Nigeria: Reshaping Nigeria's Family Planning Narrative to Meet FP2020 Goals

Young people in Nigeria know more than we think they do about reproductive health. Take for instance, some teens who shared during a focus group discussion in Abuja how they obtained varying levels of information about sex and contraceptives from their peers.

Yet, we continue to assume they know nothing and deny them access to early, quality, and age-appropriate information. And the result? Early sexual debut, unplanned pregnancies, unsafe abortions and practices. There is also the argument around the rationality of making family planning services exclusive to married people while denying sexually active unmarried people the same access to sexual health services.

As a nation, Nigeria largely aligns with effective global efforts like the Family Planning 2020 vision, a global partnership that empowers women and girls by investing in rights-based family planning information and services.

But beyond the commitments on paper, there are donors, partners, organisations, and people working hard to move from paper to action that addresses these challenges.

Celebrating Legacies
The importance of frontline workers who raise awareness and take family planning services to the last mile cannot be overlooked. Yet just as important are the policy experts who garner both national and global support for family planning policy initiatives.

One person who raised support for better health policies was the Late Professor Babatunde Osotimehin whose work life was spent ensuring equitable access to healthcare, especially as it concerned women and girls. Encomiums poured in from across the global health community when news of his death came in 2017.

Years later, his legacy continues to inspire platforms that advance the issues he passionately devoted his life to. On 19th July 2019, academicians, development experts, and partners gathered at the University of Ibadan for the maiden Annual Professor Babatunde Osotimehin National Reproductive Health Legacy Forum Lecture. The theme of the lecture centred around an initiative that Prof. Osotimehin championed: Family Planning 2020 Goal: Whither Nigeria?

The Academy for Health Development, led by Professor Adesegun Fatusi, convened the event with support from Partnership for Advocacy in Child and Family Health at Scale (PACFaH@Scale). PaCFaH@Scale is a project anchored by Development Research and Projects Centre (dRPC), a not-for-profit organisation that approaches development by building organisational and technical capacities of civil society and government to achieve inclusive development. Professor Fatusi said the annual lecture was a major outcome of the First National Conference on Adolescent Health and Development in Nigeria which took place between 11th — 13th April 2019.

Mrs. Olukemi Osotimehin thanked Fatusi and his team for furthering her husband’s work. She acknowledged the indisputable role of quality and age-appropriate sexual and reproductive health education especially for young girls. This, she said, would help address the incessant cases of sexual abuse recorded in the country. Her advice for parents to start teaching children about their reproductive health from an early age is supported by evidence. Failure to do this usually results in children getting information from wrong sources, which may lead to poor health seeking behaviours.

Professor Emmanuel Otolorin, a close acquaintance of Late Prof. Osotimehin delivered the lecture. He spoke about the life and times of Prof. Osotimehin leading Nigeria’s HIV/AIDS response agency, the Ministry of Health and the United Nations Population Fund (UNFPA) before he passed on.

Family Planning Status Update
The lecture provided an opportunity to dissect Nigeria’s progress with the FP 2020 commitments made at the 2012 London Summit. Less than four months to 2020, how has Nigeria fared? What are the plans post 2020? Wither Nigeria?

Prof. Otolorin analysed Nigeria’s demographic structure and how indices like a high fertility rate and a low contraceptive prevalence rate are potential challenges to the country due to limited resources for a growing population. This positions family planning as a conversation that makes common economic sense. Why have a population you cannot take care of? A growing population continues to take its toll on Nigeria, affecting per capita investment and income, education, employment, power, access to water and other social amenities, insecurity, and human resources for health.

Estimated to be 200 million this year and growing at a rate of 2.6% annually, Nigeria is projected to reach 543 million in 2050, Prof. Otolorin said. “Nigeria’s age-sex-population structure shows that that majority of the people are very young. It is estimated that 44% of the population is 15 years or younger. When we add the approximate 3% of the population that are over the age of 65 years, we realise that that for every working adult in the country, there is one dependent,” he said

Prof. Otolorin revealed that the number of children a woman has in Nigeria, its total fertility rate (TFR), has not reduced significantly over the past 28 years of family planning programming in Nigeria as evidenced by available data. The Nigeria Demographic and Health Survey (NDHS) 1990 put the TFR at 6 while the 2018 data puts it at 5.3, a reduction from 5.5 in 2013. The 2018 NDHS also had 19 as the childbearing age of 18.7% of Nigerians. It is even higher in the northeast at 24.5% and northwest at 28.5%. The number of women who desire to use family planning but are unable to get it also increased from 16% in 2013 to 19% in 2018.

The reasons for these figures could range from lack of access in rural areas and Nigeria’s highly conservative disposition. However, Prof. Otolorin argued that countries that are more religious like Brazil (predominantly Catholics), Egypt (Sunni Muslims) and Iran (Shiite Muslims) all have lower TFRs than Nigeria. So, what are we not doing right? Is the data telling us everything? Are we capturing enough data from private facilities?

Is there a Silver Lining?
Having a large and energetic population of young people can be an advantage for a country but it requires intentional efforts to empower young people, reduce fertility rate and reduce the number of dependents. The 2004 Nigeria National Policy on Population and Development sought to achieve this with a plan to reduce the annual population growth rate to 2% or less, reduce fertility rate by 0.6 children every five years and increase the use of modern contraceptives by 2 points yearly. If these were achieved, Nigeria’s fertility rate would have fallen to 3 children per woman by 2040. The commitments made by the Nigerian Government at the FP2020 London Conference aimed to help achieve these targets.

The commitment involved increasing CPR to 36% by 2018 even though this was reviewed to increasing mCPR to 27% by 2017. The NDHS 2018 showed that our current mCPR is 12%, still far from the target.

The FP 2020 target had associated commitments in the areas of financing, ensuring availability of services and commodities and building sustainable partnerships. Prof. Otolorin shared progress made in these areas such as in the area of sustainable financing with Nigeria releasing counterpart fund of $2.65 million and $3.313 million for 2017 and 2018 fiscal years respectively, leaving a shortfall of $2.02 million for the two years.

In as much as there are challenges to achieve the commitments, they provide opportunities for further action to change the narrative by learning from others. One of the examples cited by Prof, Otolorin was Thailand, which had a pyramid population structure just like Nigeria in the 1970s. But following far-reaching family planning efforts launched in 1971 and the adoption of their population policy, they gained control over their growth rate and in 15 years, cut it in half from 3.2 to 1.6. Use of contraceptives by married couples increased from 15% to 70%. Today, they are the second largest economy in South Asia after Indonesia. What can Nigeria learn from this?

There have been so many donor-funded projects that can now be scaled up for maximum impact across the country with better measurement and evaluation frameworks put in place to measure impact. As pointed out by Prof. Otolorin, these initiatives will be more effective if a design thinking approach is adopted where empathy is adopted, and the beneficiaries are considered first.

On partnerships, the Portfolio Director of the Nigeria Urban Reproductive Health Initiative II (NURHI II), Dr Mojisola Odeku buttressed the role of design thinking in implementing family planning interventions. She said it’s important to strengthen health systems and institutional frameworks to focus on policy implementation using user-friendly operational guidelines. Additionally, she called on partners working in demand and supply sides to stop working in silos.

There is no better time than now for the government to show financial commitment for reproductive health as organisations working in this area continue to get cutbacks on funding. More financial commitments from the Nigerian government will help prevent the shortfall in the availability of family planning commodities predicted by Dr Ejike Orji, the civil society focal person for the FP2020 partnership in Nigeria.

The conversation and the work should continue as we face forward to continue improving the lives of every woman irrespective of location, financial or social status.

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