RURAL WOMEN AND THE FINANCING

RURAL WOMEN AND THE FINANCING OF HEALTH CARE IN NIGERIA A thesis submitted by Daniel C. Oshi (Nigeria) in fulfilment of the requirements for the degree of DOCTOR OF PHILOSOPHY IN DEVELOPMENT STUDIES of the Institute of Social Studies The Hague, The Netherlands March 2009

Thesis Committee Promotor: Professor Ben White Institute of Social Studies The Hague, The Netherlands Co-promotor: Dr Jan Kees van Donge Institute of Social Studies The Hague, The Netherlands Examiners: Professor Bart Criel Insititute of Tropical Medicine Antwerp, Belgium Professor Sjaak van der Geest University of Amsterdam Amsterdam, The Netherlands Dr Auma Okwany Institute of Social Studies The Hague, The Netherlands This dissertation is part of the research programme of CERES, Research School for Resource Studies for Development. Copyright Shaker Publishing 2009 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher. Printed in The Netherlands ISBN 978-90-423-0359-1 Shaker Publishing BV St. Maartenslaan 26 6221 AX Maastricht Tel.: 043-3500424 / Fax: 043-3255090 / http:// www.shaker.nl

Acknowledgements Many people helped me greatly in surmounting the challenge of this PhD project. It is quite natural to thank every one of them as the project is accomplished. Most PhD acknowledgements start this happy phase by thanking the supervisors. I cannot agree more with them. It is not just a routine; I can confirm that from my own experience. As I muse over the entire experience over the past five and a half years (or so!), I often wonder how many tasks my supervisors undertook on my behalf. I wonder how much time they spent reading through so many pages of only one out of their many PhD and Masters candidates. So, if I devote the entire page expressing how grateful I feel toward them, I suppose you will understand. But that wouldn t even be adequate! However, I will attempt to tell them in one paragraph that I found in them my teachers, guides, academic senior friends, counsellors, and most importantly, my PhD promoters and supervisors. I appreciate every minute you put into reading my drafts. I am very grateful for your encouragement, patience, kindness, understanding, flexibility blended with sternness, your interest in the project, tutelage, etc. I appreciate you for those times you insisted I must do the necessary, and for those times you gave me all the space. I particularly thank Professor Ben White for helping me cope with my social and economic conditions in Nigeria when they got out of hand as a result of job loss as he continuously encouraged me not to give up. He combined academic supervision with giving me psychological therapy. He helped me pull through periods when I felt frustrated. He stood by me in special ways. My experience under him will live with me all my life: it is not enough to be an academic supervisor. A supervisor must show interest in other spheres of the candidate because a candidate s life is a totality of social, economic, psychological, spiritual and academic spheres. An excellent supervisor works with a candidate to take control of all these aspects. That was exactly what Prof. White did for me. Although he was very firm on achieving the standards required for a PhD, he was never bullish but was patient with me as I struggled with the peculiar iii

iv RURAL WOMEN AND THE FINANCING OF HEALTH CARE IN NIGERIA challenges of a medical doctor doing a PhD in Development Studies. Prof. White s wife, Ratna, also deserves my deep gratitude. She was consistently very humane in attending to my numerous telephone calls and questions from Nigeria. May God bless you! The idea to do a PhD in this subject area and at ISS came from Drs Loes Keysers and Professor Eric Ross to whom I dedicate this PhD. I wish to say a very big Thank You to the two of you for your faith that I could accomplish a PhD project in the Social Sciences despite my academic and professional background in the Basic Medical and Clinical Sciences. I wish to thank you for writing my reference letters for admission into this PhD programme, and for keeping up warm friendship. I benefited in many other ways from you, both financially in the form of teaching assistantship, scholarship for a certificate course at ISS, and in the form of advice, encouragement, etc. My dedicating this PhD to you is my humble way of saying that you will always remain very special to me. I also received much assistance from other academics. These include Professor Paschal Mihyo, Professors Mohammed Salih, Cris Kay, Dele Olowu, Erhard Berner, O Laughlin, and Dr Freek Schiphorst, among others. I appreciate all your kindness (and comments during my thesis seminar in the case of Profesor O Laughlin). My special thanks go to Professor Bart Criel who not only gave me useful comments during my thesis seminar but also gave me very helpful books that helped shape the direction of this thesis. The PhD process might as well have been stalled without the skilled input from many administrative staff. Among them, Ank vd Berg deserves my special gratitude. I received invaluable assistance, kindness and encouragement from her. Despite her ever-busy schedule, she was always on hand to help me surmount many challenges of being at ISS including academic, personal, financial, administrative, immigration, among others. To Ank I say, You are a very special blessing to ISS students, especially me! Keeping the monster called IND at bay is an art that Cynthia Recto-Carreon, Els van de Weele and Ank have perfected. I deeply appreciate the humane, expert and devoted way the trio I just mentioned helped me with my immigration formalities. Martin Blok is very adept at adding social value to the dreary life of ISS PhD programme. Martin, thank you very much! I am also very grateful to Maureen Koster and Dita Dirks of the PhD Secretariat, who handled both academic and personal matters for me during the programme. They always kindly answered my innumerable inquiries concerning many aspects of the PhD programme. I also heartily thank John Steenwinkel, Jeff Glasgow, Henri Robbemond, Ton Rimmelzwaan of the Computer Department,

Acknowledgements v John Sinjorgo, Gita Wijnvoord, and Rose of the Finance Department, Willy Hooymans and Ferry Bozuwa, of the Facility Department, Khalid, and every staff of the Library, especially Joy Misa who handled the editing, formatting and typesetting of the thesis. I wish to thank Sharmini Bissesar for her kindness to me when I worked as Teaching Assistant for the Understanding and Managing Reproductive Health Course. My social networks widened during the programme and I made friends from all over the world. I wish to thank my Muko, Dr Albert Musisi, Dr Marco Sanchez and his wife, Adelita, Dr Fenta Mandefro, Dr Nick Awortwi, Dr Admasu Shiferaw, Sailaja Nandigama, Bram Buscher, Rahki Gupta, Humberto Palomares and his wife, Blanca, Tomo Uchida, Dr Sunbo Odebode and Atsushi Sano. My special thanks also go to Nicky Pouw, Hannington Odame and his wife, Helen, Ifeanyi Ndubueze, Okey Ndubueze and his wife, Irma, Olive Chepkwurui, Sarah Kabasomi, Udan Fernando, Dr Ben Ugbe, Elizabeth Idoko, Henry Kifordu, and John Agbonifo. Ichie (Dr) Augustine Ajah: you are in your own class. I am very grateful to you. Completing the PhD from Nigeria posed great financial and psychological difficulties. I wish to register my profound gratitude to all those who helped me to cope with the difficulties, especially Daddy, P.C. Okeke and Mummy, A. Okeke, Ogadi, Gigi, Chi-Girl, Kenechukwu, and Chinedu, Professor and Dr (Mrs). A.O. Anya, Dr and Mrs Emeka Anyanwu, Dr Frank Korie, Bello Abdul-Lateef, Uchechukwu Dimkpa, Dr and Dr (Mrs) Blessing Okperi, Dr and Mrs Joachim Omeje, Dr and Mrs Frank Ezugwu, Dr and Dr (Mrs) Emma Iyidobi, Mr and Mrs Ken Ezemagu, Mr and Mrs Chinwike Onwuchekwa, Mr and Mrs Anyaele Ukah, Dr Okorie Anyaele, Aniekan Udo, Simeon Dickson, Engr. A.O. Tangban, Mrs F.E. Tangban, Dr (DSP) Benjamin Chukwu, Daddy Paul and Mummy Molly Wasswa, Barrister Joe Nwazi, Chijioke (from Netclick), Chief and Mrs. Boniface Amobi, Dr and Mrs Frank Oguwike, Ray Ude, Aunty Franca and Dr Emma Iroegbu, Dr U.C. Ozumba, Mr and Mrs D. Aka, Barr. Emeka Oko, Mr and Mrs Joseph Obi, Mr and Mrs Edwin Okafor, and Mr and Mrs L.M. Obieri. I am especially indebted to Dr J.N. Chukwu of GLRA, Dr and Mrs Emma Aguwa, and Mr and Mrs Martin Udeinya for being so kind and special in very many ways. You know those great things you did and still do for me: May God bless and richly reward you. I may never really be able to show you just exactly how much I appreciate you. I heartily thank Mr Hoeveenmeier, the PRO, DAHW, Wurzburg, Germany, Mr Gerhard Oehler, the GLRA Nigeria Country Administrator and Mrs Patrica A. Onyia, the GLRA Office Manager for kindly providing the pictures from which the thesis cover was designed and other assistance. Chinyere Ezeala and her husband, Felix, and

vi RURAL WOMEN AND THE FINANCING OF HEALTH CARE IN NIGERIA Ifeoma Chime and her husband, Chris Eze also deserve my special gratitude for their assistance during the course of this programme. I also thank Dr Charles Nwafor, Dr Daniel Ogbuabor, Miss Linda Chidi, Mrs Tive Diogba, Sister Glory, Aunty Stella, Aunty Evelyn, Edith, and other colleagues at GLRA Nigeria for their various support and friendship. Prof. Ikenna Njoku, Rose Sajjabi, Julius and Juliet Wabwire, Daniel and Agnes, Eddy Walakira and other great friends in Uganda: thank you for being there for us and for all your assistance to my family when they were in Uganda. To Uncle Jerry, Uncle Julius, Emmy Ntale, Mama Resty, Martina, Tessy, Luke and Ngo, Kate Naluyinda, and Ernest, I say you have been a great source of assistance and encouragement. Thank you very much. And may God bless you! While I was in Nigeria, help to surmount the difficulties also came from abroad. I wish to appreciate the financial and other assistance I received from my bosom friends Tambu Tangban and his wife, Ada, Odiche and his wife, Dr Ralph Oguariri, Professor and Mrs Sam Anya, among others. It is rather difficult to find adequate words to use to express my feelings of gratitude to my wife Sarah, and our children, Joshua and David, who directly bore the consequences of my being physically away from them for over three years and even when I returned to be with them in Nigeria, I was almost always psychologically absent. My wife has been a great source of support. She had the task of caring for our son, Joshua, alone when he was just seven months until he was almost four years. Even when David arrived, I was so often holed up at the computer that she had to do most of the care. She carried out these tasks with love, tenderness and passion. She never complained about the multiple tasks she had to take on while I worked at the computer. My gratitude to you, Sarah, may never fully be expressed! But suffice it for me to tell you once more that I love and deeply appreciate you for all you are and all you did (and do). The success of this PhD is a testimony to your sterling qualities! To Josh and Dave, Dad will no longer give you excuses for not giving you enough time. And you may now have your turn on the computer to do your own work, and read Encarta! I love you all. And to Mike Brian Mulungi, thank you very much for being such a big blessing to us! I also want to put on record my appreciation to the Netherlands Government for the Netherlands Fellowship Programme (NFP) awarded to me to carry out this programme. Most importantly, I worship the Lord God Almighty, the Great I am, who keeps His words to a thousand generations, for His faithfulness, grace, succour, mercies and inspiration to me during this programme.

Acknowledgements vii Daniel C. Oshi Enugu, Nigeria dannyoshi@yahoo.com

Dedicated to Loes Keysers & Eric Ross viii

Contents Acknowledgements Abstract Maps iii xiii xv 1 INTRODUCTION: RURAL WOMEN AND ACCESS TO HEALTH CARE IN NIGERIA 1 1.1 Introduction and Research Problem 1 1.2 Mutual Aid Mechanisms for Health Risks 6 1.3 User Fees and Access to Health Care 8 1.4 Health-seeking 10 1.5 Research Objectives and Questions 13 1.6 Research Methodology 14 1.6.1 Reasons for choice of study location 14 1.6.2 General considerations on approach and method 14 1.6.3 Methodological approaches and tools 15 1.6.4 Data analysis 21 1.7 Challenges and Limitations 22 1.8 Organization of the Study 25 2 MANAGING HEALTH RISKS: THEORETICAL AND CONCEPTUAL APPROACHES 27 2.1 Introduction 27 2.2 Social Networks 27 2.3 Collective Action 30 ix

x RURAL WOMEN AND ACCESS TO HEALTH CARE IN NIGERIA 2.4 Social Capital 32 2.5 Reciprocity 33 2.6 Risks and Mitigation Strategies 34 Risk-sharing attitudes of rural groups 36 2.7 Gender and Patriarchy 38 2.8 Community-based Health Insurance 40 2.9 Social and Economic Differentiation in Rural Societies 43 2.10 The Household 45 2.11 Summary 49 Note 51 3 SOCIAL AND ECONOMIC ORGANIZATION IN THE STUDY LOCATION 52 3.1 Introduction 52 3.2 The Igbo of Nigeria 52 3.2.1 Igbo social structure: marriage 54 3.2.2 Igbo social structure: the kinship/extended family 56 3.3 Enugu State 57 3.3.1 Enugu City 57 3.3.2 Onitsha 57 3.4 Study Village: Ukete 58 3.4.1 Topography 59 3.4.2 Transport 60 3.4.3 Population 62 3.4.4 Land control and socioeconomic differentiation 63 3.4.5 Households 65 3.4.6 Income-generating activities 66 3.4.7 Intrahousehold socioeconomic differentiation: gender and generation 73 3.4.8 Consequences of inequality in access to land 75 3.4.9 The contexts of financial risks to Ukete women 82 3.5 Conclusion 89 Notes 90

Contents xi 4 HEALTH CARE PROVIDERS 92 4.1 Introduction 92 4.2 National Health System in Nigeria 92 4.2.1 From free services to rationalization 93 4.2.2 Rationalization and gender 95 4.3 Lower Levels of Health Care Providers 97 4.3.1 Patent medicine vendor/village midwife 98 4.3.2 Traditional birth attendants 105 4.3.3 Traditional bone healing: health seeking and gender 109 4.4 Higher Levels of Health Care Providers 111 4.4.1 Primary and secondary health care facilities 111 4.4.2 Tertiary health care institutions 113 4.5 Conclusion 116 Notes 116 5 HOUSEHOLD, KINSHIP AND MUTUAL AID MECHANISMS FOR HEALTH RISKS 118 5.1 Introduction 118 5.2 Igbo Cosmology, Household and Kinship Solidarity in Health Risk Management 118 5.3 Household Mechanisms for Health Risk Mitigation 122 5.3.1 Income/savings as risk mitigation strategies 122 5.3.2 Sale of household/productive assets as risk mitigation strategies 127 5.3.3 No savings and no assets to sell 130 5.4 Extended Family Mechanisms for Health Risk Mitigation 132 5.5 Conclusion 145 6 WOMEN S ASSOCIATIONS AND MUTUAL AID MECHANISMS FOR HEALTH RISKS 147 6.1 Introduction 147 6.2 Umuchu Women s Association: A Group-based Social Network 148 6.2.1 Formation, membership and objectives 148

xii RURAL WOMEN AND ACCESS TO HEALTH CARE IN NIGERIA 6.2.2 Contributions and financial pooling: generalized reciprocity in the social network 149 6.2.3 Mutual aid mechanisms for health risk mitigation 152 6.2.4 Social control 179 6.2.5 Financial risk protection 185 6.2.6 Inadequate coverage of health expenditure: co-payments 188 6.2.7 Consequences of inadequate coverage of health costs 191 6.2.8 Exclusion: unintended effect of social networks 194 6.2.9 Social and emotional support in the social network 198 6.3 Limits of Endogenous Associations 199 6.4 Conclusion 201 Model A 202 Model B 204 Model C 205 Notes 208 7 CONCLUSIONS 210 7.1 Introduction 210 7.2 Synthesis of Empirical Findings 210 7.3 Conclusions 213 (a) Households/kinship mechanism for managing health risks 213 (b) Endogenous association mechanisms for managing health risks 214 7.4 Concluding Remarks 219 References 221

Abstract Rural Women and the Financing of Health Care in Nigeria investigates how rural women in an Eastern Nigerian village make attempts to access health care for themselves and their households. The study explores how rural women finance health care needs through the social agency of household and kinship solidarity, and locally bred women s organization. Ethnographic approaches are used to explore the constraints and opportunities women encounter in deploying these social relations in the effort to overcome financial barriers to health care access at a time when health care services have gone beyond the reach of most rural Nigerians. The study explores the possibility of incorporating locally bred community organizations (as independent titular members) in community-based health insurance (CBHI) schemes. The findings of this study show that the economic situation of most households in Ukete is stagnant or declining, and poverty is widespread. In the current contexts of user fee-based health care and pervasive poverty, access to even quite basic forms of health care is beyond the reach of the majority of the women and their households in the community. As a consequence, many cases of sickness go untreated, or treated by recourse to inappropriate sources (such as patent medicine vendors). Contrary to what might be expected, informal/traditional relationships and networks within the households and kin groups generally do not provide emergency funds for medical treatment, and certainly cannot be relied on. Local-level formal savings-and-loan associations, in which membership is not based on kinship and political factors, can survive and flourish. Poor women are capable of modest levels of savings in such associations, and the take-out dividends (or loans made against them) are frequently used to access professional and hospital treatment in cases of sickness. As regards the possibility of incorporating community-based organizations in CBHI schemes, findings of this study suggest that in relatively remote rural communities with widespread poverty (in Sub-Saharan Africa), local-level mutual aid associations may provide a stable basis for the estab- xiii

xiv RURAL WOMEN AND ACCESS TO HEALTH CARE IN NIGERIA lishment and operation of CBHI schemes. Such a model would incorporate community-based organizations as independent titular members in CBHI schemes. The author suggests that such an approach to CBHI schemes may offer greater financial risk protection to members, minimize burden of premiums, lower operational costs, and provide forum for mutual social influence, social support and social engagement for members.

Maps Map of Nigeria showing 36 states and the Federal Capital Territory Sokoto Katsina Kebbi Zamfara Kano Jigawa Yobe Borno Kaduna Bauchi Gombe Niger Oyo Ogun Lagos Kwara Osun Ekiti Ondo Edo Kogi FCT Nassarawa Enugu Anamb Ebony ra Benue Plateau Taraba Adamawa Delta Bayelsa Imo Rivers Abia Akwa Ibom Cross River xv

xvi RURAL WOMEN AND ACCESS TO HEALTH CARE IN NIGERIA Map of Enugu State showing Ukete (the study community)

Maps xvii Map of Igboland (Southeastern Nigeria) showing the various states, their capitals and important cities/towns)