Projections for Contraceptives, including Condoms for HIV/AIDS in Nigeria

Publication date: 2003

FAMPLAN MODEL FAMPLAN 1 Pro Projections for Contraceptives, including Condoms for HIV/AIDS in Nigeria Determining Needs and Cost of Contraceptives for Nigeria 2003 – 2015 Federal Ministry of Health December 2003 FAMPLAN MODEL FAMPLAN 2 Foreword Nigeria is committed to improving the reproductive health and well-being of its citizenry and this is shown through various initiatives of government and other relevant stakeholders to ensure easy access to affordable reproductive health services. This commitment if further expressed through its adoption of the National reproductive Health Policy of 2001, which reflects such international agreements as the International Conference on Population and Development Declaration of 1994 and the United Nations General Assembly Declaration of Commitment on HIV/AIDS of 2001. Reproductive Health Commodity Security (RHCS) was recognized as an emerging issue when it was identified by experts in reproductive health that the demand for RH commodities gap has been found to be increasing yearly. The need to develop a secure supply of Reproductive Health Commodities having been recognized, Nigeria took the initiative of being the first country to adopt a strategic plan using a comprehensive, long-term, holistic approach, which helps countries develop strategies to ensure that sufficient Reproductive Health commodities and supplies are available in the future. This strategic Pathway to reproductive Health Commodity Security (SPARHCS) framework is designed to be adapted to the needs and conditions of individual countries. One major step in the process is a determination of the quality reproductive health commodities necessary to meet the needs of the country and the cost implications of these requirements. This led to the development of FAMPLAN. FAMPLAN is a model that enables us to project the country’s requirements for contraceptives and condom for HIV/AIDS till the year 2010. This report using modelling techniques achieves this aim. The needs are substantial but because Nigeria is committed to protecting the health of its people, it will certainly make plans to ensure that Nigeria progresses towards the realization of the availability of commodities and supplies available at all levels so that men, women and youth can choose, obtain and use quality contraceptives and condoms for HIV/AIDS whenever the need them. Dr. M.S. Amaeshi Director, Dept. of Community Development and Population Activities December 2003 FAMPLAN MODEL FAMPLAN 3 Acknowledgement The Department of Community Development and Population Activities of the Federal Ministry of Health is sincerely grateful to the various Development Partners and individuals who worked with us in developing this report. Our appreciation goes to the USAIDS, Nigeria for its support and to the POLICY Project/Nigeria, for providing the technical assistance for the development of this document. Our final appreciation goes to the members of the Technical Advisory Group who developed the projections. These include Dr. Akinremi Dada, Dr Taiwo Avbayeru and Dr Bose Adeniran of the Department of Community Development and Population Activities FMOH; Professor A.A. Adewuyi of the Obafemi Awolowo University, Ile Ife; Mr M.K. Usman of the National Population Commission; Mr S.A. Adeyemi of the Federal Office of Statistics; Mr F. A. Okegunna of the Department of Planning and Research, FMOH; Mr I.O. Popoola of the Central Bank and Dr Wole Fajemisin of the POLICY Project/Nigeria. I do sincerely look forward to the use of the report for commodity procurement decisions to achieve reproductive health commodity security in Nigeria Dr. A. Adeyemi Consultant Special Grade I (RH) DCDPA/FMOH December 2003 FAMPLAN MODEL FAMPLAN 4 Executive Summary Nigeria’s population has grown rapidly in recent decades. The total population increased from 30.4 million in 1952, to 88.9 million in 1991 (National Population commission 1998).1 The median variant population projection for the year 2003 was estimated at 126 million and this is expected to increase to 146 million in 2008 (NPC). Nigeria’s present growth rate is estimated to be about 2.8%. The fast growing population has serious consequences on the health of the citizenry and the socio-economic development of the country. The maternal mortality is too high (704 per 100,000)2. One reason for this is the fact that too many high risk pregnancies occur. These include pregnancies occurring less than 24 months apart and having too many births (above 4). The infant and child mortality are also high (75/1000 and 140/1000 respectively)2. Studies have consistently shown that children born to the same mother with less than 24 months between them are more likely to die in childhood than children more than two years apart. Children of higher birth order are also more likely to die in early childhood. Many of these children die unnecessarily because the Nigerian woman do not adequately space or limit their children, either due to ignorance or inability to obtain and use socially acceptable effective methods they require to enable them achieve family planning. The national health policy states that the government has the responsibility to provide health care for its citizenry and this will be met through the provision of access to health care services. The policy also states that it is the responsibility of the government and the health care worker to provide adequate knowledge to the citizenry so that they can take informed decisions on matters that affect their health. The health policy therefore mandates the government to ensure that its citizenry can opt for healthy practices and to provide the necessary commodities to ensure that they can practice such choices, thereby improving the standard of living within the country and reducing the maternal, infant and child mortality which are unacceptably high. 1 National Population commission: 1998 Population Census of the Federal Republic of Nigeria; Analytic Report at the National Level. 2 National Population Commission 1999 National Demographic and Health Survey FAMPLAN MODEL FAMPLAN 5 Concerns about ensuring an uninterrupted supply of contraceptives around the world has lead to a multi-agency effort called The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS.) In August of 2002 the SPARHCS approach was field tested in Nigeria. One of the recommendations of that initiative was to develop a set of family planning projections. The POLICY Project, which supported SPARHCS in Nigeria, was requested to prepare these based on the FAMPLAN model. A technical advisory group was set up to use the FAMPLAN model to determine the country’s contraceptive commodity needs for five years (2003 – 2007). The projections showed that in 2004 Nigeria will require about 188 million condoms, 3.7million hormonal injections, 243 thousand intrauterine contraceptive devices (IUD), and 3.5 million cycles of oral contraceptive pills. The study further shows that that about $15 million is needed by the country in 2004 to supply country with reproductive health commodities to effectively space or limit childbearing, and prevent sexually transmitted infections especially HIV/AIDS. Of this amount $9 million will be spent on buying condoms. Four and a half million dollars of the total will be needed to adequately meet the needs of persons who use the public sector for condoms. This figure however will increase yearly as the percentage of families that decide to plan their families and increases population of the country grows. By 2010 this amount needed to increase secure contraceptive commodities for the country is expected to reach $22 million. In 2001 the health budget was about ?36,195 million ($322 million) out which more than one third was for recurrent expenditure. This was unusual as the year before, it had been about $141 million. When compared to the amount needed to adequately provide this essential commodity, it is clear that Nigeria may not be able to meet this need from its health budget. Nigeria has had to prioritize the allocation of resources to various health challenges due to a downturn in its economy and a large national debt. In the prioritization, emergency problems have taken precedence over long term developmental challenges and resources for long term goals have declined appreciably. Therefore strategies have to be developed to ensure that the needs of the populace are met. A strategic plan for reproductive health commodity security is being finalised and some aspects of it are already being implemented. The goals of this plan are however still far from being actualised. FAMPLAN MODEL FAMPLAN 6 Developmental partners have been very important in filling in the gaps in funding for health issues in most of Sub-Saharan Africa, Nigeria inclusive. Unfortunately there has been a noticeable decline in funding of reproductive health commodities by donors, and the gap between needs and that amount supplied has been increasing. In spite of this it is hoped that while Nigeria develops a strategy to ensure reproductive health commodity security and puts in effect, developmental partners will continue to fill in the gap to ensure that the gains of the past are not lost and that children can be born into the country with better prospects of survival, and that the needless death of women as a result of high risk pregnancy will be eliminated. FAMPLAN MODEL FAMPLAN 7 INTRODUCTION Purpose Family Planning and other Reproductive Health services have been available in Nigeria for quite a while. The public sector provides a considerable percentage of the services using various outlets especially the primary health care system. A number of NGOs and the private commercial sector also provide services. Most of the family planning commodities used by these outlets are sourced largely from donors who ensure that the commodities are affordable to the average Nigerian who needs to use them. The imminent adaptation of a revised national population policy as well as the recent adoption and launching of a reproductive health policy and strategic plan, demonstrates a renewed interest in bolstering family planning in Nigeria. This brings to the fore issues regarding the anticipated needs of family planning clients, especially in the public sector. This report is aimed at providing a set of data that can guide program planners. Specifically the report provides information about the future numbers of contraceptive users, number of contraceptives required by method, number of contraceptives required by source and the costs of such contraceptives. Demographic Background Nigeria’s population has grown rapidly in recent decades. The total population increased from 30.4 million in 1952, to 88.9 million in 1991 (National Population commission 1998).1 The median variant population projection for the year 2003 was estimated at 126 million and this is expected to increase to 146 million in 2008 (NPC). Nigeria’s present growth rate is estimated to be about 2.8%. Nigeria is presently undergoing demographic transition from a high fertility – high mortality state to a low fertility and low mortality state. Presently, it is at a mid-transition point with a high fertility rate and a declining mortality rate. This has led to a rapid population growth mainly due to a high fertility rate and the relatively young population which the high fertility/low mortality situation has created. 1 National Population commission: 1991 Population Census of the Federal Republic of Nigeria; Analytic Report at the National Level. FAMPLAN MODEL FAMPLAN 8 Life expectancy increased from 45 years in 1963 to 51 years in 1991 mainly due to improved living conditions and better health services. The further gains in life expectancy may however not have been realised due to the effects of the HIV/AIDS epidemic. The Nigerian total fertility rate (TFR) in 1990 was 6.011. This was said to have reduced to 5.2 in 19992. Authorities believe the 5.2 total fertility rate to be an under estimation, taking into consideration the proximate determinants of fertility including the contraceptive prevalence in the same year (1999 NDHS). The various figures estimated as the Nigeria’s TFR from different sources show the level of uncertainty about it. The World Development Indicators Database states that the TFR was about 5.3 in the year 20002; the World Population Data Sheet states the TFR for 2001 to be 5.83; while the WHO estimated it to be 5.74. In 1999 the contraceptive prevalence rate for modern methods among married women of reproductive age was 8.6%5. This low level of contraceptive usage was however an improvement on the 1991 level which was 3.5% (1990 NDHS)3.6 NFS: National Fertility Survey; NDHS: Nigerian Demographic and Health Survey; PES: Post enumeration survey; 1 Nigeria Demographic and Health Survey 1990 2National Population commission [Nigeria]. 2000. Nigeria Demographic and Health Survey 1999. Calverton, Maryland: National Population Commission and ORC/Macro pg 35 3 Population Reference Bureau 2001 World population data sheet 4 The World Health Report 2001 5 1999 Nigeria Demographic and Health Survey 6 1990 Nigeria Demographic and Health Survey Figure 1. Trends in Total Fertility Rates 0 1 2 3 4 5 6 7 1999 NDHS 1994 Sentinel Survey 1991 PES 1990 NDHS 1981/82 NFS Number of Chidren FAMPLAN MODEL FAMPLAN 9 The high population growth rate is of great concern and this is clearly stated in the National Policy on population for Development, Unity, Progress and Self- reliance of 1988: ‘Population pressures at the societal level: if the present high fertility and populations growth rates continue, Nigeria will have to double its entire infrastructure for food production, health services, water supply, housing sanitation and electricity in about twenty years just to maintain the present standard of living’1 Anecdotal evidence suggests that Nigeria has not been able to do this, and the standard of living is falling. To reduce the rapid population growth rate, the National Policy on Population for Development, Unity, Progress and Self-reliance of 1988 developed strategies which included making family planning services easily affordable, safe and culturally acceptable to all couples and individuals seeking such services on a voluntary basis. More recently the 1988 policy has been updated and gone through a series of reviews. A final draft has been written. The revised population policy also seeks to promote the voluntary child spacing, limiting number of children and preventing of sexually transmitted infection through the use of appropriate and acceptable methods. The revised policy is discussed below. Nigeria’s Population Policy Goals In 1988, the Government of the Federal Republic of Nigeria adopted the National Policy on Population for Development, Unity, Progress and Self reliance. This policy was designed to improve standard of living and quality of life, and promote maternal and child health. The targets pertaining to the policy were not reached. These include achieving a decrease of the population growth rate to 2.0% by the year 2000 and the reduction in the total fertility rate from 6 to 4 by the year 2000. From the present standpoint it is certain that these targets were not achieved. In 1998 the Department of Community Development and Population Activities, Federal Ministry of Health carried out an evaluation of the policy and its implementation. The reasons adduced for the policy targets not being met include weak programming, inadequate resources, weak institutional framework and a lack of strategic planning2. The goals and targets then intended, and the strategies that were then articulated, now require revision in the light of developments after its adoption; including the International Conference on Population and Development (ICPD) in 1994; the greater attention accorded reproductive and sexual health for all persons at all stages of life; the HIV/AIDS pandemic which has also 1 FMOH. 1988 The National Policy on population for Development, Unity, Progress and Self-reliance of 1988 page 7 2 FMOH, UNFPA 1998: Report of the National Population Policy Review, Nigeria 3, 31 FAMPLAN MODEL FAMPLAN 10 affected Nigeria; and the new information available from the 1991 national census and the 1990 and 1999 Nigerian Demographic Health Surveys. These considerations led to a decision to revise the National Policy on Population. The draft policy states among its targets the reduction in the national population growth rate to 2% or lower by 2015; a reduction in fertility rate of at least 0.6 children every five years; and the increase in contraceptive prevalence by at least 2 percentage points per year. The targets and goals though ambitious were based on the results obtained from other countries in which it has been found that these high targets are possible expectations with an enabling policy environment, and good programme design and implementation. Methodology There is presently no reliable data that can be used to assess the historical use of family planning clinics and commodities. The recently adopted National Health Information System has included data on the use of family planning commodities as one of its essential components, but this is yet to be implemented on a wide scale to produce country representative data. This projection is based on population-based data, especially from the Nigeria Demographic and Health Surveys. The determination of the contraceptive commodity needs was calculated by using a model; FAMPLAN developed by the POLICY Project (a USAID project) for the purpose of projecting the requirements for contraceptive commodities and to determine the cost to reach stated goals for contraceptive prevalence or desired fertility. The results were then compared with the supplies from major suppliers of contraceptives in the country and were found to be comparable when taking into consideration the market share of these suppliers. The model calculates this by taking into consideration the effect of contraceptive usage on the future fertility rates; and the effect of the proximate determinants of fertility on fertility. This is described in the figure 2. FAMPLAN MODEL FAMPLAN 11 The FAMPLAN Model The FAMPLAN model is based on the basic Bongaarts (1978) and Bongaarts-Stover (1986) model of proximate determinants of fertility. Conceptually simple, this model reflects the observation that a country’s total fertility rate is a function of average values representing the amount of time women of reproductive age are in sexually active unions, the quantity and quality of contraception practiced, the prevailing level of (induced and spontaneous) abortion, the level of postpartum insusceptibility from abstinence and intensive breastfeeding, the degree of primary and secondary sterility and the underlying level of potential fertility. Conceptually, the model states that macro influences – such as social, economic and health act by modifying these proximate determinants (intermediate variables); and that it is possible to determine the value of any of the factors from knowledge of the others. In the FAMPLAN model, the focus is on estimating either the total fertility rate, contraceptive prevalence, using % of Women of Reproductive Age in Union Post-partum Insusceptibility Exclusive Breast-feeding Post-partum Abstinence HIV prevalence Abortion Rate Contraceptive Prevalence & Effectiveness Figure 2: Factors Affecting the Total Fertility Rate Method mix Efficacy of Contraceptive Methods Sterility Total Fertility Rate FAMPLAN MODEL FAMPLAN 12 data that provide other necessary coefficients. These data are usually drawn from Demographic and Health Surveys in developing countries. The proximate-determinants model was tested first on data given from the Nigerian 1990 DHS and found to give satisfactory results, but on the 1999 NDHS data it suggested that the TFR was underestimated, a fact that the report of the NDHS also admitted1. The coefficients may be best understood if translated to “responsibility” of each proximate determinant to lower Nigeria’s “potential fertility” of 15 potential children per woman. As such the proximate determinant coefficients have been converted here into “child units” to illustrate the relative weight of the various factors: Table 1. Effect Proximate Determinants on TFR in Nigeria Factors in “Child Units” NDHS90 NDHS 99 Union duration 2.57 3.31 Postpartum insusceptibility 5.53 4.55 Abortion 0.21 0.24 Primary sterility 0.00 0.00 Contraception 0.58 1.36 TFR 6.12 5.53 Potential fertility 15.00 15.00 Sources: FOS and Macro 1991: tables 3.2, 3.5, 4.4, 5.1, 5.9 NPC and ORC/Macro 2000: tables 3.2, 3.5, 4.4, 5.9 and p. 74 Estimates: Kirmeyer / POLICY Project The Proximate Determinants of Fertility 1National Population commission [Nigeria]. 2000. Nigeria Demographic and Health Survey 1999. Calverton, Maryland: National Population Commission and ORC/Macro pg 36,204 FAMPLAN MODEL FAMPLAN 13 The relative importance of these proximate determinants in affecting the number of children per woman may be further explored by representing the above data graphically and are presented in figure 3 below. As seen they include: 1. Post partum insusceptibility 2. Duration of Sexual union 3. Abortion 4. Primary Sterility 5. Contraceptive Prevalence Rate Post partum Insusceptibility Traditionally, the long duration of breastfeeding and the postpartum abstinence have had a major suppressing effect on Nigeria’s fertility. There is evidence that the relative influence has waned considerably in the past decade are in keeping with what is occurring elsewhere. Post partum insusceptibility declined from 19 months in 19911 to 15.5 months in 19991 (Table 2). This trend will tend to increase fertility. 1 1991 NDHS Nigeria Demographic Health Survey 1991; Potential Fertility Associated with Each Proximate Determinant: Nigeria 2.57 5.53 4.55 0.58 1.36 6.12 5.533.31 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NDHS90 NDHS99 S u rv ey Percent of potential children associated with a proximate determinant Union duration PP insusceptability Abortion Primary sterility Contraception Total fertility rate Figure 3. Potential Fertility of Nigerian Women Associated with Proximate Determinants: 1990, 1999 FAMPLAN MODEL FAMPLAN 14 This trend is expected to continue as working women have less time for exclusive breastfeeding due to work out of home; women who marry late might desire to have their children faster; and the reduction in polygamy could lead to less postpartum abstinence for couples. The implication for this trend is that an expansion in the use of contraception will be needed just to maintain the present TFR. Women in Union The second most important factor has been the proportion of a woman’s reproductive years that she spends in union. The percentage of women in unions has apparently decreased over the past decade. Comparing the years 1991 and 1999 (table 2), it can be seen that the percentage of women of reproductive age in union has decreased considerably. This is expected to continue as socio-economic development continues to occur and can be expected to continue into the future as women spend more years in school thereby delaying marriage. Table 2. Proximate determinants of fertility in 1990 & 1999 Proximate determinants 1990 1999 Postpartum insusceptibility 19.0 months 15.5 months Percent of women ages 15 – 49 years who are in union 78.3% 70.1% Percent sterility (percent of women childless throughout their reproductive lifetime) 4.0% 3.0% Percentage of women in union using contraception 6% 15.3% Total abortion rate (average number of abortions over a woman lifetime) unknown unknown HIV prevalence 1.4% (1991) 5.4% Sources: Nigeria Demographic Health Survey 1991 & 1999; 2001 Technical report on the 2001 National HIV/Syphilis Sentinel Survey among Pregnant women attending ante-natal Clinics in Nigeria Primary Sterility The percentage of women who are sterile decreased from 4.0% to 3.0%. From past evidence there is no known trend in this determinant and therefore it will be difficult to predict a trend. It could be assumed that due to improvements in healthcare delivery couples with sub-fertility are able to obtain services which lead to decreased life time sterility. Known factors that affect sterility include the prevalence of sexually transmitted diseases. While these are endemic there is no epidemic of them other than the present HIV/AIDS epidemic. HIV/AIDS has been known to decrease the fertility of women worldwide. While no studies have been done in Nigeria, studies in other countries suggest that the fertility of HIV infected women decreases by 20 – 23%2 1 1999 NDHS Nigeria Demographic Health Survey 1999; 2 Carpenter et al 1997 Es timates of the impact of HIV infection on fertility in a rural cohort FAMPLAN MODEL FAMPLAN 15 Abortion It is difficult to arrive at the rate of abortion in Nigeria because the law in the country states abortion illegal except when it is done to save a woman’s life. This makes obtaining information on it difficult and unreliable. The number of abortions performed was calculated to be 25 per 1000 women 15 – 49 years in 19961. The percentage of unwanted pregnancies that result in abortions has not been determined country wide but a study done in two Nigerian towns revealed that in these towns 58% of unwanted pregnancies were aborted. This however only reflects what may be occurring in the urban areas; it may not reflect the situation in the rural areas where most of the women dwell. Apart from these uncertainties it is impossible to predict whether there will be a change in the abortion rate as there is little evidence as to whether the law on abortion will be liberalised or more rigidly enforced than it is today. HIV/AIDS The effect of the HIV/AIDS epidemic is multi- fold. HIV/AIDS has been known to decrease the fertility of women worldwide. HIV/AIDS also reduces the life expectancy and thereby the population growth rate. Since it affects women in the fertile age group it will could affect the demand for family planning. The HIV prevalence has been rising over the years and still threatens to continue – even exponentially. The HIV prevalence in 2001 was 5.8%. It is possible that the prevalence could rise even further before beginning to decline. Contraceptive Prevalence Finally, in recent years, contraceptive practice has emerged to play a minor but noticeable role, perhaps responsible for lowering fertility outcomes by 1.4 children per woman. Projecting Contraceptive Commodities In the desire to ensure reproductive health commodity security in the immediate present and the future, there is need to forecast the quantities and types of commodities that will be required with a degree of certainty. Two ways have been adopted universally: the use of service provider data and the use of population data. In Nigeria it is hard to gather reliable service provider data due to the high level of under reporting. For this estimation therefore, the population data was used. 1 Henshaw SK, Singh S, Oye-Adeniran BA et al. the incidence of induced abortion in Nigeria, International Family Planning Perspectives, 1998, 24(4): 156 – 164 FAMPLAN MODEL FAMPLAN 16 In projecting into the future it is difficult to know to what extent and at what rate Nigeria will progress towards a low fertility rate. In order to make reliable estimates a study of other Sub- Saharan African countries was made. Table 3 below presents data from sub-Saharan African countries that had two or more Demographic and Health Surveys during the 1990s. From these it can be seen that the average annual increase was 0.9%. Table 3: Changes in the CPR in Sub-Saharan Africa in the 1990’s TFR (15-49) Total CPR Modern CPR Av. Annual %- point increase in modern CPR Benin 1996 6 16.4 3.4 Benin 2001 5.6 18.6 7.2 0.8 Burkina Faso 1992/93 6.5 24.9 4.2 Burkina Faso 1998/99 6.4 11.9 4.8 0.1 Cameroon 1991 5.8 16.1 4.3 Cameroon 1998 4.8 19.3 7.1 0.4 Cote d'Ivoire 1994 5.3 11.4 4.3 Cote d'Ivoire 1998/99 5.2 15 7.3 0.6 Ghana 1988 6.4 12.9 4.2 Ghana 1993 5.2 20.3 10.1 1.2 Ghana 1998 4.4 22 13.3 0.6 Madagascar 1992 6.1 16.7 5.1 Madagascar 1997 6 19.4 9.7 0.9 Malawi 1992 6.7 13 7.4 Malawi 2000 6.3 30.6 26.1 2.3 Mali 1987 7.1 4.7 1.3 Mali 1995/96 6.7 6.7 4.5 0.4 Mali 2001 6.8 8.1 7 0.5 Niger 1992 7 4.4 2.3 Niger 1998 7.2 8.2 4.6 0.4 Nigeria 1990 6 6 3.5 Nigeria 1999 4.7 15.3 8.6 0.6 Senegal 1986 6.4 11.3 2.4 Senegal 1992/93 6 7.5 4.8 0.3 Senegal 1997 5.7 12.9 8.1 0.8 Tanzania 1992 6.2 10.4 6.6 Tanzania 1996 5.8 18.4 13.3 1.7 Tanzania 1999 5.6 25.4 16.9 1.2 Uganda 1988 7.4 4.9 2.5 Uganda 1995 6.9 14.8 7.8 0.8 Uganda 2000/01 6.9 22.8 18.2 1.7 Zambia 1992 6.5 15.2 8.9 Zambia 1996 6.1 25.9 14.4 0.9 Total Average annual increase 0.9 Source: compiled by POLICY Project from various DHS reports For countries that are close to Nigeria’s 10 % modern CPR the average increase was a bit higher at around 1.4% (Table 4). FAMPLAN MODEL FAMPLAN 17 Table 4: Increase in Modern CPR for Sub-Saharan Countries with close to 10% Modern CPR TFR (15-49) Total CPR Modern CPR Average Annual increase Ghana 1993 5.2 20.3 10.1 Ghana 1998 4.4 22 13.3 0.6 Malawi 1992 6.7 13 7.4 Malawi 2000 6.3 30.6 26.1 2.3 Tanzania 1992 6.2 10.4 6.6 Tanzania 1996 5.8 18.4 13.3 1.7 Tanzania 1999 5.6 25.4 16.9 1.2 Uganda 1995 6.9 14.8 7.8 Uganda 2000/01 6.9 22.8 18.2 1.7 Zambia 1992 6.5 15.2 8.9 Zambia 1996 6.1 25.9 14.4 0.9 Total Average annual increase 1.4 Source: compiled by POLICY Project from various DHS reports From the efforts of other countries it was estimated that Nigeria’s yearly increase in CPR points is more likely to be between 0.9 and 1.4% with some amount of programming. As a result of this 3 scenarios have been chosen to represent different rates of change of fertility over time. Other Factors affecting Fertility Life Expectancy at Birth Nigeria’s life expectancy rose from 45 years in 1960 to 51 years in 19901. This has however fallen in recent times due to the effects of the HIV/AIDS epidemic. WHO estimate that without the HIV epidemic, due to the improvement in living standards coupled with the improvement in health care, the life expectancy at birth should continue to increase. Due to the HIV epidemic, life expectancy is falling; due the life expectancy in Nigeria is presently estimated to be 46.8 years2. Method Mix & Effectiveness The “method mix” is the percentage of all users who use the different types of contraceptive methods available. These figures should sum to 100 percent. The effectiveness of different contraceptive methods are an important factor that needs to be taken into account when 1 National Population commission: 1991 Population Census of the Federal Republic of Nigeria; Analytic Report at the National Level. 2 World Development indicators database, April 2002. FAMPLAN MODEL FAMPLAN 18 considering the effect of contraceptive use on fertility. The method effectiveness is the reduction in the probability of conception occurring during a year of method use. This is determined by both the population’s ability to conceive and the extent of contraceptive method failure. Different method mixes result in different levels of decline in population growth rate. Since different methods have different levels of effectiveness the distribution of users by method will affect overall contraceptive effectiveness. The National Demographic and Health Survey is usually the best source of this data. For these projections the 1990 and 1999 NDHS reports were used. A second importance of the method mix is that it affects the cost of contraceptive commodities. The unit price of commodities and the number of commodities required to ensure a couple year of protection varies. In projecting future contraceptive requirements it is necessary to determine what the future method mix would be. This can be determined by projecting the method mix from past and present method mixes; and also the effect that social marketing; programme effort and the availability of different contraceptive commodities; the effect that cost and acceptability will have on their further use. Nigeria at present does not have a policy to increase or promote any form of contraception over the other. The method mix in Nigeria did not changed significantly between 1990 and 1999 (p = 0.79) when the two National Demographic Health Surveys were carried out. This is shown in the table 5 below: Table 5, Comparison of Contraceptive Method mix for all methods (1990 and 1999) All methods Modern Methods 1990 1999 1990 1999 MODERN METHODS 1. Injectable (hormonal) 11.67 16.7 20.0 27.9 2. Intra-uterine device (IUD) 13.3 13.9 22.9 23.3 3. Oral pills 20 16.7 34.3 27.9 4. Condoms 6.67 8.3 11.4 14.0 5. Sterilization 5.0 2.1 8.6 3.5 6. Implants 0.0 0.7 0.0 1.2 7. Vaginal barriers/foaming tablets - - 2.9 2.3 TRADITIONAL METHODS 41.67 40.3 - - (P = 0.79) (P = 0.37) Source: 1990 & 1999 Nigeria Demographic and Health Surveys When examining only modern methods, there was a noticeable increase in the percentages of those using injectables and a decrease in percentage of those using pills. The difference FAMPLAN MODEL FAMPLAN 19 however was also not statistically significant. Traditional methods were a major form of contraception in both years. This occurred in spite of the doubling in contraceptive prevalence. If lessons can be learnt from the past then it is likely that as the contraceptive prevalence rises the percentage of women using traditional methods will decrease. It is reasonable to assume that the modern method mix will not change much over the next 5 years except if very aggressive and effective means are taken to change the mix. There is no plan by the government, health ministries or authorities to promote the use of any commodity over the others. The use of condoms may however increase due to its dual usage. There is, however, a plan to promote the use of modern methods over traditional methods. It could therefore be logical to assume that the percentage of persons using modern methods will increase. If experiences of other Sub-Saharan countries are to act as a guide, the percentage of women using traditional methods could fall to as low as 20% when the CPR rises to about 30%. See Figure 4 above. An assumption is made for these projections that the percentage of traditional method use decreases from 40% in 1999 to 30% in 2015. This is done to ensure that the projections do not under estimate the required commodities for future use. Scenarios Defined Median Percentage Method Mix by Level of Modern Contraceptive Prevalence 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <10 10-15 15.1-29 >30 Modern CPR % U si ng m et ho d Trad Pill IUD Inj FS Condom FAMPLAN MODEL FAMPLAN 20 1. The first scenario for CPR growth is based on the assumption that very little change in the family planning programme effort occurs and therefore the increase in contraceptive demand is largely due to the increase in urbanization, increased female education and improved socioeconomic conditions. This assumes that the contraceptive prevalence rate increases by 0.75% every year from 2003 2. The second, the status quo scenario, is based on the fact that the Nigerian authorities who coordinate population programmes are able to undertake programme activities to meet unmet demand and increase the awareness of child spacing to some extent i.e. they make significant achievements but not the ultimate. In this scenario the assumption is made that the contraceptive prevalence increases by 1.25% a year. 3. The last scenario is based on the assumption that through very high-quality programmes and an improved enabling environment as shown by popular support at all levels, Nigeria is able to meet the target of an increase in contraceptive prevalence of about 2% per year as stated in the draft document of the revised population policy 2001. While the three scenarios above were formulated to reflect a level of realism in terms of family planning objectives, it needs to be pointed out that even the most ambitious of these (scenario 3) will require more than 25 years to achieve contraceptive use levels comparable to those of present day developed countries of over 70%. Assumptions A projection is only as good as the assumptions made in obtaining it. It is important to examine the assumptions critically in order to determine if any assumption made could significantly bias the results accomplished. Proximate determinants In these projections, no change in percentage of married women of reproductive age was made after 1999. This is because there is no evidence that it has changed or if it has to what extent. For the same reason no change in post partum insusceptibility was made after 1999. The sterility rate is also kept constant at the 1999 levels. This is due to the fact that there is no evidence of trend sterility in the country. The effect of HIV/AIDS on the pattern is however taken into account. FAMPLAN MODEL FAMPLAN 21 Finally there is no reliable estimate on the total abortion rate for women in Nigeria. The rate was kept at 0.0 abortions per woman. This is unlikely to affect the projections significantly as this number is kept constant throughout the period of the study. Source Mix The future assumptions on the source mix are also based on keeping the 1999 levels constant throughout the duration of the projections. Although no documented scientific evidence exists, it is commonly believed that the use of the public health services for family planning has dropped in recent times largely as a result of lack of commodities. It is expected that as commodities are made increasingly available and as women become more confident in receiving services at public health institutions the rate of use will again increase, perhaps even exceeding the 1999 levels. Method Attributes, Effectiveness & Mix In the absence of any scientific evidence to suggest that the effectiveness of contraceptives in Nigeria is different from that obtained elsewhere, the method effectiveness and attributes accepted universally were used. The assumptions made on method mix include those stated earlier: that there is no change in the proportions of modern methods used and that the number of traditional methods decreases gradually with increased contraceptive use. Projecting Condom Requirements One of the limitations of previous studies was the fact that such projections took into consideration women only. This is as a result of the fact that women take the major responsibility for spacing and limiting their families. The use of female needs to estimate the condom requirements have been found to underestimate the needs for male condoms in present times when condoms are used more to protect against HIV/AIDS than preventing unwanted pregnancy. A number of reasons have been adduced for this, which include: the dual use of condoms (for both family planning and protection against HIV/AIDS and STI); the fact that married women do not truly represent the women who usually use condoms; the selective nature of condom usage by males having multiple sex partners and the non inclusion of men who have sex with men. These factors made it difficult to accurately estimate future requirements for condoms based on female FAMPLAN MODEL FAMPLAN 22 usage data only. In order to estimate the needs for condoms, it is more appropriate to determine the needs of the men that will be using the commodities. Unfortunately there is very little service statistics data to estimate condom usage. This is even more so, due to the fact there is more likely to be wastage in the use of condoms than any other commodity. It is more expedient to use population data if such is available. It may however be useful to use national sales figures for condoms if available. Methodology The estimation of condom requirements is based on the number of sexual active men in the community, the percentage of men who use condoms during sexual intercourse and the average coital frequency. Sources of needed information include the reports of surveys including National Demographic Health and Surveys, behavioural surveys and research work. Coital Frequency Data on coital frequency among African societies are scanty and in the few cases where this information is available, it is limited only to people in union. DHS studies used to collect data on this question but not any more apparently because they used to get differing rates depending on who was present during the time of interview. Nevertheless, a review of literature shows that in general frequency of sexual intercourse is highest among the younger age groups and reduces with age. In addition, sexual intercourse among married people is more frequent that non-married sexually active people. A review of several studies shows that average coital frequency among married people ranges from 4 times to 9 times a month with a median of about 8 per month1. 2 Though very few studies have been done on the non-married sexually active people, studies in the USA reported an annual coital frequency of 59 times among sexually active adults (both married and un-married). Modelling has tended to use a factor of 60 – 80 to estimate the condom usage within countries and communities. When the Nigerian situation in 2002 was considered a factor 60 was found to fairly represent the condom usage in the country. It also fit in with estimates done using other measures. For this study we have opted to use a factor of 60 to represent the number of coital acts per man a year. 1 Ronald Gray et. al. 2001. “Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1 discordant couples in Rakai, Uganda.” The Lancet, 357: 1149-1153 2 Tom W. Smith, 1998. “American Sexual Behavior: Trends, Socio-Demographic Differences, and Risk Behavior.” National Opinion Research Center, GSS Topical Report No. 25 FAMPLAN MODEL FAMPLAN 23 Condom Usage Various studies in Nigeria have shown that condoms are the major type of contraceptive reportedly used by males. The 1999 NDHS reported an 8.6% current use of condoms by all men and a 6.4% use by married men. The 2003 NARHS study reported that 13.2% of men used condoms while 8.6% of married men reported current condom use. Studies elsewhere have shown that most persons reporting use of condoms do not use such regularly. This is also revealed in the NARHS study and smaller studies done in various states especially amongst the Edo state youth1. Previous efforts at modelling condom usage in other countries have shown that the percentage of sexually active men that give a positive response to the question on use of a condom during the last sexual intercourse gives a fair representation of the condom usage coupled with the regularity of condom use. The age distribution for positive responses to this in the National Reproductive and Health Survey is shown in table 6. Table 6: Male Condom prevalence rate All males Currently married males Sexually active unmarried males Age 15 - 19 8.1 8a 29.5 20 - 24 20.3 6 41 25 - 29 22.5 9.9 31.7b 30 - 39 14.9 12.1 40 - 49 8.3 8.4 50+ 3.2 3.4 TOTAL 13.2 8.6 a: based on a small sample size b: 25+ Source National Reproductive Health Survey: 2003 An assumption has to be made as to what proportion of men will use condoms in the future. To understand this it is important to understand that condoms are used for two purposes; family planning and prevention of STI and HIV/AIDS. The new population policy aims to increase the use of voluntary use of contraceptives including condoms. One target will therefore be to increase its usage. In controlling the spread of HIV/AIDS, the target is increase the use of condoms during risky sex. This target is however limited to risky sex which itself is a target for reduction. The 1 Okonofua F et al. 2000.Profile of sexual and Reproductive health of adolescents in Edo state, Nigeria . Policy Project (unpublished). FAMPLAN MODEL FAMPLAN 24 increase in use of condoms during risky sex would therefore be affected by the degree to which risky sex is practised. It is very hard therefore to determine the degree to which a rise in condom use will occur. When comparing the male condom use in the 1999 and 2003, the prevalence in use increased from 8.6% to13.2%. While these prevalence were from two different types of studies they do show a rise in use. Similarly, when comparing female condom use between the 1991 and 1999 NDHS, there is an increase in use of condoms. For the present projections some assumptions are therefore made. In the first – the low CPR growth - scenario no increase in condom usage was assumed; the increase in condom needs is as a result of increase in the population. For the medium (status quo) scenario a marginal increase of about 1 percentage increment in condom prevalence per year was assumed will occur, and for the high CPR growth an increase of about 2.0% was assumed. FAMPLAN MODEL FAMPLAN 25 RESULTS Demographic characteristics of Nigeria (1990 – 2015) The demographic characteristics of Nigeria show that while the population of Nigeria was 88.9 million in 1990 it is estimated to be about 125.5 million in the year 2003. This will increase to 132.2 million in the year 2005 an increase of about 7.7 million people within 2 years. The table 3 shows the yearly increase in number of women of reproductive age that will occur. This has implications for family planning activities because it infers that to maintain the same contraceptive prevalence an increase in the number of persons using family planning methods will be needed and subsequently more commodities will be required. The number of women of reproductive age remains the same from 2003 to 2015 in all 3 scenarios because this is not affected by immediate changes in contraceptive prevalence. The differences noticed in the number of commodities is therefore mainly as a result of the difference in the anticipated CPR goals. Table 7: Demographic Characteristics (1990 – 2015) Total population Women of Reproductive Age YEAR Low CPR scenario Medium CPR scenario High CPR Scenario All Scenarios 2003 125,807,192 125,807,192 125,807,192 28,558,644 2004 129,316,512 129,293,216 129,258,280 29,310,550 2005 132,858,856 132,786,456 132,677,888 30,086,822 2006 136,438,608 136,290,000 136,067,200 30,880,766 2007 140,062,736 139,809,408 139,429,664 31,700,788 2010 151,262,800 150,507,120 149,374,656 34,271,020 2015 171,442,624 169,095,440 165,579,120 39,962,260 Effect of Contraceptive Prevalence on Fertility Table 8. Contraceptive Prevalence Rate , and its effect on the Total Fertility Rate CPR (all) CPR (Modern Methods only) TFR Low CPR Medium CPR High CPR Low CPR Medium CPR High CPR Low CPR Medium CPR High CPR FAMPLAN MODEL FAMPLAN 26 Scenario Scenario Scenario Scenario Scenario Scenario Scenario Scenario Scenario 2003 15.0 15.0 15.0 9.11 9.11 9.11 5.60 5.60 5.60 2004 15.75 16.25 17.0 9.69 9.99 10.46 5.56 5.53 5.49 2005 16.5 17.5 19.01 10.28 10.9 11.83 5.51 5.46 5.38 2006 17.25 18.75 21.01 10.88 11.82 13.24 5.47 5.38 5.26 2007 18.0 20.0 23.0 11.49 12.76 14.68 5.42 5.31 5.13 2010 20.25 23.75 29.0 13.39 15.71 19.18 5.27 5.07 4.77 2015 24.0 30.0 39.0 16.8 21.0 27.3 5.02 4.67 4.13 Though the contraceptive prevalence was based on scenarios which assumed a yearly percentage incremental targeted goal of between 0.75% - 2%, the total fertility rate was not predetermined. The table 8 shows what could be expected based on achieving the set contraceptive prevalence rate goals in each scenario. This was determined by estimating the effect of the contraceptive prevalence rate on the fertility rate, other assumptions kept as previously stated. It can be seen that the effect of the stated goals is to decrease the total fertility rate to about 4.13 – 5.02 by the year 2015, depending on the scenario. It also shows that the percentage of women using modern methods of contraception only increases to about 19% – 28% by the same year 2015. The population policy stated target of achieving a 0.6 decrease in TFR every 5 years will only be achieved if the high impact scenario (2 percentage point increase in CPR is achieved) occurs. FAMPLAN MODEL FAMPLAN 27 Contraceptive Users The increases in contraceptive prevalence rate shown in Table 8 will be as a result of an increase in the number of women who voluntarily opt to limit or space their children. The projections of the number of women who will be using family planning by method and by year are shown in Table 9. Table 9 Estimates of Modern contraceptive users excluding condoms by method by year (in thousands) in the three scenarios Female sterilization Injectables IUD Pills Total Low 2003 68.1 541.7 450.9 541.7 1602.5 CPR 2004 74.4 591.3 492.2 591.3 1749.2 scenario 2005 81.0 643.8 535.9 643.8 1904.4 2006 88.0 699.5 582.2 699.5 2069.2 2007 95.4 758.5 631.3 758.5 2243.6 2008 103.2 820.7 683.1 820.7 2427.6 2009 111.4 886.3 737.7 886.3 2621.7 2010 120.1 955.4 795.2 955.4 2826.3 2015 171.3 1362.1 1133.7 1362.1 4029.3 Medium 2003 68.1 541.7 450.9 541.7 1602.5 CPR 2004 76.7 610.1 507.8 610.1 1804.7 scenario 2005 85.9 682.8 568.3 682.8 2019.9 2006 95.6 760.3 632.9 760.3 2249.1 2007 106.0 842.7 701.4 842.7 2492.9 2008 117.0 930.1 774.2 930.1 2751.3 2009 128.6 1022.6 851.2 1022.6 3025.0 2010 140.9 1120.6 932.7 1120.6 3314.8 2015 214.1 1702.7 1417.2 1702.7 5036.6 High 2003 68.1 541.7 450.9 541.7 1602.5 CPR 2004 80.3 638.2 531.2 638.2 1888.0 scenario 2005 93.2 741.4 617.1 741.4 2193.0 2006 107.1 851.6 708.8 851.6 2519.0 2007 121.9 969.1 806.7 969.1 2866.8 2008 137.6 1094.2 910.8 1094.2 3236.8 2009 154.3 1227.2 1021.4 1227.2 3630.0 2010 172.1 1368.3 1138.9 1368.3 4047.5 2015 278.3 2213.5 1842.3 2213.5 6547.6 The table shows a yearly increase in the number of women who practise family planning. These figures represent the total number of users each year, and not just the new users or acceptors. Persons sterilised remain so for life and acceptors of IUD may use the same implement for up to 10 years. The figures do not include persons who use condoms which have been calculated using male needs. This is shown in table 10. FAMPLAN MODEL FAMPLAN 28 Table 10: Estimated number of Male condom users in various scenarios (in thousands). Number of condom users Year No of men (15 – 64yrs) Number of sexually active men low growth rate scenario Medium growth rate scenario High growth rate scenario 2003 32,515.3 21,350.4 2,872.6 2,872.6 2,872.6 2004 33,448.9 21,942.1 2,950.8 3,129.6 3,353.2 2005 34,401.6 22,540.9 3,029.9 3,443.0 3,902.1 2006 35,449.1 23,164.8 3,111.2 3,771.2 4,478.3 2007 36,522.2 23,802.4 3,194.8 4,114.5 5,082.6 2008 37,736.4 24,456.6 3,281.6 4,475.0 5,718.0 2009 38,736.4 25,130.5 3,372.7 4,854.6 6,387.6 2010 39,880.4 25,823.8 3,467.9 5,254.4 7,093.4 2015 46,012.4 29,763.0 4,043.4 7,657.9 11,333.6 The number of men who use condoms is a reflection of the number of sexually active men and the percentage of these who use condoms users. Contraceptive Commodity Requirements The number of contraceptives that is required each year varies with method used as each method has a different number of commodities needed to provide a couple with a year’s protection (CYP). The amount of commodities needed to provide one year of CYP is shown in Table 6 below. Table 11: Commodities per method necessary to achieve a year of protection for a couple Method No of units required for one couple year protection/ no of years of protection per user Effectiveness of method of contraception Injectable (Noristerat) 6 99% Injectable (Depo Provera) 4 99% IUD 3.5 years 96% Oral Contraceptives 15 cycles 92% Source: Evaluation project For condoms this is computed by determining the coital frequency. A factor of 60 – 80 has been shown to provide good estimates of condom requirements. In this projection a factor of 60 was used. When compared to the known estimated number of condoms used in 2002, a factor of sixty closely reflected the number used. Commodities are obtained from various sources. Forty three percent of users obtained from the public sector through government hospitals, government health centres, family planning clinics, community health workers and other public sources. Another 43% of users obtain them from the private medical sector including private hospitals, pharmacies and medical FAMPLAN MODEL FAMPLAN 29 stores etc. while others obtain them from other sources including shops, religious institutions and non governmental organisations1. It is important to know the sources of various contraceptive commodities because this will determine the immediate needs and cost to the public sector. Figure 5 shows the usual sources as seen noticed during the 1999 NDHS. it shows that the source of commodities varies with type of commodity. Condoms that are available over the counter and do not need prescriptions are more commonly sourced from the non-public sector – mainly pharmacies. The same is seen for oral pills which once recommended are usually bought in pharmacies. Injectables and IUDs however require medical supervision and a considerable number of users rely on the government to provide these commodities. When comparing the sources of commodities as seen in the 1990 and 1999 NDHS (table 12), it was evident that contraceptive users were increasingly depending on the public sector for IUD and hormonal injectables. The use of the public sector for condoms and oral pills did not change significantly. It is possible that this trend of increasing dependence on the public sector will continue. There is however anecdotal evidence that there has been a decline in the patronage of the public sector due to a decline in services provided in them including the common place ‘out-of-stock syndrome’. For this forecast the source of supply of commodities was assumed to remain at 1999 levels Table 12: Sources of contraception 1 Nigeria Demographic and Health Survey 1999; 0 20 40 60 80 100 % Condoms injectables IUD Pills Figure 5: Usual Source of Commodities (1999 NDHS) Public Sector Private Sector FAMPLAN MODEL FAMPLAN 30 1990 1999 public non-public public non-public Condoms 13.4% 86.6% 12.9% 87.1% Injectable 44.9% 55.1% 68.6% 31.4% IUD 61% 39% 74.4% 25.6% Pills 29% 71% 29.1% 70.9% Sources: 1990 & 1999 National Demographic Health Survey A considerable amount of commodities are necessary to meet the needs of a country with 126 million people the requirements of the country are shown in table 8 disaggregated by usual source through which the users are expected to source them using previous experience. Table 13: No of commodities by source needed to meet expected demand Male Condoms Injectables IUD Pill Government Private Government Private Government Private Government Private 2003 22,234,188 150,123,860 2,229,796 1,020,636 149,478 51,433 2,364,689 5,761,391 2004 22,839,022 154,207,662 2,433,858 1,114,040 161,948 55,724 2,581,095 6,288,648 2005 23,451,207 158,341,097 2,649,904 1,212,930 175,244 60,299 2,810,211 6,846,872 2006 24,080,797 162,592,048 2,879,189 1,317,880 189,225 65,110 3,053,368 7,439,305 Low CPR Scenario 2007 24,727,530 166,958,749 3,121,819 1,428,937 203,899 70,159 3,310,675 8,066,216 2008 25,399,953 171,498,909 3,377,898 1,546,152 219,339 75,471 3,582,246 8,727,878 2009 26,104,494 176,255,925 3,647,933 1,669,753 235,604 81,068 3,868,617 9,425,599 2010 26,841,405 181,231,506 3,932,604 1,800,055 252,720 86,957 4,170,510 10,161,139 2015 31,295,570 211,305,751 5,606,520 2,566,250 355,344 122,269 5,945,690 14,486,234 2003 22,234,188 150,123,860 2,229,796 1,020,636 163,040 56,100 2,364,689 5,761,391 2004 24,223,205 163,553,580 2,511,123 1,149,406 180,513 62,112 2,663,035 6,488,288 2005 26,649,099 179,933,065 2,810,504 1,286,441 199,181 68,535 2,980,527 7,261,834 2006 29,188,845 197,081,271 3,129,553 1,432,478 218,915 75,326 3,318,878 8,086,200 Medium CPR Scenario 2007 31,846,061 215,022,631 3,468,687 1,587,708 239,730 82,488 3,678,528 8,962,461 2008 34,636,300 233,862,149 3,828,284 1,752,305 261,719 90,054 4,059,879 9,891,595 2009 37,574,651 253,701,711 4,209,153 1,926,639 284,962 98,051 4,059,879 9,891,595 2010 40,668,796 274,593,192 4,612,313 2,111,176 309,503 106,496 4,463,789 10,875,691 2015 59,271,913 400,200,287 7,008,150 3,207,812 458,509 157,767 7,432,113 18,107,794 2003 22,234,188 150,123,860 2,229,796 1,020,636 183,383 63,100 2,364,689 5,761,391 2004 25,953,434 175,235,979 2,627,021 1,202,456 208,360 71,694 2,785,944 6,787,747 High CPR Scenario 2005 30,202,312 203,924,141 3,051,404 1,396,707 235,088 80,890 3,236,001 7,884,277 2006 34,661,753 234,034,009 3,505,100 1,604,375 263,451 90,650 3,717,143 9,056,544 2007 39,339,252 265,616,191 3,988,991 1,825,865 293, 476 100,981 4,230,307 10,306,831 2008 44,257,494 298,823,858 4,503,864 2,061,536 325,288 111,927 4,776,328 11,637,171 2009 49,440,330 333,818,041 5,050,984 2,311,966 358,998 123,526 5,356,546 13,050,828 2010 54,902,875 370,700,809 5,631,878 2,577,857 394,677 135,803 5,972,582 14,551,754 2015 87,722,432 592,296,425 9,110,595 4,170,156 613,619 211,138 9,661,747 23,540,132 FAMPLAN MODEL FAMPLAN 31 Table 13 shows that due to the difference in sourcing of commodities by the contraceptive users, government will be responsible for only a small percentage of the condoms needed but will be responsible for the most of the IUDs and injectables needed. Family Planning Commodity Costs The cost of contraceptives is a small but significant part of the costs of family planning. Contraceptives are an essential element in family planning service provision, along with direct service provision, clinic-level costs, such as provider salaries and clinical facility costs. To estimate the contraceptive costs of family planning, we used international unit cost estimates of contraceptives. Since contraceptives are an internationally traded commodity, such an assumption is reasonable. Table 14 shows the unit cost assumptions that were used for these calculations. Table 14: Unit Cost Assumptions for Contraceptives Method Cost in Naira (?) Cost in US$ Condoms 6.4 0.0495 Injectables 120.9 0.93 IUD 189.8 1.46 Oral contraceptives 28.1 0.216 Source: JSI/deliver * US$1.00 = ? 130.00 The total commodity costs for the public sector will therefore be dependent on the percentage of commodities that will be sourced from the public sector. Using the various estimated unit commodity costs the table 15 below shows the disaggregated and total costs needed per year to provide the contraceptive commodities. Table 15: Projected Cost of Contraceptives Commodities, excluding condoms, by Source (in millions) (Cost in Naira) (Cost in US$) Government Private Total Government Private Total 2003 364.4 294.9 659.3 2.8 2.3 5.1 2004 397.5 321.8 719.3 3.1 2.5 5.5 Low Scenario 2005 432.5 350.3 782.9 3.3 2.7 6.0 2006 469.7 380.6 850.3 3.6 2.9 6.5 2007 509.1 412.6 921.7 3.9 3.2 7.1 2008 550.6 446.3 996.9 4.2 3.4 7.7 2009 594.4 481.9 1,076.3 4.6 3.7 8.3 2010 640.5 519.5 1,160.0 4.9 4.0 8.9 FAMPLAN MODEL FAMPLAN 32 2015 912.2 740.2 1,652.5 7.0 5.7 12.7 2003 375.3 358.2 733.4 2.9 2.8 5.6 Medium Scenario 2004 422.2 403.2 825.5 3.2 3.1 6.3 2005 472.2 451.2 923.4 3.6 3.5 7.1 2006 525.5 502.3 1,027.8 4.0 3.9 7.9 2007 582.1 556.6 1,138.7 4.5 4.3 8.8 2008 642.1 614.2 1,256.3 4.9 4.7 9.7 2009 705.7 675.2 1,380.9 5.4 5.2 10.6 2010 773.0 739.7 1,512.7 5.9 5.7 11.6 2015 1,173.1 1,123.5 2,296.6 9.0 8.6 17.7 2003 377.6 359.0 736.6 2.9 2.8 5.7 High Scenario 2004 444.0 422.6 866.6 3.4 3.3 6.7 2005 514.9 490.6 1,005.5 4.0 3.8 7.7 2006 590.7 563.3 1,154.0 4.5 4.3 8.9 2007 671.5 640.8 1,312.3 5.2 4.9 10.1 2008 757.5 723.3 1,480.8 5.8 5.6 11.4 2009 848.8 810.9 1,659.7 6.5 6.2 12.8 2010 945.8 903.9 1,849.7 7.3 7.0 14.2 2015 1,527.1 1,461.3 2,988.4 11.7 11.2 23.0 * US$1.00 = ? 130.00 Table 16 shows the cost to meet the condom requirements by source of commodity Table 16: Projected Cost of condoms, by source (in millions unit currency ) (Cost in Naira) (Cost in US$) Government Private Total Government Private Total 2003 143.1 966.0 1,109.1 1.1 7.4 8.5 Low Scenario 2004 147.0 992.3 1,139.3 1.1 7.6 8.8 2005 150.9 1,018.9 1,169.8 1.2 7.8 9.0 2006 155.0 1,046.3 1,201.2 1.2 8.0 9.2 2007 159.1 1,074.4 1,233.5 1.2 8.3 9.5 2008 163.4 1,103.6 1,267.0 1.3 8.5 9.7 2009 168.0 1,134.2 1,302.2 1.3 8.7 10.0 2010 172.7 1,166.2 1,338.9 1.3 9.0 10.3 2015 201.4 1,359.8 1,561.1 1.5 10.5 12.0 2003 143.1 966.0 1,109.1 1.1 7.4 8.5 Medium Scenario 2004 155.9 1,052.5 1,139.3 1.2 8.1 8.8 2005 171.5 1,157.9 1,169. 8 1.3 8.9 9.0 2006 187.8 1,268.2 1,201.2 1.4 9.8 9.2 2007 204.9 1,383.7 1,233.5 1.6 10.6 9.5 FAMPLAN MODEL FAMPLAN 33 2008 222.9 1,504.9 1,267.0 1.7 11.6 9.7 2009 241.8 1,632.6 1,302.2 1.9 12.6 10.0 2010 261.7 1,767.0 1,338.9 2.0 13.6 10.3 2015 381.4 2,575.3 2,956.7 2.9 19.8 22.7 2003 143.1 966.0 1,109.1 1.1 7.4 8.5 High Scenario 2004 167.0 1,127.6 1,139.3 1.3 8.7 8.8 2005 194.4 1,312.3 1,169.8 1.5 10.1 9.0 2006 223.0 1,506.0 1,201.2 1.7 11.6 9.2 2007 253.1 1,709.2 1,233.5 1.9 13.1 9.5 2008 284.8 1,922.9 1,267.0 2.2 14.8 9.7 2009 318.1 2,148.1 1,302.2 2.4 16.5 10.0 2010 353.3 2,385.5 1,338.9 2.7 18.3 10.3 2015 564.5 3,811.4 4,375.9 4.3 29.3 33.7 * US$1.00 = ? 130.00 Table 17. Cost for both Contraceptives and Condoms for HIV/AIDS (2003 – 2015) (Cost in Naira) (Cost in US$) Year Private sector Total Public Sector Overall Total Private sector Total Public Sector Overall Total Low Scenario 2003 1,261.0 507.4 1,768.4 9.7 3.9 13.6 2004 1,314.2 544.4 1,858.6 10.1 4.2 14.3 2005 1,369.3 583.5 1,952.7 10.5 4.5 15.0 2006 1,426.9 624.7 2,051.6 11.0 4.8 15.8 2007 1,487.0 668.2 2,155.2 11.4 5.1 16.6 2008 1,549.9 714.1 2,264.0 11.9 5.5 17.4 2009 1,616.1 762.4 2,378.5 12.4 5.9 18.3 2010 1,685.7 813.3 2,498.9 13.0 6.3 19.2 2015 2,100.0 1,113.6 3,213.6 16.2 8.6 24.7 Medium 2003 1,324.2 518.3 1,842.5 10.2 4.0 14.2 Scenario 2004 1,455.7 578.1 2,033.8 11.2 4.4 15.6 2005 1,609.1 643.7 2,252.8 12.4 5.0 17.3 2006 1,770.5 713.4 2,483.9 13.6 5.5 19.1 2007 1,940.3 787.1 2,727.3 14.9 6.1 21.0 2008 2,119.1 865.0 2,984.1 16.3 6.7 23.0 2009 2,307.7 947.5 3,255.2 17.8 7.3 25.0 2010 2,506.7 1,034.7 3,541.4 19.3 8.0 27.2 2015 3,698.8 1,554.5 5,253.3 28.5 12.0 40.4 FAMPLAN MODEL FAMPLAN 34 High Scenario 2003 1,325.0 520.7 1,845.7 10.2 4.0 14.2 2004 1,550.3 611.0 2,161.3 11.9 4.7 16.6 2005 1,802.9 709.3 2,512.1 13.9 5.5 19.3 2006 2,069.3 813.8 2,883.1 15.9 6.3 22.2 2007 2,350.0 924.7 3,274.7 18.1 7.1 25.2 2008 2,646.2 1,042.3 3,688.5 20.4 8.0 28.4 2009 2,959.0 1,167.0 4,126.0 22.8 9.0 31.7 2010 3,289.4 1,299.1 4,588.5 25.3 10.0 35.3 2015 5,272.7 2,091.6 7,364.3 40.6 16.1 56.6 * US$1.00 = ? 130.00 The Table 17 shows that the estimated cost of providing contraceptive commodities for the public sector in the year 2003 is $4 million. This increases yearly, and by 2007 would have escalated to $6 million. The cost of providing commodities for the whole country will amount to about $14 million in 2003 reaching $21 million in 2007. The cumulative cost of providing contraceptive commodities for the public sector between 2003 and 2007 is estimated to be about $25 million and for the whole country about $87 million. The total cost of commodities for the whole country is significantly greater than the anticipated costs for the public sector only. This is largely due to the fact that condoms which are by far the most costly of contraceptive commodities to achieve a CYP are mainly sourced from the private sector. In all years of the projection more than two thirds of the cost of commodities is borne by the private sector. Conclusions The Government of Nigeria has the responsibility to meet the needs of its citizenry. It also has the duty to devise and execute population policies and plans that will ensure that country’s rate of the country’s growth is such that it allows for sustainable social and economic development and has no adverse consequences on the people or the land in which they live. The people have scripted a revised population policy that articulates these objectives. While the draft goes through the various stages of adoption by the bureaucracy and the government, the stated goals, targets and objectives reflect the viewpoint of the various stakeholders and are laudable. FAMPLAN MODEL FAMPLAN 35 One of the major strategies to achieve the desired goals was the increased access and use of family planning commodities. To further give credence to the importance of this strategy the policy states that the contraceptive logistics and distribution network has to be strengthened. It also states that the government will be responsible for the procurement of contraceptive commodities in order to ensure its continuous availability. The contraceptive logistic management system has been revised and the first steps towards its implementation are being carried out. The other initiative requires a determination of the quantities of commodities required and how these will be supplied. This study was conceived to answer this question. Unfortunately, Nigeria is one of the many countries facing a growing shortage of contraceptives and other reproductive health commodities. The global contraceptive shortage is projected at hundreds of millions of dollars annually in the coming years. The cost of quality contraceptives and condoms needed is projected to rise from $811 million to $1.8 billion between 200 and 2015. While the cost of services to deliver and provide these commodities are projected to increase from $4 billion to $9 billion over the same period1. The main reasons for the short fall in supply of commodities are the increase in number of women of child bearing age opting for family planning/child spacing, the increasing number of women in the reproductive age, the high population growth rate in developing countries, the increased use of condoms for prevention of HIV/AIDS, the declining donor support and dwindling financial resources within countries. To close this gap a global strategy for reproductive health commodity security was articulated in 2000 by UNFPA and its partners. It called on all partners to use their comparative advantages in a coordinated and systematic joint effort to secure sufficient supplies of contraceptives and other Reproductive Health commodities now and in the future for those countries at risk of the lacking these essential supplies. Part of the process of ensuring contraceptive security is determining the quantity of commodities required now and in the future. To this would be determining what organization or organizations could be counted on to bear the cost presently and in the future. This study has determined that a considerable amount of money will be needed to meet the need of the country. In the year 2004 an estimated $9 million will be needed to meet the needs for condoms and another $9 million needed to meet the needs for other contraceptives 1 UNFPA. 2002. Reproductive Health Essentials: Securing the Supply. ISBN 0-89714-626-3 E/10,000/2002 FAMPLAN MODEL FAMPLAN 36 commodities. The amount required increases yearly as a result of the anticipated increase in contraceptive usage and the number of women who will be of reproductive age. By the year 2010 the amount is estimated to be about $15 million for condoms and $11 million for other contraceptive commodities. The amount of required funds poses a challenge to a country that is embroiled in many other challenges which include an unstable economy, ethnic unrest, undeveloped social infrastructure, unemployment, inflation, poverty and the HIV/AIDS epidemic. In spite of these many challenges Nigeria will have to meet its responsibilities to its citizenry. Many studies have shown a willingness of the people to pay for health services if the cost is well within their ability to pay. The fact that 43% of the populace obtain their family planning commodities and services from private medical services implies that a considerable number of users are already paying. Most of the persons using public sector health services pay a part of the cost of the services though this may be subsidised. It is likely however that the payments made will cover the cost of the commodities being used. The challenge for the country is to devise strategies that will ensure cost recovery while not discouraging citizens from using services they might want to use. A lot of the family planning commodities in the country are brought in by developmental partners notably DFID and USAID through their implementing partners. This has helped meet the needs of a lot of persons who require these commodities. About 75% of the condoms in the country are brought in through these developmental agencies. While this helps to ensure some amount of reproductive health commodity security, it also leaves the country’s population plans and goals vulnerable, since it is not being driven by in-country factors. The out-of-stock syndrome that affected many of the country’s public health facilities is an example of this. Another reality of donor dependencies the fact that it has reduced the ability of governmental agencies to acquire the logistic skills in carrying out the tasks expected of them. It would be better if civil servants who ought to carry out functions are empowered to carry out these tasks even if they are supervised while doing it. The stated decision to have the government buy all family planning commodities could be a step in the right direction but previous observations have shown that family planning is not a priority concern of the government and therefore the decision to carry it through may not actualise. The Policy Environment Score for Nigeria in 2002 showed a lacking in the government ’s willingness to commit resources to family planning initiatives. Furthermore the FAMPLAN MODEL FAMPLAN 37 requirements for ensuring contraceptive commodity is a considerable percentage of previous health budgets and due to the competing needs it is unlikely that the government will be able to afford to fund it wholly. Buying the goods may also limit private initiative in this regards as less profit would mean that the government will have to take on the task of storage, distribution for not only the public sector but the whole country as more shift to public sector use due to cost differences. Opportunities exist. The present government is committed to the control of HIV/AIDS. Increased condom usage during risky sex is one of the strategies being targeted in the behaviour change communication strategy. It is therefore possible to leverage resources by ensuring that the HIV/AIDS control program takes on the job of securing most of the condoms which account for more than 50% of the total cost for ensuring contraceptive commodity security. Funds are also more available for HIV/AIDS control from developmental partners. The country is in the process of developing a strategic plan to ensure contraceptive commodity security using the SPARHCS initiative. This five year plan will address many components of the task including advocacy, logistics, finance, service demand and coordination. It is hoped that the plan will be implemented and result in a better level of supply of needed commodities. While the plan is being conceptualised and later when it is being implemented there is a need to ensure that supplies exist and are adequate. During this phase between implementation and results generation, it is important that developmental partners will continue to fill in the gap to ensure that the gains of the past are not lost; that children can be born into the country with better prospects of survival; that the needless death of women as a result of high risk pregnancy will be eliminated; and so the country can march on to social and economic development unhindered by the effects of a rapidly growing population and its consequences. FAMPLAN MODEL FAMPLAN 38 Appendix Appendix 1: Cost of Contraceptive commodities by type and source in US$ (millions) Injectable IUD Pill Government Private Government Private Government Private 2003 2.07 0.95 0.22 0.08 0.51 1.24 2004 2.26 1.04 0.24 0.08 0.56 1.36 2005 2.46 1.13 0.26 0.09 0.61 1.48 2006 2.68 1.23 0.28 0.10 0.66 1.61 2007 2.90 1.33 0.30 0.10 0.72 1.74 2008 3.14 1.44 0.32 0.11 0.77 1.89 2009 3.39 1.55 0.34 0.12 0.84 2.04 2010 3.66 1.67 0.37 0.13 0.90 2.19 2015 5.21 2.39 0.52 0.18 1.28 3.13 2004 2.26 1.03 0.16 0.06 0.83 2.01 2005 2.53 1.16 0.18 0.06 0.92 2.25 2006 2.82 1.29 0.20 0.07 1.03 2.51 2007 3.12 1.43 0.22 0.07 1.14 2.78 2008 3.45 1.58 0.24 0.08 1.26 3.07 2009 3.79 1.73 0.26 0.09 1.38 3.37 2010 4.15 1.90 0.28 0.10 1.52 3.69 2015 6.31 2.89 0.41 0.14 2.30 5.61 2003 2.01 0.92 0.17 0.06 0.73 1.79 2004 2.36 1.08 0.19 0.06 0.86 2.10 2005 2.75 1.26 0.21 0.07 1.00 2.44 2006 3.15 1.44 0.24 0.08 1.15 2.81 2007 3.59 1.64 0.26 0.09 1.31 3.20 2008 4.05 1.86 0.29 0.10 1.48 3.61 2009 4.55 2.08 0.32 0.11 1.66 4.05 2010 5.07 2.32 0.36 0.12 1.85 4.51 2015 8.20 3.75 0.55 0.19 3.00 7.30 FAMPLAN MODEL FAMPLAN 39 Bibliography World Development Indicator Database April 2002. World Health report 2001 Annex table 1 Basic indicators for all countries National Population Commission. 1991 population census of the Federal Republic of Nigeria. Analytic report at the National level Federal Office of Statistics [Nigeria].1992. Nigeria Demographic and Health Survey 1990. Calverton, Maryland: National Population Commission and ORC/Macro National Population commission [Nigeria]. 2000. Nigeria Demographic and Health Survey 1999. Calverton, Maryland: National Population Commission and ORC/Macro Population Reference Bureau 2001 World population data sheet The World Health Report 2001 Federal Ministry of Health 1988. The National policy on Population for Development, Unity, progress and Self reliance Federal ministry of Health, UNFPA 1998: Report of the National Population Policy review, Nigeria Federal Ministry of Health. 2001 Technical Report on the 2001 National HIV/Syphilis Sentinel Survey among Pregnant Women attending ante-natal clinics in Nigeria Carpenter et al 1997 Estimates of the impact of HIV infection on fertility in a rural cohort Henshaw SK, Singh S, Oye-Adeniran BA et al. the incidence of induced abortion in Nigeria, International Family Planning Perspectives, 1998, 24(4): 156 – 164 Ronald Gray et. al. 2001. “Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1 discordant couples in Rakai, Uganda.” The Lancet, 357: 1149-1153 Tom W. Smith, 1998. “American Sexual Behavior: Trends, Socio-Demographic Differences, and Risk Behavior.” National Opinion Research Center, GSS Topical Report No. 25 Okonofua F et al. 2000.Profile of sexual and Reproductive health of adolescents in Edo state, Nigeria. Policy Project (unpublished). UNFPA. 2002. Reproductive Health Essentials: Securing the Supply. ISBN 0-89714-626-3 E/10,000/2002

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