Across Nigeria, there are thousands of unmet family planning needs, many of which are in rural and hard-to-reach communities. To bridge this gap, the Society for Family Health (SFH) initiated the IntegratE project which empowered Community Health Extension Workers and Community Pharmacists to provide simple family planning services in underserved areas. SEUN AKIOYE met with some of them in Kano state.
Every morning in the past two years, Shamsudeen Abdulahi Muhammad never failed to open the doors of his modest ‘3 Star pharmacy’, located at the entrance of Koforo Walamai community in the Eastern Bypass area of Kano state. As the only registered community pharmacist also licensed to provide quality family planning services, women who are shy to approach the general hospital walk in for various services.
Some tired of their poverty and inability to cater for their children want a break from childbearing and some like Fatimah-not real name- want to terminate the 11th pregnancy after 10 children.
“I have seen a lot,” Shamshudeen said as he rested his elbows on the long table that separated him from his customers. “Many women come here begging for a family planning method. There was a woman with 10 children begging for a termination, she is so poor the children do not attend school, when people like that come in, I usually say no and counsel them,” he said.
Since his graduation from school, Shamsudeen only wanted to serve his community, with his skills and education. “This is my community, they are my people, and I want to help them,” he said. But he had not anticipated the gravity of the help his community needed and his own capacity to meet it.
“There is widespread poverty among the people,” he began waving his arm in a semi-circle. “You will see a woman come here wanting to abort a pregnancy because they have unplanned pregnancy, another one would come with 10 children, they are not even thinking of hospital bills but food to eat,” he stated.
In Koforo Walawai, poverty walks on all fours and so is ignorance. One of the underserved communities in Kano state, women shy away from accessing family planning at designated hospitals for varying reasons. “People come to us because we provide what they can’t get elsewhere and that is interpersonal service. We are the first layer of contact with the community, and they know and trust us,” Shamsudeen said in a firm and confident voice.
But how did Muhammad and others across 11 states in Nigeria become primary providers of family planning in poor communities. The answer began with Integrat E, a proof-of-concept project supported by the Gates Foundation that asserts that Provision and Patient Medicine store Vendors (PPMVs) and Community Pharmacists (CPs) can provide more services than they are currently approved to do, if they are trained and licensed thereby bridging a critical health gaps in rural communities and hard-to reach areas.
Bridging the Gap: Integrating Community Care to Meet Family Planning Needs
In 2017, a consortium of health organisations led by the Society for Family Health (SFH) began to tinker on an innovative method that would see an upscale in meeting family planning demands of poor, unreached and excluded women in rural communities. The project that was born was the Integrat E model.
Working with the Federal Ministry of Health, it seeks to broaden the task-sharing, task-shifting policy through a tiered accreditation which would be led by the Pharmacy Council of Nigeria, (PCN). The pilot phase was a research to prove that if trained, Community Pharmacists and Patient and Propriety Medicines Vendors (PPMVs) can provide the much needed access to family planning.
This logic, according to Danjuma Sani, the Director, Pharmaceutical Services, Kano State Private Health Management Agency is because the PPMVs are closest to the communities. “They are rooted in the community, they are the first point of call,” Sani said.
The follow-up project tagged Integrate E 2.0, building on the evidence began aggressive training and Tiered Accreditation System (TAS) which divided the PPMVs into three tiers: Tier One include secondary school graduates who have a patent medicine store but no healthcare training; Tier Two covers those with some healthcare training like nurses and Community Health Extension Workers (CHEW) and Tier Three are the pharmacy technicians who have had extensive healthcare training.
Since 2021 when Integrat E 2.0 began, the project has extended to 11 states including, Kano, Kaduna, Lagos, Sokoto, Enugu, Nasarawa, Niger, Gombe, Yobe, Borno and Bauchi. By the end of the project, it aims to see an increase in women and communities’ use of an expanded range of quality family planning services through the PPMVs and CPs.
Integrat E, The Kano Model
“One of the reasons we are so important is because people don’t want to go to hospitals because of the stigma,” Bahija Tijjani Mahmud was saying. It was early in the morning, and she had just attended to her first client. In the Sharada Area of Kano, where the Double T.T Medicine store is located, Bahija is a legend.
For six years, she had been a nurse in Sharada, attending to women and meeting their very private needs, and then two years ago, she was trained by the SFH and incorporated into the Integrat E project as a Tier 2 provider. She began providing simple services like pills and injectables, then she was trained to provide counselling, since then she has provided over 200 family planning services to grateful women in the community.
“90 percent of the women who come here are for family planning and one of the key things I do is to counsel them. There is so much poverty, but people are still having unplanned pregnancies, so it is my duty to help them make better choices,” she said.
Bahija believes access for women is crucial and the privacy the PPMV provides is a jinx breaker in the community. While there are challenges with finance, the real problem with low uptake is the stigma. “The stigma is real,” she said in a matter-of-fact manner.
The women who come to Bahija’s Double T.T store did not see themselves as patients or clients, Bahija is their sister, the one they could confide in. “Our people love PPMVs more than the hospitals because we are closer to them and there is privacy. They feel free to discuss anything with us and even husbands feel safer accompanying the wife here than the hospital,” she said.
But with a combination of advocacy and counselling, stigma rates are beginning to fall in Sharada. “Before now, it was 90 percent, but it has come down, even rural people now understand what family planning is and the men have also accepted it and we have less resistance than before,” Bahija revealed.
Now, when women come to the Double T.T medicine store, it is not just for consultation, they might be there to offer their gratitude in kind. “Our community people do return to appreciate me for the work I am doing, sometimes they bring gifts, foodstuff etc,” Bahija confirmed.
Several miles away from Sharada, in the sleepy community of Kofar Ruwa, Hassan Muhammad operates a small medicine store. From outside, it looked like a regular store selling daily needs but, in the community, the demand for Muhammad’s services is high.
“I have been here for 13 years,” he began to say in smattering English. Outside, small cries of babies, suffering in the afternoon heat and the voice of the muezzin cuts across the stillness of the day. “Before I started this business, there were no patent medicine stores here and the people were complaining,” he said.
So, with only the senior secondary school certificate, he began to learn about patent medicine and became the community’s sole ‘saviour’. Then he was brought into the Integrate E project, trained to administer family planning services, counselling and referrals. That was four years ago.
“The programme has been a big blessing to this community,” Muhammad said with a smile of satisfaction. “I have seen between 400 to 500 people and provided family planning services to both male and female clients.”
Though it may sound incredible, but Muhammad brought his record out to show the numbers. He has meticulously recorded every transaction he had with every client and what services he provided. One of the keys to his success is a massive advocacy programme in the community, done with the assistance of SFH. “People look forward to these outreaches, you may think they don’t have a problem until they show up for the community mobilisation,” he said.
Some of the major success stories of the IntegratE project are in Kano. Across the 44 local government areas, PPMVs and community pharmacists are filling unmet family planning service’s needs. According to Danjuma Sani, whose office registers, monitors and regulates the PPMVs, Kano has registered more than 8,000 PPMVs while a new survey is underway to verify how many more are there in Kano. “The Tier 1 practitioners were a menace to the society, they are not trained, they have no experience, but the people prefer them because they are cheaper and closer to them. That is why we have to register them and ensure they go through the training from the partners,” Sani said.
But Sani was also quick to recognize their importance. “With the way the economy has been for some years, many people are turning to family planning and that is where the PPMVs come in, they provide important service for the community.”
Zainab Abdulsallam, the State technical Advisor, IntegratE project at the SFH agreed with Sani. In the last five years, she has worked with hundreds of volunteers across the state for training and advocacy. “From our findings, 70 percent of people in the communities say the PPMVs are their first point of call for family planning services. So, these people are providing these services and we don’t know if they are qualified, that is why this project is important,” Zainab said.
The idea behind Integrat E is novel; pilot new approaches to provide primary health care services in communities and increase compliance, regulations and quality among the people providing these services. But there is always the link between the PPMVs and government hospitals.
“We want the PPMVs to also refer patients to the hospitals, we want to strengthen the linkage between public and private health facilities. We have trained them and they are registered with the government and providing quality service in the community, so we want them to report their data,” Zainab clarified.
Mustapha Ibrahim Usman is Deputy Director, Pharmaceutical Services at Kano state Ministry of Health, he said the government will continue to work with the PPMVs and provide strict regulations.
“The programme is good; we are able to know the people operating the PPMVs and regulate them. We have told them to operate within their boundaries, and the government will not hesitate to apply the law when there are infractions,” he said.
While Women Plan, Men Offer Support
Nothing prepares you for the revelation 50-year-old Abubakar Aliyu was about to make. With a University Degree under his belt, a master’s degree underway, he also served as the Chief Imam of Ali Maifada mosque in Gama community.
“People are always shocked when I tell them my qualifications,” Aliyu said. He was sitting in the middle of the mosque in Gama B ward. The Gama community in Nasarawa Local government of Kano boasts of nearly two million residents. It is the largest ward and a ‘darling’ in the state, attracting different ethnic groups and investments.
In Gama B, the Maifada Mosque is unique and known for its very progressive preaching and initiatives, the men of Gama B would congregate every evening to learn about new initiatives and whatever decision made by this assembly of men would be binding.
“Family planning is not new to us here, in fact, we do have lectures here twice a week where we encourage our men to accept family planning and we also talk about men’s health and our role in the community,” Aliyu said.
He is also a role model, married with one wife and 9 children, who are all educated, he said he has accepted family planning for a long time. “Though culture has been a barrier to many of our men accepting this, the economy has a way of deciding for you, so the men have now seen the need to embrace child-spacing,” he said.
When IntegratE project landed in the community, one aspect that resonated with the community was the male involvement meetings. Zainab, the State Advisor for the project said that aspect was built into the programme to get the buy-in of the men as head of the households.
“Male involvement came about as evidence mounts that the husbands must be involved. There are compound or town hall meetings that were done with the men, the aim is to sensitize them to know the advantages of child-spacing and support their wives in making the decision to take up a method,” she explained.
But the programme faced initial problems, cynical men clutching to the strings of culture and religion dismissed the programme and refused to allow their wives participate. “Some men were even abusing me as an Imam supporting child-spacing,” Aliyu confirmed.
But with over two years of engagement, the men of the Gama community have a new mindset. Aliyu Adamu Maifada, who has three wives and eight children said there is no more conflict with the men of Gama. “I have accepted this family planning for the health of the mothers and the health of the children,” he said.
Maifada is now a peer-educator and has converted a lot of men in the community. “As a community leader, people listen to me and they see that I practiced what I am preaching, so that is how we succeeded in converting many men,” Maifada revealed.
One of the keys to the successful mobilization and awareness is the work of the Interpersonal Communication Agents (IPCA) who have been recruited to move from house to house sharing information and creating awareness.
“We were well received in many of the homes, even when some people reject us, we will return there with more information and they will welcome us,” Amina Nasiru Usman said. She had been one of the first agents in Gama and much of the success in that community could be attributed to her relentless work.
Today, she sat quietly in a corner at the mosque, after a mid-day meeting with a group of women who also acted as peer-educators. “This is the way it works,” she stated in a conspiratory tone. We go inside the homes to talk to the wives, many times, they would insist they needed their husband’s approval for family planning. By that time, the Imam is also talking to the husbands and so when the women seek permission, it would be easy.”
This is a masterstroke strategy employed by Integrat E project to increase access to family planning for women across Nigeria. “No project has done what we did with the PPMVs,” Zainab boasted as she sat down to an interview.
“Imagine all the small patent medicine stores are now registered with the government, you are known and monitored. Then they are trained to provide the primary level of care and in a community where trust is important, these people come in as supervised and trained hands,” she further confirmed.
In Kano, the Integrat E 2.0 has recorded some modest successes in ways and outstanding successes in others. Currently, the project has trained 832 PPMVs across the 43 local government areas, with another 100 trained in November while it targets training for 900 community pharmacists. The PPMVs and community pharmacists undergo intensive training at the School of Health Sciences for 15 days after which they would be recommended to the state government.
In September 2026 IntegratE, 2.0 will shut down. At that time, Zainab will not only be counting the numbers of trained PPMVs, but she would be hoping that a handshake of data has crossed from the private to the public sector. Mustapha Usman would be hoping that his Ministry would have utilized and profited from the data being volunteered by the PPMVs while also hoping the project has empowered enough vendors to improve the state’s health indices.
Sani would hope that he has been able to regulate more vendors who otherwise would have been operating under the regulator’s radar without the project. And Muhammad would still battle misconception among the Koforo Walawai people, he would battle poverty and ignorance and though he makes very little by providing life saving services, he would remain in his post. “I cannot leave these people,” he said, after attending to a patient who could not afford to buy a painkiller, “I am the only one they have, I am their only hope, for now.”
