Miraal Mavalvala
This blog is based on learnings from the development of the “Family Planning Service Delivery Strategy for Northern Nigeria” designed by Impact for Health International for
The Society for Family Health in Nigeria under the FCDO-funded Lafiya project.
CONTEXT
Nigeria, the most populous country in Africa, continues to battle the COVID-19 pandemic that has further crippled the healthcare system. This is not the only health related crisis on the country’s agenda: the nation simultaneously grapples with some of the poorest sexual and reproductive health outcomes in the world characterized by a low modern contraceptive prevalence rate of 13% - far below the Sub-Saharan Africa average.(1) This statistic is not a mere reflection of Nigeria’s population growth, rather a stark reminder of Nigeria’s overall health and economic development, compelling policymakers to improve the provision of family planning services.
As policymakers think of expanding task sharing policies to include the private sector for FP service delivery, a key player to focus on are Patent and Proprietary Medicine Vendors (PPMVs). PPMV refers to “a person without formal training in pharmacy who sells orthodox pharmaceutical products on a retail basis for profit".(2) These informal “drug shop owners” are often the first point of contact for communities, particularly in rural areas with limited access to formal providers. PPMVs are authorized to sell condoms, oral contraceptive pills and misoprostol and are particularly popular due to their widespread availability, extended hours, and no separate fees for consultations.(3)
CHALLENGES
So why are PPMVs not fully integrated into Nigeria’s FP service delivery system?
PPMVs remain largely unregistered and unregulated due to financial and logistical barriers to regulation
Financial and logistical barriers to regulation deter PPMVs from registering with the Pharmacists Council of Nigeria (PCN), the organization that is responsible for PPMV licensing, and the few that are registered are affected by regulatory and capacity shortfalls of the PCN.(4) A fragmented regulatory structure compounds the issue, with several agencies such as the Federal Ministry of Health and National Agency for Food and Drug Administration and Control regulating different aspects of PPMV functions. PPMVs often register with their professional association, the National Association of Patent and Proprietary Medicine Dealers (NAPPMED), which lacks the legal authority to enforce regulations.(5)
PPMVs lack access to quality-assured tools and training opportunities to enhance quality of FP services
Regulatory limitations and lack of training opportunities and quality-assured diagnostic tools affect the quality of care provided at PPMV shops. While the majority of PPMVs stock FP commodities, few receive training on FP methods creating a missed opportunity for PPMV customers to receive counselling on FP options or usage.(6) PPMVs may also provide services they aren’t legally permitted to such as injectable contraceptives as a result of regulatory shortfalls.(7)
PPMV service data has been historically excluded from the national District Health Information System (DHIS2)
The national DHIS2 platform in Nigeria allows health facilities primarily from the public sector to electronically report service statistics which informs decision-making by the Federal and State Ministries of Health. The exclusion of PPMV service data from the DHIS2 system hinders understanding of their service coverage and their inclusion in strategic planning.
RECOMMENDATIONS
IntegratE project
Increasingly, measures are being taken to enhance FP service delivery by PPMVs in recognition of their growing demand and wide coverage. Impact for Health International was brought on board by The Society for Family Health in Nigeria to design the FP Service Delivery Strategy for Northern Nigeria under the FCDO-funded Lafiya project. To provide recommendations on how best to strengthen FP service provision by PPMVs we spoke with local staff of the IntegratE project in Nigeria that seeks to increase access to contraceptives by involving the private sector especially PPMVs. Discussed below are salient features of the IntegratE project which form the basis of the recommendations.
Develop an accreditation model to train PPMVs in FP service delivery and regulate quality of services
The IntegratE project in partnership with the Pharmacy Council of Nigeria has established a regulatory system including a 3-tiered accreditation system to register and train PPMVs based on their healthcare qualifications. Trained PPMVs are supported by supervisory teams who regulate and assess the quality of care provided (including counselling) using checklists, provide feedback on performance and discuss corrective actions.
Table 1: Description of tier accreditation system
Empower PPMVs to document and report FP service data into the DHIS2 platform
To ensure PPMV service statistics are incorporated into the formal healthcare system for decision-making, IntegratE trains PPMVs to report FP service data to the Local Government Areas (LGAs) using National Health Management Information System (NHMIS) tools including registers and summary sheets. Next, PPMVs are trained to electronically report data into the DHIS2 mobile tool: FP summary reports completed by PPMVs are reviewed by the project’s M&E team on a monthly basis before being uploaded to the DHIS2 platform.
Provide continuous mentorship to PPMVs to assure data quality and verification
To ensure that reported FP data are reliable and of high quality, the project’s M&E team conduct quarterly review meetings to assess the data for completeness and accuracy.(7) Data reported into DHIS2 is validated against paper-based reporting forms and data verification exercises are conducted with randomly selected providers who receive an action plan to improve data quality after each visit. PPMVs are also provided with continuous support and mentorship via WhatsApp, the use of which allows for continual provision of remote support for data documentation in real-time.
The IntegratE project has been piloted in the Nigerian states of Lagos and Kaduna – quality of care assessments revealed that over three-quarters of women received medium-high quality of FP care from IntegratE-trained PPMVs with women receiving a range of information about method selection, possible side effects and how to manage them. (8)
References
[1] The Global Financing Facility. 2017. Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition 2017-2030 Investment Case.
[2] Brieger WR, Osamor PE, Salami KK, Oladepo O, Otusanya SA. Interactions between patent medicine vendors and customers in urban and rural Nigeria. Health Policy Plan. 2004; 19: 177–182.
[3] Brugha R, Zwi A (2002) “Improving the quality of private sector delivering of public health services: challenges and strategies.” Health Policy Plan, 13:103-120.
[4] Barnes J, Chandani T, Feeley R. Nigeria private sector health assessment. Bethesda, MD: Private Sector Partnerships-One project, Abt Associates Inc.; 2008.
[5] Liu, J., et al. "The landscape of patent and proprietary medicine vendors in 16 states of Nigeria." Abuja, Nigeria: Society for Family Health (2015).
[6] Herbert LE, Schwandt HM, Boulay M, Skinner J. Family planning providers’ perspectives on family planning service delivery in Ibadan and Kaduna, Nigeria: A qualitative study. J Fam Plann Reprod Health Care. 2013;39: 29–35. doi:10.1136/ jfprhc-2011-100244
[7] The Population Council. 2020. Improving data reporting to NHMIS from the private sector in Nigeria: Lessons from a DHIS2 pilot with Community Pharmacists and Patent and Proprietary Medicine Vendors.
[8] Population Council. 2020. Quality of care received for family planning from Community Pharmacists and Patent and Proprietary Medicine Vendors in Lagos and Kaduna, Nigeria: The IntegratE project