Correspondence

Out-of-pocket payments in Nigeria

Spine conditions are common and the surgery is evolving even in developed economies. This study aims to review the changing trends and challenges of spine surgery, particularly from a low-income country.

This is a retrospective study of patients who were surgically treated for spine conditions in Enugu, Nigeria. Patient records from 2006 to 2016 were reviewed. Relevant clinical information was extracted from the operation theater logbooks and patient case files.

A total of 463 spine surgical procedures were carried out on the same number of patients. The number of treated patients has been on the increase and shows a male predominance. Pediatric spine cases accounted for 1.5%, adult/middle aged patients accounted for 77.8%. Degenerative conditions, trauma, and neoplasms were the most frequent indications for operation, accounting for 52.3%, 30.5%, and 11.4%, respectively. The most commonly operated region was cervical and lumbar regions among male (49.3%) and female (51.8%) patients, respectively. Spine fixation was required in 137 patients (29.6%). A paradigm shift from trauma to degenerative conditions among patients was noted after 2010. Prior to 2009, spine wiring techniques were the most common spine stabilizing method, but from 2011 to 2013 anterior cervical discectomy and anterior cervical discectomy and fusion predominated, and thereafter pedicle screws predominated. Cost implications, lack of trained personnel, and lack of and basic equipment pose significant challenges to spine care.

The trend in spinal surgery has improved rapidly and consistently in Nigeria over the 10 years of the study and is related to increasing expertise, more available facilities, and implant availability.

Ability to influence household decision-making has been shown to increase with improved social capital and power and is linked to better access to household financial resources and other services outside the household including healthcare.

To examine the male-female differences in household custody of financial resources, decision-making, and type of healthcare utilised, we used a mixed methods approach of cross-sectional household surveys and focus-group discussions (FGDs). Data was collected between 10 January–28 February 2011. We analyzed a sample of 411 households and a sub-sample of 223 households with a currently married head. We conducted six single-sex FGDs in 3 communities (1 urban, 2 rural) among a random sub-sample of participants in the survey. We performed univariate, bivariate, and logistic regression analyses with a 95% confidence interval. For the qualitative data, we performed thematic analysis where broad themes relevant to the research objective were abstracted.

In all households and in those with a married head, sick male members were less likely to forgo healthcare (aOR_all0.87, 95% CI 0.80–0.90; aOR_married0.52, 95% CI 0.18–0.83) and more likely to utilise formal healthcare relative to female sick members (aOR_all3.36, 95% CI 3.20–3.87; aOR_married19.50, 95% CI 9.62–39.52). Formal healthcare providers are medically trained while informal providers are untrained vendors that dispense medications for profit. There were more reports of sole custody of household resources among men within households with married heads. Joint decision-making on healthcare expenditure improved women's access to healthcare but is not reflective of unhindered access to household financial resources. Qualitatively, women spoke of seeking permission from male household head before expenditure was incurred, while male heads spoke of concealing household financial resources from their spouse.

Gender constructs and male-female differences have important effects on household resource allocation and healthcare utilisation.