Map of Nigeria showing coverage of DR-TB Services as at November 2015.

Map of Nigeria showing coverage of DR-TB Services as at November 2015.</p

Description of basic characteristics of study and excluded population.

Description of basic characteristics of study and excluded population.</p

Flow diagram of study recruitment strategy.

Flow diagram of study recruitment strategy.</p

Time-to-treatment initiation in the Geopolitical zones, adjusted for sex, age and urban/rural.

Time-to-treatment initiation in the Geopolitical zones, adjusted for sex, age and urban/rural.</p

National and regional characteristics and predictors of treatment within 30 days amongst DR-TB diagnosed patients in 2015.

National and regional characteristics and predictors of treatment within 30 days amongst DR-TB diagnosed patients in 2015.</p

National and regional characteristics and predictors of treatment initiation amongst 996 DR-TB patients diagnosed in 2015.

National and regional characteristics and predictors of treatment initiation amongst 996 DR-TB patients diagnosed in 2015.</p

(a) Short- term disruptions due to COVID-19 reported by private clinics in Kano and Lagos; (b) Long-term disruptions due to COVID-19 reported by private clinics in Kano and Lagos.

(a) Short- term disruptions due to COVID-19 reported by private clinics in Kano and Lagos; (b) Long-term disruptions due to COVID-19 reported by private clinics in Kano and Lagos.</p

Service disruptions due to COVID-19.

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.</div

Facility closures due to COVID-19, 2020–2021.

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.</div

Sampling frame and survey response.

Constructing the enumeration lists for the COVET Facility Survey in Nigeria frame was a multi-step process conducted using data collected through September 2020. Eligible facilities were operational and had known location information. SHOPS Plus network facilities were identified using the SHOPS Plus monthly program monitoring dataset containing service delivery data submitted by network facilities between 2018 and September 2020. There were 2,405 unique facilities that had ever reported data as a SHOPS Plus network member. Of those, 275 facilities were determined by SHOPS Plus program staff to be closed or unknown operational status as of September 2020 and were excluded from the study. We were unable to determine what proportion of these closed as a result of COVID-19 or other reasons. 234 facilities had no location information available and were considered ineligible for this study, leaving 1,896 SHOPS Plus network facilities included in the sampling frame. An additional 1,007 non-network heath facilities were included in the enumeration list, identified from a dataset of facilities that were assessed in 2018 to gauge interest and suitability to participate in a SHOPS Plus program network. Facility names from this database were cross-referenced with the list of unique SHOPS Plus network facilities. Any facilities in the 2018 Assessment dataset that did not have a match on name in the SHOPS program data list were assumed to be eligible for this study as non-network facilities. Data collectors tried to increase overall percent of target achievement by attempting to survey additional SHOPS Plus or non-network facilities that did not make it on to the original enumeration list (i.e., because these facilities lacked minimal contact/location information), but because so little information was available for these facilities these back-up lists yielded very few additional successful interviews. Twenty-three additional facilities (15 in Kano, 8 in Lagos) of unknown network status are included in the total. (TIF)</p