Reviewer’s report
Title: 
Scale-up of the DMPA-SC in Nigeria: Why policy matters
Version: 
2 
Date: 
25 Aug 2022
Reviewer: 
Dela Nai
Reviewer's report:
Thank you for the opportunity to review this article. I was eager to read it as it
adds to the growing body of work on DMPA-SC, this time bringing a much-
needed perspective on scale-up with emphasis on policy. Specifically, the aim of
the article was to explore the role of enabling policies in the introduction and
diffusion of DMPA-SC and self-injection in Nigeria.
The authors explain that the study used a mixed methods approach and cross-
sectional in design, consisting of a desk review of policy documents, key
informant interviews, and in-depth interviews.
Reading about the case of Nigeria with the inclusion of DMPA-SC into the
Essential Medicines List (EML) and the Approved Patent Medicines List
(APML) are two game changers and provide an example for other countries.
Nevertheless, the article lacks descriptives on what it actually took for these
inclusions to occur and how this was accomplished in a structurally complex
country like Nigeria. 
My comments and suggestions are as follows, in no particular order:
* The use of the term "partner": my suggestion is to specify where FP partner is
first mentioned, that the authors are referring to implementing partner.
* In the quotation by "Female, Healthcare Provider" there is a line stating: "Then
assured procurement of the commodity because the government buys what is in
the EML and then it dispels at batches to enable a wider range of providers." It is
not clear what "dispels at batches" means in this context. The authors may want
to ensure that the transcription is accurate and if it is, include the meaning in
brackets as it may not be apparent to all.
* It is unclear in line 11 why roadmap is in quotation marks when it has been
described in preceding text/paragraphs. The suggestion is to remove the
quotation marks. 
* The respondent named "Female Health Provider" appears to be very well
informed about the introduction and scale up of DMPA-SC, which is somewhat
unusual for health providers. The authors may want to provide more qualitative
details about each of the respondents to provide context. 
* It is not clear why the gender of the respondents matters for this paper. The
authors may consider removing that characteristic and replacing it with the
respondent's level of operation (national, regional, district, health facility), for
example. 
* Add "TSTS" to the acronyms table.
* Credit is not given to PATH when it comes to developing self-injection
materials, for both the health provider and the FP client, which were used by
most countries during training. If the FMOH developed its own self-injection
tools, the authors may want to highlight this. Otherwise, the existing PATH
resources are likely to have played a significant role in the introduction and scale
up process and should be mentioned. 
* Scaling up in a large and populous country like Nigeria is no small feat.
However, the authors do not include any information about Nigeria's governance
structure and levels (i.e. federal, state) and how federal policies are instituted at
state level. The impact on scale and scaling up isn't discussed in the paper. I
recommend that the authors add such background information and to discuss
what scale up is achieved in a country like Nigeria.
* In the same vein, there is no contextual information about Nigeria itself
(population, number of states, governance structure, etc). I find this information
necessary for this article. 
* One aspect about policy implementation or change that rarely gets reflected in
papers is the amount of advocacy and the making of policy champions. This
paper glosses over or does not discuss any of the work it took to get MoH
officials on board for DMPA-SC, not to mention self-injection. There is mention
of previous research and findings that were used to buttress but even that quote
comes from a Health Provider and it is not clear at what level of the governance
change she operates. No data from the KIIs are presented (nor any description of
the roles of persons interviewed for the KIIs) to give an idea of who provided
information on this process, and among them, who actually gave the green
light(s). Behind policy change are humans who have bought into the benefit of
the policy, those who have the "political will". The authors should include some
descriptives of the KII and preferably some quotations.
* Likewise, the authors explain that KIIs were conducted with "policymakers
and health system managers to generate information, ideas, and explore the main
issues surrounding DMPASC scale-up and the influence of policies in Nigeria".
As a reader, I was eagerly awaiting to read about the number of meetings (formal
and informal) necessary to move the dial for policy uptake among policy makers.
Similarly, I thought I would read about policy champions and their efforts in
getting DMPA-SC on the EML and AMPL. The authors should add this
information where available. 
* Was the use of impact twice in line 39 where it states "The impact of
ambiguity on policy impact" intentional? If not, the authors should kindly
consider replacing the first 'impact' with "consequence".
* It is also not clear exactly what was done after the scale up of DMPA-SC for
self-injection by FP clients. What did the rollout look like? Or what are the
plans? Cascade training, from provider to client? The self-care portion is
described as a policy not, but how it affected practice or was planned to affect
practice. Adding this information will help to round out the positive
consequences of the policy.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
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No
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from apparent manipulation?
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