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CHOICE ASSESSMENT OF THE FORMAL AND INFORMAL HEALTHCARE SYSTEMS IN Kano state: A study of Four Selected local Government Areas

AHMED IDRIS FABUDA (SMS/10/ECO/01127)

BEING A RESEARCH PROJECT SUBMITTED TO THE DEPARTMENT OF ECONOMICS, BAYERO UNIVERSITY, KANO, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF BACHELOR OF SCIENCE (B.SC) DEGREE IN ECONOMICS

MARCH, 2015

DECLARATION I hereby declare that, this work is the product of my own research efforts, undertaken under the supervision of Dr. Mansur Idris and has not been presented anywhere for the award of a degree or a certificate, except in partial fulfilment of the requirements for the award of Bachelor of Science degree in Economics, Bayero University Kano. All sources and materials used have been duly acknowledged in the references, and any act of commission or omission is not with intent and is highly regretted.

_____________________ AHMED IDRIS FABUDA SMS/1O/ECO/01127

APPROVAL/CERTIFCATION This dissertation entitled "Choice Assessment Of The Formal And Informal Healthcare Systems In Kano State" by Ahmed Idris Fabuda has been read and approved as meeting the requirements for the award of Bachelor of Science Degree in Economics, Bayero University, Kano and is approved for its literary presentation and contribution to knowledge.

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Dr. Mansur Idris

Date

Supervisor

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Dr Mohammed Aminu Aliyu

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Level Coordinator

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Dr Mustapha Mukhtar

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Head of Department

DEDICATION In the memory of my late Grandmother (Hajiya Ramatu Yusuf Fabuda) and my parents, May the Almighty Allah forgive them and grant them Aljannatul Firdaus, Amin.

ACKNOWLEDGEMENTS Praise is to Allah the Almighty, the Master of the universe, He who with His Blessing and Majesty good things are accomplished. I am very grateful to Him for sparing my life and blessing me with good health and the wisdom to undertake this dissertation. I owe all my efforts and success unto Him. My deepest appreciation goes to Almighty Allah and my supervisor, Dr. Mansur Idris, for his priceless guidance, tolerance and comprehensive supervision and assistance, throughout the period of this research study. And to my Level Coordinator Dr. Mohammed Aminu Aliyu, and Head of Economics Department, Dr Mustapha Mukhtar, may Allah reward them abundantly for their patience and fatherly care. My special thanks also goe to Professor Alimi Isiaka Pedro, Professor Dalhatu Mohammed Galadanchi, Professor Garba Ibrahim Sheka and to all other members of staff of the Department of Economics, Bayero University, Kano, and especially Dr. Hassan Suleman, Mallam Nura A. Kabuga, Dr. Shehu Muhd Tijjani, Dr Badamasi Usman and Mallam Ahmed Abdullahi for their support and priceless contributions towards the successful completion of this work. I also appreciate the support and immense contributions of my course mates for the successful completion of this work, especially Fauziyya Hamidu Kindi, Mu’awiyyah Usman, Timothy Ter Ayati and Mohammed Kayode Oyewale of Accounting department just to mention but a few. I would also like to express my appreciation to my friends and colleagues too numerous to be mentioned, who have significantly contributed in making this research a success, including Ahmad Surajo (namesake), Shehu Usman Ahmed Sa’id, Mohammed Nasa’i Ibrahim and Dr Isma’ila Ojochogwu Abdul Saba. I thank them all for their advice and well wishes. Finally, I would also like to express my sincere appreciation to my loving mother Hadiza Idris Fabuda, my elder Brother, Yusuf Idris Fabuda, my younger sister Habiba Idris Fabuda, my father Idris Yusuf Fabuda and my dear Uncle Abubakar Yusuf Fabuda and Aunt Hauwa Dawood for the concern, care, advice, patience and love given to me. Their words and contributions really count a lot towards the accomplishment of this work. May the Almighty Allah forgive all their short comings and grant them Al-jannatul Firdaus (Amin).

ACRONYMS CAM - Complementary and Alternative Medicines FHC – Formal Health Care FBH - Faith Based Healers GDP - Gross Domestic Product GNI - Gross National Income HIV/AIDS - Human Immune-deficiency Virus / Acquired Immune-deficiency Syndrome HMO - Health maintenance organizations IHC – Informal Health Care IHP – Informal Healthcare Provider IV - Instrumental Variables IMF - International Monetary Fund LPM - Linear Probability Model MDGs - Millennium Development Goals MOH - Ministry of Health MC - Modern Care NAFDAC - National Agency for Food and Drugs Administration and Control NDP - National Drugs Policy NHIA - National Health Insurance Authority NHIS - National Health Insurance Scheme NHS - National Health Service

NIE - New Institutional Economics NGO - Non-Governmental Organisation OECD - Organisation for Economic Cooperation and Development OU - Outcome Utility OTC - Over-the-Counter PPO - preferred provider organizations TBA - Traditional Birth Attendants TC - Traditional Care TH - Traditional Healers TMPC - Traditional Medicine Practice Council TCAM – Traditional, Complementary and Alternative Medicines TM/H - Traditional Medicines/Healers WB - World Bank WHO - World Health Organisation WHS - World Health Survey

CONTENTS Preliminary Pages

i-vi

Contents

vii CHAPTER ONE

General Introduction 1.0. Background

1

1.1. Statement of Research Problem

6

1.2. Objectives of the Study

8

1.3. Research Questions/Hypotheses

8

1.4. Justification of the Study

9

1.5. Scope and Limitations of the Study

9

1.6. Study Area

11

1.7. Approach and Organisation of the Study

12

CHAPTER TWO Literature Review 2.0. Introduction

13

2.1. Conceptual Literature Review

14

2.2. Theoretical Literature Review

24

2.3. Empirical Literature Review

37

2.4. Healthcare Demand Modeling

45

2.5. Summary and research Gaps

49

CHAPTER THREE Methodology 3.0. Introduction

50

3.1. Research Design

50

3.2. Population

51

3.3. Sample

51

3.4. Instrumentation

52

3.5. Data Collection Procedure

52

3.6. Data Processing and Analysis

52

3.7. Model Specification

53 CHAPTER FOUR

Data Presentation and Analysis 4.0. Data Presentation

64

4.1. Data Analysis

64

4.2. Summary of Findings

67 CHAPTER FIVE

Summary, Conclusion and Recommendations 5.0. Summary

68

5.1. Conclusions

68

5.2. Recommendations

69

Appendix

71

Bibliography

85

CHAPTER ONE 1.0: Background to the Study: Good health of a population is vital and a prerequisite to achieving optimum socio-economic and political development. It is also an important indicator of quality of life and a major contributor to human capital, this is reflected in the fact that “Improved health leads to improvement in life expectancy and reduces production time wasted, thus resulting in economic development”according to Mugilwa (2005). The linkages of health to general economic performance - like poverty reduction and long-term economic growth, are much stronger than is generally understood (WHO, 2001). It has also been illustrated with the macro-triangle (Suleman, 2012) that, there is strong duplex interdependence between health systems and economic systems. From the health perspective, on one hand, the health (status) of a country’s population is seriously influenced by the level and quality of economic activities and by the availability of effective healthcare services. On the other hand, health is one important determinant of national economic performance and expenditures on healthcare products and services. From an economic perspective, poverty has adverse effects on health status as economic deprivation restricts access to quality healthcare; conversely, poor health contributes to being poor as declining productivity leads to low income levels. The fashion in which effective healthcare services are provided affects the health of individuals and populations. Therefore, in the delivery of services of proven efficacy and effectiveness, emphasis must be placed on evidence-based decision making and achieving cost-effectiveness. It is expected that if, a population’s health improves and all other factors remain fixed, the future need for healthcare should lessen. This implies that healthcare services with lower overall costs

of maximizing one’s health are preferred as needs, new and old, are redefined and made apparent, respectively. In addition to those influences on the need for healthcare which may arise indirectly through the influence of economic performance on health, a prosperous economy could conveniently provide the capacity to sustain the delivery of comprehensive and high quality health services to its population. The interrelationship of prices and wages in the healthcare sector and the general economy gives allowance for the expansion of an economy’s domestic medical goods industry to have spillover effects on the choice and intensity of healthcare utilization and expenditure. Conversely, healthcare indirectly influences economic performance through its impact on health as commitment of resources to healthcare may have direct effects on the economy which is determined by the alternative uses to which those resources would have been put. In many developing countries, accessibility to healthcare is an integral part of the strategies for health improvement then consequently, increased productivity and poverty reduction. Health is a priority in its own right, as well as a central input in economic development (WHO, 2001). The Millennium Development Goals (MDGs) identify health as an integral part of strategies for fighting poverty. Improvement in accessibility to quality healthcare portends much social benefits to the poor and consequently spillovers to the wealthy as it leads to reduction in poverty, not just as a result of time-saving, but in the development of more productive human capital as well. The established importance of health to development stimulates societies to make provisions for healthcare delivery systems for its members. It is a common practice for countries to enunciate healthcare policies aimed at the maintenance and improvement of the health status of the

citizenry. This is with a view to providing medical and related services for the maintenance of good health, particularly through the prevention and treatment of diseases and borne out of the realization that good health care is paramount for the well-being of the citizens and subsequently the socio-economic development of their various societies (Adefolaju, 2014). The World Health Organisation defines Traditional medicine as that which “refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being” W.H.O., (2002). In as much as alternative forms of healthcare still prevail in most parts of the world, there seems to still be few and inadequate statistical data on the level of their activities. The first attempt at compiling comprehensive information on traditional medicine globally as regards policy, regulation, financing, education, research, practice and utilization was the efforts of the World Health Organisation (W.H.O.) when it published the WHO Global Atlas of Traditional and Complementary Medicine (Bodeker et al 2005). The publication declares with clarity that it relied on secondary data due to shortage of primary data in most of the targeted countries. Payyappallimana (2009) reveals that, according to a regional overview in the WHO Africa Region (AFR) only 50% of the population has access to essential healthcare while 80% continue to rely on African Traditional medicines that include herbal medicine, spiritual therapies and manual therapies. Individuals all over the world continue to utilise traditional, complementary and alternative medicines (TM), as primary or complementary sources of health care. The World Medicines Situation report (World Health Organization 2011, p. 3) estimates that between 70 and 95% of the population in developing countries consume TM and that every country in the world uses it

in ‘some capacity’. High utilisation rates are reflected in the rapid growth in number of herbal outlets, clinics and hospitals (Bloom & Standing, 2001; van der Geest & Whyte, 1988), and a significant world market worth an estimated $83 billion in 2008 (World Health Organization, 2011, p.3). Such figures are evident despite rapid economic and social development, through which countries have experienced improved financial and political capabilities to provide modern public health systems. This raises the question, ‘why do people continue to utilise Informal healthcare when formal (modern) healthcare services are available’? Specifically, what kinds of economic, social and procedural rationales can explain this behaviour? And what are the implications for the distribution of health services among the population (Sato, 2011)? Traditional medicine as a practice has been transmitted across generations largely through oral communication. Above 4000 species are used in Alternative and Traditional Medicine which is predominantly (90%) plant based. Over half (56%) of the countries in the African continent have formulated traditional medicine policies and have established department in national health ministries and developed several strategies for the promotion Alternative and Traditional Medicine and its integration into the general healthcare system (Payyappallimana, 2009). More so, in 2001, a regional strategy for promoting Alternative and Traditional Medicine was adopted after which at the World Health Assembly 2003 a resolution on Alternative and Traditional Medicine was passed. An Alternative and Traditional Medicine day is also observed on the 31st of August every year for advocacy among member countries. The African Summit of Heads of State in 2001 declared 2001-2010 as Alternative and Traditional Medicine decade. Government instituted and Self-regulatory bodies have been established in many countries across the continent (Kasilo et al. 2005). The W.H.O. and African Summit of Heads of State have laudably

promoted these developments with a view to facilitating research and integration in the management of HIV/AIDS, Tuberculosis, Malaria and other infectious diseases. Most existing research into issues on healthcare – socioeconomic performance focus on contemporary or formal (modern) healthcare delivery, the few investigations into traditional and other forms of informal healthcare have not penetrated adequately deep into the crust of traditional and informal healthcare market analysis and its effect on national economic performance. Studies on informal healthcare systems, especially traditional healthcare in subSaharan Africa, have taken subjective approaches. Using descriptive-comparative analysis they provide mostly sociological and cultural explanations for the intrinsic value of informal healthcare products and services on the lives of individuals and on the society as a whole. The bulk of research informal healthcare especially in the developed world tend to focus mostly on informal care-giving (i.e. caring for the needy – children, elderly and sick) in non-corporate enterprises as an alternative to corporate public and private care institutions. Empirical literature related to the topic in focus centered on sub-Saharan Africa though limited in quantity, have been emphasized in the literature review as they are more applicable to this study. Nigeria runs a dual system of health care delivery - the officially recognized orthodox system and the barely tolerated traditional system. The stiff opposition to traditional medical practice from official quarters has not whittled down its level of patronage by the people simply because it was developed in response to the dictates of their environment. Consequently it is considered affordable, accessible and efficacious by the people. The importance of informal healthcare practices in meeting the medical needs of the Nigerian population has been emphasized by many researchers like Emmanuel (1973), Ademuwagun (1969), Sofowora (1973 and 1982), Akinkugbe (1979), Noah (1995), Omogbadegun and Adegboyega(2013), and Adefolaju (2014).

As Health economics applies to reflections of humans’ desire for maximizing monetary and resource value by ensuring not just the clinical effectiveness but also the cost effectiveness of healthcare provisions and interventions (Haycox 2009), this study works from this perspective to assess the economic manifestation of the clinical and cost effectiveness of an old and suppressed but very much existing and vital sub-division of the healthcare sector. This work aims to contribute towards bridging that gap, which kept informal Medicare from the spotlight of economic and econometric analyses with a view to providing empirical evidence based interpretations of economic relationship between informal healthcare systems and the individual in the society and between the informal healthcare system and the society at large. 1.1: Statement of the problem: In the recent, past there has been growing interest in the age long Traditional/Complementary and Alternative Medicine (TCAM) and its significance to public health in developed and developing nations alike. According to Payyappallimana (2009), “Diversity, flexibility, easy accessibility, broad continuing acceptance in developing countries and increasing popularity in developed countries, relative cost, low levels of technological input, relative low side effect and growing economic importance are some of the positive features of traditional medicine (WHO, 2002).” While pointing out that there is a critical need to push back traditional medicine into the mainstream in order to attain improvement in access to healthcare facilities, Payyappallimana informs that evidence suggests a disparity between personal choices the public make in terms of integration of the different medical/healthcare systems. Some shortcomings and policy issues of informal healthcare (TCAM) may include safety, efficacy quality and rational and regulated use of informal healthcare products.

In almost all continents, there is acute shortage of data on the nature of Informal healthcare utilisation, patient (consumer) choice, socio-demographic and socio-economic characteristics of users, economics of utilisation and safety issues (Payyappallimana, 2009). Self-regulation seems quite widespread in Africa, Americas and Europe, though in other continents Informal healthcare is managed and regulated by government agencies. In continents such as South East Asia and the West Pacific, there are well established university programmes for Traditional and Complementary medicine, while on other continents, TCAM education is informal. On all continents, the role and patronage played by the civil society, community groups and other active members of the society in the survival, promotion and integration of TCAM is an issue one cannot overlook. As in most regions, information about non-registered TCAM practitioners in Nigeria is fairly scant and, unlike some other regions, there is a low tendency for creating uniformity among systems and standardisation is attempted through what is often criticized as ‘bio-medicalization’. These issues affect the sustenance of the diversity of TCAM. Being a key resource for the general healthcare industry, this situation is a real paradox and requires immediate attention. This work attempts to address the question of the relative and absolute significance of the Informal healthcare (IHC - TCAM) industry in the Nigerian economy. This problem is first approached through the investigation of the relationship between the size of the informal healthcare industry (supply side) in relation to influencing factors like employment, bank loans to SMEs and other relevant variables. Secondly, the nature of healthcare demand choices and utilization is investigated; this involves estimating the relationship between the probability of an individual resorting to a particular type of healthcare provider and factors that influence choices in healthcare.

1. 2: Research Questions: This dissertation deals with informal healthcare (TCAM). The adopted approach is mainly economic - econometric, but also concepts and methods from other disciplines like sociology psychology, community medicine and public health are used. i.

Determine factors that affect healthcare choice.

ii.

Determine if there is 50% likelihood of the respondents preferring IHC to FHC.

In trying to find answers on the research questions, we will combine economic theory with econometric techniques. Therefore, one used primary sources of data collected by the researcher within the framework of the analysis of healthcare users’ demand for healthcare services (Timmermans, 2003) was used. We deal with these different but related economic problems regarding informal healthcare in form of these above stated research questions. 1.3: Objectives of the study: The main purpose of this research is to reveal the general significance of the informal healthcare industry in the country. In this quest, the study specifically aims to: 

Estimate the determinants of healthcare choice.

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Determine the proportion of the population that prefer Informal Healthcare to Formal Healthcare.

1.4: Justification of the Study: The purpose for conducting this research is to review the current status of informal healthcare service delivery and reasons behind its continued existence. This works also goes to reveal the impact of the activities of the informal healthcare industry on the Nigerian economy particularly, the productivity of users, the employment opportunity it provides and the seeming competition or collaboration (as the case may be) with contemporary healthcare. The research contributes to the existing body of literature by applying the theory of institutional economics in a quest to address the polarity of sociologic and economic approaches (Kroeger, 1983; Sachs & Tomson, 1992; Sato, 2011). In so doing, this work reaches out to a broad social science and medicine audience and analyses self-collected data to build upon already existing household surveys. This research presents a user’s perspective on the continued use of TM within the framework of existing modern health systems. By placing Informal Healthcare on equal footing with modern healthcare utilisation and allowing for multiple sources of care for a given episode, individuals were more inclined to mention it and therefore reveal its significance (Sato, 2011). This research could also be beneficial to students and scholars of the economics (health economics), sociology (anthropology) and medicine (community medicine and public health) disciplines as it adds to the wealth of literature and data compiled on Informal healthcare. It shall also be attractive to individuals whom have inherent interests in the development of Traditional and Complementary Medicine in the Nigeria. 1.5: Scope and Limitations: The study encompasses individuals and groups directly involved in medical practice – formal and informal medical practitioners alike, and users of both forms of healthcare. It also draws it

samples from members of the community in Kano state, Nigeria, in Western Africa. This is so because; Kano state remains one of the most populous states in the federation and is home to numerous tribes and religious groups with good representation. The state is also known for being the commercial nerve centre of the northern region accommodating business visitors and tourists from far and near that gives the researcher the opportunity assessing the implications of differences in healthcare choices on a wide variety of trades, crafts and businesses. This work, on one hand, focuses on the static picture of the Informal healthcare system utilisation pattern of members of the Kano community within a year (2014). On the other hand, it covers only four local government areas in Kano state (Fagge, Gwale, Kumbotso and Ungogo). This is because; they are among the most populated and culturally mixed areas in the state. Fagge homes the three largest markets in the state in an urban setting; Gwale hosts three campuses of different tertiary institutions and several renowned secondary schools also in an urban setting; Kumbotso is home to two large industrial areas, one tertiary institution and wide expanse of residential area in a suburban background; and Ungogo being the host of a university campus, farmlands, ranches in rural and sub-urban terrain. This work is limited by lack of adequate financial resources to conduct the investigations on a wider scale than what was achieved. It is also hindered by shortage of ample time to conduct the study in a more convenient manner and lack of adequate literature, especially on accurate econometric models, accompanying variables, measurement standards and quantitative data relating to Informal healthcare. Another limitation of this study is that concurrent use of orthodox with herbal medicines was not evaluated. This is because individuals with chronic illnesses, who are likely to use prescribed orthodox medicines regularly, were excluded from the study. Our data represent one point in time and do not reflect changes in patients’ experiences

with herbal medicines over time. Although, the demographics of the herbal medicine users in this study were similar to the characteristics of users reported in previous works, our findings may not be necessarily generalizable to other populations in Nigeria. 1.6: Study area: Kano is a state in northern Nigeria, in the Sahelian geographic region south of the Sahara. Located within the coordinates: latitude 12000’ North and longitude 8031’ East. It is the second most populous state in the country, with a population of above 11 million people (2006 Census figures) The capital city, Kano, is also the second largest city in the country, with an estimated population of above 2.2 million people (2006 Census). The metropolis also accommodates an estimated population of about 3 million people in 499 km2 (193 sq. miles) of fairly arable land (2006 Census). The main Kano urban area covers 137 km2 and comprises six local government areas (LGAs) – Kano municipal; Fagge; Dala; Gwale; Tarauni; and Nassarawa. The metropolitan area comprises of the six mentioned above plus Ungogo and Kumbotso (Source Wikipedia, the free encyclopedia – accessed December 19th, 2014). This research is conducted in four local government areas of Kano state, North-Western Nigeria, West Africa, namely: 

Fagge:

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Gwale:

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Kumbotso:

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Ungogo:

1.7: Approach and Organisation of study: This research attempts to contribute to the theoretical and policy oriented economic literature on informal healthcare (TCAM). This research contains five chapters. This first chapter introduces the entire work, the following chapter review past literature – conceptual, theoretical and empirical – concerned with the items in focus. The third chapter carries the adopted methodology (clarifying the approach style and angle on what variables entail, and how the gathered data is processed), while the fourth chapter presents the data gathered on the field and their subsequent analyses. Conclusions and recommendations follow in the fifth chapter.

CHAPTER TWO LITERATURE REVIEW 2.0: Introduction: In Nigeria, a dichotomy exists between traditional and orthodox medical practices even though there are now moves towards policies of some tolerance and recognition (Raphael, 2011). This chapter presents reviews of past research studies relevant to the general topic in question, beginning with definition of the conceptual structure followed by theoretical background support and finally an in-depth review of empirical literature from past studies. Globally, people developed unique indigenous healing traditions adapted and defined by their culture, beliefs and environment, which satisfied the health needs of their communities over centuries [WHO, 2011]. The increasing widespread use of TM has prompted the WHO to promote the integration of TM and CAM into the national health care systems of some countries and to encourage the development of national policy and regulations as essential indicators of the level of integration of such medicine within a national health care system [WHO, 2011]. Despite the widespread use of herbal medicines globally and their reported benefits, they are not completely harmless. The indiscriminate, irresponsible or non-regulated use of several herbal medicines may put the health of their users at risk of toxicity (Abt et al, 1995). Also, the World Health Organisation reveals that there is limited scientific evidence from studies done to evaluate the safety and effectiveness of traditional medicine products and practices. Adverse reactions have been reported to herbal medicines when used alone [Oshikoya, 2007; Oreagba, 2011] or concurrently with conventional or orthodox medicines [Langlois-Klassen, 2007; Oreagba, 2011]. Despite the international diversity and adoption of TM in different cultures and regions, there is

no parallel advance in international standards and methods for its evaluation. National policies and regulations also are lacking for TM in many countries and where these are available; it is difficult to fully regulate TM products, practices and practitioners due to variations in definitions and categorizations of TM therapies [WHO, 2011]. Lack of knowledge of how to sustain and preserve the plant populations and how to use them for medicinal purposes is a potential threat to TM sustenance. Previous studies of herbal medicine use in Nigeria were focused on adults with various forms of chronic illnesses [Danesi et al, 1994; Amira et al, 2007; Ogbera et al 2010; Oreagba et al, 2011], pregnant women and children with chronic illnesses and others [Fakeye et al, 2009; Osemene et al , 2011; Oreagba et al 2011]. The use of herbal medicines among a general population without chronic health conditions has never been evaluated in Nigeria or other African countries [Oreagba et al, 2011]. 2.1: Conceptual Literature Review: This section presents definitions and further explanations on the concepts employed in this work, with an attempt to clarify the basis on which the work was done. 2.1.1: Definition of Terms and Concepts: a) Concept of The Informal Sector: An informal economy or informal sector plays an important role on employment, income and the supply of overlooked markets in developing economies. Its expansion and changing structures have attracted the interests of researchers and international policy-makers to the factors hindering its formalization (Saglam, 2008). The term was first used by Keith Hart in 1973 to describe – compliance with government regulations (registration, tax payments and adherence to labour and trade regulations); size of firm; firm’s level of resource endowments

and applied technology (i.e. labour or capital intensive); location; physical space of operation; and the characteristics of workforce and ownership - in relation to interrelated aspects. According to Wikipedia, the term informal economy refers to all economic activities that fall outside the formal economy regulated by economic and legal institutions. Saglam (2008) says that it refers to the general market income category (or sector) in which certain types of income and the means of their generation are unregulated by the institutions of society, in a legal and social environment in which similar activities are regulated. It also deals with economic activity that is not properly taxed or completely monitored by the government; and is not included in that government’s Gross National Product; as opposed to a formal economy. The above definitions facilitate the application of the term ‘informal’ to traditional and complementary and alternative medicine as most players in this sub-sector in Nigeria operate informally. b) Concept of Informal Healthcare (IHC): In this work, TCAM and TM/H denotes ‘traditional, complementary and alternative medicine’ and ‘traditional medicines/healers’, and are collectively referred to as Informal Healthcare (IHC). Traditional Medicines refer mainly to ‘herbal medicines’ including ‘herbs, herbal materials, herbal preparations, and finished herbal products that contain parts of plants or other plant materials as active ingredients’ (World Health Organization, 2008). The practice of informal medicine takes many different forms, encompassing Traditional, Complementary and Alternative Medicine (TCAM). The scenarios represent ubiquitous events in the lives of health care professionals as they routinely experience medically-related requests from friends, family, co-workers, and neighbors. These events may begin as early

as when individuals are still in training or apprenticeship. Informal medicine covers a broad range of phenomena. The major part of informal healthcare practice, Herbal medicines, also called botanical medicines or phytomedicines, refer to herbs, herbal materials, herbal preparations, and finished herbal products that contain parts of plants or other plant materials as active ingredients [Oreagba, 2011]. The plant materials include seeds, berries, roots, leaves, bark or flowers [Ehrlich, 2010]. Many drugs used in conventional medicine were originally derived from plants, for instance, Salicylic acid is a precursor of aspirin that was originally derived from white willow bark and the meadowsweet plant (Filipendula ulmaria (L) Maxim) [Raskin, 1992]. In Nigeria, about 205 medicinal plant species are endemic in nature in the Northern, Western, Central and Eastern zones of the country (FEPA, 1992). Intense debates surround the issue of how to conduct clinical trials of herbal medicine according to western pharmaceutical clinical standards (Osemene et al, 2011), while critics say that there is an inherent problem with the single active ingredient approach favoured by orthodox medicine companies that are effectively interested in deeper research into herbal medicine. According to Chaudhurry (1992), it is argued that isolating a single compound may not be the best approach in situations where a plant’s activity reduces due to further fractionalization or where the plant contains more than one active ingredient that must be consumed together to be fully effective. Several cases as documented by Beckstrom-Sternber and Duke (1994) show where synergy has been lost by applying the single ingredient approach to developing drugs from herbal plants. Pharmanews in 2010, reveals that other issues associated with informal healthcare practices worth noting include lack of dosage specifications, prominent doubts herbal

preparations such as lack of proof of efficacy and safety, proper packaging problems, appropriateness of level of hygiene, cost of production and level of acceptability especially among the literate and educated class of members of the society and healthcare industry who continue to favour and prescribe only formal healthcare products (orthodox medicine) in hospitals, clinics, pharmacies and so on. c) Traditional, Complementary and Alternative Medicine (TCAM): Traditional medicine has a broad range of characteristics and elements which earned it the working definition from the World Health Organization (WHO). Traditional medicines (TM) are diverse health practices, approaches, knowledge and beliefs that incorporate plant, animal and/or mineral based medicines, spiritual therapies, manual techniques and exercises which are applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness. In the developed countries, TM has been adapted outside its indigenous culture to “Complementary” or “Alternative” medicine (CAM) (WHO, 2011). In many cases, this means medication by plants obtained from within the community or from an informal (unregulated/untrained) vendor or by self (Oreagba et al 2011). Traditional Medicine differs from modern, scientific medicine (formal healthcare) typically produced by pharmaceutical companies. The label ‘Complementary And Alternative Medicines’ (CAM) is used in systems in which health care is predominantly ‘modern’. WHO thus uses ‘TM’ for countries in Africa, Latin America, South East Asia and the Western Pacific, whereas ‘CAM’ is used for Europe, North America and Australia (World Health Organization, 2002). Traditional Healers are defined as individuals who provide traditional health services to the public and the term is used interchangeably with ‘Traditional medicine practitioners’ (TMP) or ‘faith based healers’ (FBH). Such practitioners typically have little

or no ‘training’ from formal institutions but are typically recognised by local communities (Helman, 2000). A widely used, all-encompassing definition of Traditional Medicine is: ‘the diverse health practices, approaches, knowledge and beliefs incorporating plant, animal and/or mineral based medicines, spiritual therapies, manual techniques and exercises applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness’(World Health Organization, 2001, pp. 1-2). Another definition of TCAM is: ‘the sum total of knowledge, skills and practices based on the theories, beliefs and experiences in\digenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses’ (World Health Organization, 2002; Raphael, 2011; Sato, 2012). d) Concept of Informal Healthcare Providers (IHP): While the precise definition of the term ‘‘Informal Health Care Providers’’ is inconsistent across studies and no developed typology in the literature found, it is paramount to provide a working definition in order to identify relevant studies. A flexible set of criteria as opposed to specific delineations for characteristics such as duration of training or group membership is hereby used. Such rigid definitions are inappropriately constrictive in light of significant contextual variation. To be classified as such, IHPs must meet the first criteria below, and at least two of the remaining three criteria which include the following as suggested by Sudhinaraset, Ingram, Lofthouse and Montagu (2013): i. Training: IHPs include those who have not received formally recognized training with a defined curriculum from an institution (i.e. government, NGO, or academic institution). IHPs, however, typically have some level of informal training through apprenticeships, seminars, and workshops, and are typically not mandated by any formal institution.

ii. Payment: IPs collect payment from patients served, not from institutions. One notable exception to this criterion involves NGO or other sponsored voucher programs, where informal healthcare providers exchange services or goods for payment from a sponsoring body in the form of reimbursement vouchers. Payment is usually, but not always, undocumented and tendered in cash. IPs are chiefly entrepreneurs. iii. Registration and regulation: IHPs are not typically registered with any government regulatory body and operate outside of the purview of regulation, registration, or oversight by the government or other institutions iv. Professional affiliation: IHP professional associations, if they exist, are primarily focused on networking and business activities and conduct minimal self-regulation. (Source: Sudhinaraset, Ingram, Lofthouse, Montagu, 2013) IHPs are a heterogeneous group of providers with differences in type of training, regulatory frameworks, and services provided; however, in this paper, we purposefully decided to take an all - inclusive approach and include in the results and discussions all types of informal providers into one category for a number of reasons. First, local governments tend to think of providers outside the formal sector as one group with little knowledge on the size and utilization of this sector. A comprehensive global summary is needed given the lack of information known. Second, the current literature typically does not specify what type of informal provider is included rather it includes multiple types of informal providers in the study. It is quite common that informal providers in different contexts are performing similar preventative and curative activities, even if they have different titles depending on their locale. Therefore, key lessons learned can translate to a variety of providers who are untrained and work outside regulatory frameworks. A major example is given below:

Traditional Healer: Traditional Healers are defined as individuals who provide traditional health services to the public and the term is used interchangeably with ‘traditional medicine practitioners’ (TMP) or ‘faith based healers’ (FBH). Such practitioners typically have little or no ‘training’ from formal institutions but are typically recognised by local communities (Helman, 2000). Some Traditional Healers use the trade as a second or third job while for others it is a full time (albeit largely informal) occupation. The classification of TH remains somewhat unclear, with only rudimentary, conflicting definitions available (Stekelenburg et al., 2005; Twumasi, 1979). However, they can broadly be categorised into four broad groups: i.

Herbalists; are the most common type of healers; usually men who primarily use medicinal plants but occasionally also use animal parts and minerals. Herbalists can be spiritual or non-spiritual. The non-spiritual ones do not relate their practice to divine or religious backgrounds, while spiritual herbalists incorporate religious aspects and items into their practice (Sato, 2012). In this light, the non-spiritual herbalists are closely aligned to modern or formal healthcare practitioners and are relevant in this study.

ii.

Diviners; are usually women and were ‘chosen’ or encouraged to take up the practice through a dream or a ‘calling’ (Twumasi, 1979b). Often diviners belong to a revival sectarian or African-based syncretic church (Dixon, 2008) and an increasing number of ‘church camps’ claim to heal some illnesses, including impotence, infertility and mental illness, by communicating with the supernatural (Twumasi, 1979b).

iii.

Fetish priests; are similar to diviners but diagnose illnesses via deities by acting as an agent between the patient and the supernatural (gods or ancestors, for example).

Sometimes a shrine can be found in villages or towns to honour these deities and locals offer gifts in return for their safekeeping (own observation). iv.

Healers; refer to those who utilize physiotherapy and physical manipulation of body parts and other physically based methods to achieve health improvement results without application of synthetic drugs and or dissections. They are classed according to their specialism. They use a wide variety of healing techniques according to their line of work.

For the purpose of this research, the spotlight is focused on only two – herbalists and healers – as they are more relevant to this study. e) Concept of Formal Healthcare: This term, in this research is used to imply all that falls under orthodox and contemporary medicine. Orthodox medicine refers to the knowledge, practices and organization and social roles of medicine in westernized cultures, according to Good et al (1979). Osemene et al (2011), says that disease in this aspect, is viewed as a mechanical or physical disorder with little relationship to a person’s psychological, social and spiritual afflictions. Treatment often involves reacting to and suppressing symptoms rather than encouraging self-healing or disease prevention (Thomas, 2002). Osemene and his colleagues went further to show that orthodox medicine is an offshoot or outgrowth of scientific inquiry and the technological revolution with its test tubes, use of laboratory-synthesized chemicals and high-tech diagnostic equipment (Pharmanews, 2006). f) Concept of Economic evaluation: An economic evaluation is a systematic valuation of the relative efficiency of health care interventions. It deals the uncertainty about the effects of health care to provide decision

makers information that can be used in decisions making regarding the implementation of new interventions or the prioritisation of different interventions, given the health care budget. Implementation involves, among other things, deciding on what interventions to include in insurance packages. In a system of regulated competition, insurance companies rather than individual consumers purchase care from health care suppliers, because individual consumers lack the necessary knowledge and bargaining power to purchase the care for the price-quality relation of their choice (Wikipedia). g) Stated Preference Methods of Economic Evaluation: Stated preference methods rely on survey questions that ask individuals to make a choice, describe a behavior, or state directly what they would be willing to pay for specified changes in environmental services not traded in markets. The various stated preference techniques are distinguished by how the information is presented, what questions are asked, and how their responses are formatted. It is important to acknowledge that the choices, stated values, or revised patterns of use are derived from answers to questions that ask respondents what they would do, or how much they would pay for, or how they would alter their choices in response to changes in the amount of a non-market good or service in a specified hypothetical setting. This is in contrast to Revealed Preference Methods, which are based on observing the actual choices made by people facing real constraints on income, etc. Stated preference methods offer the opportunity to measure trade-offs for anything that can be presented as a credible and consequential choice. Hence, their primary advantage is their ability to, in principle, measure a wider set of values. In particular, they are the only economic methods that can measure non-use values.

Although not all authors use the same terminology, the term stated preference methods generally include any survey questions in which respondents are asked hypothetical questions designed to reveal information about their preferences or values. The term encompasses three broad types of questions. The first type involves questions that ask directly about monetary values for a specified commodity or environmental change. These are usually called contingent valuation method questions (CVM). In the past, the most commonly used CVM questions simply asked people what value they place on a specified change in an environmental amenity or the maximum amount they would be willing to pay to have it occur. These are usually open-ended in that the individual has to state a number rather than respond to a number offered by the researcher. The responses to these questions, if truthful, are direct expressions of value. The other major type of CVM question asks for a yes or no answer to the question, “Would you be willing to pay $X ...?" Each individual's response reveals only an upper bound (for a no) or a lower bound (for a yes) on the relevant welfare measure. Questions of this sort are termed discrete choice questions. Responses to discrete choice questions can be used to estimate willingness-to-pay functions or indirect utility functions. The second and third major types of Stated Preference methods do not reveal monetary measures directly. Rather, they require some form of analytical model to derive welfare measures from responses to questions. The second type of question is called variously "choice experiment," "conjoint analysis," or sometimes an "attributes based method” (Holmes and Adamowicz, 2003). In this approach to questioning, respondents are given a set of hypothetical alternatives, each depicting a different bundle of environmental attributes. Respondents are asked to choose the most preferred alternative, to rank the alternatives in

order of preference, or to rate them on some scale. Responses to these questions can then be analyzed to determine, in effect, the marginal rates of substitution between any pair of attributes that differentiate the alternatives. If one of the other characteristics has a monetary price, then it is possible to compute the respondent's willingness to pay for the attribute on the basis of the responses. In the third type of Stated Preference question, individuals are asked how they would change the level of some activity in response to a change in an environmental amenity. If the activity can be interpreted in the context of some behavioral model such as an averting behavior model or a recreation travel cost demand model, the appropriate indirect valuation method can be used to obtain a measure of willingness to pay. These are known as contingent behavior or sometimes contingent activity questions. 2.2: Theoretical Literature Review: Society requires that some basic needs must be satisfied in order to maintain and guarantee its continued existence. From a sociologic theory perspective, Functionalism posits that social life persists because societies develop structures through which to achieve certain functions. These functions are the prerequisites of organized social life, and the performance of these functions signifies the effectiveness of the existing structure and its relevance to the existence of the entire society as a whole system (Adefolaju 2014). Any health system is developed to enable members of the society to meet their medical needs with a view to improving their health levels thereby improving their productivity. When placed under the pressure of modernity and the process of modernization, in which what is not ‘up to date’ in space and time is filtered out, any system gradually fades out of prominence by the time a better or superior alternative comes into

existence. Modernization is a far reaching process in which peripheral societies transit from traditional or less developed institutions to those characteristic of more advanced societies (Schaefer, 2004). Many societies have developed indigenous healthcare systems suitable to their needs, capabilities and resources available. Such systems that have stood the test of time could be proven to be of relevance and effective in approach. Although, the history of orthodox medicine traces its root back to Hippocrates, the father of medicine, the practice of orthodox medicine today is not strictly in line with the principles of the fathers of medicine (Rees and Shuter, 1996). Orthodox medicine began over a century ago during the period of Renaissance. As at then the objective thinking of the causative theory of modern science replaced the ecological model which had predominated for over 2000 years (Bhikha, 2004). The new paradigm is often termed the Cartesian model being named after the French philosopher, Rene Descartes (1596-1650). This model, it was claimed, invalidated the humoural concepts of the holistic principles of Hippocrates. Galen and Ibn Sina promoted the ideology that man was separate from nature could be viewed objectively through experiment (Boussel et al, 1982). This heralded the birth of scientific or orthodox medicine. The frontiers of orthodox medicine were further broadened by Rudolph Virdow (1821-1902) who demonstrated that disease begins with changes in living cells and by Louis Pasteur (1822-1895) whose role in the development of fhe germ theory of infection was of key importance (Rees and Shuter. 1996; Gilbert et al, 1998; Bhikha and Haq, 2000). Under the germ theory, disease was associated with specific micro-organisms. Since, then technology through research and development (R and D) had played tremendous roles in the propagation of orthodox medicine which is scientifically based and evolve along certain specifications or routes. These routes led to the manifestations of plethora of specialists in

disorders of specific organs, tissue and cells such as cardiologists, dermatologists and neurologists among others. Hence, it has been advocated that patients should be regarded as collections of separate body parts and organ systems (Thomas. 2002). Generally, the philosophy of orthodox medicine is exclusively based on the physical world and excludes any explanation that goes beyond this (Hammond-Tooke. 1989; Gilbert et al.. 1998). For instance, health and illness are seen as a relationship between the body's components and sub-structure while the mind is considered independent of the body. The causes of disease are therefore, scientific and presented in terms of such concepts as chemical imbalance, virus replication, serum level overload and so on (Bhikha. 2004). In any population, illness and disease concepts are shaped by physiological or psychological factors, especially in populations where there is limited exposure to modern systems (Sato, 2012; Moerman and Jonas, 2002) argue that an individual’s perception of treatment efficacy and understandings of illness are shaped by their culture and social environments, and health-seeking behaviour is an example of a ‘meaning response’, such that people respond according to how they interpret illness. The assessment of characteristics of herbal and orthodox medicines in academic research had over the years centered on issues concerning regulation and standardization with emphasis on quality assessment based on certain quality assurance parameters of quality itself, safety and efficacy without recourse to obtaining first-hand information from their users about certain salient but common physical attributes such as level of acceptability, packaging, affordability, availability, level of advertisement in print and electronic media, among others. The burden of healthcare costs trickles down to the purses of members of the public as they are meant to pay for high prices of orthodox medicines due to the enormous costs for experimental

techniques through Research and Development (R & D) (Osemene et al, 2011). It is also commonly expected that formal healthcare products which are scientifically based are more reliable, safer and more effective. This ideology may be wrong due to the fact that drugs, once thought to be safe are often withdrawn from the market for causing severe side effects and sometimes, fatalities. A tragic example is the ‘thalidomide’ incidence that occurred between the 1950s and 1960s. Hundreds of women, whom were given thalidomide to cure their early morning sickness, ended up giving birth to deformed babies. More so, antibiotics which were initially meant to provide protection against diseases caused by bacteria, ended up killing bacteria that are beneficial to the human body reducing the body’s resistance to the harmful bacteria (Bradstreet, 1998). In Nigeria recently – July, 2005 precisely - NAFDAC, banned the use of Novalgin (a potent analgesic and an antipyretic agent) because of its severe side-effects that led to the death of several children. 2.2.1: Modern healthcare demand analysis: This theoretical background, known simply as rational utility, is based on the neo-classical paradigm of rational consumers and constrained utility maximization theories (Lohlein, Jutting and Wehrheim, 2002). The underlying idea is that an individual, facing different healthcare providers, is assumed to maximize utility from health and consumption of a composite good subject to income and health production function constraints. This means that, in case of sickness or injury, individuals or households must first decide to source medical care and then choose from which healthcare provider to seek the medical care while considering price, quality and other non-price factors. Individuals will choose the healthcare provider that gives them the maximum utility from a range of providers.

Following the two theoretical approaches elaborated by Grossman (1972) on one hand, and Acton (1975) and Christianson (1976) on the other, literature dedicated to health care demands as well as its deciding variables is rich and has experienced noticeable evolution across the world. For instance, in Africa, research results provoked mixed feelings and could not provide a unanimous conclusion on the impact the introduction or the increase of sanitary services on health care demand. Hence, Akin, et al (1995) in Nigeria, Juillet (1999) in Mali and Perrin (2001) in Ivory Coast deduce an inelastic health care/cost proportion. Simultaneously executed researches [Sauerborn, et al (1994) Burkina Faso; Ellis, et al. (1994) Egypt; Barlow and Diop (1995) Niger; Bolduc et al. (1996) Benin; Tembon (1996) Cameroon; Kipp, et al. (2001) Uganda], contrarily deduce an elastic positive cost / negative health care demand, particularly for the poor. A new study line on the role service quality (evidenced by patient’s satisfaction) plays in health care demand was carried out amid this state of contradictory results. In addition, a peep is taken into to the works of Lavy and Quigley (1993) in Ghana; Litvack and Bodart (1993) in Cameroon; Mwabu, et al (1993) in Kenya; and Mariko (2003) in Mali. Other works [Haddad and Fournier (1995)] carried out in Zaire showed that the compensating role assigned to quality, while being able to neutralize the negative effect of increased health care resort tariffs, will not be systematic but would depend on a variety of parameters such as the extent of costs’ increase and quality components involved in these increases. Furthermore, Audibert et al. (1998) deduce an increase in health care demand, alongside service costs in a case study in Ivory Coast. Most original utilisation models are based on rational utility, and consider individuals to vary health-seeking behaviours according to predisposing characteristics (demographic, social structures, health beliefs), enabling resources (personal/family, community) and need for care

(perceived, evaluated) (Andersen, 1968; Andersen & Newman, 1973). Predisposing characteristics include demographic traits such as age, gender and other biological factors influencing need, in addition to ‘social structures’ (which describes an individual’s status within society), their ability to cope with presenting health needs and their physical environment. Typically, social structures are measured through educational achievements, occupation and ethnicity. Health beliefs are attitudes and values people hold about health and health services, which in turn affect perceived need and utilisation of care. Enabling resources describe availability of facilities and associated infrastructure (community resources), personal means and know-how to access them. Frequently used indicators include income, health insurance, travel and waiting times. Together, enabling resources may be seen as affecting ‘potential-access’, as increasing enabling resources will increase the likelihood of utilisation, whereas ‘realised access’ is the actual use of services (Donabedian, 1988). Finally, equitable access can be evaluated by balancing the predisposing, enabling and need factors alongside value judgements on what is ‘fair’. Traditionally , access is equitable if demographic and need variables account for all or most of the variation in utilisation (Andersen, 1968). Andersen and colleagues have since built upon this original framework (Aday & Andersen, 1974; Andersen, 1995; Andersen & Newman, 1973). The subsequent framework (‘Phase two’) attempted to incorporate better the supply side (‘health care system’) which included national health policy, resources and their organisation as additional determinants of utilisation. A direct outcome measure, consumer satisfaction, was also added. This measured satisfaction according to convenience, availability of providers, financing mechanisms, provider characteristics and overall quality. ‘Phase three’ was further expanded with the inclusion of the external environment (physical, political, economic) and personal health practices (diet, exercise,

self-care) as potential influences on health care use. Finally, in ‘Phase four’, Andersen (1995) allows for a dynamic model in which multiple influences and health statuses are depicted. Thus, the utilisation model supposes that health-seeking behaviour is not a one shot game, rather sequential, with present day behaviour dependent on past behaviour and outcomes. Their relevant contribution was clear: the evolving models allow for inter -disciplinary and nonstatic approaches to modelling health behaviour. The final model also provides a framework upon which others can bring their own ideas and niches. Andersen’s models have the differential ability to explain utilisation depending on the type of service evaluated, and as such, the same framework can be used to model modern and traditional health care utilisation alike, although Andersen (1968) originally envisaged his model to be used for evaluating formal health services. Further, in appending the environment as a potential influence on health-seeking behaviour, Andersen (1995) has explicitly allowed for social factors to be analysed. This is particularly appropriate for modelling TM, which are often used in areas where societal or local community influence is strong and formal services weak. Kroeger

(1983a, 1983) attempted to incorporate such ideas as an offshoot to the Andersen

model (Andersen & Newman, 1973) by combining socio-medical with anthropological approaches, promoting that: ‘different disciplines who classically prefer their own specific variable should act with their research like instruments in an orchestra’ (Kroeger,1983). He continues that there is: ‘‘a division of scholars into two camps: some authors have stressed particularly the importance of predisposing factors...whereas others have pointed to the particular importance of enabling factors...this perceived antagonism has diminished opportunities for common approach and mutual understanding’’ (Kroeger,1983).

2.2.2: Demand for Healthcare in Nigeria: Nigeria healthcare system presently accommodates both traditional and modern medical systems; this non-cordial relationship depicts traditional medicine as fetish, primitive and therefore not ‘modern’. This accounts for its relegation to the background in favour of modern medicine. This follows from when traditional medicine was labeled as “non-rational” and therefore deprived of recognition and funding from government like its western counterpart. This differs from the situation in most Asian countries like India, Indonesia China, North Korea, South Korea and Taiwan where traditional medicine is already fully integrated into the general healthcare system (NOU New Delhi, 2001; Adefolaju 2014). Babatunde (2008) reveals that the health care system in Nigeria may be viewed as a complex made up of three interrelated components: health care consumers; the professionals and practitioners called health care providers; and the institutions or organizations of the health care system. The institutional component includes hospitals, clinics, and home-health agencies; the insurance companies and programs that pay for services, managed-care plans such as health maintenance organizations (HMOs), and preferred provider organizations (PPOs); and entitlement programs. Other institutions are the professional schools that train students for careers in medical, public health, dental, and allied health professions, such as nursing. Also included are agencies and associations that research and monitor the quality of health care services; license and accreditation providers and institutions; local, state, and national professional societies; and the companies that produce medical technology, equipment, and pharmaceuticals. Much of the interaction among the three components of the health care system occurs directly between individual health care consumers and providers. Other interactions are

indirect and impersonal such as immunization programs or screening to detect disease, performed by public health agencies for whole populations. The Nigerian health sector is broad and comprises of public, private for-profit, nongovernmental organizations (NGOs), community-based organizations (CBOs), faith-based organizations (FBOs), and traditional health care providers. The health sector is very heterogeneous, and includes unregistered and registered providers ranging from traditional birth attendants and individual medicine sellers to sophisticated hospitals. Thirty-eight percent of all registered facilities in the FMOH health facilities database are privately owned, of which about 75% are primary care and 25% are secondary care facilities (World Bank, 2005). Private facilities account for one-third of primary care facilities and could be a potentially important partner in expanding coverage of key health services. Babatunde (2008) goes further to point out that, the market for private health care is believed to have grown rapidly since the mid-1980s; a period marked by deep economic recession characterized by falling social expenditures and household incomes in real terms. The extent to which these factors have shaped the sector still remains unclear due to the paucity of data, in particular those relating to private expenditures on health care. The private sector (including FBO facilities) plays a significant role in the provision of care across the country. It has a wide range of providers including physician practices, maternity homes, clinics, and hospitals. Private for-profit health facilities have proliferated since the mid-1980s and together with the FBO facilities, are reported to provide 80% of health services to Nigerians (USAID and FMOH, 2008). The private for-profit facilities provide mostly curative services, while the faith-based facilities provide a wider range of preventive and health promotion services. There are also traditional medicine practitioners and informal medicine vendors.

Various explanations for high utilisation rates of informal healthcare have been put forward. Scholars point to an individual’s economic rationality – that traditional medicines are more accessible, readily available and affordable than modern drugs (Leonard, 2003; World Health Organization, 2002), which remain unobtainable for two thirds of the sub Saharan population (UN Millennium Project, 2005). For example, a study in Uganda estimated there is one healer per two to four hundred people, in sharp contrast to one modern practitioner for 20,000 people (World Health Organization, 2002, p. 12). Further, Informal medical care tend to be more affordable because herbal products are cultivated locally, reducing both direct and indirect costs and individuals can self-apply (van den Boom, Nsowah, Nuamah & Overbosch, 2008). Traditional healers are also known to charge based on ability to pay and accept different modes of payment i.e. in-kind, by instalments and so on (Asenso and Okyere, 1995; Sato, 2012) rather than by a flat rate payable in advance as is often the case when visiting a physician or using modern providers (Hausmann, Muela, Mushi, & Ribera, 2000). Still, apart from accessibility, availability and affordability, the question still comes to mind as to what other reasons can account for continued utilization of informal healthcare methods (Raphael, 2011; Sato, 2012). High population growth rates, poverty and declining economic reserves in Nigeria stimulate most Nigerians into resorting to cheaper sources of healthcare for their health needs. Nigeria already has a deep rooted culture of informal medicine rich in its diversity and eminence. Nigerian informal healthcare practitioners are actively involved in providing health services for the teeming population. The practice of informal healthcare provides a good source of livelihood for a considerable amount of individuals as they rely on it as their main source of income (Raphael, 2011).

2.2.3: Informal Healthcare Market in Nigeria: According to Bloom, Gerald, et al. (2011), a market systems analysis of informal healthcare providers reviews of interventions to influence private providers (a term employed more generally to cover a wide range of providers not directly employed by the state) have acknowledged both the importance of informal providers as a source of health-related goods and services for the poor, and the special challenges governments face in attempting to improve their performance (Millset al. 2002; Waters et al. 2003; Peters et al. 2004). A recent review by Shah et al. (2010) of the evidence on the impact of interventions to improve the performance of informal providers identified 70 studies that met their criteria for inclusion. Although training of informal providers was the most common intervention, in line with the arguments of Elliott et al. (2008) and Cross and McGregor (2010), such interventions were relatively ineffective on their own, and worked best when combined with strategies that altered institutional relationships and the incentives informal providers face. The more successful examples tended to require the measurement and disclosure of performance. A review by Goodman et al. (2007) of the malaria treatment purchased from medicine sellers in sub-Saharan Africa similarly concluded that effective strategies for improving their performance combined training with measures to modify incentives. The data on Nigeria were derived from physical inspection of the premises of 106 drug shops; interviews with 110 IHPs and 113 households selected through a multi-stage random process in six urban and six rural local government areas in Oyo, Kaduna and Enugu States; and interviews with 54 community leaders and 55 officers of IHP associations from these areas (Oladepo et al. 2007). Both studies documented the high proportion of households who obtain treatment from an informal provider. In Nigeria, 39% of people reported that they obtained treatment for their last episode of malaria

from an IHP and another 25% took medicine they had previously obtained from a shop (Oladepo et al. 2007). These studies confirm findings in other countries of problems with the quality of the services of informal providers (Wachter et al. 1999; Syhakhang et al. 2001). In Nigeria, only 9% of the sample of shops stocked the recommended first-line malaria treatment (artemisinin combination therapy), whereas 92% of shops had non recommended sulfadoxine-pyramethamine and 72% had chloroquine. Of greater concern was the fact that 32% of shops stocked monotherapy artesunate, which is contraindicated because of its potential to contribute to drug resistance. In the light of these findings, the challenge was to design interventions to reduce harm and improve the treatment practices of informal providers, exemplifying the value of taking a health market systems approach, as shown by Bloom, Gerald, et al. (2011), the analysis of the intervention options in these two cases focuses on the interconnectedness of the sources of knowledge of informal providers, the financial incentives that informal providers face, and the formal and informal institutional arrangements that affect their local reputation. It shows how this interconnectedness systematically influences the performance of informal providers. The studies in Nigeria as conducted by Bloom, Gerald, et al. (2011), revealed that a high proportion of informal providers had been in business for a long time. They had to maintain a good reputation to compete with newcomers. The interviews with community members in Nigeria revealed the high regard with which these practitioners are held as often well-respected members of their communities (Sharmin et al. 2009). The behaviour of informal providers is strongly influenced by the institutional context within which they are embedded. They have established a niche because neither government health facilities nor private providers have adequately met the population’s needs. The health regulatory system neither recognizes their legitimacy nor oversees their performance. For example, the Nigerian government made little

effort to inform the IHPs about a change in its guidelines for the treatment of malaria (Oladepo et al. 2007). On the contrary, national health development strategies have tended to ignore the existence of these unorganized markets for health services. In some cases, the formal health system actively seeks to diminish their role by, for example, identifying them as ‘quacks’ and ‘thugs’, who take advantage of people. Although there is no doubt that the population needs protection against opportunistic behaviour, this labeling of all informal providers can also be seen as boundary protection by licensed professionals and as unhelpful in the realities of the environments where there is a chronic scarcity of qualified providers. On the other hand, the informal providers of health services and drugs have an identity as small businesses in both Bangladesh and Nigeria. They are required to obtain business licenses and are subject to routine inspections. They also face harassment by local licensing officials. The Nigerian IHPs have been organized in trade associations for several decades (Oladepo et al. 2007). This follows a common pattern for a number of trades in West Africa (Joshi and Moore 2004). The National Association of Patent Medicine Dealers was established in 1951 and incorporated in 1962. These associations are organized in a tiered structure, which parallels the levels of government. They can punish members who supply fake or expired drugs or sell in unlicensed zones with fines, exclusion from social events or even expulsion. Many associations purchase drugs in bulk for their members to reduce the cost and protect against counterfeit products. They also protect their members against actions by local government or other actors that prejudice its members’ ability to earn a living. Interviews with association officers revealed that they were very interested in providing clinical knowledge to their members, working with them to establish standards of treatment and testing drugs to ensure they were not counterfeit.

2.3: Empirical Literature Review: Lohlein, Jütting and Wehrheim in their work, “Provision of Public goods in the transition process… (2002)” The objective of the paper was to identify the determinants of access to health care in rural Russia. They started out with the observation that the transition process had affected the provision of social services in the Russian Federation in general, and in rural areas in particular, owing to the overlap with agricultural reforms. Based on this observation they questioned how the reduced role of the state and the concomitant decentralization of policy making have affected access of the rural populace to social services. The review of the available literature resulted in the formulation of the following three hypotheses. Firstly, that income is a determinant of access to health care. Secondly, that informal payments play an important role in determining access, and thirdly that there are large differences in access to health care services between districts. The hypotheses were tested using household data from a survey conducted in two regions of Russia in 2000. The results indicated that in the study regions, contrary to expectations, neither income nor informal payments are important determinants of access. However, there are large differences in out-of-pocket expenditures between districts, indicating that access to health care varies between districts. Xu, James and Carrin (2006) in an empirical research undertaken in their paper focused on the impact of the Kenyan health financing system in the year 2003 on access to care and health spending. It shed light on the extent to which the prevailing system impoverished the population, as a result of the lack of a functional system, there were waiver and exemption mechanisms built into the user fee system, at least on paper, it did not work in practice for various reasons. They provided summaries of the determinants of health insurance membership, utilization of healthcare, out-of-pocket spending and catastrophic expenditure, together with their expected

effects. Logistic regression models were applied to test the hypotheses on health service utilization and catastrophic expenditure. In the analysis of health insurance membership, regressions were run for both public and private health insurance. A log-linear model was used to explore the determinants of out-of-pocket health expenditures given utilisation of health services. A number of those surveyed reported use but not out-of-pocket health expenditures. Those same respondents failed to answer further questions related to utilization (such as which health facility they visited), they were treated as missing observations in the regression for out-of-pocket expenditures. Some of the data employed came from the Kenya Health Expenditure and Utilisation Survey, conducted between February and March 2003. Income data gathered there in reflected random shocks, yet expenditure data conform better to the notion of capacity to pay.They noted that most of the household surveys expenditure data are more reliable than income data particularly true in developing countries as they discovered where the informal sector is typically relatively large, survey respondents may not wish to reveal their true income for various reasons. The same argument applied to the choice of expenditure quintiles used in the regressions rather than income quintiles. From the various empirical results presented in the paper it was revealed that, first, it is important for a health insurance scheme to adequately define membership and then ensure that the eligible population is effectively financially protected. In the present reform, it is intended for all of the population to become a member of the new social health insurance scheme. As the scheme needs to strive for nation-wide membership, steady progress in membership registration of the formal sector workers, the self-employed and informal sector workers as well as their families will need to be carefully managed. Secondly, considerable attention is to be paid to the design of the benefit package of health services, and of the provider payment and co-payment schedule for these services. The benefit package will need

to take account of important and unmet needs by specific population groups. Furthermore, the provider and co-payment schedule needs to be defined in such a way that citizens receive financial protection against the cost of illness of its members, thereby avoiding catastrophic spending and impoverishment. Finally, a similar quantitative study could be undertaken after one or two years of operation of the new NHIS in order to measure performance and make comparisons with that of the previous health financing system. Kamgnia et al (2007), researched on compensating the poor out of traditional healing in Cameroon. The objectives were to identify the determinants of the choice of health care providers in Cameroon, and determine the compensation to the poor to get them away from traditional/self-healing. The methodology was a nested Logit model, accounting for the poor’s decision in terms of a Spline function of consumption. Overall, the majority of the determinants had the expected sign with a significant effect. The compensation to the poor is at least 46.20% of the lower poverty line, while the intermediate group receives a compensation of at least 14.47% of the upper poverty line. Omogbadegun and Adegboyega (2013) in their paper provided a strengthened collaborative virtual framework for overcoming barriers towards accepting complementary and alternative medical practice into conventional healthcare system. Quantitative and qualitative data were gathered with semi-structured questionnaires and interviews from General Practitioners (GPs) with Complementary and Alternative Medicine (CAM) knowledge, CAM Practitioners with biomedicine knowledge, CAM patients, and scholars. 2,760 semi-structured questionnaires exploring knowledge, attitudes, and skills’ barriers to integrative medical collaboration efforts were administered. Focus group discussions were held interviewing GPs, CAM practitioners, and others claiming effective prescriptions. Practitioners’ team meetings, retreats, interaction, and

prescription operations were observed. In this study, a videoconferencing-based healthcare services delivery system was developed and implemented for seamless exchange of healthcare information. 2,591 (93.5%) questionnaires representing 657 physicians (23.80%), 997 CAM practitioners (36.12%), 855 patients (30.98%), and 82 healthcare researchers (2.97%) responded, while 169 (6.12%) declined response. Fifty-two percent of the 657 GPs still referred patients for CAM treatments. Patients found complementary approaches more aligned with “their own values, beliefs, and philosophical orientations”. Non-medical acceptance of CAM (43.27%) continued impeding CAM growth in Nigeria. CAM practitioners require evidence-based knowledge towards finding solutions and suggestions for seamlessly integrating CAM with modern healthcare practices. Ngangue` (2014), conducted a research work to identify the determinant of health care resort in Cameroon in order to propose many improvement axes to the health system. Data was collected from the Cameroon’s Third Household Investigation (ECAM 3) used in the Logit model, and gave the following results: (i) the consultation’s price had a negative impact on the demand of the health services no matter the type of resort and the location; (ii) when individuals became richer, they were tempted to desert hawkers, native doctors and health centers to use clinics and more specialized hospitals with more skilled personnel; (iii) the fact to be educated increases the probability to go to clinics or private health facilities, and decreases the probability to attend to native doctors or to hawkers. The work suggested ways to allow for better fulfillment of the poor’s needs. Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D (2013) in their article “What Is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review” showed that Informal health care providers (IPs) comprise a significant component of health systems in

developing nations. Yet little was known about the most basic characteristics of performance, cost, quality, utilization, and size of this sector. To address this gap they conducted a comprehensive literature review on the informal health care sector in developing countries. They reviewed studies published since 2000 after searching through electronic databases PubMed, Google Scholar, and relevant grey literature from The New York Academy of Medicine, The World Bank, The Center for Global Development, USAID, SHOPS (formerly PSP-One), The World Health Organization, DFID, Human Resources for Health Global Resource Center. In total, 334 articles were retrieved, and 122 met inclusion criteria and chosen for data abstraction. Results indicate that IPs make up a significant portion of the healthcare sector globally, with almost half of studies (48%) from Sub-Saharan Africa. Utilization estimates from 24 studies in the literature of IP for healthcare services ranged from 9% to 90% of all healthcare interactions, depending on the country, the disease in question, and methods of measurement. IPs operate in a variety of health areas, although baseline information on quality is notably incomplete and poor quality of care is generally assumed. There was a wide variation in how quality of care is measured. In their review, they found that IPs reported inadequate drug provision, poor adherence to clinical national guidelines, and that there were gaps in knowledge and provider practice; however, studies also found that the formal sector also reported poor provider practices. Reasons for using IPs included convenience, affordability, and social and cultural effects. Their recommendations from the literature argued for a call for more engagement with the IP sector, while saying that IPs are a large component of nearly all developing country health systems and concluding that research and policies of engagement of the IP sector were needed. Ibrahim Adekunle Oreagba, Kazeem Adeola Oshikoya and Mercy Amachree (2011) in an article “Herbal medicine use among urban residents in Lagos, Nigeria” observed that over three-quarter

of the world’s population is using herbal medicines with an increasing trend globally and that herbal medicines may be beneficial but are not completely harmless. The study aimed to assess the extent of use and the general knowledge of the benefits and safety of herbal medicines among urban residents in Lagos, Nigeria. Methods: The study involved 388 participants recruited by cluster and random sampling techniques. The participants interviewed using structured open- and close-ended questionnaires and information obtained comprised the demography and types of herbal medicines used by the respondents; indications for their use; the sources, benefits and adverse effects of the herbal medicines they used. The results obtained showed that, the respondents used 12 types of herbal medicine (crude or refined), either alone or in combination with other herbal medicines. Two hundred and fifty nine (259 - 66.8%) respondents reportedly used herbal medicine. ‘Agbo jedi-jedi’ (35%) was the most frequently used herbal medicine preparation, followed by ‘agbo-iba’ (27.5%) and Oroki herbal mixture® (9%). Family and friends had a marked influence on 78.4% of the respondents who used herbal medicine preparations. Half of the respondents considered herbal medicines safe despite 20.8% who experienced mild to moderate adverse effects. Conclusions reached were that herbal medicine is popular among the respondents but they appear to be ignorant of its potential toxicities. It may be necessary to evaluate the safety, efficacy and quality of herbal medicines and their products through randomised clinical trial studies. The authors suggested that public enlightenment programme about safe use of herbal medicines may be necessary as a means of minimizing the potential adverse effects. Ghina S Ghazeeri, Johnny T Awwad, Mohammad Alameddine, Zeina MH Younes and Farah Naja (2012) in their research titled “Prevalence and determinants of complementary and alternative medicine use among infertile patients in Lebanon: a cross sectional study observed

that Complementary and alternative medicine (CAM) is widely used for the treatment of infertility. While the Middle East and North Africa region has been shown to house one of the fastest growing markets of CAM products in the world, research describing the use of CAM therapies among Middle-Eastern infertile patients is minimal. The aim of this study is to examine the prevalence, characteristics and determinants of CAM use among infertile patients in Lebanon. Methods applied include a cross sectional survey design was used to carry out face-toface interviews with 213 consecutive patients attending the Assisted Reproductive Unit at a major academic medical center in Beirut. The questionnaire comprised three sections: sociodemographic and lifestyle characteristics, infertility-related aspects and information on CAM use. The main outcome measure was the use of CAM modalities for infertility treatment. Determinants of CAM use were assessed through the logistic regression method. Results obtained were on overall, 41% of interviewed patients reported using a CAM modality at least once for their infertility. There was a differential by gender in the most commonly used CAM therapies; where males mostly used functional foods (e.g. honey & nuts) (82.9%) while females mostly relied on spiritual healing/prayer (56.5%). Factors associated with CAM use were higher household income (OR: 0.305, 95% CI: 0.132–0.703) and sex, with females using less CAM than males (OR: 0.12, 95% CI: 0.051–0.278). The older patients were diagnosed with infertility, the lower the odds of CAM use (p for trend