Positioning the Private Health Facilities Towards Continuous Service Provision During the COVID-19 Pandemic

Copyright © 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http:// creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. Background The coronavirus disease 2019 (COVID-19) pandemic has triggered an increased demand for health services.1-3 A noteworthy response to this demand is the increasing urgency for testing, tracing, treating, and isolating COVID-19 positives while maintaining the continual provision of healthcare.1,4 However, public health facilities are becoming increasingly inadequate to cater for the increasing COVID-19 cases.5,6 The PHFs account for 33% of health facilities in Nigeria and cater for nearly a third of the population mainly at the secondary healthcare level.7 Profound results have been obtained on the involvement of PHF in many health-related events, including Ebola, measles, polio, malaria, youth-friendly services, etc.811 In spite of existing laudable successes, PHFs are being underutilized in the ongoing COVID-19 outbreak response. Therefore, positioning the PHF to contribute to the COVID-19 outbreak response is a necessity. 2. The Relevance of PHFs Amid the COVID-19 Pandemic Nigeria reported her index case of COVID-19 on the 27th February, 2020.12-14 Since this period, the infection rate has spiraled to 73 175 cases as of 21st December, 2020.15 Also, 1197 fatalities have been associated with the COVID-19 infection as of the reference period.15 The Nigerian government has taken responsive actions towards engaging a multi-sectoral approach in the COVID-19 response, with the health sector centrally positioned.9,16 This has included the approval of COVID-19 testing and isolation of COVID-19 cases in designated private health facilities (PHFs), a number of which are widely distributed across the thirty-six states of the Federation and the Federal Capital Territory, Abuja.17 These have enhanced COVID-19 sample collection, testing, result turn-out rate, and management of COVID-19 positives. Private sector involvement has been of immense benefit to individuals with short travel notices who are required to provide COVID-19 certificates at the airport. Unfortunately, the Abstract

huge cost associated with health-seeking at PHF is a major challenge being faced in the COVID-19 dispensation. This, therefore, identifies the need for increased government support for PHF.

Opportunities for Positioning PHF for an Improved Response Amid the COVID-19 Pandemic
Presently, guidelines for the involvement of PHF in the COVID-19 outbreak response are unavailable in Nigeria. To position PHF for an improved COVID-19 outbreak response, guidelines that provide clarity on the role of PHF in the COVID-19 outbreak response need to be developed. The specifications on the guidelines should include patient risk assessment and triaging mode of sample collection, sample storage, requirements in biosafety level, mode of COVID-19 result disclosure, isolation equipment, frequency of re-testing, treatment modalities using the approved anti-malarial medications, the required minimum number of skilled and unskilled health personnel, and duty schedule. The availability of these guidelines would provide adequate information on the requirements to be met before PHF could be enrolled to partake in the response activities. Knowledge of such guidelines would enhance scaling-up in PHF where deficiencies exist. At the same time, the capacity of PHF needs to be enlarged through the decentralization of COVID-19 testing centers and the allocation of COVID-19 isolation centers to PHF who meet the requirements for accommodating COVID-19 confirmed cases. 18 The PHF are for-profit organizations, therefore specific regulations should be tailored towards the government acting as a financial risk protector for PHF. For instance, health loans should be made available to PHF who are willing to partake of the COVID-19 response activities where capacities to return such loans exist within the stipulated time. Also, a logical conclusion should be reached between the federal government and designated PHF on the mode of sharing income generated by each COVID-19-centred activity. The COVID-19 outbreak has been associated with a PPE such as face masks, alcoholbased hand rubs, goggles, and face shields. 19 To enable the contribution of PHF to the COVID-19 response, equity in the distribution of PPE across the public, and PHF from the federal government should be ensured. Meanwhile, subsidies should be provided on PPE, including goggles, hand sanitizers, and face masks. This would enhance private sector involvement in the COVID-19 outbreak response, and also reduce the risk of engaging in COVID-19 patient care secondary to PPE inadequacy. Meanwhile, the purchase could be made by PHF on a large scale at subsidized costs through the PHF professional bodies and associations.
As part of the joint health workforce, practitioners in PHF should be involved in requisite infection prevention and control (IPC) training. This posits the need for their involvement in the attendance at such IPC training similar to their counterparts in the public health facilities.
The training of trainers should also adequately involve practitioners at PHF to ensure that knowledge gained from such pieces of training have an impact on other staff at their facilities. Also, modalities of risk assessment, triaging, handling of COVID-19 cases, and management of confirmed cases of COVID-19 should be taught through organized training for practitioners in public and PHF. 20 Rather than sticking to the traditional physical training, some of these could be held virtually on online platforms such as WhatsApp, Telegram, Zoom, and Blue Jean. The adoption of virtual means overcomes the challenge of transportation to physical meeting venues and enhances attendance on a large scale especially among PHF. It should however be noted that omission in the practicality of knowledge gained from COVID-19-focused training in the management of COVID-19 positives should attract corrections and sanctions which should be equally served across public and PHF. Also, commendations should be awarded for optimal management of COVID-19 positives. These, therefore, bridge the gap between practitioners at public and PHF foundations.
Moreover, a comprehensive assessment of the human and infrastructural capacity of PHF needs to be conducted regarding the COVID-19 response. Results obtained from such assessment would inform on the existing human resources needs of the private sector and opportunities by which PHF's capacity could be enhanced for an effective national outbreak response, as well as raising data quality. A 2011 private sector assessment in Ghana revealed fragmentation as a major challenge to health delivery due to the involvement of a wide range of players, including individuals, professional groups, and sub-groups. 21 Results obtained therefore explained the poor health data quality obtained in Ghana during the reference period. Drawing on lessons learnt from the Ghana experience, registered professional groups should be represented in public-private sectors' engagement during the COVID-19 outbreak response in Nigeria to improve harmonious relationship between the professional groups. Meanwhile, such comprehensive assessment would foster interdisciplinary action amid the groups as required for an improved outbreak response.
Furthermore, assessing the extent of representativeness of PHF in the existing rapid response team needs to be conducted. In areas where adequate representativeness of the private sector is lacking, the inclusion of stakeholders in the PHF needs to be considered. 1 This, therefore, implies that the COVID-19 response is a joint responsibility for which total control does not lie with any single sector. [22][23][24][25][26] When PHF are adequately represented, feuds and distrust in the modality of task execution are overcome. [27][28][29] In addition, the adequate representativeness of the private sector would be required to enhance feedback from community members who access both private and public facilities for currently-implemented COVID-19 outbreak response measures. 30,31 The quality of knowledge acquired on these grounds would promote decision-making regarding the successes and failures of these measures, and help to adequately plan new interventions or improve existing ones. [32][33][34]

Conclusion
The COVID-19 outbreak has placed great demands on the Nigerian health system. However, the COVID-19 outbreak has explicitly highlighted the need for public-private collaboration in the outbreak response. Positioning PHF aright becomes promising for an improved COVID-19 outbreak response in Nigeria. All challenges delimiting the active involvement of the PHF should be addressed. Moreover, adequate support systems need to be developed and well-placed to promote the involvement of the PHF in the outbreak response. In addition, PHF must be adequately involved in relevant health projects. This will build positive relationships between the public and PHF and a sense of togetherness which will enable a timely and adequate response to the current COVID-19 outbreak or future pandemics. Adequate involvement of PHF will also reduce wastage of resources attributed to the sole management of health projects by public stakeholders. Similarly, the involvement of PHF will overcome the barriers associated with the complexities of accessing care in public health facilities. The involvement of PHF also prevents the deprivation of accessing care among individuals who would not seek COVID-19 care at public health facilities.

Authors' Contributions
OSI conceptualized the research, while AAA and OSI wrote the initial draft of the manuscript and revised it for critical intellectual content, and approved the final version.