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

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.