Barriers Between People and Health Care Practitioners in Calabar, Nigeria

BARRIERS BETWEEN PEOPLE AND HEALTH CARE PRACTITIONERS IN CALABAR, NIGERIA Wilbert M. Gesler INTRODUCTION. An important aspect of any health care delivery system is the effort people must make to overcome barriers that separate them from health care practitioners. The principal types of barriers considered in this study are distance between client and provider and both time and money spent to obtain health care. Measures of these barriers include distance traveled, travel mode, travel time, travel cost, waiting time at practitioner, and treatment cost. The investigation was carried out in the urban area served by the Family Health Clime in Calabar, Nigeria. (1) The study population consisted of children under six, the group that, along with their mothers, is eligible to attend the clinic. Both "modern" and "traditional " practitioners were considered to be potential sources of health care. This paper addresses three research questions that involve the interplay among children, health practitioners, and the barriers between these two groups. First, must people make different levels of effort to reach the three types of practitioners most often visited in Calabar: 1) facilities that employ doctors and nurses trained in Western medicine (referred to as western practitioners); 2) pharmacies , which are much like American drug stores; and 3) patent medicine stores, small shops that sell non-prescription drugs? Second, do people make trade-offs among distance traveled, waiting time, and treatment cost? Third, what is the relative importance of travel distance, waiting time, and treatment cost in visits made to Western facilities as opposed to visits made to patent medicine stores and pharmacies? The analysis was performed with policy implications for the Family Health Clinic in mind. Distance from client and the way in which health practitioners deliver care were both found to be of importance in the analysis of the research questions. These findings Dr. Gesler is Assistant Professor of Geography at Rutgers College, New Brunswick, NJ 08903. 28Southeastern Geographer should be useful to the clinic in assessing its present location and its role relative to other sources of health care in the city. Because most health care studies have been conducted by Westerners , only institutionalized or formal Western-style facilities have been included in most investigations carried out in developed and in developing areas. Some researchers have realized the importance of bringing all practitioners, "traditional" or "modern," into health care studies. Good's agenda for the inclusion of traditional medicine in research, Maclean's work in Ibadan, and a study by Orobuloye and Caldwell in a rural area of Nigeria, are examples of steps taken in this direction. (2) Representative studies of the spatial aspects of health care delivery systems include King's work in Africa, using various measures of distance between people and health clinics. A study conducted in Uganda by Gershenberg and Haskell focused on distance traveled, population density in the service area, and waiting time for several types of health care facilities. Fuller's study of fertility decline in a Chilean community found that distance between residences of women and a maternal and child health clinic with a family planning unit was "the most powerful discriminator between users and non-users of contraceptive techniques." Morrill, Earickson, and Rees used hospital discharge data in Chicago to show that Blacks and the poorer people tend to travel farther to hospitals than Whites and the richer people, often beyond intervening hospitals not open to them, and that religious persuasion takes some people beyond intervening hospitals by choice. Girt found partial confirmation of his hypotheses that the recognition of illness increases with distance from a hospital and that the decision to consult a doctor decreases with distance. (3) THE STUDY SETTING. Calabar, the capital of Cross River State in the southwestern corner of Nigeria, is for the most part built on high ground between the valleys of the Calabar and Kwa rivers. These rivers are tributaries of the Cross River which flows into the Bight of Biafra. At present the rivers act as barriers to contact by the people of Calabar with the rest of Nigeria as they can be crossed only by ferries or other boats at points 40 or more kilometers from the city. It is difficult to know...