UNFPA facilitates Kenya and India South-South learning on Family Planning

Interview with Dr. S.K Sikdar Advisor, Maternal Health and Family Planning, Ministry of Health and Family Welfare, India

With over 40 years of experience working in public health, Dr. S.K Sikdar has been at the forefront of the development of many of India’s policies and programmes on Family Planning. He currently serves as the Advisor, Maternal Health and Family Planning Division in the Ministry of Health & Family Welfare. Dr. Sikdar describes himself as a feminist who is passionate about the health and well-being of women and girls. 

“India has a robust family planning programme with a wide range of contraceptive methods available to the public. We are however yet to introduce contraceptive implants into the public health system,” says Dr. Sikdar. This is however set to change as India’s Ministry of Health and Family Welfare recently greenlit the initial introduction of Implanon NXT, a single-rod contraceptive implant, in select states and identified public health facilities. 

Recently, Dr. Sikdar led a team from India’s Ministry of Health and Family Welfare on a mission to Kenya to learn more about the country’s contraceptive implant programme that has been successfully implemented in public health facilities over the last two decades. In addition to a meeting with officials from Kenya's Ministry of Health, the team visited county and sub-county public health facilities,  and spoke to family planning providers at private clinics in Nairobi, Kiambu, and Narok counties. They also interacted with community health volunteers and beneficiaries who provided a firsthand look at the programme in action.

Shared realities drive south-south learning on family planning

“While the public health systems in Kenya and India differ in many ways, there are some similarities in the challenges we face,  such as geographical disparities in access to family planning, poverty, and wealth inequality, that can be unique to developing countries such as ours,” says Dr. Sikdar. “When mulling over the introduction of contraceptive implants in India, south-south learning was the only option. It made the most sense to learn  from Kenya as the country has been doing this successfully for a long time.”

Kenya first introduced contraceptive implants in 1992,  with the goal of offering women a choice in long-acting, reversible methods that can offer contraception for up to five years. Since  2011, implants have been offered free of charge to eligible women at public health facilities across Kenya.  Uptake has been steadily rising over the years, with the Kenya Demographic and Health Survey 2022 showing that implants remain the second most preferred method of family planning among married women aged 15-49, with a 19% prevalence rate. Injectables are the most popular method of contraception, with a prevalence rate of 20%. 

Following the visit to health facilities in the three counties as well as meeting with representatives from the Ministry of Health in Kenya, Dr. Sikdar had this to say about the experience:

“From our interaction with counterparts in the ministry of health and healthcare workers in the facilities, we were able to learn about Kenya’s experience with the roll-out of implants including procurement and supply chain processes, demand generation among communities, and the training of healthcare workers. What was most surprising to witness is that the family planning programme in Kenya is entirely run by nurses and midwives, with doctors only intervening when there is a complication. This is unlike in India, where doctors are very much involved in administering family planning. Kenya’s approach of empowering lower cadre healthcare workers who can reach a wider population is important as it has enabled a scale-up of the family planning programme,” says Dr. Sikdar.

Healthcare worker training key to success

Implant insertion and removal is a skilled practice that requires training and mentorship for skills transfer. The Kenya government has developed a training package and family planning guidelines, deploying 30 master trainers who conduct three to five training sessions annually in every sub-county to equip as many reproductive healthcare workers with the right skills on family planning administration and counseling. Training on contraceptive implant insertion and removal is conducted over a six-day period, with participants spending 3 days learning theory and a day at a skills lab where they practice on models. This is followed by two days at a health facility where trainees are required to perform several implant insertions which are assessed by a mentor. If found satisfactory, the nurse or clinician is then certified to administer implants. 

By assessing Kenya’s training approach, Dr. Sikdar is confident that India can learn from the successes and challenges experienced for better preparedness in introducing implants into the new national family planning programme on implants. “From our interaction with service providers, we noted that the six-day learning period is much too short for full competency, and therefore training continues at the health facility, with more experienced nurses teaching their colleagues on the job,” says Dr. Sikdar.  “The “each one teach one” approach has its advantages in that it allows for consistent mentorship, but it also has its setbacks in that the training methodology is not standardized at that level. We saw this when we visited facilities in different locations, where for example the follow-up procedures for patients who had received an implant were different at a lower-level health facility in Nairobi than at the main hospital in Kiambu county. Our approach in India therefore will be to have master trainers at the national, state, and district level, with emphasis on standard training methodologies that go down to the lowest level, to ensure that service remains the same across all public health facilities.”

As Kenya has already established a demand for contraceptive implants, Dr. Sikdar hopes that healthcare workers from India can fast-track their clinical practicum at Kenya’s health facilities where clients regularly seek services. “In Narok county, for example, we were able to witness three implant insertions within the span of one hour. It may take India some time to reach that level of demand among women in the pilot states, and we, therefore, hope to further collaborate with Kenya in the training of India’s healthcare workforce.”

Local manufacture of contraceptives, and other lessons for Kenya

India has initiated local manufacturing of contraceptive implants, a move that is expected to contribute to the cost-effectiveness of the new family planning program. Local production is a key step in sustainability, and for a lower middle-income country like Kenya, this presents a key opportunity in the journey to attaining 100% local financing for family planning. 

“Kenya has very high rates of institutional deliveries, but fewer women opt for postpartum family planning compared to India. India is a champion when it comes to immediate post-partum family planning, which greatly improves pregnancy spacing and maternal and child health outcomes. This is certainly an area in which Kenya can learn from India, to strengthen post-partum uptake of family planning both at public and private sector health facilities,” notes Dr. Sikdar.

UNFPA supports the Governments of Kenya and India in strengthening family planning programmes through technical and financial assistance. In the 2022/23 financial year, UNFPA has provided more than USD 4.65 Million worth of family planning supplies to the Kenya government, for distribution across over 8,000 health facilities in the country. In India, UNFPA is providing support to the Government in the procurement of contraceptive implants as well as technical assistance to ensure adequate preparedness in the roll-out of the implant programme across 10 identified states of India.