Institutionalizing linkages between informal healthcare providers and the formal health system in Nigeria: what are the facilitating and constraining contextual influences?

With most households in rapidly urbanizing cities in low- and medium-income countries using private and informal providers for basic healthcare, the need to establish linkages with the formal sector is paramount in the drive for universal health coverage. Successful and effective linkage of informal healthcare providers to the formal health system requires an understanding of prevailing contextual factors and how they can be modulated to support the linkages. Context plays a pivotal role in shaping the nature and success of any integration efforts. This paper, based on a qualitative study, explored the facilitating and constraining contextual influences shaping the linkage of informal healthcare providers into the formal health system in governance, service delivery, and data reporting. The research was conducted in Enugu and Anambra states in southeastern Nigeria. In-depth interviews were held with 12 senior healthcare managers, 16 primary healthcare facility managers, 32 informal providers, and 16 community leaders. Eight sex-disaggregated focus group discussions were held with health service users. Transcripts were coded in NVivo using a pre-defined coding framework comprising facilitators and constraints at the individual, organisational, and environmental levels. Individual factors that influence linkage of informal providers into the formal health system include personal attitudes towards linkage, capacity of informal providers to deliver quality services, nature of existing relationships between formal and informal providers, and trust in the formal health system. Organizational factors include leadership structure, coordination and accountability mechanisms, functional management capacity of the formal health system, and multiple regulatory frameworks. External factors include supportive health policies on integration, sustainable funding for continuous training and supportive supervision, and global agenda/support for integration. This study has provided valuable insights for decision makers and practitioners for harnessing the contextual factors to link informal healthcare providers successfully and effectively to the formal health system in order to improve access to quality health services in urban slums.