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Table of Contents
Year : 2021  |  Volume : 26  |  Issue : 1  |  Page : 11-16

The inverse care law: implications for universal health coverage in Nigerian rural communities

1 Department of Community Medicine, University of Calabar, Calabar, Nigeria
2 Department of Preventive and Social Medicine, University of Port Harcourt, Nigeria

Date of Submission12-Dec-2019
Date of Decision13-Jun-2020
Date of Acceptance10-Jul-2020
Date of Web Publication21-Oct-2020

Correspondence Address:
Aniekan Etokidem
Department of Community Medicine, University of Calabar, Calabar.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_38_19

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Background: The inverse care law states that the availability of good healthcare tends to vary inversely with the need for it in the population served. This situation is easily observable in developing countries like Nigeria, and poses a threat to the attainment of universal health coverage (UHC) in rural communities. Objective: To examine how the inverse care law plays out in the Nigerian healthcare system, and how this may lead to a difficulty in achieving UHC in rural communities. Materials and Methods: Standard procedures were used in locating, selecting, extracting and synthesizing data. Electronic databases and internet resources such as PubMed, Google Scholar, SCOPUS and Web of Science were searched. Selection of studies was conducted by a two-stage process. Data extraction was done using data extraction forms. During data synthesis, major themes, strengths, weaknesses and critical gaps in each paper were identified. Results: There are several factors that boost the operation of the inverse care law in the Nigerian healthcare system. How this poses a threat to the attainment of UHC has also been documented. Among these are limitations in the range of services provided in rural healthcare facilities, inadequate production and maldistribution of health personnel, and low health manpower retention in rural areas. Conclusion: There is a need for concerted efforts by the government to address the factors that facilitate the inverse care law in the Nigerian healthcare system. This is necessary for the attainment of UHC specifically and the Sustainable Development Goal number three generally.

Keywords: Health, inverse care law, Nigeria, rural, sustainable development goal, universal health coverage

How to cite this article:
Etokidem A, Ogaji D. The inverse care law: implications for universal health coverage in Nigerian rural communities. Int J Med Health Dev 2021;26:11-6

How to cite this URL:
Etokidem A, Ogaji D. The inverse care law: implications for universal health coverage in Nigerian rural communities. Int J Med Health Dev [serial online] 2021 [cited 2023 Jun 5];26:11-6. Available from: https://www.ijmhdev.com/text.asp?2021/26/1/11/298784

  Key Message: Top

The inverse care law manifests as the maldistribution of health facilities and personnel in Nigeria. This affects mainly rural and semi-urban dwellers in Nigeria. There is a need to tackle this problem to ensure attainment of universal health coverage in Nigerian rural communities.

  Introduction Top

The inverse care law was enunciated by Julian Tudor Hart in 1971. According to it, the availability of good medical care tends to vary inversely with the need for it in the population served.[1] A study in Australia has found that those who were more likely to need care because of their socioeconomic circumstances had a higher chance of experiencing limitations in their choice of provider, and to be dissatisfied with the care received.[2]

Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of such services does not expose the user to financial hardship. The attainment of UHC is one of the targets of the health-related Sustainable Development Goal (SDG) number three.[3]

While developed and higher-income countries may seamlessly attain UHC for their citizens in the rural and urban areas, low- and middle-income countries (LMICs), especially those in sub-Saharan Africa, will find it difficult for several reasons. One of the reasons is the operation of the inverse care law with respect to the distribution of healthcare services and healthcare personnel in these countries.[4],[5] Nigeria presents a typical scenario of how challenging it will be to achieve UHC in rural communities of developing countries.[6],[7]

How does the inverse care law apply to Nigeria?

In Nigeria, more people live and work in rural areas where limited healthcare facilities and fewer healthcare personnel are found.[4],[5],[8] Conversely, fewer Nigerians live and work in urban centers (than rural areas) with an abundance of healthcare facilities. There is therefore a higher density of healthcare providers in these urban centers than in rural areas.[4],[8],[9] Most state capitals in Nigeria have tertiary health institutions, mostly university teaching hospitals and federal medical centers. Some university teaching hospitals have hundreds of doctors, nurses and other healthcare providers. On the contrary, most primary healthcare centers (which constitute the main form of healthcare delivery facility in rural areas) do not have a single doctor or nurse/midwife. They are rather manned by community health extension workers.[10]

A study by the International Labor Organization has found that even if access to healthcare is guaranteed by law, people in rural areas remain excluded because such laws are not enforced in places they live. The study further added that although half of the world’s population lives in rural areas, only 23% of the global health workforce is deployed to these areas.[11] In Africa, 83% of rural dwellers are not covered by essential healthcare services.[12] Considering the fact that Nigeria is the most populous country in Africa, it can be argued that a majority of these are Nigerian rural dwellers.

Study objectives

The objectives of this review paper were:

  • (a) to examine how the inverse care law plays out in the Nigerian healthcare system;

  • (b) to document the implications of the inverse care law on the attainment of UHC in Nigerian rural communities and other developing countries.

  Materials and Methods Top

This is a review article. The review covers relevant literature from 1971 to 2019.

Standard (recommended) procedures were used for locating, selecting, extracting data and data synthesis.[13] Studies included in the review were located by searching electronic databases; relevant internet resources such as PubMed, Google Scholar, SCOPUS, Web of Science and African Journals Online; conference proceedings; and citation searching. Reference lists of articles were also browsed to identify potential studies. Additional publications were searched for by snowballing method where references in one publication were used to search for more literature. Medical Subject Heading (MeSH) terms for inverse, care and law were used. Boolean operator ‘AND’ was used to ensure that the searches would identify only those papers that used the complete phrase ‘inverse care law’. The selection of studies was conducted by a two-stage process. In the first stage, the selection was based on study title and abstracts. Citations identified by the search were sifted through. The second stage involved obtaining the full paper, where available. Data extraction was done using data extraction forms by a research assistant, while the researchers checked the extracted data for completeness. During data synthesis, each paper was read several times and the major themes were noted. Also considered in the review were the strengths, weaknesses and critical gaps in each paper.[14]

  Results Top

Challenges in achieving UHC in Nigerian rural communities

Achieving UHC among Nigerian rural dwellers is a challenge because of the inverse care law. UHC proposes to provide services of ‘sufficient quality’.[3] One of the components of quality healthcare deals with the knowledge and skills of care providers. How can quality be guaranteed when the lowest level of healthcare providers (community health extension workers) is the only health manpower available in most Nigerian rural communities? They are trained to provide basic healthcare under the guidance of standing orders.[12],[15] This problem is compounded by the fact that health facilities at the lowest level, that is, primary health facilities, are the only ones available in most Nigerian rural communities.[16] Will the rural dwellers use what is not available?

Currently, out-of-pocket expenditure is the main mode of healthcare financing in Nigeria amidst very low budgetary allocations by the three tiers of government. This situation is further worsened by abysmally poor health insurance penetration.[17] Because of the high level of poverty in rural communities compared to urban areas, it is almost certain that access to health services will expose rural healthcare consumers to a financial hardship.[18]

Factors that boost the inverse care law in Nigeria

The following factors boost the inverse care law in Nigeria, making the attainment of UHC a challenge.

Limitations of range of services

UHC implies that healthcare consumers have easy access to promotive, preventive, curative, rehabilitative and palliative health services. This too is an uphill task for Nigerian rural communities. Where healthcare services are available in Nigeria, the emphasis is on curative care.[19],[20] While there may be some attention being paid to promotive and preventive services, health facilities located in most Nigerian rural communities have no provision for rehabilitative and palliative services. This is because these services are beyond the basic level of services that should be provided by primary healthcare facilities. Equally, healthcare providers in most of these rural healthcare facilities, that is, community health extension workers, lack the competence to provide such services.[10] The full range of services from promotive to palliative (and competent providers) can only be found in secondary and tertiary health institutions that are usually located in state capitals and major towns. Access to such facilities by rural dwellers is often hindered by several sociocultural, geographic and financial barriers. Therefore, only a strong and determined paradigm shift can ensure the availability of, and access to, a full range of services in rural areas.

Rural–urban population disparity

Although the proportion of Nigerians living in rural areas keeps decreasing due to increasing urbanization, it has always remained higher than the proportion living in urban areas. During independence in 1960, the proportion of Nigerians living in rural areas was 84.59%, while 15.41% lived in urban areas. Currently, 51.40% of Nigerians are rural dwellers, while about 48.60% are urban dwellers.[5]

The past 20 years have witnessed a collapse of industries located in urban centers, resulting in a high rate of unemployment in Nigeria.[21],[22] This has likely slowed the pace of urbanization. As the cost of living in urban areas keeps increasing, a disparity in population distribution is likely to remain. There are instances where people relocate and commute to work from rural areas in order to cushion the high cost of renting houses. In other instances, people who had lost employment or retired from service had to relocate from urban centers to their rural communities of origin so as to cushion the economic effect of unemployment or retirement.[23]

Inadequate production and maldistribution of health personnel

The WHO has observed that Nigeria’s healthcare system suffers from insufficient turnout and maldistribution of skilled personnel, with a majority of healthcare providers being concentrated in tertiary facilities in the southern part of the country, especially in Lagos.[4]

Low health manpower retention in rural areas

There is low retention of health workforce in rural areas. This may be attributed to several factors including a lack of incentives and motivation.[24] Other contributors include a lack of social amenities such as roads, water supply and electricity, a lack of good schools for the children of health workers, and even poor communication network in rural areas. It has been documented that the attrition rate of health personnel is three times higher for doctors and two times higher for nurses in rural areas than in urban areas.[25]

Dysfunctional health facilities in rural areas

Not only are the majority of health facilities located in urban areas, the few located in rural areas are of low quality, with some in a state of disrepair and, therefore, dysfunctional. The dysfunctionality is partly due to the fact that primary healthcare is the most neglected and poorly managed in Nigeria.[26] Some dysfunctionality may be due to frequent unavailability of essential medicines. The Nigerian drug system has been marred by the ‘out-of-stock’ syndrome.[27]

Lack of access to health facilities for rural dwellers

Inaccessible health facility is as good as unavailable health facility. Sometimes, health facilities are located too far away from where people live. A study by Uneke et al. has found that the ratio of households within 10 km of a health facility is 50% higher in urban areas than rural areas of Nigeria.[28]

Regarding geographic accessibility, an earlier study has found that about 20% and 38% of households are located beyond 5 km from any health facility in urban and rural areas, respectively, and even if available, they are inaccessible due to poor road network and topography.[29]

Inaccessibility could also be due to a lack of means of transportation, especially in rural riverine communities where there are no boats and canoes, or the waterways have been taken over by water hyacinths. In some riverine communities, water transport services are available only on market days. If health facilities are located in places accessible only by boats and canoes, the chance of accessing them during emergency situations is ruled out since these transportation services are available only on market days.

The World Bank had earlier documented that distance has an impact on the health-seeking behavior of people, especially in situations where transportation is limited.[30]

Low utilization of available services

The utilization of all aspects of facility-based healthcare services is lower in rural than urban areas of Nigeria. Although sociocultural factors might contribute to this, health system factors such as lack of health facilities and complete absence or paucity of competent personnel also play a role.

It has been documented that attendance to antenatal clinics (at least four times) was 74.5% in urban areas and 38.2% in rural areas in Nigeria.[31] Demand for family planning satisfied by modern methods was 40.5% in urban and 22.6% in rural areas. Skilled birth attendance in urban areas in Nigeria stands at 67% compared to 22.7% in rural areas. Only 21.9% of deliveries took place in health facilities in rural areas compared with 61.7% in urban areas. Similarly, only 29.0% of mothers in rural areas underwent postnatal care within 2 days of delivery against 59.1% in urban areas.[32]

Poor health literacy and health-seeking behavior of rural dwellers

Health-seeking behavior has been found to be higher among urban than rural dwellers.[33] Education has a positive influence on one’s health-seeking behavior. According to Mirowsky and Ross’s theory of human capital, education leads to good health as it engenders the adoption of healthy lifestyles. Furthermore, the researchers’ theory of personal control suggests that education encourages a sense of self-control over one’s life, a process that leads to better health information-seeking behavior.[34]

Inherent weaknesses in the Nigerian healthcare system

Some inherent weaknesses in the Nigerian healthcare system make quality healthcare unavailable to rural dwellers. Nigeria runs a three-tier system of government, which also reflects in the healthcare system. The federal government is in charge of tertiary healthcare, while the state governments take charge of secondary healthcare, and the local governments take charge of primary healthcare. In most Nigerian rural communities, primary healthcare facilities, which are controlled by the local government, constitute the only healthcare facilities available. Incidentally, local government authorities do not have financial autonomy. This affects the funding of primary healthcare to the extent that the lowest cadre of healthcare providers, the community health extension workers, are the main healthcare providers in primary healthcare centers.[10] The higher cadre of healthcare providers, including doctors, nurses and midwives, are mostly available in non-primary healthcare centers.[35] Irregular payment of salaries and poor working conditions act as demotivators to this category of healthcare providers. The salary system in Nigeria also reflects the three-tier system of government. Federal workers are usually better paid than state workers, who, in turn, are better paid than local government workers. Nurses, pharmacists and doctors are found mainly in secondary and tertiary health facilities located in urban centers.[4]

Certain healthcare services, such as those provided only by nurses and doctors, are often not available to rural dwellers because of the obvious limitation in the knowledge and skills of health workers in rural healthcare facilities. To make matters worse, referrals to higher levels of care are usually hampered by a lack of means of transportation and poor (or absence of) road networks.[36],[37]

Health manpower shortage

The WHO had identified Nigeria as one of the 57 countries in the world with health manpower crisis. It found that Nigeria has densities of nurses, midwives and doctors that are still too low to effectively deliver essential health services.[4] More so, primary healthcare suffers from deficient health manpower, a situation that is worsened by unequal distribution between zones and among urban and rural areas.[4]

Curiously, Nigeria remains one of the major health workforce-exporting countries in Africa. Recent research shows that Nigeria is the leading African source of foreign-trained nurses practicing in OECD countries. Nigeria is also one of the three leading African sources of foreign-born medical doctors.[38]

Sociopolitical factors

Rural dwellers lack the voice and political power to attract amenities, including health facilities. Equally, when poor rural dwellers migrate to urban areas, they find themselves in urban slumps where deprivation, both of general infrastructure as well as health infrastructure, appears to be the norm. The skewed distribution of health facilities in favor of urban centers also follows the distribution of other health-related infrastructure such as potable water.[39]

Rural poverty

The Brookings Institute recently documented that ‘Nigeria has already overtaken India as the country with the largest number of extreme poor in early 2018’. Their trajectories suggested that, by end of May 2018, Nigeria had about 87 million people in extreme poverty, compared with India’s 73 million. The Institute also found that extreme poverty in Nigeria is growing by six people every minute, while poverty in India continues to fall.[40] Following this, both international and local news media were awash with screaming headlines such as ‘Nigeria is now the Poverty Capital of the World’.[41]

Poverty in Nigeria wears a rural mask. An earlier research documented that the majority of poor Nigerians live in rural areas. In 1980, 1985, 1992 and 1996, the proportion of poor people in Nigerian urban areas were 17.2%, 37.8%, 37.5% and 58.2%, respectively, while the corresponding figures for rural areas were 28.3%, 51.4%, 46.0% and 68.8%.[42]

According to UNICEF, in spite of Nigeria’s vast oil wealth, 71% of the population live on less than one dollar a day and 92% on less than two dollars a day.[43]

Most rural dwellers in Nigeria lack the resources to make their economic situation better. Rural poverty in Nigeria affects all of the country’s geopolitical regions.[44] One would have expected the oil-rich Niger Delta Region to be an exception. On the contrary, UNDP documented that the region is characterized by pervasive poverty.[45]

The inability of rural dwellers to pay for health services makes rural areas economically unattractive for private healthcare providers to locate and operate their facilities there. The primary motivation of private healthcare providers is profit-making, which cannot be guaranteed in rural areas due to pervasive poverty.

Implications for Nigeria and other developing countries

There is a threat to the attainment of health-related SDG, of which the attainment of UHC is a key component. Nigeria and many other developing countries did not perform optimally regarding the attainment of health-related MDGs. Both the government and people of Nigeria and other developing countries should work towards ensuring that health-related SDG becomes a reality by addressing the facilitators of the inverse care law identified in this paper.

Limitations of the paper

The authors could not search some databases due to access restrictions. Moreover, being a review article, it has a word limit restriction.

  Conclusion and Recommendations Top

The implementation of UHC in Nigerian rural communities is facing a number of barriers. In order to succeed, the government should embark on massive health system strengthening. Attention must be paid to manpower and material needs. Measures must be put in place to ensure attraction and retention of health workers in rural areas. Special allowances and provision of basic amenities such as roads and accommodation for healthcare providers could motivate rural healthcare providers. Employment of a Medical Officer of Health (MOH) in each local government area and granting fiscal autonomy to local government authorities to ensure adequate financing are some of the measures that would facilitate UHC in these communities.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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