The private sector plays a major role in reducing inequities in access to health, with over 54% of the private sector outlets providing modern contraceptives in Nigeria. Patent proprietary medicine vendors (PPMVs) and Community Pharmacists (CPs) make up an essential part of the primary health care provision in Nigeria. They are a primary source of healthcare in the communities where they serve, especially for the purchase of medicines including contraceptives and they account for about 71% of modern contraceptive service delivery in Nigeria.
According to the United Nations Population Fund, Nigeria has not made significant progress in achieving universal access to sexual and reproductive health, therefore, improving the quality of services available from these providers is crucial to improving health status in Nigeria.
IntegratE -- Increasing access to contraceptives
Championed by the Pharmacy Council of Nigeria (PCN), and in collaboration with the federal and state ministries of health, the IntegratE project is being implemented by a consortium led by the Society for Family Health (SFH). In its first phase, the project was aimed at increasing access to modern contraceptives through the private sector, particularly CPs and PPMVs in the delivery of family planning services. The PCN established a regulatory system to enable PPMVs to provide quality family planning services through the three-tiered accreditation system and report service statistics to the Health Management Information System (HMIS). The project is supported through the PCN Act 2022 to regulate and control pharmacy education, training and practice in all aspects, including regulating service provision by PPMVs.
The project was piloted in Lagos and Kaduna State and further scaled up to Bauchi, Borno, Enugu, Gombe, Kano, Nasarawa, Niger, Sokoto and Yobe states. The scaled up IntegratE project is piloting new approaches to testing, integrating and increasing the provision of quality family planning and selected primary healthcare (PHC) services (such as providing the minimum package of healthcare for pneumonia, diarrhea, malaria, nutrition and tuberculosis based on the National Standard Treatment Guideline).
With regulatory support and access to training during the pilot IntegratE project, PPMVs gained adequate knowledge and the motivation to deliver quality healthcare services. Thus far, the PPMVs in the pilot states have shown acceptability of and willingness to pay for the PCN accreditation program; however, willingness to be accredited was directly linked to the perceived benefits of the accreditation programme which included increased client inflow and revenue as well as improved access to quality medicines and business management skills. While the increased revenue for the PPMVs can motivate continued renewal of the license, there is need to explore other incentives (financial and non-financial) to ensure sustainability in line with the World Health Organization's (WHO) global recommendations and guidelines for Task Shifting (Recommendation 13).
PACS: Expanding and sustaining the wins from IntegratE
Promoting Accreditation for Community Health Service (PACS) seeks to build on lessons and gains from the IntegratE project to improve adherence of community pharmacists and PPMVs to PCN's accreditation and licensing guidelines. PACS aims to implement prioritised incentive options and ultimately increase the quality and quantity of family planning and PHC services delivered by PPMVs. The project is implemented by a coalition of SFH and Solina Center for International Development and Research (SCIDaR), with funding from MSD for Mothers.
To build a strong value proposition for PPMVs to join and adhere to the three-tiered accreditation programme in Nigeria, SCIDaR assessed PPMVs in seven states through in-depth desk review, qualitative interviews, quantitative survey, and an ideation workshop.
Findings from the assessment showed that majority of PPMVs identified access to loans or grants; capacity building; certification, licensing and branding; and access to quality commodities as their most preferred incentive options to join or continue in the accreditation program. Findings showed that access to loans and grants as well as PCN licensing and branding will serve as incentives and motivate most of them to enroll and remain in the programme.
Maintaining quality service delivery rendered by PPMVs.
As part of efforts to institutionalise sustainable incentives for the PPMVs, the PACS project convened multisectoral stakeholders (including the Federal Ministry of Health, Pharmacy Council of Nigeria, National Agency for Food and Drug Administration and Control (NAFDAC), National Collateral Registry, financial institutions and other stakeholders to deliberate on the feasibility for implementing the incentives for the PPMVs.
In his presentation at the project's official launch on the assessment of PPMVs in seven states, Efosa Omoregie, the Programme Manager on the SCIDaR side said "Almost 60% of them (PPMVs) mentioned they wanted access to loans. If they had access to loans and grants, they would stay on the 3-tier accreditation program as they, in addition to solving the healthcare problem, want to grow their business and expand." He highlighted that the recommendations from the assessment informed three proposed incentives for the PPMVs -- access to grants, access to quality commodities, and licensing and branding.
Following in-depth deliberations, stakeholders in the financial institutions resolved that the PPMVs coming to them as a group and a registered entity with the Corporate Affairs Commission of Nigeria (CAC) will make it easier for the PPMVs to access loans as they will be able to stand in as guarantors for each other in the absence of immoveable assets.
To ensure accredited PPMVs receive quality medicines as stock, PACS will deploy a two-legged approach -- utilising technology to deliver quality medicines to their doorstep and post-marketing surveillance mechanisms as means of verification. While describing this intervention, Pharmacist Sebastine Ikejide, from SFH said, "PACS will employ technology-enabled inventory management approach that guarantees sourcing of medicines from a quality assured source". PACS will engage vendors who will conduct post-marketing surveillance on the medicines provided to customers to ensure quality compliance".
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The PCN will continue to play the regulatory role and is committed to improving the quality of services from pharmacies and patent medicine stores as part of its mandate and has encouraged the financial institutions to open up access to credit facilities for the CPs and PPMVs that are licensed for this project implementation. The PCN will also be leveraging the PACS project to field-test and roll out approved branding for PPMVs licensed under the three-tiered accreditation programme.
Leveraging the services of trained PPMVs will increase access to quality healthcare in hard-to-reach communities, from family planning to selected primary healthcare services through the three-tiered accreditation programme. However, there is a need to ensure that the PPMVs remain accredited to continue to provide quality services. Provision of financial and non-financial incentives to the PPMVs, like access to finance and branding, will help to keep them engaged.
"This publication is supported by funding from MSD, through its MSD for Mothers initiative and is the sole responsibility of the author. MSD for Mothers is an initiative of Merck & Co., Inc., Kenilworth, NJ, U.S.A."
