The most recent meeting of the Systematic Approaches to Scale-up of Family Planning (FP) and Reproductive Health (RH) Best Practices Community of Practice highlighted government voices on scale-up. The topic came from community of practice (COP) members, and the meeting was designed as a listening session to yield deeper understanding of on-the-ground experience with scale-up. The essential role of government in scale-up has gained traction recently, and at least three meetings touching on this topic were held the same week. While last-minute constraints allowed only two of the four panelists from the governments of Uganda, Nigeria, Ghana, and Chad to join the COP that day, the conversation was deeply insightful and practical, benefiting from the experience and expertise of our panelists. Dr. Thomas Ocwa Obua, Senior Pharmacist at the Ministry of Health of Uganda, and Dr. Mohammad Rilwanu, Executive Chairman of Bauchi State Primary Health Care Development Agency in Nigeria, shared details of successes and of failures, which are an essential, often overlooked part of learning. We highlight a few key reflections from the conversation below. Karen Lam and Nora Dettor from Spring Impact also briefly shared the Journey to Scale with Government Tool, which poses key questions for better collaboration between organizations and government. Find a recording of the full listening session here. You can also find a link to our March 2021 meeting at the end of this post.
We asked the panelists what key activities led to policy change for the rollout of sub-cutaneous DMPA (DMPA-SC) in Uganda.
Dr. Obua explained that the remnants of British law still in place in Uganda classified injectables (intramuscular, at that time) as a highly medicalized method that could only be administered by professionals such as doctors, pharmacists, dental surgeons, veterinary surgeons, and some midwives. This colonial legacy restricted public access to DMPA until recently. Dr. Obua and his team had to make a case to the top officials at the Ministry of Health (MOH) to adjust the law to meet the contraceptive needs of the population. Researchers from the National Drug Authority conducted a study on administration of injectables through drug shops and proved the effectiveness of administration of DMPA-SC through this type of service delivery. This led to approval of expanded delivery at all levels of government. The government selected drug shops in a few districts and retooled its weeklong training to strengthen the capacity of the drug shop owners.
With the introduction of DMPA-SC into the market, Dr. Obua and his team advocated to the Ministry of Health that it enlarge the pool of health workers approved to administer DMPA-SC, a practice known as task-shifting. Dr. Obua said, “I am proud of this because we had to put a serious, strong argument to relax regulations and laws so that this commodity reaches the community and [is] not … stuck in centers.”
Panelists shared what advice they had for implementing partners to scale up with government.
Dr. Obua highlighted several recommendations including the importance of equal, transparent partnership among government, community, and partners. He noted the value of alignment among partners so that they move forward together rather than separately. Sometimes progress is hampered by outdated laws, so one role of government is to facilitate access to services by updating regulations. Dr. Obua reflected on the vital importance of commodities and supply chain management, as well as male involvement and support from community, religious, and tribal leaders. The private sector can also be supportive, but Dr. Obua noted the need to watch for unfair profiteering where commodities are sold.
We asked if they had an example of something that was expected to go to scale but did not, and if so, why it did not scale.
Dr. Obua shared the experience of adoption of the village health team (VHT) model in Uganda. The Ministry of Health wanted to scale up a community health practice that had been successful in Ethiopia. Two trained community members from every village would serve as VHTs and provide technical advice to citizens. During implementation in Uganda, however, uptake was not as successful as hoped. Dr. Obua said his team paused to reflect on where they went wrong. They thought their method was the best, but when they talked to strategic decision-makers, they were asked to go back to the drawing board. Two years later, the energy and motivation for the initiative had declined, and the team failed to develop a stronger implementation strategy. This was a painful experience for the team, but they learned to live with it. He noted that the intervention and service quality may have scaled better if the team had trained the people coordinating the VHTs. Interestingly, Dr. Obua said that implementation science failed the team because the ‘science’ and the ‘art’ were there, but the team lacked understanding of how to merge the two.
Dr. Rilwanu shared an experience when scale-up was a challenge in Nigeria. The country wanted to scale up the addition of family planning centers to 648 primary care clinics. Challenges included a need for human resources capacity strengthening, absence of support from religious leaders, and misconceptions about FP at the community level. The reframing of FP as a way to reduce maternal and infant mortality and consistent advocacy by religious leaders contributed to successful scale-up.