Resilient & Accelerated Scale-up of DMPA-SC/Self Injection in Nigeria (RASuDiN)

Resilient & Accelerated Scale-up of DMPASC/Self injection in Nigeria (RASuDiN) project is funded by the Bill and Melinda Gates Foundation and Children Investment Fund Foundation (CIFF) to expand the acceptance, utilization, availability and accessibility of DMPA-SC within a broader contraceptive method mix, and kick start the rollout of Self-injection among women of reproductive age in 10 states (Lagos, Oyo, Ogun, Enugu, Anambra, Delta, Rivers, Kwara, Niger and Plateau) in Nigeria from 2018 to 2021.

ARFH as the principal recipient of the grant implements the project in collaboration with the Centre for Communication and Social Impact (CCSI) Nigeria, as the Social Behavioural Change Communication (SBCC) partner and it is been coordinated by the Federal Ministry of Health. The RASuDiN project aims to contribute to reducing maternal and infant morbidity and mortality by presenting opportunities to expand voluntary access to contraceptives and family planning services through the introduction, rollout, and scale-up of DMPA-SC self-injection within a broader contraceptive method mix among women of reproductive age in Nigeria. 

To enhance the resilience and sustainability of the project, ARFH is working with key government agencies and partners at the state and national levels. At the state level, the project activities are conducted in collaboration with the State Ministry of Health, SPHCDA, the media (for SBCC), and key community stakeholders comprising of traditional and religious leaders, youths, and male community members. The joint stakeholders’ inclusion is to promote maximum support, commitment, active local involvement, improve community-health facility linkages and sustainability of the project.

RASuDiN is one of Nigeria’s Scale-up models of commitment by the Government of Nigeria  to expand the acceptance, utilization, availability, and accessibility of DMPA-SC within a broader contraceptive method mix and kick start the roll-out of Self -injection among women of reproductive age

Project Goal

To increase acceptance, utilization, availability and accessibility of DMPA-SC as a family planning method within a broader contraceptive method mix among women of reproductive age in Nigeria.

Project Objectives

1. To enable the introduction and scale-up of DMPA SC – by maximizing and supporting government stewardship and key stakeholders in creating a favorable policy and community environment for health facility, community and self-injection (SI) based service delivery of DMPA-SC.
2. To optimize service delivery channels – through capacity building of different cadres of health workers (Nurses, Midwives, CHEWs), community resource persons (CORPS) and women who wish for self-injection. This is to ensure DMPA-SC reaches new users and expands method choice and access for women in hard-to-reach areas.
3. To generate demand for service uptake – by promoting information and social behavioural change communication on contraceptives and family planning service, supporting women who chose to self-inject DMPA-SC and improving efficient referral linkage between the community and primary health center for other methods and health services. This is to ensure increase in new acceptors and continuation rate for existing users towards increasing the Modern Contraceptive Prevalence Rate in Nigeria.
4. To optimize the use of data – by ensuring proper capturing and documentation of project service implementation data, self-injection rates and capturing of essential indicators for result tracking for efficient and evidence-based programming.

Implementation Approaches

Stakeholder Engagement, Capacity Building, Demand, Supply & Theory of Change, Demand Generation, Service Delivery (both at facilities and communities) and Evidence based research activities in collaboration with other implementing partners.

Program Innovations:

1. Hub-Spoke approach: to strengthen synergy between the CORPs and facility service delivery, data reporting and supervision.
2. Total saturation: continuous expansion to ensure total coverage especially to moribund and non-reporting facilities in the 217 LGAs across the 10 project states.
3. Government Ownership and sustainability enhanced at all levels: engagement of FMoH, NPHCDA, SMoH and SPHCDB by building the capacity of State FP coordinators and LGA Supervisors on coordination, quality improvement and Health Systems strengthening.
4. Boosting Service Delivery in low-performing LGAs: service surveillance and evidence based data analysis and reporting lead to supportive supervisory visits and mentorship directed at the affected facilities and communities accordingly.
5. Integration of COVID-19 Messages as the new normal: This represents a two-pronged approach to enlighten women about COVID-19 while advocating on DMPA-SC/SI FP method
6. Use of mass and social media to counter myths and misconceptions with clarifications on side effects.
7. Trained 13,231 providers on DMPA-SC/SI and Quality Improvement (QI) services, comprising 12,361 facility providers and 870 Community Oriented Resource Persons (CORPs).
8. Trained 676 Community Volunteers (CV) on strategic DMPA-SC/SI demand generation.

iii.       Over 10-fold increase in DMPA-SC/SI uptake from 17,810 clients in year 1 to 194,295 clients in year 2. 8

1. Self-Injection (SI) recorded a remarkable increase from 5 clients in year 1 to 4,157 clients in year 2 across the 10 project states.
2. Progressive spike in SI during the peak of the COVID-19 pandemic as a result of the door-to-door service delivery by the CORPs.
3. Contribution to other FP method mix.

vii.      Another 4,353 women were referred to the facilities by CORPs for other long-acting reversible methods (LARC).

viii.      The project recorded a 20% increase in DMPA-SC/SI with a 30.7% continuation trend at the peak of the COVID-19 pandemic (between March and April 2020).

Following the successful training of facility-based providers, CORPS and Community Volunteers on DMPA-SC/SI/SI in the first year, and subsequent recruitment, training of new and retraining of existing providers, demand generation and service delivery continued across all the health facilities and communities. This resulted in a significant increase in DMPA-SC/SI/SI uptake across the 10 implementation states; at the end of the reporting period, the total utilization of DMPA-SC/SI showed a remarkable increase from 17,889 in year 1 to a cumulative total of 608,778 as of the end of year 3 implementation period (August 2018 – July 2021).

Table 1: DMPA-SC/SI uptake at the end of year 1, year 2, and year 3

STATE	Baseline	Total utilization by end of Year 1	Total utilization by end of Year 2	Total utilization by end of Year 3	Cumulative DMPA-SC/SI utilization	SI at end of year 1	SI at end of year 2	SI at end of year 3	Cumulative SI Uptake
Anambra	226	1,958	14,248	26,991	43,192	0	344	1142	1486
Delta	41	996	19,412	36,308	56,716	0	104	822	926
Enugu	55	1,681	14,757	26,749	43,187	0	772	3494	4266
Kwara	36	902	14,021	27,314	42,237	0	331	1290	1621
Lagos	465	3,545	23,771	42,622	69,938	0	633	2213	2846
Niger	305	2,485	40,992	80,827	124,304	0	795	5912	6707
Ogun	172	2,541	19,895	30,175	52,611	5	355	979	1339
Oyo	209	2,747	31,511	53,531	87,789	0	463	3535	3998
Plateau	35	385	10,769	31,199	42,353	0	143	3682	3825
Rivers	294	649	18,643	28,159	47,451	0	250	1538	1788
Total	1,838	17,889	208,019	383,875	609,778	5	4,190	24,607	28,802

Milestones

Demand Generation

1. There was 28% increase in the number of people reached through social mobilisation activities in year 3 (493,638) when compared to year 2 (316,730).
2. Strategically expanded the scope of social mobilisation (SM) activities by 13%, to accommodate more activities to reach the hard-to-reach target audiences. Amongst five different types of SM activities conducted, 42% were door-to-door neighbourhood campaigns. A total of 31,191 SM activities were successfully conducted in Year 3 when compared to 24,182 SM activities implemented in Year 2. These activities boosted FP service delivery in the implementation states.
3. Expanded the scope of RASuDiN social media campaign and online youth engagement activities to reach more audiences via Twitter, Instagram, and Facebook platforms.
4. Supported Federal Ministry of Health and other Partners to produce FP SBC materials that provide correct information and create awareness for DMPA-SC/SI method.
5. Strategically increased male involvement and spousal communication for FP through the radio program.
6. The project implemented the following activities on its journey to self-reliance.
   1. Strengthened capacity of the existing 676 state-owned social mobilisation agents (CVs) to create awareness for DMPA-SC/SI within the general FP method mix.
   2. Conducted refresher training for the CVs to address capacity gaps identified during the course of monitoring field activities.
   3. Trained state-based FP coordinators/experts as resource persons for RASuDiN radio program; for ease of program ownership.

FP Service Delivery

1. Over 65% increase in DMPA-SC/SI uptake from 208,019 clients in year 2 to 383,875 clients in year 3.
2. Self-Injection also recorded 5-fold increase from 4,190 clients in year 2 to 24,607 clients in year 3 across the 10 project states.
3. Leverage on all stakeholder engagements and SSVs to ensure last mile distribution of FP commodities, SBC materials, and other project documentation tools.
4. Strategic focus on increasing youth access to DMPA-SC/SI and self-injection and roll-out of service delivery among the out-of-school youth intervention in three (3) LGAs each of two (2) pilot states – Oyo and Ogun states.
5. Introduction and conduct of cluster meetings which encouraged: (i) peer-to-peer learning among service providers, (ii) total saturation, (iii) training and retraining of providers, and (iv) on-the-job training and mentoring.
6. Support to the Federal Ministry of Health and other Partners on the roll-out of the National Self-Care Guidelines including DMPA-SC/SI in Nigeria.
7. The project implemented the following activities on its journey to self-reliance.
   1. Commencement of meetings with the National Primary Health Care Development Agency (NPHCDA) for the transitioning of RASuDiN CORPs to the State Community Health Influencers, Promoters and Services (CHIPS) Program
   2. Attended periodic structural meetings with state/LGA stakeholders, community leaders, and religious leaders to report project updates and seek sustainable solutions to the challenges expressed by the CVs and CORPs; in conducting family planning activities across the LGAs.

Adaptation to COVID-19 Pandemic

• Alignment with the National Health Promotion Unit of the Federal Ministry of Health (FMoH) to integrate the FP Demand Generation and Service Delivery into the COVID-19 messaging.
• Households/door-to-door services utilized as a measure for managing the program in a changing context through continuous service provision by CORPs working with CVs to drive demand generation and support uninterrupted access to DMPA-SC at the communities.
• Community intervention through CORPs ensured the sustenance of traction and the gains of FP service delivery which would have been a missed opportunity.
• 41,473 unplanned pregnancies were averted during the peak of COVID-19 pandemic (March to April 2020).
• DMPA-SC/SI was one of the FP options presented to WRA for Self-care during service provision