Nigeria Private Health Sector Assessment

Publication date: 2012

1SHOPS Project • Nigeria Private Health Sector Assessment Nigeria Private Health Sector Assessment BRIEF Keywords: Nigeria, private sector health, insurance, private sector assessment, policy Recommended Citation: SHOPS Project. 2012. Nigeria Private Health Sector Assessment. Brief. Bethesda, MD: Strengthening Health Outcomes through the Private Sector Project, Abt Associates. Cover photo: Bonnie Gillespie, Courtesy of PhotoShare Project Description: The Strengthening Health Outcomes through the Private Sector (SHOPS) project is USAID’s flagship initiative in private sector health. SHOPS focuses on increasing availability, improving quality, and expanding coverage of essential health products and services in family planning and reproductive health, maternal and child health, HIV/AIDS and other health areas through the private sector. Abt Associates leads the SHOPS team, which includes five partners: Banyan Global, Jhpiego, Marie Stopes International, Monitor Group, and O’Hanlon Health Consulting. Disclaimer: The views expressed in this material do not necessarily reflect the views of USAID or the United States government. Cooperative Agreement: No. GPO-A-00-09-00007 Download: To download a copy of this publication, go to the resource center at www.shopsproject.org. Abt Associates Inc. • www.abtassociates.com Summary: This brief is a summary of the Nigeria private health sector assessment conducted by the SHOPS project in 2010. Ananya Price prepared this brief which presents the assessment methods, findings, and the following key recommendations: 1. Expand the supply of quality private sector health services in RH/FP 2. Enhance demand for private sector RH/FP services 3. Create an enabling policy environment for the private sector 4. Ensure effective donor coordination for strengthening the private health sector 5. Support a rigorous research agenda for the private health sector To increase utilization of all modern family planning methods through the private sector, efforts need to be made by the government and its development partners to effectively link active and targeted demand-creation efforts to supply side strategies, to create an effective policy environment, and to pursue a rigorous research agenda for this sector to reach its maximum potential. August 2012 1SHOPS Project • Nigeria Private Health Sector Assessment Nigeria Private Health Sector Assessment In December 2010, the United States Agency for International Development (USAID)/Nigeria commissioned the Strengthening Health Outcomes through the Private Sector (SHOPS) project to conduct a private sector assessment in Nigeria to identify ways in which USAID and other donors/stakeholders could engage the private sector effectively to achieve Nigeria’s reproductive health (RH) and family planning (FP) goals. This brief is a summary of that assessment. The assessment updated information regarding the size, quality, financing, and utilization of private health sector services, especially with regard to RH/FP. This information was instrumental in identifying opportunities for designing a large-scale, comprehensive program to enhance the private sector’s ability to provide quality RH/FP services. The assessment also focused on the prevailing supply, demand, policy, and knowledge barriers that impede the ability of private providers to contribute to RH/FP outcomes in the country. It highlighted the importance of implementing regionally distinctive strategies and interventions for building the private sector’s capacity, pursuing a rigorous knowledge agenda to better understand the private sector, and ensuring coordination across different donor-funded projects to leverage resources and avoid duplication of efforts. Background Located in West Africa, with more than 148 million people and an annual population growth rate of 3 percent, Nigeria is the most populous country in the continent. Despite large budgetary expenditures in the health sector and some improvements in key health indicators, the health of most Nigerians remains poor, especially when compared to other countries with similar per capita income. In spite of various large-scale responses over the last few decades, malaria, TB, and HIV continue to be major contributors to the disease burden of the country. Malaria is the leading cause of child mortality with an estimated 300,000 children dying each year (Nigeria GHI, 2011). Life expectancy at birth is only 54 years for women and 53 years for men (WHO, 2009). Nigeria has the second-highest maternal mortality in the world, with one out of 18 women dying each year from complications during childbirth. According to the Nigeria Demographic and Health Survey (NDHS) 2008, Nigeria’s total fertility rate is relatively high at 5.7, which contributes to Nigeria’s poor maternal health status. The contraceptive prevalence rate, while low at 15 percent, masks varying regional discrepancies in health status and access to health services. For instance, 32 percent of married women, age 15 to 49, in the southwest uses contraception, compared to 3 percent in the northwest. The 2008 NDHS also revealed that unmet need is high, with about 21 percent of non-users reporting that they intend to use contraception in the future. The assessment highlighted the importance of implementing regionally distinctive strategies for building capacity in the private sector, pursuing a knowledge agenda, and ensuring coordination across projects. SHOPS Project • Nigeria Private Health Sector Assessment2 The private sector is an important entry point for addressing Nigeria’s unmet need for contraception. The 2008 NDHS revealed that the private medical sector was the most frequently reported source of contraceptive supplies, providing contraception to approximately 2.5 times as many women as the public health sector. Among the private sector facilities, private pharmacies and patent medicine vendors are the most common suppliers (see figure). According to the latest national health accounts report for Nigeria (Soyibo, 2009), private health facilities (including private hospitals, clinics, pharmacists, and patent medicine vendors) are the most patronized type of health facilities in Nigeria. Thus, there is no doubt that strengthening the private health sector is an important step in expanding high-quality RH/FP counseling and services in Nigeria. Source of FP Methods Among Users of Modern Methods Source: NDHS 2008 Source of FP Methods among users of Modern Methods Private Chemist/Pharmacy 48 Public sector 23 Other Sources 13 Private Hospital/Clinic/Doctor 11 Unknown/Missing 3 Other Private Medical Sector 2 Source: NDHS 2008 NEW – 08.03.12 Private Chemist/Pharmacy - 48% Public sector - 23% Other sources - 18% Private Hospital/Clinic/Doctor - 11% Private Chemist/Pharmacy 48% Public Sector 23% Other Sources 18% Private Hospital/ Clinic/Doctor 11% 3SHOPS Project • Nigeria Private Health Sector Assessment Scope of the Assessment The assessment took into account developments in Nigeria such as the National Strategic Health Development Plan 2010-2015, the Nigerian financial crisis of 2009, and the plethora of donor-funded programs focused on RH/FP. It provided information on: • The regional discrepancies between northern and southern Nigeria regarding the demand for and provision of private sector services in RH/FP. • Targeted regional interventions that need to account for the heavy concentration of private facilities in southern Nigeria, as well as the nascent private health sector in the north, which is dominated by public health facilities. • Key constraints that create barriers for effective private sector participation in the areas of supply, demand, policy, and knowledge. • Opportunities for building the capacity of the private sector and avenues for this sector to access federal Ministry of Health guidelines, activities, and interventions related to RH/FP at the national level. • Donor collaboration for leveraging resources, harmonizing efforts to avoid duplication, and ensuring that activities across projects complement one another. METHODS The assessment team conducted a detailed literature review of the health situation in Nigeria. It examined government and donor-country strategies, as well as reports addressing the status of RH/FP and related topics, including provider quality, contraceptive supply, and sources of health financing in the private sector. The team interviewed stakeholders from health maintenance organizations (HMOs), government, USAID implementing partners, donor agencies, professional associations, financial institutions, nongovernmental organizations, and industry. The team also met with product and service providers in Abuja, Kano, and Lagos including hospitals, clinics, pharmacists, nurses, and midwives. FINDINGS Overview of the Private Health Sector Nigeria is a large, complex country with a strong and growing private, for-profit health sector. Despite inconsistencies in data collection and interpretation, available resources demonstrate the existence of a growing, heavily utilized Nigerian private health sector that offers a wide range of services and is characterized by variable quality levels. The private sector covers the entire gamut of tertiary, secondary, and primary health care facilities, patent medicine vendors, drug sellers, and traditional practitioners. Services provided by the private sector are either subsidized (e.g., faith-based health facilities) or full-cost (e.g., privately owned clinics SHOPS Project • Nigeria Private Health Sector Assessment4 and hospitals), and payment for these services can be made in cash or in kind (Barnes, 2008). The private sector in Nigeria offers several priority public health services, including RH/FP and HIV/AIDS services. Private expenditure on health as a percentage of total health expenditure has continued to grow and accounts for 75 percent of health expenditures (NHA, 2003–2005; NDHS, 2008). Given that health insurance and other health financing schemes are primarily available to individuals who are formally employed, private, for-profit facilities account for a high percentage of health expenditures. Even the National Health Insurance Scheme is implemented by private enterprises contracted by the federal Ministry. Regional and urban-rural disparities exist regarding the utilization of private sector services. On average, private health facilities are concentrated in southern Nigeria, while public health facilities dominate service provision in the north (Dutta, 2009). Knowledge rates about FP are persistently low in the north with only 55 percent of women having heard of any modern FP method. The private, for-profit health sector is often concentrated in urban areas where there is a higher willingness to pay for services. Nonetheless, more than 50 percent of rural Nigerians also routinely use private, for-profit health facilities (IFC, 2008). Utilization rates of the private sector by both rural and urban Nigerians are even higher when including faith-based, nongovernmental, and nonprofit organizations, and traditional healers. Although a large portion of Nigeria’s population uses the private sector and consumers pay a high out-of-pocket share for health expenditures, much of those funds go toward low-quality products and services. The assessment found that the vast, diverse, fragmented, and highly unregulated Nigerian private health sector makes it difficult to measure the quality of services being provided by the private sector. Supply of FP/RH Services and Products Supply of essential health commodities to private providers remains a persistent difficulty in Nigeria. Supply side challenges, such as inconsistent training of providers in contraceptive technologies and FP counseling, lack of development of the private sector in the north, and inconsistent access to long-acting contraceptives all contribute to the low national contraceptive prevalence rate in Nigeria and impede high utilization rates. According to 2008 NDHS data, while 61 percent of Nigerian women obtained FP services from the private sector, only half of these women were informed about the side effects of the FP methods and counseled on side effect management. This may be due to the relatively low access to contraceptive technology updates and training among private providers. While many private providers and representatives of professional associations anecdotally reported high levels of interest from women for long-acting methods (injectables, implants, and IUDs), in reality, these Use of Modern Contraceptives Below is a ranking of modern contraceptive methods in Nigeria for women ages 15–49, in percent. Male condom 4.7 Injectables 2.0 Pill 1.6 Lactational amenorrhea method 1.1 IUD 0.7 Female sterilization 0.3 Implant 0 Female condom 0 Source: NDHS 2008 5SHOPS Project • Nigeria Private Health Sector Assessment providers and representatives had little access to updated information on the methods. Given the lower economic status of those living in the north and the strong influence of statist views, the public sector is the predominant source of health care services in these states. The only northern states with sizeable numbers of registered private providers are Kano and Kaduna, and even there the numbers are extremely small. The assessment identified an opportunity to make significant investments in developing regionally distinctive, capacity-building strategies for the north and south. In the north, these strategies need to take into account the widespread presence of faith-based health facilities, religious opinion leaders, and community service organizations that are an important source of service provision. Distance learning or mhealth initiatives could be used to deliver training to providers not easily reached through HMOs or professional associations. Similarly, partnering with multinational companies, many of which are located in the south, would help reach new sources of private providers. There are substantial opportunities for integrating FP counseling and service provision into the on-going health programs of these multinationals, many of which provide on-site health services for their employees. The assessment confirmed that lack of access to credit, financing, and business development support services continues to impede private providers from expanding and improving the quality of their services. The financial crisis of 2009, which resulted in a lack of liquidity and higher interest rates in Nigeria, also posed considerable challenges to private provider borrowing. The fact that the private sector is substantial in size and has not accessed much financing represents a major market opportunity for Nigerian financial institutions. In 2010, the establishment of a USAID Development Credit Authority (DCA) guarantee was an encouraging step, as it should motivate financial institutions and microfinance lenders to lend to a sector that they view as especially risky, thereby helping existing private providers expand and attract new entrants. Additional supply-side challenges in Nigeria include a lack of consistent consumer access to long-acting contraceptive methods. The private sector has filled some of the gaps left by the public sector in supplying contraceptives to Nigerian consumers, especially through the national social marketing program, but having a sustainable contraceptive supply is still a challenge. With the exception of the social marketing programs, commercial sources of supply have not achieved significant market share in Nigeria. Commercial players interviewed as part of the assessment mentioned untargeted distribution of contraceptives by social marketing programs, leakage of highly subsidized public sector contraceptives into the commercial market, and the fear of donors flooding all segments of the market with subsidized contraceptives as reasons for their lack of investment. The assessment confirmed that lack of access to credit, financing, and business development support services continues to impede private providers from expanding and improving the quality of their services. SHOPS Project • Nigeria Private Health Sector Assessment6 The assessment identified multiple plans and policies developed by the government in partnership with relevant stakeholders that acknowledge the private sector as a vital partner in the supply of FP commodities. Key among them is the Reproductive Health Supplies Coalition (RHSC) Strategic Plan 2003–2007, which covers the procurement of contraceptives. In spite of these policies, there is limited coordination between the sectors, except for the RHSC stakeholder committee, which serves as the key mechanism for coordinating stakeholder activity related to facilitating commodity security. However, this committee only exists at the national level and is yet to be replicated at the state level. Even though some states coordinate between the Ministry, nongovernmental organizations, and international partners, no formal committees exist. The assessment also stressed that, to achieve wide coverage and increase access, FP counseling and commodities should be covered by NHIS and community health insurance schemes. Demand for Accessing RH/FP Services Although approximately 70 percent of Nigerian women are aware of at least one modern method of contraception, overall utilization rates of modern methods remain low, even among the wealthiest. While 96 percent of women in the highest wealth quintile reported having heard of at least one modern FP method, utilization was low at only 22 percent. The need for targeted, demand-creation campaigns that will appeal directly to these women is great. The assessment revealed the wide discrepancy in knowledge and use of modern FP methods within the country. Knowledge rates about FP are persistently low in the north with only 55 percent of women having heard of any modern FP method, compared to 89 percent of women in the south who are aware of at least one method (NPC and ICF Macro, 2009). Existing cultural barriers in the north related to religion, the role of women and gender equity, and inheritance and divorce structures impede the adoption of modern FP methods for many women. Strong, culturally appropriate efforts are needed to raise the awareness of modern methods in the north, which should also take into consideration local traditions and comfort levels of female patients. Nonetheless, the assessment affirmed that southern Nigeria is particularly conducive with a high density of private providers, strong entrepreneurship and market-based approaches, and many women in upper-income levels who could pilot private sector and commercially sustainable models to improve services. A targeted approach to building demand for modern FP, primarily in the south, may be particularly useful in raising the overall contraceptive prevalence rate in Nigeria. Even though distinctive, demand-creation strategies are recommended for northern and southern Nigeria, the assessment emphasized that demand creation should reflect a cohesive, non-coercive approach to raising contraceptive prevalence in Nigeria. This is critical since the assessment found that there is insufficient coverage, distribution, and coordination of While 96 percent of women in the highest wealth quintile reported having heard of at least one modern FP method, utilization was low at only 22 percent. 7SHOPS Project • Nigeria Private Health Sector Assessment national FP messages. Ample opportunities exist for major donor projects, for the federal Ministry to coordinate messages, and to build a cohesive national campaign promoting the use of modern FP in the public and private sectors. Policy Environment The assessment identified multiple areas where the private health sector is negatively affected by weak or weakly enforced policies. While the scopes of practice for private service providers are well defined by the federal Ministry, and in theory do not constitute a constraint to private sector development, in reality they need to be linked to actual measures for leveraging how Nigerian women choose to access FP commodities. For instance, 67 percent of women access oral contraceptive pills through private pharmacies or patent medicine vendors. Given the high level of medical education required for private pharmacists, and the high utilization of this type of provider for the pills, policy changes coupled with extensive training on the provision of injectable contraceptives for private pharmacists could result in a strong increase in the utilization of long- acting methods. In Nigeria, the state and federal ministries of health, as well as professional bodies with regulatory power on issues of key concern to private providers, should be routinely engaged by private provider associations on key advocacy issues. The assessment found that even though most providers are members of their respective professional associations, private sector representation in key policy and decisionmaking bodies is limited and unorganized. In theory, these associations should offer members opportunities for continuing medical education while engaging them in advocacy work on important issues such as improving RH benefits under NHIS—including the coverage of FP counseling and commodities. These associations should help members improve transparency in calculating and paying capitation under NHIS, and advocate for greater use of partnerships and other appropriate legal structures for group practices that can increase economies of scale and mobilize health financing. However, management gaps often limit the role that many of the professional associations can play in governing their members, advocating for a private sector voice in public-private dialogue, and ensuring the quality of services provided by their members. Limited and inconsistent information about private sector service provision, pricing, and quality severely limits integration efforts by the public sector with private providers and allows misconceptions to flourish. Although the private, for-profit sector provides a large share of health services, the private service statistics are not captured by the National Health Management Information System. This information gap limits the ability of public sector decisionmakers to fully understand service provision by the private sector, and to utilize appropriate quality assurance mechanisms and oversight when necessary. Thus, efforts are needed to streamline national information at the federal and state levels so that collecting Enabling Environment Key actors that contribute toward creating an environment favorable to private sector engagement include: • Federal Ministry of Health • State Ministry of Health • Public-private partnership units • Professional associations SHOPS Project • Nigeria Private Health Sector Assessment8 USAID/Nigeria supported training in the use of IUDs through the Strengthening Private Sector Family Planning and Reproductive Health project. D an la di A bu ba ka r routine health service statistics from private providers is conducted in a non-onerous manner. Despite the federal Ministry’s recommendations to increase the role of the private sector in service delivery and promote collaboration and cooperation between private and public organizations, the Nigerian health sector continues to face challenges in forging effective and sustainable public-private partnerships (PPPs). Creating an enabling policy environment for the private health sector requires building the capacity of federal and select state PPP units to better leverage the contributions of private providers to health services. These PPP units are critical to increasing public-private cooperation at the national and state levels and in helping enact and enforce regulations. Lack of Information about the Private Sector One of the greatest barriers to fully integrating and leveraging the private health sector in Nigeria is the dearth of valid, accurate, and consistent data about the private sector concerning its quality, the utilization of its services, and its size. Maintaining a rigorous research agenda to advance knowledge about the private sector’s contribution to RH/FP outcomes in Nigeria can help alleviate misconceptions and contribute to integration and evidence-based policy dialogue. A comprehensive research agenda that includes mapping of private sector health facilities can help determine new areas for expansion based on the density and utilization of clinic-based private facilities. Similarly, impact evaluations can help understand the effectiveness of ongoing interventions, such as the relationship between improved access to credit for private providers and improved provider quality of RH/ FP services, as well as improved client outcomes for RH/FP. Baseline measures of quality at multiple levels of service provision in the private health sector are also important for prioritizing interventions that will work best to improve the quality of private health services. Increased knowledge about the effectiveness of RH/FP interventions will allow donors, policymakers, and program implementers to make informed decisions about resource allocation and programming, thereby strengthening the private sector’s role in delivering RH/FP services in Nigeria. 9SHOPS Project • Nigeria Private Health Sector Assessment Donor Support for RH/FP Services Current donor resources need to be maximized through effective collaboration, especially those mandated to strengthen the private health sector in Nigeria. USAID/Nigeria has been championing RH/FP and MNCH issues in Nigeria through its health projects such as ACCESS/Maternal and Child Health Integrated Program; Access, Quality and Use in Reproductive Health; Improved Reproductive Health in Nigeria; Private Sector partnerships- One, and the SHOPS project. Any new program working in the Nigerian private sector needs to coordinate closely with these projects as well as with the recently awarded Expanded Social Market Project in Nigeria, whose mandate is to build demand for modern FP methods throughout the country, including in private health clinics. Other donors such as the U.K. Department for International Development (DFID) have long-standing presences in Nigeria and remain committed to improving overall health outcomes, primarily as related to maternal, neonatal, and child health. DFID’s two largest health programs in Nigeria— the Partnership for Transforming Health Systems 2 and the Partnership for Reviving Routine Immunization in Northern Nigeria: Maternal, Newborn, and Child Health Initiative—hold promise for strong, future collaboration with other donor-funded projects dedicated to increasing private sector participation in policy dialogue and integrating child-spacing and postpartum FP messages in MNCH packages delivered by private providers in northern Nigeria. Similarly, the five-year NURHI project funded by the Bill and Melinda Gates Foundation provides ample opportunities for collaborating with other donor-funded projects in reducing barriers to FP among the poorest women in urban areas, and integrating both public and private sector resources in service delivery and commodity optimization. RECOMMENDATIONS The following are key recommendations for building the capacity of the private sector to significantly contribute to RH/FP outcomes in Nigeria. 1. Expand the supply of quality private sector health services in RH/FP. • Partner with professional associations such as the Association of General and Private Medical Practitioners and the Association of General Private Nurse Practitioners to build the capacity of clinic- based private providers, especially those in rural areas. • Collaborate with the corporate sector and multinationals that have a strong presence in southern Nigeria to integrate RH/FP/MNCH services within their workplace programs. SHOPS Project • Nigeria Private Health Sector Assessment10 • Build the business and financial management capacity of private health providers by designing and offering appropriate training and technical assistance services. • Enhance the ability of private providers to access credit and pay back loans under agreed-upon timeframes and interest rates. • Build the capacity of Nigerian financial institutions to expand lending to the private health sector and ensure compliance with the established USAID DCA guarantee. • Advocate for inclusion of FP commodities under the NHIS. 2. Enhance demand for private sector RH/FP/MNCH services. • Design and implement targeted, culturally appropriate, demand- creation campaigns to raise awareness and eventually increase utilization of modern FP methods in northern Nigeria while respecting the local norms and comfort level of women. • Instead of creating new materials from scratch, review existing communication materials, make necessary revisions and updates, and reproduce appropriate materials that have already been developed. • Coordinate RH/FP behavior change communication materials and interventions with the Ministry and donor-supported projects focused on FP messaging to ensure a cohesive national message promoting the utilization of modern FP methods. • Train private providers in the use of behavior change communication materials when counseling clients on RH/FP, and ensure that adequate quantities of these materials are available at training facilities. 3. Create an enabling policy environment for the private sector. • Encourage and advocate for greater engagement and coordination among the public and the private sector regarding contraceptive supply through the RHSC subcommittee, which has been established by the Ministry, and donor partners between the public sector and Society for Family Health. • Strengthen the newly formed PPP at state and national levels to utilize its expertise in addressing key issues such as market segmentation, demand creation, training, and raising awareness of FP/RH. • Capture private sector provision indicators through the NHMIS that will help public sector decisionmakers fully understand service provision by the private sector, and also utilize appropriate quality assurance mechanisms and oversight when necessary. • Build the leadership and management capacity of professional associations that represent the private sector, along with their capacity in training private sector providers on RH/FP and business and financial management issues. 11SHOPS Project • Nigeria Private Health Sector Assessment 4. Ensure effective donor coordination for strengthening the private health sector. • Stress the need for new programs targeted toward the private sector as it collaborates and integrates with existing projects such as ESMPIN, NURHI, and PRRINN-MCH. • Coordinate with PATHS2 to advocate for a receptive policy environment that allows for optimal service delivery by the private sector. 5. Support a rigorous research/knowledge agenda for the private health sector. • Conduct appropriate full-range mapping of private providers— from private hospitals to patent medicine vendors—to alleviate any existing misconceptions about their size and the utilization of their services. • Implement rigorous studies to determine quality-of-care baselines and ensure that quality assurance mechanisms extend into the private sector. • Design and implement gap analyses and impact evaluations to address the gaps in RH/FP services of private providers, and identify opportunities for increasing knowledge and use of RH/FP products and services at all levels of the health sector. CONCLUSION With the growth in Nigeria’s gross domestic product, new opportunities for investment in and expansion of its private health sector abound. Private providers have a key role in contributing to positive public health outcomes. But in order to increase utilization of all modern RH/FP methods through the private sector, efforts need to be made by the government and its development partners to effectively link active and targeted demand- creation efforts to supply side strategies, create an effective policy environment, and pursue a rigorous knowledge agenda for this sector to reach its maximum potential. Undoubtedly, a vibrant and expanding private sector will help reduce the demand on public sector facilities in providing priority health services including but not limited to RH/FP. SHOPS Project • Nigeria Private Health Sector Assessment12 REFERENCES Babale, A. 2010. Report of Assessment and Mapping of Public Private Partnership Organisations in Jigawa State. DFID/PATHS 2. --- 2010. Report of Assessment and Mapping of Public Private Partnership Organisations in Kano State. DFID/PATHS 2. Banyan Global. 2008. Access to Finance Brief – Nigeria Case Study. Banyan Global. 2010. 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Accessed December 8, 2010. 14SHOPS Project • Nigeria Private Health Sector Assessment For more information about the SHOPS project, visit: www.shopsproject.org Abt Associates Inc. 4550 Montgomery Avenue, Suite 800 North Bethesda, MD 20814 USA Telephone: 301.347.5000 • Fax: 301.913.6019 www.abtassociates.com BRIEF Nigeria Private Health Sector Assessment

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