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

1. HEALTH CARE DELIVERY, ACCESS AND UTILISATION IN SLUMS OF URBAN SOUTH-WEST, NIGERIA. S. Akinmayọwa Lawal PhD Candidate Centre for Global Health Trinity College Dublin. Supervisors Femi Omololu, PhD University of Ibadan, Nigeria Joseph Assan, PhD Trinity College Dublin, Ireland

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

3. Health Statistics in Nigeria Percentage Share of Total Health Expenditure by Financing Agents, 2002 (%) (Soyibo, 2005). Source of Health Expenditure in Nigeria 2003 (%) (Soyibo, 2005). Source: WHO, 2009

4. Health Statistics in Nigeria (2) Source: WHO, 2009

5. Health Care Delivery in Nigeria Source: WHO, 2009

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

7. Urban Slums in Sub-Saharan Africa • Sometime in the next year, a woman will give birth in the Lagos slum of Ajegunle... Davis, Planet of Slums, 2006 • Slums are underserviced and or with no service parts of cities where living conditions are often appallingly poor (Chowdhury and Nurul-Amin, 2006). • Slums are an active, grassroots attempt by the desperately poor to take care of themselves (Sclar and Northridge 2003). • The UN-HABITAT 2003 Global report on human settlement “The Challenge of Slums” reveals that: • Within the developing regions, sub-Saharan Africa had the largest proportion of the urban population resident in slums in 2001 (71.9 per cent). • Slums are a physical and spatial manifestation of urban poverty and intra-city inequality. • Slums in Nairobi are homes to urban residents who earn comparatively low incomes and have limited assets. • The majority of slum dwellers in developing country cities earn their living from informal sector activities located either within or outside slum areas.

8. Slums in Urban South West Nigeria • In Nigeria, the growth of slums is 4.23 per cent with urban population in 2007 of 50 per cent; • These Slums are precarious, unplanned and environmentally degraded, while existing available health facilities cannot cater for the growing number of slum dwellers. • In Lagos state, slums can be located in the following areas of Makoko-Ebute-meta, Ajegunle, Okokomaiko, Abaranje, Akesan-Igando, Berger, Iyana-Ipaja/Ayobo, Mushin, and Agege; while • In Ogun state, slum communities exist in Abeokuta, Sagamu, Ijebu-ode, Ilaro, Mowe, and Ibafo areas of south west Nigeria. • Makoko in Lagos (Up) and Ibafo in Ogun state (Down).

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

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

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

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

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

14. Theoretical Framework Structuration Theory • The use of Structuration theory for this study will show: • How Giddens' concepts of 'social system', 'structure' and 'agency' help to conceptualize health care delivery in urban slums; • Access and utilisation of health services among actors in urban slums of south west Nigeria; • The relationship between “Structures of Health Care” (Health System) and “Actors of Health Care” (Providers, Slum Dwellers). Social Determinants of Health • The SDH holds that: • The social gradient in health within countries, and the marked health inequities are caused by the unequal distribution of power, income, goods, and services. • Unequal distribution of health-damaging experiences is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics; • Health inequality exist especially among slums dwellers of urban south west Nigeria.

15. Conceptual Framework

16. Methodology Qualitative/Quantitative Sampling Technique Multi stage sampling; Systematic random sampling of households Purposive sampling Snowball sampling Study Area Lagos State and Ogun State • In-depth interviews • Key Informant Interview • Focused group discussion • Survey Study Population • Households, Public Health Officials, Key Informants, Community Leaders, Health Care Practitioners, Folk Healers, Community Residents, Drug Peddlers and Local Pharmacy, NGOs Study Design • The study will adopt an exploratory and evaluation approach. A triangulation of research methods to capture existing social realities of health care delivery, access and utilization in urban slums of south west, Nigeria

17. Methodology Table 1

18. Methodology Table 2

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

20. PhD Work Plan

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

22. THANK YOU