In this interview with PMParrot’s LANRE OLABISI and OYELADUN OLABIYI, Mrs. Stella Akinso, the team leader of the Nigerian Urban Reproductive Health Initiative in Oyo State explains how early sexual exposure necessitated the inclusion of adolescent sexual and reproductive health into NURHI’s scope of operation in Oyo State.
She also explained why she believes government needs to do more in the area of reproductive health, especially to reduce maternal mortality. Excerpts:
Please can you kindly introduce yourself?
I am Mrs. Stella Akinso, the State Team leader for Nigerian Urban Reproductive Health Initiative in Oyo State here. The Nigerian Urban Reproductive Health Initiative is a project that seeks to bridge the gap between demand and supply of contraceptives. Basically, what we aim at is to reduce maternal mortality and to make family planning a household affair or a social norm, both at structural level, community and facility levels. So by saying that, family planning should be embraced by all family members because what we are saying is that embracing family planning helps in improving the quality of life, reducing maternal mortality, improving the health of women and those of children. So basically, that is what we intend doing by reducing the barrier between the demand and supply of family planning and to make family planning a social norm.
How was NURHI established? You earlier told us that there was Phase 1 and now you are in Phase 2, can you explain further?
Nigerian Urban Reproductive Health Initiative started in 2009 in Nigeria and at that time in the phase 1, we worked in six cities – Abuja, Kaduna, Ilorin, Benin, Ibadan and Zaria. The project was funded initially by Bill Gates Foundation, and it was meant to ensure that people who resided in urban areas have access to family planning, that is why it is called Nigerian Urban Reproductive Health Initiative. The idea was to bring family planning to people in the urban centers and based on the fact that people usually migrate from rural areas to urban thereby increasing slums. A lot of people get engaged in sexual intercourse and they do not have access to family planning. We used three-pronged approaches in delivering our program namely Advocacy, Demand generation and Service delivery. In our advocacy strategy, we engaged with policy makers, religious and opinion leaders and community members using Bottom-up and Top-down approaches. The advocacy was meant to create a supportive policy environment and to increase funding support for family planning.
We engaged policy makers, religious leaders and other leaders, to get them informed about family planning, for improved understanding of the benefits and the linkage between family planning and sustainable development and how government can save money for developmental activities by embracing family planning. Government needs to be on the driving seat by funding family planning effectively as most family planning programs are largely donor-driven.
The second approach was demand generation which aims to create awareness about family planning among the populace in the urban areas using entertainment, education, social mobilization approaches and using the community people to reach other community members.
And then the last one was service delivery. We found out that if we create demand, where do they access service? They access service in the facility so the thing to do is to train service providers in the knowledge and skills needed to provide quality FP services
So we strengthened the system by developing the capacities of various categories of providers, renovated and equipped health facility and then provided tools for them to work with coupled with on-the-job training and continuous supportive supervision. Five years after the end of the first phase, the end line evaluation showed a significant improvement and a shift from a low contraceptive preference of 18% to 24.4% in Oyo state, this was corroborated with the National Demographic and Health Survey (NDHS) which was conducted in 2013, it was found out that particularly in Oyo State, we had an increase of over 6% of contraceptive prevalent rate (CPR) and so that informed our moving to Phase 2.
At Phase 1, we worked in five local governments, which were Ibadan North, Ibadan North-East, Ibadan North-West, Ibadan South-West and Ibadan South-East. We worked in those five local government areas which are typically municipal but because of the need to cover rural areas based on request and peculiarities of the rural areas, NURHI added 10 additional semi urban and rural LGAs including Oke Ogun areas and Ibadan less cities. Our emphasis in Phase 2 is to scale up NURHI proven models and ensure ownership by government.
The sustainability, scalability and insuring ownership mantra is what NURHI seeks to promote with government. What that means is that those models that have proven to be very effective, the government should embrace.
People believe that your activities at NURHI and that of PPFN are similar, so what is the difference between NURHI and Planned Parenthood Federation of Nigeria?
We are both family planning organizations – however, our strategies are different. I really don’t want to talk about PPFN, and what they do but I know they focus on providing services but our own is based on evidence. We use evidence-based approach to design, review and implement our programs
So for everything we do, we ensure that we find out what is on ground and we ask ourselves, are our strategies working? If they are working, what is working well? If they are not working, we go back to the drawing table and say, this is what we are doing that we are not doing right so we go back to do it. For instance, every six months, we conduct what we call omnibus survey to find out what is happening at the community level, whatever we do, we want to see if it is working in the community. What are the community people saying about our strategies? Again, unlike some other family planning organizations, we embark on system strengthening by building the capacities of critical mass of health providers to provide quality family planning services, we renovate dilapidated health facilities, (sometimes we construct new ones) and we supply state of the art equipment to enhance quality service provision; which others don’t do. If the clinic environment is not appealing, then, many women will not like to access family planning services from such dilapidated facility. Our 72 hours clinic makeover has been uniquely identified with NURHI. We go into a facility on Friday, and by Monday morning we have turned the facility ambiance into something to ‘whao’ about. The state government is particularly appreciative of this unique strategy by NURHI and this has made NURHI a house hold name
Again we ensure that we create awareness among the populace through our radio and TV entertainment education programs and our various social mobilization activities.
Our social mobilization activities also involve neighborhood campaign, door to door to campaign, to talk to people, to give them referral and ask them to go to the facility for family planning. We also conduct community dialogue to get the views of community members on their perception about family planning and their concerns about services they are receiving
For instance, if they have a particular issue with a family planning method or a particular clinic or facility, and then we need to go back to the facility and speak to the providers there, engage the providers to iron things out. We also have different engagements with providers and clients during client/providers interaction that allows the community members to speak about their concerns about family planning and about their concerns within the facility. One of the major challenges from the client’s provider’s dialogue is the issue of payment for services which is expected to be free. However, health providers complain that they do not have consumables to work with because government is not making funds available to purchase consumables. Again, time spent at clinics is long because of shortage of staff. Our responsibility as NURHI is to get government informed about the numerous challenges using advocacy network to address the various issues
We also engage religious/ traditional leaders who are custodians of culture and faith to get their support and further step down the good message of family planning to their various constituencies. The community is our primary target because at the end of the day, our program is aimed at reaching them and transforming their lives.
Once the community access family planning information, they then use the information to make informed decisions about family planning. In effect, the difference between us and other Family planning organization is that we are using wholistic and evidence based approaches to deliver our programs.
Recently, you put something into play called LPAY, can you explain the concept?
LPAY is our adolescent sexual and reproductive health program which is a new layered-on program based on the reality that young people are becoming more sexually active and they lack the needed information to empower them to make the rightful decision about their sexuality.
We started with the adolescent sexual and reproductive health program which actually came up as a result of many requests, even from community leaders asking why are we not involving young people in our program because young people are getting more sexually active. The age of sexual debut has gone down significantly, so you see a young person, 11 year old girl that has already started menstruating, at 14 they are already engaged in sexual intercourse and we conducted a research and found out that in Oyo State in particular, the age of sexual debut has gone down, people are engaged in sexual intercourse at age 14, for several reasons. Some of them because they don’t have money so they exchange sex for money. In fact, we found out that in some of the higher institutions they live couple’s life, I’m sure that you understand what I’m saying, people are living together as couples even when they are not married, sometimes they get pregnant and they go for abortion with its dire consequences.
Our programs cover women of reproductive age (WRA) who fall between ages 15-49 years, which also include adolescent, so in effect, we are working with the age bracket of our target group
Adolescent and contraceptive often raise eyebrows by traditional and religious leaders and parents especially, because of this we focused on ensuring that youth have better life by engaging in healthy practices, this informed our nomenclature of “Life planning for adolescent” which is LPAY.
So, this LPAY started barely six months ago following our research that we conducted and so right now, what we are doing is engaging different stakeholders including institutions. We are working with NYSC, working with higher institutions, polytechnics, tertiary institutions in Oyo state. And then, we are also working with various religious leaders to ensure that they understand why we are mainstreaming adolescent and youth in our program. This is not meant to dole out contraceptive for young people but to pass the right information to young people so they can make decision about what they want. For instance if they want to stay out of sexual intercourse, they have the information and if they are sexually active and they want to continue being sexually active, they have information about contraceptives that they can use to prevent unwanted pregnancy.
But more importantly, it is also to be able to develop the capacity of young people to be able to assert themselves, to be able to determine in life what they really want, to make the right choice so that they are not going to regret their future. All of these information are what we are passing across to them – particularly, the skills that will help them abstain from sexual intercourse, such skill like communication for instance – how can a young person communicate his/her feelings without anybody harassing him/her; negotiation skill, refusal skill, abstinence skill. If you want to abstain, there is a whole lot of pressure outside there, that even when you want to abstain, because of pressure form peers and so many other pressures, it may become difficult.
They may not be able to abstain like they would like to but what our program is doing is to help young people to understand, to be focused and be determined, using the right information we are passing to them to determine whether they want to abstain or not and to make the right choice of whether to stay chaste or to engage in sexual intercourse and if they want to engage in sexual intercourse, the right contraceptive to use so that they do not abort pregnancies and die in the process.
What age do you deem appropriate to engage in sexual intercourse?
It is not right to say what age to engage in sexual intercourse, two year olds are being molested, I’m sure you’ve heard an uncle or a father molesting his two year old daughter so anybody can get raped at any age. In fact people rape one year old, you’ll be surprised. What we know is in the Nigerian culture, you have sex when you get married; it is when you have the certificate that you have sex but you can have sex anytime, when you choose. Like I’ve said, the information that we pass across to help young people stay away from sex, we are putting those information there but if a young person decides, for instance if a girl is going out with a boy and the boy is putting pressure on her saying that if you really love me let’s do it and then the girl is saying no let’s wait and the guy is saying let’s just do it since nobody respects anybody carrying virginity anymore but that’s a lie. People still value those with virginity so these are the information we give to young people, the lies that people tell to get you into sexual activities. So they tell you that virginity is not in vogue again, but people still respect virgins. They have different ways but coming back to your question, there is no age limit; I can’t tell you that this is the age because now, what we are seeing is quite different from what we’ve seen in the past. The message to young people is abstain or use something to protect yourself from sexually transmitted infection and from unplanned pregnancy.
In this local government, you have been talking about women; you did not mention anything about men. Do you offer family planning services to men?
We offer family planning services to men. Most of the services men come for is condom, in fact more men come for condoms than women so we offer family planning services to men and we also engage men so we have male involvement in family planning. For instance we are working with those spare part sellers in gate, we are working with the landlords’ associations, ward development committee members, we are also working with the Okada riders and so on; talking to them about family planning, engaging them and ensuring that we get their buy-in into family planning and tell them to support their spouses to use family planning.
Can you talk about the challenges you face carrying out all your programs?
We still have a lot of myths and misconceptions out there. I will start from the community level, there are still a lot of people despite our engagement with religious leaders – some even go as far as quoting the Bible and Quran with the aspect that is suitable for them, they say Genesis 1;48: “Be fruitful and fill the earth” leaving out the side that God said “Subdue it and have dominion over that which I have given to you.”
We still have people resisting and saying family planning is foreign and of course, because some people have some side effects with family planning so when they go and tell their pastors or imams, they are blowing it beyond proportion and that is because we are having challenges with quacks. We have some people who are not even trained and are not nurses or community health officers, but are are providing family planning services with resultant consequences.
Another problem we are having is that the government is not on the driving seat, they are relying so much on partners and donors. Oyo State government is trying but they need to try more, most of the local governments where we are working are making funds available for consumables and other family planning activities but government needs to do more by making funds available for Family planning programs to work.
The biggest challenge we have is that we do not have health facilities personnel. Since we started this program in 2010 over 50% of those we have trained that have retired and have not been replaced because there is embargo on employment. Government needs to employ trained staff, I don’t know how that is going to be done but that is what we need.