Background
Methods
Study design and area
Study participants
Stakeholder category | No. of participants |
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1. State Policy and decision makers • State Primary Health Care Development Agency (Executive Secretary) • State Ministry of Health ◦ Permanent secretary ◦ Department of Pharmacy ◦ Department of Medical Services (providers licensing officer/desk) • State Health Insurance Agency (Executive Secretary) | 10 |
2. State programme managers • Malaria or RMNCAH or HIV/TB or NCDs | 2 |
3. Local government health authority (Enugu East, Enugu North, Enugu South, Onitsha North, Onitsha South LGAs): PHC coordinator (HOD of health) | 5 |
4. Regulatory bodies with chapters in Anambra & Enugu States • Pharmaceutical Council of Nigeria • Nursing and Midwifery council • Community Health Practitioners’ Council • Traditional Medicine Board | 8 |
5. Informal health service providers • State Chairman NAPPMED • Coordinator of PMVS or director (MD) of most popular PMV in each slum area • State Chairman Traditional Healers/medicine practitioners • Chairperson Traditional Birth Attendants • Chairperson Bone setter’s association | 10 |
6. Formal health service providers (in Abakpa and Okpoko) • OIC of most popular PHC in the slum area • Medical director of most popular Community pharmacy in the slum area • National Medical Association • National Association of Nurses and Midwives | 4 |
7. Professional associations • National Medical Association • National Association of Nurses and Midwives | 4 |
Total | 43 |
Data collection
Data analysis
Results
Existing linkages between the formal health system and informal healthcare providers
“It is imperative for State Ministry of Health policymakers to understand that this people [informal providers] play a very important role, and that for us to succeed in getting our health indices in the right direction, there must be a linkage between these two sectors” (State policy maker, Anambra).
Types of linkages | Identified by formal sector respondents | Identified by informal sector respondents |
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Registration of informal service providers and standardization of practice by the formal health system (including enlisting of traditional medicine unit into the State Ministry of Health) | 6 + | 1 + |
Training of informal service providers by stakeholders in the formal health system | 6 + | 1 + |
Referral of clients from informal service providers to formal service providers | 6 + | 1 + |
Data reporting on specific programs from informal service providers to the formal health system | 6 + | 1 + |
Provision of free commodities such as insecticide-treated bed nets, to informal service providers | 6 + | 0 |
Stakeholders’ willingness to institutionalize existing (and potential) linkages between the formal health system and IHPs
Perspectives of respondents in the formal health sector
“Some of the linkages have been found beneficial – for instance TBA’s participation in the HIV case identification and referrals and PMV’s participation in Malaria diagnosis and treatment. They could be easily trained in referrals as the people believe more in them than formal health providers (State programme manager, Enugu)“These informal providers are reachable and accessible to the wider community already, so integration will help fill the gap of health care access issues” (State policy maker, Enugu).
“Very willing! Our people are patronizing them (traditional medicine dealers) and there is no guideline for controlling their activities. In fact, it is better to institutionalize linkages so that our people will have quality care” (Regulatory agency, Anambra).
“In China, both the orthodox and un-orthodox medicine are well recognized, and they work hand-in-hand. Their acupuncture and local herbs are still used, and they work till date” (State Policy maker, Enugu).“I think the formal sector is willing because nobody can deny the fact that our people are patronizing the informal providers. The government can help by making policies and giving it a legal bite” (State Policy maker, Anambra).
“No institution in the world has recognized Traditional Birth Attendants, so Nigeria should not be the first. So, they shouldn’t be used as alternatives in any place” (State policy maker, Enugu).“Quality is the underlined word, at an affordable rate but the functional words are, access, quality, affordability. PMVs cannot give all of these to patients, especially quality” (State policy maker, Anambra).“For now, I’m not willing to have close institutional links with the informal providers. What will improve provision of appropriate health services is employing more health workers in the PHCs and motivating them. If the government does that, people will start patronizing PHCs instead of informal providers” (Formal health service provider, Anambra).
Perspectives of respondents in the informal health sector
“We are willing to have close institutionalized links with the State Ministry of Health. We believe that will give us more opportunity to showcase our products. We want to be recognized by the government so that people can boldly use us as an alternative to hospitals” (Informal health service provider, Anambra).“That is what we are praying for. We are willing to have close links with the Ministry of Health. However, we don’t want to work with the formal providers. We want every group to have the opportunity to present what they have. Government should build treatment centres for us, employ us and supervise our activities” (Informal health service provider, Anambra).
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Loss of clientele: informal providers do not want anything that will make them lose their clients or threaten their practice.
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Increased taxation: they fear that they will be taxed more in the course of institutionalizing these linkages, complaining that they do not make much money as it stands
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Disparagement by formal health system: informal providers fear that they will be addressed as ‘quacks’ by formal service providers
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Limitation of practice: they also fear that their scope of work may be forcefully limited.
Proposed strategies for institutionalizing linkages between formal and informal providers
Proposed strategies | Identified by formal sector respondents | Identified by informal sector respondents |
---|---|---|
Advocacy to policymakers and gatekeepers | Seminars and sensitization workshops on integration, continuous stakeholders’ engagement | Open discussions on integration to ensure transparency |
Mapping of informal providers in urban slum areas | Formalization of linkages with informal service providers involves obtaining information on who informal providers are, where and how they are operating | Mapping and categorization of informal providers in urban slums (e.g. PMVs, TBAs, TMPs, Bone setters, etc.) to help regulate their practices and control profusion of quacks questionable remedies. |
Registration and accreditation | Creation of a legitimate association whose functions includes registration, renewal of licenses and accreditation | Creation of a legitimate board whose functions includes registration, renewal, accreditation, and discipline of defaulters |
Training and certification | Training of informal providers on preventive care, data collection and client referrals. Encouraged certified training programmes for informal service providers | Training and re-training of informal service providers on rapid diagnostic tests, drug resistance, midwifery, early warning signs and emergency care, record keeping and infection prevention. Training should be based on curriculum and certified for only registered members |
Engagement in service delivery | Involving the informal providers in curative care in very remote areas where there are no functional primary health centers. Standard referral protocols are encouraged | Advocates for more official recognition and support as contributors to health service delivery. (e.g. creation of unit in the Ministry of Health to coordinate and provide link with Informal sector, formal employment as a cadre of health workers in public service, a government-sponsored hospital complex for informal health providers) |
Monitoring and supportive supervision | Activities of informal providers should be properly monitored and supervised by the Ministry of Health and other relevant agencies | Expressed preference for supportive supervision devoid of criticisms, condemnation or disparagement by Ministry of Health and relevant agencies |
Platforms for communication | Monthly/quarterly meetings to facilitate referrals from informal providers to the formal providers. Monthly meetings were encouraged | Establish communication and open discussion channels between the formal and informal sectors for knowledge and idea sharing |
Advocacy to policymakers and gatekeepers
“Seminars and sensitization workshops on the importance of integration of formal and informal health providers” (Regulatory agency, Enugu)“Continuous stakeholder engagement on linkages and support (empowerment) issues to ease grey areas” (State policy maker, Enugu).)
“Here, a forum for discussion of the agenda for integration will be created, so that everybody will understand the plan and see that there are no hidden agenda” (Informal health service provider, Enugu)
Mapping of all informal providers in urban slums
“First, locate them and know exactly what they are doing” (Formal health service provider, Anambra).
Registration and periodic accreditation of informal healthcare providers by a recognized board
Training and certification of informal health providers
“Enforce certificate courses for registered Informal health providers through accredited health schools” (State policy maker, Enugu)“[informal providers should] Receive regular certified training schemes and retraining of their members by the formal health workers to upgrade their capacity to identify early warning signs for referral (Informal health service provider, Enugu).
“Government can create a framework for training […] to ensure the informal providers do not go beyond their scope. For instance, PMVs should only sell over the counter drugs” (Professional association, Anambra)“Trainings [should be] guided by a training manual to help informal providers in areas of health sensitization, referral and reporting of community incidence” (State policy maker, Enugu)
“The certificates are very important to them [informal providers] as they exhibit it in their treatment rooms with the belief that it increases their client’s trust in them and attracts more clients as well”. (State policy maker, Enugu).
Engaging informal healthcare providers in service delivery
Monitoring and supportive supervision
Regulation to curb quackery in health care is very important. There are some registered hospitals that are not owned and managed by a doctor. The government should fight quackery. There is no funding for effective supervision and monitoring. So many things need to be corrected in the formal sector as it is now and informal sector before we can think of integration (State policy maker, Enugu)
Establish platforms for communication
“Creating a forum where the formal and informal health providers can meet and discuss cordially as was done during the PATHS 2 project” (Informal health service provider, Anambra)“There should be regular monthly/quarterly meetings involving their representatives of the informal health providers to deliberate on any emerging issues and ensure adherence to policies and laws are strictly done”. (State policy maker, Anambra)
Proposed stakeholders and their contributions to institutionalizing linkages between the formal health system and informal healthcare providers
Stakeholders | Roles proposed by formal sector respondents | Roles proposed by informal sector respondents |
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Federal government | - | Soft loans to TMP to produce their products in large quantities for exportation. Send federal agencies to support them with trainings on product preservation and exportation processes |
State government | Build training schools for traditional medicine | Build training schools for traditional medicine. Organize fairs for TMPs to showcase their products. Integrate informal providers’ services Provide ambulance at strategic locations to enhance referral especially in urban slums and rural communities |
Local government | Establish an agency/desk to monitor and supervise informal service providers | |
Ministry of Health and SPHCDA | Establish an agency/division to coordinate trainings, supervision and regulation of informal providers Registration and accreditation of informal providers and enforcement of standards of operation | Registration and accreditation of informal providers and enforcement of standards of operation Advocacy and sensitization on need for linkage between formal health system and informal providers |
SPHCDA | - | Administration and evaluation of capacity building and possible funding |
Pharmaceutical Council of Nigeria | Regulation of practice of PMVs, including development and enforcement of standards of operation and other guidelines Standardizing and regulating locally produced drugs and herbs | Regulation of practice of PMVs, including development and enforcement of standards of operation and other guidelines |
Medical and Dental Council of Nigeria | Training on best practices in preventive care for all informal providers | - |
Nursing and Midwifery Council of Nigeria | Training TBAs on best practices including cord care, sterilization of delivery and circumcision instruments, recognition of danger/warning signs, prompt referral Regulation of the practice of TBAs | |
Association of General Private Medical Practitioners of Nigeria | - | Support integration efforts |
Health development partners | - | Funding support – to implement proposed interventions Technical support – training of service providers |
NGOs and CSOs | - | Engender community participation. Sensitization and advocacy |
Health officers | - | Engender community participation |
Informal health service providers | Prompt referral of cases to formal health services Adherence to recommended guidelines Mobilization of members to comply with registrations and accreditations |