SECTION 1

Desk Review: SITUATION ANALYSIS

1.1 Introduction: The Global Context

Family planning (FP) is one of the most cost-effective ways to prevent maternal, infant, and child mortality. It can reduce maternal mortality by reducing the number of unintended pregnancies, the number of abortions, and the proportion of births at high risk1. It has been estimated that meeting women’s need for modern contraceptives would prevent about one-quarter to one-third of all

maternal deaths, saving 140,000 to 150,000 lives per year globally. Family planning offers a host of additional health, social, and economic benefits; it can help slow the spread of HIV, promote gender equality, reduce poverty, accelerate socioeconomic development, and protect the environment. Among women of reproductive age in developing countries, 867 million (57%) are in need of contraception because they are sexually active but do not want a child in the next two years. Of these, about 222 million (26%) do not have access to modern methods of contraception, resulting in significant unmet needs.

1.1.1 London Summit on Family Planning

On July 11, 2012, FP stakeholders worldwide assembled for the London Summit on Family Planning. The United Kingdom (UK) government, through its Department for International Development (DFID), and the Bill & Melinda Gates Foundation (BMGF) partnered with the United Nations Population Fund (UNFPA) to host a gathering of leaders from national governments, donors, civil society, the private sector, the research and development community, and other interest groups.

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The meeting deliberated on the renewal and revitalization of the global commitment to ensure that women and girls, particularly those living in low-

resource settings, have access to contraceptive information, services, and supplies. The objective of the summit was to “mobilize global policy, financing, commodity, and service delivery commitments to support the rights of women and girls in the world’s 69 poorest countries to use contraceptive information, services, and supplies without coercion or discrimination by 2021.” Doing so would prevent staggering 100 million unintended pregnancies, 50 million abortions, 200,000 pregnancy/childbirth-related maternal deaths, and 3 million infant deaths 4

The London Summit on Family Planning committed to the following: • Increase demand and support for family planning by removing barriers to its access and use

• Improve supply chains, systems, and service delivery models and procure more affordable high-quality contraceptives through better global coordination, including new methods for expanded choices • Improve market dynamics, including country forecasting capacities and increased availability and quality of a range of FP methods • Promote accountability at the global and country levels through improved monitoring and evaluation (M&E) • Advocate for sustained government and donor funding

Nigeria was represented at the London Summit by a team of experts led by the Federal Ministry of Health (FMOH). At the summit, they committed to increasing domestic funding for family planning. The Federal Government of Nigeria (FGON) committed to disbursing an additional $8.35 million per year specifically for family planning and reproductive health (RH), which translated to about a 300 percent increase.

After the summit’s conclusion, the FMOH team of experts identified the following key steps to ensure the increased uptake of FP services:

Support advocacy Strengthen accountability Improve supply chains Increase contraceptive supply Promote best practices Support new innovations

Nigeria developed the National Family Planning Blueprint (Scale-Up Plan), evolving from the commitments made at the London Summit. It provides a roadmap for achieving the FGON’s goals for improving access to family planning and reducing maternal mortality through a concerted national effort to scale up family planning over five years (2013‒2018) now extended to 2021. The Blue print also provides guidelines and encourages states to develop their state specific family planning costed implementation plans.

1.2 The Nigeria Context

With more than 200 million people, Nigeria is the most populous country in Africa and the seventh most populous country in the world5 . Annual population growth is 3.2 percent, and the total fertility rate is 5.3, with variations across states and regions (NDHS, 2018). Most projections place Nigeria as the third most populous country behind India and China by 2050. There are approximately 48 million women of reproductive age in Nigeria and the country will have an early 7.5 million births in 2017 alone6 .

Nigeria’s Gross Domestic Product (GDP) grew consistently at above 6 percent per year between 2001 and 2014 and experienced a decline between 2015 and quarter 2 of 2017. There is some improvement over time as in quarters 2 and 3 of 2017; Nigeria GDP experienced a positive growth taking Nigeria out of economic recession. However, income inequity remains a key issue in Nigeria. The top 10 percent wealth bracket in Nigeria receives more than 34 percent of the income share, whereas the lowest 10 percent receives less than 2 percent. This pattern

has been relatively stable for the past 20 years. These inequities persist along regional lines, with oil revenues concentrated in the South.

From an RH perspective, the Federal Government is charged with developing policies, strategies, guidelines, and plans that provide direction for the Nigerian healthcare system. However, implementation of these guidelines ultimately falls on the State Ministry of Health (SMOH). Each SMOH is responsible for health programme direction and coordination in its State. The State Ministry of Local Government Affairs (SMOLGA) is responsible for hiring, managing, and paying health workers at the primary healthcare level (as part of the civil service). Each State also has an FP coordinator who facilitates commodity ordering and transportation as well as advocacy. Effecting change in reproductive health requires a concerted effort and clear alignment from the federal government down to the LGAs.

According to the 2018 NDHS, 17 percent of married women of reproductive age (15‒ 49) are using any contraceptive method; however, only 12 percent of these women are using modern FP methods, an increase of 2.2 percent from 2013. This national rate has largely remained at this level since the late 1990s. The modern method mix predominantly comprises condoms, pills, and injectables

5 World Population Review, 2020

6 Health Policy Plus 2017: 4th National RAPID

Figure 1: Nigeria Modern Contraceptive Method Mix, 2015. Source: FP 2020

As part of its FP 2020 commitment, the Nigerian government had set a target of reaching a 36% CPR by 2018 now revised down to 27 percent and extended to 2023. To achieve this goal, the government pledged additional funds starting from 2014 and several donors and non-governmental organizations (NGOs) are currently committed to supporting FP/RH efforts in Nigeria.

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Figure 2: Nigeria Population Pyramid. Source: NBS 2017

1.3 Imo State Context

Imo State is one of the five states in the South-East region of Nigeria. Its capital and largest city is Owerri. The state is inhabited and populated primarily by the Igbos and a few non-Igbo speaking indigenes. Imo state has 27 LGAs: Mbaitoli, Ngor Okpala, Ikeduru, Owerri West, Owerri North, Owerri Municipal, Aboh Mbaise, Ahiazu Mbaise, Ezinihitte Mbaise, Orlu, Nkwerre, Isu, Njaba, Orsu, Nwangele, Oguta, Ohaji-Egbema, Oru East, Oru West, Obowo, Okigwe, Isiala Mbano, Ihitte Uboma, Ehime Mbano and Onuimo. Imo State is bordered by Abia State on the East, Anambra State on the North and Rivers State to the South. The state lies within

latitudes 4°45'N and 7°15'N, and longitude 6°50'E and 7°25'E.

The chief occupation of the local people is farming. The cash crops include oil palm, raffia palm, rice, melon, cashew, cocoa, rubber, and maize. Consumable crops such as yam, cassava, cocoyam and maize are also produced in large quantities.

With an estimated population of 6,135,073 (NPC 2020 estimate) land area of about 5,530sq.km, Imo is primarily an agricultural region and it is a producer of

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yam, potatoes, maize and cassava in Nigeria. The state has several solid mineral resources, including lead, crude oil, and natural gas, but few large-scale commercial mines. The population of women of reproductive age (WRA), 15-49 years is about 1,349,715.99 (WRA is 22% of total population).

1.4 Imo State Family Planning Situation

Imo State contraceptive prevalence rate among married women (including those co-habiting) aged 15-49 is 30.7% though significantly higher than the national average of 17% and is the third among all the states in South East geopolitical zone of Nigeria 7. The modern CPR according to NDHIS 2018 stands at 10.9%. Of all current users, as high as 19.8% use traditional methods while about 2.6% either used condoms, tablets, injections or other methods.

Figure3: South East CPR. Source 2018 NDHS Figure 4: Imo State CPR. Source 2018 NDHS

Imo State has relatively high unmet need for family planning. Of the 1,349,715.99 women of reproductive age, 283,440 (21%) married and sexually active women

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in Imo state want family planning services but currently are not able to access it. The total demand for family planning in Imo State stands at 51.7% (NDHS 2018). According to National Bureau of Statistics Bulletin of 2017, Imo State fertility rate is 5.1, ranking 20th in Nigeria along with Abia and 2nd in the South East zone.

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Figure 5: South East States Fertility Rates as at 2016. Source: NBS Bulletin 2017

1.4.1 Service Delivery

Sources of Family Planning Services: Imo State women seek FP services from both the public and private sectors. Because intrauterine contraceptive devices (IUCDs) and implants require trained service providers, they are usually sourced via the public sector and the private facilities whose staff have been trained on provision of Long Acting Reversible Contraceptives (LARC) services. Condoms and pills are available from a wide variety of sources, including Proprietary Patent Medicine Vendors (PPMVs), pharmacies, and private and public health clinics. Scaling up access through the public and private sectors will increase FP uptake in the state.

Imo State has approximately two thousand one two hundred and eighty-four (2284) healthcare facilities made up of Public (564) and Private (1720). (DPRS)). There are two tertiary healthcare facilities, each in the State providing family planning services with

• Federal Medical Centre (FMC), Owerri and

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• Imo State University Teaching Hospital (IMSUTH), Orlu

The secondary healthcare facilities include 10 State General Hospitals and Imo State Specialist Hospital, Owerri. As at October 2020, 236 out of 564 public health facilities provide FP services (source: Imo FP Unit records).

Figure 6: Sources of FP Services by Method in Imo State

FP Usage in the state: The use of any Family Planning method decreased from 34.1% in 2013 to 30.7% in 2018. However, this was largely because of decrease in the use of traditional methods which decreased almost significantly within the period compared with modern methods that slightly increased from 10.7% to 10.9%. Traditional methods are very unreliable and have the least couple year of protection. More reliable methods such as implants, IUCDs and sterilization remained almost unchanged. However, there was a marked decrease in the use of injectables and condom male from 2013 to 2018. The use of Implants jumped from 0% in 2013 to 1.6% in 2018, a remarkable achievement by the State. This could be due to more aggressive mobilization in the use of implants by the State and Partners

Figure 7: Imo State FP method use 2013 and 2018. Source: 2013 and 2018 NDHS report

Staff Skills and training: there are 236 facilities providing Family planning services in Imo State. Of these 236 facilities, 217 have LARC-trained providers. The target is to have at least one LARC-trained nurse/midwife in each of the 564 public health facilities. So far, the State is far from achieving this target due paucity of fund and a shortfall in the number of development partners to assist the State in capacity building. Currently, only Marie Stopes International Organisation Nigeria (MSION) and Rotary International are responsible for training Nurse/midwifes on LARC in the State and the SMOH remains appreciative of that effort

Figure 8: Imo State human resource capacity. Source: SMOH

Family Planning Human Resource Capacity in Imo State

Figure 9: Imo State Family Planning Coverage. Source: SMOH

Compliance with Task Shifting/Sharing Policy: Task shifting/sharing policy has yet to be domesticated in Imo State. There is need to train CHEWs on the provision of modern family methods, especially the long acting and reversible contraceptives across all rural health facilities to expand service delivery capacity, bridge the biting capacity gap between nurses and CHEWS and to reach more clients.

Provision of Adolescent and Youth-Friendly FP Service: Adolescent and youthfriendly FP services are being provided by Public and Private Sectors in the state. Each of the three Senatorial zones has Adolescent and Youth-Friendly Health Service (AYFHS) Centres and a Focal Person. Many adolescents and youths however still find it difficult to come to these centres to access FP services

because of misconception that only married women should access FP services. Adolescents who seek FP services are often misconceived as being promiscuous by the Service Providers.

FP Service Provision through the Private Sector and the Current Challenges: Private sector health care providers such as private health facilities, CSOs, PPMVs provide

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FP services. Most of them buy their commodities and collect high service charge. The challenge is that most of them do not report their activities hence services provided are not captured on HMIS (DHIS2) and state report. Some private facilities provide services on LARC even though they do not have the necessary training and capacity to do that hence there is urgent need to identify these facilities and evolve a platform to standardize their skills to ensure patient safety.

Human Resource for Health Challenges: Human resource for health (HRH) is grossly in short supply in Imo State. Some of the state’s General Hospitals have only one State employed Medical doctor. There has been a continued

depletion of health workers due to retirement for the past 16 years without any replacement. All State-owned healthcare facilities are currently understaffed.

1.4.2 Supplies and Consumables

The purpose of Contraceptive Logistics Management System (CLMS) is to ensure clients are able to receive the FP method of their choice when needed through existing Service Delivery Points (SDPs). In order to achieve commodity security of contraceptive products, there must be a logistic system that ensures accurate forecasting, procurement, storage, distribution and inventory management of the contraceptive products.

Forecasting: This involves the estimation of the contraceptive products that will be dispensed to users by a program for specific period of time in the future. Currently, in Imo State, forecasting of contraceptive products is conducted by Logistics Management Coordinating Unit (LMCU) in collaboration with a

Partner: Global Health Supply Chain

PSM (GHSC-PSM). However, the LMCU members need to be trained to improve on their health commodities forecasting skills.

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Procurement and Storage: Procurement of contraceptive products is done at the national level and distributed to states from the Federal Central Medical Store to

the State Central Medical Store.

Distribution: The State Family Planning Coordinating Unit through her logistics officer distributes commodities to LGA FP supervisors and focal persons in tertiary and secondary facilities. Family Planning Providers in the public primary health centres pick their commodities from their supervisors at the LGA warehouse. This method, though an improvised one has a major disadvantage as commodities do not get to the SDPs in a timely manner. The coordinating unit does not carry out last mile distribution to the service delivery points due to lack of fund. The Bimonthly (2 Months) Requisition Issue and Report Form (RIRF) is generated at the SDPs and submitted to the coordinating unit by the LGA supervisors for resupply. The State is currently embracing the National Product Supply Chain Management Program (NPSCMP) model of health commodities distribution.

Inventory Management: Within the logistics system, records are kept of all

transactions at each level. Stock cards or Inventory Control Cards (ICC) are used to track movement of products, while RIRFs are used for reporting and LMD matrix is developed using the data from RIRF on the NHLMIS platform. Stock cards are available at the CMS but will soon be distributed to the SDPs. Besides, most health personnel at the SDPs need training on CLMS to enable them to manage the LMIS tools. In addition, the LMCU needs support to conduct quarterly Mentoring and Supportive Visits (MSVs) to SDPs to provide on the job training to staff.

1.4.3 Demand Generation

Demand generation is aimed at increasing awareness of family planning services to the population for uptake of services.

Awareness on Family Planning: According to the 2013 NDHS, contraceptive in Imo State was very high as almost 9 out of every 10 persons were aware of a modern

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method, Awareness of a modern method increased from 92.3% in 2008 to 99.8% in 2013. Evidence shows that increase in awareness has not really translated to demand in FP.

Figure10: Awareness of methods of contraceptives

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Current Demand Generation Activities in the State and How they are Addressing

the Unmet Needs: There is low level of uptake of family planning services in the State due to misconception, religious belief and stereotyped perception of the numerical value of children. Some partners in the past few years have made laudable attempts to reach men and women of reproductive age with key information on family planning and child birth spacing to influence individual and collective actions.

However, more needs to be done to reach all eligible men and women with quality information on family planning services.

As a strategy to increase the awareness on family planning services in the State, Imo State Ministry of Health in collaboration with development partners have developed workable strategies for demand generation and uptake. The strategies include monthly outreach and in-reach activities in communities and health facilities targeted at increasing the uptake of LARC sponsored. This has been consistently sponsored by Marie Stopes International Organization Nigeria (MSION) since 2015. Rotary International is currently supporting the training of 25 health workers on LARC. In June 2019, Action Health Incorporated (AHI) with fund from UNFPA supported the training of 40 Community Health Volunteers (CHVs) on Sayana Press injectable, part of which include demand creation. The role of CHVs is to create awareness in the communities of six pilot LGAs about Sayana Press Injectable contraceptive, refer clients to the nearest SDP for Family Planning and join in the monthly Sayana Press outreach activities sponsored by UNFPA.

The Effectiveness of the Current Demand Generation Activities in Terms of

Increase in Long Acting Reversible Contraceptives Uptake: Very notable among the milestone achievements in this regard in the State is the remarkable increase in the use of implant contraceptives from 0% in 2013 to 1.6% in 2018. This is a testimony to the huge effort of all the Partners and Imo State Ministry of Health.

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IEC and

BCC Tools for Demand Generation: Limited availability

of IEC /BCC materials for demand generation activities continues to be a huge challenge towards efforts aimed at increasing the uptake of family planning Services in the State. Implementing Partners have been responsible for the production of

IEC/BCC materials in the State which are still inadequate.

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1.4.4 Policy and Enabling Environment

As the primary responsibility bearer, the new administration in Imo State

promises to be health-friendly and has demonstrated strong political will to move the health sector forward.

Measures taken to support FP service delivery in the State are:

Establishment of the State Primary Health Care Development Agency backed by legislation;

Financial commitment to the basic health care provision fund (BHCPF) to ensure basic minimum health package for the poor people. Establishment of Imo State Health Insurance Scheme

Financing of MNCH week Programs to ensure scale-up of FP services

However, inadequate human resources for health in the state and Local Government health facilities, and inadequate budgetary provision for FP and delay/or non-release of approved funds are the major challenges that will hamper the successful implementation of the FP services in the state.

Therefore, the priority area of policy and environment focuses on

advocacy for family planning within various levels of government and the private sector, including faith- based organizations, civil society and private providers to ensure that the best policies are available and fully implemented.

1.4.5 Financing

The financing of family planning in Imo State is primarily the responsibility of the Federal, State and Local Government with the support of Development Partners. The Federal Government is saddled with the responsibility of

procuring FP commodities and transports same from their central warehouse to the State. A large chunk (almost 92%) of these commodities and logistics cost is funded by donor agencies. The State Government is expected to

handle last mile distribution of commodities by transporting the commodities to the SDPs, maintain an effective human resource, create demand, maintain and coordinate the operation of the health facilities that provide FP services. However, this is mostly funded by donors. The Local government is expected to support service delivery and human resources as much as possible, but this is often left for other stakeholders to handle.

The state’s investment in human resource and equipment is inadequate as many facilities are understaffed or non-functional. This maybe because the priority of the State Government in recent years has been in the area of infrastructure development and free education and little has been done in balancing this with the need for adequate human resource for health. Since 2014, there has been zero release of family planning budgetary allocation despite the paltry sum allocated to the program.

Worthy of note is that the proposed budget (runs in millions) by the coordinating unit always starkly differs from the final budgetary allocation (runs hundreds of thousand) for Family Planning by the Ministry of Health. No release of allocated funds also limits the state spending and results in making the FP activities largely funded by out of pocket and donor funds.

However, SOML Program for Result (P4R) program is an opportunity to limit the funding gap as it has CPR indicator as one of its major pillars.

Table 1: Family Planning budgetary allocation in Imo State Ministry of Health from 20142018. Source: SMOH

Year Actual Budgetary Allocated Funding Gap Allocation to FP Amount Released

2018 2,000,000 0 2,000,000 2019 500,000 0 500,000 2020 500,000 0 500,000 The Development partners currently supporting the State FP intervention in the State include UNFPA, MSION, AHI, Rotary International, and JSI. They support the state in demand generation, Advocacy, policy and systems strengthening, logistics, service delivery and human resource development.

1.6.4 Supplies and Logistics Management

Most of the facilities that reported usually providing a particular FP method were found to also have it in stock at the time of the survey, but very few of these facilities (especially the public facilities) also had experienced stockouts in the past six months. In the facilities that usually provided IUCDs, 93% also had it in stock at the time of the survey. Of the facilities that usually provided Implanon, it was generally found to be in stock at the time of the survey. Overall, more than 90% of all facilities had injectables and oral contraceptive pills in stock.

All Public HFs reported receiving theirs supplies form either the LGA

Warehouse/store or Central Medical Store which are all Government sources, while 40% of Private hospitals received their supplies from Government sources (LGA store & Central medical store) and 60% either from supporting NGOs and or through market purchase.

95% of public HFs said they did not receive full quantities of contraceptives that they ordered for in the last three months. Reason being that quantities supplied were determined by suppliers based on quantities available in the store.

There was absence of consumables being supplied by Government sources in 99% of Public HFs. This absence, they said, is the major reason most the public HFs charge clients as consumables are either bought out-of-pocket by providers or by clients.

1.6.5 Quality of Care

Most of the FP clients reported receiving services at no cost, satisfied with providers’ quality of care and service delivery and willingness to return to the same facility in future. However, 30% of clients reported paying receiving services at a cost. When asked the reason for the payment, they reported being asked by providers to bring money for either consumables or pregnancy test and other laboratory tests. In these cases, an average of G500 was paid by clients.