Building on the preceding Human Resources for Health (Chankova et al. 2006) and ART Costing (Kombe et al. 2004) assessments, the Nigeria HIV/AIDS Service Provision Assessment provides evidence-based results on the infrastructure, type of services, and logistics required to support HIV/AIDS service delivery scale-up.
HIV/AIDS continues to pose major challenges to the socioeconomic development of Nigeria. As of 2006, 2.9 million Nigerians from age 0-49 are living with HIV, and AIDS deaths have taken 220,000 lives. The government in collaboration with development partners has made tremendous progress in expanding services across the country. Much more work is needed to make sure that country has the capacity to expand and sustain services over time. Policy makers and program planners need empirical evidence on the availability of HIV/AIDS-related services in both public and private health facilities in order to effectively and efficiently increase access to care and treatment. Building on the preceding Human Resources for Health (Chankova et al. 2006) and ART Costing (Kombe et al. 2004) assessments, the Nigeria HIV/AIDS Service Provision Assessment provides evidence-based results on the infrastructure, type of services, and logistics required to support HIV/AIDS service delivery scale-up.
The objectives of the assessment were to:
• Measure the extent to which basic and advanced HIV/AIDS services are available in public and faith based facilities
• Examine facilities’ ability to provide auxiliary services
• Assess the quality of care being provided by facilities through infection control, training, reporting, and protocols
• Review facility management and administration practices
A representative national sample of 200 public and 100 faith-based facilities was selected for the survey. In January 2008, interviews following a structured questionnaire format were completed at 280 public and private faith-based facilities in all 36 states and the FCT. Data were collected on the availability of basic and advanced HIV/AIDS prevention, treatment, and care and support services, as well as laboratory and pharmacy support, staff training, and management and quality assurance practices. For almost all the key indicators analyzed, there are substantial disparities in service provision according to the level of facility, managing authority, and location. Higher-level and federally-managed facilities are the most likely to provide key services, while service provision at the primary level, in rural areas, and in LGA-managed facilities is substantially lower. Service availability at Faith-Based Organization-managed facilities matches (or slightly exceeds) that at LGA-managed facilities, but is frequently weaker than service availability at state-managed and federally-managed facilities.
The assessment examined HIV/AIDS services and HIV/AIDS related services including Counseling and Testing (CT), Prevention of Mother-to-Child Transmission (PMTCT) services, Antiretroviral Therapy (ART), Tuberculosis (TB) services, and Post-Exposure Prophylaxis (PEP) services. The study found that 77% of facilities offer HIV counseling and testing. Less than two-fifths of all facilities offer PMTCT services (39%), while less than one in six offer ART services (16%). A little under half of the facilities surveyed provide TB diagnosis and/or treatment (48%). Of significant concern is the limited availability of post-exposure prophylaxis for health workers (20%).
The availability of appropriate drugs and laboratory services is critical for the success ART programs. Despite providing the bulk of ART services, most secondary facilities (81%) did not have essential first line ARV drugs (such as AZT, EFV, 3TC, NVP, and D4T) in stock on the day of the survey. Similarly, less than one-third of all pharmacies had the first-line tuberculosis drugs – ethambutol, isoniazid, pyrazinamide, or rifampin – in stock on the day of the interview. The assessment found that approximately two-thirds of health facilities have laboratories; however, few have the capacity to measure CD4 counts (20%), viral load (2%), or conduct liver function tests (28%), and only 28% of laboratories have the necessary supplies and equipment to analyze sputum smears for diagnosis of tuberculosis.
Training on HIV counseling, testing, confidentiality practices, and prevention is available in more than half of all facilities. However, only 39% of facilities provide training on post-exposure prophylaxis. Half or fewer of all facilities have national protocols or guidelines for ART, PMTCT, and VCT available. Between 18% and 24% of facilities charge user fees for PMTCT, ART, or VCT services despite national policies that mandate free provision of these services.
The Nigeria HIV/AIDS SPA report identifies 10 conclusions based on the assessment findings. An important positive conclusion is that CT services are widely available across Nigeria; 77% of facilities sampled provided CT. However, this is not matched by secondary prevention and treatment services like PMTCT services, ART, and TB services that support individuals who have tested positive for HIV. Only 39%, 16%, and 48% of all facilities provide PMTCT, ART, and TB services, respectively.
Second, there is a great deal of heterogeneity in service availability by level, management and location of facilities. Primary-level facilities are consistently less likely to provide CT, PMTCT, ART, TB, or PEP services than secondary or tertiary facilities. This heterogeneity is also mirrored in differences by managing authority, since most primary care facilities are LGA-managed. Rural facilities also have lower service availability than urban facilities. In particular, rural facilities are 75% less likely to provide ART and half as likely to provide PMTCT as urban facilities- this is a concern since most of the Nigerian population lives in rural areas.
Third, HIV/AIDS-related service availability at Faith-Based Organization (FBO)-managed facilities slightly exceeds that at LGA-managed facilities, but is usually weaker than service availability at state-managed and federally-managed facilities. This suggests both opportunities and challenges with expanding the role of FBO-managed facilities in HIV/AIDS service delivery through public-private partnerships.
Fourth, PEP services are available in only 20% of all facilities, with especially low availability in primary level, LGA-managed, and rural facilities. Staff training on PEP is provided in almost two-fifths of facilities, but this training is not translated into PEP service availability.
Fifth, limited laboratory capacity is a critical concern in primary-level, LGA-managed and rural facilities. Among facilities that provide laboratory services, only small proportions have the equipment and supplies to perform critical tests like CD4, viral load and liver function tests. Close to three-fourths of FBO-managed facilities have laboratories, which suggests potential for public-private partnerships to expand laboratory services at lower levels of the health system.
Sixth, the availability of HIV drugs (in terms of stocks on the day of the survey) is very low, especially at primary care and LGA-managed facilities. Tertiary care facilities had widespread availability of first line ARV drugs: lamivudine, nevirapine, zidovudine, efavirenz and stavudine. However, fewer than half of all
tertiary facilities had second line drugs in stock.
Seventh, less than one-third of surveyed facilities with pharmacies had each of the key TB drugs in stock on the day of the interview. This is of great concern given increasing TB prevalence rates and HIV/TB co-infections. For diagnosis of TB, most facilities use sputum smears alone or sputum smears in combination with X-rays, although 4% of facilities that provide TB services rely only on X-rays or clinical symptoms for diagnosis.
Eighth, counseling HIV-positive mothers on infant feeding and provision of breast milk substitutes is limited at primary care facilities. As well, at the primary level there is a substantial gap between provision of ARV prophylaxis to mothers (36%) and newborns (10%) indicating an important missed opportunity for prevention.
Ninth, quality assurance, monitoring and evaluation (M&E), and surveillance are areas that require attention. A very limited proportion of facilities implement routine quality assurance activities. This is a problem in all types of facilities except federally-managed and tertiary care facilities. The limited availability of HIV/AIDS or TB protocols in facilities is potentially also indicative of the problem, as is the small proportion of facilities that provide training on monitoring and surveillance.
Tenth, user fees are charged at three-quarters of all facilities in Nigeria, though more than half of facilities that charge fees report providing exemptions to some groups. Despite a national policy that CT, ART, and PMTCT services should be provided free of charge, 18 to 24% of all facilities charge user fees for these services.
Key recommendations that emerge include the following:
1. Expand the provision of ART, PMTCT, and TB services, especially in primary-level and LGA managedfacilities that are more accessible to rural populations.
2. Ensure that PEP services are available in all facilities to protect health workers from the risk of occupational exposure.
3. Ensure the consistent availability of HIV/AIDS and TB drugs at health facilities.
4. Institutionalize quality assurance programs and M&E at health facilities, especially at secondary and primary-level facilities.
5. Explore public-private partnerships with FBOs to expand service availability to underserved populations.
6. Increase access to laboratory services, especially at the primary level.
7. Expand access to ARV prophylaxis for newborns and pregnant women, especially at the primary level and through outreach-based methods.
Kind of Data
Sample survey data [ssd]
Unit of Analysis
Public and Faith Based Facilities
The assessment examined HIV/AIDS services and HIV/AIDS related services including
- Counseling and Testing (CT)
- Prevention of Mother-to-Child Transmission (PMTCT) services
- Antiretroviral Therapy (ART),
- Tuberculosis (TB) services
- Post-Exposure Prophylaxis (PEP) services
The target population for this survey was all public and faith-based health facilities in Nigeria.
Producers and sponsors
Health Systems 20/20 Project
U.S. Agency for International Development
Federal Ministry of Health
Federal Government of Nigeria
National Agency for the Control of AIDS
Federal Government of Nigeria
President's Emergency Plan for AIDS Relief
U.S. Agency for International Development
The Federal Ministry of Health (FMOH) provided a list of all public and faith-based health establishments in each state, which was used as the sampling frame. There were 773 public facilities and 496 faith-based facilities on this list. No sampling frame was available for private for-profit sector health facilities. It was decided not to include private commercial facilities in this survey since no clear documentation of their numbers and location exists.The target sample size was 300 facilities, allocated between public (n=200) and faith-based (n=100) facilities. This allocation slightly overrepresented the proportion of public facilities in the population. All teaching hospitals, military hospitals, specialist hospitals, and federal medical centers that were listed on the sampling frame (N=83) were included with certainty in the sample of public facilities, in view of the importance and volume of work at these hospitals. The remaining 690 public sector facilities in the sampling frame were sorted by region, state, and type of facility. An equal probability systematic sample of 117 public facilities was selected using a fractional sampling interval of 690/117 = 5.897. This selection method ensured proportional representation of regions and types of facilities. Next, the sampling frame of 496 faith-based facilities was sorted by region and then state. An equal probability systematic sample of 100 facilities was selected with a sampling interval of 496/100 = 4.96. Again, this method ensured proportional representation for regions and states in the sample. The target sample size was selected to provide estimates of important survey characteristics with a margin of error of plus or minus 6 percentage points at the 95 percent confidence level under simple random sampling. The precision of estimates may be slightly higher than for a simple random sample because of the certain selection of some public facilities and the use of region and state as stratification variables.
Of the 300 facilities in the original sampling plan, interviews were conducted at 292 health facilities. Access was denied at three facilities, two facilities were found to be duplicates, two facilities did not exist, and one was no longer operational. Of the 292 facilities where interviews were initiated, 12 did not provide any responses to the main questionnaire; these facilities were dropped from the analysis. The final analytic sample size was 280 facilities, representing a response rate of 95% (280/295).
Dates of Data Collection
Data Collection Mode
Sixty interviewers (40 data collectors and 20 supervisors) implemented the national roll-out of the survey. Health Systems 20/20 staff conducted a three-day training for the data collectors in mid-January 2008. They provided an in-depth overview of the survey protocol, training on interviewing techniques, and practice opportunities. In addition, the 20 supervisors were trained in the use of geographic positioning system (GPS) and digital cameras.
Data Collection Notes
The Health Systems 20/20 team adapted previous SPA data collection instruments developed by ORC Macro, as well as the Côte d’Ivoire SPA protocol developed by Health Systems 20/20 (Kombe et al.2007), in drafting the Nigeria SPA questionnaire. The protocol was carefully tailored to the Nigerian context, thoroughly updated and reviewed by Health Systems 20/20 experts, and approved by representatives of FMOH/NASCP and NACA. It was pilot tested in collaboration with NACA, NASCP, and AHP in November 2007 at three sites in the capital: the National Hospital Abuja, the General Hospital Kubwa, and the Daughters of Abraham Catholic Hospital Kubwa.
Data collection took place in all 36 states and the Federal Capital Territory (FCT) between January 20 and February 1, 2008.
In each health facility, an initial screening questionnaire was used to determine the general types of services provided and identify the relevant sections of the questionnaire. Thereafter, each section of the instrument was administered to the health worker most familiar with the type of service being discussed. Most questions were close-ended as this allowed more flexibility for analysis and comparisons between regions and facility types. Open-ended questions were used for data related to numbers of patients at a facility and the costs associated with various facility services.
The data entry tool was developed using CSPro software version 3.2 (U.S. Bureau of the Census n.d.). Health Systems 20/20 trained eight data entry clerks to use the database. Data entry was conducted over the course of 8 days, after which the data were cleaned and checked. Health Systems 20/20 staff on site oversaw the data entry and cleaning process to ensure a high standard of quality.
Data analysis was completed using SPSS version 13. Simple tabulations were used to explore the data and identify any variables that needed further cleaning. Two-way cross-tabulations were produced for each analytic outcome variable, using the facility level, managing authority, region, and urban/rural
location as key predictor variables.
Health Systems 20/20 Project
Health Systems 20/20 Project
Use of the dataset must be acknowledged using a citation which would include:
- the Identification of the Primary Investigator
- the title of the survey (including country, acronym and year of implementation)
- the survey reference number
- the source and date of download
Disclaimer and copyrights
The user of the data acknowledges that the original collector of the data, the authorized distributor of the data, and the relevant funding agency bear no responsibility for use of the data or for interpretations or inferences based upon such uses.