Improving Contraceptive Service Quality and Accessibility for Adolescents and Youth Through Proprietary Patent Medicine Vendors in Four Nigerian States

"State governments should continue to strengthen collaboration with PPMVs [proprietary patent medicine vendors] through national, state, and local associations to maintain adolescent and youth sexual and reproductive health service quality and referrals."

In Nigeria, healthcare services and commodities have increasingly been accessed through private sector entities, including proprietary patent medicine vendors (PPMVs). Given the sociocultural bias associated with nonmarital and premarital sex, especially among adolescents and unmarried youth, PPMVs are considered a safe haven for the provision of discreet contraceptive services. However, PPMVs cannot provide long-acting or permanent methods, and concerns have been raised about their quality of services and their need to better comply with government regulations. This article describes how The Challenge Initiative (TCI)'s family planning programme supported 4 state governments in Nigeria to develop a model to strengthen public-private partnerships between PPMVs and primary health centres (PHCs) to leverage PPMVs to provide adolescents and youth aged 15-24 years in urban economically poor communities with high-quality contraceptive information, services, and referrals to PHCs.

Between October 2019 and August 2021, the intervention implemented a hub-spoke model by strengthening the linkages between neighbouring PPMVs and large PHCs for delivering contraceptive services to adolescents and youth. The steps in the implementation process included: (i) introducing the intervention to state governments, (ii) selecting PPMVs as spokes and high-volume PHCs as hubs, (iii) conducting whole-site orientations to orient PPMV and PHC staff on quality FP and adolescent and youth sexual and reproductive health (AYRSH) counseling, including informed choice, the full range of contraceptive options, and the unique SRH needs of adolescents and youth, (iv) strengthening referral links between PPMVs and PHCs (e.g., through referral cards known as "Go-Cards"), (v) implementing supportive supervision and coaching, and (vi) strengthening client data management. TCI worked with the state and local ministry of health to improve PPMV operators' knowledge, attitudes, and skills to deliver adolescent- and youth-friendly services.

Analysis of data records during early and intensified intervention periods for the PHC-PPMV hub-spoke partnership showed that participating PPMVs recorded a 54% increase in contraceptives dispensed to adolescents and youth aged 15-24 years, from 25,267 to 46,463.

TCI observes that, with proper orientation, a simple record-keeping system, and supportive supervision, PPMVs proved willing and able to document their age-disaggregated service provision, providing useful information that was added to the service registers at the PHCs. A total of 797 persons were referred through the PPMV-PHC referral in Plateau State within a period of 3 months. The establishment of a this referral mechanism between PPMVs and PHCs "allowed greater method choice for adolescents and youth, increased contraceptive uptake, more assurance that PPMVs were not offering contraceptive commodities and services they were not legally permitted to provide, and improved ability to monitor the referral linkages between PPMVs and PHCs".

However, the other 3 states in the intervention were unable to fully execute and document a referral system to PHCs. For example, Edo State (which started the PPMV-PHC linkage later than the other states) had a wide catchment area between the spoke PPMVs and hub PHCs area, making it challenging to retrieve completed referrals from the PHCs due to transportation costs.

Some of the challenges affecting implementation, with potential solutions, include:

• The profit-focused nature of PPMVs required costly staggered coaching sessions to allow them to attend to clients and to strengthen their capacity. Flexible coaching methods, such as digital platforms and mobile apps, can accommodate the profit-driven schedules of PPMVs.
• High staff attrition disrupted training continuity, impacting programme effectiveness. However, recognising and rewarding experienced staff can create a stable environment for continuous learning and skill retention.
• The limited availability of referral data affected the attribution of the effectiveness and impact of the interventions. Simplifying data management through user-friendly digital tools and incentivised training can encourage accurate record-keeping.

"A robust system of engaging in meaningful dialogue with PPMVs, understanding their challenges, and incorporating their feedback into the FP/AYSRH program could ensure that they remain responsive and tailored to their evolving needs."

Based on this experience, TCI recommends that the government strengthen the working relationship between PPMVs and PHCs, incorporate PPMVs into the routine supportive supervision of the state health system, and establish a referral linkage with PHCs in the design and implementation of PPMV programmes.

In conclusion: "By strategically integrating PPMVs into the state FP/AYSRH program through targeted interventions, including capacity-building, supportive supervision, referral systems, and efficient data management, the government can significantly expand access to high-quality FP services. This intentional collaboration between PPMVs and PHCs, established at the grassroots level in local communities and LGAs, could create a powerful partnership. By leveraging this extensive network of PPMVs and linking them to high-volume PHCs in urban dense informal settlements, a diverse range of contraceptive methods tailored to the specific needs of adolescents and youth could be offered. Empowering this cohort with comprehensive choices and knowledge will not only improve their overall well-being but also promote the responsible use of contraceptives, ensuring a healthier future for the nation."

Full list of authors, with institutional affiliations: Dorcas Akila, TCI Nigeria Hub; Oluwasegun Akinola, TCI Nigeria Hub; Olukunle Omotoso, TCI Nigeria Hub; Saori Ohkubo, TCI/CCP; Adewale Adefila, TCI Nigeria Hub; Philemon Yohanna, TCI Nigeria Hub; Nwanne Ikodiya Kalu, TCI Nigeria Hub; Adebusola Oyeyemi, TCI Nigeria Hub; Olubunmi Ojelade, TCI Nigeria Hub; Aisha Waziri, TCI Nigeria Hub; Winifred Kwaknat, TCI Nigeria Hub; Olusola Solanke, TCI Nigeria Hub; Bernard Emonena, TCI Nigeria Hub; Oluwafemi Rotimi, TCI Nigeria Hub; Lisa Mwaikambo, TCI/CCP; Victor Igharo, TCI Nigeria Hub; Lekan Ajijola, TCI Nigeria Hub; Krishna Bose, TCI, Bill & Melinda Gates Institute for Population and Reproductive Health