Nigeria Private Sector Health Assessment - SHOPS project

clinical update training. Ministry of Health training programs are nominally open to the private sector,
but there are no mechanisms for identifying and recruiting private providers to attend governmentor
donor-supported training. Typically invites to private-sector providers are ad hoc and depend on
personal connections. Of course, given the fluidity between the public and private sectors, publicsector
investments in training often reach private-sector facilities. It is unclear what the criteria are for
courses that qualify as continuing medical education, although the standards seem to be flexible. All
councils think that training about management within the NHIS (such as capitation, covered benefits, and
preventive skills) would be appropriate for continuing education credits.
Under its own rules and procedures, each state health department licenses facilities. Before providers
can establish a practice, the state must license their facility—even if it is licensed and registered at the
national level. The licensing requirements vary from one state to another, as does the monitoring and
enforcement of licenses.
5.4 Service Quality Monitoring and Assurance
The assessment team was not able to identify any significant assessments of the quality of care in the
private sector, even with a limited focus on reproductive health. Government and donor resources have
been focused on the public sector, and the main strategies addressing quality have involved increasing
and strengthening supervision and training. Thus most of the evidence about quality in the private sector
is partial and anecdotal. Paradoxically the private sector in Nigeria seems to provide both the best and
worst quality of health care. In Lagos and other major cities, some of the private hospitals and clinics
serving the upper-income groups offer the best care in the best facilities with the most well-trained
staff in the country. The vast majority of private-sector care (and the vast majority of the out-of-pocket
expenditures), however, are spent on providers at the other end of the spectrum—TBAs, community
health workers, PMVs, traditional healers, and quack doctors.
Given the high share of deliveries attended by TBAs (20.4 percent according to the 2003 DHS),
government and policy makers cannot ignore these providers. Still there are concerns about the quality
of TBAs’ services. According to COMPASS staff that works with some TBAs in Lagos, the focus of
collaboration with TBAs is to improve their links to clinics, train them to recognize complications, and
emphasize the need for referrals. A small study of TBAs in Atakumosa, Nigeria, identified a number
of common concerns of TBAs: lack of a facility for deliveries, no recognition of at-risk pregnancies or
complications, and lack of referrals. The TBAs the assessment team interviewed who had benefited
from COMPASS training were able to cite the signs of at-risk pregnancies that should be the basis for
referrals. During the discussions, however, they also said that in traditional practice, complications call
for incantations or other more occult solutions. For traditional providers it is not customary to refer
patients to more qualified providers. This information points to another factor in the use of unskilled
providers in the private sector: an apparently large number of Nigerians do not perceive quack doctors
or traditional healers as low-quality practitioners of Western medicine, but instead view them as quality
providers of African medicine. This belief raises a broader issue about western “modern” medicine
vs. African traditional medicine that would require more research to design effective demand-creation
strategies.
Data is available in the DHS on one indicator of quality: informed choice for contraception. On this basis
private-sector providers seem to be offering lower quality services than the public sector.
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