Patient-Centred Policy revives Family Planning uptake in Lagos State

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Three years ago, Olubunmi Taiwo, then a mother of three girls, had an unplanned pregnancy. Though she was desperate to have a son, it was not the right time to get pregnant, so she terminated the pregnancy.

“I cried because I was not ready for the baby; it was painful. The day I aborted, I had a dream I gave birth to a boy,” she said. Taiwo knew about family planning but could not afford to invest in such a long-term plan because family planning services were not free. She was also not sure exactly how it worked.

A year after she terminated the pregnancy, Taiwo got pregnant again. This time she did not terminate the pregnancy. She had a baby boy and because she could now access family planning services, she opted for a birth control implant six weeks after giving birth. But this wasn’t because Taiwo’s financial situation had changed, in 2016, the Lagos State Government initiated a policy for all women of reproductive age to access family planning services, free of charge. Taking advantage of this policy, she requested the implant at  the Araromi Primary Health Center in Kosofe Local Government, Lagos.

Taiwo had a baby boy and because she could access family planning services she opted for a birth control implant six weeks after giving birth. Photo credit: Nigeria Health Watch

Nasrat Sulaimon has four children, her last child is 10 years old and from 2009 to date, she has terminated two pregnancies. “I don’t want to do abortion again that is why I collected the family planning service and it was free,” she said. In April 2018, she requested for an implant at the Cardinal Odumbaku Primary Health Centre in Orile Agege Local Government Development Area, Lagos State and she has returned since to receive further services as instructed.

Victoria Fuwa has accessed free family planning services since 2016. After having three children, she decided to use a family planning method because she wanted to space out her pregnancies. “I have an implant and it is up to three years now,” she said, pointing at the implant inserted in her left arm. “I feel good having it. Because of it, I don’t have an unexpected pregnancy and I’m enjoying myself with my husband and I have time to take care of my children.” Fuwa, who received the implant for free at Kosofe Local Government, said her husband was only using condoms, but she didn’t want to take chances.

Victoria Fuwa shows the implant inserted in her left arm. Photo credit: Nigeria Health Watch

According to the United Nations Population Fund (UNFPA), there are no fewer than 20 million Nigerian women who do not have access to safe and effective family planning services and a lack of funds has been identified as a major drawback. According to the 2018 Nigeria Demographic Health Survey (NDHS) only 17% of currently married women and sexually active unmarried women aged 15-49 use any method of contraception, with 12% using a modern method and 5% using a traditional method. This compares with the NDHS in 2013 where Nigeria’s Contraceptive Prevalence Rate (CPR) was 15%, with 10% using any modern method of contraception and 5% using a traditional method.

According to the 2013 NDHS report, the Lagos State CPR was 48%. However, in 2016, when the state developed a family planning costed implementation plan, the document showed that the CPR was 38%. The state recognised the critical importance of family planning, which has been hailed as a development best buy if we are to make progress towards the Sustainable Development Goal (SDG) of universal access to sexual and reproductive healthcare services, including family planning by 2030.  Access to family planning services enables couples to better plan for the number of children they can cater for, reduces unsafe abortions, enables women to recover between deliveries and properly take care of their children. This is key to reducing Nigeria’s maternal and infant mortality rates. 

The Root Cause: Removing the cost barrier to family planning in Lagos
Dr. Ore Finnih, Reproductive Health Programme Officer at the Lagos State Primary Health Care Board, said that in 2015, the state government noticed that women were not taking up family planning services because the services had to be paid for. This was a problem because almost 70 percent of the state’s population preferred to use private healthcare facilities. Some of these private facilities charged about NGN 2,000 for family planning services for each visit, therefore many women opted not to use them.

Access to family planning services enables couples to better plan for the number of children they can cater for. Photo credit: Nigeria Health Watch

To solve the low uptake problem, the state government began by removing the cost barrier, and initiated a policy, which is part of the Lagos State Family Planning Costed Implementation Plan, 2016-2018 to ensure that married women had access to free family planning services in primary, secondary and tertiary healthcare facilities in the state. To ensure this policy was implemented, the state directed all local governments and local government development areas to cover the cost of family planning consumables like cotton wool, iodine, surgical blade, xylocaine, bandage, etc. and to make family planning services free.

In 2017, for the first time, the state government created a line item budget of N50 million for family planning consumables but the budget was not released. The same has also been done in 2019 and it’s yet to be released. “Usually, the family planning budget is inside the reproductive health budget and then we extract the family planning budget from it,” said Finnih. Besides Lagos, Kaduna and Oyo States are reported to also have included budget lines for family planning.

Since the budget for family planning was not released, the Primary Health Care Board decided to extract a budget for family planning from its overall budget to ensure that consumables are made available. “We are hopeful that when the 2019 budget is released, we will have more money for consumables,” Finnih said.

The family planning manager of Odumbaku Primary Health Center, Grace Opadotun, counseling Nasrat Sulaimon on family planning. Photo credit: Nigeria Health Watch  

Family Planning Manager at Cardinal Odumbaku Primary Health Centre, Grace Opadotun, said family planning enrolment figures have increased in her clinic in the past four months, and identified the free services and community outreach as a factor. “We had 75 clients in May,” she said, noting that the number of clients increased when they reach out to rural areas and educate people about the benefits of adopting family planning.

Infusing quality into Family Planning services in Lagos
Lagos State has not only removed the cost barrier to increase uptake of family planning, but the state has also worked to increase the quality of family planning services by going into partnership with Nigeria Urban Reproductive Health Initiative (NURHI) 2 to renovate family planning units in selected local government areas (LGAs). NURHI 2 renovated 54 family planning units in 10 local government areas with separate rooms for counselling and insertion using its innovative 72 hours makeover technique and providing the clinics with consumables.

Dr. Edun Omasanjo, Lagos State team leader said NURHI 2 supports the state government to strengthen service delivery. Photo credit: Nigeria Health Watch

NURHI 2 is a five-year initiative with a vision to eliminate supply and demand barriers to contraceptive use and to make family planning a social norm in Nigeria. The initiative is working in three states, including Lagos State. Dr. Edun Omasanjo, the Lagos State team leader said the initiative “supports the state government to strengthen service delivery and improve and sustain the demand for family planning in the state.”

NURHI 2 offers additional support to the state by training health workers to provide quality family planning services, helping the state to strengthen its data collection processes and supporting the Public Health Sustainable Advocacy Initiatives (PSHAI) to advocate for free family planning services. Supported by Advance Family Planning (AFP) local partner Pathfinder International, Lagos State established Public Health Sustainable Advocacy Initiative (PHSAI) in January 2015.

Unrelenting advocacy
PSHAI advocates to ensure that there is access to family planning for women of reproductive age. Ayo Adebusoye, PSHAI Chairman said accessing the family planning consumables was a barrier and a lot of advocacy has been done to remove the barriers. Adebusoye said that besides its advocacy around funding for family planning, “PSHAI works in all local governments of the state by engaging community leaders and religious leaders who discourage members from adopting family planning. We also organize town hall meetings and community dialogues to ensure women adopt family planning,” he said.

Ayo Adebusoye, PSHAI Chairman said accessing the family planning consumables was a barrier. Photo credit: Nigeria Health Watch

The NDHS 2018 showed that Lagos state CPR rate is now 49.4%.  The state failed to reach its target of achieving a CPR of 74% by 2018 and has now extended the target to 2020. Adebusoye is confident that once the state eliminates supply and demand barriers to contraceptive use, it will meet its CPR target and make family planning a social norm in the state. He identified the non-release of the budget as a drawback, but said PSHAI is committed to advocating for the release of the budget allocated to family planning, as well as continued community advocacy to increase the number of family planning clients in the state.

Many women want to space their children but find it difficult to do so due to hidden fees. The Lagos State Government in initiating its’ free family planning policy, has successfully removed this cost barrier, enabling women of reproductive age to access free family planning services, thereby paving the way to a reduction in the state’s maternal and infant mortality rates.

Although the Lagos State Family Planning Costed Implementation Plan, 2016-2018 clearly lists married women as its primary target, unmarried women and young girls can also access free family planning services in primary, secondary and tertiary healthcare facilities in the State. Other states should take a page from Lagos’ example in order to ensure that family planning services around the country meet the sexual and reproductive health needs of Nigeria’s women and girls. 

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