I recently attended a global conference on family planning filled with learnings that struck a chord – one session had panellists embody the stories of men and women whose access to contraceptive information and services, or lack of it, influenced and affected their lives. One story was that of a young girl who was sexually active but believes standing during sex or jumping up and down after intercourse will prevent sperm transport to the site of fertilisation, thereby preventing pregnancy. You can guess the end of the story.
You might wonder, how anyone will have such line of reasoning but must acknowledge that every knowledge gained was either given or taken and wrong information can be given and taken. Another story was that of a girl living on the street who knew how to prevent pregnancy and wanted to access contraceptives but was denied access and sent out of a health facility. Her friend who also lives on the streets got pregnant and had a baby, but she didn’t want that life because she had a dream of leaving the street and becoming a teacher.
This issue of lack of access to contraceptive information and services is not exclusive to young unmarried women and girls but affects all women as evident in the huge unmet need for family planning in most developing countries, often fuelled by barriers.These barriers are numerous and challenging but the existence of success stories and solutions from around the world presents an uplift –solutions that can greatly address a country’s family planning need, increase contraceptive prevalence rate (CPR), reduce total fertility rate (TFR) and promote the health and economic development of citizens.
African countries like Burkina Faso, Uganda, Malawi and Rwanda are a few models for countries, such as Nigeria whose modern CPR is very low, to learn from.The 2014 Nigeria Demographic Health Survey placed the country’s mCPR at 11.1%; the 2016-2017 Multiple Indicator Cluster Surveys reported an mCPR of 10.8% and the most recent survey, the 2018 National Nutrition and Health Survey reported an mCPR of 17.3%. All these indicates very low use of modern contraceptives in Nigeria even compared with the regional average.
In 2012, Nigeria joined several countries at the FP2020 London summit and made commitment to increase CPR by 2% every year to achieve 36% by 2018. In 2017, this commitment was revised to 27% mCPRby 2020. An action plan (2018-2019) was also developed to guide the realisation of this goal. An observation from the 2012 and 2017 commitment is the Government’s realisation of interdependency in the 2017 commitment, clearly highlighting the potential collaboration of the Government of Nigeria with its partners and the private sector towards the achievement of the commitment.
Consequently, the following policy steps have been taken: the recent launch of three policy documents – “Global Family Planning Visibility and Analytical Network/National Logistics Management Information System”; “National Guidelines on Safe Termination of Pregnancy for Legal Indication”; and the National Depot Medroxyprogesterone Acetate (DMPA-SC) Accelerated Introduction and Scale-Up Plan 2018 – 2022.
In addition, evidence from Population Council’s work on the feasibility of patent and proprietary medicine vendors (PPMVs) to provide injectable contraceptive services and learnings from Uganda provided impetus for the FMoH to include the PPMVs in the DMPA-SC scale-up plan and ignited deliberations on the suitability of self-injection in Nigeria
Despite these policy progress and other country partner efforts, the question lingers “Why is the mCPR for Nigeria among the lowest globally?”
Multi-Sectoral and Youth Engagement
The importance of family planning on economic development had been emphasized by several partners in the development sector including the World Bank and most recently, the Minister of Finance, Zainab Ahmed. The country must understand that family planning is inter-twined with other national priorities such as rural development,gender, women empowerment, education, economic development, youth and demographic dividend in its totality. Hence, the ministry of health must engage other relevant ministries, department and agencies (MDAs) in consultation with beneficiaries to develop a specific national family planning program that is owned and implemented by the government across the country.
Youth remains overarching in all national priorities mentioned which reiterates the necessity of investing in youth-focused programs to advance family planning while ensuring meaningful engagement beyond the tokenistic status quo. In addition, young people must be included,empowered,supported in the family planning community and provided with requisite tools needed to effect change in the country.
Community engagement in this perspective transcends communal borders and the recognition that a place of worship or a place of business, and with the world becoming a global village, the internet, subscribers to a channel and followers of a radio station represents several communities. National, regional, state and community leaders in various spheres need to begin or intensify efforts to promote the idea of smaller and well-spaced families as a positive norm.
Nigeria is predominantly a religious country and we need a mindset reorientation from having the perceived number of children that God ‘put in her loins’ to have to having the number of children that she and your spouse wants and can cater for’ and this cannot happen without the community and religious institutions.
Strengthening Task-shifting Task-sharing Implementation
The potential of the TSTS in improving health service delivery is limitless if implemented at a full scale. With specificity to family planning, the policy provides for the expansion on the range of methods and options available for uptake and promotes access to long-acting methods at health centres and posts, including improving post-partum family planning. Despite these benefits, only 22 of the 36 states have adopted the policy and are currently at different levels of implementation with only a minority at full implementation. With ongoing plans to review the policy, the FMoH must incorporate strategies to ensure all states adopt the reviewed policy within one year for effective implementation, evaluation and promotion of learnings across states.
The private sector plays a huge role in family planning service delivery in Nigeria with the increasing popularity of social marketing in the FP space. Nigeria needs to move from a partnership of initiating conversations with the private sector for support when possible to instituting a formal arrangement through which investments, risks and rewards are shared to advance family planning.
Studies and program suggest that public-private partnership for family planning can be established across five focus areas: financing, service delivery and personnel, health information and communication, medical products and innovative technology, and leadership and governance. The government has made relevant effort including the partnership with John Snow, Inc. for FP commodity forecasting.
Notwithstanding, much more is needed including building partnerships with social marketing ventures and NGOs that drive demand generation and the prompt inclusion of the private sector facilities including PPMVs (within their legal framework) in the National Health Management Information System (NHMIS). These discussions on the integration or synergy between the public and the private sector need to commence specially to fully fulfil its coordinating role, monitor quality of care and data reporting and management.
Financing the Health Sector
This is often highlighted as the most important as other strategies are dependent on financing. Investing in family planning leads to a lifetime of returns across health, quality of life, economic growth and stability. Nigeria committed to spending 15% of its budget on health through the Abuja Declaration in 2001 but has never met this commitment with current estimates at about 4%. In the FP blueprint, approximately US$600 million is needed between 2013 and 2018 to achieve Nigeria’s FP goals.
Nigeria is one of the ten largest recipients of donor funding but differ from India, Bangladesh, Pakistan, Egypt, the Philippines, and Kenya who are also top recipient but have huge domestic government funding. The federal government of Nigeria needs to invest more than $8,520,000 which smaller countries like Niger and Burkina Faso who have a total population of ≥50% of women aged 15-49 are investing. Universal health coverage is an area the government must invest in including the integration of family planning within UHC to ensures citizens gets quality care and the sustainability of family programs.
There’s a common saying “put your money where your mouth is” which means to show by your actions and not just your words that you support or believe in something. The Federal Government of Nigeria needs to embody this quote.
About the Author
Chiamaka Uzomba is the Program Director at Active Voices and a recognised young leader and influencer on gender-based violence; and sexual and reproductive health research and programs.