two Nigerian states during a workshop. Urban areas are characterised by double burden of diseases. Poor housing, lack of basic amenities, poverty, and poor access to information are determinants of health of the urban poor. Shortage of health workers, stock-out of medicines, high cost of care, lack of clinical practice guidelines, and dual practice constrain access to primary health services. An overarching strategy, that prioritises community-driven urban planning, health-in-all policies, structured linkages between informal and formal providers, financial protection schemes, and strengthening of primary health care system, is required to address health needs of the urban poor.

Maternal mental health and child well-being in Nigeria: A systematic review

Maternal mental health distress has a disease burden of severe adverse effects for both mother and child. This review identified maternal mental health concerns, their impact on child growth and the current practice of maternal healthcare for both mothers and their children in Nigeria. The Population, phenomenon of Interest and Context (PICo) model was adopted to formulate the review strategy, and five databases were searched for published articles between 1999 and 2019. Databases include Scopus, PubMed, ProQuest, Applied Social Science Index and Abstracts and Web of Science. Boolean operators (AND/OR/NOT) helped to ensure rigorous use of search terms which include 'maternal', 'pre/peri/postnatal', 'mental health', 'mental illness', 'disorders', 'intervention,' 'Nigeria', 'child', 'infant growth', and 'wellbeing'. Thirty-four studies met the inclusion criteria, and extracted data were qualitatively synthesised and analysed thematically. Five themes emerged. These include (i) marital difficulties, (ii) relationship status of the mother, (iii) child's gender, (iv) mode of child delivery and (v) child growth and development. The review showed a significant paucity of literature on the impact of specific maternal mental health problems on child physical growth and cognitive development. We concluded that culturally appropriate and evidence-based psychological interventions for maternal mental health problems would benefit Nigerian indigenous mothers. Therefore, the study recommends randomised controlled trials that are culturally appropriate and cost-effective for distressed mothers with children.