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

Abstract

Nigeria has the second largest share of undiagnosed TB cases in the world and a large private health sector estimated to be the point of initial care-seeking for 67% of TB patients. There is evidence that COVID-19 restrictions disrupted private healthcare provision, but insufficient data on how private healthcare provision changed as a result of the pandemic. We conducted qualitative interviews and a survey to assess the impact of the pandemic, and government response on private healthcare provision, and the disruptions providers experienced, particularly for TB services. Using mixed methods, we targeted policymakers, and a network of clinical facilities, laboratories, community pharmacies, and medicine vendors in Kano and Lagos, Nigeria. We interviewed 11 policymakers, surveyed participants in 2,412 private facilities. Most (n = 1,676, 70%) facilities remained open during the initial lockdown period, and most (n = 1,667, 69%) offered TB screening. TB notifications dipped during the lockdown periods but quickly recovered. Clinical facilities reported disruptions in availability of medical supplies, staff, required renovations, patient volume and income. Few private providers (n = 119, 11% in Kano; n = 323, 25% in Lagos) offered any COVID-19 screening up to the time of the survey, as these were only available in designated facilities. These findings aligned with the interviews as policymakers reported a gradual return to pre-COVID services after initial disruptions and diversion of resources to the pandemic response. Our results show that COVID-19 and control measures had a temporary impact on private sector TB care. Although some facilities saw decreases in TB notifications, private facilities continued to provide care for individuals with TB who otherwise might have been unable to seek care in the public sector. Our findings highlight resilience in the private sector as they recovered fairly quickly from pandemic-related disruptions, and the important role private providers can play in supporting TB control efforts.

Individual journeys to tuberculosis care in Nigeria’s private sector during the COVID-19 pandemic

“…This study was part of a larger research project in three high-burden countries. We previously published the timelines of the COVID-19 epi curve, TB notifications and the timing of our data collection in Nigeria 20. Our study took place among individuals seeking TB care in 18 private facilities in Kano and Lagos, the states with the highest TB burden and levels of private sector activity,15 and with estimated population of 14.7 million and 13 million, respectively, in 2021 42.…”

“…Nigeria recorded 88 388 confirmed cases of COVID-19 in 2020, with over 2 66 000 cases as of December 2022 16. During the initial lockdowns in March–April 2020, there were several reports indicating significant disruptions to TB services 17–20. Nigeria and other high-burden TB countries reported delays in care-seeking for respiratory symptoms due to fear of COVID-19 diagnosis 19 21–24.…”

“…Nigeria and other high-burden TB countries reported delays in care-seeking for respiratory symptoms due to fear of COVID-19 diagnosis 19 21–24. However, TB case-finding began to rebound in June 2020 and by the second wave in December 2020 to March 2021, TB notifications had fully recovered to pre-pandemic levels 20. This made Nigeria an outlier for pandemic recovery among other high-burden TB countries 1.…”

Public-Private Sector Mix Approach to Achieving Effective, Efficient and Value-Added TB Programming in Nigeria: Lessons Learned

“…Nigeria was among the very few countries that recorded an increase in TB notifications in 2020 at the height of the COVID-19 pandemic, the attendant lockdown and other measures introduced to combat the pandemic [ 5 ]. These affected all spheres of human endeavour, including health services.…”

Private sector tuberculosis care quality during the COVID-19 pandemic: A repeated cross-sectional standardized patients study of adherence to national TB guidelines in urban Nigeria

“…Additionally, the overlap in symptoms between COVID-19 and TB could be hypothesized to increase misdiagnosis of TB cases as COVID-19 cases or vice-versa (24,25). As part of a multi-country research effort to examine how COVID-19 has affected the delivery of private sector TB services in high-burden countries (26)(27)(28)(29), this study explored whether private providers' practices are in alignment with national standards for TB screening in Nigeria, how these practices have changed following the onset of the COVID-19 pandemic, and what factors are associated with providers that deliver clinically correct TB screening services.…”