key: cord-1048896-z8tujvxv
authors: Iwuoha, Victor Chidubem; Aniche, Ernest Toochi; Obiora, Charles Arinze; Umeifekwem, Uchenna T.
title: Citizens lack access to healthcare facilities: How COVID‐19 lockdown and social distancing policies boost roadside chemist businesses in South‐Eastern Nigeria
date: 2021-09-02
journal: Int J Health Plann Manage
DOI: 10.1002/hpm.3316
sha: 43519f1c4442e1a8c7e0ae904d45c55d13e7906e
doc_id: 1048896
cord_uid: z8tujvxv

This study examines how COVID‐19 lockdown and social distancing policies impacted on citizens' access to healthcare facilities and the level of patronage of chemist/pharmacies for self‐treatment. A cross‐sectional questionnaire survey method was used to collect data by asking individuals quantitative and qualitative questions in person which included 6 structured open‐ended questions. Participants include operators of purposively selected three classes of small businesses/self‐employed services in South‐Eastern Nigeria. This involves 120 fashion/event related businesses, 80 food related businesses and 100 general merchandise–a total of 300 small businesses. Quantitative data were analysed by frequencies and descriptive statistics while qualitative data were analysed using thematic/content analysis. It concludes that although COVID‐19 lockdown policies are generally perceived to have negative effects on small businesses, these policies have particularly had positive effects on the chemist/pharmacies businesses compared with other small businesses. About 85% increase in patronage of chemist businesses compared with 63.7% decline in patronage of other small businesses is essentially linked to increasing rate of self‐medication as a result of government's poor implementation of COVID‐19 public health policies amidst lockdown measures–which limited people's access to hospitals and healthcare centres. The study proposes reformed pandemic‐lockdown policies to increase people's access to healthcare services and reduce overreliance on self‐medication and excessive patronage of roadside chemist/pharmacies.

The COVID-19 pandemic is an infectious viral disease that started in Wuhan, China in November 2019. The index case in Nigeria was announced on 17 February 2020 when an Italian national who travelled to Lagos tested positive.

Nigeria has recorded 164,756 confirmed cases and 2062 deaths (only second to South Africa in sub-Saharan African region with confirmed cases of 1,576,320 and 54,186 deaths) as of 27 April 2021. 1 Nigeria's fiscal capacity to fund growing COVID-19 health expenditures and needs has been very weak, as implicated in underestimated confirmed COVID-19 cases in the country, especially in the fragile northeastern states, 2 the limited testing capacity and shortage in medical equipments and logistics such as test kits, ventilators, personal protective equipment, oxygen, isolation centres, intensive care units, electricity supply; with geometric increase in the number of newly infected cases. 3 Recent studies appeal for home-grown approaches and multilateral collaborations in putting a stop to the negative impact of COVID-19 protocols such as lockdown and social distancing measures in order to improve people's access to essential healthcare facilities during the pandemic lockdown. 3, 4 Particularly, there has been inconsistent and irregular timing of lockdowns across the states in Nigeria, which ranged from total to partial and ease of lockdowns, thus allowing for indiscriminate and irregular enforcement of lockdown protocols. 5 These were further complicated with imposition of curfews, restriction of movements and ban on social gatherings including markets and street businesses at irregular intervals. In most cases, the government allowed operation of some businesses half-day. This was sometimes combined with partial opening of food markets, and intermittent opening/closure of other street businesses in the study areas. 5 These brought serious conflicts, confusion and contradictions, making it too difficult for small business operators to understand the specific periods that require lockdown compliance and enforcement.

The federal government through the Central Bank of Nigeria (CBN) announced and implemented some policy interventions to cushion the social/economic impact of the COVID-19 containment policies on small businesses such as 100 billion Naira credit intervention scheme; 50 billion Naira Targeted Credit Facility (TCF); and 2.3 trillion Naira stimulus package and survival fund. 4 Some scholars argue that the inability to meet the fund conditions such as guarantor, collateral, business registration, provision biometric verification number (BVN), etc, generally impeded small business operators' access to these credit facilities and stimulus packages. 6 The dynamic effects and impacts of COVID-19 lockdown and social distancing measures on specific categories of small businesses and how these implicate their distinct performances during the COVID-19 lockdown have been generally neglected by scholarship. Many important studies focus mainly on the negative impacts of COVID-19 pandemic on the informal sector. 7-10 Importantly, COVID-19 lockdown and social distancing policies are generally perceived to have negative effects on small businesses. 8 pitals and healthcare centres. The study proposes reformed pandemic-lockdown policies to increase people's access to healthcare services and reduce overreliance on self-medication and excessive patronage of roadside chemist/ pharmacies.

Africa, chemist business, COVID-19, healthcare services, lockdown, Nigeria, public health, small businesses, social distancing packages to cushion the effects of COVID-19 containment policies). 14 Hence, the need for government policy interventions to tackle the negative effects of COVID-19 lockdown in the informal sector by improving the disbursement of palliatives and loan facilities to SMEs. 12, [15] [16] [17] The key objectives of this study are as follows: First, to ascertain the effects of COVID-19 lockdown and social distancing policies on some categories of small businesses such as the chemist/pharmacies/medical stores compared with other small businesses in terms of patronages. Secondly, to explain how the implementation of COVID-19 lockdown and social distancing policies impact on people's access to healthcare centres and hospitals, especially to establish a link between limited people's access to healthcare facilities and the patronage level/performances of chemist/ pharmacies/medical stores during pandemic lockdown. This is important as any lockdown policies that limit people's access to healthcare services could heighten the level/risks of self-medication/death if no government policy interventions are promptly dispensed. Thirdly and importantly too, the study aims to help the government in developing and formulating more appropriate and effective COVID-19 lockdown and public health policies that will increase the level of people's access to hospitals and healthcare facilities during lockdowns and reduce self-medication and its health risks among citizens.

The study conducts a cross-sectional survey on small business categories such as fashion/event, food, chemist/ pharmacies/medical stores, and general merchandise (i.e., supermarkets, ICT/computer centre, electrical accessories/ repairs, stationeries), to depict a cross-sectional disparity in the patronage levels of specific categories of small business units such as the chemist/pharmacies/medical stores. It argues that these policies have had varying degrees of effects and impacts (i.e., both positive and negative) on small businesses.

More than 400 million people who live in Africa lack access to healthcare. 18 Half of this population lives in rural areas, but only one-quarter of doctors in Africa are deployed to rural areas. 18 This problem has now worsened and more complicated as a result of COVID-19 lockdown measures. Oyediran et al. maintain that in times of global pandemic African people should develop alternative access to important health services that can be delivered remotely in order to lower the risks of COVID-19 infection for both the client and health workers. 19 In essence, doctors can be accessed remotely through telemedicine or through mobile clinic to minimise in-patient encounters and transmission of infections at health facilities during the COVID-19 pandemic. Hence, accessing healthcare services remotely can provide credible and reliable opportunities to maintain non-urgent healthcare services in the interim, and overcome the gaps in healthcare systems prompted by the outbreak response. Unfortunately, low awareness of remote healthcare services among citizens in Africa expose many patients to health dangers in public health facilities during the COVID-19 pandemic. Although in most cases there is generally lack of access to remote healthcare services such as telemedicine and mobile clinic in Africa.

Parajuli and Doneys demonstrate that providing remote access to patients during COVID-19 lockdown can reduce gender-based limitations of access to healthcare and bridge the gap in physical appearance in the health facilities especially for non-invasive, non-surgical, and non-life threatening ailments. 13, 20 This can eliminate the risks of nosocomial transmission of COVID-19 infections to otherwise uninfected patients as well as increased protection for the health workers. 21 In Africa where fewer doctors are available for large populations and where most public health facilities have been cordoned off for specific treatment of COVID-19 patients, alternative healthcare services and/or traditional medicine prove to be more easily accessible across diverse geographic swathes thereby increasing healthcare access for the people despite the lockdowns. 5 For example, with doctor to people ratio in Nigeria at one medical doctor for 6000 thousand people, Nigeria needs 303,333 medical doctors to meet the World Health Organisation's (WHO's) recommendation on the doctor-to-patient ratio of 1:600. 22 In this regard, Iwuoha and Aniche argue for lockdown pol-icies that will increase people's access to alternative public healthcare services and the need to develop traditional/ herbal medicine for treating COVID-19 infections in Africa. 5 More importantly, lockdowns and physical distancing policies constrained the mobility of patients which impinged on regular access to healthcare services. These limitations impelled increased reliance to self-medication, use of chemist/pharmacies/medical stores (i.e., over the counter drugs), and alternative medicine for clients' healthcare needs. 10 Self-medication, poor management of health conditions, or resort to quack healthcare providers during the COVID-19 pandemic led to many health crisis and deaths.

There are also important concerns on the inherent discriminatory nature of COVID-19 lockdown and social distancing policies. 5 Particularly, the people's healthcare needs during lockdowns are generally sidelined in the decision making process such as the designing, formulation and implementation of COVID-19 lockdown and social distancing policies. 23 Thus, the masses are often excluded from policy process because their opinions and interests are rarely factored into policy process. 24, 25 The case of Nigeria is not different as public health policies are primarily though not exclusively in the interests of the elites. 26 Therefore, COVID-19 public healthcare policies in Nigeria are usually reflections of the interests of the governing class and the rich who have easy access to remote medical services (or private healthcare service providers), while the poor masses cannot easily access healthcare services in public hospitals during the lockdown because the public hospitals have been converted to COVID-19 isolation and treatment centres.

The research data for this study was collected during one-month fieldwork visits to study areas in Nigeria, June-July 2020. The purposive sampling method was used to select four urban areas across South-Eastern Nigeria whose streets are dotted with small businesses, petty traders, low-income earners and households who live on daily income.

These include: Onitsha (Anambra state), Aba (Abia state), Owerri (Imo state) and Nsukka (Enugu state). Convenience/ pre-designed availability research design helped to capture respondents who were conveniently or accidentally available to participate in the study. Method of data collection was based on cross-sectional questionnaire survey across three classes of small businesses/self-employed services such as fashion/event related businesses, food related businesses and general merchandise. Small businesses under the fashion/event category include clothing/foot wears, catering and decoration, tailoring, camera/video coverage services, shoemaking and hairdressing/barbing saloon. The food sub-sector includes restaurant/beer parlour, foodstuff, bakery/confectionary, and fruit/vegetables. The general merchandise category includes supermarkets, ICT/computer centre, electrical accessories/repairs, stationeries, and chemist/pharmacies/medical stores.

A cross-sectional survey method was used to collect data by asking individuals quantitative and qualitative questions in person which included 6 structured open-ended questions, with responses recorded on paper by the researchers and analysed based on sub-sectoral evaluation. This helped to underpin the specific levels of patronage of chemist/ pharmacies/medical stores compared with other small businesses being investigated. Tables 1 and 2 provide important details on the study methodology.

In view of COVID-19 pandemic, the researchers provided face masks to interviewees (if they have none) before conducting face-to-face interview using high-powered recording-enabled android phone. This research was conducted during the period of 'partial or ease of lockdown' making it possible for researchers to move freely from one study area to the other. Up to 5 respondents (small business owners) were interviewed for each of the 15 subsectors across the study areas which make up a total of 300 respondents (i.e., Onitsha -75, Aba -75, Owerri -75, Nsukka -75).

Although up to 328 shops owners/vendors were approached to take part in the survey but only 300 actually took part in the survey/interviews. Respondents' responses (1 point for each) were tabulated and scored based on three options (i.e., improved, unimproved and worse/for each subsector) in order to evaluate the level of patronage and income across each small business unit. Quantitative data was analysed by frequencies and descriptive statistics while data collected in qualitative/open ended questions was analysed using thematic/content analysis. Only about 15%, 10%, 10%, and 5% of the respondents in spheres such as foodstuffs, bakery/confectionaries, supermarkets and fruits/vegetable items, respectively, admitted that they had slightly improved sales/incomes during the period. However, the case of chemist/pharmacies/medical stores was exceptionally remarkable and outstanding with as much as 85% of responses, showing significant improvements in sales and incomes during the period. The remaining 10 small businesses did not record any improved sales and incomes. On the whole, only 25 small business operators, representing 8.3% of the respondents had improved sales and increased incomes during the period.

A good number of respondents across the small businesses, except camera/video coverage, stated that they experienced 'business as usual' without any improved patronage and income levels. Only up to 60% and 60% of respondents specialising in foodstuff and hairdressing/barbing saloon businesses respectively stated that they were able to maintain their normal/usual patronage and income levels (i.e., unimproved) during the lockdowns. Again, responses

showing normal/usual patronage and income levels during the lockdown were not more than 50% in each of the other specific spheres. On the whole, 84 respondents representing 28% expressed that they simply had 'business as usual'

with normal (unimproved) patronage and income levels despite the lockdowns.

Overall responses taken across all fields of small businesses investigated showed alarming low levels of patronage and high income losses. All small business fields showed worse performances supported by over 45% responses in each sphere, except foodstuff where only 5 respondents (i.e., 25%) stated that they had very poor sales and income. Note: Authors' field study (2020). Note: (i) Improved (level of patronage/income compared to pre-Covid-19 lockdowns); (ii) unimproved (level of patronage/income compared to pre-Covid-19 lockdowns); (iii) worse (level of patronage/income compared to pre-Covid-19 lockdowns).

Source: Authors' field study 2020.

lockdowns. The overall proportion of the 300 responses elicited from small business operators showed that only 25 (8.3%) had improved sales; 84 (28%) had unimproved sales while as many as 191 (63.7%) confirmed that their businesses had been worse off during the state-imposed lockdowns.

2.2.1 | Sub-sectoral impact of lockdown and social distancing policies on chemist/ pharmacies/medical stores compared with other small businesses Importantly, the small businesses shown in Table 2 are categorised under three clusters. These include fashion/event, food, and general merchandise. Some indications across these clusters are imperative, compelling and remarkable. A sub-sectoral assessment of the small businesses shown in Table 2 On the other hand, the general merchandise category experienced low/moderate patronage and income levels. In this category were subsectors such as supermarkets, ICT/computer centre, electrical accessories/repairs, stationeries, except chemist/pharmacies/medical stores, which recorded very high patronage and improved income levels during the COVID-19 lockdowns as underpinned by 85% positive responses. Interestingly, this impressive performance is essentially attributable to the limited access to healthcare centres and hospitals occasioned by COVID-19 lockdowns.

Two reinforcing narratives are adducible for this surprising trend. First, the rise in COVID-19 infections resulted to panic and fear among the citizens, hence, many sick people were afraid to visit healthcare centres and hospitals to avoid being suspected and quarantined due to their symptoms. Again, some healthcare workers got infected with COVID-19 which led to the shutdown of a number of hospitals and healthcare centres. This impelled majority of the people to increasingly rely on chemist/pharmacies/medical stores (i.e., over the counter drugs) for their healthcare needs. A popular chemist store owner revealed:

I know you will be surprised to hear that we even had more customers now than before (prior to lockdown). The secret is that many people now rely on us since this COVID-19 lockdown for their health problems, and they get the drugs they need from us easily. Some people usually call their doctors on phone to tell them the particular drugs to buy. Do you know that some of these people that come here are afraid to go to hospitals because they don't want to be declared infected with COVID-19 and quarantined? (Interview with a 36-year old chemist man along Orlu road, Owerri on 23 June 2020).

Importantly, there are also impediments resulting from the complexity of many African cultures and social systems which produce complicated interpretations and diverse socio-cultural and spiritual understandings of the causes of disease which more often affect individual's health-seeking behaviours, public health system, policy, planning, and implementations. 10 Hence, COVID-19 was viewed by most patients as sickness invented by white people to deplete African population (Interview with a group of three middle aged women at Aba-Owerri road, on 8 June 2020). This made most people to avoid accessing hospital services for fear of being infected in the process and increased their reliance on self-medication. Again, most patients often look at their ailments as a misfortune associated with the social, natural, and spiritual environments. This generally makes people to downplay the importance of physician's-patients contact for healing or treatment in African setting. Most patients prefer getting face-to-face consultation with unqualified chemist/pharmacies/medical stores operators whereas some prefer interacting with their spiritual leaders before thinking of orthodox intervention. 27 This confirms Iwuoha et al.'s claim that lockdowns and physical distancing policies constrained the mobility of patients which impinged on regular access to healthcare services. 10 The limitations therefore impelled increased reliance to self-medication, use of chemist/pharmacies/medical stores (i.e., over the counter drugs), and alternative medicine for clients' healthcare needs. 10 In addition, the poor health systems on the African continent including the infrastructural gaps in emergency situations discourage most people from going to hospitals as they prefer to easily access the roadside chemist/pharmacies/medical stores and get quicker attention.

The conflicting nature as well as inconsistent (irregular timing) lockdowns across the states in Nigeria has been established. 5 This ranged from total to partial and ease of lockdowns, which allowed for indiscriminate and irregular In Aba-Owerri road, economic activities were shallow even though some shops were seen making sales unimpeded.

These troubling scenarios terribly affected small business operators most of whom were self-employed despite 

This study shows that the chemist/pharmacies/medical stores recorded exceptional customer patronages during the Hence, there is need to prioritise state policy intervention that will enhance citizen's access to healthcare and medical facilities (including mobile healthcare services) during pandemic lockdowns.

The article also identified the gaps in the policy interventions directed at cushioning the severe effects of Covid-19 lockdown and social distancing protocols on small businesses. Unfortunately, the federal government's economic stimulus packages to cushion the general effects of COVID-19 on small businesses have been marginal. As argued, the inability to meet the fund conditions such as guarantor, collateral, business registration, provision biometric verification number (BVN), etc, generally impeded small business operators' access to these credit facilities and stimulus packages. 3, 6 Most small business owners do not benefit from the government's intervention policies they are ill-informed and poorly educated. In most cases bigger incorporated business owners hijacked the process at the expense of smaller business owners because they are more qualified and posses the required collateral to access the available funds. Therefore, on the one hand, the state COVID-19 policy responses have not had the mitigating effect on the small businesses, while on the other and, the state the COVID-19 policy responses have contributed in impeding people's access to healthcare services and at the same time promoting a general reliance on chemist/pharmacies/medical stores for self-medication. Self-medication, poor management of health conditions, or resort to quack healthcare providers during the COVID-19 pandemic led to many health crisis and deaths. The article recommends pro-poor rejigging of the policy interventions so as to bridge the gaps and devise pro-illiterate means of disseminating of the information in order to close the communication gaps. It also recommends the introduction of effective mobile clinics during pandemic lockdowns and establishing effective tele-medicine systems in various hospitals in order to promote greater and easier access to healthcare services among citizens during pandemic lockdowns.

We conducted a cross-sectional questionnaire survey on the effects of COVID-19 lockdown and social distancing policies on small business units in South-eastern Nigeria, especially extricating how COVID-19 lockdown and social distancing policies which is implicated in the observed increase in the level of patronage of chemist/pharmacies during the lockdown period. This is particularly attributed to the government's poor implementation of COVID-19 public health policies amidst lockdown measures which limited people's access to hospitals and healthcare centres. This in-formed the high rate of self-medication and patronage of chemist/pharmacies by majority of the citizens during COV-ID-19 lockdown period which exposed majority of the citizens to greater health risks and deaths.

Three significant contributions are imperative in this study. First, it shows that despite the perceived harsh effects and severity of COVID-19 lockdown and social distancing policies on small businesses, these policies impacted positively on some categories of small businesses such as the chemist/pharmacies/medical stores which recorded improved sales and increased patronages. Secondly, the study submits that the implementation of COVID-19 lockdown and social distancing policies limit people's access to healthcare centres and hospitals thus leading to increased sales and improved patronage level/performances of chemist/pharmacies/medical stores. The lockdown policies rather heighten the level/risks of self-medication/death and thus require specific government policy interventions to promptly correct its bad effects. Thirdly and importantly too, the study helps the government in developing and formulating more appropriate and effective COVID-19 lockdown and public health policies that will increase the level of people's access to hospitals and healthcare centres during lockdowns and reduce self-medication and its health risks among citizens.

The findings of this study suggest that the need to develop state policies that will increase people's access to healthcare and medical facilities (including mobile healthcare services) during pandemics and lockdowns. The government should sensitise the people on the availability of healthcare services (including mobile and/or remote healthcare provisions) and where they can easily access them during lockdowns. This information can be disseminated using pro-illiterate means like direct (door-to-door) and indigenous means of communication using local languages.

None.

This material is the authors' own original work, which has not been previously published elsewhere. The paper is not currently being considered for publication elsewhere. The paper reflects the authors' own research and analysis in a truthful and complete manner. The paper properly credits the meaningful contributions of co-authors and co-researchers. The results are appropriately placed in the context of prior and existing research. All sources used are properly disclosed (correct citation) and accorded proper reference. All authors have been personally and actively involved in substantial work leading to the paper, and will take responsibility for its content.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Victor Chidubem Iwuoha https://orcid.org/0000-0001-9056-988X

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