"I don’t want to be pregnant at this age. I want to continue my education". Says 17-year-old Precious Haruna as she comes out of a patent medicine store in her Karatudu community in Chikum Local Government Area (LGA) of Kaduna State. Precious has come for a counselling session about the injectable contraceptive method she is using. She has just graduated from secondary school and says she is looking forward to her tertiary education. She says she is sexually active and does not want her dream of furthering her education to be scuttled by an unplanned pregnancy. She decided to start using contraceptives when she completed her senior secondary certificate examinations.
In a small, well-stocked medicine store in Karatudu, a rural suburb off the Abuja-Kaduna highway, Mrs. Stella Eko and her sales assistant are busy dispensing drugs to people. She takes time to attend to three women who have been waiting on a bench. The women have all come for issues relating to their use of contraception methods. One after the other, Eko attends to them in a small room demarcated by curtains. "I do this daily,’’ she says after seeing the last of the three women. “After starting them on the products, you have to listen to complaints they have regarding any side effects".
A resident nurse by training, Eko has provided family planning services in her store in July 2018. Her shop carries the “Green Dot” inscription that signifies family planning services are provided in her facility. She is among the over 300 Patent and Proprietary Medicine Vendors (PPMVs) trained alongside 92 Community Pharmacists (CPs) to provide counselling, administer family planning commodities, and report uptake of these commodities in communities across seven LGAs in Kaduna state. The initiative is called IntegratE, implemented by a consortium led by Society for Family Health and co-funded by the Bill & Melinda Gates Foundation and MSD for Mothers.
The project, which started in November 2017, aims to improve access and uptake of family planning services. The overall objective is to improve the contraceptive coverage which currently stands at 37% nationally and 14.9% in Kaduna state according to the 2018 National Demographic and Health Survey (NDHS). The project has three components:
- Train health cadre (nurses, community health extension workers and pharmacy technicians) PPMVs and CPs to counsel and administer oral, injectable and insertable family planning commodities.
- Train non-health cadre PPMVs to counsel and provide oral family planning commodities and condoms.
- Engage, train and deploy community volunteers known as Interpersonal Communications (IPC) agents to advocate and sensitise people in communities on the benefits of family planning and refer women to the services of PPMVs and CPs.
Proximity and trust are vital
Usually located in communities and neighbourhoods, patent medicine stores and pharmacies are normally the first port of call for many Nigerians seeking healthcare. Research has shown that about 62% of Nigerians first seek care from PPMVs when they fall ill. The vendors and pharmacists are usually members of the communities. This makes them strategic influencers for people’s lifestyle and health choices because of the trust built over time. However, the kind of care these outlets provide is limited.
In Nigeria, family planning services are mostly accessed in hospitals and clinics, except for condoms and contraception pills, which can be bought from pharmacies. Nigeria’s adoption of a task-shifting policy in 2014 empowers other health workers to receive training and provide services which were previously provided only by doctors. One of such services is family planning. However, the policy was silent on the provision of these services by PPMVs and CPs.
One of the objectives of the IntegratE project is to present evidence to the Federal Ministry of Health on the impact of PPMVs and CPs in the provision of basic health services, especially family planning. The aim is to make a case for their inclusion in the next revision of the policy, according to Dr. Emeka Okafor, the IntegratE Project Director. He adds that the project received permission from the federal and state Ministries of Health as well as the Pharmacists Council of Nigeria (PCN) to train and allow PPMVs and CPs to provide family planning services in the implementation areas.
IntegratE carried out intensive training for PPMVs and CPs in June 2018, and has continued quarterly retraining since then. The training has built the capacity of the PPMVs and CPs in the areas of client counselling, administration and documentation of various commodities, says Mrs. Samira Umar, chairperson of the Association of Community Pharmacists of Nigeria in Kaduna State. A study conducted by Population Council showed that PPMVs knowledge and skills to administer injectable contraceptives improved significantly after undergoing trainings for some time.
Every community pharmacy and patent medicine store under the project has a register and a summary form from the federal Ministry of Health, with records of family planning commodities dispensed. Reports are sent monthly using the DHIS system to a server housed at the Ministry of Health, and officials of the project go to the stores every month to review the data. Every store has a referral directory used to refer clients to health facilities in the event of adverse effects that cannot be handled at the pharmacy or store.
A community pharmacy owner herself, Umar believes that in addition to giving people an opportunity to access family planning services from locations other than hospitals, clients feel more comfortable with CPs because they get basic care from them.
Safe spaces for Nigerian youth
The availability of family planning services in these outlets encourages young women aged 16-24 to seek reproductive health services. According to Eko, the majority of her clients belong to that age bracket. Precious says she and her friends who use family planning commodities feel more comfortable approaching Eko than visiting h0spitals, for fear of being judged.
This is a challengepolicymakers and health workers should address. The availability of a safe, secure and comfortable atmosphere in health facilities where young people can confidently go to discuss their contraception options and access the services they need, will surely go a long way in reducing unintended pregnancies and empowering young women to have more control over their sexual and reproductive health.
Some family planning options may come with side effects. This a major source of discouragement and often a barrier to the uptake of contraception. Having a place to go helps resolve issues fast and restore confidence. Gloria Patrick, 19, has been using the commodities for close to a year. Gloria experienced some side effects in her first month and promptly rushed to Eko, who counselled and gave her medication. This encouraged her to continue.
Beyond availability, awareness is key
Availability of family planning services is one thing, getting people to use them is another. In providing healthcare services, demand and supply must be balanced to have impact. This is even more necessary in conservative areas like northern Nigeria, where issues like contraception are not fully embraced due to cultural and religious beliefs. This is where the work of IPC agents comes into play. Fatima Yusuf is an agent in the Kabala area of Kaduna metropolis. She goes from house to house, five days a week, to speak to women about the benefits of family planning. Cultural sensitivities are often a hindrance she says, so she uses words that will be acceptable to the people she is conveying her messages to.
The Hausa phrase, ‘Tazaran Iyali’ which means child spacing, has proven to be more welcoming and Fatima uses it to get women to buy into family planning. After the talks, Fatima accompanies interested women to the nearest patent medicine store or pharmacy where they can access services after receiving further advice on best options. This way, Fatima has been able to convince many women like 26-year-old mother of three, Hauwa Ahmed, to start spacing their children.
Even though Hauwa had always wanted to use family planning to space her children, she remained skeptical because she lacked information. Myths around family planning use, like long-term infertility and bleeding, discouraged her. Her fears were assuaged by Fatima, who counselled her repeatedly until she reluctantly agreed about a year ago, when her third child was two years old. Her husband also supported her after the idea was shared with him.
Within a year of adopting family planning, Hauwa said her family is already benefiting. ‘’We want to make sure we can take good care of the children. We want to give them the best education and the only way to do that is to space them’’, an elated Hauwa said, affirming how she intends to allow her child reach five years of age before thinking of having another child. Hauwa now voluntarily advocates for child spacing to her friends and has successfully encouraged some of them to start. The relative affordability of the commodities is encouraging, she affirms. A sachet of 30 pills is sold at N100, injectables N150 and implants N500.
The IntegtratE project must now target the “elephant in the room” when it comes to family planning; Men. Not every woman has an understanding and supportive partner like Hauwa and in many cases in Nigeria, men are the ultimate decision makers. Devoting a special aspect of the project that will focus specifically on men will go a long way in deepening its impact.
Implementers of the project must also liaise with relevant authorities to have a clear plan of how the benefits can be sustained and rolled out at the end of the project in 2021. There is also a need to have strict monitoring of the PPMVs and CPs to ensure substandard commodities are not sold to clients. Monitoring of the non-health cadre PPMVs must also be aggressive to ensure they don’t go beyond the scope they are allowed. For now, young women like Precious and mothers like Hauwa in Kaduna State have been empowered and have greater control over when they get pregnant, enabling them to fulfill the dreams they have for themselves and their families.