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

Abstract

Background The widely available informal healthcare providers (IHPs) present opportunities to improve access to appropriate essential health services in underserved urban areas in many low- and middle-income countries (LMICs). However, they are not formally linked to the formal health system. This study was conducted to explore the perspectives of key stakeholders about institutionalizing linkages between the formal health systems and IHPs, as a strategy for improving access to appropriate healthcare services in Nigeria. Methods Data was collected from key stakeholders in the formal and informal health systems, whose functions cover the major slums in Enugu and Onitsha cities in southeast Nigeria. Key informant interviews (n = 43) were conducted using semi-structured interview guides among representatives from the formal and informal health sectors. Interview transcripts were read severally, and using thematic content analysis, recurrent themes were identified and used for a narrative synthesis. Results Although the dominant view among respondents is that formalization of linkages between IHPs and the formal health system will likely create synergy and quality improvement in health service delivery, anxieties and defensive pessimism were equally expressed. On the one hand, formal sector respondents are pessimistic about limited skills, poor quality of care, questionable recognition, and the enormous challenges of managing a pluralistic health system. Conversely, the informal sector pessimists expressed uncertainty about the outcomes of a government-led supervision and the potential negative impact on their practice. Some of the proposed strategies for institutionalizing linkages between the two health sub-systems include: sensitizing relevant policymakers and gatekeepers to the necessity of pluralistic healthcare; mapping and documenting of informal providers and respective service their areas for registration and accreditation, among others. Perceived threats to institutionalizing these linkages include: weak supervision and monitoring of informal providers by the State Ministry of Health due to lack of funds for logistics; poor data reporting and late referrals from informal providers; lack of referral feedback from formal to informal providers, among others. Conclusions Opportunities and constraints to institutionalize linkages between the formal health system and IHPs exist in Nigeria. However, there is a need to design an inclusive system that ensures tolerance, dignity, and mutual learning for all stakeholders in the country and in other LMICs.

How to build bridges for Universal Health Coverage in Nigeria by linking formal and informal health providers

“…Additionally, they are apprehensive about the negative implications of government oversight 29–31. Conversely, formal providers harbour scepticism about informal practices, especially over the lack of scientific evidence of their services, poor quality of care, and concerns about the challenges of running a mixed healthcare system 28. Competing institutional norms can also exacerbate conflicts arising from differing operational approaches and goals 32.…”

“…Establishing a negotiation forum is crucial for building respectful partnerships. The preferred areas for cooperation include training to enhance the skill set of informal providers; regulations to ensure high-quality services and prevent unqualified practitioners; provider incentives to motivate informal providers to provide enhanced practices and services; and improved access to formal healthcare through effective two-way communication and referrals 28–30 33 34. It is important to consider the larger political and economic context and other systems and factors influencing public health outcomes when seeking local partnerships.…”

“…It is important to consider the larger political and economic context and other systems and factors influencing public health outcomes when seeking local partnerships. For managing the expanded PHC system at the macro level, it is imperative to have multidisciplinary cooperation and collaboration across different sectors 28 32…”

“…Research has shown that strengthening the links between public health systems and informal healthcare providers can boost rural healthcare access and improve health outcomes. 28 Below is a conceptual framework (figure 1) that illustrates various platforms for establishing strong linkages between formal PHC systems and informal health providers in rural communities.…”

“…[29][30][31] Conversely, formal providers harbour scepticism about informal practices, especially over the lack of scientific evidence of their services, poor quality of care, and concerns about the challenges of running a mixed healthcare system. 28 Competing institutional norms can also exacerbate conflicts arising from differing operational approaches and goals. 32 Despite these challenges, fostering collaboration is possible through open communication channels, dialogue, and mutual respect.…”