Tuberculosis care quality in urban Nigeria: A cross-sectional study of adherence to screening and treatment initiation guidelines in multi-cadre networks of private health service providers

Abstract

Nigeria has a high burden of tuberculosis (TB) and low case detection rates. Nigeria’s large private health sector footprint represents an untapped resource for combating the disease. To examine the quality of private sector contributions to TB, the USAID-funded Sustaining Health Outcomes through the Private Sector (SHOPS) Plus program evaluated adherence to national standards for management of presumptive and confirmed TB among the clinical facilities, laboratories, pharmacies, and drug shops it trained to deliver TB services. The study used a standardized patient (SP) survey methodology to measure case management protocol adherence among 837 private and 206 public providers in urban Lagos and Kano. It examined two different scenarios: a “textbook” case of presumptive TB and a treatment initiation case where SPs presented as referred patients with confirmed TB diagnoses. Private sector results were benchmarked against public sector results. A bottleneck analysis examined protocol adherence departures at key points along the case management sequence that providers were trained to follow. Except for laboratories, few providers met the criteria for fully correct management of presumptive TB, though more than 70% of providers correctly engaged in TB screening. In the treatment initiation case 18% of clinical providers demonstrated fully correct case management. Private and public providers’ adherence was not significantly different. Bottleneck analysis revealed that the most common deviations from correct management were failure to initiate sputum collection for presumptive patients and failure to conduct sufficiently thorough treatment initiation counseling for confirmed patients. This study found the quality of private providers’ TB case management to be comparable to public providers in Nigeria, as well as to providers in other high burden countries. Findings support continued efforts to include private providers in Nigeria’s national TB program. Though most providers fell short of desired quality, the bottleneck analysis points to specific issues that TB stakeholders can feasibly address with system- and provider-level interventions.

How Do Private Providers Unaffiliated With the Nigeria National TB Program Diagnose and Treat Drug-Susceptible TB Patients? A Cross-Sectional Study

“…Lagos has the highest TB burden in Nigeria and accounts for 11% of the national population. 20 Health care in Lagos is organized at 3 levels: primary, secondary, and tertiary.…”

“…We conducted the study in Lagos State, Nigeria, which has a population of 24.6 million people in 2015 and is divided into 20 LGAs. 27 Each LGA is supervised by an LGA TB supervisor.…”

“…19 Conversely, in Nigeria, results from a standardized client model study showed that private practitioners, except pharmacies, performed better than providers in public settings in managing presumptive TB cases. 20 Although 60% of Nigerians initially sought care in the private sector when they were sick, they contributed only 11% to TB notification in 2017. 21 Also, a previous review noted that only 56% (277/406) of private not-for-profit facilities and 5% (646/13448) of private for-profit facilities have been engaged by the National TB Program (NTP) to notify TB.…”

“… 19 Conversely, in Nigeria, results from a standardized client model study showed that private practitioners, except pharmacies, performed better than providers in public settings in managing presumptive TB cases. 20 …”

Tuberculosis service disruptions and adaptations during the first year of the COVID-19 pandemic in the private health sector of two urban settings in Nigeria—A mixed methods study

“…These providers were sampled from the Sustaining Health Outcomes through the Private Sector (SHOPS Plus) Program, led by Abt Associates. As part of its program mandate, SHOPS Plus had previously formed networks of private health service providers including clinical facilities, stand-alone laboratories, community pharmacies (CPs), and medicine vendors, who are trained and systematically engaged to provide appropriate TB screening, diagnosis, and treatment practices [24]. The SHOPS Plus program activities were implemented in Kano and Lagos, two of the states with the highest TB burden and numbers of private sector providers in Nigeria, as part of efforts to scale up private sector involvement in TB.…”