HEALTH CARE DELIVERY, ACCESS AND UTILISATION IN SLUMS OF URBAN SOUTH-WEST, NIGERIA.

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HEALTH CARE DELIVERY, ACCESS AND UTILISATION IN
SLUMS OF URBAN SOUTH-WEST, NIGERIA.

• S. Akinmay?wa Lawal
• PhD Candidate
• Centre for Global Health
• Trinity College Dublin.
• Supervisors
• Femi Omololu, PhD
• University of Ibadan, Nigeria
• Joseph Assan, PhD
• Trinity College Dublin, Ireland

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INTRODUCTION

• In Sub-Saharan Africa gaining access to health
  care services is still a challenge as health
  systems performance is very low (Kruk and
  Freedman, 2008).
• There exist profound inequities in health within
  this region (Haines and Cassels, 2004, Sanders et
  al, 2005 and World bank 2004) and
• As a result of either geographical, physical,
  financial or socio-cultural barriers, the use of
  effective health services and interventions is a
  challenge (Hanson et al, 2003),
• In Nigeria, Private Out-Of-Pocket Expenditure
  (OOPE) accounts for over 70 of the estimated 10
  per capita expenditure on health (FMOH, 2004),
  therefore limiting equitable access to quality
  health care services (Ibekwe, 2010), also in
  urban slums.

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Health Statistics in Nigeria

• Percentage Share of Total Health Expenditure by
  Financing Agents, 2002 () (Soyibo, 2005).

Source of Health Expenditure in Nigeria 2003 ()
(Soyibo, 2005).
Source WHO, 2009
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Health Statistics in Nigeria (2)
Source WHO, 2009
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Health Care Delivery in Nigeria
Source WHO, 2009
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Background to the Problem

• Across countries of sub-Saharan Africa and parts
  of Asia and Latin America slum dwellers, do not
  have access to basic amenities such as potable
  water, electricity, drainage, roads, sanitation,
  education, health care, recreation and waste
  disposal facilities (DFID, 2004 Ndulu et al.,
  2005 Ayogu, 2006 World Bank, 2006).
• As a result of this, many urban slum dwellers in
  these regions live in deteriorating conditions
  that affects human health (UN-HABITAT, 1992,
  2003 DFID, 20032 WHO, 2005 ADB, 2007 UNFPA,
  2007).
• Slum dwellers occupy irregular settlements,
  squatter housing, unauthorized land developments,
  and rooms and flats in dilapidated and
  uncompleted buildings (Chome, 2002). Nigeria has
  a fair share of these irregular settlements
  (Agboola and Olatubara, 2003).

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Urban Slums in Sub-Saharan Africa

• Sometime in the next year, a woman will give
  birth in the Lagos slum of Ajegunle... Davis,
  Planet of Slums, 2006
• Slums are underserviced and or with no service
  parts of cities where living conditions are often
  appallingly poor (Chowdhury and Nurul-Amin,
  2006).
• Slums are an active, grassroots attempt by the
  desperately poor to take care of themselves
  (Sclar and Northridge 2003).

• The UN-HABITAT 2003 Global report on human
  settlement The Challenge of Slums reveals that
  
• Within the developing regions, sub-Saharan Africa
  had the largest proportion of the urban
  population resident in slums in 2001 (71.9 per
  cent).
• Slums are a physical and spatial manifestation of
  urban poverty and intra-city inequality.
• Slums in Nairobi are homes to urban residents who
  earn comparatively low incomes and have limited
  assets.
• The majority of slum dwellers in developing
  country cities earn their living from informal
  sector activities located either within or
  outside slum areas.

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Slums in Urban South West Nigeria

• In Nigeria, the growth of slums is 4.23 per cent
  with urban population in 2007 of 50 per cent
• These Slums are precarious, unplanned and
  environmentally degraded, while existing
  available health facilities cannot cater for the
  growing number of slum dwellers.
• In Lagos state, slums can be located in the
  following areas of Makoko-Ebute-meta, Ajegunle,
  Okokomaiko, Abaranje, Akesan-Igando, Berger,
  Iyana-Ipaja/Ayobo, Mushin, and Agege while

• In Ogun state, slum communities exist in
  Abeokuta, Sagamu, Ijebu-ode, Ilaro, Mowe, and
  Ibafo areas of south west Nigeria.
• Makoko in Lagos (Up) and Ibafo in Ogun state
  (Down).

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Objective of the Study

• To examine access to health care services and
  effective utilisation of health care in slum
  communities of urban south west Nigeria.
• To explore the social processes by which health
  care services emerge in urban slums of south west
  Nigeria.
• To determine the extent in which the health care
  needs of residents are being met and evaluate the
  effectiveness of health care delivery services in
  slum communities of urban south west Nigeria.

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Research Question

• How do health care services emerge in slum
  communities of urban areas in south-west Nigeria?
  
• How do households in urban slums of south west
  Nigeria access health care services?
• To what extent is health care delivery meeting
  the needs of residents in urban slums of south
  west Nigeria?
• How are the health care needs of residents in
  urban slums of south western Nigeria met?
• How effective is health care delivery services in
  slum communities of south west Nigeria?

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Research Hypothesis

• Presence of health facilities in urban slums
  increases the utilization of the health services
• Affordability of health care services in urban
  slums of south west Nigeria increases patient
  utilization
• Good road network, transport system and income
  increases access to health care services among
  households
• The quality of care offered to patients
  encourages the effective utilization of health
  care services
• Availability of drugs, equipments, attitude of
  health workers and prompt treatment increases the
  utilization of health care services in urban
  slums of south western Nigeria

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Justification and Significance for the Study

• The findings of this study will
• Provide information on the varied nature of
  health care delivery in slum communities.
• Help in the conceptualisation of health care
  delivery and utilisation in urban slums
• Highlight the social determinants of access to
  health care services in slum communities in
  relation to what the literature says.
• Contribute to strengthening health care systems
  in slum communities.
• Provide insight into the social processes by
  which the health system in urban slums develop
  overtime.

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Selected Literature Review

• Scalar and Northridge (2003) Indeed, slum
  settlements represent an active, grassroots
  attempt by the desperately poor to take care of
  themselves.
• Janovsky (2006) argues that improving health
  services and strengthening health systems is
  equally essential in slum communities
• Dahlgren and Whitehead (2007) adequate policies
  and strategies to promote social equity in health
• According to WHO 2008 report on Social
  determinants of health, access and utilisation of
  health care in informal settlement is problematic
• Ibekwe (2010) asserts that access to health care
  services is a challenge especially in slum
  communities Africa
• Omachonu and Einspruch (2010) concedes that
  innovation in healthcare delivery systems will
  improve health conditions even in slum
  communities

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Theoretical Framework

• Social Determinants of Health
• The SDH holds that
• The social gradient in health within countries,
  and the marked health inequities are caused by
  the unequal distribution of power, income, goods,
  and services.
• Unequal distribution of health-damaging
  experiences is the result of a toxic combination
  of poor social policies and programmes, unfair
  economic arrangements, and bad politics
• Health inequality exist especially among slums
  dwellers of urban south west Nigeria.

• Structuration Theory
• The use of Structuration theory for this study
  will show
• How Giddens' concepts of 'social system',
  'structure' and 'agency' help to conceptualize
  health care delivery in urban slums
• Access and utilisation of health services among
  actors in urban slums of south west Nigeria
• The relationship between Structures of Health
  Care (Health System) and Actors of Health Care
  (Providers, Slum Dwellers).

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Conceptual Framework
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Methodology

• Sampling Technique

• Qualitative/Quantitative

• Multi stage sampling
• Systematic random sampling of households
• Purposive sampling
• Snowball sampling
• Study Area
• Lagos State and Ogun State

• In-depth interviews
• Key Informant Interview
• Focused group discussion
• Survey
• Study Population
• Households, Public Health Officials, Key
  Informants, Community Leaders, Health Care
  Practitioners, Folk Healers, Community Residents,
  Drug Peddlers and Local Pharmacy, NGOs
• Study Design
• The study will adopt an exploratory and
  evaluation approach. A triangulation of research
  methods to capture existing social realities of
  health care delivery, access and utilization in
  urban slums of south west, Nigeria

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Methodology Table 1
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Methodology Table 2
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Research Hypothesis

• The stated hypothesis will be answered through
  the items of the quantitative research instrument
  and analyzed to state existing relationship
  between the independent and dependent variables.
• Changes in the study thus far
• Concept of Emerging Communities removed from
  title
• Research Hypothesis
• WHO Health System Framework
• Literature on Health Systems
• Key Informant Interview
• Inclusion of NGO, Folk Healer in study population
• Social Model of Health removed from the
  theoretical framework

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PhD Work Plan
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Dissemination of Findings

• Supervisor and Co-Supervisors
• Centre for Global Health, Trinity College Dublin
• Department of Sociology, University of Ibadan,
  Nigeria
• School of Medicine, Trinity College Dublin
• Postgraduate School, University of Ibadan,
  Nigeria
• Federal Ministry of Health, Nigeria
• Commissioner of Health, Lagos State, Nigeria
• Commissioner of Health, Ogun State, Nigeria
• Host Communities
• Reputable Journals for Publication

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