Nigeria

Differentiated Service Delivery Implementation in Nigeria

Nigeria, the 7^th most populous country in the world, joined the HIV Coverage, Quality, and Impact Network (CQUIN) in November 2020.

The National AIDS, Sexually Transmitted Infections Control and Hepatitis Programme (NASCP) coordinates Nigeria’s HIV Treatment Program, which started in 2002 under the Department of Public Health, Federal Ministry of Health (FMOH). The overall mandate of NASCP is to coordinate the formulation and effective implementation of national policies, guidelines, and standard operating procedures to prevent new HIV infections and treatment, care, and support for those infected and affected by the virus in Nigeria.

Nigeria integrated decentralized care into service delivery by adopting and implementing the antiretroviral therapy (ART) Hub and Spoke Network Model (Cluster System) in March 2010. This enabled the devolution of stable recipients of care from larger, centralized secondary and tertiary facilities (hubs) to smaller, more peripheral primary facilities (spokes) to continue receiving ART.

In August 2014, the FMOH approved and started implementing the Task-Shifting and Task-Sharing for Essential Healthcare Services policy in Nigeria. This policy presented an opportunity to increase access to care by making it easier to integrate task-shifting to lower cadres of health care providers, decentralizing and simplifying care and treatment using differentiated ART models. As a result, since 2015/2016, the National Program has offered facility-level differentiated service delivery (DSD) for stable recipients of care using individual appointment spacing, which provided multi-month ART refills and fast-tracked visits. 

Nigeria first recommended DSD packages of care in the 2016 National Guidelines for HIV/AIDS Prevention, Treatment, and Care, which was further updated in the 2020 National Treatment Guidelines. Based on these recommendations, Nigeria currently implements diverse ART models that provide differentiated client flows, schedules, and locations to ensure that all recipients of care are provided appropriate care packages in stable and unstable contexts.

In collaboration with its donors and implementing partners, Nigeria provides eight (8) less-intensive facility-based DSD models and six (6) community-based DSD models for five different target groups – children above five years, adolescents, adults, key population, and pregnant and breastfeeding mothers. Multi-month ART distribution (MMD) is not considered a DSD model itself, but an enabler of the models designed for people doing well on ART/retained in care. These include:

Facility-Based Individual Models

• Fast-track
• Decentralization (Hub and Spoke)
• After hours
• Weekend and Public holidays

Facility-Based Group Models

• Facility ART group: HCW-led
• Facility ART group: Support group-led
• Child/Teen/Adolescents club (Peer managed)
• Mother-infant pair/Mentor mother led

Community-Based Individual Models

• Community Pharmacy ART refill
• Home delivery
• One-Stop-Shop (OSS)

Community-Based Group Models

• Community ART Refill Group: HCW- led
• Community ART Refill Group: PLHIV- led
• Adolescent Community ART/ peer-led groups

Since joining CQUIN, Nigeria has addressed gaps to strengthen DSD implementation. The country has finalized its DSD Operational Manual and developed training slides and facilitators’ manuals for the training of health care providers on delivering differentiated service delivery. The training of trainers at the national and state levels will commence in the fourth quarter of 2021. 

In September 2021, Nigeria conducted its first CQUIN-supported DSD Performance Review (DPR) in two states (Federal Capital Territory and Akwa Ibom). Nigeria has also joined several of CQUIN’s communities of practice, including those on differentiated M&E and differentiated maternal/child services, to foster joint learning and further strengthen DSD implementation in the country. Nigeria has also hosted south-to-south visits from other CQUIN member countries, to share its experience with decentralized drug distribution and other differentiated treatment models. In addition, there are ongoing plans to enhance the DSD subcommittee at NASCP, which will help drive DSD implementation and stakeholder engagement in the country.