Informal health care providers in Nigerian slums: perspectives on how to link them with the formal health system

Informal healthcare providers (IHPs) play a crucial role in healthcare delivery in urban slums, but the lack of linkages between IHPs and the formal healthcare system results in fragmented, low-quality care. Integrating IHPs into the formal healthcare system poses challenges that are common across such settings. This study explores the perceptions of healthcare providers and consumers in Nigerian urban slums regarding linking IHPs to the formal healthcare system, while also aiming to identify stakeholder perceptions on how the linkage might best work. Using cross-sectional consumer and provider surveys we collected data via questionnaires from 1024 households and 255 providers, purposively selected from eight urban slums in Anambra and Enugu states, southeast Nigeria. We estimated overall and subgroup-specific percentages, percentage-point differences, and associated 95% confidence intervals for question responses using logistic regression models and marginal effects methods. Most consumers were female (96%), with a median age of 31 years, reflecting the sampling design and focus on females in households with women of childbearing age and/or young children, and 63% were employed in the informal sector, reflecting the setting. Most providers were IHPs (93%) and private (94%), with the most common job title being patent medicine vendors (54%). We found that 92% (95% CI: 84%, 96%; n/N = 943/1025) of consumers and 87% (95% CI: 60%, 97%; n/N = 221/255) of providers supported linking IHPs to the formal health system. Both groups of respondents primarily favoured 1) training, supervision, and referral as the main strategies and aspects of services to be linked, 2) having the Ministry of Health lead the linkage, and 3) managing the linkage through government legislation. There was little evidence for any large differences in consumer or provider views across subgroups based on key socio-demographic characteristics or provider attributes. The study findings offer guidance for future policymaking.