title: Transaction costs of access to health care: Implications of the care-seeking pathways of tuberculosis patients for health system governance in Nigeria.
abstract: Health care costs incurred prior to the appropriate patient-provider transaction (i.e., transaction costs of access to health care) are potential barriers to accessing health care in low- and middle-income countries. This paper explores these transaction costs and their implications for health system governance through a cross-sectional survey of adult patients who received their first diagnosis of pulmonary tuberculosis (TB) at the three designated secondary health centres for TB care in Ebonyi State, Nigeria. The patients provided information on their care-seeking pathways and the associated costs prior to reaching the appropriate provider. Of the 452 patients, 84% first consulted an inappropriate provider. Only 33% of inappropriate consultations were with qualified providers (QP); the rest were with informal providers such as pharmacy providers (PPs; 57%) and traditional providers (TP; 10%). Notably, 62% of total transaction costs were incurred during the first visit to an inappropriate provider and the mean transaction costs incurred was highest with QPs (US$30.20) compared with PPs (US$14.40) and TPs (US$15.70). These suggest that interventions for reducing transaction costs should include effective decentralisation to integrate TB care with services at the primary health care level, community engagement to address information asymmetry, enforcing regulations to keep informal providers within legal limits and facilitating referral linkages among formal and informal providers to increase early contact with appropriate providers.
authors: a School of Public Health , University of Sydney , Sydney , NSW , Australia.|b National Primary Health Care Development Agency , Abuja , Nigeria.|c The George Institute for Global Health , Sydney , NSW , Australia.
authors: Seye
authors: S
authors: Abimbola
authors: d Department of Medicine , Federal Teaching Hospital , Abakaliki , Nigeria.
authors: Kingsley N
authors: KN
authors: Ukwaja
authors: e College of Medicine , University of Nigeria , Enugu Campus, Nsukka , Nigeria.
authors: Cajetan C
authors: CC
authors: Onyedum
authors: a School of Public Health , University of Sydney , Sydney , NSW , Australia.
authors: Joel
authors: J
authors: Negin
authors: a School of Public Health , University of Sydney , Sydney , NSW , Australia.|c The George Institute for Global Health , Sydney , NSW , Australia.
authors: Stephen
authors: S
authors: Jan
authors: a School of Public Health , University of Sydney , Sydney , NSW , Australia.|c The George Institute for Global Health , Sydney , NSW , Australia.|f Dalla Lana School of Public Health , University of Toronto , Toronto , ON , Canada.
authors: Alexandra L C
authors: AL
authors: Martiniuk
mesh_terms: D000328:Adult; D015897:Comorbidity; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000191:economics* / Q000453:epidemiology; D019538:Health Care Surveys; D005102:Health Expenditures / Q000145:classification / Q000706:statistics & numerical data*; D006296:Health Services / Q000145:classification / Q000191:economics* / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D009549:Nigeria; D014397:Tuberculosis, Pulmonary / Q000191:economics* / Q000453:epidemiology / Q000628:therapy
keywords: Nigeria; governance; informal providers; information asymmetry; transaction costs
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