REPRODUCTIVE HEALTH AND FAMILY PLANNING

INCREASING ACCESS TO QUALITY REPRODUCTIVE HEALTH SERVICES

Research findings on the state of health in Nigeria indicate a rather poor Reproductive health situation despite government’s investment in the health sector. With a population of 140 million, the growth rate remains high at 3.2% per annum while the total fertility rate Nigeria is 5.7 children per woman. The neonatal mortality rate is 48 per 1,000 live births; the infant mortality rate is 100 per 1000 live births and the under-five mortality rate is 201 per 1000 live births. The maternal mortality rate is 1000 per 100,000 live births (NDHS 2003). Unfortunately the contraceptive prevalence rate (CPR) still remains low (9%) This high mortality rate in part is due to inadequate access to quality family planning and Reproductive Health Services.

ARFH as part of its contribution to reduction in maternal morbidity and mortality is currently implementing diverse intervention projects with support from David and Lucile Packard Foundation (USA), the United Nations Population Fund and ENHANSE Project.

PRIVATE HEALTH SECTOR CAPACITY BUILDING PROJECT IN TWO NIGERIAN STATES

A 2 year project titled Private Health Sector Capacity Building in Two Nigerian States (Kogi and Borno) commenced in December 2005 in collaboration with the Association of General Private Medical Practitioners of Nigeria , Nigerian Private Nurses and Midwives Association, and Patent Medicine Vendors . The project is being supported by the David and Lucile Packard Foundation, USA . The current initiative is the third phase and a build-up on an earlier project which commenced in 1999. To date, the project has been implemented in 8 Nigerian states namely: 140 Facilities in Oyo, Ogun, Gombe; 71 Facilities in Kwara, Kebbi, Yobe; and 30 facilities in Kogi and Borno states. The current phase of the project which will end in November 2007 is being implemented in 30 health facilities (22 doctor and eight nurse-owned health facilities) with demand generation support and referral from the traditional birth attendants, Patent Medicine Vendors and the male advocates. The general objective of this project is to improve maternal health and increase access to comprehensive RH/FP information and services through the private health sectors in the two states thus, contributing to maternal health related millennium development goals (MDGs) in the project sites.

Combinations of strategies being employed include Advocacy, Need Assessment, Baseline Survey, Capacity Building , Service Delivery , Demand Creation and Generation, Partnership and Collaboration, Monitoring and Supervision, Documentation and Dissemination. A total of 191 health workers, drawn from various categories, were trained. This comprised Physicians, Nurses, Auxiliaries, Patent Medicine Vendors (PMVs), Traditional Birth Attendants (TBAs) and Male Advocates. Take-off drugs, instruments, family planning commodities and IEC materials were supplied to each facility to facilitate the immediate integration and provision of quality Reproductive Health and Family Planning Services, HIV testing and referral.

The midterm evaluation results revealed an increased number of facilities providing Family Planning Services since the baseline. This is evident in the average monthly clientele for family planning services at the facilities. The number of facilities using MVA kits for post-abortion care (PAC) increased from 10% to 46% and utilization of family planning services after post abortion care also increased from 89% to 97%. A refresher training programme was also conducted after the mid term evaluation to update knowledge and enhance the provision of quality services.

Group Work by some of the participants during the refresher training for Auxiliaries

Project Accomplishments

The project which is on-going has accomplished the following.

• 30 private health facilities strengthened to provide FP/RH/PAC services
• The project facilitated the establishment of standard procedures in the project clinics to ensure quality management, quality of care and infection prevention procedure.
• There was a consistent and significant increase in the number of clients that received various reproductive health services (June 2006- June 2007).

-Number of clients accepting FP services-79,548
-Number of clients accepting PAC Services -7598
-Number of clients treated for STI- 1,6998
-Number of clients who tested positive to HIV that were referred -285

• Enhanced networking and improved referral of HIV/AIDS cases from the private hospitals to tertiary hospitals.
• Integration of youth friendly services into 30 private health facilities in the two states (15 per state) encouraged the youth to access.

• Poor record keeping by the facilities which necessitates continuous technical assistance.
• The tension during the political election affected regular demand creation activities.
• The request by some of the volunteer male advocates for financial remuneration contrary to agreed voluntary health services including factual information

• The use of TBAs and PMVs increased the demand for non prescriptive family planning methods in the two states.
• Regular update trainings enable providers to be well informed and can further motivate private health workers to be more committed to project implementation.
• Integrating HIV prevention programming into FP services is feasible in the private health sector.
• The involvement of the patent medicine vendors and the TBAs created access to family planning services and provided opportunities for social marketing of non-prescriptive family planning contraceptives.
• Involvement of the PMVs, TBAs and Male Advocates increased demand and utilization of RH/FP services through referral to the project facilities.
• Integrated RH/FP and PAC services in the private health facilities increased FP acceptance.

1.2 ENHANCING THE CAPACITY OF NGOS/CBOS/FBOS TO CARRY OUT REPRODUCTIVE HEALTH/FAMILY PLANNING ADVOCACY

A significant number of NGOs have assumed an important role in Reproductive Health information and service delivery. Many of these NGOs/CSOs/FBOs possess unique potentials and strength that can be harnessed to effectively respond to policy issues in Nigeria ; however they lack the requisite skills to effectively advocate for an enabling environment for RH programmes.

To fill this void, there is a need to systematically build the capacity of NGOs/CBOs/FBOs and major health providers in developing and deploying advocacy skills for the support and implementation of existing policies. The Association for Reproductive & Family Health with support from ENHANSE project is implementing a 9-month project aimed at building the capacity of 12 NGO/CSO/FBO partners in 3 states (Osun, Ogun and Kwara) to enable them conduct advocacy and policy related activities focusing on Reproductive Health/Family Planning issues.

Since project commencement in January 2007, the following activities have been conducted these included: capacity assessment of selected NGOs/CBOs/FBOs in Osun, Kwara and Ogun states, advocacy visits to policy makers and stakeholders in the states, training needs assessment of selected staff of collaborating NGOs/CBOs/FBOs, conduct of training on Advocacy in RH/FP for staff of NGOs/CBOs/FBOs partners and mentoring of trained advocates. Some of the accomplishment of the project are: enhanced knowledge and skills of trainees on the conduct of RH/FP advocacy programmes, formation of a formidable RH/FP advocacy team in the project states linkage and partnership between the NGOs/FBOs/CBOs and the State Ministry of Health and State Ministry of Women Affairs and Information.

One of the p articipants in Osun State , Dr Adenle, presenting a fact sheet on Maternal health to the Traditional Leader - the Ataoja of Osogbo, Oba Iyiola Oyewale Matanmi, one of the key stakeholders visited during the advocacy practicum. With him are the Iyalode of Osogbo (Women Leader)- Chief (Mrs.)Benice Kolade and Mrs Adebola of ARFH.

1.3 COMMUNITY BASED DELIVERY OF REPRODUCTIVE HEALTH & FAMILY PLANNING SERVICES

Community-based programmes have been of immense importance in improving the reproductive health status at the grassroots. In 2005, ARFH with support from the United Nations Population Fund (UNFPA) commenced the implementation of a three(3) year project titled ” Increasing access to Quality Reproductive Health/Family Planning Services at the Grassroots in Five Nigerian States”.

The project is being implemented in 10 LGAs of 5 states of Nigeria – Bauchi, Edo , Gombe, Ogun and Plateau States using trained Community based delivery agents and Male advocates. The strategies being employed are advocacy, capacity building, service provision, male involvement, behavior change communication, monitoring and supervision, evaluation, documentation and dissemination.

A CBD Agent providing information on RH/FP to clients in Gombe State –Northern states

Project Accomplishment

The project which is on-going has accomplished the following.

• Training of collaborating NGO and Local government staff on Management and supervision of CBD projects and Training of Trainers on Community Based Delivery Services
• Training and refresher training programmes for 253 CBD Agents and 50 Male Advocates.
• Provision of non-prescriptive family planning commodities and drugs for the treatment of minor ailments by 253 CBD agents to community members using the drug revolving fund system.
• Provision of RH/FP services, treatment of minor ailments and referral by the CBD Agents.
  • As at June 2007, a total of 158,548 clients had received family planning services; 20,945 pregnant women were monitored and referred while 39,567 clients received treatment on minor ailments.
  • 62,591 people were reached with RH/FP information during health education/outreach activities while the Male Advocates provided RH/FP information to 25,289 male

A key challenge on the project, is the attrition of CBD agents however, this factor is mitigated by re-training other volunteers as CBD agents.

Lesson Learnt

• The project has demonstrated the feasibility of the CBD approach in increasing the utilization of FP services in far-to-reach areas as well as traditionally conservative pronatalist communities.
• The project also demonstrated the effectiveness of male involvement as a pathway to overcoming obstacles experienced by women to the acceptance of RH/FP services.
• The integration of management of minor ailments into family planning service provision increased the clientele of the CBD Agents and in particular, FP use.
• The involvement of significant stakeholders, such as members of the Project Advisory Committee, has facilitated the acceptance of the project and also provided oversight functions to ensure that the CBD agents actively provide services in the community.
• The involvement of the LGA personnel has contributed to the successful implementation of the project. For instance, in Uhunmwode LGA of Edo State when NGO staff failed to perform oversight functions as expected, the LGA personnel played this role.
• The clientele for prescriptive RH/FP services at the PHC centers has also increased based on the mobilization activities and referral of clients by the CBD agents.