Public Healthcare Access: Burdens and Adaptation in Ibarapa Nomadic Community of Southwestern Nigeria

Abstract

Health burden, coping strategies and access to public healthcare facilities are examined using a medical ecological approach and ethnography among Ibarapa nomads. They live in bands in far distances from Yoruba populated towns in the Ibarapa area, where grazing culture makes healthcare facilities inaccessible. Vulnerable to high morbidity and health risks due to snake-bites, malaria, zoonosis and some other infections, but lacking healthcare facilities, they mostly use faith-based healing, herbal remedies and self-medications. Seventeen percent of the nomads access healthcare facilities from distant towns in Ibarapa. Equitable access to healthcare requires mobile healthcare for semi-sedentary nomads and permanent health clinics for sedentary nomads.

Keywords

Ibarapa nomads pastoral economy healthcare access health risks health adaptation

Introduction

In Africa, there exists a significant dearth of modern healthcare facilities among the people of the margins, the mostly affected being the pastoral nomads. Pastoral nomads are grossly exposed to a number of both actual and potential health risks associated with the grazing patterns and their pastoral environment. The Massai of Kenya and the Fulani of Nigeria, for example, are always on seasonal movements (Habib and Jumare, 2008), pasturing their animals without location of healthcare facilities in their herding fringes and margins, and thus exposing them to health risks. Specifically, the Nigerian nomads engage in long distance pasturing of cattle, which exposes them to a number of occupational and biological health risks. Similarly, spatial location of nomadic bands, usually far away from towns and cities where modern healthcare facilities are often located, as evident in the Ibarapa area of southwestern Nigeria, limits access to treatment and care among nomadic populations. A similar situation exists among the Massai, where Habib and Jumare (2008) observed that inequitable access to healthcare facilities is a threat to the fight against human immunodeficiency viruses/acquired immunodeficiency syndrome (HIV/AIDS) among the Massai of Kenya. While Ibarapa nomads are yet to be linked with HIV/AIDS, they are exposed to varieties of health risks such as livestock transmitted diseases, health risks associated with nomadic economy, environmentally induced health risks and health risks due to conflicts with their neighbouring communities. All these health risks require prompt and regular access to healthcare facilities, whereas in the Ibarapa pastoral community of southwestern Nigeria, there is no single healthcare institution such as maternity, dispensary or primary healthcare centres, and access to water is also poor.

The Ibarapa pastoral community occupies about 150 square kilometres accommodating roughly 173 pastoral bands with a human population of about 6415 herders with cows and other ruminants numbering about 8700 (Oyo State Bureau of Statistics, 2016). Ibarapa pastoralists are left to seek healthcare facilities in the neighbouring towns and cities that are located between 10 and 62 kilometres away from the various nomadic bands.

The pastoral nomads are the largest minority subsistence group in Ibarapa. The nomads are believed to have migrated to Ibarapa from other parts of Nigeria following the southward spread of the Fulani Jihad in the 1830s (Ajala, 2013). Ibarapa comprises three clustered regions consisting of seven communities locally known as “Ibarapa Meje”. These are: Eruwa and Lanlate in Ibarapa East with Eruwa as its headquarters; Idere and Igbo-Ora in Ibarapa Central with Igbo-Ora as its headquarters; and Tapa, Ayete, Igangan in Ibarapa North with Ayete as the headquarters. The Ibarapa regions are located in Oyo South Senatorial District of Oyo State (see Figure 1). Hundreds of nomadic bush settlements are found on the fringes of these Ibarapa towns and the cattle economy remains their major source of subsistence and survival.

Figure 1.

Map of Oyo State showing the study areas.

The Ibarapa pastoralists lack modern healthcare facilities in their fringe bush settlements and due to long distance and communal hostility, the pastoralists in Ibarapa have limited access to healthcare facilities located in the neighbouring towns and cities. The distances between the pastoralist bands and the neighbouring cities and towns range between 10 and 62 kilometres. Nomadic children have a low immunization rate. For instance, in Ifeloju, the Local Government Area (LGA) of Oyo State, Nigeria, as at 2017, only 2.6% of the children had received full immunization compared to an estimated coverage of 48% among all target children. Similarly, their settlement is often not included in guinea worm surveillance and control (Brieger, 2002, 2011; Brieger et al., 1997, 2002; Dao and Brieger, 1995; Odusanya et al., 2003). The south-western nomadic cattle herders (at Ifeloju and Ibarapa, Oyo State) who often settle near rivers to access water for their herds, complained of reactive skin lesions resulting int itching which often prevented them from sleeping (Brieger et al., 2002). There is also prevalence of onchocerciasis (a tropical disease of humans caused by infestation with parasitic worms) which has a negative effect on nomadic women’s fertility as it leads to spontaneous abortions (Akogun et al., 1991; Akogun et al., 1994; Kelly and Akogun, 1997). This is not without its social implications particularly in societies where a woman’s status in the family depends largely on her ability to produce children. Apart from the annual immunization exercise and private hawking of drugs in bags, there are no official efforts to solve these health problems in order to improve access to healthcare among cattle nomadic communities in Ibarapa.

Pastoralists in Nigeria often migrate from their traditional northern Nigerian arid environments to rainforest environments of southern Nigeria in search of green pasture and water for their livestock. Having settled in many parts of southern Nigeria due to the availability of green pasture that is capable of sustaining their cattle economy, they occupied semi-savanna but humid regions with their cattle and built their bands otherwise known as kraals, from where they engaged in different patterns of grazing. Firstly, the migration from the north to the south automatically confers on them the status of “strangers” which in turn limits their access to modern healthcare facilities located in towns and cities of their new host communities. The neighbouring communities are hostile due to nomads’ grazing of animals on their farmlands. The hostility further drives away the nomads from utilizing public healthcare facilities in the hosts’ neighbouring towns. Secondly, the patterns of grazing compel nomads to live on the fringes of the host communities where they establish settlements in the marginal forest, which Tonah (2005) described as a jungle. The “jungles” are distanced from locations of modern healthcare facilities. Lastly, the Ibarapa pastoral environment which is dispersed and gradually emerging as semi-arid in nature (Sowunmi, 1986), fails to attract the attention of modern healthcare providers both public and private, and thus hinders the nomads from accessing modern healthcare. Hence, the Ibarapa nomadic environment is a marginal location like many other pastoral locations in sub-Saharan Africa, which are inaccessible to the modern healthcare system and the modern healthcare facilities located in the neighbouring towns and cities are non-accommodating to a nomadic lifestyle (Okeibunor et al., 2013: 2). As observed, even though some Ibarapa nomads are sedentary with the dearth of electricity, motorable roads, security and hygienic water among others, modern healthcare facilities are also elusive in the entire Ibarapa nomadic community.

Theoretically, several scholars have however observed over time that in most parts of sub-Saharan Africa, pastoralists constantly move and reside in border areas, highly unsecured and unstable environments that are often beyond the reach of healthcare systems and other welfare resources (Foggin et al., 1997; Gele et al., 2009; Hampshire, 2004). As migrants, this automatically places them on the margins wherever they move to. Hampshire (2004) further asserts that being on the margins results in double ambivalence: the migrants are unable to return to their original home; and they also find it difficult to be accommodated in the new settlement. Within this medical ecological approach, the migrants are entangled in a state of being “outside-in” as regards social positioning to the “other and self”. This is an interstice social position that places Ibarapa nomads in a disadvantaged position where they hardly gain equitable access to any of the welfare resources as citizens. The experience of being “outside-in” has also been described by Okeibunor et al. (2013) as eliciting reactions of “losing, using, refusing and/or cruising” in narratives reflecting the complexities of marginality. Thus, the medical ecological discourse on the healthcare access of the Ibarapa nomads embodies lots of interactional social, ecological, cultural and environmental complexities, which trigger health risks and further constrain access to basic healthcare facilities. This in turn leads to high rates of infectious diseases such as tuberculosis, malaria, anthrax, and bilharzia, among others. This is a nomadic state of “disequilibria”, according to Hampshire (2004), which calls for probing about what health risks are induced by the environment in which Ibarapa nomads live in southwestern Nigeria, how they gain access to healthcare facilities and what coping strategies they engage with to control high morbidity and mortality. Hence, through qualitative ethnography, focusing on cattle nomads in the Ibarapa community in Oyo north, southwestern Nigeria, this paper examines health risks, patterns of access to healthcare and healthcare adaptive mechanisms among the Ibarapa nomads.

Materials and methods

The study area

The study was conducted in the Ibarapa community of Oyo north in southwestern Nigeria. Ibarapa is one of the Yoruba sub-ethnic groups located in Oyo State, southwestern Nigeria. Oyo State is one of the 36 states forming the Nigerian federation. Ibarapa was originally a rainforest environment with abundant grasses and shrubs as pasture for cattle grazing, but due to cattle overgrazing, intensive and un-environmentally protected farming activities and indiscriminate felling of trees for charcoal production, the region is gradually becoming derived savanna although with high humidity and some parts becoming semi-arid (Sowunmi, 1986). The community is also a bucolic environment, which hosts about 173 kraals (nomadic bands) and Gaas/Guuros (settlements) located in about 150 square kilometers.

Ibarapa has three LGAs, out of 774 LGAs that constitute the federation of Nigeria. The area has Yoruba indigenous farmers and hunters, a heavy presence of nomads, and a scanty population of other cultural groups from Nigeria and the Republics of Benin and Togo. The indigenous people of Ibarapa community are mainly farmers growing cassava, plantain, fruits and yam (Awojobi, 2011a, 2011b, 2013; Lawal et al., 2012).

A description of each of the three Ibarapa LGAs presents a vivid picture of the context of this study. Each LGA has different categories of pastoralists living in separate unique camps known as Gaa and led by a Seriki-Fulani (nomadic head). The three Ibarapa LGAs are delimitated as Ibarapa East, Central and North. Ibarapa East LGA has its headquarters in Eruwa and an area of 112 km² with a total population of 118,226 at the last 2006 Nigerian census (National Population Commission, 2006). The Ibarapa East LGA lies between latitude 7° to 32°N and longitude 3° to 25° E. It is bordered in the North by Iseyin, in the west by Odeda LGA in Ogun State, and in the East by Igbo-Ora in Oyo State. It has a few public and private hospitals but the most functionally outstanding is the Awojobi Clinic, Eruwa. This is a private clinic which was owned by an accomplished rural surgeon and renowned primary healthcare provider – the late Dr Oluyombo A. Awojobi – and was established in 1983 (Awojobi, 2007).

Ibarapa Central LGA has its headquarters in Igbo-Ora, a town with an area of 440km² and a population of 102,979 according to 2006 Nigerian national population census. The Ibarapa Central LGA has ‘three general hospitals run by Oyo State Government, five clinics managed by local government authority, many medicine shops mostly unlicensed and managed by unlicensed pharmacists and numerous indigenous and faith-based healers’ (Oyadoke et al., 2004, p. 251).

Ibarapa North LGA was created in 1996 from the old Ifeloju LGA (Amahia, 2014: 5) with its headquarters in Ayete. It has an area of 1218 km² and a population of 101,092 as at the 2006 census. This LGA differs from others because it hosts a government-owned grazing reserve. However, from an in-depth interview (IDI) conducted in 2014 with the Seriki Fulani in Igangan, the Ibarapa North LGA is shown to be unique because it has a large settlement of nomads with a mixture of all categories of cattle pastoralists numbering about 6831. Though this figure was derived from the 2006 Nigeria Census Data, the local office of the National Population Commission in Ayete declared the figure incorrect. Since there is no other verifiable data, we rest on the existing data. However, the nomads’ population in Ibarapa East LGA was agreed to be 11,215 nomads based on 2006 Nigerian census figures.

Study population and sampling

The study population comprised mainly nomads who resided in each of the three Ibarapa locations, where both males and females were selected for interviews. While the Ibarapa nomadic community was purposively selected due to the heavy presence of pastoral nomads in the location, respondents were both purposively and randomly selected. Purposive selection was used mainly for the key informants who were mainly pasturing nomads, aged nomads in their bands and adult women nomads found in cities and towns where they were marketing dairy products. Purposive selection was also used to select medical doctors located in towns and cities where they established modern healthcare facilities. A total of 104 key informants which comprised medical doctors (8), women nomads in towns (43), pasturing nomads along grazing tracks (19) and heads of the bands (34) were purposively selected. Random selection was used for IDIs, where multi-stage random sampling was employed, featuring purposive sampling to select the Ibarapa community, followed by cluster sampling to select the study sites and random sampling to select the enumeration areas and households, while the last level of multi-stage sampling featured both purposive sampling to select the key informants and random sampling to select respondents for IDI. Randomization of bands (kraals) forming Enumeration Areas (EAs) was firstly done through the location map of the Ibarapa nomadic settlement, which was obtained from Ibarapa East and Ibarapa North Local Government Secretariats. From one 173 existing nomadic bands identified in the map, we selected 20% numbering only 34 bands spread across the length and breadth of the Ibarapa nomadic community. The selection was based on the order of every fifth band listed on the map. Households were also randomly selected from each of the kraals that were selected as EAs. Most of the kraals have more than two households defined by separate house structures and occupied by a family segment each. For IDIs, head of the band, head of household and a woman from a selected household in each band were selected. A total of 68 respondents were selected for IDIs.

Focus group discussions (FGDs) centred on the intersection of discussants considering varied ages, gender and occupations in the bands. Ten FGDs were conducted with a minimum of seven discussants in each of the FGDs. Four FGDs were conducted in Ibrapa East LGA comprising two in each of Lanlate and Eruwa. Three FGDs were conducted in each of Ibarapa Central and Ibarapa North. One session of female FGDs was conducted at Gaa Alapa in Lanlate comprising eight elderly women of ages between 60 and 87 years and young women and girls who were between 18 years and 35 years of age. Another session of FGDs comprising six males was also conducted at Gaa Alapa in Lanlate (Ibarapa East) involving adult men, youths aged 18 years and above and the elderly men of ages between 60 and 87 years. One female FGD session involving six women was conducted at Gaa Abulemeji. One female FGD and one male FGD session comprising six participants each were conducted at Abulemeje and Elera all in Eruwa (Ibarapa East). In Ibarapa Central, two male FGD sessions comprising six males and eight males, respectively, were conducted at Abule Iyakoko in Gaa Alhaji Sani, which is mainly occupied by Bororo cattle nomads. Later, one other FGD session was conducted among Bororo women. Finally, in Ibarapa North, two other male FGD sessions comprising eight males and six males and another female FGD session comprising six women were conducted at Gaa Seriki Saliu also known as Gaa Alagolo. All the discussants in all FGDs engaged in pastoralism. While the males were involved in cattle flocking, the females were involved in production and sale of dairy products. The health status of the FGD discussants is difficult to establish due to the fact that the present study lacks capacity to engage in epidemiological study.

Data collection methods

The study began with a successful application for research ethics approval from the University College Hospital/University of Ibadan Institutional Review Board, which guided human conducts in the fieldwork. Specifically, ethics regarding protection of human subjects, respondents’ right of debriefing and retraction, and right of withdrawal from interviews, among others, were rigorously observed throughout the fieldwork.

Eighteen months of ethnographic fieldwork involving interviews in 34 selected nomadic settlements was carried out between February 2014 and July 2015. As noted earlier, data were collected through IDIs, key informant interviews (KIIs) and FGDs, using guided protocols designed to capture seasonal nomadic healthcare challenges. For the validation and transferability of qualitative data in terms of ascertaining the limit of the quantity and quality of the interviews held, the principle of saturation was employed as recommended by Krueger and Casey (2000) and Teddlie and Tashakkori (2003, 2009). Saturation describes the point in qualitative data collection when the researcher has heard enough of the range of ideas, and is experiencing repetition of the same issues with little or no new information emerging. At this saturation point, conduct of more KIIs, IDIs, and FGD was discontinued. The fieldwork interviewed 68 informants using IDIs, 104 KIIs, and 10 gender-based FGDs that consisted of 66 discussants. Table 1 shows the frequency of interviews.

Table 1.

Number of focus group discussions (FGDs), key informant interviews (KIIs), and in-depth interviews (IDIs) used in this study.

	FGD	KII	IDI
Ibarapa East	4 (24 discussants)	31	22
Ibarapa Central	3 (20 discussants)	37	20
Ibarapa North	3(22 discussants)	36	26
Total	10 (66 discussants)	104	68

Data management and analysis

Guided by the study objectives, the data collected from the fieldwork and stored in field-notes, diaries, memos and electronic devices were transcribed, sorted, and coded. The contents were also analysed as guided by the study objectives and emerging themes. Firstly, themes were searched from the collected data through careful reading and re-reading of the stored information. Themes related to each of the study objectives and newly emerging themes were collated.

This was strengthened by familiarization with the data through continuous and regular reading and listening to voice records of the data from recorded tapes, and viewing the pictures taken during the interviews. This stage saw data cleaning and categorization, whereby the unwanted data were separated from the necessary, and counter opinions were also grouped. The transcripts were compared with the field notes to ensure that all the details were captured. Following the transcription, translation and transliteration of data were carried out because data were collected in pidgin English, Fulfulde, Hausa and Yoruba. Through translation and transcription, exact words in the English language in some critical opinions were sought for accuracy.

After the process of transcription, data were imported into NVivo software version 10 which was subsequently used to manage the data. The use of an intra-coder reliability test, which is a process that measures the consistency of a single coder coding the same material twice with a time interval was helpful as suggested by De-Graft Aikins (2005: 3). A second coder subjected the transcripts to an inter-coder reliability test to ensure rigour. Further reliability and rigour in this study came up when transcripts were read to cattle nomads and they were asked to confirm the interpretations or understanding obtained from their views on access to healthcare systems in Ibarapa. One factor that was of greater benefit in this study was the prolonged fieldwork engagement which made it possible for detailed accounts to be obtained from the nomads, and also made it possible for “an audit trail” to be maintained (Aziato et al., 2014: 2). After using the NVivo to bring the data into a manageable form, report writing began and verbatim quotes were used to support the themes that emerged.

Findings

Socio-demographic characteristics of the respondents

Among the respondents for this study, 37.8% were aged between 18 and 27 years, 25.5% were aged between 28 and 37 years, 21.0% were aged between 38 and 47 years, while 8.5% were aged between 48 and 57 years. In addition, 5.9% were aged between 58 and 67 years, while 1.3% were aged between 68 years and above. The above shows that the majority of the study respondents were nomadic youths between the ages of 18 and 27 years.

In terms of gender, 45.7% (172) of the study respondents were males while 54.3% (201) were females. 88.6% of the respondents had no formal education. However, 7.7% (29) of the study respondents had first school leaving certificates, 2.1% (8) of them had senior school certificates, while 1.6% (6) of them had National Certificates in Education and Ordinary National Diplomas. This implies that the majority of the respondents were illiterates (unable to read or write).

The primary occupation of 43.4% (163) of the respondents was cattle herding. Similarly, 2.9% (11) of them engaged in farming and 0.8% (3) engaged in agro-pastoralism (cattle rearing and farming). 50.5% (190) of the respondents were traders while 0.5% (2) of them were students. Also, 0.5% (2) of the respondents were civil servants and 1.3% (5) of them chose other occupations not mentioned. This analysis reveals that the occupation of the majority of the respondents was trading. Women were mostly engaged in the sale of dairy products such as cheese (waara), milk, butter, etc., while males were mostly involved in trading in cattle. They travelled to Northern Nigeria to buy cattle and transported them to Southern Nigeria for sale. This livestock (cattle) trading is prominent among male pastoralists in Ibarapa; only a few graze cattle to fatten them up for sale in the local cattle markets popularly known as kaara.

Health risks in Ibarapa nomadic community

Pastoralists in Ibarapa were exposed to three main categories of health risks, namely occupational risks, socio-economic risks and bio-medical/seasonal climate risks. Occupational health risks included snake-bites, fatigue, injuries sustained when herders step on traps set by hunters and farmers for animals, malnutrition/hunger, “spirit attacks”, and gunshots from neighbouring hunters who mistake them for games, among others. Socio-economic health risks included financial loss due to poor management in cattle businesses, livestock mortality, human injuries and death caused by road traffic accidents when crossing highways, mob attacks against the nomads by neighbouring farmers, robbery and insecurity issues. Accusations of possessing small and light weapons (guns) attracting police arrest and huge fines for crop damage were also seen by nomads as great socio-economic challenges, which remotely affected the health status of nomads within the Ibarapa pastoral environment. Most nomads claimed that these socio-economic challenges triggered biomedical health problems such as hypertension (high blood pressure), restlessness, insomnia, headache and other associated illnesses, and in extreme cases resulted in deaths especially when hunters mistook nomads for animals and shot them.

Nomads also experienced some biomedical/season-induced health risks associated with Ibarapa nomadic environment. Thus according to IDI interview scripts:

Cattle herders often suffer cold and arthritis in rainy seasons, as a result of rainy and very cold weather. Also, malaria affects us most in the rainy seasons, but this disease is not common to only cattle nomads as even those in the cities also suffer malaria. The one that seems to be unique to cattle nomads is cold that penetrates deep into the nomads’ bones (severe cold). (An excerpt from personal interview with a retired aged cattle nomad at Gaa Orisumbare in Ibarapa East LGA on 1 September 2014)

During rainy seasons, there is usually too much cold for the cattle nomads. At times someone will be having cold in the bone marrow and severe body and joint pains (arthritis). The infection in the bone marrow is called ‘lagunlagun’; it is an internal sickness which cattle nomads suffer most times. (An excerpt from personal interview with Mr. I.A.S at Gaa Lagaye in Ibarapa East LGA, July 17, 2016)

Biomedical/season-induced health risks are numerous. According to a KII:

Malaria, chicken pox, snake bites are common diseases experienced by cattle nomads. Again, if you look around, you will see that the trees are gradually disappearing, there is no tree in the bush to protect us (cattle nomads) from cold and this increases the spread of some airborne diseases. (An excerpt from personal interview with an Ilorin Fulani at Gaa Alapa on 20 March 2015)

These diseases often require treatment in hospitals. During the wet grazing season, nomads are often exposed to severe cold (pewol), pneumonia (pewuri), guinea-worm (balk), cough (douru, chowuru), catarrh (mura, dambi), diarrhoea/cholera (saarol), and other diseases. During the dry grazing season, common illnesses include children convulsion (sukaabel/chukapil, palte), chicken pox (babaru, pultoi), body heat and rashes (pinni, serungo), measles (duudu, pultei – singular; pultoi – plural), among other diseases, which are due to excessive heat without facilities for cooling.

There are also some health risks that defy seasonal categorizations because nomads claim they are prevalent in all seasons. Such health risks include zoonosis (animal–human communicable diseases) caused by animal–nomad intimacy: sleeping sickness; and skin infections transmitted from cattle to the nomads. All-season health risks include exposure to malaria (papolje) due to excessive mosquito bites during grazing, and lack of good water which often leads to a risk of typhoid/fever (yontere, kpanduwuli) infection. Long-distance trekking and most especially when confronted with environmental challenges such as climbing mountains, crossing big rivers and rifts during grazing, exposed Ibarapa nomads to severe bodily pains (nawudupando), serious and chronic fatigue and headache (nawolhoore, nawduhori). Also, exposure to dry weather and lack of potable water often triggered dry cough and tuberculosis among the grazing nomads. Nomads believed that the three categories of health risks were interwoven as one could lead to another. According to a translated script extracted from an IDI with Alfa Yaaya Musa, a grazing nomad in Ibarapa Central who was interviewed on 18 September, 2016, socio-economic and occupational health risks can lead to bio-medical health risks:

These problems are more in dry seasons. Due to the scarcity of pasture and in a bid to get cattle satisfied, cattle often enter into farms and it becomes a very big problem. An example was the issue that happened yesterday when a cattle nomad was grazing and his cattle went near somebody’s farm. The farmer raised alarm. He shouted. . .and angrily came chasing the cattle, which almost caused an accident. . .and before we knew it, the farmer butchered the cattle nomad with his cutlass. The victim (cattle nomad) is still lying in the hospital as I am talking to you.

There is hardly any Ibarapa nomad who is not confronted with one health risk or another in their everyday pasturing activities. As shown in Table 2, an account of various grazing nomads who have been exposed to different categories of health risks within the period of one month before the interview was conducted is tabulated. Table 2 shows that in all the research areas, every nomad was exposed to health risks in the Ibarapa marginal pastoral environment.

Table 2.

Frequency of health risks among the respondents.

	Socio-economic health risks	Occupational health risks	Biomedical health risks	Total
Ibarapa East	30	29	32	91
Ibarapa Central	22	23	24	69
Ibarapa North	31	18	29	78
Total	83	70	85	238

Table 2 shows a total of 91 (Ibarapa East), 69 (Ibarapa Central) and 78 (Ibarapa North) study participants who had experienced aspects of the socio-economic, occupational and biomedical health risks in the three LGAs. When confronted with these health risks, how did nomads gain access to healthcare facilities and which of the healthcare facilities was easily accessible within pastoral settlements?

Availability and access to healthcare facilities

There were government-owned nomadic primary schools in many pastoral bands in the Ibarapa pastoral community but there was no single healthcare facility in the community. Ibarapa nomads were left to access healthcare facilities in distant towns and cities. Apart from the fact that these distant healthcare facilities were located in Yoruba towns and cities which were mostly hostile to the nomads, they were also far away from the pastoral bands. The closest pastoral band to healthcare facilities in towns and cities was at a distance of about eight kilometres while some bands such as Gaa Amala and Gaa Nuhu were as far as 53 kilometres from the nearby towns.

Healthcare facilities available in neighbouring communities included one public primary healthcare centre located in each of the three LGAs that constituted the Ibarapa community, two general hospitals located in Igangan and Eruwa, and 17 maternity and dispensary facities found in all the research areas. All the healthcare facilities suffered shortage of medical personnel and equipment. As at the time of fieldwork, there were only 15 public and 12 private medical doctors in all the Ibarapa LGAs, which had a population of about 513,000 people according to 2016 Nigerian estimated population figure (National Population Commission, 2017). Poor access to water, good roads and electricity also barred the public healthcare facilities from optimal function. Most hospitals and clinics depended on deep wells and motorized electric-powered boreholes, which often suffered from irregular supply of electricity and always ran out of production during the dry season. Many of the inter-communal roads were dilapidated and posed threats to access to available healthcare institutions in the towns. In all the three LGAs in the Ibarapa community, there were only seven standard private hospitals and uncountable quack doctors and unlicensed drug vendors.

Pastoral nomads living on the fringes of the towns were left to compete with the inadequate health facilities in the towns and cities, who the nomads claimed were hostile to them. Thus, when in need of modern drugs, pastoral nomads in Ibarapa mostly relied on drug vendors who plied their trade in the bands regularly. This practice also posed health risks to the nomads considering the quality of the drugs sold by the quack drug vendors. Also, drugs were often bought and taken without medical prescription, a practice which on its own constituted serious health risks. Grazing nomads always struggled to reach distant healthcare facilities in cases of dire needs and emergencies, whenever they were stalked inside the deep forest grazing their animals. Within the period of 18 months of this fieldwork only 16.8% of the respondents who had sicknesses visited hospitals and clinics located in the towns for treatment, as shown in Table 3.

Table 3.

Respondents’ visits to hospitals and clinics in Ibarapa towns.

Ibarapa Local Government Areas	Respondents’ visit to hospitals/clinics in towns
Ibarapa Local Government Areas	n = 238
Ibarapa East (n = 91)	13 (14.2%)
Ibarapa Central (n = 69)	15 (21.7%)
Ibarapa North (n = 78)	12 (15.3%)
Total	40 (16.8%)

With bad roads and the reluctance of commercial drivers to pick up the grazing nomads who were in need of emergency medical facilities in the towns, Ibarapa nomads were often deprived access to healthcare facilities. The Ibarapa nomads were often refused services by commercial drivers because the drivers accused them of having repulsive body odours and unkempt appearances. These, according to the drivers, were consequent on the fact that the nomads were too preoccupied with their grazing activities to bath regularly or groom themselves. Thus, an extract translated from an IDI with Yusufu Ali, who is a paid-grazer (alagbada), explained the experience of an average grazing nomad in reaching a distant clinic when he was caught by a metal trap while grazing in the forest:

I had that experience at Sando around Tapa in Ibarapa North. On that day I was grazing my cattle, and they wanted to enter someone’s farm. So, I ran shouting ahhhhhhh kaaiiiiiiiii trying to redirect the cattle. As I was running, and chasing my cattle out of the farm, I just heard gbaaagam (intense hit) on my foot. When I looked, it was a trap; there was blood everywhere, a wide wound and deep holes on my left leg. It took two co-grazers about 30 minutes to remove the trap and release my leg. There was serious bleeding and I nearly bled to death. They pulled me to the roadside but there was no vehicle in sight for over an hour. They had to call home with a phone and a relative came with a motorcycle and took me to the hospital. After I was injected and the wound was treated, I resorted to treating it with traditional herbal remedies at home. The treatment lasted for about one month before I recovered and started grazing again (IDI – Ibarapa North).

Many similar narratives abound in both KII and IDI data scripts, where the distance to healthcare facilities in towns remained a huge challenge in accessing healthcare among the Ibarapa pastoral nomads. Although grazing nomads harboured some traditional health beliefs, they still preferred modern healthcare systems to other forms of healthcare. However, they were compelled by non-accessibility to modern healthcare facilities to rely on traditional herbal remedies (agbo), drugs supplied by itinerant Yoruba quack drug vendors from the towns and Islamic faith-based care. The commonly accessible healthcare system in the nomadic settlement was the faith-based healing mostly provided by nomads without cattle who were Islamic clerics (Alfa) performing healing rituals known as hantu. Hantu is the inscription of some healing verses of the Quran (Koran) on wooden boards, then washed with water into a bowl and given to ill persons or any client to drink. This spiritual drink is an Islamic practice, which symbolically represents the group’s faith in the holy words of the Quran and is believed to be potent, preventive and curative for curing most illnesses, such as socio-economic misfortunes, pregnancy complications, other maternal and child health problems, etc. .

Herbal remedy involving the extraction of plant and animal parts for medication was also common among the grazing nomads. The pastoral nomads were endowed with knowledge about the usage of plants and animals for medication. Such knowledge was often transferred from generation to generation with new knowledge acquired through their daily observations of the responses of their animals when they ate certain shrubs and grasses during grazing.

Health adaptation strategies

Adaptation strategies adopted by cattle nomads in the semi-humid Ibarapa nomadic environment against the above identified health risks varied. These strategies can be categorized into two broad streams such as preventive health adaptation (PHA) and curative health adaptation (CHA); and temporary adaptive strategies (TAS) and permanent adaptive strategies (PAS). PHA are those strategies employed through the use of local healthcare facilities such as faith-based healing, self-medication and herbal treatment engaged to ward off diseases and infirmities by the perception of health risks and potential severity of such perception, even when the actual health threat was not yet experienced. In this instance, grazing nomads engaged the use of local charms to ward off bodily harms and used herbal concoctions made from plant and animal tissues as antioxidants to control malaria infections and protect pregnant women from childbirth complications. Hantu was also engaged as a protective device against misfortune on cattle business and against infections. Preventive adaptive strategies also included the use of protective gadgets for extreme weather conditions (extreme sunshine and rainfall). Such strategies included the use of umbrellas, plastic shoes, rain coats, living in grass huts, and contracting of actual grazing activity to hired/paid labourers in order to reduce workloads and stress, among others. As observed in an IDI translated script, the nomads:

often wear rubber shoes to prevent wounds, blisters and snake bites; umbrellas for covering our heads under rains and sunshine; and also use cutlasses to remove obstructions and protect ourselves. (IDI – Ibarapa East)

Interview scripts on preventive and adaptive strategies related to pregnancy and childbirth revealed that self-help and community support were mostly engaged. The following scripts further explained health behaviours associated with pregnancy care and child birth among the Ibarapa cattle nomads:

We do experience health problems when women want to give birth; my wife had such problems. Sometimes she gives birth without stress and sometimes passes through complications. Those pregnant nomadic women without any form of pregnancy problems are monitored while they give birth at home. Anyone (pregnant woman) we notice showing signs of problems is taken to the hospital for care (Personal interview with Mr. I.A.S. at Gaa Lagaye in Ibarapa East LGA, 31 August 2014).

If God helps and we give birth without complications, we prefer to give birth at home but if it is a pregnancy that has been problematic, we go to the hospital. We do not have traditional birth attendants [TBAs] here, and as we have said earlier, we give birth by ourselves at home and also use the hospital in some cases. (Personal discussion with nomadic female FGD at Gaa Abulemeje, Eruwa, Ibarapa East LGA, 25 April 2015)

Our nomadic women often have pregnancy challenges and we can recall a few incidences. One happened at our former settlement before we came here eight months ago. One of our pregnant women was passing through severe pains, and we hurriedly took her to Awojobi hospital, and she delivered there peacefully. In another case, after taking her to the hospital, Awojobi said it was not yet time for her delivery, but she delivered at night at home with the assistance of her fellow women. (Personal discussion with a Bororo male at Gaa Iyakoko, Igbo-Ora, Ibarapa Central LGA, 2 September 2015)

Giving birth at home is the culture of the Fulani women. It is a sign of a strong and ‘complete Fulani woman’. We grew up to see this culture of self-delivery and continued with the practice, but we go for anti-natal to collect drugs. During childbirth, we give birth at home unassisted (there is no need for professional TBAs in nomadic settlements); when the baby is ready to come out, we close the door and deliver our babies in our huts. After delivery we open the door and as the baby cries, people come around to shout and celebrate the birth of the baby. (Personal interview with Mrs H. at Gaa Elera, Ibarapa East LGA, 24 April 2015)

Nobody helps a Fulani woman to deliver her baby, we only give birth on our own and, after birth, our fellow women come to bath the baby. We Fulani women don’t call for help in labour; we call for help only after birth to clean up and bath the baby. We prefer to give birth at home except when a woman has developed problems or is undergoing complications during pregnancy; that is only when she will give birth in the hospital. (Personal interviews with three women at Gaa Igboiyangi, Igbo-Ora, Ibarapa Central LGA, 2 September 2014).

All these local remedies are also used as CHA. In cases of severe threats arising from exposure to health risks, the grazing nomads often visited hospitals and clinics in the towns and cities. Thus a key informant who engaged a clinic in the town to manage diabetes expressed his experience as follows:

I have been a diabetic patient for over 4 years now and I constantly go to Awojobi Clinic at Eruwa town for treatment and drugs. I collect drugs from Awojobi Clinic every month. (Personal interview with a key informant and nomad leader at Gaa Alapa, Lanlate, Ibarapa East LGA, 28 August 2015).

Nomads rarely wanted to patronize public hospitals as they often complained of poor service delivery and perceived ethnic hostility from the Yoruba people. But largely, they preferred private clinics that claimed to have better healthcare services and minimal or no ethnic hostility against them.

The TAS included the use of mosquito nets, living under trees and another make-shift shelter for protection against harsh climatic and environmental conditions such as overheating that could cause health risks. Grazing nomads engaging in inter-border herding who were always on-the-move used these adaptive mechanisms against potential health risks. PAS included building more secured huts and in rare cases modern buildings with corrugated roofing sheets, mostly adopted by intra-border grazing nomads. Another PAS employed by the sedentary nomads was the use of paid labourers who engaged in hired grazing (agbada) mostly used by Fulani-Ilorin cattle nomads to reduce stress and exposure to risks in the forests. Hired grazing is an adaptive practice among cattle grazers who moved in twos such that when one was bitten by a snake or fell sick while grazing, the other could call home for folk support. The use of modern technology such as phones has also been adopted to disseminate information on risk-ridden areas. These strategies were either preventive or curative.

In sum, though living and moving within the pastoral environment induced health risks, the above health adaptation strategies have, for years, proven to be a way of averting uncontrollable morbidity and mortality in spite of the conspicuous absence of healthcare facilities in Ibarapa pastoral community of Oyo State.

Discussion and conclusion

Access to healthcare facilities is essentially strategic and critically operationalized – it is often examined where a population has no access to utilization of healthcare facilities due to a number of factors which include environmental and occupational constraints as well as attitudes towards the use of such facilities. In this study, access to healthcare facilities implies location, availability and the right and opportunity to utilize healthcare facilities within the pastoral environment. Cattle nomads have the right as citizens of Nigeria to access, demand and enjoy modern healthcare facilities. However, apart from the general trend of Nigerian underdeveloped healthcare services, most times the opportunities to access healthcare among the nomads are inhibited by the patterns of grazing and the pastoral environment where the nomads operate their cattle economy in Nigeria. Pastoral cattle nomads prefer to live within the pastoral environment because the subsistence and survival of the nomadic group and their livestock depend on this space. Being a medically underserved population, the cattle nomads of the Ibarapa community of southwestern Nigeria have poor access to healthcare facilities, which in turn imposes health risks on them. As reflected in the data presented above, grazing culture, nomads’ cultural perception of personal health as less prioritized than their livestock’s health and the pastoral environment, mostly located in the fringes and deep forests with varied weather conditions greatly impede the access of Ibarapa nomads to modern healthcare.

The Ibarapa pastoral environment is replete with many health risks and challenges which include seasonal climatic, occupational and socio-economic health risks. Shaped by the two major climatic conditions in Nigeria, health risks in Ibarapa nomadic settlements were described by nomads as seasonal health risks (dry and rainy seasons’ health risks). These health risks are heightened during dry seasons as a result of the scarcity of basic natural resources (pasture and water) needed by the cattle. The non-disease health risks are conceptualized as socio-economic challenges of the cattle economy and are often triggered by chaotic inter-group and intra-group relations, which directly or indirectly have implications for the health of nomads. Other health risks are occupational in nature and are often life-threatening in the absence of a modern healthcare system within the pastoral environment. Put differently, the absence of a modern healthcare system in proximity to nomadic bush settlements makes it difficult for cattle nomads to easily access healthcare when they are confronted with illnesses. This makes nomads rely on a faith-based healthcare system provided by itinerant Islamic clerics, and on a traditional healthcare system provided by herbal drug hawkers though occasionally, these settlements are visited by itinerant modern drug hawkers who expose drugs to high temperature (hot sunlight).

To reduce the negative impact of identified health risks and the difficulties encountered while trying to access healthcare in distant towns, the Ibarapa cattle nomads have devised several self-help strategies such as learning the language of their hosts so as to communicate effectively with clinical healthcare personnel resident in the neighbouring towns and cities. They have also ensured that their educated children are recruited in hospitals/clinics (mostly privately owned) as interpreters. They have also learnt to engage actively in local politics, so as to get appointments and elective positions in order to have improved access to welfare resources such as healthcare. This is in a bid to increase cattle nomads’ access to public goods and welfare resources within the Ibarapa pastoral environment. Other self-help strategies include sending delegations to government officials to inform them of their collective needs, and sometimes inviting journalists from different national media organizations to improve their public image. The Ibarapa nomads are deprived access many public resources due to the nature of their occupation and location of the nomadic settlements. To eliminate some of the socio-economic health risks, the Ibarapa cattle nomads have suggested that government, interested individuals and organizations should help the nomadic populations in the provision of grazing reserves, grazing routes, potable water (boreholes) and at least maternity facilities and other health centres in nomadic settlements. This could help to make healthcare easily accessible to nomadic populations in Ibarapa.

From the above, it is clear that the barriers preventing accessing healthcare services are mainly distance from nomadic bush settlements to health facilities in the towns and finding means of transportation from these settlements when needed. Other barriers are communication and language problems (friendly/unfriendly health personnel), neglect of nomadic band by government and absence of modern healthcare facilities in proximity to nomads’ settlements. Also, cost of healthcare (cost of healthcare is dependent on sub-themes such as affordability and unaffordability, severity and intensity), delay issues, location of health facilities, transportation issues and transportation costs. These were vividly captured by a key informant as follows:

We have only three motorcycles in this settlement. If the owners of the three motorcycles have gone out with their bikes and there is a case of emergency, there is nothing we can do than to try getting a commercial motorbike. So, we normally call the motorcyclists by phone to come over to our settlement. (Personal interview with Mr. M. at Gaa Abulemeje, 25 April 2015)

In view of nomads’ exposure to a variety of health risks, many of which pose potential dangers to their livelihood and the cattle economy, and also to food security in Nigeria, it then becomes rational for the Nigerian government and private healthcare providers to establish quality healthcare facilities within pastoral environments to facilitate easy and equitable accessibility. This suggests that every nomadic healthcare policy/programme must be ecologically suitable and also accommodate the pastoral culture of the Ibarapa nomadic community. Thus, in line with the medical ecological approach that “a social group’s level of health reflects the nature and quality of the relationships within the group, with neighbouring groups, and with the plants and animals as well as non-biotic features of the habitat” (McElroy and Townsend, 1996: 12), it is necessary that every nomadic healthcare policy should take cognizance of adaptability to the culture of pastoralists and the pastoral environment in general.

In conclusion, the findings of this study have revealed that socio-environmental and economic conditions which perpetuate health risks and cause marginal access to healthcare facilities cannot be comprehensively remedied by the usual intermittent external interventionist approach to healthcare alone. There is a great need to look inwards to examine holistically the contextual socio-ecological factors inducing health risks within the broader frame of healthcare realities. In the case of this pastoral environment and the activities of marginal populations, such factors as population’s perception of healthcare services, location of healthcare facilities in terms of distance and availability, nature of health risks in a society, and environmental factors promotive and/or inhibitive of quality health are factors influencing access to healthcare facilities. These factors need to be critically considered before any meaningful solutions could be designed to avert health risks and improve healthcare access. However, it should be noted that in quality healthcare delivery, access is a means to an end and not the end in itself. The end is the point at which quality healthcare is attained or gained, and this is the goal to which access should be strategically operationalized if a qualitative and equitably accessible healthcare delivery is to be attained. Hence, as stressed, discourses on nomadic healthcare should refocus from prevention of infectious diseases to critical intervention on the general health conditions of the nomads. To achieve this, a more culturally sound approach that aligns with nomadic lifestyle is imperative. As witnessed in the Ibarapa, since most of the nomads engage in animal grazing and have homesteads lasting some years of residence in a particular expanse of land where they build their bands and revolve round the space, a provision of permanent healthcare infrastructure within the nomadic settlements will improve access. Similarly, constantly moving cattle nomads such as the Bororos should be provided with mobile healthcare caravans (healthcare without walls) for a holistic nomadic healthcare to be attained in Ibarapa nomadic locations. This can serve as a model to improve equitable access to healthcare facilities for other Nigerian nomads who live in the margins.

Study limitations

The inability to speak Fulfulde and Hausa languages fluently was disturbing initially. The two languages are predominantly spoken among the cattle nomads in Ibarapa. This was a great limitation to ethnography in Ibarapa nomadic locations. However, this was managed through the researcher’s ethnographic skills and experiences and by the utilization of three trained research assistants who spoke Fulfulde, Hausa, and Yoruba.

The sparse location of band settlements in the far distance bush also disturbed the seamless ethnography in the nomadic environment. However, spending a long period of time in the field between 2014 and 2016 reduced the problems associated with the disturbing spatial location of the band settlements. Similarly, the gender-sensitive structure of the cattle nomadic society in Ibarapa posed some challenges one of which was the need for a male escort and interpreter before a female researcher could effectively interact with male nomads. This therefore increased the cost of fieldwork in nomadic settlements.

Footnotes

Declaration of conflicting interests

The authors affirm that there is no conflict of interest.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Compliance with ethical standard

Ethical approval with certificate number NHREC/05/01/2008a was obtained from University College Hospital/University of Ibadan Bio-ethic Review Board. The ethical approval was based on the assurance of informed consent, anonymity, debriefing, confidentiality and safety from injury/harm in the course of conducting research among the Ibarapa nomadic population.

ORCID iD

Aderemi Ajala

Author biographies

Aderemi Ajala is a Professor of medical anthropology at University of Ibadan, Nigeria. A recipient of British academy, UK (2006), Rockefeller Foundation Fellowship (2013) and Alexander von Humboldt Foundation Fellowship, Germany (2009).

Blessing Nonye Onyima is a Senior Lecturer in Anthropology at Nnamdi Azikiwe University, Awka, Nigeria. She is a recipient of African Humanity Programme (AHP) Fellowship 2016. Her contribution in this publication comes from the fellowship funds enjoyed from AHP.

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