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In November 2016, Yaba, a suburb of Lagos, Nigeria, removed all user fees associated with family planning services in public health facilities. Women there can

now receive contraceptive services completely free for the first time, eliminating a significant barrier to family planning uptake. The decision makes Yaba one of the first local council development areas (LCDAs) to follow through on the Lagos State health commissioner’s directive that all family planning consumable costs should be completely covered. It also makes Lagos State a leader in fulfilling the government of Nigeria’s Family Planning 2020 commitment to provide free family planning services to all Nigerians.

The Hidden Costs

Although family planning commodities are already free nationwide in Nigeria, users are often responsible for paying fees associated with provision of services—including disinfectant, gloves, cotton balls, and/or surgical blades, depending on the method. These out-of-pocket charges can range from 500 to 2,000 Nigerian naira (US $1.41- $5.52) per visit, a steep price when the national monthly minimum wage is 18,000 naira ($50.85).1

Although cost is not cited among the top reasons Nigerian women who do not wish to become pregnant

do not use modern contraception, the poorest women have the highest unmet need for modern contraception, at 30.1%.2 And in Lagos State, 57.5% of modern method users reported they had paid for family planning methods, supplies, services, or transportation in the past year.3

A State Committed to Family Planning

Lagos State has long been at the forefront of national family planning efforts. It has the largest population of all of the states—approximately 11.8 million people.4 Lagos aims to raise the contraceptive prevalence rate from 38% to 74% by 2018,5 and contribute to the national goal of increasing women’s use of family planning services and reducing maternal and infant mortality.6

It established a family planning budget of 16.8 million naira ($46,872) in 2013 and has maintained the allocation since. Out of all 36 states in Nigeria, Lagos was the first to officially disburse funds directly for provision of family planning services.7

Supported by Advance Family Planning (AFP) local partner Pathfinder International, Lagos State established a family planning advocacy working group, now known as the Public Health Sustainable Advocacy Initiative (PHSAI) in January 2015. The group comprises members

Lagos State Leads Nigeria in Making Family Planning Services Free

January 2018

CASE STUDY

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of civil society, faith-based organizations, the media, and local government units for budget and reproductive health and family planning.

PHSAI applied the AFP SMART advocacy approach to the problem of consumables costs. They noted that although Lagos State had a family planning budget, the local government area (LGA) and LCDA budgets—a potential source of funds for consumables—did not. Their objective to create dedicated local budgets for family planning services stalled however when elections delayed their advocacy. With no decision-maker in place, the working group focused instead on strengthening its coalition and fostering valuable discussions among stakeholders over the course of 2015.

In late 2015, PHSAI re-focused their advocacy on Lagos State’s Honorable Commissioner for Health. The working group met with the commissioner in January 2016 to present the many barriers women face in obtaining family planning services, including costs. After seeing the evidence, the state commissioner agreed then and there that consumables should be funded. He issued a policy directive that same month, mandating that family planning services in Lagos should be completely free of charge to the client and instructing all LGAs and LCDAs to cover the cost of family planning consumables. In accordance with this directive, the Lagos Director of Primary Healthcare informed all medical officers of health, who coordinate health services in LGAs and LCDAs, to put an end to user fees.

It was a significant step forward. However, the State Ministry of Health did not allocate any additional funds to support this directive, and LGAs and LCDAs still did not have a separate budget for family planning. The mandate was unlikely to be implemented without additional advocacy.

Following Through to Free Services

Equipped with the new directive, PHSAI spent months in 2016 reaching out to key stakeholders in Lagos with support from Pathfinder International, the Nigerian Urban Reproductive Health Initiative, and other partners. They engaged with sole administrators of the local government areas, heads of local council development areas, medical officers of health, and chairmen of community development committees. Together they tried to identify ways to leverage existing funds for family planning.

PHSAI’s continuous engagement since 2015 with medical officers of health from across the state proved fruitful. PHSAI attended one of the medical officers’ monthly convenings to discuss the state commissioner’s new directive. Their advocacy, backed by the directive, inspired the officers to discuss funding solutions, such as using their own monthly funds, called imprest, to cover the consumables costs.

In November 2016, Yaba’s medical officer of health took the first step. He directed the four primary health care centers within his jurisdiction to allocate funds from

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the imprest for family planning consumables. All of the centers in Yaba complied, allocating between $32 and $64 per month. The four health care centers serve a catchment population of 260,510.8

With the final cost barrier removed, Yaba is seeing a surge in family planning visits.9 (See Figure 1) In the first nine months of 2017, 1,644 family planning visits occurred where the client received a method of contraception. Compared to the same time period in 2016 (1,242 visits), the total volume of family planning service provision increased 32%. This is a positive indication that as family planning services become increasingly available to users free of charge, contraceptive uptake will also continue to rise.

The successful implementation of free family planning services in Yaba will likely be a catalyst—already other LCDAs in Lagos state are following suit. In July 2017, the Lagos State Commissioner for Health requested that the state’s Primary Healthcare Board also make funds available for family planning consumables.

Lessons Learned

• Work innovatively with what you have: PHSAI originally sought to establish a specific local government budget for family planning consumables. But when the state health commissioner approved a directive, they did not wait to act. They worked with stakeholders to identify ways to cover the costs leveraging existing funds.

• Start collaboration early and maintain it throughout: Members of the reproductive health

department from the Lagos State Ministry of Health participated actively in PHSAI. They opened up many inroads for the advocates early in the advocacy process. Continuous engagement with the Primary Healthcare Board and medical officers of health led to forward momentum. When the directive came through, all stakeholders were already on board to follow through and find creative ways to implement the directive.

Next Steps

PHSAI members are tracking funding in Yaba and other LGAs and LCDAs to monitor how fully funds are able to cover the costs of consumables. PHSAI will also continue to engage with other local government units to secure new funding for consumables across the Lagos State’s 37 local council development areas and 20 local government areas. If successful, family planning access would improve for the approximately 2.5 million women of reproductive age in the state. Pathfinder International plans to conduct a budget tracking workshop in 2018 to help state-level advocates follow up on funding commitments at all levels.

References1 Nigeria Labour Congress. 2017.2 Centre for Population and Reproductive Health (CPRH), University of

Ibadan; Centre for Research, Evaluation Resources and Development (CRERD); Population and Reproductive Health Program (PRHP), Obafemi Awolowo University (OAU); Bayero University Kano (BUK); and the Johns Hopkins Bloomberg School of Public Health (JHSPH). Performance Monitoring and Accountability 2020 (PMA2020) Survey round 2, PMA2017/Nigeria-R2. Nigeria and Baltimore, Maryland, USA.

3 Centre for Research, Evaluation Resources and Development (CRERD); Bayero University Kano (BUK); and the Johns Hopkins Bloomberg School of Public Health (JHSPH). Performance Monitoring and Accountability 2020 (PMA2020) Survey round 4, PMA2017/Nigeria-R4 (Lagos). Nigeria and Baltimore, Maryland, USA.

4 World Bank Subnational Population Database. 2015. 5 Lagos State Family Planning Costed Implementation Plan, 2016-2018.

March 2016. 6 Nigeria Family Planning Blueprint (Scale-Up Plan). October 2014. 7 Lagos State Costed Implementation Plan 2016-2018. November 2016. 8 Nigeria District Health Information Software - 2 (2016-2017) 9 Nigeria District Health Information Software - 2 (2016-2017) 10 Nigeria District Health Information Software - 2 (2016-2017) 11 The estimate was found using the World Bank projection for the Lagos

State total population in 2015 (11,824,000 people) and multiplying by the national percentage of women of reproductive age according to the 2015 World Population Prospects, UN Population Division (21.08%).

Cover photos by Jeremy Weate, World Bank, European Commission DG ECHO; page 2: USAFRICOM; page 4: Pathfinder Nigeria

FIGURE 1: FAMILY PLANNING SERVICE VISITS INCREASE BY 32% IN YABA FOLLOWING ELIMINATION OF FEES

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Acknowledgments

Members of the Public Health Sustainable Advocacy Initiative; the Lagos State Commissioner of Health; the Permanent Secretary of the Primary Health Care Development Board; the Reproductive Health Coordinator of the Lagos State Ministry of Health; all medical officers of health in the local governments in Lagos; the Medical Officer of Health in Lagos Mainland LGAs and the Yaba Local Council Development Area; Pathfinder International.

About Advance Family Planning

Advance Family Planning (AFP) aims to increase financial investment and political commitment needed to ensure access to quality family planning through evidence-based advocacy. Based in the Population, Family and Reproductive Health Department of the Johns Hopkins Bloomberg School of Public Health and led by the Bill & Melinda Gates Institute for Population and Reproductive Health, AFP aims to achieve the goals of the Family Planning 2020 initiative: to enable women and girls in some of the world's poorest countries to use contraceptive information, services and supplies, without coercion or discrimination. AFP is supported by the Bill & Melinda Gates Foundation, the David & Lucile Packard Foundation, and The William and Flora Hewlett Foundation.

Pathfinder International NigeriaNo. 35 Justice Sowemimo Street, AskoroAbuja, NigeriaTel: +234 9 2916282Email: fjega@pathfinder.orgwww.pathfinder.org/nigeria

Advance Family PlanningBill & Melinda Gates Institute for Population and Reproductive Health Johns Hopkins Bloomberg School of Public Health615 N. Wolfe Street, Ste. W4503Baltimore, MD 21205Tel: +1 (410) 502 8715Email: afp@jhsph.eduwww.advancefamilyplanning.org