EFFECT OF INCOME INEQUALITY ON HEALTH OUTCOMES AND HEALTH-SEEKING BEHAVIOUR IN NIGERIA

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EFFECT OF INCOME INEQUALITY ON HEALTH OUTCOMES AND HEALTH-SEEKING BEHAVIOUR IN NIGERIA

ABSTRACT

During the periods of 1960s through 1980s, poor health outcomes (illness and deaths) resulting from strokes, hypertension, high blood pressure, cancers and heart diseases were very rare among Nigerian. But in recent decades, these has become more prevalent and remains deadly rising, as illnesses and deaths from non-communicable diseases rose from 21% to 29% between 2010 and 2016. However, the percentage of Nigerians with appropriate health-seeking behaviour declined from 54% in 2013 to 32% in 2019. While the share of income earned by the richest 10% of Nigerian increased from 26% in 2004 to 31% in 2017, the income belonging to the bottom 40% at the lower-end of income distribution declined from merely 6.3% to 2.8% at the same periods. Yet, the effect of income inequality on health particularly in emerging nations such as Nigeria has remained relatively unexplored. Further, how household’s characteristics mediate the income disparity-health link also remains unclear. Thus, this study examined the effect of income inequality on health outcomes and health-seeking behaviour in Nigeria. The thesis draws insights from the seminal works of Wilkinson (1992, 1994) which opined that in the growth process, there will be a point at which income disparity rises and this corresponds with the shift in the main causes of ill-health from infectious to non-communicable diseases. The adapted model was estimated using Panel Logistic technique based on data collected from the four Waves of repeated cross-section surveys, the Nigerian General Household Panel Survey, conducted by National Bureau of Statistics (NBS) in 2010, 2013, 2016 and 2019. The main findings of the study are that, first, the percentage of male and female reported having an illness rose from 13.7% and 15.2% to 22.6% and 24.5% between 2016 and 2019, respectively; while those with appropriate health-seeking behaviour decreased from 27.9% to 17.9% for male and 28.3% to 19.1% for female between the periods. Second, nearly 95% of states in Nigeria had higher income disparity among their households between 2010 and 2019. Third, the likelihood of a percentage-point rise in these income inequalities worsens illness by 1.41%. Fourth, it was also evidenced statistically that larger household size, low educational level of household heads, nutritional deficiency, lack of access to electricity and drinkable water, alcoholic consumption, self-medication, non-utilization of healthcare services, and low household earnings indirectly mediate the income inequality-health outcomes effect in Nigeria. Fifth, the likelihood that income inequality will limit appropriate healthcare-seeking was 1.25%. Sixth, the link between income inequality and appropriate healthcare-seeking is also mediated by larger family size, marital status, education, and low earnings significantly in Nigeria. Therefore these results suggest that though income inequality is detrimental to both health outcomes and health-seeking behaviour in Nigeria, the devastating effect of income inequality on health is also mediated by household’s factors. Hence, policies that reduce income inequality such as cash transfers, entrepreneurship programs and job creation need to be enhanced. Also, increasing human capital investment through health and education as well as raising public awareness on self-medication and healthy lifestyles can help improve health outcomes and appropriate medical-care seeking in Nigeria.

TABLE OF CONTENTS

TITLE PAGE…………………………………………………………………..…………………..i

DECLARATION ……………………………………………………………………………………………………………. ii

CERTIFICATION …………………………………………………………………………………………………………. iii

DEDICATION ………………………………………………………………………………………………………………. iv

ACKNOWLEDGEMENTS ……………………………………………………………………………………………… v

ABSTRACT ………………………………………………………………………………………………………………….. vi

CHAPTER ONE

INTRODUCTION…………………………………………………………………………..……1

1.1 Background to the Study………………………………………………………………….1

1.2 Statement of the Research Problem………………………………………………………5

1.3 Research Questions……………………………………………………………………….7

1.4 Objectives of the Study……………………………………………………………………8

1.5 Justification for the Study…………………………………………………………………8

1.6 Scope and Limitation of the Study………………………………………………………10

1.7 Organizations of the Study………………………………………………………………11

CHAPTER TWO

STYLIZED FACTS ON INCOME INEQUALITY, HEALTH OUTCOMES, AND HEALTH-SEEKING BEHAVIOUR IN NIGERIA…………………………………………………..……12

2.1 Introduction……………………………………………………………………………..12

2.2 Stylized Facts on Income Inequality in Nigeria…………………………………………12

2.2.1 Trends of Income Disparity in Nigeria………………………………………………….12

2.2.2 Trends in Income Distribution in Africa…………………………………………………15

2.2.3 Income Inequality-Adjusted-to-Health………………………………………………….16

2.3 Causes of Income Inequality in Nigeria………………………………………………….17

2.3.1 Regional and States’ Factors……………………………………………………………..17

2.3.2 Household and Individual’s Factors……………………………………………………..18

2.4 Health Outcome Issues in Nigeria……………………….………………………………19

2.4.1 Infectious and Communicable Diseases…………………………………………………21

2.4.2 Non-Communicable Diseases (NCDs)………………………………………………….23

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2.4.3 Under-five Mortalities……………………………………………………………………25

2.4.4 New-born and Maternal Deaths……………………………………………….….……..27

2.4.5 Longevity (Average Life Expectancy at Birth) ………………………………….……..28

2.5 Health Outcome Issues Across Regions and States in Nigeria…………………………30

2.6 Trend of health-Seeking Behaviour in Nigeria………………………………………….31

CHAPTER THREE

LITERATURE REVIEW………………………………………………………………………35

3.1 Introduction…………………………………………………………………………….35

3.2 Conceptual Reviews…….………………………………………………………….….35

3.2.1 Income Inequality………………………………………………………………………35

3.2.2 Health Outcomes………………………………………………………………………37

3.2.3 Health Seeking Behaviour………………………………………………………….….41

3.3 Theoretical Reviews……………………………………………………………………43

3.3.1 Classical Thought………………………………………………………………………43

3.3.2 Neoclassical Theories………………………………………………………………….44

3.3.3 Marxian Theories………………………………………………………………………45

3.3.4 Keynesians Views………………………………………………………………………46

3.3.5 Absolute Income-Health Hypothesis……………………………………………….….47

3.3.6 Relative Income-Health Hypothesis……………………………………………………47

3.3.7 Political Capture Mechanisms…………………………………………………………50

3.3.8 Social Capital Mechanisms…………………………………………………………….51

3.3.9 Neo-Material Mechanisms……………………………………………………………..51

3.3.10 Psycho-Social Mechanisms…………………………………………………………….52

3.4 Review of Empirical Studies……………………………………………………………55

3.4.1 Cross-Country Evidence……………………………………………………………….55

3.4.2 Country-Specific Evidence…………………………………………………………….58

3.4.3 Evidence from Nigeria…………………………………………………………….……61

3.5 Income Inequality-Health-Seeking Behaviour Nexus………………………………….62

3.6 Observed Gaps in the Literature……………………………………………………….64

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CHAPTER FOUR

RESEARCH METHODOLOGY…………………………………………………………….66

4.1 Preamble….……………………………………………………………………….….66

4.2 Theoretical Framework………………………………………………………………66

4.3 The Model…………………………………………………………………………….71

4.4 Estimation Procedures……………………………………………………………….80

4.4.1 Panel Logistic Regression……………………………………………………………81

4.4.2 Heteroskedasticity………………………. ………………………………………….81

4.4.3 Hausman Specification Test…………………………………………………………82

4.4.4 Other Estimation Issues.……………………………………………………………..83

4.4.5 Test for Significance of Model Parameters…………………………….……………83

4.5 Data Issues……………………………………………………………………….…..84

4.5.1 Sampling……………………………………………………………………………..84

4.5.2 NGHPS Questionnaires………………………………………………………….…..85

4.5.3 Data Quality…………………………………………………………………………85

4.6 Measurement of Income Inequality…………………………………………………86

4.6.1 Gini-Coefficient Method…………………………………………………………….86

4.6.2 Generalized Entropy (GE) Method………………………………………………….87

4.7 Robustness Checks……………………………………………………………….….87

CHAPTER FIVE

RESULTS AND DISCUSIION OF FINDINGS……………………………………………88

5.1 Introduction………………………………………………………………………….88

5.2 Descriptive Statistics…………………………………………………………………88

5.3 Demographic and Socio-Economic Characteristics of Households…………………91

5.3.1 Gender of the Respondents……………………………………………………………91

5.3.2 Relationship with Head of Households………………………………………………91

5.3.3 Household’s Size………………………………………………………………….….92

5.3.4 Level of Education of Respondents………………………………………………….93

5.3.5 Marital Status…………………………………………………………………………94

5.3.6 Household’s Sources of Water……………………………………………………….94

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5.3.7 Access to Electricity…………………………………………………………………95

5.3.8 Type of Toilet Facility……………………………………………………………….95

5.4 Level and Magnitude of Income Inequality in Nigeria………………………………97

5.5 Effects of Income Inequality on Health Outcomes (Illness)………………………..103

5.5.1 Preliminary Results for NGHPS (All Waves) ……………………………………..103

5.5.2 Regression Results for NGHPS Waves…………………………………………….103

5.5.3 Heterogeneity Test: Breusch-Pagan Lagrange Multiplier………………………….113

5.5.4 Hausman Specification Test…………………………………………………………113

5.5.5 Robustness Checks for Income Inequality-Health Outcomes……………………….114

5.5.6 Evidence from Individual Wave Estimations ……………………………………….116

5.6 Estimates of the Effects of Income Inequality on Health-Seeking Behaviour………120

5.6.1 Preliminary Results for NGHPS (All Waves) ………………………………………120

5.6.2 Regression Results for NGHPS Waves………………………………………….….120

5.6.3 Breusch-Pagan LM for Heterogeneity Test…………………………………………128

5.6.4 Hausman Specification Test…………………………………………………………128

5.6.5 Robustness Checks for the Income Inequality-HSB Effect.…………….………….129

CHAPTER SIX

SUMMARY, CONCLUSION AND RECOMMENDATIONS……………………………138

6.1 Introduction…………………………………………………………………………138

6.2 Summary of Major Findings..………………………………………………………138

6.3 Conclusion………………………………………………………………………….141

6.4 Recommendations………………………………………………………………….142

6.4.1 Policy Recommendations…………………………………………………………..142

6.4.2 Recommendations for Further Studies……………………………………………..143

REFERENCES………………………………………………………………………….….144

APPENDICES………………………………………………………………………………162

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LIST OF TABLES

Table 2.1: Trends of Gini-Coefficient of Selected Africa Countries, 1990 to 2015…….….15

Table 2.2: People living with Heart Diseases (as at 2015) …………………………………20

Table 2.3: Percentages of Reported Infections and Communicable Diseases

by Sex in Nigeria (2010-2015) …………………………………………………22

Table 2.4: Percentages of Infectious Diseases causing illness in Nigeria……………..……23

Table 2.5: Causes of Illness in Nigeria………………………………………………………24

Table 2.6: Comparative Under-five Deaths (per 1,000) in SSA region………………………26

Table 2.7: Five Nations Accounted for Half of the Global Infant Deaths in 2017…….……27

Table 2.8: Comparative Average Life Expectancy at birth (total) in SSA region…………..30

Table 2.9: Mortality Statistics from all Ill-Health Cases across the Geo-Political Zones….31

Table 2.10: Trend of Healthcare Consultation during Illness in Nigeria…………………….31

Table 3.1: Subjective and Objective Measures of Health Outcomes………………………..40

Table 3.2: Relationship between Income Inequality and Health……………………………53

Table 4.1 A-priori Expectations (Income Inequality-Health Outcomes Links)……………77

Table 4.2 A-priori Expectations (Income Inequality-Health-Seeking Behaviour Links)….80

Table 4.3: Summary of Questionnaire Context of NGHPS Waves………………………….85

Table 5.1: Descriptive Statistics Table………………………………………………………89

Table 5.2: Distribution of Respondents According to their Gender…………………………91

Table 5.3: Distribution of Relationship with Households’ Head……………………………92

Table 5.4: Distribution of Respondents According to Family Size…………………….……92

Table 5.5: Distribution of Respondents according to Marital Status…………………………94

Table 5.6: Gini-Coefficient and Theil Indices of Households in North-East Zone…….……97

Table 5.7: Gini-Coefficient and Theil Indices of Households in North-West Zone…………98

Table 5.8: Gini-Coefficient and Theil Indices of Households in North-Central Zone………98

Table 5.9: Gini-Coefficient and Theil Indices of Households in South-South Zone…………99

Table 5.10: Gini-Coefficient and Theil Indices of Households in South-East Zone…………99

Table 5.11: Gini-Coefficient and Theil Indices of Households in South-West Zone………..100

Table 5.12: Magnitude of Income Inequality in Nigeria (2010-2019)……………………….102

Table 5.13 Pooled OLS Regression (Dependent Variable: Illness) ………………………..104

Table 5.14: Fixed Effect Estimation (Dependent Variable: Illness) ………………………..107

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Table 5.15: Random Effect Estimation (Dependent Variable: Illness) …………………….110

Table 5.16: Homogeneity Test Results (Dependent Variable: Illness) …………………….113

Table 5.17: Hausman Test Results (Dependent Variable: Illness) …………………………114

Table 5.18: Robustness Check: Multilevel Logistic Regression (Illness)……………………115

Table 5.19: Pooled OLS Regression (Dependent Variable: HSB) …………………………121

Table 5.20: Fixed Effect Estimation (Dependent Variable: HSB) …………………………124

Table 5.21: Random Effect Estimation (Dependent Variable: HSB) ………………………126

Table 5.22: Homogeneity Test Results (Dependent Variable: HSB) ………………………128

Table 5.23: Hausman Test Results (Dependent Variable: HSB) ……………………………129

Table 5.24: Panel Logistic Estimations from NGHPS Wave I………………….……………130

Table 5.25: Homogeneity Test Results from Wave I (Dependent Variable: HSB) ………..131

Table 5.26: Hausman Test Results – Wave I (Dependent Variable: HSB) …………….……132

Table 5.27: Panel Logistic Estimations from NGHPS Wave II….………………….………133

Table 5.28: Homogeneity Test Results from Wave II (Dependent Variable: HSB) ….….…134

Table 5.29: Hausman Test Results – Wave II (Dependent Variable: HSB) ………. ……….134

Table 5.30: Panel Logistic Estimations from NGHPS Wave III….………………………….135

Table 5.31: Homogeneity Test Results from Wave III (Dependent Variable: HSB) …….…137

Table 5.32: Hausman Test Results – Wave III (Dependent Variable: HSB) ………. .….….137

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LIST OF FIGURES

Figure 2.1: Income Shared by top 10% at the Upper-End of Distribution in Nigeria………13

Figure 2.2: Income Shared by bottom 40% at the Lower-End of Distribution in Nigeria….13

Figure 2.3: Index of Income Inequality by Zones in Nigeria, 2004, 2013.……….…………14

Figure 2.4: Income Inequality-Adjusted to Health in selected SSA Nations for year 2015..16

Figure 2.5: Global Deaths from Ill-Health Causes………………………………………….19

Figure 2.6: Trend of Poor Health Outcomes in Nigeria, 2010-2019………………………..20

Figure 2.7: Health Problem Experiences in Nigeria (2016-2019)…………………………..21

Figure 2.8: Percentages of Infectious Diseases in Nigeria………………………………….22

Figure 2.9: Percentages of Non-Communicable Diseases in Nigeria………………………24

Figure 2.10: Annual Deaths from NCDs Ill-Health in Nigeria………………….……………25

Figure 2.11: Global Comparative of Under-five Deaths……………………………………..26

Figure 2.12: Global Comparative of Infant Deaths ………………………………………….27

Figure 2.13: Trends of Infant Deaths in Nigeria………………………………………….…..28

Figure 2.14: Global Comparative of Longevity…………………….…………………….….29

Figure 2.15: Trends of Average Life Expectancy in Nigeria………………………………..29

Figure 2.16: Health-Seeking Behaviour in Nigeria (2010-2019)……………………………32

Figure 2.17: Healthcare-Seeking Among Men in Nigeria…………………………………..33

Figure 2.18: Health-Seeking Among Females in Nigeria……………………………………33

Figure 3.1: Internal and External Causes of Health Outcomes……………….……………39

Figure 3.2: Determinants of Health-Seeking Behaviour….………………….………………42

Figure 3.3: Income Inequality-Health Problems Among Rich Countries…………………48

Figure 3.4: Stages of Epidemiological Transition.…………………………………………49

Figure 3.5: Income Inequality-Health Mechanisms………………………………………53

Figure 3.6: Income Inequality-Health Mediators…………………………………………54

Figure 4.1: Conceptual Framework…………….………………………………………….70

Figure 5.1: Frequency Distribution of Respondents by Education Level…………………93

Figure 5.2: Frequency Distribution of Respondents by Households’ Access

to Safe Water………………………………………………………………….95

Figure 5.3: Percentage Distribution of Respondents by Households’ Access

to Electricity…………………………………………………………….….…95

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Figure 5.4: Percentage Distribution of Respondents by Households’ Access

to Toilet Facility………………………………………………………………96

Figure 5.5: Gini Estimates for all the States in Nigeria (2010-2019)…………………….101

Figure 5.6: Gini Estimates across Geo-Political zones in Nigeria…………………….….102

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LIST OF APPENDICES

Appendix A: Summary of Empirical Studies Reviewed……………………………………163

Appendix B: Estimation of Gini-Coefficient……………………………………………….166

Appendix C: Description of Variables and Apriori Expectations……………………….….167

Appendix D: Descriptive and Socio-Economic Characteristics………………………….…171

Appendix E: Sources of Income Disparities in Nigeria…………………………………….175

Appendix F: Household’s Total Incomes (Naira)……………………………………….…

Appendix G: Estimation Results for NGHPS Waves………………………………………

Appendix H: Estimation Results for Wave I……………………………………………….

Appendix I: Estimation Result for Wave II………………………………………………..

Appendix J: Estimation Result for Wave III………………………………………………

Appendix K: Income Inequality and HSB (All Waves) ……………………………………..

Appendix L: Income Inequality and HSB Waves Estimation……………………………

 

LIST OF ABBREVIATIONS

BPLM Breusch-Pagan Lagrange Multiplier

FCT Federal Capital Territory, Nigeria

FE Fixed Effect

GE Generalized Entropy

HDI Human Development Index

HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome

HSB Health-Seeking Behaviour

IIAH Income Inequality-Adjusted to Health

IIH Income Inequality Health

IMF International Monetary Fund

NBS National Bureau of Statistics

NCDs Non-Communicable Diseases

NDHS Nigeria Demographic and Health Survey

NGHPS Nigerian General Household Panel Survey

OECD Organization for Economic Co-operation and Development

POLS Pooled Ordinary Logistic

RE Random Effect

SDGs Sustainable Development Goals

SSA Sub-Saharan Africa

SWIID Standardized World Income Inequality Database

UN United Nations

WHO World Health Organization

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CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

The prevalence of poor health outcomes1 particularly from non-communicable diseases (NCDs) is on the disastrous rise among the populations of both developed and developing nations (World Bank, 2019; United Nations Children’s Fund, UNICEF, 2019). At the global level, NCDs make up 4 of the 10 leading causes of chronic illnesses and deaths in 2000. This issue increased speedily to 7 of the world’s top 10 causes of poor health outcomes in 2019 (World Health Organization, WHO, 2020). The statistics clearly suggest the urgency and need for an intensified global focus on preventing and treating NCDs in all regions of the world, as set out in the agenda for the United Nations Sustainable Development Goal (SDG) 3 of achieving good health for all at all ages.

It is worthy of note that prior to the 1990s, infectious diseases such as, malaria, yellow fever, tuberculosis, pneumonia, cholera, measles, polio and sexually transmitted diseases, were the main causes of human ill-health and deaths, especially in Africa (Gubler, 1998:442; WHO, 2017). The discovery, effective use of insecticides, control and prevention programs in the last three decades contributed significantly to reducing the prevalence of infectious diseases globally. For instance, pneumonia and bronchitis were the deadliest group of communicable diseases and together ranked as the 4th leading causes of poor health outcomes in 2000. However, it claimed fewer lives in 2019, with the global number of deaths decreasing by nearly half a million (WHO, 2020). Tuberculosis is also no longer in the global top 10 causes of death, as it decreased from 7th place in 2000 to 13th in 2019, with a 30% reduction in global’s poor health outcomes. Again, HIV/AIDs (an infectious diseases) is not among the world’s top 10 causes of poor health outcomes, having reduced from 1.5 million in 2000 to less than a million in 2019. For example, HIV/AIDs dropped from the 8th leading cause of deaths in 2000 to 19th in 2019. All these reflect the success of efforts to prevent infection, test for the virus and treat the disease over the last two decades.

However, from the 1990s onwards, global medical sciences began to emphasize the serious threat and growing trends of poor health outcomes from NCDs particularly in low and middle-income countries (WHO, 2017). Chronic illness from diabetes alone claimed 1.6 million lives globally in

1 Health outcomes are the changes in the health status of people. It could be poor or better. While the former relates to illnesses and deaths; the latter concern functioning well mentally, physically, socially and being alive.

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2016, up from less than 1 million in 2000 (WHO, 2018a). The deaths from diabetes increased by 70% between 2000 and 2019, with an 80% rise in deaths among males (WHO, 2020). Similarly, illness cases due to dementia (symptoms of decline in memory) more than tripled between 2000 and 2019, making it the 3rd main cause of global deaths in 2019 compared to 14th in 2000 (WHO, 2020). Heart diseases and stroke are the world’s biggest killers, accounting for about 17.7 million lives in 2016. Similarly, the number of deaths from heart diseases increased by more than 2 million since 2000 to nearly 9 million in 2019; which represents 16% of total deaths from all causes of poor health outcomes at the period (WHO, 2020). While illnesses from heart diseases, diabetes, stroke, and all forms of cancer collectively responsible for nearly 100 million deaths, in total NCDs accounted for more than 71% of deaths globally in 2019 alone (WHO, 2020). These issues also associated with weak healthcare seeking behaviour (HSB) as non-use of appropriate health facilities and undesirable HSB such as patients using traditional remedies or self-medication especially in developing countries leads to more health issues (Kuuire, Bisung and Luginaah, 2015; Khan, 2018).

Interestingly, reports of WHO (2017, 2018, and 2020) established that tackling the risk factors of poor health outcomes from NCDs will not only save lives; it will also provide a huge boost for the economic development of countries. These risk factors are chronic stress, anxiety, unhealthy diet, raised blood pressure, shock, poverty, smoking, lack of economic investment and inaccessibity to preventable healthcare services. As Mikkelson (2019) and Ganju (2020) noted, NCDs prevention will be most effective when focusing policy on its roots. These poor health outcomes according to considerable evidence in the health economics literature are inextricably and largely linked to income inequality (see Bakkeli, 2016; Liu, 2017:35; Tan, Shi, Liang and Xu, 2018; Sigh, Antunes and Pere, Harford, 2018; and Hill, Jorgenson, Ballistite and Clark, 2019).

Wilkinson’s seminal papers of 1990s were the first to formalize the income inequality-health link (See Wilkinson, 1992; 1994). He opined that in the process of economic growth, there will be a point at which income disparity rises. This point corresponds with the shift in the main causes of ill-health from infectious diseases to more of chronic illnesses particularly the NCDs. This suggest that rising income inequality is the primary cause of poor health outcomes, because of it explicit psycho-social impacts through chronic stress, status anxiety, debt burden, long working hours, depression and frustration (Patel, 2018; Kim, 2019), as well as social dysfunction that causes fear

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and shock via low social capital (Kragten and Rozer, 2017). The synthesis of all these explanations is that, rising income inequality relates with social comparison, competition, social dysfunction, reduced social cohension and trust. These intensify fear and shocks which lower the immulogical resistance to health issues.

Though, widening income inequality is necessary to reward talents, skills and a willingness to innovate and take entrepreneurial risks; increasing disparities in income hurts everyone, particular their health outcomes and HSB. This is because it related with violent crimes, insecurity and kidnapping that intensify fear and shock for all citizens, including those at the top and bottom of the income distribution (Seery and Arendar, 2014; Hardoon and Fuentes-Nieva, 2016). With rising income inequality, the budget line of households chiefly those at the bottom income-quintile is constrained, due to allocation to other competing needs such as food, education, house rent, and so on. This basic need amidst low economic opportunities rises the debt burden on all citizens, which could also culminate in fear and shock which may in turn lead to stroke and high blood pressure. All these implies that the adverse consequences of income disparities via disinvestment in public health and human capital could affect the health of all citizens, not only of those citizens at the bottom of the income distribution (Coady and Dizidi, 2017; Dotollenaere et al. 2018).

Again income disparities concern less stable and inefficient economic system (Stiglitz, 2012). As it accelerates the vulnerability of people to economic crises, creating poverty traps and discourages every effort of establishing healthy outcomes especially in times of ill-health (Matthew and Brodersen, 2019). This further suggest that, rising income disparities could motive inappropriate healthcare seeking; mainly because of its tendency to limit quality access to healthcare services and reduce the quantity and quality of health-promoting goods and services. Thus, the high income inequality, in addition to its implication on social unrest and purchasing-power disparities, suggests that income inequality may exert both direct and indirect effects on health outcomes and HSB.

In Africa, the 2nd most (income) unequal continent in the world after Latin America, 46% of the adults above the age of 25 are hypertensive (WHO, 2018a; African Development Bank, ADB, 2019). Due to the epidemiologic transition of diseases in Africa, the continent is expected to have the world’s largest increase in NCDs illness and deaths over the next decades. For instance, while the number of poor health outcomes from HIV/AIDs dropped by more than half in Africa, falling from 1.5 million in 2000 to 435,000 in 2019 (WHO, 2020); in most African countries, NCDs are

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responsible for more than three-quarters (75%) of all deaths, which could continue if urgent and evidence-based policies are not successfully implemented (Idris, Mensah and Kitamusa, 2020). This explain that the widening income gaps in Africa could be detrimental to both poverty reduction efforts and health policies, because rising income inequality can have an adverse effect on political representation and cause political capture (Bartels, 2008; Wolf, 2015), where the rich citizens use their favour at the expense of everyone else. Tita and Aziakpolo (2016:2) observed that the greatest challenge facing the African continent is rising levels of income inequality and poorest health outcomes.

In Nigeria, there is also a growing income gap since the 1990s (Isah, 2011; Aigbokhan, 2017). While the nation’s income inequality was merely 0.36 in 1980s, poor health outcomes from NCDs were very rare in Nigeria at the same periods. Surprisingly, as income disparity rose steadily in the nation, illness and deaths particularly from NCDs increase speedily (Federal Ministry of Health, 2013; WHO, 2018b). According to Seery and Arendar (2019), Nigeria has slightly average growth rate than Bangladesh before her economic recession of 2015-2016, but it is far less equal in terms of income distribution. Consequently, a child born in Nigeria is three times more likely to die before his or her 5th birthday, than a child born in Bangladesh (see World Bank, 2019). This seem to suggest that the widening gap between the rich and poor coexist with poor health outcomes and weak HSB in Nigeria. It further implies that the rising income inequality in Nigeria might have a major effect on health outcomes and HSB.

These issues also underscores the United Nations SDG number 3 and 10 of achieving good health for all at all ages and reduce income inequality within and among nations, respectively, before the year 2030. However, efforts geared at these have been hindered partly by insufficient knowledge of how income inequality affects health outcomes and motives inappropriate healthcare-seeking among households. This perhaps inhibits policy planning and formulation toward achieving the United Nation’s goals.

Therefore, with the advent of the SDGs, in-depth studies of both direct and indirect effects of income inequality on health outcomes and health-seeking behaviour of households are needed in order to articulate necessary measures for improving good health for all citizens and reducing income disparities in Nigeria with a view to inform policies to achieve these goals.

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1.2 Statement of the Research Problem

The poor health outcomes and weak healthcare-seeking behaviour in Nigeria has been a major concern for both scholars and policy makers over the past decades. This issue is also reinforced by international pressures on nations (Nigeria inclusive) to achieve the SDGs target 3 before 2030 (United Nations, 2018). Though illness and deaths from NCDs are not a new problem having long been of concern in developed countries; they are however, of increasing issue in Nigeria. For instance, the percentage of deaths in Nigeria from NCDs alone such as, dementia, stroke, heart disease, and high blood pressure increased rapidly from 21.9% in 2000 to more than 29% in 2016 (WHO, 2019). Furthermore, more than 31% of Nigerian adults older than 25 years are hypertensive (WHO, 2020). Again 23% and 25% of men and women, respectively, reported having an illness in the four weeks preceding the Nigeria General Household Panel Survey (NGHPS) Wave 4 of 2019, compared to 14% and 15%, respectively, in Wave 3 of 2016 (National Bureau of Statistics, NBS, 2016, 2019).

There is also a growing concern about weak healthcare-seeking behaviour in Nigeria. Arguably, inappropriate health-seeking behaviour worsen health outcomes (Nonvignon, 2017). This is because HSB is all behaviours associated with establishing and maintaining physical, social and mental health (WHO 2015). However, with the rise in the number of public, private and non-governmental health facilities between 1980 and 2019, the trend of inappropriate HSB in Nigeria (that is healthcare services from chemist, traditionalist, spiritualist, and self-medication) increase steadily from 46.7% in 2013 to 68.1% in 2019 (NBS, 2013, 2019). In addition, 71% and 53% of rural and urban dwellers respectively, reported inappropriate HSB during their last illness episode (Latunji and Adeyemi, 2018). This suggest that the nation’s HSB is weak (Fagbemigbe, 2015:2; Abiola et al., 2018:381).

These poor health outcomes and weak HSB in Nigeria could pose devastating health, social and economic consequences for individuals, families and nation at large (Becker, 1964; Cai and Kalb, 2005). It could lead to a decline in working-age population, and participation in the labour force, reduce productivity and in turn limit per capita Gross Domestic Product (GDP). It can also affect households’ finance and drive them to poverty through catastrophic healthcare expenditures (Fukai and Iwamoto, 2003). This implies that poor health outcomes linked to NCDs is predicted to much higher risk of falling into poverty trap. This is especially true for inpatient treatment. Overall, it

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could lead to reduced human capital and opportunities because those with poor health outcomes often have lower educational attainment and poorer access to employment (Becker, 1964; Cai and Kalb, 2005; UNICEF, 2019).

Despite these adverse consequences, poor health outcomes and weak HSB are neglected in public health policies and discourse in Nigeria. Furthermore, the Nigeria’s public health policies for many years have focused on the control of infectious diseases, with attendant dearth of necessary data for policy decisions to reduce the poor health outcomes from NCDs and promote appropriate HSB in Nigeria. As a way forward, both UNICEF (2019) and WHO (2020) reports revealed that, larger burden of health problem from NCDs is avoidable in developing countries if policy is targeted on reducing risk factors of these health issues.

Wilkinson’s hypothesis (Wilkinson, 1992 and 1994) argued that there is a strong link between income inequality and health outcomes and HSB. Perhaps income inequality relate to comparison, competition, chronic stress, status anxiety, depression, frustration, insecurity, low trust and social capital, and kidnapping. All these intensifying fear and shock for those at the top and bottom of income distribution, and then increasing illness and deaths (Liu, 2017; Tan et al. 2018; Massa et al. 2018; and Hill et al. 2019). Hence income inequality has a direct detrimental effect on health (Wilkinson, 1994). However, the pathways or the mediators of income inequality-health links is still unknown. According to Grossman (1972, 2000 and 2017), health depends on many factors particularly those that associated with household characteristics, such as, family size, diets, water, housing conditions, education, people’s lifestyle, and demand for medical services. This suggest that these characteristics could link income inequality to poor health outcomes and inappropriate HSB in Nigeria. These explanations are lacking in previous income inequality-health studies in Nigeria, such as, Orji et al. 2013, Alawode and Lawal, 2014, Karimo et al. 2017, Ogunsanya and Agboola, 2018.

The level of income inequality also remains high in Nigeria. For instance, the income belonging to top 10% at the upper-end of income distribution in Nigeria rose rapidly from 26.6% in 2004 to 31.1% in 2016 (International Monetary Funds, IMF, 2018). However, the income shared by the 40% at the lower-end of income distribution in Nigeria decline from merely 6.36% in 2004 to as low as 2.8% in 2016 (IMF, 2018). This reveal that the income gap between the rich and poor is

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wider now in Nigeria than ever (Reinders and Dekker, 2019). Similar pattern also exists in several societies and regions of the country (See Isah, 2011; Usman, 2016; Aigbokhan, 2017:6). However, information on level and magnitude of income inequality across the 36 states and FCT Abuja is not available. This might hinder effective welfare policies particularly those that relates to the health of citizens.

Though income disparity is commonly understood as a problem for low-income citizens. However, evidence have further opine that high income gaps is also bad for the affluent (Organization for Economic Co-operation and Development, OECD, 2015:67; Hill et al. 2019:268). This is because inequality fosters crime and social unrest, reduces trust and social capital, which is not only detrimental to health but also any economic developmental efforts that can lead to improvement in health status. Hence, income inequality has a direct effect on health (Kragten and Rozer, 2017). Likewise, it can widen the debt burden, constrains budget in the face of competing needs. It can also reduce ability of households to obtain health-promoting goods and services. Perhaps high level of income inequality increases purchasing-power disparities between the less well-off households and wealthier ones. While low-income citizens could resolve to self-treatment and low-price healthcare by unregulated private and traditionalists (Fuentes-Nieva, 2014). This will constrain aggregate HSB of all households in the society.

All these suggest that the wide income gaps between the rich- and poor-households in Nigeria might have a major effect on health outcomes and HSB directly and/or mediated by some pass-through factors. Hence, a careful study of the effect of income inequality on health outcomes and health-seeking behaviour (both directly and indirectly) in Nigeria is invaluable.

1.3 Research Questions

The foregoing thus gives rise to the following research questions that this study addressed:

i. What has been the trends of health outcomes and health-seeking behaviour in Nigeria?

ii. What is the level and magnitude of income inequality across the 36 states and FCT Abuja?

iii. What is the direct and indirect effect of income inequality on health outcomes in Nigeria?

iv. What is the direct and indirect effect of income inequality on health-seeking behaviour among households in Nigeria?

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1.4 Objectives of the Study

The broad objective of the study was to estimate the effect of income inequality on health outcomes and health-seeking behaviour of households in Nigeria. The specific objectives were to:

i. Examine the trends of health outcomes and health-seeking behaviour in Nigeria;

ii. Estimate the level and magnitude of income inequality across the 36 states and FCT Abuja;

iii. Estimate the direct and indirect effects of income inequality on health outcomes; and

iv. Estimate the direct and indirect effects of income inequality on health-seeking behaviour among households in Nigeria.

1.5 Justification for the Study

Theoretically, the income inequality-health (IIH) hypothesis as pioneered by Wilkinson (1992, 1994) and its extension by Pickett and Wilkinson (2015) argue that income inequality has a direct effect on health through stress, status anxiety, competition, comparison, depression, long-working hours, frustration, low trust, insecurity, fear and shock. These affects the health outcomes and HSB of both the rich and poor citizens alike (Bakkeli, 2016; Khan, 2018; Mattew and Brodersen, 2019). However, little is known about the potential pathways through which income inequality affects health outcomes and HSB (for instance, the so-called “indirect effect”). The understanding of these indirect effects could have important implications for the design of health policies to achieve the SDGs 3 before year 2030.

Noteworthily, the major determinants of health outcomes and HSB are largely associated with household characteristics (Grossman, 1972; Galama and van Kippersluis, 2013). These factors such as, family size, access to healthy food, water, housing conditions, education, and people’s lifestyle, all have considerable impacts on health outcomes; whereas the more commonly considered factors is access and use of healthcare services (WHO, 2013). This then suggest that these factors are the interlinking vary between income inequality and health outcomes and HSB. Thus, the indirect link from income inequality, household’s characteristics, and health is also key to this study. This is because, income inequality affects the quality and quantity of healthy goods and services that people buy, consume or have access to. For instance, income inequality reduces the purchasing-power of household’s resources and trapped them into poverty. This could leads to poor health outcomes and inappropriate HSB (Lewis, 1972), low-quality diet (Food Research and Action, 2018); and unhealthy lifestyle (Macinko, 2003). Again, citizens particularly low-income

households in unequal societies often use a high share of their income on other basic needs such as food, shelter and education amongst others, and sometimes, burdened by debt and long working hours. However, existing literature on IIH in Nigeria such as, Orji et al. (2013), Alawode and Lawal (2014), Karimo et al. (2017), Odusanya and Agboola (2018) focused on financial burden (anxiety, competition, and stress) among households.

In terms of empirical findings, Olaniyan et al. (2015), Karimo et al. (2017), Odusanya and Agboola (2018) found that income inequality is detrimental to health outcomes in Nigeria. Conversely, the results by Nilson and Bergh (2012), Pulok (2012), Fatukasi and Ayeomoni (2015) indicated that rising income inequality associated with better health outcomes in Nigeria. The major limitation of these studies is that they remain inconclusive regarding the transmission channel of the impact of income inequality on health in Nigeria. This may not be appropriate as it could lead to misleading inferences drawn for policy planning and formulation.

Furthermore, no studies investigate the income inequality-HSB links, except Fagbemigbe, et al. (2015). While their study focused on people living with HIV/AIDS in Nigeria, it might not be adequate for policy to improve appropriate HSB for over 200 million Nigerian. This, therefore, necessitated the estimate of the effect of income inequality on HSB to cover the entire country. The thesis also contributes to existing studies by examining the level and magnitude of income inequality across the 36 states and FCT Abuja. This is important due to heterogeneity across households in various states and regions. Therefore, the findings hope to informs policies to achieving the United Nation’s SDGs 3 and 10 in Nigeria before 2030.

The study further contributed to methodological literature in terms of the use of Nigerian General Household Panel Survey (NGHPS) database2 by National Bureau of Statistics – Waves 1, 2, 3 and 4. Survey-data provide ample opportunity to carry out in-depth assessment of household welfare and allied matters. Recently, scholars turned to micro-based data because it accounted for household heterogeneity to conduct health research (for instance, See Tan et al., 2018 for China; Massa et al., 2018 for Brazil; Singh et al., 2018 for Australia; and Mattew, 2018 and Hill et al., 2019 for United States).

2 NGHPS data provide detail statistical information on welfare trends of households. The data was collected in 4 waves for the period of 6 months in each for detail coverage, while each wave consists of post-planting and post-harvest.

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Unlike the studies of Orji et al. (2013), Alawode and Lawal (2014), Karimo et al. (2017) for Nigeria that relied on ordinary logistic model but failed to account for heterogeneity issue. This study used Panel logistic (pooled OLS, FE, RE and Hausman test) and Multi-level techniques. These have several advantages over ordinary logit regression test. For instance, changes often occur over time among households within states and these approaches are able to track these changes (Rozer and Volker, 2015). Secondly, they also control for unmeasured confounders such as health status difference (see Deaton, 2018:105-110). And lastly, it’s substitute for longitudinal cross-sectional data, which shift focus from macroeconomic to more detailed microeconomic data (Kragen and Rozer, 2017).

1.6 Scope and Limitation of the Study

The study focused on the effect of income inequality on health outcome and HSB of households across the 36 states and FCT in Nigeria. The analysis explored not only the direct effect from rising income disparities, but also the indirect mechanisms pass-through household characteristics – size of the family, food/diet, water, housing conditions, education, people’s lifestyle, and their demand for healthcare services.

The units of analyses in the study were households and states. While the dataset for this study was secondary data from Wave 1, 2, 3 and 4 of the Nigerian General Households Panel Survey3 (NGHPS). These datasets were collected by the National Bureau of Statistics (NBS) in 2010, 2013, 2016 and 2019, respectively. Thus, the scope of the study was from 2010 to 2019.

An important limitation of the study draws from the fact that self-reported incomes from various sources (wages and salaries, business enterprise/trading, farming/livestock, remittances, monetary transfers, pensions, dividends from investment, and properties owned) might be lower or higher than the actual incomes. This could influence the level and magnitude of income disparities among households. Also, the cultural and/or religious beliefs may pose a significant influence on perception of health outcomes and orthodox healthcare-seeking. These issues are important but not captured in the panel survey data but can serve as the basis for further research as data becomes more available. Notwithstanding, the NGHPS remains the most recent and valid source of

3 With the technical support from the World Bank, the Wave 1 data was published in March, 2012. Wave 2, 3 and 4 were similarly published in October, 2016, and July, 2017, and December, 2019, respectively. The NGHPS emerged from the micro-level analysis of the World Bank’s Living Standards Measurement Study (LSMS) of late 1990s.

 

secondary data required for the analysis carried out in this thesis. Furthermore, it provides detailed information on households and has a wide coverage across the six geo-political zones, and 36 states (including FCT).

1.7 Organizations of the Study

The study is organized into six chapters. Following the introductory Chapter one, two focused on stylized facts on income disparity, health outcome and HSB in Nigeria. Detailed literature reviews was presented in chapter three. Chapter four dwells on theoretical framework, methodology, data and variables descriptions. However, chapter five was dedicated to findings and detail discussions of results. This was followed by summary, conclusion, and recommendations in chapter six.

 

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