Nigeria: Facilitating partnership agreements

Context

Nigeria has one of the world’s highest TB burdens in terms of incidence, TB-HIV co-infections, and the presence of multi-drug resistant strains. At the same time, it also has some of the lowest rates of detection and treatment. One reason for this gap is the nature of the country’s response: until recently, the national TB program was almost entirely based in the public sector, yet the private sector accounts for over 60 percent of health care services nationwide.¹⁵ By excluding the private sector, Nigeria’s TB program was forgoing the opportunity to systematically screen and identify cases among the large portion of its population that seeks care in private facilities. SHOPS Plus sought to address this gap and bring the public and private sectors together in a formal partnership to increase TB case detection and treatment in Lagos and Kano states.

Approach

Based on a successful model used in India,^{16, 17} SHOPS Plus collaborated with the national TB program and private provider associations representing doctors, nurse-midwives, pharmacists, laboratory scientists, and proprietary and patent medicine vendors to develop a public-private model in Lagos and Kano states. The approach required identifying strategies and providing incentives to motivate private providers to participate.

The large and interconnected public-private model engages a number of public and private entities, which have specific roles in strengthening the TB response:

• Private provider networks spearhead TB case detection in the private sector. The networks include proprietary and patent medicine vendors, community pharmacists, private laboratories, and clinical facilities. All types of providers engage in community mobilization and screening. They identify suspected TB cases, and collect and send testing samples to public and private laboratories. Confirmed cases are then referred to network clinical facilities for treatment. Participating facilities and laboratories charge a discounted rate for services in exchange for free TB drugs and reagents needed to test and treat patients.
• National and state TB programs provide oversight and training to align the provider networks with relevant policies and procedures. Their role includes providing access to free TB drugs, GeneXpert testing, and microscopy testing reagents in return for providers submitting routine data reports, undergoing supervision, and adhering to treatment protocols.
• Private intermediary organizations lend supervisory and practical support to private providers in the networks. They liaise with government stakeholders to support the operations of the provider networks, including giving administrative guidance, technical assistance for TB services, data and reporting, and helping to ensure the continued availability of commodities.

Setting up this model and formalizing the partnership agreement required an intensive and targeted investment in public-private dialogue throughout the process. SHOPS Plus organized a series of meetings for stakeholders to get their support and decide on roles and responsibilities. At the beginning, the project met individually with each stakeholder, including key government agencies, provider associations, and USAID/Nigeria to explain the model and get their inputs. SHOPS Plus framed and articulated a value proposition during early engagements with private sector associations and prospective network members. In particular, the community mobilization component of the model would incentivize private provider participation through increasing their visibility and raising their business profile in the community. These early engagements with private provider associations allowed the national and state TB programs to see that many providers prioritized community recognition and public health contribution over individual profits. Following these initial meetings, the project convened stakeholder roundtables to align everyone’s expectations with the proposed model. These roundtables provided participants with the opportunity to voice their concerns in a larger setting, offer suggestions for strengthening linkages and provider incentives, and flag potential implementation challenges.

Providers were happy about the fact that they would have increased [outpatient] numbers due to community mobilization. By collaborating with us [they] also gain more visibility, which is something that the private sector struggles to get from the government.

Kano State TB coordinator

Throughout this process, the project noticed a strong desire on both the public and private sides to jointly pursue national health goals. What had been missing was the facilitation to bring them together and organize this engagement. These efforts culminated in the signing of memoranda of understanding by national and state TB programs, intermediary organizations, private clinical facilities, and private standalone laboratories. The agreements outlined entities’ roles in the partnership.

Between October 2018 and April 2020, 1,914 private providers participated in the networks. Private providers in Lagos and Kano screened 2.3 million clients for TB resulting in the identification of 8,871 cases (Figure 3). In 2019, the networks contributed to 32 percent of the cases identified in Lagos and 22 percent of the cases in Kano.

A number of factors were key to the success of the engagement effort: Multiple stakeholder meetings ensured that all partners had an opportunity to help shape the public-private model. Active and continued involvement of national and state TB program managers enabled private provider access to commodities and trainings, which allowed providers to offer TB services. The effectiveness of the model in Nigeria was predicated on timely and accurate data reporting. Previously, standard processes for documenting the patient’s pathway involved up to six separate paper registers, often resulting in delays in decision making, follow-up, and care. This reporting burden presented a risk to the continued motivation and involvement of private providers and to the sustainability of the model. To streamline the reporting process and keep entities motivated, the project facilitated the development and use of a new mobile application, TB STARR (tuberculosis screening and tracking for accelerated referral and reporting). The application, which was well-received by the providers, replaced paper forms and was tailored to the reporting needs of each provider type.

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