Study settings

This study was carried out in The Gambia, West Africa, the smallest country within mainland Africa. The Gambia is surrounded by Senegal, with the exception of its Atlantic coast, and is divided into northern and southern areas by The Gambia River that runs through its center. Its population was estimated at 2.5 million inhabitants in 2022 [17]. The Gambia is divided into eight local government areas (LGAs), including the capital Banjul, with a further division of the LGAs into forty-three districts. All eight LGAs were included in the study sample, representing the country in its entirety. Considering the research was conducted mainly at health facility level, not all districts were selected in the sample.

Study design and participant recruitment

We applied a mixed-methods design in which quantitative data from a cross-sectional survey [18] and qualitative data from semi-structured interviews [19] were triangulated and interpreted [20–22]. No a priori sample size calculation was done.

Data triangulation, analysis and interpretation

The triangulation process for this mixed-methods study began with the creation of a protocol (S1 Table. Triangulation protocol), and included actively looking for patterns (themes) that emerged by synthesizing and comparing within and across the quantitative and qualitative datasets. Themes were categorized by hand, based on conceptual similarities. Data from both the quantitative and qualitative datasets were then interpreted manually using a convergence coding matrix [24]. Findings were categorized as ‘convergent’ if they directly concurred, ‘complementary’ if they offered corresponding information on a similar matter, ‘silent’ if there was no overlap or connection between datasets, and ‘dissonant’ if the datasets contradicted one another. To develop cross-linkages within the themes, and provide practical recommendations, an additional column was added to the coding matrix and labeled ‘policy action points’. As a reminder, quantitative data were analysis with IBM SPSS version 26 and qualitative data with NVivo Pro 1.6.1 [2, 19].

Ethics statement

This study was approved by The Gambia Government and Medical Research Council Gambia (MRCG) at the London School of Hygiene and Tropical Medicine Joint Ethics Committee (Reference 22446) and The University of Sheffield–School of Health and Related Research (ScHARR) Research Ethics Committee (Reference 03785–038109). Written informed consent was obtained from all participants prior to completing in the survey, and the confidentiality of the data was assured. All methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki).

Establishing and maintaining political commitment and national priority for fertility care

According to Fox et al. (2015), the extent of political commitment can vary from: (i) ‘expressed commitment’ or verbal support on a health issue by policymakers and leadership; (ii) ‘institutional commitment’ or the creation of policies and national guidelines to support and implement a health issue; and (iii) ‘budgetary commitment’ or the allocation of a dedicated budget to a specific health issue. The expression of engagement, without policy, action plan, and budgetary apportionment, is not a credible commitment and is seen as ‘rhetorical’ [25]. The engagement of The Gambia government toward fertility care appears very much aligned with the institutional commitment perspective because of the recent creation (Dec 2022) of a specific and dedicated strategic plan to challenge infertility as part of a broader strategy on SRH.

However, a strong political commitment toward a specific health matter is not always the sole driver favoring prioritization and policy creation and/or reform. Other factors exist that can have equal or even stronger influence forming political commitment, including social and religious values, activism, and the desire of politicians to stay in power [26]. Those drivers may work with or against political will and can influence policymaking and policy reform. Fertility care interest could follow a similar trajectory, and in the case of The Gambia, the involvement, coordination, and collaboration of the multiple national and international stakeholders working to enhance SRH outcomes could generate (and maintain) interest in infertility and push forward for a more holistic implementation of fertility care.

Strategic framing

How health concerns are perceived and understood may be influenced by strategic framing. Framing entails using a multitude of analogies or arguments to draw the audience’s attention to certain parts of a subject to elicit a positive response [27, 28]. Through open and inclusive dialogue, views are challenged and changed [29]. Strategic framing can be applied to bring SRHR concerns (including infertility) to the attention of the government and international agendas and to influence decision-making processes. For infertility, commitment, and priority could be achieved by influencing health policy audiences and involving stakeholders through conducting health research on fertility care, among others. When health research addresses national priorities and action points with consideration of the context (such as funding and service delivery), they are more likely to be adopted at the national level [30, 31]. The creation in 2021 of the Fertility Care Network in the Global South (www.fertilitycareforall.org) whose members are mainly academics, but also policymakers has have a positive impact. Gambian policymakers who are within this network have been involved in the research process allowing to sustain fertility care prioritization. This has resulted in the creation of key interventions for infertility embedded in the new reproductive health strategic plan 2022–2026.

Financial engagement

A promising body of knowledge has explored the links between social development derived from public financing of ART with the economic benefits generated by the return on investment for each child born via IVF [32, 33]. This was further supported by studies in which infertility insurance schemes were assessed for having effects on female infertility prevalence. Particularly, when infertility is covered by insurance schemes a reduction in female infertility is noted and women with insurance coverage had a higher likelihood of undergoing several IVF treatments, raising their cumulative birth rate [34]. The Gambia has demonstrated its commitment to upholding universal health coverage (UHC) standards by passing “The National Health Insurance Bill—2021” and by preparing to launch a National Health Insurance Scheme (NHIS). Additionally, the Ministry of Health pledged that both public and private health facilities will have access to the NHIS. This is important because previous research has evidenced that the majority of infertility treatments are delivered by the private sector [18]. However, there are also potential challenges in financing fertility care in The Gambia, such as continuity of the national budget and/or the viability of funding to maintain fertility care. In low-income nations like The Gambia, where public resources committed to health are already stretched, expenditures (partial or entire) for fertility care may negatively impact the long-term sustainability of services. This is much more evident in African countries where costs associated with infertility treatment and the Gross Domestic Product (GDP) is negatively linked, with fertility care costs reaching up to 200% of GDP per capita [35].

Creating awareness and increasing the involvement of men in SRH and fertility

People with infertility fear discrimination and stigma, and this is one of the main reasons for keeping their status hidden [36]. In The Gambia one exception is represented by the kanyalengs, a group of women who publicly and explicitly share their childless status [37–39]. Members of these groups shared reproductive setbacks through dances, rituals, and prayers, and help women socially, emotionally, and occasionally financially [39]. In the country, Safe Haven Foundation (SHF - www.facebook.com/foundationsafehaven/"www.facebook.com/foundationsafehaven/) operates. Safe Haven Foundation is a local non-governmental organization that supports women and men through their fertility journey focusing on providing psychological help to deal with infertility, miscarriages, and other fertility issues. Dimbayaa is an organization of health professionals from the Netherlands who aim to bring attention toward the problem of infertility in Sub-Saharan Africa. The presence of both these organizations and the kanyalengs is of great importance for men and women living with infertility in the country and offers a window of opportunity to target fertility awareness starting from the community level. However, the data triangulation shows a scarce recollection of any fertility awareness-related activities, and there is a need, for the MoH, to include these organizations more holistically in the discussions about fertility care.

Another element that emerged from the triangulation of the datasets, regards the involvement and participation of men in fertility care. In general terms, male participation in SRH has historically suffered from conceptual uncertainty, and the emergence of the slogans such as ‘men as clients, men as partners, and men as agents of social change’ brought a different perspective on men’s involvement in the reproductive health matters [40, 41]. Men as Partner (MAP) is an approach that could effectively address the involvement of men in fertility care because it is a multidimensional intervention intended to frame men as part of the solution instead of part of the problem [42–44]. Further, the role of men in SRH is pivotal for their capacity to influence care-seeking (e.g., through financial control), to impact fertility decisions, and to provide proactive support to female partners. MAP for fertility care can be explored in settings such as The Gambia, with similar results than in other countries where this approach has targeted men’s involvement in SRH [45].

Ensuring data-driven health policymaking

Measuring infertility is complicated due to the challenges in collecting data and the lack of appropriate indicators [46–48]. The lack of indicators may play a relevant role in the limited prioritization and implementation of fertility care programs [49]. In The Gambia, insufficient financial and logistical assistance, an inadequate referral system, insufficient funding for IT infrastructures, and scarce human resources all contribute to the operational challenges of the health management information system [50]. These challenges, coupled with the absence of routine data surveillance for infertility, do not help to advocate for international support, nor enable comparisons across countries [51]. The establishment and monitoring of these indicators would help Gambian policymakers in developing effective responses to address infertility and may support tailored interventions that meet greatly the health needs of the citizens. Although the data collected from fragile systems are often criticized as being over-explained, excluding them entirely diminishes the efforts to make changes because they can still expose the health concern in needs to be investigated, and act as tools for developing knowledge and setting priorities [52].

Offering affordable IVF alternatives and regulations of standards

The Gambia has not yet introduced ART in its health system nor are any high-end medical techniques to assist infertile couples broadly available [18]. This offers a window of opportunity to the current health leadership as they are approaching the operationalization of fertility care. To this effect, considering that 48% of the population lives in poverty [53] and affording ART would be a difficult task for most Gambian couples, low-cost IVF initiatives may be explored. A few of those have been used by The Walking Egg (TWE) project and pioneered in African settings [54, 55]. In addition, to further reduce the cost of infertility care, the Gambian health leadership may explore partnerships with the private sector, facilitate transnational cooperation, and purchase ‘second-hand’ laboratory equipment to increase access to fertility care [56].

Whatever formula is adopted to cover or contribute to the cost of ART, such technologies must be medically and ethically regulated based on international guidelines, protocols, and evidence-based research. Regulations should be in place before the inclusion and implementation of ART in the health system. In fact, few studies cited that the regulatory component for assisted reproduction is often overlooked or missing, despite the provision of ART [57, 58]. Moreover, ART clinics usually adopt their own rules, which leads to different standards of care [59], contributes to inequality in access, and may facilitate professional liberty, with medical protocols not always in line with evidence-based standards or adapted to the needs of patients [60].

In The Gambia, considering that ART are not yet available, there is the opportunity to “start from scratch” with both the regulations and ART implemented at the same time with legislation, laws, and biomedical best practices. The establishment of a national fertility society and involvement with the African Federation of Fertility Societies (AFFS) may facilitate exchange and collaboration among society members, with the adoption of protocols and guidelines in alignment with those already existing in African countries that have included ART in their national policies [6, 10].

The Gambia might not be able to adopt, in the immediate future, comprehensive ART to assist its patients with infertility, but to comply with the UHC and strengthen its health system, it may ensure a minimum package of care for individuals and couples with fertility concerns.

Improving knowledge of, and means for fertility care

Data triangulation highlighted how The Gambian health workforce needs fertility care training. Particularly, the medical education curricula need to be more comprehensive, not only focusing on the clinical practice but also providing mental and psychological support to couples with infertility [19, 60]. Furthermore, health staff providing infertility care need to learn how to manage patients’ expectations and any gaps in the adherence to treatments, because even in those settings where IVF is available, such as the case in many European countries, drop-out from infertility treatment is recorded as high [61] and this is strongly related to the mental and psychological burden of patients under fertility treatments [62–64].

Specialized fertility care training

In terms of skills development for fertility care, in The Gambia, there are currently some initiatives for training on infertility management, mainly provided by the Merck Foundation through its program More than a Mother. This initiative supports the educational development of medical doctors in fertility, embryology, and sexual and reproductive medicine but is limited to this professional category, and other health providers, such as nurses and midwives, are currently excluded from the training. Considering that most of the secondary health facilities providing infertility services are managed by nurses and/or midwives, there is a substantial portion of the Gambian healthcare providers lacking specialized training for fertility care. Moreover, to the best of knowledge, no training or any other information on infertility prevention and awareness is provided to first-line healthcare providers, namely the Community Health Workers and the Community Birth Companions. The training of these workers is thought to be important due to the social stigma caused by infertility that often starts at household and community levels [65–67]. Moreover, these community workers can sensitize patients on the importance of early referral to initiate infertility screening and treatment as soon as possible [68].

Enhancing collaboration among stakeholders and building links with the private sector

The triangulation of the datasets validated how the collaboration between the government and health facilities providing fertility care is somehow missing. This has resulted in an uneven distribution of infertility services among public health facilities, easing the rise of the private sector as the main provider of fertility care in the country, and exacerbating the restrictive access to, and the high cost of, infertility treatment [18, 69–71]. Further, the international development agencies currently in the country supporting multiple aspects of SRH have no targets to address infertility. This could be explained in several ways. First, (in)fertility care is not a priority on the agenda of international cooperation agencies. For this reason, the support of those agencies overlooks infertility and concentrates on addressing reproductive health matters considered to be of utmost importance [72]. Second, the private sector is in some way unregulated, with a census of the private clinics, including the health services provided and related costs, missing. Lastly, there are few mechanisms allowing the exchange of information between stakeholders, for example, thematic meetings or workgroups on infertility.

Availability of infertility services in private care

Despite the unavailability of ART in The Gambia, the private sector largely provides the most comprehensive care for infertility but with services often not accessible to all people in need. This picture is not far from that in many other countries of SSA, where infertility services and particularly ART are mainly delivered by private clinics with little or no collaboration with the public health sector. In the few instances where fertility care is available in public hospitals (e.g., South Africa), this model requires large capital venture and investments in infrastructure and human resources [73]. Collaborative efforts in fertility care services, such as public-private partnership (PPP) may eventually reduce overhead costs through shared responsibilities [74] and could contribute in improving availability and access to services [75, 76].