|Year : 2022 | Volume
| Issue : 4 | Page : 534-539
A comparative assessment of the level of stockouts of modern family planning services in private and public health facilities in Nigeria
Ali J Onoja1, Felix O Sanni2, Sheila I Onoja1, Aisha Abu3
1 Research Department, African Health Project, Abuja, Nigeria
2 Department of Public Health, Fescos of Data Solutions, Triune Biblical University Global Extension, Sango Ota, Ogun State, Nigeria
3 Microbiology Department, National Institute for Pharmaceutical Research and Development, Idu, Abuja, Nigeria
|Date of Submission||22-Jun-2022|
|Date of Acceptance||12-Dec-2022|
|Date of Web Publication||29-Dec-2022|
Dr. Felix O Sanni
Department of Public Health, Fescos of Data Solutions, Triune Biblical University Global Extension, Sango Ota, Ogun State
Source of Support: None, Conflict of Interest: None
Background: The use of family planning (FP) methods and stockouts of contraceptives are major challenges to the FP program in Sub-Saharan Africa. This study assessed the level of stockouts of contraceptives in Nigerian health facilities. This survey was carried out in 767 health facilities offering FP services across all six geopolitical zones of Nigeria. Materials and Methods: This was a cross-sectional study involving a quantitative technique. Data were collected from 116 private and 651 public health facilities in Nigeria. A structured questionnaire was used to collect data from the facilities, and a physical inventory was taken. Data were analyzed using IBM-SPSS, version 25.0. Results: The stockout rate in the last 3 months was 63.8% in private and 47.5% in public health facilities (P = 0.001), whereas stockouts on the visit day were 63.8% in private and 51.0% in public facilities (P = 0.011). On the day of the visit, the stockout rate in private health facilities ranged from 9.3% to 26.5%, whereas it ranged from 5.3% to 24.2% in public health facilities. The main causes of stockouts of some contraceptives are low/no demand and a lack of supply. Conclusions: This study found a high level of stockouts of FP services in private and public health facilities, but higher in private facilities. Both the poor supply and low demand for FP services in Nigeria require the attention of policymakers and health officials.
Keywords: Child spacing, contraception, family planning, stockouts
|How to cite this article:|
Onoja AJ, Sanni FO, Onoja SI, Abu A. A comparative assessment of the level of stockouts of modern family planning services in private and public health facilities in Nigeria. MGM J Med Sci 2022;9:534-9
|How to cite this URL:|
Onoja AJ, Sanni FO, Onoja SI, Abu A. A comparative assessment of the level of stockouts of modern family planning services in private and public health facilities in Nigeria. MGM J Med Sci [serial online] 2022 [cited 2023 Jan 27];9:534-9. Available from: http://www.mgmjms.com/text.asp?2022/9/4/534/365981
| Introduction|| |
Family planning (FP) is essential to advancing the health sector population growth control. FP plays an important part in the improvement of maternal health. The improvement of maternal health is one of the 169 targets of the sustainable development goals that world leaders have pledged to achieve by 2030. Two components of these goals are to reduce the global maternal mortality ratio to less than 70 per 100,000 live births and to ensure that people have access to sexual and reproductive healthcare services, including FP.
FP helps individuals or couples decide by themselves when to have children, the number of children to have, how to space the children, and when to stop giving birth., The use of FP services in third-world countries has been better since FP started in the 1950s when contraceptive products were uncommon. Since then, FP has been known as a primary factor in reproductive health. The public acceptance of FP has resulted in an improved range of instruments for carrying out FP services. The use of contraceptives in Africa (primarily in Sub-Saharan Africa) remains low, and this, with the unmet need for contraceptives, has resulted in high fertility rates in the region.,
The private health sectors provide an important role in healthcare services for low- and middle-income countries (LMICs), both in rural and urban regions, and for all socioeconomic groups and the wealthy. According to some studies, the provision of healthcare services by the private sector is unbalanced because the wealthy have access to significantly better services than the poor., Some other studies have made recommendations, which include giving out healthcare services to the private sector can advance equity or that a growing private sector does not harm service delivery equity., Services offered by the private sector differ between regions and the type of care required by individuals of different socioeconomic classes. The findings of 2015 data collected from 57 LMICs showed that about 25% of contraceptive users are from the “poorest regions of Sub-Saharan Africa, the Middle East/Europe, Asia, Latin America, access care in private facilities while, about 50% of contraceptive users in the wealthiest location of these regions also make use of the private facilities.”
Sources of funds differ for public and private facilities. At the same time, policymakers usually give funds for healthcare deliveries in public healthcare facilities; private facilities are usually self-funded and depend solely on funds raised through their services. However, there is a growing interest in ways the private sector can complement the public sector.
A study has assessed FP uptake and child health services in the private sector in Nigeria, but information comparing the availability of FP services in both private and public health facilities is rare. Also, the common belief (but not backed up with facts) that private health facilities always perform better than public facilities needs to be investigated. Therefore, this study aims to compare the stockouts of FP services in private and public hospitals in Nigeria.
| Materials and methods|| |
Information about the study was communicated to the management of each facility, and consent was obtained. Confidentiality was assured. No ethical approval was needed because the study was based on facility assessment and not directly gathering data about human participants.
This was a cross-sectional study using a structured interviewer-administered survey instrument that included observations of physical inventory and interviews with service providers at the surveyed sites. The study was carried out in 767 health facilities of which 116 were private and 651 were public. The health facilities were selected based on the six geopolitical regions in Nigeria. The facility assessment was conducted using a quantitative method. The site assessments were carried out between November 15 and December 20, 2018. To this study, stockout means when one or more FP services are unavailable at a health institution that normally offers that technique or should supply that method based on policy.
The sites were visited for interviews, and an inventory of all FP methods (condoms, oral contraceptives, injectables, intrauterine devices (IUDs), implants, sterilizations, and emergency contraceptives) available was taken; the team of trained researchers visited the health facilities to collect data from the health professionals in charge of FP programs. The respondents were asked if their facilities were offering FP services and the kind of contraceptives available in their facilities.
Data collection tools
A validated assessment tool by “the World Bank and Federal Ministry of Health adapted Health Facility Assessment Tool” was modified and used for the survey. This tool was a structured interviewer-administered questionnaire used to collect FP data from the facilities. The availability of the modern contraceptives in each site was evaluated through physical inventory observations.
The sample size was determined with the formula:
n represents the sample size, N is the total number of facilities in Nigeria, and e represents precision = 5% = 0.05 at a 95% confidence level.
The number of functional and registered public (14,522) and private (6,009) healthcare facilities after the states with security challenges (Adamawa, Borno, and Yobe) was excluded. When the formula above was applied, the minimum sample size was estimated as a minimum of 761 facilities. Based on the proportion of private and secondary facilities, 116 private and 651 public healthcare facilities were selected, making a total of 767 facilities. For 34 states (including the Federal Capital Territory), an average of four private and nine public healthcare facilities was targeted using a simple random sampling method, meaning an average of 23 facilities was selected per state.
Data collection and analysis
Relevant officers were contacted to obtain clarifications on some data or indicators. The researcher visited the facilities offering FP services across the state. The data collected from the different facilities were collated in a database using MS Excel. The data were screened using the standard format to correct any errors identified. The cleaned data were analyzed with the IBM-Statistical Package for Social Sciences (SPSS), version 25. Descriptive statistics were conducted, and the results are presented in tables and figures, setting a significant level as P < 0.05.
| Results|| |
This survey was carried out in 767 health facilities offering FP services comprising 116 private and 651 public health facilities. A higher proportion of public health facilities were offering male condoms (87.3%), female condoms (62.6%), and oral contraceptives (93.0%) than private health facilities with 67.2%, 32.7%, and 81.0%, respectively (P < 0.001). In addition, 95.6% and 57.1% of public institutions offered injectables and implants, respectively, compared with 92.2% and 52.3% of private institutions, though the differences were not statistically significant (P > 0.05). On the other hand, the proportion of private facilities offering IUDs (84.5%), sterilization for females (63.4%), and emergency contraceptives (48.5%) as compared to 65.4%, 51.6%, and 33.5%, respectively, for public health facilities (P < 0.05) [Table 1].
|Table 1: Distribution of contraceptive methods available in private and public health facilities|
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Among the 78 private health facilities offering male condoms, 23.1% have experienced stockout on any day of the last 3 months before the interview compared to 10.6% in public facilities (P = 0.001). Similarly, higher proportions of private facilities than the public have experienced a stockout of female condoms, oral contraceptives, injectables, IUDs, implants, sterilization for females, and emergency contraceptives. More than half (63.8%) of private facilities have experienced a stockout of one or more contraceptive methods on a given day in the last 3 months before this survey, as compared to 47.5% in public health facilities (P = 0.001) [Table 2].
|Table 2: Stockout of family planning methods on any day of the last 3 months in public and private health facilities|
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The proportion of private health facilities that have experienced stockout of one or more contraceptive methods was 63.8% compared with 51.0% in public facilities (P = 0.011). Also, a higher proportion of private health facilities were out of stock of all FP methods assessed than public facilities, except sterilization for males, as shown in [Table 3].
|Table 3: Stockout of contraceptive methods on interview day in private and public health facilities|
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The reasons for the stockout of some FP methods are shown in [Figure 1]. The major reasons include low or no demand and the method not supplied from a higher level (for public facilities). The “higher level” means from the local, state, or federal ministry or other higher institutions responsible for supplying FP methods to the facilities.
|Figure 1: Reasons for stockout of family planning methods in Nigerian health facilities|
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| Discussion|| |
This study identified nine categories of contraceptive methods, ranging from condoms to emergency contraceptives. For private health facilities, injectables, IUDs, and oral contraceptives were the most offered contraceptives compared with other contraceptives such as sterilization for males, female condoms, and implants. The most offered contraceptives in public health facilities are injectables, oral contraceptives, and male condoms compared to other contraceptive methods. These findings are similar to what was obtained in Ghana, where oral and emergency contraceptives were the most available in private health facilities. Our study showed that a significantly higher proportion of public health facilities offered male condoms, female condoms, and oral contraceptives (P < 0.001). On the other hand, the availability of IUDs, sterilization for females, and emergency contraceptives are higher in private health facilities than in public health facilities (P < 0.05). A similar finding was also reported in Ghana, where the availability of female condoms and long-acting reversible contraceptives such as implants and IUDs were very low in public health facilities.
This study discovered that private (63.8%) health facilities had a significantly higher rate of stockout of one or more contraceptive methods on any day in the previous 3 months preceding the interview than public (47.5%) health facilities (P = 0.001). The proportion of private facilities that experienced stockout of condoms (male and female), oral contraceptives, injectables, and IUDs. Implants, sterilizations, and emergency contraceptives on any day of the last 3 months before this survey ranged from 7.1% to 28.6%, whereas the range was 2.9% to 20.7% in public health facilities. The level of stockout found in this study is slightly lower than 49.9% of facilities that reported stockouts of contraceptives in the 3 months before the survey conducted by the United Nations Population Fund (UNFPA) in Nigeria in 2013 though the stockout rate for private health facilities was higher.
Furthermore, the inventory taken on the day of the visit revealed that a greater proportion of private health facilities (63.8%) were out of stock of one or more contraceptive methods, compared with 51.0% of public health facilities. The stockout range was 7.1% to 26.5% in private facilities, whereas the stockout range was 5.3% to 24.2% in public health facilities. This shows an improvement from the previous report that contraceptive stockouts ranged from 25% to 70% in health facilities in Nigeria.
Emergency contraception, oral contraceptives, and condoms were the most commonly stocked contraceptive methods in private health facilities (more than 20% of facilities). Public health facilities were mostly out of stock of emergency contraceptives. A similar report has been documented in Ghana. This finding contrasts with the findings from Armenia, where condoms and hormonal contraceptive pills had the lowest stockout and IUDs had the highest. In contrast to a recent study in Ethiopia that reported that private facilities are less likely to have implants, this study did not find any significantly different stockout rates of implants between private and public health facilities.
Various reasons were given for being out of stock of some contraceptives, including low or no demand, contraceptives not supplied at a higher level (for public facilities), expired, logistic or storage challenges, a lack of trained personnel, and parents buying the contraceptives by themselves. Private facilities were out of stock of emergency contraceptives because of low demand, and lack of supply in public facilities. A similar trend occurs for other contraceptive methods. Studies have also reported a lack of available personnel and demand/request for FP commodities as constraints of FP programs.,,,,, This low demand and poor supply of FP commodities require the consideration of health officials, policymakers, and religious leaders because low demand has been associated with the influence of religious leaders who are opposed to contraceptives.
Although the availability of contraceptives in private health facilities is relatively high, this study found higher availability of contraceptive methods in public health. This finding agrees with a previous study that reported a missed opportunity for contraceptive provision in the private sector in Nigeria, Ethiopia, and the Democratic Republic of the Congo. A study conducted in Nigeria has emphasized the impact of the availability of FP commodities in Nigeria, including a reduction in unintended pregnancy and maternal mortality. Improved health outcomes were also documented among women and children, with the immediate impact increasing in “school enrolment, nutritional status, and women’s empowerment.” This underscores the need to improve FP provisions in Nigeria’s private and public health facilities.
| Conclusions|| |
This comparative assessment of the level of stockouts of contraceptive methods in both private and public health facilities in Nigeria has revealed the stockout rates of some contraceptives in both public and private health facilities in Nigeria. This study found that condoms, emergency contraceptives, and oral contraceptives were generally in short supply in both private and public health facilities. Although implants were the most in short supply in public facilities, this study also clears the doubts about whether private or public health facilities offer better FP services in Nigeria, as the study found that a higher proportion of private facilities experienced stockouts of contraceptives than public facilities. The supply and low demand for FP services in Nigeria require the attention of policymakers and health officials.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]