Policy action points and approaches to promote fertility care in The Gambia: Findings from a mixed-methods study.

INTRODUCTION: In the Global South, (in)fertility care is scarcely recognized as a priority, yet the government of The Gambia has recently included it as one of the key priorities in its reproductive health strategic plan. This inclusion appears to be the result of years of engagement between policy actors, academic researchers, and activists in the field of reproductive health and specifically of infertility. However, the operationalization of the strategic plan may be hampered by multiple factors. The research aims to identify and analyze challenges that may impede the effective implementation of the strategic plan, thereby providing policy action points and practical guidance into the operationalization of (in)fertility care in the context of The Gambia's health system. METHODS: This is a mixed-methods study with data from a survey and semi-structured interviews collected between 2020 and 2021 in The Gambia that were separately published. In this paper, we present the triangulation of quantitative and qualitative data using a convergence coding matrix to identify relevant policy action points. RESULTS: Six fertility care policy action points, driven by data, arose from the triangulation and interpretation process, specifically: (i) establishing and maintaining political commitment and national priority for fertility care; (ii) creating awareness and increasing the involvement of men in SRH and fertility; (iii) ensuring data-driven health policymaking; (iv) offering and regulating affordable IVF alternatives; (v) improving knowledge of and means for fertility care provision; and (vi) enhancing the collaboration among stakeholders and building links with the private healthcare sector. CONCLUSION: This study found the implementation of the fertility care-related activities in the reproductive health strategic plan may face challenges that require careful mitigation through a holistic approach. Such an approach conceptualizes infertility not just as a biomedical issue but as a broader one that incorporates educational and socio-emotional aspects, including male and (not only) female involvement in sexual and reproductive health. Moreover, it is supported by a comprehensive health management information system that includes capturing data on the demand for, and access to, infertility services in The Gambia health system.

'It's about time': policymakers' and health practitioners' perspectives on implementing fertility care in the Gambian health system.

BACKGROUND: Infertility is a major health issue worldwide, yet very few examples of interventions addressing infertility in the Global South have been documented to date. In The Gambia, West Africa, infertility is recognised as a burden and the health authorities have included it in several health policies and the new National Reproductive Health Strategy however, a detailed operationalisation plan for fertility care has not yet been established. Here, we aim to understand and document the factors that influence the implementation of fertility care in The Gambia. METHODS: We conducted 46 semi-structured interviews with policymakers, implementers, and health practitioners in both the public and private sectors from July to November 2021. The interviews were transcribed, anonymised and analysed with NVivo Pro version 1.6.1. The analysis was initially inductive, with themes arising from the coding categorised according to the WHO health systems building blocks framework. RESULTS: This study identified several barriers to a successful implementation of fertility care in The Gambia, including (i) a lack of routinely collected infertility data; (ii) an absence of financial protection mechanisms for patients, and/or a specific budget for infertility; (iii) limited cooperation between the public and private sectors in the provision of fertility care; and (iv) gaps in fertility care training among health practitioners. Conversely, enablers included: (i) strong national infertility leadership; and (ii) the integration of infertility care within public reproductive health services. CONCLUSION: The Gambian health system is not yet in the position to support a comprehensive fertility care package in its public health facilities. Several aspects of the implementation of fertility care must be considered in operationalising the health strategy including the systematic collection of infertility data, fertility awareness, and the provision of specialised fertility care training. Furthermore, a stronger partnership between the public and private sectors must be developed. Given the increasing availability of assisted reproductive technologies in the sub-Saharan Africa region, and the tendency to locate these technologies in the private sector, further research is needed to understand and identify the processes underlying the implementation of fertility care and to foster better integration with the existing health system.

Introducing assisted reproductive technologies in The Gambia, a survey on the perspectives of Gambian healthcare professionals and medical students.

BACKGROUND: Infertility remains a global reproductive health burden with the highest prevalence in low and middle-income countries. In sub-Saharan Africa, the ability to procreate holds great societal importance. Couples, and particularly women, with infertility can face devastating challenges, leading to social stigma, isolation and/or divorce. However, attention to addressing infertility is lacking in sub-Saharan Africa. In The Gambia, where this study is based, little is known about the potential for introduction of assisted reproductive technologies (ART) in the public health sector. METHODS: A quantitative survey was conducted using detailed questionnaires on infertility services available, staff knowledge, perceived barriers, and personal motivation to support assisted reproductive technologies. Data was collected electronically between April and June 2021 from healthcare providers (n = 70) in eleven health facilities throughout the country, as well as from medical students (n = 55) enrolled at The University of The Gambia. RESULTS: Basic infertility services were found to be lacking in the rural areas. Furthermore, 39% of staff (n = 27) providing fertility care had not receive any formal training on the topic. However, 91% of staff (n = 64) showed interest in acquiring additional knowledge and had a positive attitude towards supporting the introduction of ART. Perceived challenges of doing so included: (i) the competing importance of other health priorities; and (ii) religious and cultural barriers. CONCLUSION: This survey highlights that expansion of infertility services is needed, especially in rural areas. Staff perceived the introduction of ART as important, but this should be coupled with specialized training, as most medical staff had not received any formal infertility training. Future care providers (current medical students) showed both interest in ART and reported having received some basic training in infertility management. Given the reported lack of infrastructure and services, additional targeted investment in infertility care, including ART, will be needed to improve reproductive health for all, countrywide.

In Sub-Saharan Africa, the prevalence of involuntary childlessness (infertility) is high. However, services to help address this problem are inconsistent or lacking ­ including in the West African country of The Gambia, where this study was conducted. There is currently limited information on the infrastructure available and the level of knowledge and training among healthcare providers in the country to help address this issue. To address this gap in knowledge, we conducted a survey with health staff from different hospitals and with medical students at the University of The Gambia. The survey focused on the reported availability of services as well as participants' knowledge and training in both basic and advanced treatments for infertility. We found a major lack of infertility care services in rural areas. Furthermore, staff knowledge about infertility was minimal, and there was little knowledge about more advanced infertility care services, such as in vitro fertilization (IVF). The survey also found that staff and students perceived other health priorities and religion as major barriers for ART introduction. Staff noted that government funding for infertility treatment is minimal. In conclusion, this survey found a lack of reported infrastructure for infertility in rural areas of The Gambia, as well as a lack of formal training by staff. However, both staff and students showed interest in the potential introduction of ART. Overall, this survey highlights that more investment and training is needed to implement changes in order to modernize reproductive healthcare in The Gambia, in particular for those who face infertility.

Availability of services for the diagnosis and treatment of infertility in The Gambia`s public and private health facilities: a cross-sectional survey.

BACKGROUND: Infertility is a long-standing reproductive health issue, which affects both men and women worldwide and it is especially problematic in the Global South. In sub-Saharan Africa, understanding the current availability of diagnostic and treatment services for infertility is important because this could guide health systems to improve access to fertility care for all. Yet, few studies have explicitly started from a health system perspective to grasp the availability and integration of infertility services in sub-Saharan Africa. This quantitative study, the first in The Gambia, West Africa, examines the availability of infertility services in public and private facilities as part of a wider endeavour to improve fertility care policy and practice in the country. METHODS: A cross-sectional survey using Qualtrics was administered to 38 health facilities. The survey was carried out between March and August 2021 and involved closed-ended questions. Data analysis consisted of descriptive statistics and t-tests performed using SPSS version 26. RESULTS: A total of 25 facilities (66%) offered infertility services, of which 13 (52%) were public and 12 (47%) private. Although the availability of screening tests was similar between health institutions, most diagnostic and treatment services were available only in the private sector. Treatment services included: (i) ovarian stimulation (n = 16, 42%); (ii) reversal of tubal ligation and/or blockage (tuboplasty) (n = 4, 11%); and (iii) intrauterine insemination (n = 3, 8%). Assisted reproductive technologies such as IVF and ICSI were not available in public or private sectors. The Gambian health management information system lacked a dedicated space to capture data on infertility. Reported barriers to integration of infertility services in existing reproductive health services included a lack of specialised training, an absence of national guidance on infertility management, and a shortage of appropriate equipment, supplies, and medication. CONCLUSIONS: The availability of infertility services in The Gambia follows a trajectory that is similar to other SSA countries in which services are mostly obtainable through the private sector. Yet, access to private care is expensive and geographically restricted, which exacerbates inequalities in accessing fertility care for all. Improving the provision of infertility services in the public sector requires systematically capturing data on infertility and investing in the provision of a full-range fertility care package.

Barriers and facilitators for the inclusion of fertility care in reproductive health policies in Africa: a qualitative evidence synthesis.

BACKGROUND: Infertility affects over 50 million couples worldwide and impacts people's social and emotional wellbeing. In low- and middle-income countries, particularly across Africa, the inclusion of fertility care into reproductive health (RH) policies remains fragmented or non-existent. OBJECTIVE AND RATIONALE: This review aims to provide a framework for understanding the inclusion (or lack thereof) of fertility care in RH policies in African settings. It synthesizes the barriers and facilitators to such inclusion, with a view to uncovering the positioning of fertility care in broader health systems and on the agendas of key stakeholders such as health policymakers and practitioners. SEARCH METHODS: A qualitative evidence synthesis was performed, systematically searching papers and grey literature. Searches were conducted in MEDLINE, EMBASE, CINAHL, Web of Science and Scopus between February and April 2020. No date restrictions were applied. Language was limited to publications written in English and French. Two reviewers independently screened titles and abstracts, and extracted data, applying thematic coding. The quality of the included papers was evaluated using The Joanna Briggs Institute Checklist for Text and Opinion Papers. OUTCOMES: The search identified 744 papers, of which 20 were included. Findings were organized under four cross-cutting categories, namely: perceived importance of infertility; influence of policy context; resource availability and access; and perceived quality of care. Across these categories, key barriers to the inclusion of fertility care in RH policies were limited political commitment, under-recognition of the burden of infertility and high costs associated with ART. Conversely, facilitators comprised specialized training on infertility for healthcare providers, standard procedures for ART safety and guidelines and North-South/South-South collaborations. WIDER IMPLICATIONS: The inclusion of fertility care in African RH policies depends upon factors that include the recognition of infertility as a disease, strong political engagement and proactivity and affordability of ART through opportunities for partnership with the private sector, which ease costs on the public health system. Further qualitative and quantitative research, including context-specific analysis and in-depth comparative approaches across diverse African countries, will help to delineate differential impacts of local and global factors on fertility care to address this neglected RH issue.