Abstract
Introduction
The Gambia, West Africa, has made recent progress on infertility, a component of sexual and reproductive health that is lagging behind others. Since 2016, there is favourable policy environment stemming from infertility research and partnership building with national stakeholders and local civil society organisations focussing on infertility. Here, we report outcomes from a participatory workshop on infertility policy implementation in The Gambia and provide insights on setting national priorities for fertility care in resource-limited settings.
Methods
We conducted a participatory workshop involving 29 participants from Gambia’s public and private health sectors. Using selected participatory group work tools, stakeholders identified and prioritised key activities within the framework of five pre-defined areas of action, including (i) creating guidelines/regulations; (ii) recording/reporting data; (iii) building public–private partnerships; (iv) training health providers; and (v) raising awareness and health-seeking.
Results
A total of 17 prioritised activities were proposed across the five action areas, according to short-, medium-, and long-term timeframes. Three were further prioritised from the overall pool, through group consensus. A group model building activity helped to envision the complexity by elucidating links, loops, and connections between each activity and their expected outcomes.
Conclusions
The participatory workshop identified actionable interventions for fertility care in The Gambia, with stakeholders setting a clear path ahead. Despite challenges, the continued engagement of Gambian policymakers, practitioners, researchers, and activists in efforts to move beyond policy creation to its implementation is essential. Improving fertility care in The Gambia and other low- and middle-income countries is feasible with effective collaboration and financial support.
Lay Summary
In The Gambia, a partnership of stakeholders from various domains, including research, grassroots activism, clinicians, and policymakers, contributed to an increased awareness of infertility. This, in turn, led to the inclusion of infertility in the national reproductive health strategic plan. An in-country participatory workshop involving participants from both public and private health sectors was held in October 2023 with the objective of identifying priorities for moving beyond planning to implementation, within the context of resource constraints. The top three identified priorities were: (i) training about infertility for health providers; (ii) harmonisation of data collection; and (iii) the development of clinical guidelines for infertility management. It is important for the Gambian Ministry of Health to implement these proposed locally relevant fertility care activities. Despite current and future challenges, having a clear vision and pathway will help establish fertility care in the country, with Gambia potentially leading the way among many other countries
Introduction
The Gambia, a small country in West Africa, has made significant strides in improving sexual and reproductive health (SRH) over the last two decades. For example, the total fertility rate decreased from 5.6 children per woman in 2013 to an estimated 3.5 in 2024 (CIA Factbook 2024). Home deliveries have reduced substantially, and an estimated 98% of pregnant women now receive antenatal care (ANC) from a skilled provider (doctor, nurse, or midwife) (Nigatu 2023). This SRH success, however, is not comprehensive. Important challenges remain when it comes to, among other issues, adolescent pregnancies, intimate partner violence (Jatta et al. 2021, The Gambia Bureau of Statistics and ICF 2021), and fertility care (Dierickx et al. 2019a,b, Afferri et al. 2022a, Bittaye et al. 2023, Afferri et al. 2024a,b).
Despite infertility being recognised as a core component of SRH by the International Conference on Population Development in 1994 (UNFPA 1994), The Gambia, in line with many other low- and middle-income countries (LMICs) and international health organisations, has paid little attention to this issue. Except for a few studies in the 1990s (Sundby 1997, Sundby et al. 1998), fertility care policy, practice, and research have been largely absent. Since 2016, however, there has been a sustained effort of research from both ethnographic and health policy and systems perspectives. For example, Dierickx et al. (2018, 2019a,b, 2021) provided an in-depth understanding of the experiences of women and men with infertility among urban and peri-urban populations, while Afferri et al. (2022a, 2024a,b) offered a comprehensive view of The Gambian health system’s response to infertility, and its readiness to implement fertility care in public and private health facilities.
While The Gambian health system remains highly dependent upon international aid, which might determine the agenda of national policies and activities (Sundby 2014, Sine et al. 2019), Gambian reproductive activists and some political leaders have been vocal in promoting fertility care interventions (Dierickx et al. 2019a,b). Those interventions include, among others, ‘fertility awareness, support and fertility management with an intention to assist individuals and couples to realise their desires associated with reproduction and/or to build a family’ (Zegers-Hochschild et al. 2017).
Other initiatives included some (limited) opportunities for healthcare providers to attend infertility training, albeit abroad (Merck Foundation 2020). Through early and continued engagement with in-country civil society organisations and key health system stakeholders, researchers were able to support local fertility champions in their aims to increase public awareness of infertility and to improve fertility care policies and services (Dierickx et al. 2019a,b, Afferri et al. 2022a, Bittaye et al. 2023, Afferri et al. 2024a,b). It is notable that this partnership between academia, civil society, and health policy and system national stakeholders, generated significant momentum for infertility in The Gambia over the last 8 years (Fig. 1). Moreover, it helped facilitate the creation of the Fertility Care in the Global South Network – a platform that combines almost 20 other LMICs from within and beyond sub-Saharan Africa. The network, which embraces more than 50 members, including researchers, health workers, policymakers, and activists, aims to raise infertility awareness, strengthen health system and policy change, and increase access to fertility care for all through partnership building, capacity development, research, and evidence generation (Fertility Care in the Global South Network 2023).
Timeline of factors enabling fertility care inclusion in The Gambia’s National Reproductive Health Strategic Plan (2022-2026).
Citation: Reproduction and Fertility 5, 4; 10.1530/RAF-24-0029
As a result, in 2022, fertility care was included as one of the SRH priorities in the National Reproductive Health Strategic Plan (NRHSP) 2022-2026 for the first time (Ministry of Health & Social Welfare 2022). The Gambian Ministry of Health has the responsibility for the allocation of funds and implementation of the strategic plan, in partnership with the regional health teams, the health facilities within its health system, and the international cooperation agencies.
The enabling environment, which both facilitated and was facilitated by the network, was the platform upon which Gambian policymakers have strengthened public health policy interest in fertility care, and where it continues to thrive. Yet, while the inclusion of fertility care in The Gambian NRHSP was an important step forward, there are significant challenges in moving from the creation of fertility care policy to its implementation (Afferri et al. 2024a,b). Some of these challenges relate to the struggle of The Gambian health system to systematically collect data on the prevalence of infertility and the proliferation of private fertility clinics offering services without clear guidelines or regulations (Afferri et al. 2024a,b). Furthermore, The Gambia has no involvement with the African Network and Registry for Assisted Reproductive Technology due to ART unavailability.
Here, we explore mechanisms and timelines for the implementation of fertility care, identified during a participatory workshop with key health system stakeholders, and offer insights into the current state and future prospects of fertility care in The Gambia.
Materials and methods
Background and areas of action
This work builds on earlier research, including a mixed-methods study (Afferri et al. 2022a, 2024a,b) which highlighted the importance of participation, policy, partnerships, and capacity-building to transform fertility care in The Gambia. Drawing on this work and the NRHSP 2022-2026, the study team identified five key areas of action for fertility care implementation. These were (i) creating guidelines and regulations; (ii) recording and reporting data; (iii) building public–private partnerships; (iv) training health providers; and (v) awareness and health seeking. Each area of action addressed critical aspects of fertility care implementation, providing a holistic perspective on the challenges and opportunities for The Gambia’s health system.
Participatory workshop on fertility care implementation
A one-day participatory workshop on fertility care implementation was held in October 2023, in Serekunda, The Gambia. The workshop was organised by the Gambian Ministry of Health (MoH) and Safe Haven Foundation, a Gambian civil society organisation working toward infertility de-stigmatisation, with the support of the Medical Research Council at the London School of Hygiene and Tropical Medicine, the Gambia Unit (MRCG), and the Fertility Care in the Global South Network. Sixty-four invitations (including eight to private fertility clinics) were sent to selected national and sub-national level stakeholders, encompassing policymakers, regional health teams, international cooperation agencies, and health practitioners from both the public and private health sectors in The Gambia (Supplementary Table 1B, see section on supplementary materials given at the end of this article). Invited stakeholders were purposefully selected based on their involvement in reproductive health policy and practice, and according to geography – aiming for representation from each of The Gambia’s regions (Fig. 2).
Map of The Gambia, illustrating administrative regions and the capital city, Banjul.
Citation: Reproduction and Fertility 5, 4; 10.1530/RAF-24-0029
The workshop aimed to elicit areas of action for implementing fertility care, taking into consideration the broader health system context. It was structured into three overarching sessions, namely: (i) presenting research findings and lived experiences of infertility in The Gambia; (ii) group work exercises within each of the five key areas of action for the implementation of fertility care; and (iii) feedback from the groups and plenary discussion, eliciting group modelling and overarching plans for the short, medium, and long term.
The group work included five to seven participants per table, each with one member of the facilitation team and only one area of action to be discussed per group. Participants were free to choose the group/area of action that best suited their background and interest. In the case of any one group being disproportionately larger than others, the facilitation team planned to relocate some participants to smaller groups; however, this was not required. Groups received detailed verbal instructions that were also printed on a 1-page information sheet before the start of the group work. The instruction sheet listed the overall aim and purpose of the group exercise and outlined the various steps of the group exercise. Templates were also included, forming the tools used to reach the desired output. The group work included: (i) brainstorming and (ii) graphs over time, while the plenary session included (iii) prioritisation exercise – timeline, and (iv) group model building (GMB). Groups were asked to nominate a representative to feedback on behalf of the group during the plenary discussion.
Brainstorming
Each group was requested to propose as many activities as possible within their allocated area of action and then brainstorm, discuss, and identify the main fertility care activities. The brainstorming activity was an opportunity for the members of the group to eviscerate their area of action and select three/four interventions they deemed to be of the highest priority.
Graphs over time
Once the groups had identified fertility care activities pertaining to their area of action, they were required to plot their expectations of changes ‘over time’ using the graphs over time technique (Calancie et al. 2018). Participants were presented with a blank graph template, with time on the X-axis and rate of infertility on the Y-axis. They were instructed to depict the historical pattern and two future paths they thought would occur: (i) if present trends were maintained; and (ii) once the intervention took place. Participants were particularly reminded to consider the unintended consequences of interventions when plotting the graphs.
Prioritisation and timeline
The groups were then asked to discuss and agree on a timeline for the prioritised activities according to a short-, medium-, and long-term framework. Short-term was described as a period including the next 12–24 months following the workshop; medium-term was defined as 24–60 months in length; and long-term as over 60 months in length from the workshop date. The overall timeline mirrors the current NRHSP 2022-2026 and beyond. The next exercise was to recognise one activity they considered as a priority. During the plenary session, all prioritised activities and timeframes were discussed, and activities were further listed by priority, to identify the overall combined top three. The combined prioritised activities were verified by reaching a consensus during the plenary discussion. The feasibility of implementation of each of the activities was discussed within the context of The Gambia, and this was a key criterion in the prioritisation process.
Group model building
The GMB approach is a participative strategy that is extensively used to facilitate systematic reflection among stakeholders and collaboratively explore solutions for multifaceted situations. The application of qualitative system mapping in public health research aims to investigate the origin, contributing elements, and viable solutions or responses to a complicated situation (Siokou et al. 2014, Gerritsen et al. 2020, Estrada-Magbanua et al. 2023). During the plenary session, as each of the groups presented their outcomes, a GMB was created ‘in real time’ until consensus was achieved among all the participants. The consensus was evaluated through verbal assessment by the participants. The model was later elaborated by the authors, using Microsoft PowerPoint, to show links, loops, and connections between fertility care activities, drawing on the group discussions and existing knowledge.
Workshop evaluation
At the end of the event, participants were requested to complete an anonymous feedback form to analyse the strengths and weaknesses of the workshop and to understand their learning. The form contained nine questions, including four open-ended questions. Two were answered through a five-point Likert scale ranging from ‘excellent’ to ’poor,’ two rated effectiveness and organisation of the workshop on a scale from 1 to 10, and one question was closed-ended, inquiring if the participants would recommend the workshop to their colleagues. The five-point Likert sections appraised general aspects of the workshop (content, handouts, working groups, venue, and facilitators) and the quality of each of the sessions. Four questions allowed the participants to provide additional comments or feedback regarding the workshop and to bring up any significant points that were omitted during the plenary discussion.
Results
A total of 29 participants and six facilitators attended the workshop (Supplementary Table 1A and 1B). Participants included policymakers, policy implementers, and health practitioners from the public and private health sectors. Most participants were male (76%; 22/29) and from the public sector (93%; 27/29). Ten out of 29 participants (34%) came from areas of the country considered ‘rural’.
Participants self-divided into five working groups, selecting an area of action of their choice, with roughly equal numbers per group (four to six participants and one facilitator per group, with one additional facilitator moving between groups for quality control). Although groups were asked to prioritise only three activities, some selected three, four, or as many as five priorities due to a lack of group consensus on the top 3. A total of 17 priority activities were identified across the five areas of action with some minor overlap between groups. The top three prioritised activities included the development of clinical guidelines, the update of the current data collection tool to capture information about infertility, and fertility care training for healthcare providers. Other concurrent activities consisted of infertility awareness messages both at the community and national levels, research on infertility risk factors, the incorporation of infertility in the recently introduced national health insurance scheme, and the development of a public–private partnership to harmonised service delivery and data sharing (Table 1).
Fertility care activities identified and prioritised by each of the workshop groups.
| Areas of action | Selected fertility care activities1 |
|---|---|
| Creating guidelines and regulations for infertility |
|
| Recording and reporting infertility data |
|
| Building public-private partnerships in infertility |
|
| Providing infertility training for health providers |
|
| Raising infertility awareness and health-seeking |
|
1Overall combined top three prioritised activities are illustrated in bold.
Activities
Group model building
In the plenary discussion, participants discussed and identified the overall combined top three short-term key priorities as: (i) developing treatment protocols and clinical guidelines for infertility management; (ii) updating current data collection tools and software to include infertility; and (iii) providing specialised fertility training to healthcare providers. Participants also emphasised the urgency of addressing medium- and long-term activities (2025 and beyond) such as research on risk factors for infertility, the incorporation of fertility care (or part of it) in the national health insurance scheme, and fertility awareness messages both at the community and national levels (Fig. 3).
A timeline of proritised fertility care interventions according to short-, medium-, and long-term timeframes.
Citation: Reproduction and Fertility 5, 4; 10.1530/RAF-24-0029
The group model (Fig. 4) depicts the most crucial interventions within the five key areas of action by presenting the prioritised activities of each group. The model was built in real-time while each group was presenting their ideas.
Initial sketch of group model building for fertility care implementation in The Gambia, illustrating prioritised activities within the five key areas of action.
Citation: Reproduction and Fertility 5, 4; 10.1530/RAF-24-0029
From this initial sketching, the GMB was further elaborated by the authors based on the workshop, showing which activities were acknowledged for having the highest level of implementation priority in the short-term. These were depicted in gradient colours in the middle area of the model, such as specialised training for health providers, updating data collection tools, and developing clinical guidelines (Fig. 5). The model was expanded with links, loops, and connections explaining the intricacy of the relations between fertility care activities. The feasibility of implementation of all activities in a resource-limited context, such as The Gambia, was discussed and taken into consideration during the prioritisation process.
Final model from Group Model Building for fertility care implementation in The Gambia, illustrating prioritised activities and connections and interlinkages.
Citation: Reproduction and Fertility 5, 4; 10.1530/RAF-24-0029
Evaluation
In terms of the evaluation provided, the participants found the workshop useful, including both the dissemination of previous research findings conducted in the country in 2022 and 2023, and the group work carried out during the workshop. All participants (100%; 29/29) reported they would recommend the workshop to colleagues and peers. From the qualitative feedback, participants also indicated the need for further discussions on psychological support for couples with fertility issues, increasing research focused on risk factors for infertility, and improving the management of couples with fertility issues.
‘…the importance of psychological support for people with infertility’ (P9; P18).
‘We need to increase or raise awareness of the risk factors associated with infertility’ (P4).
‘…I will make sure I investigate [infertility] before giving any treatment’ (P2).
Discussion
For The Gambia to move from infertility policy creation to policy implementation, stakeholders identified three key priority activities, namely: (i) providing specialised fertility training to health providers; (ii) updating current data collection tools and software to include fertility, for data reporting and analysis; and (iii) developing treatment protocols and clinical guidelines for infertility management. These activities were prioritised by health system stakeholders through group consensus, following rigorous discussion, and by taking into consideration the financial, technical, and human resources available within the Gambian health system. They are also grounded in recent evidence from in-country ethnographic and health policy and system research, through which the five areas of action were broadly defined ((Dierickx et al. 2018, Dierickx et al. 2019a,b, Afferri et al. 2022a,b, Bittaye et al. 2023, Afferri et al. 2024a,b).
The findings underscore critical priorities for the implementation of fertility care in The Gambia. The urgency expressed by participants in addressing these immediate priorities aligns with the need for swift action to remedy existing gaps in fertility care provision. First, training for health providers, which emerged as the top concern, underscores the need to enhance the capacity of healthcare professionals to deliver effective services that include infertility prevention, diagnosis, and treatment. As illustrated by Bittaye et al. (2023), medical staff has shown interest in acquiring additional knowledge and has had a positive attitude toward supporting fertility care, mainly with the introduction of ART. As cited in the NRHSP 2022-2026, The Gambia has planned the training of over 6500 service providers, many of whom are working at the primary health level of care, specifically in counselling and referral of infertile couples, and in fertility assessment, infertility prevention, and management (Ministry of Health & Social Welfare 2022). Considering IVF is not yet available in the country, despite the presence of one embryologist (master’s degree), training on the IVF program is not yet a priority for the Gambian MoH.
Secondly, the need for data collection and harmonisation addresses a fundamental aspect of healthcare delivery, ensuring that information is efficiently managed and utilised for evidence-based decision-making and bi-directionally shared between public and private health sectors. A recent survey has, indeed, shown how data on infertility is neither collected nor systematically reported in the national health management information system, leaving important gaps in understanding the scale of the challenge (Afferri et al. 2022a). Finally, the development of clinical guidelines is paramount, providing a standardised framework for fertility care practices. This is essential, given the recent emergence of private fertility clinics in the country. In this sense, regulation of Intrauterine Insemination (IUI) and hormonal stimulation with Clomiphene Citrate – both currently used in The Gambia – is a priority.
Additional activities that were proposed and prioritised by the groups include the incorporation of fertility care into the national health insurance scheme, which would signify a notable strategic move towards making fertility care more accessible to a broader segment of the population. However, based on common challenges in healthcare systems, potential roadblocks for the incorporation of fertility care in health insurance might be identified as (i) high costs associated with fertility treatments with potential high out-of-pocket expenses for patients; (ii) stigma, cultural beliefs, and norms that may influence acceptance and demand for fertility care services; (iii) challenges in defining the scope and extent of fertility treatments to be covered; and (iv) limited public awareness about infertility issues and available treatments.
Infertility awareness initiatives and research into risk factors specific to The Gambia, both of which were also proposed, would demonstrate an important commitment to addressing the root causes of infertility and improving public understanding and engagement with fertility care among women and men. For example, ongoing research in the country includes the exploration of home-based testing of semen to understand the willingness of men with infertility concerns to engage with the issue and seek healthcare services. Finally, the participants emphasised other areas requiring implementation attention, specifically conducting research to assess infertility risk factors in the Gambian context, and the need for a public–private partnership to harmonise data sharing and the delivery of services. Despite the challenges acknowledged in previous research, including financial constraints and health system obstacles, the engagement of Gambian policymakers in fertility care decision-making stands out as a positive indicator. Indeed, the very recent establishment of a national fertility society and the ongoing clinical guideline development efforts represent an institutional commitment to advancing fertility care in The Gambia. These developments provide a foundation for overcoming challenges and fostering a conducive environment for the successful implementation of prioritised fertility care activities.
Long-term partnerships between civil society leaders, health policymakers, healthcare practitioners, and researchers have been a key driver in the recognition of the importance of addressing infertility, starting from policy creation and leaning toward policy implementation. The inclusion of fertility care in the NHRSP marked a shift in the approach to infertility in The Gambia, reflecting a new formal recognition of this condition and its broader implications for health and well-being. Recognising the inherent complexity of enacting such an ambition in The Gambia, as in many other LMICs, stakeholders identified key activities with which to begin moving beyond policy development to implementation.
The participatory methodology, involving a diverse group of participants from both public and private sectors, and within varied roles (policymakers and healthcare practitioners), is a strength of this workshop. Stakeholders were all familiar with The Gambian health system and were, therefore, best placed to make such suggestions. In addition, the tools used during the participatory workshop helped participants reflect on and draw upon their combined expertise, knowledge, and operational skills to identify priority interventions for fertility care, with consideration of what is feasible within the current context of The Gambia. The utilisation of the GMB added a layer of complexity, aiding in the visualisation of interrelations between fertility care interventions.
Limitations
The workshop recorded a low presence of private clinics despite representatives of those institutions having been invited. This may have hindered complementary information and impacted the understanding of the perspective of the private health sector for the implementation of the strategic plan. The private health sector, although still relatively small, plays a substantial role in the provision of fertility care in the country. If not addressed, the current low engagement of private facilities within the public health system might be reflected in poorer future implementation of the NRHSP.
Conclusion
Although there are exceptions, in many LMICs, policies surrounding infertility care are either non-existent or remain written but unimplemented. To drive policy implementation on infertility in The Gambia, stakeholders identified priority activities that could take place despite limited resources. The three top priorities were: (i) training healthcare professionals; (ii) improving systems for the collection, reporting, and analysis of data on infertility; and (iii) developing clinical guidelines for infertility management. The Gambian MoH, with support from partners, is responsible for delivering the implementation of fertility care, which can start based on the three prioritised activities. Implementation research can help track and identify how and whether these priorities are comprehensively addressed over time. The plausibility of implementing prioritised fertility care activities remains contingent on continued national leadership and dedication, sustained collaborative efforts and support, financial backing, and a commitment to addressing emerginig challenges. Indeed, collaborative efforts and financial support are vital components that will play a pivotal role in the success of these endeavours. In taking this crucial step forward, The Gambia will enter the next phase in translating fertility care policy into action and producing the desired change. Despite existing challenges and health system limitations, the workshop outputs represent a significant step towards realising comprehensive fertility care within the national healthcare framework, and The Gambia has shown the potential to be a leading example in the development of fertility care in LMICs.
Supplementary materials
This is linked to the online version of the paper at https://doi.org/10.1530/RAF-24-0029.
Declaration of interest
AA, SD, MB, MM, SMC, HB, and JB declare that they have no competing interests. AAP reports paid consultancy for Cryos International, Cytoswim Ltd, Exceed Health, and Merck Serono in the last two years, but all monies have been paid to the University of Sheffield (former employer). AAP is also an unpaid trustee of the Progress Educational Trust (Charity Number 1139856).
Funding
This work was supported by the White Rose Collaboration Fund awarded to Balen et al. (Grant no. 176252, 2021).
Author contribution statement
AA and JB conceived the workshop. AA drafted the first version of the manuscript. All co-authors (SD, MB, MM, SMC, HB, AAP, JB) contributed to the revision and editing of the final version of the manuscript.
Acknowledgements
The authors thank all the workshop participants for their engagement, contribution, and positive feedback.
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