CHALLENGES TO THE

IMPLEMENTATION OF
REPRODUCTIVE HEALTH
SERVICES IN NIGERIA
BY
DR GODFREY IFEYINWA
MPH/MED/36467/2012-13

1
 OUTLINE
• INTRODUCTION
• SITUATION ANALYSIS
-GLOBAL
-NIGERIA
• CHALLENGES TO THE IMPLEMENTATION
OF RH
• RECOMMENDATIONS
• CONCLUSIONS
• REFERENCES

2
 INTRODUCTION
• Reproductive health (RH) is a key facet of
human development) Singh S et al
UNFPA/Guttmacher institute, 2004)
• Improvements in RH have generally lagged
improvements in other health outcomes in
many low income countries
• However, a renewed global consensus on
the need to make progress on MDG5 is
refocusing attention to RH
3
 INTRODUCTION
HISTORICAL PERSPECTIVES
• During the 1960s the UNFPA established
with a mandate to raise awareness about
population and to assist developing
countries on how to address them.
• Population booms
• Scarcity of foods
• Demographic entrapment

4
 HISTORICAL PERSPECTIVES
• In 1972, WHO established the special
programme of research, development and
research training in human reproduction
• In the 70s and 80s population policies in
developing countries became widespread
supported by UN
• Agencies particularly the international
planned parenthood federation (IPPF) were
most prominent
5
 HISTORICAL PERSPECTIVES
• The 1994 international conference on population
and development (ICPD) has been marked as
the key event in the history of reproductive
health
Key concepts
• RH and reproductive rights
• Gender equity and women empowerment
• Integration of population concerns into
development planning
• Population, education and development
6
 HISTORICAL PERSPECTIVES
CONTD
• The recognition by the 1994 Cairo conference
on reproductive health (RH) as an integral part
of an individuals well being critical and central
to human developement is well documented
• The ICPD established a paradigm shift from the
previous concept of MCH/FP to a more
comprehensive approach to RH.
• Lifetime concerns for men and women from
birth to old age .

7
 INTRODUCTION CONTD

• By Definition
• Reproductive health(RH) is a state of
complete physical, mental and social well
being and not merely the absence of disease
or infirmity in all matters relating to the
reproductive system and its functions and
processes. (ICPD, PoA).

8
 COMPONENTS OF RH
• Safe Motherhood Initiatives
• FP information and services
• Prevention and management of the
complications of abortions
• Prevention and management of RTIs
including HIV/AIDS
• Promotion of sexual maturation from pre
adolescents throughout life

9
 COMPONENTS OF RH CONTD

• Elimination of harmful practices

• Management of non infectious conditions of
the reproductive system
• Prevention of infertility and sexual
dysfunctions in both males and females
• Gender equality, equity and male
involvement

10
 COMPREHENSIVE RH SERVICES
• Pregnancy –ante partum care, intra-partum
and post partum care, Immunization services
• STI clinic and health promotional services
• Post abortal care. Safer sex practices and
promotional activities .Family Panning
services
• Infertility clinic services and counselling etc
• Host of other prev. Prom. Cur. and Rehab serv.
• Pre marital, HIV test and counselling etc 11
 RH SITUATION ANALYSIS

Global Burden
• 20 years after the Cairo declaration the facts
speak for themselves
• Every day 800 women die due to
preventable pregnancy and childbearing
related complications. (WHO, 2012).
• For each death 20 more suffer severe
injuries. (UNFPA safe motherhood)
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 GLOBAL BURDEN

• An estimated 222 million women are facing

unmet need for modern method of
contraception leading to-
- 80 million unintended pregnancies
- 30 million unplanned births
- 20 million unsafe abortions. (Guttmach
institute/UNFPA 2012)

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 GLOBAL BURDEN CONTD

• Every year more than 133 million babies are

born, of which 3 million are stillborn,
almost a quarter dying during childhood.
• It is estimated that 60 million girls are child
brides.
• Nigeria, and 9 other countries now
contribute to 60% of all world maternal
deaths burden (WHO, 2014)
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 GLOBAL BURDEN
• The global contraceptive prevalence rate is
57% and as low as 30% in developing
countries. (UN, 2012)
• One out of three girls in developing countries
will be married without their consent before
the age of 18 years. (UNFPA, 2012)
• Despite progress 34 million people are
currently living with HIV/AIDS with 2400
young people infected every day.
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 GLOBAL BURDEN

• An estimated 499 million new cases of

curable STIs occur annually. (WHO,2012)
• The life time risk of physical and / or sexual
violence in women is 7 in 10, and 30%
reported forced first sexual intercourse.
• 140 million women and girls have
undergone female genital mutilation.
(WHO, 2013 )
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 THE NIGERIA SITUATION-THE
EPIDEMIOLOGIC CHALLENGE
• Has a population of 177,155,754 (July 2014 est.)
• Demographic implications
• Age structure
• 0-14 years 43.2%, 15-24 years 19.3%
• Median age 18.2 years (2014 est.)
• MMR-560/100,000 live births, 630 in 2010
• 40,000 maternal deaths occurred in 2013 (WHO)
• IMR- 69/1000 live births 2013, NDHS est.
• U5M-128

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 RH BURDEN NIG.CONTD
• Contraceptive prevalence rate of 15% among
married women NDHS, 2013 est.
• TFR-5.5% (NDHS 2013 est.) 15-49 years,
(2003) 5.7%, and (2008) 5.7%
• Physician density 0.4/1000 pop. (2008 est.)
• More than 97% of Nigerians have no health
insurance coverage. (2008 NDHS)
• Primary infertility rate 3% -2008 NDHS
• The median age of 1st sexual intercourse age 20-24
is18.2years

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 RH BURDEN CONTD

• Overall 20% of currently married woman

have an unmet need for family planning
• RH- related mortality and morbidity
account for almost one-third of the global
burden of disease among women of
reproductive age (World Bank,2010)

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 TRENDS IN CHILDHOOD
MORTALITY (2008-2013)
250

200

150
2003 NDHS
100 2008 NDHS
2013 NDHS
50

0
INFANT CHILD UNDER 5
MORTALITY MORTALITY MORTALITY

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 DIFFERENTIALS IN
CONTRACEPTIVE USE NIG. 2013
NDHS
urban

rural

no education

more than secondary

0 5 10 15 20 25 30 35 40

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 NIGERIA BURDEN

• 61% of pregnant women reported

consulting a skilled health provider (2013
NDHS) with regional differences as low as
17% in Sokoto and as high as 98% in Osun
state.
• Overall 17% of children age 12-59 months
received all basic immunizations on time at
12 months old.
22
 ANC BY A TRAINED PROVIDER
NDHS 2013
100%
90%
80%
70%
60%
50% ANC BY TRAINED
40% PROVIDER

30%
20%
10%
0%
NORTH WEST NORTH EAST SOUTH EAST SOUTH WEST

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 ANC BY RURAL URBAN
DIFFERENTIALS AMONG WOMEN
100%
20-34YEARS
90%
80%
70%
60%
50%
% COVERAGE
40%
30%
20%
10%
0%
RURAL URBAN

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 BURDEN OF DELIVERY CARE
• 38% of deliveries are attended to by a
skilled provider at birth. (35% a decade
ago)
• Only 36% of deliveries take place in health
facilities. (33% ten years ago)
• Urban mothers- 67% delivered in health
facilities (HF)
• Rural mothers- only-23% delivered in HF

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 BURDEN OF DELIVERY CONTD

• Mothers with education more likely to be

attended to by skilled provider-93%
• Mothers with no education-12%
• Births attended to by skilled provider
showing regional differences
• SW-83%, SE-82%
• NE-20%, NW-12%

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 DELIVERY ATTENDED TO BY A
SKILLED PROVIDER
100% WITH MORE
THAN SOUTH WEST,
90% 83%
SECONDARY
80% EDUCATION,
70% URBAN, 67% 93%
60%
50%
40%
30%RURAL, 23% WITH NO
EDUCATION, NORTH WEST,
20% 12% 12%
10%
0%
AREA OF LEVEL OF REGIONAL
RESIDENCE EDUCATION DIFFERENCES

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PLACE OF DELIVERY
NDHS 2008
PLACE OF DELIVERY
OTHERS, 2%

PUBLIC
SECTOR, 20% HOME
PRIVATE SECTOR
PRIVATE PUBLIC SECTOR
SECTOR , HOME, 62%
OTHERS
15%

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 TRENDS IN THE NUTRITIONAL
STATUS OF U5 CHILDREN
45% 42%41%
40% 37%
35%
30% 29%

25% 24%23% 2003 NDHS

20% 18% 2008 NDHS
14% 2013 NDHS
15%
11%
10%
5%
0%
STUNTING WASTING UNDERWEIGHT

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POLICY DEV. AND PROGRAMMES
OF ACTION
• Nigeria since Cairo
• National RH policy
• National policy on pop. and dev.
• National women policy
• Adolescent health training manual and
service guidelines
• Integrated rural health manual.

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• Family Planning standard of practice
• Guidelines for the prevention and control of
STIs, HIV/AIDS.etc

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 CHALLENGES TO
IMPLEMENTION OF RH SERVICES
• DESPITE ALL THESE EFFORTS GAPS
ABOUND
• POLICY LEVEL
• HEALTH SYSTEM LEVEL
• COMMUNITY LEVEL

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 CHALLENGES TO
IMPLEMENTATION
Health Sector Policy Level Challenges
• Weak political will to implementation-
• Mobilising policy and priority setting is weak
• Failure in identifying gaps in policies and
programmes
• Failure to recognise the magnitude of the problem
in the population
• Multisectoral approaches are not fully appreciated
and collaborated

33
 POLICY LEVEL CHALLENGES
CONTD
• Many programmes are being run in vertical
manner
• The information management system is
fragmented and not well coordinated
• Quality assurance plan for most RH services not
available-QC and QI processes
• Failure in seeking commitments from SMOH
and other stakeholders when revising policies
• Lack of investment in reproductive health
research

34
 POLICY LEVEL CONTD
• Failure to create communication channels and
regular opportunities for program managers and
policy makers to discuss
• Failure to identify capacity strengthening needs
in delivery of SRH services
• Policies criminalizing some safe RH health
services
• Failure in enforcing laws regarding RH rights
especially on women, children and adolescents
• Failure to incorporate the the private sector

35
 HEALTH SYSTEM LEVEL
CHALLENGES
Service Delivery-
• Problems accessing Health care-location, poor
distribution-political reasons
• Failure to reach populations that are often at
high risk men, young people and sex workers
• Weak linkage with facilities having better
diagnostic facilities- weak referral system
• Failure to create new or modify existing service
protocol, job aides and information.
36
 HEALTH SYSTEM LEVEL CONTD

• Indicators for monitoring progress is donor

driven-weak HMIS
• Facilities capacity to undertake basic
procedures are still lacking in many instances.
• Essential medicines are either not available or
are out of stock. ART coverage still low

37
 HEALTH SYSTEM LEVEL CONTD
• Failure to develop innovative strategy to
encourage men/husbands/partners seek RH
services for themselves and support their
wife/partner.
• Attitude of Health care workers and
management practices impedes access
• Failure disseminate new /revised service
delivery guidelines and its introduction to
health service managers to ensure
understanding. 38
 HEALTH SYSTEM LEVEL
BARRIERS CONTD
• Failure to sustain capacity building for
upgrading providers in new and revised
procedures
• Lack of communication and communication
skills among HCWs
• Lack of appropriate no of skilled health
attendants e.g. doctor :patient ratio
• Inefficient emergency obstetric Care services
which is key to maternal survival

39
 PROBLEMS IN ACCESSING
HEALTH CARE 2008 NDHS
At least one problem accessing health
care

Concerned no provider is available

Having to take transport

Distance to health facility

Getting money fo treatment

Getting permission to go to treatment

0 10 20 30 40 50 60 70 80

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 COMMUNITY LEVEL BARRIERS
Could be in form of-
• Knowledge- insufficient education
• Attitude-having many children
• Behaviour-health seeking behaviour
• Social and public opinion-old traditions hold
sway
• Gender discrimination-male dom. societies
• Religious, ethnic and racial issues-abortion
taboo. 41
 COMMUNITY CHALLENGES

• Role of traditional birth attendants

• Beliefs (superstitions, myths, misconceptions,
taboos etc very strongly held by communities
• Early age at marriage as low as 12-15 years in
many places
• High fertility rate-
• Low contraceptive prevalence and increase in
the incidence of unwanted pregnancies
• Poor level of rural infrastructure-roads
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 COMMUNITY BARRIERS CONTD
• Lack of decision making power of women,
low status of women
• Concerns about the quality of care at the
health facility
• The role of quacks
• High volume of unmet needs
• Continual acceptance of harmful traditional
practices

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 COMMUNITY BARRIERS CONTD
• Poor access arising from lack of awareness of
effective FP/RH services
• High level of dependence on herbal medicine
and home remedies
• Very low level of male involvement in RH
services
• Economic factors-High levels of poverty is a
huge challenge, women and children high
targets which reduces economic access

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ADOLESCENTS SEXUALITY AND
REPRODUCTIVE HEALTH (ASRH)
CHALENGES TO IMPLEMENTATION
• Large population- Age structure in
population pyramids
• No decision making power
• Easily abused, used as sex slaves, raped.
• Want to explore the world

45
 ASRH CHALLENGES
• Early marriage is common, often involuntary,
and violates international agreements
• Adolescents have a diversity of experience and
needs
• Unintended and mistimed pregnancies are
common
• Risk of Unsafe abortion is high for young
women

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 ASRH CHALLENGES CONTD
• Young women are at risk of unintended
pregnancy, often resulting in unsafe
abortion
• Young married women rarely use
contraceptives, although many want to
avoid becoming pregnant
• Young women are more likely to experience
gender-based violence which is culturally
accepted by both men and women.
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 ASRH CHALLENGES CONTD

• Religious and cultural conservatism are

very pervasive in most regions.
• Youth account for significant share of HIV
burden. Half of all new infections and 12
million globally in 2002 live with
HIV/AIDS.(Pop ref bureau, Washington
DC)

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 ASRH ADOLESCENTS CONTD

• Access to Adolescent Friendly RH services

and information are restricted or non
existing.
• Legal restrictions on abortions-
• Peer pressure and influence(etuk SJ et al
Nig PG med J. 2004) Calabar.

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 ASRH ADOLESCENTS CONTD
• Contraceptive use is low and youth
underestimate risks of unprotected sex
• Current health services are generally not
organized to fulfil the reproductive need
and demands of adolescents.
• In Nigeria today just as in many parts of the
world, leaders, community members and
parents are reluctant to provide education
on sexuality for fear of promiscuity
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 RECOMMENDATIONS
• Political leadership and policy making
• Building Effective health systems
Removing barriers to access to RH
services
• Addressing community challenges
including taking adolescents issues
seriously
• Accountability at all levels
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 RECOMMENDATIONS FOR
POLICY MAKERS
• There should be strong expression of
commitment to RH issues by policy makers
• A renewed policy dialogue to guide investments
in RH issues
• Improvement in the socio-economic welfare
Addressing malnutrition-Community Nutrition
HHFS, water and sanitation
Health care financing options for RH services
• Implementation research should be built into the
design of interventions
52
 RECOMMENDATION CONTD

• Innovations in financing should be built into

action plans
• Tracking resources through the national
health account (NHA), RH sub account
will show actual amount going into PHC
• Reproductive health research- male
involvement, health seeking behaviours-
adolescent sexuality and client satisfaction
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 RECOMMENDATION CONTD
Health System Levels-The government
• Improve quality of care by improving the quality of
existing facilities-re-designing waiting places,
reduction of waiting time, change in attitude etc
• Improving system inputs and processes creates
demand for RH services- contraceptive
consumables IPT, and LLITNs, MVA, and evenTT
• Track access for demand utilization of services-
immunisation coverage, ANC attendees,
institutional delivery by all stakeholders.
54
 RECOMMENDATIONS CONTD
FOR THE GOVT.
• Address issues of inequality in facility
distribution by governments at all levels
• Capacity building in a continuous and
sustained basis –undergraduate, in-service or
on the job
• Ensure standard of care, protocols, and
professional ethics are adhered to by
programme managers
• HCWs motivation should always be
maintained at all levels by all stakeholder. 55
 RECOMMENDATIONS
• COMMUNITY LEVEL-By all stakeholders
• Capacity building of individuals and
communities to demand for services
Focus on-
 Pregnancy complications
 FP, HIV/AIDS, Gender based violence, STIs
 When and were to seek help
 Where to seek help
56
 COMMUNITY REC. CONTD
• Done through community mobilization,
sensitization and awareness creation and regular
review meetings
Target groups-
• Religious leaders
• Traditional leaders
• Opinion leaders
• Community educators
• NGOs and CSOs
57
 COMMUNITY REC. CONTD
• Promoting male involvement by all stake
holders
 Mentoring and sensitization programs on RH
issues, emphasis –
Household decision making
Financial support for their spouse
Nutrition, gender based violence and girl child
education
Girl child marriage
58
COMMUNITY LEVEL REC. CONTD
• The government, NGOs, and CSOs -Develop and
disseminate culturally sensitive media materials on
Behavioural change.
Targets –
Women, young people and other vulnerable groups
on correct SRH information
• All efforts should be made to stamp out female
genital cutting.
• Health seeking behaviours
• Girl child education

59
 COMMUNITY LEVEL REC.

• Capacity building for

• Line ministries- information, women
affairs, education in implementing BCC
programs to help strengthen access to
behaviour change communication for young
people and adolescents
• Women empowerment-social and legal
rights, economic and educational.
60
 CONCLUSION
• In conclusion, it is very obvious that 20 years
after the ground breaking and visionary
programme of action (PoA) of Cairo declaration
their is an unfinished agenda and the urgency
and relevance of ensuring full implementation
still stand, the PoA has inspired policies and
programmes that have improved millions of
lives but critical gaps and emerging issues still
remain unresolved
61
 CONCLUSION CONTD

• All efforts should be mobilised for the

successful implementation to enable the
realisation of full reproductive potential of
all persons.

62
 REFERENCES
• International conference on population and
development (ICPD, Beyond 2014).2013 High
level task force for ICPD
• WHO, 2012 facts sheet. No348, maternal
mortality.
• UNFPA Safe motherhood.
www.unfpa.org/public/mothers
• Guttmach institute & UNFPA 2012 Fact sheet.
NPF(NY).

63
 REFERENCES
• United Nations department for economic
research and social affairs. Population
division 2012. World contraceptive use
2012.
• UNFPA (2012), Report; marrying too young
NY
• WHO (2012) Early marriages, adolescents
and youth pregnancies secretariate report
65th WHA.
64
 REFERENCES

• WHO (2012). STIs- The importance of

renewed commitment to STI prevention and
control in achieving global
sexual/reproductive health
• NDHS 2003
• NDHS 2008
• NDHS 2013 Preliminary report

65
 REFERENCES

• WHO (2013) Facts sheet No 241 female

genital mutilation
• Population reference bureau, Washington
DC
• Etuk SJ et al Nigeria Postgraduate medical
Journal. 2004) Calabar.

66