An Equity Analysis of the Prevalence, Costs and Coping Mechanisms of Informal Payments in the Utilisation of Healthcare Services in Nigeria

ABSTRACT Background Informal payments in healthcare facilities increase the cost of services, negatively impacting access and utilisation, particularly for poor and vulnerable populations. However, those affected may adopt various coping strategies to alleviate the financial burden. This paper presents evidence on the costs and coping mechanisms used by different population groups in response to informal payments in healthcare facilities in Nigeria. Methods The study was conducted in the states of Enugu and Kano, located in the southeast and northwest regions of Nigeria, respectively. We collected data from 1659 randomly selected households using a pre‐tested interviewer‐administered questionnaire. We collected data on reported unapproved payments for healthcare services, amounts paid and coping strategies adopted by respondents. We explored the prevalence and drivers of making informal payments, the amounts paid and the coping mechanisms among different population groups. Concentration indices (CI) were used to examine socio‐economic status (SES) inequities in payments, dividing SES into quintiles (poorest, poor, average, rich, most well‐off). Results The prevalence of informal payments was high, especially payments for drugs (77.7%), consultations (54.3%), medical consumables (54.0%) and diagnosis (53.4%). Among the coping mechanisms used were household income (63.9%), help from family members (46.1%) and help from someone/organisation/ (22.3%). Wealthiest households were most likely to make informal payments (28.0%), spending the largest sums (₦941,220, €550). However, poor households had the highest average expenditure on informal payments (₦8579.71, €5). Conclusion Informal payments are widespread in Nigeria's healthcare system, contributing to increased costs and inequities in access to healthcare services. This underscores the urgent need for systemic reforms to combat corruption in healthcare facilities. Eliminating informal payments is essential for improving equity and ensuring that the health system can deliver services at a low cost. Transparent service pricing, regular audits and robust oversight mechanisms are recommended to detect and prevent informal payments.