Scale-up of the DMPA-SC in Nigeria: Why policy matters.

BACKGROUND: Injectable contraceptives have contributed substantially to Nigeria's rise in modern family planning methods usage. They are one of the most commonly used and preferred means of contraception among women in the country. Enabling policies are required to assure contraceptive access, security, and use. This study aimed to investigate the policy environment and how it supports or limits Nigeria's introduction and scale-up of subcutaneous depot-medroxyprogesterone acetate (DMPA-SC). METHODS: The design of this mixed-methods study was cross-sectional. Desk reviews of policy papers, key informant interviews, and in-depth interviews were used to obtain information from respondents about the introduction of DMPA-SC in Nigeria and how existing policies influenced its scale-up. Data on DMPA-SC and other injectables were gathered from Nigeria's national electronic logistics management information system. RESULTS: The findings suggest that policies such as task-shifting and task-sharing, cost-free policies, reproductive health policies, and others created an enabling environment for the scale-up of DMPA-SC adoption in Nigeria. The inclusion of DMPA-SC on the essential medicines list and the approved patent medicines list facilitated the scale-up process by ensuring private sector participation, removing economic barriers to access, fostering greater collaboration among health worker cadres, improving intersectoral partnerships, and improving logistics and client access. Despite significant anomalies in some implementing policies, injectable contraceptive consumption data demonstrate a progressive increase in DMPA-SC use during the study period. The results also indicate that policy initiatives have a favorable impact on the use of DMPA-SC throughout the country. CONCLUSION: The existence of policies, the active participation of stakeholders, and the political will of the Nigerian health system's leadership have all aided in the scaling-up of the DMPA-SC. Understanding how to build an enabling policy climate is critical for providing women with family planning options. These lessons from Nigeria emphasize the importance of these levers, which should be considered by teams intending to introduce innovative health products, particularly in developing countries.

Thinking outside of the [cold] box: implementing a human-centered design approach to understand barriers and craft solutions to cold chain equipment maintenance in Niger.

BACKGROUND: Vaccines require cold chain equipment (CCE) to ensure quality and potency, yet the risk of CCE failing is well-documented, often due to lack of equipment maintenance. While general barriers to a reliable CCE maintenance system are known, little has been done to understand the barriers from the cold chain technician's perspective. This human-centered design (HCD) study in Niger sought to better understand the gap in the current maintenance approaches from the technicians' perspectives and to collaboratively identify forward-thinking solutions. METHODS: The research team collected data through semi-structured and open-ended in-depth consultations. Rapid qualitative research was followed by co-creation workshops with study participants to identify solutions. RESULTS: The research team conducted 20 in-depth consultations in two regions with participants directly involved in the management of the cold chain. Fourteen people participated in the online co-creation workshop, and 20 people participated in the in-person workshop. Insights were organized in three main areas: (1) the lack of system agility and ability to optimize resources constrain performance of the maintenance system; (2) cold chain is often an afterthought within the overall context of immunization services and should instead be prioritized; and (3) knowledge sharing across the system and key stakeholders is ad hoc with limited understanding of roles and responsibilities. During the co-creation workshop, participants identified four main concepts as potential solutions: (1) create an on-line platform to connect people and to share knowledge across regions; (2) develop practical CCE technical resources; (3) use gamification and friendly competition to motivate staff to value maintenance; and (4) create a real-time maintenance tracking system. DISCUSSION: This study took a unique HCD approach to engage people directly involved in CCE maintenance to more deeply understand challenges with the current system and create space to identify innovative solutions that are tailored to the context. The results demonstrate that stakeholders can identify potential solutions that have not been part of the typical approaches to a maintenance system. This HCD approach has implications for all global health challenges and demonstrates a methodology that can encourage key stakeholders to think about problems and solutions differently.

A Tale of 2 Countries: Implementation of the Cold Chain Equipment Optimization Platform in Guinea and Kenya.

In 2016, the Gavi Cold Chain Equipment Optimization Platform (CCEOP) was approved and launched in recognition of the fact that functional cold chain equipment (CCE) is essential to strengthening vaccine supply chains and ultimately achieving Gavi's immunization equity and coverage goals. Through CCEOP, Gavi committed to investing US$250 million between 2016 and 2021 to commission CCE in more than 63,000 facilities to upgrade and expand their CCE footprint while stimulating the market to provide affordable, technologically advanced, and accessible equipment. We present case studies from Guinea and Kenya, both of which received CCEOP support, that highlight 2 ways for countries to prioritize investments and implement activities through a large funding and support mechanism. The studies explore the different ways that each country implemented CCEOP and consider how aspects of leadership and technical capacity influence country priorities and results. They also uncover key lessons on sustainability of a large immunization supply chain effort. The experiences of Guinea and Kenya can help other countries embarking on similarly large health system interventions, especially related to supply chain strengthening and immunization programs. In particular, these experiences offer important lessons in leadership, processes and systems, country ownership, technical capacity, and sustainability.