Enhancing Private Healthcare Effectiveness in Lagos State, Nigeria: An Overview of the Effect of Quality Improvement Initiatives and Implications for Sustainable Healthcare Delivery ()
1. Introduction
Nigeria, a country at the intersection of rapid population growth, economic complexities, and intricate healthcare challenges, faces an evolving landscape in delivering quality healthcare to its diverse populace. As the most populous state and the economic heartbeat of the nation, Lagos State grapples with the intricate task of ensuring access to adequate healthcare for its teeming population. With a healthcare system stretched thin, the private healthcare sector has emerged as a linchpin in meeting the escalating demand for medical services and addressing the multifaceted health needs of the populace [1] . The intricate interplay of factors such as urbanization, lifestyle changes, and the increasing burden of non-communicable diseases adds layers of complexity to the healthcare scenario in Lagos. The burgeoning population and urbanization in Nigeria have led to a surge in healthcare needs, with Lagos State being particularly affected as the economic epicenter. The private healthcare sector, therefore, plays a crucial role in bridging the healthcare gap and addressing the diverse health challenges faced by the population. The World Health Organization (WHO) emphasizes the significance of adapting healthcare systems to changing demographics, underlining the pivotal role of private healthcare entities in achieving this goal [1] .
The healthcare scenario in Lagos is complex, influenced by factors ranging from rapid urbanization to a rising burden of non-communicable diseases. Private healthcare providers, in their role as key contributors to healthcare services, become central to the discourse on healthcare quality and accessibility. This sets the stage for an in-depth exploration of the quality improvement projects undertaken by the government to enhance the effectiveness of private healthcare in Lagos State. Oleribe et al. [2] emphasize that private healthcare providers are instrumental in complementing the efforts of the public sector and play a significant role in achieving universal health coverage. With the private sector contributing substantially to healthcare provision, understanding the dynamics of their engagement in quality improvement projects becomes imperative for a comprehensive assessment of the healthcare landscape in Lagos State.
Recognizing the significance of the private healthcare sector, the government of Lagos State has embarked on various healthcare interventions and quality improvement projects. Ogundeji et al. [3] note that these initiatives are designed to enhance healthcare standards, address systemic challenges, and create an enabling environment for private healthcare providers. The collaborative efforts between the government and private healthcare entities signify a commitment to achieving sustainable improvements in healthcare delivery across the state.
Within the context of Lagos State, the implementation of quality improvement projects becomes a critical focal point. These projects, often initiated and supported by the government, are tailored to address specific challenges within the private healthcare sector. Understanding the intricacies of these projects, their methodologies, and the extent of their impact is fundamental to comprehending the evolving healthcare landscape.
Private healthcare providers, despite their crucial role, encounter systemic challenges that can impede the effectiveness of healthcare delivery. Financial constraints, workforce management, and infrastructural deficiencies are among the challenges faced by private healthcare facilities in Lagos State [4] . Quality improvement projects, therefore, become instrumental in addressing these challenges and fostering a more resilient healthcare system. Lagos, as an urbanized megacity, experiences unique health challenges stemming from rapid urbanization. Urban health issues, including increased prevalence of lifestyle-related diseases, environmental health risks, and the strain on healthcare infrastructure, necessitate targeted interventions. Quality improvement projects need to navigate this intricate interplay between urbanization and health to ensure effective healthcare delivery.
Quality improvement projects also play a vital role in bridging gaps in healthcare access across diverse socio-economic strata. Initiatives that focus on improving the quality of care provided by private healthcare entities contribute significantly to reducing disparities in access. This aligns with broader global health objectives, emphasizing the importance of equitable healthcare delivery. Achieving sustainable impact in healthcare necessitates collaborative efforts between the government, private healthcare providers, and relevant stakeholders. As the government initiates quality improvement projects, fostering a collaborative environment becomes paramount. Successful collaboration ensures that the impact is not only immediate but also sustainable, fostering a culture of continuous improvement.
The aim of the study is to comprehensively assess the impact of donor-funded quality improvement projects on private healthcare providers in Lagos State, Nigeria. This research aims to gain insights into the level of participation, perceived support, and the tangible effects of these initiatives on healthcare delivery within private healthcare facilities. Furthermore, the study aims to explore how these initiatives influence patient inflow and facility ratings, and bring about additional benefits and improvements. In addition to understanding the challenges faced by private healthcare providers in implementing these quality improvement projects, the research seeks to elicit recommendations for improving the effectiveness of such initiatives. The study also aims to gauge the readiness of private healthcare facilities to participate in health insurance schemes, particularly focusing on the Ilera Eko health insurance scheme, and propose policy recommendations based on the findings.
This study is organized as follows: Section 2 details the research methodology, including data collection and analysis. Section 3 presents the study’s findings, discussions, and implications. Finally, Section 4 concludes the study.
2. Methodology
2.1. Study Design
This study employs a qualitative research design to delve into the perceptions and experiences of private healthcare providers regarding donor-funded quality improvement projects in Lagos State, Nigeria. The qualitative approach is deemed appropriate for capturing the nuanced insights, opinions, and challenges articulated by the respondents during in-depth interviews. Specifically, a phenomenological research methodology was adopted in this study. Phenomenology was chosen for its suitability in exploring and understanding the lived experiences and perspectives of private healthcare providers in the context of donor-funded quality improvement initiatives. This method allows for an in-depth examination of individual experiences, shedding light on the unique aspects of each participant’s encounter with quality improvement projects. The choice of phenomenology aligns with the study’s aim to uncover the essence of the participants’ perceptions and experiences, providing a rich and contextual understanding of their perspectives.
2.2. Participants
The study involves private healthcare providers in Lagos State who participated in the SP4FP Quality Improvement Project. A purposive sampling technique is utilized to ensure representation from various healthcare facilities, considering factors such as facility size, location, and level of involvement in the quality improvement initiative.
2.3. Data Collection
Data is primarily collected through semi-structured interviews with private healthcare providers. The interviews are designed to elicit detailed responses regarding the participants’ perceptions of the quality improvement support, its impact on healthcare delivery, challenges faced during implementation, and recommendations for future initiatives. To ensure the effectiveness of the data collection process, the semi-structured interview guide underwent a thorough development and piloting phase. Initially, the interview guide was crafted based on a comprehensive literature review and consultation with subject matter experts. Subsequently, it was pilot-tested with a small sample of participants similar to the target group to assess the clarity, relevance, and comprehensiveness of the questions. Feedback from the pilot phase was invaluable in refining the interview guide, and enhancing its appropriateness and effectiveness in addressing the research questions. The finalized guide was then utilized for the main data collection process, ensuring that key topics were systematically explored while allowing flexibility for participants to express nuanced perspectives.
2.4. Interview Process
Interviews are conducted face-to-face to facilitate open and candid discussions. The interview questions are designed to cover a range of topics, including the level of participation in quality improvement projects, perceived support received, observed changes in healthcare delivery, challenges encountered, and recommendations for improvement. While face-to-face interviews are chosen to encourage open discussions, it is crucial to acknowledge the potential impact of the interviewer’s presence on participants’ responses. To address this, particular attention was given to establishing a rapport with participants through an initial informal discussion and a transparent explanation of the research objectives. Additionally, participants were assured of the confidentiality of their responses, aiming to mitigate any potential influence on the candor of their answers. Regarding the duration of each interview, sessions typically lasted between 45 to 60 minutes. This timeframe allowed for comprehensive coverage of the interview topics while respecting participants’ time constraints. Probing techniques were employed to encourage participants to elaborate on their responses, ensuring a thorough exploration of the chosen themes.
2.5. Data Analysis
Thematic analysis was applied to systematically identify recurring themes, patterns, and insights from the qualitative data. The transcripts of the interviews underwent a rigorous review process, involving multiple coders to enhance the reliability and validity of the analysis. Member checking was performed, involving a subset of participants who were provided with the coded data and preliminary themes. Seeking their feedback and input, their perspectives were incorporated into the analysis, thereby strengthening the credibility and trustworthiness of the identified themes.
2.6. Ethical Considerations
This research adheres to ethical guidelines, ensuring confidentiality and informed consent. Participants are provided with information about the study’s purpose and their right to withdraw at any stage. Anonymity is maintained throughout the reporting of findings.
2.7. Limitations
While qualitative research offers rich insights, it is essential to acknowledge its inherent limitations, such as the potential for subjectivity and the challenge of generalizability. The findings are context-specific to the experiences of private healthcare providers in Lagos State and may not be universally applicable. The qualitative methodology adopted in this study aims to uncover the depth of private healthcare providers’ perspectives on government-led quality improvement projects, providing valuable insights for enhancing healthcare delivery in Lagos State.
3. Findings and Discussion
3.1. Level of Participation in Quality Improvement Projects and Perceived Support for Government Initiatives
The respondents uniformly attested to their deep involvement in the SP4FP Quality Improvement Project. A Medical Doctor (MD) respondent emphatically stated, “We participated fully in whatever they said”. This sentiment echoed across varied facility sizes and locations, showcasing a widespread commitment to the initiative. Another respondent concurred, saying, “We were actively engaged in the training sessions and implemented the recommended changes in our facility”. Expressions of gratitude for donor-funded quality improvement projects were recurrent in respondents’ feedback. One respondent acknowledged, “It is encouraging, at least. We thank the government for doing something, at least to some extent”. This acknowledgment reflected the positive role perceived by private healthcare providers, especially in mitigating financial constraints and facilitating necessary improvements.
The unanimous affirmation of deep involvement in the SP4FP Quality Improvement Project among the respondents aligns with existing literature emphasizing the crucial role of private healthcare providers in donor-funded initiatives. This commitment resonates with the findings of Ogundeji et al. [3] , who emphasize the collaborative efforts between the government and private healthcare entities. The respondents’ emphatic statement, “We participated fully in whatever they said”, echoes the sentiments of Oleribe et al. [4] , who note that private healthcare providers are instrumental in complementing the efforts of the public sector. The literature underscores the significance of private healthcare engagement in quality improvement projects to enhance overall healthcare standards. The proactive involvement reported by respondents, including active engagement in training sessions and the implementation of recommended changes, corresponds to the findings of studies such as Oleribe et al. [4] . These studies highlight the willingness of private healthcare providers to embrace and implement positive changes brought about by donor-funded initiatives.
Expressions of gratitude from the respondents for donor-funded quality improvement projects reflect a positive perception of the role played by the government in mitigating financial constraints and facilitating necessary improvements. This resonates with the broader discourse on the importance of collaborative efforts in achieving sustainable improvements in healthcare delivery, as indicated by Ogundeji et al. [3] . The acknowledgment of the government’s role in alleviating financial constraints is consistent with studies that emphasize the need for external support to address systemic challenges faced by private healthcare facilities [4] .
3.2. Effect on Patient Inflow and Facility Ratings
The impact on patient inflow and facility ratings presented nuanced perspectives. A respondent humorously remarked, “I will not say yes (laughs), it does not who… Nigeria is… it’s not easy in Nigeria”. This sentiment reflected the broader challenges within the Nigerian healthcare landscape, indicating that while quality improvement projects had positive effects, they were not the sole determinants of patient numbers or facility ratings. Respondents consistently reported a positive influence on facility rating, aligning with the study’s objective to assess the impact of donor-funded quality improvement projects on private healthcare providers in Lagos State. One respondent noted, “Our partnership with Lagos State and participation in initiatives like Ilera Eko significantly improved how our facility is perceived. Patients now recognize us as a reliable and credible healthcare provider”. This sentiment was also echoed by another respondent, who mentioned, “Being part of government-supported programs elevated our facility’s visibility. We noticed a positive shift in our facility ratings, which we attribute to these collaborative efforts”. These quotes highlight the tangible impact of government initiatives on private healthcare providers’ facility ratings, validating the study’s overarching objectives. The acknowledgment of positive influence on facility ratings by respondents resonates with findings from studies such as Akinola et al. [5] , which emphasize the significance of collaborations between private healthcare providers and government initiatives. The positive shift reported by respondents in how their facilities are perceived aligns with the objectives of the study, validating the impact of government-supported programs on enhancing the credibility and reliability of private healthcare providers.
The specific mention of partnerships with Lagos State and participation in initiatives like Ilera Eko contributing to improved facility perception echoes the findings of Oleribe et al. [2] , highlighting the importance of government-supported programs in shaping positive perceptions. The tangible impact on facility ratings reported by respondents corresponds to the broader discourse on the role of government interventions in bolstering the image of private healthcare facilities [3] .
3.3. Readiness for Health Insurance Schemes
While there was expressed interest in health insurance schemes, concerns regarding tax requirements to qualify for empanelment surfaced. A respondent candidly stated, “The tax director… tax director this thing is my problem”. This echoed the hesitations of many private healthcare providers, particularly regarding financial implications and taxation hurdles, hindering full engagement with health insurance schemes. The study delved into private healthcare facilities’ readiness to participate in health insurance schemes, particularly the Ilera Eko health insurance scheme. The responses revealed a readiness to engage, contingent on overcoming administrative hurdles. The taxation challenges faced by co-directors, as highlighted by a respondent pose a significant barrier. This aligns with the findings of Oleribe et al. [4] , emphasizing that systemic challenges faced by private healthcare providers need to be addressed to enhance their involvement in health insurance schemes.
3.4. Impact on Healthcare Delivery
The tangible impact of quality improvement projects on healthcare delivery was a prominent theme. Respondents pointed to specific areas of improvement, with one stating, “They gave us clues on what to do and what not to do”. The emphasis on staff management, patient care processes, and organizational efficiency demonstrated a palpable positive influence on the overall quality of healthcare services.
3.5. Challenges Encountered during Implementation
Financial constraints emerged as a recurring challenge during the implementation of quality improvement projects. A respondent elaborated, “Well, we will say financial, nothing more. Buying new things, recurrent training of the staff as recommended, and the rest of it”. This financial hurdle underscored the pragmatic difficulties faced by private healthcare providers in sustaining recommended changes.
3.6. Additional Benefits and Improvements
Unanticipated benefits and improvements emerged as a noteworthy outcome of the quality improvement projects. Respondents highlighted insights gained into organizational structures, enhanced staff management practices, and improved Information and Communication Technology (ICT) infrastructure. One respondent affirmed, “They’ve opened our eyes to so many things; the organization of the center and staff management”. This resonates with Oleribe et al. [2] , who stress the role of private healthcare entities in achieving sustainable improvements in healthcare delivery. The findings indicate that beyond the immediate goals of these projects, there are ripple effects on organizational efficiency and patient management.
3.7. Implications of Findings
The implications drawn from the findings of this study hold significance for both policy development and practical interventions within the healthcare landscape of Lagos State, Nigeria.
• Government Support and Collaboration: The positive recognition of donor-funded quality improvement projects by private healthcare providers suggests the need for sustained support and collaboration between the public and private sectors. Policymakers should consider reinforcing initiatives that enhance the working relationship between the government and private healthcare entities. This collaborative approach can contribute to addressing systemic challenges, fostering a more resilient healthcare system in Lagos State.
• Financial Constraints: The acknowledgment of financial constraints as a significant challenge for private healthcare providers implies the necessity for targeted interventions. Policymakers should explore mechanisms to alleviate financial burdens on private facilities, such as providing subsidies, tax incentives, or financial support programs. These measures can enhance the financial sustainability of private healthcare providers, ensuring the continuity of quality healthcare services.
• Patient Inflow and Facility Ratings: The nuanced perspectives on patient inflow and facility ratings underscore the need for a holistic approach to healthcare improvement. While quality improvement projects play a positive role, policymakers should recognize that other factors, including broader healthcare policies, economic conditions, and public perceptions, influence patient inflow and facility ratings. Future policies should aim for comprehensive strategies that address various dimensions of healthcare delivery.
• Health Insurance Participation: The study’s exploration of private healthcare facilities’ readiness to participate in health insurance schemes, particularly the Ilera Eko health insurance scheme, indicates an opportunity for policymakers to enhance engagement. Understanding the challenges faced by private providers, especially related to tax obligations, is crucial. Policymakers should consider streamlining registration processes and addressing tax-related concerns to encourage more private facilities to participate, thereby expanding the reach of health insurance programs.
• Continuous Quality Improvement: The positive impact of quality improvement projects on facility ratings emphasizes the need for continuous efforts in this direction. Policymakers and healthcare managers should prioritize ongoing training, capacity-building, and support programs to ensure that private healthcare providers stay abreast of best practices. This can contribute to sustained improvements in healthcare quality and patient outcomes.
In practice, healthcare managers, administrators, and private healthcare providers can leverage these implications to advocate for supportive policies, engage in collaborative initiatives, and actively participate in quality improvement programs. The findings provide a roadmap for stakeholders to work collectively towards strengthening the private healthcare sector in Lagos State, ultimately contributing to improved healthcare delivery for the population.
4. Conclusions
In conclusion, this study has delved into the intricate landscape of private healthcare provision in Lagos State, Nigeria, with a particular focus on the impact of donor-funded quality improvement projects. The findings offer a nuanced understanding of the challenges, successes, and opportunities within the private healthcare sector, providing valuable insights for policymakers, healthcare managers, and practitioners. The multifaceted healthcare scenario in Lagos, shaped by rapid urbanization, demographic shifts, and a rising burden of non-communicable diseases, necessitates targeted interventions. The pivotal role played by private healthcare providers in bridging the healthcare gap and addressing diverse health challenges is evident. Quality improvement projects, initiated and supported by the government, have emerged as catalysts for positive change within the sector.
The study reveals a commendable level of participation by private healthcare providers in the SP4FP Quality Improvement Project. The sentiment of active engagement and appreciation for government initiatives was echoed across diverse facility sizes and locations. Despite financial constraints being a recurring challenge, the positive impact of these projects on healthcare standards, workforce management, and overall facility organization is evident. Notably, the influence of quality improvement projects on patient inflow and facility ratings presents a nuanced picture. While challenges within the broader Nigerian healthcare landscape contribute to the complexities of patient numbers, collaboration with Lagos State and participation in initiatives like Ilera Eko significantly improve facility ratings. Private healthcare providers recognize the tangible benefits of these collaborative efforts, emphasizing the importance of continuous improvement.
The implications of these findings for policy and practice underscore the need for enhanced financial support, streamlined health insurance participation processes, continuous training programs, and strengthened collaboration between public and private sectors. Comprehensive healthcare policies, monitoring and evaluation mechanisms, advocacy for equitable healthcare delivery, incentives for quality improvement, research-driven decision-making, and regular stakeholder engagements are recommended to foster a resilient and effective healthcare system. The study lays the groundwork for future research and underscores the importance of ongoing collaboration between stakeholders to navigate the evolving healthcare landscape in Nigeria. As the nation progresses, the lessons gleaned from this study will play a crucial role in shaping healthcare policies and practices that prioritize the well-being of the population.
Ethical Approval
Ethical approval for the study was obtained from the Health Research and Ethics Committee of Lagos State University Teaching Hospital (LREC), with approval number NHREC04/04/2008.
Acknowledgements
This research represents a collective endeavor, acknowledging the collaborative dynamics that have shaped its outcomes. The positive changes documented in healthcare facilities, such as enhanced standards, improved ratings, and organizational insights, emanate from a confluence of initiatives within the healthcare sector. These improvements underscore the collaborative efforts of various stakeholders, including donors, policymakers, healthcare professionals, and administrators.
Availability of Data and Materials
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request (info@hscgroup.org).
Funding
This work was supported by the Bill and Melinda Gates Foundation (BMGF) through the Nigerian State-Led Strategic Purchasing for Family Planning grant (grant number: INV-007359) assigned to Health Systems Consult Limited (HSCL).
NOTES
*First author.
#Corresponding author.