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Family planning: Informal private-sector care providers can provide quality services

Nigeria faces several reproductive health care challenges from high rates of unplanned pregnancies, to adolescent pregnancies and poor sexual and reproductive health education.

Improved awareness, increased accreditation of informal private-sector care providers and public-private partnerships are critical elements that can ensure barriers to accessing and providing family planning services are curtailed.

This means leveraging reviews on the task-sharing and task-shifting (TSTS) policy, subnational decision-makers being aware of national policies and committing to those goals, providers understanding their roles in providing high-quality services and young people being aware of their rights under existing policies.

Another area of improvement that requires attention is the criticality of resources, infrastructure and the political commitment needed to translate policy goals into reality.

Additionally, for far-reaching acceptance and use of family planning services and modern contraception methods, the formalisation of health trained Patent and Proprietary Medicine Vendors (PPMVs) and Community Pharmacists (CPs) is seen to have the potential of dramatically improving access to primary health care access for Nigerians, especially underserved populations, expanding services and supplies through these retail channels in a way that ensures quality and sustainability.

Also, scaling up trained PPMVs and CPs has the capacity to routinely provide service delivery data which can be integrated into the National Health Management Information System. This will provide the country with robust data for decision-making and planning.

Addressing these specific necessities will present an opportunity to rapidly and safely provide expanded family planning services like injectable and implants when properly supervised and supported.

Over time, the failures of the primary health care system have created an overburden on the private health sector and made informal health care more prominent. This necessitates the need for government to hasten to strengthen health care capacity of the 30,000 Primary Health Care centres in Nigeria, of which only about 20 percent is functional.

The Federal Government of Nigeria prioritizes family planning (FP) as a part of an inclusive strategy to reduce maternal morbidity and mortality rates in the country.

In Nigeria, from the National Demographic and Health Survey (NDHS) 2018, the unmet need for contraception among married women is about 19 percent, and the unmet needs among unmarried women are as high as 48 percent.

Most Nigerians have made Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs) as their first point of primary health care, and these PPMVs are popular sources for family planning (FP) due to their widespread availability, ease of access, consistent drug stocks, extended hours, personable interactions, and lack of consultation fees.

To achieve Nigeria’s Modern Contraceptive Prevalence Rate (MCPR) of 27 percent by 2024, the work of initiatives, such as the IntegratE project would guarantee success.

IntegratE is a proof of concept led by the Pharmacists Council of Nigeria (PCN) that provides a structure for development partners and advocacy groups to work with PPMVs and CPs to provide family planning services to identify and implement catalytic interventions for family planning in the area of advocacy, research, capacity development, policy and expansion of the family planning market.

This framework utilised a 3- tier accreditation model that recognises the heterogeneity of PPMVs presenting an opportunity to scale basic health care services especially in rural communities in line with the task shifting and task sharing policy, and considering stratifying the three tiers in line with their eligibility criteria and scope of work.

“The IntegratE project, implemented by a consortium led by the Society for Family Health (SFH) and co-funded by Bill & Melinda Gates Foundation and MSD for Mothers, has since 2017 been working with the Federal Ministry of Health (FMoH).

At inception, the project conducted a GIS mapping of CPs and PPMVs in Lagos and Kaduna States to understand the size, distribution, and characteristics of the providers to enable PCN to categorize the PPMVs into tiers for training and service delivery.

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Between July 2018 and June 2021, 461 CPs and 998 PPMVs enrolled in the IntegratE project were trained in FP based on the tiering system. A mobile District Health Information Software, DHIS2, was developed to aggregate FP data reported on the daily
registers by the trained providers and all CPs and PPMVs were trained on data reporting and documentation using the national tools.

The results from the 27-month knowledge retention studies reveal that CPs and PPMVs have been trained to provide an expanded scope of FP services including FP counseling,
injectable administration, and implant insertion/removal, and this knowledge
can be retained over time.

Leveraging results from the 9-month follow-up, most CPs and PPMVs (94percent) felt that more people in their communities have confidence in the quality of FP services that
they provide, and 85percent agreed that they received more demand for FP as a
result of the training.

However, PCN-3-Tier Accreditation system classifies Tier 1 PPMVs as categories lacking health qualifications and any training. The eligibility for these criteria is the ability to read and write, attainment of 21 years of age, submission of reference from two referees to PCN, Qualified personnel will include those who attempted to obtain a Secondary School Certificate. This tier will be licensed to sell over-the-counter products and manage common illnesses. FP services will include condoms, cycle beads, emergency contraceptives, refill of pills but not initiation, counseling, and referrals.

Tier 2 categories are the health-qualified PPMVs that must fulfill the tier 1 eligibility
criteria. In addition, must possess a Diploma or degree in Nursing or Midwifery
or, CHEWs, CHOs, or any other health qualifications recognized by PCN. PPMV
operators in this tier will be enabled to provide selected PHC services in line with the Task shifting and task sharing policy. They will provide tier 1 services as well as use Rapid Diagnostic Test kits (RDTs), administer amoxicillin DT, conduct HIV Self-Testing, sell self-injecting contraceptives, and refer patients to PHCs and higher-level facilities for nutrition counseling and treatment of any other common ailment.

Tier 3 categories the health qualified PPMVs, these persons must fulfill the tier 1 eligibility criteria and in addition, must be a Pharmacy technician. PPMV operators in this tier will be enabled to provide selected PHC services (in line with the Task shifting and task sharing policy); they will provide tier 1 services as well as use Rapid Diagnostic Test kits (RDTs), administer amoxicillin DT, conduct HIV Self-Testing if trained, sell self-injecting contraceptives and refer patients to PHCs and higher-level facilities for nutrition counselling and treatment of any other common ailment.

“While a significant proportion of CPs and PPMVs have health qualifications, many often do not have the necessary skills and knowledge to competently provide these
services, are not formally recognised as part of the health system, and are prohibited from offering many PHC products and services that they are or could be trained to provide,” said Oluwayemisi Philips, Registered Nurse/Registered Midwife (Tier 2 PPMV), Lagos.

According to Philips, before now, family planning had not been widely accepted but with the IntegratE project, I can say that many people whom we have reached through the advocacy and intervention work have embraced family planning methods. Ordinarily, most people would not want to come to the family planning clinic, except it has gotten to the point where they are advised medically on risks they are exposed to.

Zainab Aliyu, registered nurse/registered midwife (Tier 2 PPMV), Kaduna says people are particular about the cost and that has discouraged turnout but despite that, facilitators of the IntegratE project are putting in their best to change buy-in behaviour.

Family planning requires an added explicit definition as a national public good in Nigeria. Other requirements are increased financing as well as the establishment of
public-private partnerships to accelerate planning and implementation. Improving access to family planning by CPs and PPMVs, and freeing up more time for skilled health workers to focus on providing more complex services would provide for a more efficient family planning service value chain.

According to Abiodun Adediran, CP, Director/ Superintendent Pharmacist, Sybarmedics Pharmacy Ikorodu, Lagos, “Public-private partnerships can be made to work, for those barriers in accessing and provisions of family planning services will be
overcome by such strategic working relationship.”

In Nigeria, family planning is a part of an inclusive strategy by the federal government to reduce the prevalent maternal morbidity and mortality rates. The success of the
IntegratE project has presented evidence-based indications of the ability of PPMVs and CPs to provide quality family planning services and administer quality commodities that will produce better outcomes for women, children and communities. The outcome of this phase of the project is a call for increased multi-stakeholder and multi-sectoral collaboration, increased funding and increased private sector participation in the value chain for family planning.

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