J.10_Benin_Private_Health_Sector_Census.pdf

December 2014

This document was produced for review by the United States Agency for International Development. It was prepared by Andrew Carmona, Sean Callahan, and Kathryn Banke for the Strengthening Health Outcomes through the Private Sector (SHOPS) project.

BENIN PRIVATE HEALTH

SECTOR CENSUS

Recommended Citation:

Carmona, Andrew, Sean Callahan, and Kathryn Banke. 2014. Benin Private Health Sector Census. Bethesda, MD:

Strengthening Health Outcomes through the Private Sector Project, Abt Associates Inc.

Download copies of SHOPS publications at: www.shopsproject.org

Cooperative Agreement: GPO-A-00-09-00007-00

Submitted to: Ricardo Missihoun

Commodities and Logistics Specialist United States Agency for International Development/Benin

Marguerite Farrell, AOR Bureau of Global Health Global Health/Population and Reproductive Health/Service Delivery Improvement United States Agency for International Development

Abt Associates Inc.

4550 Montgomery Avenue, Suite 800 North Bethesda, MD 20814 Tel: 301.347.5000 Fax: 301.913.9061 www.abtassociates.com

In collaboration with:

Banyan Global Jhpiego Marie Stopes International

Monitor Group O’Hanlon Health Consulting

BENIN PRIVATE HEALTH

SECTOR CENSUS

DISCLAIMER

The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States government.

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TABLE OF CONTENTS

Acronyms ........................................................................................................................... vi

Acknowledgements .......................................................................................................... vii

Census at a glance........................................................................................................... viii

Executive summary ........................................................................................................... ix

1. Introduction

1.1 Objectives 1

1.2 Questions 2

1.3 Stakeholders

2. Methodology

2.1 Instruments and Target Populations

2.2 Obtaining Lists of Facilities

2.3 Training of Data Collectors

2.4 Data Collection

2.5 Data Analysis

3. Results

3.1 Facility Results

3.1.1 Infrastructure

3.1.2 Geographic Distribution

3.1.3 Affiliation and Regulation

3.1.4 Training 11

3.1.5 Services 12

3.1.6 Clientele 16

3.1.7 Barriers to Expanding Business

3.1.8 Drugs and Stock

3.2 Provider Findings

3.2.1 Geographic Distribution

3.2.2 Provider Characteristics

3.2.3 Training 23

3.2.4 Affiliation and Registration

3.3 Pharmacies

3.3.1 Geographic Distribution

3.3.2 Pharmacy Staff

3.3.3 Insurance 26

3.3.4 Affiliation and Registration

3.3.5 Clientele 27

3.3.6 Barriers to Expanding Business

iii

3.3.7 Stock of Drugs

4. Discussion

Annex: Facilities and Pharmacies by Zone Sanitaire and Commune

References iv

LIST OF TABLES

Table 1. Frequency and Percentage of Private Facilities Table 2. Key Infrastructure Indicators of Private Facilities Table 3. Geographic Distribution of Facilities by Department Table 4. Membership of Private Facilities in Associations/Networks Table 5. Frequency of Submission of Monthly Reports to Authorities Table 6. Clinical Training for Private Facilities and Providers Table 7. MCH Services Provided by Private Facilities that Offer MCH Services Table 8. RH/FP Services Provided by Private Facilities that Offer RH/FP Services Table 9. FP Products Offered at Private Facilities that Offer FP Products Table 10. HIV Services Offered at Private Facilities that Offer HIV Services Table 11. Other Services Offered at Private Facilities Table 12. Number of Counseling Rooms at Private Facilities Table 13: Percentage of Clients Paying in Full or Paying Nothing at Private Facilities, By Facility

Type Table 14: Health Insurance Plans Accepted at Private Facilities Table 15. Barriers to Expanding Private Facilities’ Business Table 16: Geographic Distribution of Surveyed Providers by Department Table 17. Frequency and Percentage of Private Providers Surveyed Table 18. Average Years of Work Experience of Surveyed Private Providers Table 19. Top Two Clinical Trainings Desired by Providers Table 20. Top Two Supportive Trainings Desired by Providers Table 21. Registration Status by Provider Type Table 22. Number of Pharmacies by Department Table 23. Pharmacy Ownership by Gender Table 24. Insurance Plans Accepted at Pharmacies Table 25. Pharmacy Affiliation by Association/Wholesaler Table 26. Barriers to Expanding Business Table A1. Geographic Distribution of Facilities by Zone Sanitaire Table A2. Geographic Distribution of Private Facilities by Commune Table A3. Geographic Distribution of Surveyed Private Providers by Zone Sanitaire Table A4. Geographic Distribution of Providers by Commune Table A5. Number of Private Pharmacies by Zone Sanitaire Table A6. Geographic Distribution of Private Pharmacies by Commune Table A7. Stock of Drugs at Private Pharmacies v

LIST OF FIGURES

Figure 1. Facility Ownership by Gender Figure 2. Number of Private Facilities by Department Figure 3. Number of Private Facilities per 10,000 People by Department Figure 4. Geographic Distribution of Facilities by Department and by Urban/Rural Figure 5. Number of Private Facilities by Commune Figure 6. Frequency and Percentage of Private Facilities by Urban/Rural Figure 7. Timing of Accreditation Visits to Private Facilities Registered Before 2014 Figure 8. Map of Private Facilities Offering RH and FP Services Figure 9. Map of Private Facilities Offering HIV and AIDS Services Figure 10. Number of Beds in Private Facilities with Inpatient Services Figure 11. Outreach Services Conducted by Private Facilities Figure 12. Stock of Key Drugs/Treatments/Tests in Private Facilities Figure 13. Number of Surveyed Private Providers by Department Figure 14. Number of Surveyed Private Providers by Commune Figure 15. Density of Providers per Facility Figure 16. Last Accreditation Visit by Regulatory Body Figure 17. Stock of Key Drugs/Treatments/Tests in Private Pharmacies vi

ACRONYMS

ABPF Association Béninoise pour la Promotion de la Famille

ACT Artemisinin-based Combination Therapy

AIDS Acquired Immune Deficiency Syndrome

AMCES Association des Oeuvres Médicales Privées Confessionnelles et Sociales au Bénin

ART Antiretroviral Therapy

FEDAS La Fédérale des Assurances

FP Family Planning

GIS Geographic Information Systems

GPS Global Positioning System

HIV Human Immunodeficiency Virus

MCH Maternal and Child Health

MOH Ministry of Health

NGO Nongovernmental Organization

NSIA Nouvelle Société Interafricaine d’Assurance

ORS Oral Rehydration Solution

PMTCT Prevention of Mother to Child Transmission

RAMU Régime d'Assurance Maladie Universelle

RH Reproductive Health

RH/FP Reproductive Health/Family Planning

SHOPS Strengthening Health Outcomes through the Private Sector

USAID United States Agency for International Development vii

ACKNOWLEDGEMENTS

We would like to thank USAID/Benin for its support of the Benin private health sector census and Ricardo Missihoun, Commodities & Logistics Specialist, in particular for his leadership and insights. Dr. Christian Chaffa, Director of Health Regulation and Promotion at the Benin Ministry of Health provided valuable assistance during the design of and preparation for the census as well as overall support for the activity. We also thank the team at the Centre de Formation et de Recherche en Matière de Population (CEFORP) for their hard work and dedication to collecting high quality, complete data from private health providers across the entire country. We are especially grateful for the leadership of CEFORP’s Moustapha Gibigaye, who coordinated fieldwork and finalization of the data. We thank Dr. Toukourou Tidjani Moutiatou, President of the National Order of Pharmacists of Benin, and Dr. Lucien Dossou-Gbété, Director of the Association of Private Clinics in Benin, for their support, which facilitated fieldwork immensely.

Finally, the report has greatly benefited from inputs from the ANCRE Project in Benin, and Francis Okello, Sara Sulzbach, Doug Johnson, Caroline Quijada, and Bettina Brunner of Abt Associates.

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CENSUS AT A GLANCE

55% of facilities are rural

52% of facilities are in the South: Ouémé, Littoral, Atlantique, and Mono departments

77% of facilities offer at least one maternal/child health service

22% of facilities offer voluntary testing and counseling for HIV and AIDS

66% of facilities have access to electricity

16% of facilities are affiliated with an NGO or other organization

33% of registered facilities received an accreditation visit in the past 6 months

8% of facilities accept medical insurance

4% of facilities stock antiretroviral drugs

27% of facilities offer oral contraceptives

66% of facilities cite a shortage of medical equipment/supplies as a barrier to growth

54% of providers are registered to practice health care in Benin

7 clients, on average, are seen per facility each day

8.7 years is the average time a provider has worked in the private sector

49% of providers are medical aides

8% of providers work both in the private and public sector

20% of providers have been trained in diarrhea treatment with ORS protocols

53% of providers choose malaria treatment updates as a top priority for clinical training

48% of providers choose quality assurance systems as a priority for supportive training

3,174 private facilities mapped

6,217 private providers interviewed

All 77 communes canvassed ix

EXECUTIVE SUMMARY

Until now, an understanding of the full size and scope of the private health sector in Benin has been relatively incomplete, particularly with regard to the number and type of staff at private health facilities. To address this gap, the Strengthening Health Outcomes through the Private Sector (SHOPS) project conducted a private health sector census in 2014 to describe the size, scope, and geographic distribution of private health care facilities and providers in the country.

For the purposes of this census, SHOPS defined the private health sector as for-profit private, faith-based, and nongovernmental organizations, as well as the pharmaceutical sector. Private for-profit facilities included individual medical cabinets or clinics, midwife-led maternités, nurse-run cabinets de soins, and other general and specialized medical practices, while the faith-based and nongovernmental sector consisted primarily of hospitals. As part of the census, SHOPS collected data on private health facilities and pharmacies, services offered, and provider characteristics. Private providers and pharmacists were also asked to identify any obstacles to expanding their practice.

SHOPS collected existing information and worked with national health regulatory bodies and private provider associations to develop a comprehensive and current list of all private health care facilities in Benin that was supplemented with snowball sampling during data collection.

The goal of the census was to survey as many facility owners, private providers, and private pharmacists as possible in all 12 departments of the country. Over a seven week period, SHOPS visited a total of 2,850 non-pharmacy private health facilities and completed interviews with 2,462 facility managers and 6,217 private providers in those facilities about their staff, certifications, onsite medical supplies, and training and financing needs. The SHOPS census identified a greater number of non-pharmacy private health facilities than the Ministry of Health census conducted in 2012, which identified 2,197 non-pharmacy private health facilities nationwide. In addition, the SHOPS census identified a total of 324 private pharmacies and completed interviews with 281 of them.

Facility findings: In the census conducted by SHOPS, just over half of Benin’s private health facilities were found in rural areas, but private pharmacies were more likely to be located in urban areas. Nearly half (48 percent) of all facilities were located in the southern departments of Atlantique, Ouémé, and Littoral, with the smallest number (4 percent of facilities each) located in Mono and Alibori departments. The number of private facilities per 10,000 people was highest in Littoral (6.0), Ouémé (4.1), and Atlantique (3.7) departments, and lowest in Alibori (1.2), Donga (1.2), and Atacora (1.0) departments. Nurses’ offices were the most common type of private facility (43 percent). Only 20 percent of rural facilities had access to running water and 45 percent had access to electricity. This census found a reported total of 10,801 beds in private facilities in Benin.

Private facilities identified in the census offered a range of services: 77 percent offered maternal and child health (MCH) services; 48 percent offered reproductive health (RH) or family planning (FP) services; and 27 percent offered human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) services. Among facilities offering FP, injectables were by far the most common method offered (84 percent), followed by oral contraceptives (61 percent) and male condoms (60 percent). While voluntary counseling and testing was the most common HIV and AIDS service, found in 84 percent of facilities that offered such services, only 87 private facilities in the country offer antiretroviral therapy (ART). Sixty-three percent of private facilities x offered malaria testing. Malaria treatment and prevention was the most common service provided in outreach, with 58 percent of facilities providing this service.

Eighty-four percent of private facilities were for-profit; ABMS/ProFam was the largest network with 155 facilities. Forty-seven percent of private health facilities and 83 percent of private pharmacies were registered with the relevant agency. Almost a quarter of those registered private health facilities had not received a supervisory visit from their respective directorate at the Ministry of Health in over a year and 16 percent had never received such a visit. Only 8 percent of private facilities and 27 percent of pharmacies accepted health insurance.

The most commonly cited barrier to expanding private health facilities’ businesses was a shortage of medical equipment (66 percent of facilities), followed by lack of transport (41 percent), and lack of space (36 percent).

With regards to stocking drugs, treatments, and diagnostic tests, cotrimoxazole and amoxicillin were stocked in nearly 75 percent of private facilities. Artemisinin-based combination therapy (ACT) for malaria was stocked in about half of the facilities and almost two-thirds of the pharmacies, but rapid tests kits for malaria were not widely available in these facilities. In addition, the first-line treatments for uncomplicated pediatric diarrhea, oral rehydration solution (ORS), zinc, and the Orasel-Zinc diarrhea treatment kit, were not widely available at private facilities and pharmacies and were frequently out of stock in those facilities that did report carrying them regularly.

Provider findings: During the facility survey, facility managers reported a total of 10,729 providers working in private facilities. The SHOPS team surveyed the 6,217 providers who were present at the time that data collectors visited the 2,462 facilities where facility interviews were completed and who gave their consent to participate. The most common cadres of private providers interviewed in this census were medical aides (49 percent), followed by registered nurses (12 percent). Fifty-two percent of the surveyed providers were concentrated in the southern districts of Atlantique, Littoral, and Ouémé, with Atacora (3.5 percent), and Donga (2.9) having the lowest number of providers of all surveyed. Ninety-two percent worked exclusively in the private sector and 6.5 percent worked at more than one facility.

In terms of training, 20 percent of providers reported that they had been trained on diarrhea treatment with ORS and zinc protocols, 29 percent had been trained on malaria treatment with ACT protocols, and 12 percent had been trained on HIV treatment with ART. Malaria treatment updates (53 percent) and child health updates (39 percent) were providers’ most commonly desired clinical trainings. For supportive trainings, providers were most interested in training on quality assurance systems (48 percent) and communications and counseling (42 percent).

As noted earlier, just under half of the health facilities, but 83 percent of pharmacies, were registered with the relevant agency. Similarly, only half of private providers, including doctors, nurses, dentists, and pharmacists, reported being registered to practice.

The SHOPS private sector census was the first attempt to comprehensively capture the size and geographic distribution of the private health sector in the entire country. The maps created by this exercise and the information obtained from private facility owners and providers can be used by key stakeholders, including the Ministry of Health, USAID, and private provider associations, to inform key policy and programmatic decisions. The resulting maps showing geographic distribution of private facilities enable stakeholders to see where private facilities are located in relation to the population, and identify potential gaps in coverage. Additional district-level maps and analyses can further pinpoint service delivery gaps and identify areas where increased efforts to engage the private sector may be warranted.

1. INTRODUCTION

Benin is a West African country with a population of 9.6 million people, 58 percent of whom live in rural areas. With a per capita gross national income of $780, Benin ranks 167 out of 187 on the United Nation’s Human Development Index (UNDP 2012) with forty-four percent of Beninese below 15 years of age, and 37.4 percent currently living below the poverty line.

According to the most recent Demographic and Health Survey 2011-2012 report, the average Beninese woman has 5 children. Among married women, the rate of use of a modern contraception method is 8 percent, with male condoms and injectables being the most popular methods (INSAE and ICF International 2013). The maternal mortality ratio is 350 per 100,000 live births, and 74 percent of live births have a skilled attendant at delivery (Countdown to 2015, 2012).

The private health sector in Benin consists primarily of a for-profit private and pharmaceutical sector based mainly in the south and faith-based and nongovernmental organizations (NGOs) found mostly in the interior of the country. Private for-profit facilities include individual medical cabinets or clinics, midwife-led maternités, nurse-run cabinets de soins, and other general and specialized medical practices, while the faith-based and nongovernmental sector consists primarily of hospitals. The private sector has the potential to play a larger role in improving the health indicators of Benin. Private expenditures on health currently make up 51 percent of total health expenditures, the vast majority of which are through out-of-pocket payments (93 percent). The private health sector is a significant source of treatment for illnesses among children under five years of age, including diarrhea (approximately 46 percent of cases that sought treatment) and fever (38 percent of cases that sought treatment) (INSAE and ICF International 2013). The private medical and non-medical sector is also an important source for male condoms and oral contraceptives, with 75 percent of women buying condoms and 54 percent buying oral contraceptives from for-profit pharmacies and informal shops (INSAE and ICF International 2013).

The true magnitude and distribution of the private health sector has been largely unknown, with a common perception among stakeholders surveyed from the SHOPS Private Health Sector Assessment in 2012 that unregistered private facilities and providers are vastly underrepresented in official figures. In October 2012, the United States Agency for International Development Benin Mission (USAID/Benin) commissioned the global Strengthening Health Outcomes through the Private Sector (SHOPS) project to conduct a Private Health Sector Assessment that would identify opportunities for increased involvement of this sector. Building on the assessment findings, USAID/Benin requested that SHOPS conduct a census of all private provider facilities in the country to document the size, scope, and characteristics of Benin’s private health sector. This information will give the government of Benin, other health sector stakeholders, and development partners a clearer understanding of the private sector’s ability to contribute effectively to efforts to improve health outcomes in Benin.

1.1 OBJECTIVES

The primary objectives of the private health sector census were to:

Provide stakeholders with an accurate picture of the size, scope, and geographic distribution of the private health sector

Identify gaps in infrastructure, services, and locations of private facilities

Identify gaps in capacity, training, and perceived barriers of private providers

This information is needed to develop effective programmatic interventions to improve the performance of the private sector.

1.2 QUESTIONS

The private provider census sought to answer the following questions:

1. What is the geographic location and distribution of private facilities and private providers throughout Benin? Where are they concentrated (e.g. rural or urban, and by department)?

2. How many private providers are there and what are their characteristics (e.g., years worked, specializations, affiliations, etc.)?

3. What types of services do private facilities offer (e.g., maternal and child health (MCH), family planning (FP), human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), etc.)?

4. What is the reported volume of services delivered by private providers?

5. What trainings would help private providers improve the quality and extent of their services?

6. What are the major barriers to expanding private health practices?

1.3 STAKEHOLDERS

The data collected from this exercise may be used in a number of ways by a variety of stakeholders, including USAID/Benin, especially the Family Health Team; Benin Ministry of Health (MOH) and other government ministries; professional provider associations; networked private clinics and hospitals, such as those of ProFam, Association Béninoise pour la Promotion de la Famille (ABPF), and Association des Oeuvres Médicales Privées Confessionnelles et Sociales au Bénin (AMCES); bilateral USAID projects in Benin; and other multilateral, foreign government, and NGO-funded health sector projects in Benin.

2. METHODOLOGY

A census methodology was used to collect data from health facilities, health providers and pharmacies. SHOPS subcontracted the data collection and entry work to a local research firm, selected through a competitive process, associated with a university in Cotonou.

2.1 INSTRUMENTS AND TARGET POPULATIONS

The SHOPS project team developed three separate questionnaires: a private health facility questionnaire, a private provider questionnaire, and a pharmacy/drug store questionnaire.

The facility questionnaire included 64 questions and was administered to the facility owner or most knowledgeable provider present at the time the survey team visited. It collected data related to the services provided, affiliations and registration status, staffing, and stocks of certain drugs as well as rapid tests for HIV and malaria.

The provider questionnaire included 28 questions and was administered to all providers who were present at the facility at the time the surveyors arrived and were willing to be interviewed. Eligible providers included doctors, midwives, nurses, pharmacists, pharmacist assistants, pharmacy technicians, and specialist practitioners. The provider questionnaire collected data on individual characteristics, provider training, experience and professional affiliation.

The pharmacy questionnaire included 40 questions and was administered to the pharmacy owner or employee most knowledgeable about that pharmacy’s operations at the time of the visit. It collected data on staffing, affiliations, registration status, client volume, and stocks of the same drugs and rapid tests examined in the facility survey.

2.2 OBTAINING LISTS OF FACILITIES

The Benin MOH shared with SHOPS a list of 2,197 private health facilities based on a census conducted in 2012. SHOPS used this list as a starting point to develop a comprehensive list of all private facilities/providers. The local data collection firm contracted by SHOPS augmented this list with information received from departmental and national government offices, donors and other organizations working with private health providers, and professional provider associations.

2.3 TRAINING OF DATA COLLECTORS

Prior to data collection, a SHOPS survey specialist traveled to Cotonou to oversee the training of data collectors, field supervisors, and coordinators. Key elements of the four-day training program included detailed discussions regarding informed consent and ethics, in-depth review of the survey instruments and procedures, and one day for pre-testing the survey. All supervisors and data collectors participated in the pre-testing to gain experience administering the instruments in field conditions. The SHOPS specialist then worked with the local data collection firm to finalize the instruments and field procedures based on the pre-test results.

2.4 DATA COLLECTION

Data collection took place from March through May 2014, facilitated by an introductory letter from the Ministry of Health. The local research firm deployed 39 teams of two interviewers each across six geographic zones: Atacora-Donga; Alibori-Borgou; Atlantique-Littoral; Mono-Couffo;

Zou-Collines; and Ouémé-Plateau. In each commune, the data collection teams worked with local officials (such as the village leader) to supplement the existing lists of facilities, pharmacies, and providers. They systematically identified all private facilities in each locality and then proceeded to visit each one to collect global positioning system (GPS) coordinates and conduct the interviews. If the private facility was closed or if the main proprietor was not available at the first visit, enumerators made up to three re-visits to complete the interviews. The data collection teams also employed “snowball” sampling, in which they asked interviewees about additional private health providers/facilities close by to identify facilities which may not have been included in original lists.

A total of 19 field supervisors accompanied the data collection teams and seven coordinators oversaw the supervisors to ensure data quality control. The field supervisors oversaw the identification of facilities, attended interviews, did daily verification of all completed questionnaires, and conducted verification back-check visits on five percent of the completed interviews. They sent completed and verified questionnaires to the coordinators who also reviewed completed questionnaires and conducted random back-checks during field visits to assure that visits had been done and that information was collected accurately.

2.5 DATA ANALYSIS

The research firm entered the data into three separate CSPro (U.S. Census Bureau and ICF Macro) databases, one each for private facilities, pharmacies, and providers, and submitted them to the SHOPS team in June 2014. The SHOPS team cleaned and analyzed the data from all three questionnaires in Stata v. 12 (StataCorp 2011). SHOPS analysts and geographic information systems (GIS) specialists used ArcGIS ® software by Esri to create maps for selected key analyses.

3. RESULTS

3.1 FACILITY RESULTS

The first part of the results section concerns the facility questionnaire. Section 3.1 is divided into eight parts: geography, infrastructure, providers and staff, affiliation and registration, services, clientele, barriers to expanding business, and drugs/stock. For purposes of this report, the use of the world “facility” denotes the 2,850 non-pharmacy facilities only, unless otherwise specified.

Pharmacy findings are presented separately in section 3.3.

3.1.1 INFRASTRUCTURE

In total, SHOPS identified and visited 2,850 private health facilities and completed 2,462 surveys with facility managers, which is significantly higher than the 750 facilities found in the MOH’s official registries and somewhat higher than the 2,197 private facilities found in the 2012 census.1 Just 117 (4.1 percent) of the identified private facilities refused to participate in the census. Other reasons for non-completion were inability to locate a respondent despite three re-visits (6.5 percent) and finding the facility closed (2.5 percent). The largest category of private facilities surveyed (43.3 percent) was nurse-led offices (Table 1). The remaining facilities were largely medical offices (18.5 percent), maternity clinics (11.2 percent), or clinics (11.0 percent).

TABLE 1. FREQUENCY AND PERCENTAGE OF PRIVATE FACILITIES

Type of structure Number Percent

Nurse’s office 1,066 43.3

Medical office 456 18.5

Maternity clinic 275 11.2

Clinic 271 11.0

NGO clinic 198 8.0

Hospital 40 1.6

Medical specialist’s office 33 1.3

Specialist clinic 31 1.3

Group medical office 22 0.9

Dental office 22 0.9

Biomedical laboratory 16 0.6

Radiology or other imaging office 9 0.4

Physical therapy office 3 0.1

Other 20 0.8

Total 2,462 100.0

Nationwide, 40 percent of facilities had access to running water and 66 percent had access to electricity, but there were differences based on setting. For example, most (65 percent) urban facilities reported having access to running water compared with just 20 percent of rural facilities

There are no updated, comprehensive, readily available statistics on the number of public sector facilities at the commune level for comparison purposes. In general, the public sector is organized into 34 health zones, each with an average of 2.25 communes. The arrondissement health center should be staffed by a nurse, midwife, and auxiliary staff. The commune health center is to be staffed by a doctor, several nurses, and midwives and offers a wider range of health care services. The zonal hospital is the first referral level of specialist care, and should be staffed by a pediatrician, surgeon, and obstetrician-gynecologist. At the top are two layers of referral care—the departmental and the central hospitals. (Adeya et al., 2007).

(Table 2). Similarly, 91 percent of urban facilities had access to electricity compared with 45 percent of rural facilities. Regarding hours of operation, 85 percent of urban facilities and 91 percent of rural facilities reported that they were open 24 hours per day.

TABLE 2. KEY INFRASTRUCTURE INDICATORS OF PRIVATE FACILITIES

Type Of Structure Access To Running Water (%)

Access To Electricity

Open 24 Hours (%)

Urban (n=1,111)

Rural (n=1,351)

Urban (n=1,111)

Rural (n=1,351)

Urban (n=1,111)

Rural (n=1,351)

% n % n % n % n % n % n

Nurse’s office 53.5 201 15.8 109 86.4 325 42.9 296 87.0 327 91.0 628

Dental office 95.5 21 NA 0 100.0 22 NA 0 18.2 4 NA 0

Medical office 71.5 138 22.1 58 90.7 175 48.3 127 82.9 160 93.9 247

Group medical office 71.4 10 12.5 1 85.7 12 75.0 6 85.7 12 87.5 7

Medical specialist’s office 93.6 29 0.0 2 100.0 31 100.0 2 51.6 16 50.0 1

Radiology or other imaging office

100.0 4 20.0 1 100.0 4 100.0 5 25.0 1 0.0 0

Physical therapy office 100.0 2 0.0 0 100.0 2 100.0 1 50.0 1 0.0 0

NGO clinic 70.2 66 32.7 34 94.7 89 54.8 57 86.2 81 96.2 100

Specialist clinic 96.6 28 0.0 0 96.6 28 50.0 1 65.5 19 50.0 1

Clinic 72.4 113 23.5 27 93.6 146 39.1 45 96.2 150 87.0 100

Maternity clinic 48.5 66 18.7 26 94.1 128 41.7 58 99.3 135 95.7 133

Biomedical laboratory 84.6 11 66.7 2 100.0 13 66.6 2 30.8 4 66.6 2

Hospital 90.6 29 37.5 3 100.0 32 87.5 7 100.0 32 100.0 8

Other 100.0 9 36.4 4 100 9 27.3 3 55.6 5 72.7 8

Total (average of all facility types)

65.4 727 19.6 265 91.4 1,016 45.2 610 85.2 947 91.4 1,235

Just over half (58 percent) of private facilities were male-owned (Figure 1). The remaining share was almost evenly split between women (22 percent) and professional organizations and associations (19 percent), with 1 percent jointly owned by both a man and a woman.

FIGURE 1. FACILITY OWNERSHIP BY GENDER

3.1.2 GEOGRAPHIC DISTRIBUTION

As shown in Table 3, close to half of the facilities were concentrated in the southern tip of the country in just three departments (Atlantique, Ouémé, and Littoral). These three departments

Owned by a man 58%

Owned by a woman

22%

Owned by a man and a woman 1%

Owned by an organization/ association

19% together comprised almost one-third of the national population. Comparatively, the three departments with the fewest private facilities (Alibori, Atacora, Donga), located in the north and west of the country, only accounted for an 8.8 percent share of all private facilities.

TABLE 3. GEOGRAPHIC DISTRIBUTION OF FACILITIES BY DEPARTMENT

Department Population (2013)* Number of private facilities Percent of all private facilities

Atlantique 1,396,548 521 18.3

Ouémé 1,096,850 450 15.8

Littoral 678,874 407 14.3

Borgou 1,202,095 278 9.8

Zou 851,623 250 8.8

Collines 716,558 198 7.0

Plateau 624,146 196 6.9

Couffo 741,895 185 6.5

Mono 495,307 115 4.0

Alibori 868,046 106 3.7

Atacora 769,337 79 2.8

Donga 542,605 65 2.3

Total 9,983,884 2,850 100 *Source: L’Institut National de la Statistique et de l’Analyse Economique du Benin, 2013

The overall number of private facilities by department is presented in Figure 2. The five categories (represented by different colors) indicate the five quintiles of the distribution.

FIGURE 2. NUMBER OF PRIVATE FACILITIES BY DEPARTMENT

Looking at the raw numbers of facilities per department only tells a part of the story. Comparing facility numbers with the population in a specific geographic area can highlight differences in access to the private health sector. Using population estimates from the 2013 population census, a calculated ratio of private facilities per 10,000 people in each department demonstrates this differential access. Nationwide, there were approximately 2.9 private health facilities per 10,000 people. The lower facility to population ratios in Atacora, Donga, and Alibori (1.03-1.22 private facilities per 10,000 people) may be indicative of poor access to private facilities in these departments. Comparatively, people living in southern departments have much higher access, with Littoral (6 private facilities per 10,000 people) possessing twice the national average of facilities per 10,000 people (Figure 3). The SHOPS census did not include public facilities and it is uncertain how these ratios compare to those for public sector health facilities in each department.

FIGURE 3. NUMBER OF PRIVATE FACILITIES PER 10,000 PEOPLE BY DEPARTMENT (N=2,850)

Within these departments, there was great variation in how facilities were geographically concentrated. Nationwide, 53.7 percent of private health facilities were located in rural areas, although this was skewed by the urban Littoral department. Excluding Littoral, the rural share ranged from a minimum of 55 percent in Ouémé department to a maximum of 80 percent of facilities in Couffo department (Figure 4).

FIGURE 4. GEOGRAPHIC DISTRIBUTION OF FACILITIES BY DEPARTMENT AND BY

URBAN/RURAL

1.03 1.20 1.22

2.31 2.32 2.49 2.78 2.86 2.94 3.14

3.73 4.10

6.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

N u m b e r o f

F a c il it ie s p e r

,0

P e o p le

0% 20% 40% 60% 80% 100%

Alibori

Atacora

Atlantique

Borgou

Collines

Couffo

Donga

Littoral

Mono

Oueme

Plateau

Zou

Total (average)

Urban facilities (%)

Rural facilities (%)

The number of private health facilities also varied based on zone sanitaire and commune. As shown in Figure 5, within departments there was significant variation in the number of facilities.

This distribution is represented on the color coded map below. The three most populated communes were all in the south: Abomey-Calavi (312 facilities), Seme-Kpodji (129 facilities), and Cotonou (119 facilities). While most of the facilities were located in the south, there were some pockets in the center and northern departments with large numbers of private providers.

For example, Barikora in Alibori department (33 facilities), Kerou in Atacora department (33 facilities), Parakou (98 facilities) and Tachourou (97 facilities) in Borgou department, and Djougou in Donga department (58 facilities) all had numbers similar to what is seen in the southern communes, as expected because these departments have larger cities. See Tables A1 and A2 in the Annex for a detailed summary of the geographic distribution of facilities by zone sanitaire and commune.

FIGURE 5. NUMBER OF PRIVATE FACILITIES BY COMMUNE

As previously mentioned, just over half of all private facilities were in rural areas of the country.

However, this distribution varied based on facility type. Most (65 percent) nurse-led offices were found in rural areas (Figure 6). Medical offices (58 percent), radiology offices (56 percent), and maternity clinics (51 percent) were all also more likely to be found in rural than in urban settings.

Dental offices (100 percent), specialists’ clinics (94 percent) and medical specialists’ offices (94 percent) were almost exclusively located in urban areas.

FIGURE 6. FREQUENCY AND PERCENTAGE OF PRIVATE FACILITIES BY URBAN/RURAL

3.1.3 AFFILIATION AND REGULATION

Eighty-four percent of facilities were not affiliated with a network or franchise in Benin. Of the 461 private facilities that had an affiliation, most (53.1 percent) reported affiliations with “Other” associations/networks, largely meaning local and international NGOs, faith-based organizations, and academic institutions (Table 4). ABMS/PSI/ProFam (33.6 percent) and ABPF (24.3 percent) were the next two largest associations and networks.

TABLE 4. MEMBERSHIP OF PRIVATE FACILITIES IN ASSOCIATIONS/NETWORKS

Association/network Number (n=461) Percentage

Other 245 53.1

ABMS/PSI/ProFam 155 33.6

ABPF 112 24.3

AMCES 39 8.5

ROBS 25 5.4

REBA-Plus 11 2.4

ROAFEM 9 2.0

*Note: Percentages add up to more than 100 since facilities could report registrations with more than one organization

A total of 1,146 private facilities (47 percent) reported that they are registered with a relevant agency or association. However, of registered facilities established before 2014 (n=1,079 facilities), 22 percent had not received any sort of supervisory or accreditation visit from the MOH within the past year and 16 percent had never received an accreditation visit (Figure 7).2

Most facilities that were established in 2014 had not had time to complete their registration at the time of the census, so the

SHOPS team excluded them from this analysis.

0% 20% 40% 60% 80% 100%

Nurse’s office

Dental office

Medical office

Group medical office

Medical specialist’s office

Radiology office

Physical therapy office

NGO facility

Specialist clinic

Clinic

Maternity clinic

Biomedical laboratory

Hospital

Other

Total (average)

Urban (%)

Rural (%)

FIGURE 7. TIMING OF ACCREDITATION VISITS TO PRIVATE FACILITIES REGISTERED BEFORE

2014 (N=1,079)

A total of 941 (38 percent) of the private facilities reported that they at least occasionally send monthly reports to district health authorities. Of these, 13 percent said that they send the reports monthly, but a full 77 percent reported that they do not submit reports with any regular frequency (Table 5).

TABLE 5. FREQUENCY OF SUBMISSION OF MONTHLY REPORTS TO AUTHORITIES

Frequency of monthly data submissions Frequency Percentage

No specific frequency 727 77.3

Each month 125 13.3

Less than one time per month 44 4.7

Once every 2-6 months 19 2.0

Once every 7-12 months 26 2.8

Total 941 100

3.1.4 TRAINING

The survey also collected information on three specific health topics in which staff at private facilities was trained in the past two years: ORS and zinc for diarrhea treatment, ACT protocols for malaria treatment and ART for HIV treatment. Most private facilities did not have employees who had been trained in these priority health problems in the past two years. Just 27.7 percent of facilities had someone who has been trained in ORS and zinc for diarrhea treatment, 37.1 percent for ACT protocols for malaria treatment, and 12.2 percent for ART for HIV treatment (Table 6). The average number of trained providers in each facility for ORS, ACT, and ART were 4.5, 6.1, and 1.8 respectively, but the median number of trained providers was 1 for all three treatments. The census did not collect information on the entities that conducted the trainings.

Less than six months ago

34%

Between 6 and 12 months ago

22%

More than a year ago 22%

Never 16%

Refuse to respond 1%

Don't know 5%

TABLE 6. CLINICAL TRAINING FOR PRIVATE FACILITIES AND PROVIDERS

Training Facilities (N)

Facility

Providers (N)

Providers

Trained providers per facility

(mean)

Trained providers per facility

(median)

Diarrhea treatment with ORS and zinc protocols

683 27.7 1,258 20.2 4.5 1

Malaria treatment with ACT protocols

914 37.1 1,804 29.0 6.1 1

HIV treatment with ART 300 12.2 749 12.1 1.8 1

3.1.5 SERVICES

As part of the census, SHOPS asked facilities about their services offered in three main health areas: maternal and child health, reproductive health and family planning, and HIV and AIDS. Of these health areas, private facilities were most likely to provide maternal and child health services, followed by reproductive health and family planning, and finally HIV and AIDS.

Most (76.8 percent) private facilities offered at least some MCH services. Of these services, sick child services (93.9 percent), prenatal care (74.5 percent), and birth delivery (74.1 percent) were offered most commonly (Table 7). Emergency obstetrical care (24.5 percent), prevention of mother-to-child transmission of HIV (18.8 percent) and vaccinations (17.8 percent) were the least common. “Other” responses primarily included surgery and caesarean sections.

TABLE 7. MCH SERVICES PROVIDED BY PRIVATE FACILITIES THAT OFFER MCH SERVICES

MCH service Frequency (n=1,891) Percentage

Sick child services 1,776 93.9

Prenatal care 1,409 74.5

Birth delivery 1,401 74.1

Neonatal and post-natal care 1,271 67.2

Growth monitoring 987 52.2

Nutrition monitoring 900 47.6

Emergency obstetrical care 463 24.5

Prevention of Mother to Child Transmission (PMTCT) 356 18.8

Vaccination 337 17.8

Other 83 4.4

Almost half (48.2 percent) of private facilities interviewed provided some sort of reproductive health and family planning (RH/FP) service. The most common type of RH/FP service was general family planning, which was available at virtually all (92.3 percent) of these facilities (Table 8). HIV testing was available at 39 percent of these facilities and 13.7 percent provided pap smears.

TABLE 8. RH/FP SERVICES PROVIDED BY PRIVATE FACILITIES THAT OFFER RH/FP SERVICES

RH/FP service Frequency (n=1,187) Percentage

Family planning 1,095 92.3

STI management 668 56.3

Breast examination 645 54.3

HIV testing 465 39.2

Pap smear 162 13.7

Other 28 2.4

Figure 8 shows the location of private facilities offering RH and FP services in Benin. Facilities offering these services generally appear to be concentrated in the southeast of the country, though they were also found in urban areas throughout the country.

FIGURE 8. MAP OF PRIVATE FACILITIES OFFERING RH AND FP SERVICES

The most popular family planning products or services available in the private facilities that offer FP services (n=1,095) were injectables (83.6 percent), oral contraceptive pills (61.4 percent), and male condoms (59.6 percent) (Table 9). The least common were male and female sterilization (3.6 and 5.8 percent, respectively). Noristerat injections accounted for 66 percent of the answers in the “Other” category.

TABLE 9. FP PRODUCTS OFFERED AT PRIVATE FACILITIES THAT OFFER FP PRODUCTS

FP Product Frequency (n=1,095) Percentage

Injectables 915 83.6

Oral contraceptive pill 672 61.4

Male condoms 653 59.6

IUD 350 32.0

Implants (Jadelle) 348 31.8

Cycle beads 288 26.3

Emergency contraception 225 20.6

Female sterilization (tubal ligation) 64 5.8

Other 48 4.8

Male sterilization (vasectomy) 39 3.6

Only 652 private facilities (26.5 percent) offered HIV and AIDS services. The most common HIV services were prevention efforts like HIV counseling and testing (84.1 percent) and safe medical male circumcision (63.5 percent) (Table 10). Only 87 private facilities offered antiretroviral therapy (ART) for HIV positive individuals. Of the 548 facilities offering voluntary counseling and testing for HIV and AIDS services, 268 (or 48.9 percent) report having private counseling rooms.

Of those facilities with private counseling rooms, 76.1 percent (204 facilities) have 1 room, 15.7 percent (42 facilities) have 2 rooms, and 6.3 percent (17) have 3 or more rooms.

TABLE 10. HIV SERVICES OFFERED AT PRIVATE FACILITIES THAT OFFER HIV SERVICES

HIV and AIDS service Frequency (n=652) Percentage

Voluntary counseling and testing 548 84.1

Male circumcision 414 63.5

PMTCT 249 38.2

ART 87 13.3

Other 26 4.0

Figure 9 shows the location of private facilities offering HIV and AIDS services in Benin. Those offering HIV and AIDS services appear to be concentrated in the southeast, with other clinics interspersed in urban areas throughout the country.

FIGURE 9. MAP OF PRIVATE FACILITIES OFFERING HIV AND AIDS SERVICES

Outside of these three health areas, private facilities offered a number of other services. For example, 62.8 percent offered testing for malaria (Table 11). Just over one-quarter (26.6 percent) reported offering “other” services including birth delivery services, ultrasound, ophthalmology, minor surgery, nursing care, and malaria treatment. Fewer than one in five private facilities provided laboratory, dental, radiography, or tuberculosis (TB) testing services.

TABLE 11. OTHER SERVICES OFFERED AT PRIVATE FACILITIES

Service offered Frequency (n=2,462) Percentage

Malaria testing 1,547 62.8

Other 654 26.6

Laboratory 431 17.5

Dental care 273 11.1

Radiography 94 3.8

TB testing 69 2.8

Of the 2,462 facilities surveyed, 98.5 percent reported having counseling rooms. Most (71.4 percent) had one counseling room, 20 percent had 2 rooms, 6.9 percent had 3-10 rooms, and

0.2 percent had more than 10 rooms (Table 12).

TABLE 12. NUMBER OF COUNSELING ROOMS AT PRIVATE FACILITIES

Number of counseling rooms Frequency Percentage

0 36 1.5

1 1,757 71.2

2 493 20.0

3-10 170 6.9

10+ 5 0.2

Total 2,461 100

Inpatient services were available at 62.4 percent (n=1,536) of the private facilities. Of those with inpatient services, the average number of beds in a facility was 7, with a median of 4. This census found a reported total of 10,801 beds in private facilities in Benin. Two percent of the facilities with inpatient services had more than twenty beds, and 6 percent had from 11 to 20 beds (Figure 10).

FIGURE 10. NUMBER OF BEDS IN PRIVATE FACILITIES WITH INPATIENT SERVICES (N=1,536)

Just over half (51.2 percent) of facilities did some type of outreach sensitization activities. The most common services mentioned as outreach were malaria treatment and prevention (58.1 percent), STI/HIV/AIDS treatment and prevention (37.2 percent), and hygiene (33.9 percent) (Figure 11).

5%

18%

20%

18%

8%

6-10 23%

11-20 6%

>20 2%

FIGURE 11. OUTREACH SERVICES CONDUCTED BY PRIVATE FACILITIES (N=1,261)

3.1.6 CLIENTELE

On average, private facilities reported seeing 7 clients per day, with a median of 4 clients. Most (65 percent) clients were female. Polyclinics saw the most daily patients (mean of 43), while nurse’s clinics saw on average 5 patients per day. Only 16 percent of private facilities provided this information based on official registers that track daily patients, while the remaining 84 percent estimated these numbers. On average, private providers reported that about 63 percent of their clients pay full price for services, while 26 percent pay reduced prices, and 11 percent do not pay for services. The proportion paying full price for services ranged from 41.7 percent at physical therapy offices to about 90 percent at dental offices. The proportion paying nothing for services was highest at physical therapy offices (25 percent), group medical offices (14 percent), and NGO clinics (12 percent) (Table 13).

TABLE 13: PERCENTAGE OF CLIENTS PAYING IN FULL OR PAYING NOTHING AT PRIVATE

FACILITIES, BY FACILITY TYPE

Type Of Facility Frequency (n=2462)

Average percentage of clients who pay in full

Average percentage of clients who pay nothing

Nurse’s office 1,051 60.7 11.6

Dental office 21 89.8 1.2

Medical office 445 63.9 11.0

Group medical office 22 62.1 14.4

Medical specialist’s office 29 81.2 8.6

Radiology or other imaging office* 5 80.0 0

Physical therapy office* 3 41.7 25.0

NGO clinic 197 62.4 12.3

Specialist clinic 24 78.8 6.0

Clinic 268 69.0 10.0

Maternity clinic 259 56.6 9.7

Biomedical laboratory* 14 68.2 10.9

Hospital 39 65.2 9.9

Total (n) 2344 62.9 10.9

58% 37%

34% 24%

13% 10% 10%

4% 3% 3%

2% 1% 1% 1% 0% 0% 0%

0% 20% 40% 60% 80%

Malaria treatment and prevention STI/HIV/AIDS treatment and prevention

Hygiene Family planning

Nutrition and growth monitoring of children Prenatal consultation

Vaccination NCD treatment (alcoholism, hypertension,…

Hepatitis viral treatment Acute respiratory infections treatment

Other Blood donation Ophthalmology

Gastric diseases Sickle cell disease

Dermatology Medicines

Percent of Private Facilities

Eight percent of private facilities (n=197) in Benin accepted health insurance. This proportion was highest among clinics (31.5 percent, or 62 facilities), medical offices (13.2 percent, or 26 facilities), and polyclinics and hospitals (11.7 percent, or 23 facilities). The most commonly accepted insurance plans were Africaine des Assurances (57.4 percent), la Fédérale d'Assurances (FEDAS) (44.7 percent), and Nouvelle Société Interafricaine d'Assurances (NSIA) (40.6 percent) (Table 14). The most common “other” choice was a mutuelle de santé with 16 facilities accepting this form of insurance.

TABLE 14: HEALTH INSURANCE PLANS ACCEPTED AT PRIVATE FACILITIES

Insurance plan Frequency (n=197) Percentage

Africaine des Assurances (AA) 113 57.4

La Fédérale d'Assurances (FEDAS) 88 44.7

Nouvelle Société Interafricaine d'Assurances (NSIA) 80 40.6

Gras Savoye 73 37.1

Ascoma 73 37.1

Générale des Assurances du Benin (GAB) 61 31.0

Colina Vie/Assurances 61 31.0

Other 57 28.9

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