Corruption and the emergence of a healthcare 'marketplace' in Nigeria's primary health centres: reframing drivers and solutions

TY - JOUR

T1 - Corruption and the emergence of a healthcare 'marketplace' in Nigeria's primary health centres

T2 - reframing drivers and solutions

AU - Odii, Aloysius

AU - Hutchinson, Eleanor

AU - Onwujekwe, Obinna

AU - Agwu, Prince

AU - Orjiakor, Tochukwu C.

AU - Ogbozor, Pamela

AU - McKee, Martin

AU - Balabanova, Dina

N1 - Publisher Copyright: © 2025 The Author(s)

PY - 2025/10

Y1 - 2025/10

N2 - Corruption in the health systems of low- and middle-income countries (LMICs) is fuelled by many factors, including health system failures, practical norms, informal rules, and social networks. Researchers have historically scrutinized these factors in isolation, often failing to grasp the intricate interconnections and the combined manner in which they manifest. In this ethnographic study, we present evidence from Nigeria's healthcare system, where these factors converge, fundamentally reshaping the structure and operation of the healthcare system away from those set out in policy. Our study entailed three months of simultaneous participant observation at six Primary Health Centres in Enugu, Nigeria by four researchers. Following this, we conducted in-depth interviews with healthcare workers and their managers, and focus group discussions with service users. Our findings show that informal payments and rent-seeking, are widespread. Failures to provide basic infrastructure, staff and commodities means that healthcare providers have to use informal means to raise money in order to address these deficiencies. These practices are deeply embedded in reciprocal obligations among staff members, coordinated by groups who collaborate and engage in sustained interactions. Over time, their shared norms and networks are underpinned by informal agreements when and how to charge patients and allocating collected resources. Under this situation, healthcare facilities metamorphose from the ideal of primary health facilities as a setting in which care is provided according to need, into a 'marketplace,' where access to care and health commodities is profoundly shaped by economic imperatives and intricate social processes. The findings of this study suggest that any single “silver bullet” approach, such as solely focusing on norms, and health system failures, is likely to have minimal impact. Instead, policy makers should seek innovative ways through which more equitable access to care can be achieved in the current context.

AB - Corruption in the health systems of low- and middle-income countries (LMICs) is fuelled by many factors, including health system failures, practical norms, informal rules, and social networks. Researchers have historically scrutinized these factors in isolation, often failing to grasp the intricate interconnections and the combined manner in which they manifest. In this ethnographic study, we present evidence from Nigeria's healthcare system, where these factors converge, fundamentally reshaping the structure and operation of the healthcare system away from those set out in policy. Our study entailed three months of simultaneous participant observation at six Primary Health Centres in Enugu, Nigeria by four researchers. Following this, we conducted in-depth interviews with healthcare workers and their managers, and focus group discussions with service users. Our findings show that informal payments and rent-seeking, are widespread. Failures to provide basic infrastructure, staff and commodities means that healthcare providers have to use informal means to raise money in order to address these deficiencies. These practices are deeply embedded in reciprocal obligations among staff members, coordinated by groups who collaborate and engage in sustained interactions. Over time, their shared norms and networks are underpinned by informal agreements when and how to charge patients and allocating collected resources. Under this situation, healthcare facilities metamorphose from the ideal of primary health facilities as a setting in which care is provided according to need, into a 'marketplace,' where access to care and health commodities is profoundly shaped by economic imperatives and intricate social processes. The findings of this study suggest that any single “silver bullet” approach, such as solely focusing on norms, and health system failures, is likely to have minimal impact. Instead, policy makers should seek innovative ways through which more equitable access to care can be achieved in the current context.

KW - Corruption

KW - Informal payments

KW - Marketplace

KW - Primary health centres

KW - Rent-seeking

UR - https://www.scopus.com/pages/publications/105010911342

U2 - 10.1016/j.socscimed.2025.118356

DO - 10.1016/j.socscimed.2025.118356

M3 - Article

C2 - 40680478

AN - SCOPUS:105010911342

SN - 0277-9536

VL - 383

JO - Social Science and Medicine

JF - Social Science and Medicine

M1 - 118356

ER -