Successful Elements of Family Planning Interview with Mr. Bright Ekweremad, Managing Director of Society for Family Health

Conducted on May 1, 2008 by Katie Richey

Katie Richey: What kinds of communication and outreach does the Society for Family Health use to promote family planning in Nigeria?

Bright Ekweremadu: What kinds of communication and outreach does the Society for Family Health use in promoting family planning in Nigeria? Basically, we have two broad target groups: the broad range of providers (ranging from doctors to nurses, midwives, pharmacists, and paramedical deliverers in some cases). And then of course we have the other broad group which is the consumers or the clients if you want. We use a mix of communication strategies. We do a lot of mass media--of course you do know in Nigeria that no family planning brand is allowed to be used in mass media, so what we do is communicate the broad range of products. For instance, we talk about the oral pills, we talk about injectables, we talk about the IUCD as generics, not mentioning any particular brand. Our effort in doing that is to make sure that people know at least a number of family planning methods available that they can choose from if they want to practice family planning.

We also do interpersonal communication, particularly at the community level where we actually target the consumers themselves. We do some training which has some element of communication in them. Most of the training is targeted at providers, teaching the provider about what product and what method that is approved for them to supply or resupply in Nigeria.

We also use Community Theater. We have specially made vehicles with theaters on top of them, where we get to communities and assemble people, and then talk to them about particular methods of family planning and the benefits. In all our communication efforts, we emphasize the benefits of family planning, depending on the region that we are in. To some people we talk about the economic benefits, to some we talk about the health benefits. So that's what we do.

KR: You mentioned the community theater activities. Can you provide some specific examples of similar activities that SFH has used to promote family health at the community level? Road shows, dramas, street musicians?

BE: Our community efforts basically follow our HIV/AIDS efforts. What we are trying to do is to start to run integrated programs. Currently, SFH is working in all 36 states of Nigeria, where we have selected specific sites and communities to work in. We have selected communities that we call the "Family Planning Communities" and these are specially selected on the density of the population, the number of women and men of reproductive age and perceived family size. In Nigeria of course, family size is a big issue, people like to have many people in their family.

So what we do is we go to these communities and identify role models that we train as peer educators. What we are trying to do there is achieve some sustainability. We train these peer educators on several elements of family planning. And then we have guides. The guides are contained in a peer education model we developed called the peer education plus model that deal with family planning. So we go through this model with the peer educators. At the end of several weeks of training, they are graduated as proficient in teaching their peers about these FP methods. What our staff will do at the end of the day is follow up with these peer educators to provide them with updated training, to monitor what they are doing to measure that they are doing everything correctly. Some times we provide them with incentives, in terms of money for food, water, travel so they just continue to do this work.

So what we do is peer education training where you have ranging from 10-20 people gathered together among their peers. They talk specifically about benefits of FP and FP methods of choice available to them.

We occasionally use community theater. We started off using outsiders (those that are from outside the community) to perform some of these dramas and then have questions and answers. And then we graduated to where we have to have members of the community forming their own theater groups. So sometimes you see members of community with people from the outside coming together to perform dramas on elements of FP. Value of this is people in community are able to identify with one of their own who is telling stories talking to them about FP, and they end up being much better accepted than having people from the outside.

Of course at the end of the day we make sure the products are available, using a group called the detailers these people are basically pharmacists these people follow up with the education, update of providers while the community activities concentrate on the consumers.

KR: In your experience in the 16-17 years you've been working with this organization, how should FP Managers begin to develop a FP outreach strategy?

BE: I have been working in the FP and working with SFH for about 16 years after working about 3 years with USAID, where I basically did FP working with clinics. I think the issues of FP differ. Depends on the method of FP you promoting, depending on the community you are talking to. So it's difficult for me to talk about tailor made strategy or process. I will talk from my experience about what should be done.

First of all, you have to be sure you have products you are talking about in place. Secondly, you have to establish benefits clients you are going to be talking to would listen and use as selling point. It's going to be a kind of promise to clients. This is how they will benefit if they do take on FP activities. Most importantly, the element missing from most FP programs is good training of the providers. Providers are what make FP efforts worthwhile or not worthwhile. I said it because a number of clients depend completely on information they get from outside on making decisions about family planning. Some of them have myths like FP causes infertility and so on and so forth. A well trained provider stands a very good ground debunking myths and working with women to help them believe that family planning is good way to go. Not only the woman; in some cases also the man. One element very very important is to make sure there is male involvement and endorsement and appreciation of why FP is important. I know of some FP projects, in the past, that concentrated more on women and leave men out. It's very difficult to have successful program leaving the men out. Put all these things together and you will have a successful FP program.

KR: Can you speak to the importance of involving the community in the family health promotion that SFH engages in?

BE: The involvement of community is very important component because you really do need community support in anything that you want to succeed. Community pressure can actually destroy a good intended program. So, the first thing is to make sure community accepts what you want to sell. The moment they do that you expect them to not only support you but to also support each other in getting on. Once the community does not accept something it becomes taboo—and you don't see anyone wanting to be a part of it.

First thing we do when we get into a community is buy the confidence of stakeholders and opinion leaders. Normally in the north for instance, we go to the community leader who is the emir or chief, explain what we have come to do. The moment we receive the blessing, we will seek the other opinion leaders, the church leaders, community leaders, role models of different groups. We discuss with them and bring them together for agreement of what we want to do and how they want support us. Once we have the support of these stakeholders and opinion leaders, your entry point is well made and you wouldn't have a problem. We do this for everything we do, particularly for FP which is very sensitive topic still in Nigeria.

KR: In SFH, how do you define success? How can you say what makes a community level communication campaign successful?

BE: How do we measure success? We believe very strongly in measuring our impact and we have several ways of doing that. The first one is we engage in independent surveys. We buy into independent surveys that are done twice a year and one of them is basically on family planning. This is the Nigerbus Survey conducted by a group called Research and marketing services. We would normally contribute questions to that survey and expect responses from them. We also do track surveys, which is SFH’s in house survey where we look at what we are doing and how impactful they have been depending on objective set at beginning of process.

We also use sales as proxy. We do not sell our products on credit – all sales are made on cash and carry basis. So the fact that we are able to attract cash for every single product we sell gives us confidence that the wholesalers are purchasing the product for someone is ready to pay for it. So we conduct MAP survey (which is Measuring Access and Performance). We try to find out how accessible our products are to our clients our target group and we do these very frequently. This helps us find areas where our products are not widely accessible and we improve on opening new outlets. Of course, where product is not successful it's a proxy to the fact that consumers or providers in that area may not even know what you're talking about. By putting the product very close to consumers the next thing we do is to follow it up with training, some awareness creation, and then sometimes we create our communities and train them on peer education model.

KR: Can you explain why SFH emphasizes choice and empowerment in its community missions and strategies?

BE: Empowerment and choice. These are two very strong and important words in our activities. First of all, in a country like Nigeria, people live in communities where they are individuals. And so the first thing is for a women for a man for a family to practice FP, they have to be convinced within themselves that it's the right thing to do. And the only way that that happens is that they are empowered. Empowerment is not about fighting, it’s about empowering with information, with the benefits that we want you to do. We try to do this by laying on our table the benefits of FP and child spacing to women, the child and the society.

The issue of choice is important as you know no single FP method that suits every woman. You have to make all methods available, train providers in every method to avoid provider bias on counseling for only one method. So with that choice and empowerment you have achieved quite a lot in terms of the woman or the family accepting family planning.

KR: Why is government support so important in FP programs?

BE: The government certainly has to support FP not only for it to be successful but also because they create an enabling environment for you to do your work. For instance, if the government does not have a set of policies, a set of standard of practices, you need to follow and you see people do different practices at different times, mostly the wrong things. So it's very important that the government supports FP and child spacing because that gives the client themselves the confidence that if government supports activity carried out by group is doing (whether it is NGO or public or private sector) it must be worthwhile. It's very important that government has to support FP for it to be successful.

KR: Following up to that question, how has your organization partnered with government to ensure successful and sustainable programs?

BE: We are an NGO so it's very natural that we have to work within the ambits of the policies set by the government. Having said that, what we normally do would be to look at what the government sets out to achieve and draw from those broad strategies some contribution we can make. We have been partnering very closely with the government. In some instances they ask for our assistance in number of areas. For instance, SFH has noted to be an organization with efficiency in logistics. We have helped government occasionally in getting products from warehouse to points in need. We have contributed in training and of course government has supported us with their vast resources. There’s just no part of this country where you wouldn’t have government presence, either in terms of infrastructure in terms of human resources. So we really it's a true partnership. We are beginning to realize the only way we can succeed is to work together. We have a biannual survey called National AIDS and Reproductive Health Survey, which is normally funded by SFH through the donors but we conduct this survey in partnership with Federal Ministry of Health. They have the infrastructure, the wide reach, and of course it has political power. We contribute our finances, technical knowledge and our resources have been very helpful in terms of family planning and HIV programming.

KR: We'll shift a little bit and focus on leadership. One participant stated that a program cannot improve without strong leadership. What role do leaders play in not just maintaining but improving programs?

BE: Strong leadership is very important for the success of any program. In a place like Nigeria (and I think for most other African countries) the success of a program depends so much on the acceptability of leaders. For instance in churches or mosques, the members depend so much on what priests or imams say. You have community leaders who are role models and their words are like laws and policies in the community. You have to elicit the support of this group for you to be successful. Without strong leadership you can't be successful. However great your strategy is if you do not have the acceptance of your leaders who will actually drive it and be the opinion leaders, the role models for the subjects, you don't stand any chance of success. We respect this and one of the first things we do is elicit support of leaders and that helps us be successful.

KR: How do cultural and religious factors in Nigeria play into your organization's strategy? Can you talk about the importance of partnering with faith based organizations?

BE: Culture and religion happen to be two of the few barriers that we have to contend in our FP efforts in Nigeria. It is a cultural belief that a family should be as large as God wants them to be. This cultural belief is related to the religious belief that children are from God, so you have to have as many children as God wants.

We have done quite a lot of work in addressing these barriers. We partner with faith-based organizations particularly in the Christian religion we have gone after certain faiths. For example the Anglican Communion and the Evangelical Church of West Africa, we have working closely with each of them trying to put together policies of why we have to do family planning. We have recently started working closely with Muslim groups. What we have done is to provide choices. We know that some religious faiths do not believe in modern contraception. So we now have a natural family planning method called CycleBeads or the Standard Day method. People are now beginning to accept that FP is an important element of their life. One more time, we don’t force anything on anybody, and if you are able to use modern contraception you can use it, if you want to use a natural family planning method please do use it. We are also doing quite a bit in communication through the mass media addressing these cultural and religious issues. The most important way we have done this is by partnering with these different religious faiths, Christian and Muslim faiths.

KR: Would you like to add anything else about how your organization works towards achieving success in family planning?

BE: Part of what I want to share has been discussed. I'd like to emphasize one more time the importance of providing choices to both providers and clients. We started off in 1993 with one injectable which was the Noresterol. Today, we have three today, 2 month, 1 month and three month injectables. We have also added Implant, Norplant and Jadelle,

Again, we have stepped up our provider training, which we think has not given attention it deserves in Nigeria. One reason I think this was I remember the last major training conducted was SFH and Pathfinder 1995-1996, where we trained 3,500 providers in injectable contraceptive method. Although there has been some training ongoing in institutions like the Planned Parenthood Federation of Nigeria, Pathfinder International, and in selected clinics, I think we need to do more nationwide training particularly long lasting methods.

Fortunately SFH recently got some funding through Population Services International which is our partner overseas to deepen our activities in long lasting methods particularly IUCD and implants. So we're going back on nation-wide training in the very near future. We're currently doing analysis to find out where gaps are to see where we should concentrate. Basically two items, we need to do a lot more training of providers and the of course we need to continue to increase our method choices so people are able to pick what suits them.