December 13, 2019

Dr. Ilene Speizer

Dr. Ilene Speizer

Family planning programs in Nigeria have been successful in influencing the population to accept and adopt the practice of family planning and increase usage of modern methods of contraception. However, an adequate plan is necessary to address the sustainability of these effects after the program ends. This is according to research in two new studies from Ilene Speizer, PhD, professor of maternal and child health at the UNC Gillings School of Global Public Health.

The studies collected data from women and health care facilities in two Nigerian cities, Ilorin and Kaduna, which were part of the Phase I roll-out of the Nigerian Urban Reproductive Health Initiative (NURHI). The initiative, working in five-year phases, is funded by the Bill & Melinda Gates Foundation with the goal of improving contraceptive access and use in Nigeria, as well as making family planning a social norm. Phase I ended in 2015, and Phase II is currently underway in Kaduna until 2020.

Understanding the sustainability of a family planning program is important. A program that is sustainable reaps long-term benefits from its investment after it ends, and it can also further the outreach of its message to a broader range of the population, which increases the normalization of family planning. While both studies examined long-term sustainability of the NURHI program in the two Nigerian cities, one study focused on facility-level service quality, while the other focused on the overall sustainable impact NURHI programming had on family planning behavior in Ilorin and Kaduna.

Previous studies have shown that increasing contraceptive use requires providing high-quality family planning services in health facilities. Continuing provision of high-quality services once a program has ended is key to sustaining gains made in contraceptive use. The first study, published in August in BMC Health Services Research, reviewed data from both NURHI and non-NURHI family planning facilities, beginning in 2011 before facilities were supported by NURHI, extending through Phase I completion in 2014, and ending two years post-Phase I (2017).

While the results indicate that quality of service and service use increased at NURHI facilities overall, Speizer and her team found that after Phase I ended, the quality of service increased at a higher pace in the NURHI facilities in Kaduna, where Phase II of the program had been rolled out. This is despite the fact that in 2014 service use was higher in Ilorin, the city where the NURHI program ended in 2015. Both quality of service and service use increased at a lower rate in Ilorin after the program ended.

The second study, published in September in PLOS ONE, examined the post-Phase I outcomes of the NURHI program in Ilorin and Kaduna – specifically, the belief in the need for family planning (ideation) and the use of modern contraception. Using data from 2015 and 2017, Speizer’s team found that while exposure to family planning program activities decreased in Ilorin after program completion, those who were exposed were significantly more likely to use family planning than those who were not exposed.  Similar to the first study, an increase in family planning activities were reported in both cities post-Phase I, but use of contraceptives and belief in the need for family planning continued to increase at a lower rate in the city where the program ended.

Because Phase I of NURHI did not have an explicit plan for sustainability, there is a risk that the effects of the program on social norms around family planning and contraceptive use in Ilorin may eventually fade. The results of these studies identify key factors that should be considered for designing programs that sustain after a program ends. Improving quality of service at the facility level means putting systems in place to prevent contraceptive stockouts, continually training providers and properly maintaining facilities and equipment. At the individual level, designing mass media and print media efforts that are not costly to maintain and can be easily shared beyond the target areas can help to sustain and spread family planning messages into rural areas and beyond.

“Rarely do donors or programs examine what happens after the funding ends,” said Speizer. “In this case, we were fortunate that the donor was interested in this important question and willing to learn from the findings for improving their future family planning programs with an eye toward sustainability and not just designing one-off programs for the duration of the funding. Our findings have been used to help inform these future programs in Nigeria and in the other priority countries of our funder.”

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