The Impact of Family Planning Training on Private Sector Health Care Performance in Nigeria

Sikiru Baruwa
Minki Chatterji
Doug Johnson
Modupe Toriola
Jorge Ugaz
Fieldwork by:
965 health care facilities
2013 - 2014
Target group:
  • Health care providers
Outcome of interest:
  • Social service delivery
  • Productivity
Intervention type:
  • Training
AEA RCT registration number:

Many individuals in sub-Saharan Africa lack access to high-quality, modern contraceptives. In this context, private health care facilities often are important providers of family planning services. Researchers, in partnership with the USAID SHOPS Nigeria program, evaluated the impact of a package of trainings targeted to private health care providers in Lagos State. The provision of targeted training and supportive supervision increased the quantity of contraceptive methods offered and quality of family counseling provided at private health care facilities.

Policy issue

Despite decades of family planning programming, many individuals in sub-Saharan Africa still lack access to modern contraceptives. In this region, private health care providers are often an important source of family planning services—as of 2015, approximately one third of modern contraceptive users in sub-Saharan Africa obtained these methods from a private sector source. However, private sector providers face unique challenges in service provision. Limited access to training can prevent for-profit providers from improving their skills, lack of access to credit may minimize their ability to routinely offer high-quality family planning services, and inadequate reporting often means that governments are unable to effectively manage and fully leverage private sector resources. In response to these challenges, researchers conducted a randomized evaluation to measure the impact of a package of trainings and supportive supervision activities targeted to private health care providers in Lagos State, Nigeria.

Context of the evaluation

In Nigeria, the modern contraceptive prevalence rate—the percentage of women, or their partners, currently using at least one method of contraception—is extremely low (10 percent as of 2013). Private sector health care providers cover approximately 60 percent of all health services received in the country, placing them in a key position for delivering family planning services. However, these for-profit providers often lack appropriate training, particularly in the provision of long-acting reversible contraceptives, including implants and intrauterine devices (IUDs).

To better train private sector health care providers, from 2013 to 2014, the United States Agency for International Development’s (USAID) Strengthening Health Outcomes through the Private Sector (SHOPS) project provided training and supportive supervision targeted to for-profit private clinics, hospitals, medical centers, and nursing homes in Lagos State. By providing training on clinical family planning issues and business practices, the program aimed to improve the general quality of services provided, increase the number of facilities providing implants as a contraceptive method, and improve business skills and access to credit among providers.

A health care worker takes a patient's blood pressure
Photo: Deji Adeyi | Abt Associates

Details of the intervention

Researchers, in partnership with USAID, conducted a randomized evaluation to measure the impact of the SHOPS project on private health care providers’ performance. The research team identified 965 private health facilities in Lagos State that offered family planning services, had not already received training from the SHOPS project, and had more than 800 clients per month. They randomly assigned 484 to the treatment group that participated in that SHOPS training and supportive supervision program. The remaining 481 facilities did not participate and served as the comparison group.

SHOPS Nigeria sent letters to treatment facilities inviting their staff to attend a series of family planning and business training courses (see table) that took place between January 2013 and April 2014. Prior to these trainings, the research team sent follow up reminders via short text messages and telephone calls. Facility staff could select which training sessions to attend and were encouraged to share information with colleagues in their facilities.

Training Length Content Follow-up Audience
Contraceptive technology 3-day Providers practiced inserting implants and IUDs on models and were given a starter stock of contraceptives -- Doctors, nurses, and nurse-midwives
Family planning counseling 2-day Participants received training on balanced counseling strategy—a series of steps to determine the contraceptive method that best suits the client Monthly text messages to reinforce training information Doctors, nurses, and nurse-midwives
Recordkeeping 1-day Staff received data collection training to monitor family planning goods and services at the facility level Monthly follow-up visits from SHOPS project data collector to verify checks Staff member responsible for health information systems
Long-acting reversible methods 4-day Participants practiced IUD and implant insertion with real clients and were given a starter stock of 10 implants and 12 IUDs Monitoring visits conducted within three months of training Doctors, nurses, and nurse-midwives
Infection prevention and control 1-day Staff received training on best practices for controlling and reducing potential infections Monitoring visits conducted three months after training, followed by monthly text messages All facility staff
Managing a healthy business 2-day Trainers focused on building staff capacity to apply fundamental business management practices -- Facility owners, proprietors, and management / administrative personnel
Financing a healthy business 2-day Trainees learned best practices for working with financial institutions and developing financing plans -- Facility owners, proprietors, and management / administrative personnel

The research team administered surveys to facility managers and finance personnel to gather facility-level data on infrastructure, services offered, staffing, patient volume, and revenue in 2012 and mid-2014. In addition, researchers sent mystery clients to visit health facilities and request counseling regarding family planning in order to assess the quality and availability of family planning services. Researchers trained 12 women between ages 28 and 35 to assume the role of mothers who did not wish to have additional children for the next two to three years. 

Results and policy lessons

Contraceptive methods: Access to the SHOPS training program increased the number of modern contraceptive methods that facilities provided. Treatment facilities offered 0.6 more contraceptive methods (10 percent more) than comparison facilities, which offered six methods, on average. This result was largely driven by wider provision of long-acting reversible methods, such as implants and, to a smaller extent, IUDs. Increasing the provision of implants, in particular, was a main goal of the program; by the end, 74 percent of treatment facilities offered implants compared to just 33 percent of comparison facilities. By contrast, the SHOPS training program had no impact on the availability of short-acting or permanent birth control methods, other than an increase in availability of birth control pills.

Family planning counseling: The quality of family planning counseling improved in treatment facilities. When researchers scored the overall quality of counseling visits against an ideal template of 59 items and measures, providers in treatment facilities addressed 29.4 items (50 percent) on average, whereas providers in comparison facilities only addressed 26.3 items (45 percent). Treatment providers scored higher on items related to information given and received, interpersonal relations, and family planning knowledge. However, the program had no impact on the range of methods covered, technical competence, or continuity, indicating that important issues still lacked coverage in counseling sessions.

Recordkeeping: Access to training increased the likelihood that treatment facilities kept accurate, up-to-date records. Treatment facilities were 28 percentage points (56 percent) more likely to possess a federal register—family planning monitoring data reported to the Ministry of Health—relative to 49 percent of comparison facilities. Furthermore, they were 26 percentage points (89 percent) more likely to keep these registers up to date, relative to 29 percent of comparison facilities.

Loans and revenue: The proportion of facilities that applied for and obtained a loan in the previous 24 months was 6 percentage points (32 percent) higher in treatment facilities, relative to 18 percent of the comparison group. Facilities mostly used loans for purchasing hospital equipment, expanding inventory, or renovating and expanding facility buildings. Despite this increase in loans, the program had no effect on facility revenue.

Taken together, these results indicate that providing targeted training and supportive supervision to private health care providers in sub-Saharan Africa can be effective in improving family planning service delivery. However, additional research suggests that patient interest in implants in Lagos State remains low. As a result, more research is needed to determine whether expansions in family planning offerings can be sustained without additional efforts to increase demand among clients of private providers.

Use of Results:

The SHOPS program applied lessons from the randomized evaluation to improve counseling for private providers on family planning options. During supportive supervision visits, the program implementers placed greater attention on improving providers’ consistent coverage of important family planning issues during counseling sessions. In addition, they trained local volunteers as Community Health Promoters at the grassroots level to expand the family planning information pool in project communities. Finally, to improve sustained access to long-acting reversible contraceptives (LARCs), SHOPS trained professional associations of private doctors and nurses in six states as LARC trainers.