Abstract
BackgroundFollowing the successful pilot of the community-based distribution of injectable contraceptives (CBDIC) by community health extension workers (CHEWs) in Gombe, northern Nigeria in 2010, there was a policy decision to scale-up the innovation to other parts of the country. However, there is limited understanding of health system factors that may facilitate or impede the successful scale-up of this innovation beyond the pilot site. Thus, this study assessed the health system readiness to deliver CBDIC in Nigeria and how this may influence the scale-up process.MethodsThis study was conducted in two Local Government Areas in Gombe State in September 2016. Seven key informant interviews were held with purposively sampled senior officials of the ministries of health at the federal and state levels as well as NGO program managers. Also, 10 in-depth interviews were carried out with health workers. All transcripts were analyzed using the thematic framework analysis approach.ResultThe availability of a policy framework that supports task-shifting and task-sharing, as well as application of evidence from the pilot programme and capacity building programmes for health workers provided a favourable environment for scale-up. Health system challenges for the scale-up process included insufficient community health workers, resistance to the task-shifting policy from professional health groups (who should support the CHEWs), limited funding and poor logistics management which affected commodity distribution and availability. However, there were also a number of health worker innovations which kept the scale-up going. Health workers sometimes used personal resources to make up for logistics failures and poor funding. They often modify the process in order to adapt to the realities on the ground.ConclusionThis study shows health system weaknesses that may undermine scale-up of CBDIC. The study also highlights what happens when scale-up is narrowly focused on the intervention without considering system context, capacity and readiness. However, agency and discretionary decision-making among frontline health workers facilitated the process of scaling up, although the sustainability of this is questionable. Benefits observed during the pilot may not be realised on a larger scale if health system challenges are not addressed.
Highlights
Following the successful pilot of the community-based distribution of injectable contraceptives (CBDIC) by community health extension workers (CHEWs) in Gombe, northern Nigeria in 2010, there was a policy decision to scale-up the innovation to other parts of the country
In Nigeria, following the successful pilot of a communitybased distribution (CBD) of injectable contraceptives programme in Gombe State, a decision was taken by the National Council on Health – Nigeria’s highest decision-making body on health – to scale-up the intervention starting with expansion elsewhere in Gombe State and later extending to other parts of the country [1]
Human resource and personnel training challenges The scale-up plan was to extend the service to reach all administrative wards in all Local Government Authority (LGA) in Gombe State
Summary
Following the successful pilot of the community-based distribution of injectable contraceptives (CBDIC) by community health extension workers (CHEWs) in Gombe, northern Nigeria in 2010, there was a policy decision to scale-up the innovation to other parts of the country. Scale-up was intended to ensure that benefits identified during the pilot ( higher contraceptive uptake) [1] were made available throughout the country. This innovation was important in Nigeria, a country with very low contraceptive prevalence rates (CPR) 14.6% for any method and 9.7% for modern methods (condoms, pills, intrauterine devices and implants) [2,3,4]. The low contraceptive prevalence is said to be an important contributor to the unacceptably high maternal mortality ratio of 576 per 100,000 live births with maternal deaths accounting for 32% of all deaths among women aged 15–49 years [7]
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