and insurers/third party purchasers Consumer/patient and second-line provider Health care goods in exchange for money Economic First-line provider and government Labour in exchange for money (wages). Also professional independence and authority for self-regulation in exchange for citizens’ safety Economic and ethical First-line provider and insurers/third party purchasers The providers are conceptualised as serving as conduits to consumers for the purchasers and get money in return Economic First-line provider and second-line provider The providers are conceptualised as serving as conduits to consumers for the second-line providers and get practice inputs (goods) in return Economic for providers and professional for the first-line providers Government and insurers/third party purchasers The government provide market access and investment security for the insurers/third party purchasers in exchange for money (tax) Economic Government and second-line provider The government provide market access and investment security for the second-line provider in exchange for money (tax) Economic Insurers/third party purchasers and second-line provider The second-line provider bring features that the insurers/third party purchasers can exchange with consumers through the first-line provider in exchange for money Economic Population and the organizations that generate resources Not featured in Evans’ Framework. The population can provide the personnel needed by resource generators to produce the health resources needed by the population Social Gaps and issues The table (Table 2-2) highlights important exchanges and relationships in health systems that could be deduced from the frameworks described. line
in: various departments of the Local Government Area such as primary healthcare, environment; different hospitals including a tertiary hospital owned by the federal government, two faith-based hospitals patronised by many people from the study site; and private hospitals and pharmacies. All these institutions demanded some form of review or approval process before I could interview their staff. For the tertiary hospital some of the challenges of getting ethical review as highlighted for ABUTH-REC (See Appendix III: Weighting of relevant ethics committees in Nigeria) made it unrealistic to go through that process. The options were to exclude participants from that hospital from the research, which will leave a significant gap in the data or to find alternative ways of including them that are ethical and does not involve going through the ABUTH-REC. For the LGA Departments, proper review systems do not exist. Personal networks were needed to connect with the individuals concerned as well as when making connections with most of the private hospitals and pharmacies. For the latter, their biggest concern is time away from work for staff participating in interviews. In the two faith-based hospitals, one has a management system that values and understands the need for research and the process was formal but efficient, while the second relied more on personal contacts with the head of the hospital. Among the organisations presenting the most challenges, the most ethically challenging was dealing with the staff from the tertiary hospitals. Here again, personal relationship with individuals working in the hospital played an important role. The participating institution recommended that the most efficient route for ethics approval were either to apply to and use the acknowledgement of receipt of application and proceed with the research on that basis as is the tradition with most ongoing research at time in the institution or approach individual Heads of Departments where relevant staff that were to be interviewed are located and interview the staff based on their department’s approval. The latter option was taken, and four departments were approached out of which 3 agreed and in 2 of these the heads of the departments themselves were interviewed while in remaining one a representative of the Head of Department was interviewed. Dilemmas in accessing participants There were a number of ethical dilemmas in accessing participants. First, the minimal presence of state in the study setting brings about competition to fill in the vacuum where old power bases (such as traditional rulers) and new contenders (such as Salafi ulama) will seize the opportunity to claim or reclaim authority. The district head of the settlement served as one of
understanding of what the ‘research’ is about and form their judgements whether or not to participate based on these reasons (). The reasons are often entirely different from the researcher’s objectives or the expectations of ethics review committees which are often couched in terms of informed consent jargon – understanding of risk and benefits, freedom, privacy and confidentiality. Another issue with respect to consent is the expectation from the ethics review committee that participants must be given a period not less than 24hrs to decide if they would like to participate in the research was another concern. This requirement was difficult to fulfil because it conflicts with social and cultural norms of the study setting. In Tudun Jukun, traditional hierarchies are respected. These hierarchies and structured by age, gender and traditional authority and are very influential in shaping peoples' freedom with respect to decisions about certain aspects of their lives including, for example, whether or not they can take part in this research. A wife, for example, would be violating her normative role in that context if she decides against participating in research that her husband had already consented to, and such action could have long-term consequences beyond the life span of the research. For example, there was an occasion when one of the gatekeepers warned that my insistence on further seeking individual consent after he had secured same from the participants would undermine his position in the community. Third, as described above (see dilemmas related to research governance), recruiting institution affiliated participants such as staff of the Local Government Area (LGA) health office and Hospitals presents a considerable challenge in meeting requirement of the ethics committee at the University of Sheffield. Dilemmas in adhering to standardised ethical procedures Adhering to prescribed ethics procedures such as ensuring privacy and confidentiality also presented significant challenges, I did not have control over the interview location (as explained above). One female interviewee, for example, requested that we wait for her husband to come in first before we can start the interview (PP002; 61-70; Traditional birth attendant). Occasionally during interviews family members could get in. Several interviews were interrupted by family members or neighbours coming in during an interview, and they ensured that they went through the lengthy traditional greeting with everyone that was present before the moved on. Dilemmas about giving money to participants
Table 41: Incidents of health problems (problems observed) along with mechanisms and actions taken (strategies). S/no. ID Interviewee age categories (years) Sex Problems observed Strategies observed (Outcome of interest) Interpretation of the results of the strategies 1 IP001 81+ Female Hypertension and convulsions Care at a private hospital predominantly supplemented with spiritual healing "feel good" about the care at the hospital but the spiritual care "did not work" 2 IP002 61 - 70 Female Age at marriage Moved from father's house in the village to live in the city with uncle who is against early marriage Married at age of 15 years which was considered a success to her and her uncle 3 IP002 61 - 70 Female Place of birth Home (16 deliveries all at home) Successful because "all the births came easy…and ...6 of the girls already married" 4 IP002 61 - 70 Female How to regain shape and increase strength after childbirth Traditional birth practices - hot water bath, herbs and potash beverage "...that makes you healthier…but… if you try it nowadays the person will not survive" 5 IP002 61 - 70 Female How to improve resilience and strength Changes in cooking practices, use of food additives and fertilizer to grow crops as the cause. Failure - people not as resilient as in the past 6 IP002 61 - 70 Female Number of children that a woman can have Rejected offer of contraceptive (Having many children not considered a problem) Happy and proud of number of children she has also as an evidence of her strength as a woman
Table 42: Summary of the different elements within the home health systems landscape Home Actors involved* Processes§ Strategies Knowledgebase Underpinning relationships Index participant Interpretation Decision making "Doing nothing" Not applicable Not applicable Women in their different roles as mothers, mother wives, older women with birth experience, daughters Interpretation Decision making Providing care (most of caring role within the home are done by women in their different roles) Home birth Hausa medicine Islamic medicine Biomedicine (sometimes midwives are called to attend to a woman giving birth at home) Family ties Marriage or ties "Catching head" for headaches "Blowing some (Qur’anic) recitation on" a family member with convulsions Reciting prayers and blowing or placing hand on the affected Rubutu, tofi or use of honey and other herbs mentioned in the Qur'an to make women give birth with ease or to improve general strength and wellbeing of children Islamic medicine Family ties Marriage or ties Use of tazargade, marke, kajiji, garlic, lime, honey and other varieties of plants, spices and herbs Use of near-boiling hot water baths for Hausa medicine Family ties Marriage or ties residence residence residence
Uncertainty about pregnancy Nature of the problem – uncertainty about pregnancy outcome Governance – abusive and disrespectful midwives at hospitals Social norms - beliefs about women fertility and reproduction Social norms – respect for elders Agreeing with and obeying social norms Avoids abuse and disrespect by concealing number of previous births Confidence in hospitals’ ability to address uncertain pregnancy outcomes Angry with midwives’ disobeying social norms of respect for elders Attends for antenatal care for all her pregnancies but would refuse to divulge the true number (14) of her previous births (she usually tell the health workers halve the number of previous births that she has had instead) Multiple home births Social norms – safeguarding individual and family honour around privacy of intimate body parts Governance – abusive and disrespectful midwives at hospitals Agreeing with and obeying social norms Avoiding abuse and disrespect Unsupervised birth at home Uncertainty about pregnancy Nature of the problem – uncertainty about pregnancy outcome Governance – abusive and disrespectful midwives at hospitals Confidence in hospitals’ ability to address uncertain pregnancy outcomes Avoids abuse and disrespect by making sure she registers in case difficulties occur later Register pregnancy at a hospital just in case Basir (bleeding haemorrhoids) Nature of the problem – profuse bleeding Confidence in hospitals’ ability to address problems with bleeding Taken to hospital Generalised body and stomach pains Governance – poor quality of services (failed to diagnose and solve the problem after several attempts at hospitals) resigning to fate doing nothing Open fracture Nature of the problem – open fracture Economic realities – unable to pay for hospital care after financing withdrawn by patron Pluralism – existence of traditional bone-setters Confidence in the ability of the A&E at the hospital to be able to fix open fractures Loss of financial support from the patron Improvise with traditional bone-setter Taken to hospital A&E Called traditional bone-setter who came and apply splint at home
mental health issue in a child Nature of the problem – mental health problem Pluralism - Mental health problem as oppose to physical health problem (tends to be seen from a different underlying perspective where biomedical knowledge system is considered to be poor at dealing with compared to other knowledge systems). Availability of a well-regarded alternative Neglect – mental health neglected by relevant authorities Confidence in traditional herbal medicine for mental health problem Lack of confidence with hospital in addressing mental health problems Traditional Hausa herbal medicine for mental health condition and PMV medicines for physical health symptoms Refuse Neglect – refuse collection in this area is neglected by the responsible authority resigning and feeling disempowered to do anything doing nothing - not clearing up the refuse and not advocating against it Vomiting and stomach ache Absence of an accountable authority – no support with reliable public transport, payment arrangements or information system Anxiety over consequences of the illness and ability of the children to arrange transport, get information about suitable treatment and pay. taken to a private hospital where he was admitted and receive treatment for the condition Awon hakori (teething) Social norms - respect for elders (advise of older women) Social norms - male dominant gender norms (respect the preferences of her husband) Pluralism - Availability of a well-regarded alternative Anxiety about the health of the child getting worse and obeying social norms initially but later disagreeing (secretly) with the norms of her in-laws household because of Confidence in the hospitals’ ability to deal with the problem Prepared herbs at home and gave them to the child and as the problem did not improve decided and took the child to the hospital without the knowledge of her husband or the women (this will be difficult if she had to go to a hospital outside the neighbourhood as it will take some time raise suspicion - she had also taken advantage of when she is visiting her parent to also take the children to receive health care)
Premature birth Absence of an accountable authority - a neglected neighbourhood in siting maternity services Social norms - living in a multigenerational and expected to respect the advice of husband and older women anxiety about first labour especially coming before term obeying social norms of complying with the wishes of her husband and older women ability to call on a nurse that lives in the neighbourhood gaves birth at home, a nurse was called upon to come and help at home - after initially going to the PHC TJ who failed to diagnose labour Progressive loss of power in legs and hands Governance/pluralism - lax regulation around nature of medical practice allowing frequent informal care/prescription Confidence in the ability of the visiting doctors to address the problem and didn't feel that going to hospital will make any difference or better results can be achieved elsewhere a doctor that lives in the areas pays him regular visit to assess and prescribe medicines for him Dizziness Governance – poor quality of diagnostics - failure of the different hospitals to solve the presenting problem Economic realities - availability of care through husband's employer anxiety about the illness (preventing her from reading especially the Quran) and the hope that one of the hospitals may be able to address the problem been to different hospitals and trying many different options place of birth (daughter Nature of the problem – pregnancy in a young inexperienced mother Social norms – safeguarding individual and family honour around privacy of intimate body parts Social norms - living in a multigenerational and expected to respect the advice of husband and older women Absence of an accountable authority – no support with reliable public transport, payment arrangements or information system Pluralism – availability of informal care from a local midwife Anxiety about the outcome considering lack of experience of the young mother anxiety about the possibility of losing the new-born A compromise since they were unable to go to hospital was to at least have a nurse present a local nurse conducted the delivery at home even though hospital delivery was planned by mother in-law
place of birth (self) Nature of the problem – vastly experienced mother but under an unusual circumstance "it was seven months and I was feeling that I was going to give birth." Social norms – safeguarding individual and family honour around privacy of intimate body parts Governance - hospitals in the area not sensitive to cultural values feels hospitals are helpful in assessing and helping with wellbeing of the unborn child resisting some of the hospital procedures that she feels are not acceptable Delivered on her own despite being in a hospital delivery suite (refused to call attention of midwife when the urge to push comes as she believed her labour was going on fine and doesn't agree with their procedure). "my body is opening fine". place of birth (daughter Nature of the problem – pregnancy in a young inexperienced mother Social norms – safeguarding individual and family honour around privacy of intimate body parts Social norms - living in a multigenerational and expected to respect the advice of husband and older women Absence of an accountable authority – no support with reliable public transport, payment arrangements or information system Pluralism – availability of informal care from a local midwife Economic - mothers in-law worried about the cost of hospital delivery on their sons Confidence in hospitals ability to address problem deliveries in this instance a young, "modern" and inexperience mother and preterm confidence in the ability of local midwife’s help at home as a good compromise a nurse was called and she came and assisted with the delivery at home birth tear during home delivery Pluralism - able to afford the stitching by the midwife but considered it inferior to the norm of using herbs , the norm of applying traditional medical practices for these types of conditions Social norms - living in a multigenerational and expected to respect the advice of husband and older women Confidence in the traditional way of dealing with the problem and do what is normally done in this circumstance refused stitching offered by the nurse attending the delivery at home and opt for home treatment applying traditional herbs for sitz-baths