A Platform for Sustainable Scale: The Challenge Initiative’s Innovative Approach to Scaling Proven Interventions

Background

TCI builds on the success of the Urban Reproductive Health Initiative (URHI), a Bill & Melinda Gates Foundation (Gates Foundation)—funded urban FP project implemented in India, Kenya, Nigeria, and Senegal from 2010 to 2015. URHI was a proof of concept that aimed to test a set of supply, demand, and advocacy interventions to improve quality, accessibility, and contraceptive services for the urban poor. The rationale for the focus on low-income urban communities is the demographic importance of this growing population, their poor health outcomes,^14,15 the lack of scaled approaches for reaching them with FP services, and the paucity of philanthropic investments to do so. During the first 3 years of URHI, intervention packages were tested in 4 cities in each country, with each country having a different package. With technical assistance (TA) to support a systematic approach to scale from ExpandNet¹⁶ and findings from the midterm evaluation, streamlined packages of URHI’s interventions were tested for scalability in additional cities in each country, with cities taking a leadership role and contributing some of their own funding.

An external evaluation of URHI found positive associations between the interventions and contraceptive uptake and identified interventions associated with the highest impact on contraceptive uptake.^17–21 Equally important, URHI’s pilot and scalability phases generated important learnings that would inform the design of the TCI model, including the feasibility of local governments to lead—and contribute their own resources to—the introduction of a set of innovations while still achieving positive outcomes in contraceptive uptake.^22,23

In 2016, the Gates Foundation funded TCI to serve as a platform to support governments to sustainably scale URHI’s proven interventions in urban areas of East Africa, India, Nigeria, and francophone West Africa. Unlike URHI, TCI’s mandate from the outset identified sustainability as a key performance outcome for the platform’s rapid scale-up of proven FP approaches to cities across multiple countries. Originally designed to support the scaling of URHI’s evidence-based interventions, TCI has evolved into a platform for also scaling global High Impact Practices (HIPs)²⁴—a set of evidence-based practices representing global expert consensus on what works in FP programming—along with other approaches that have shown promise for increasing access to FP by the urban poor.

Organization and Management Structure

TCI’s management structure was designed to facilitate rapid scale-up of FP interventions in urban areas across multiple countries. The Bill & Melinda Gates Institute for Population and Reproductive Health based at Johns Hopkins Bloomberg School of Public Health (Gates Institute) oversees regional TA “hubs” that support governments to scale up the high-impact interventions in their regions. Until 2020, the platform included 4 TA hubs, each managed by different implementing partners: Jhpiego in East Africa, Population Services International in India, Johns Hopkins Center for Communication Programs in Nigeria, and IntraHealth International in francophone West Africa. Three of these hub partners led the original URHI project in the same region with significant continuity of staff. In 2020, a fifth TA hub was established in the Philippines, led by the Philippine-based Zuellig Family Foundation, and in 2022, a sixth hub was added in Pakistan, led by Greenstar Social Marketing, also locally based.

In its role as the global platform manager, the Gates Institute ensures standardization, coordination, and quality control across all hubs, while also engaging donors to mobilize funding for the platform to expand to new geographies. The global platform manager has proven valuable in managing the relationships with donors (i.e., reporting and day-to-day management), developing and continually updating TCI University (TCI-U) to reflect and share hub-specific learnings with other hubs and the global community, and ensuring adherence to TCI’s core principles, including that local leaders drive the change process. For example, the global platform manager guided the Nigeria hub to transition demand generation work from a subcontractor to the states’ own government-run social and behavior change communication committees to strengthen sustainability. The global platform manager also supported hubs in streamlining coaching design to enable institutionalization within government structures. For example, the India hub was advised to shift from direct implementation to building the capacity of urban primary health center–based auxiliary nurse midwives to manage accredited social health activists.

The regional TA hubs engage directly with local stakeholders and provide guidance to participating governments to identify and adapt the interventions for the local context and to develop scale-up plans aligned with the resources, policies, and guidance of their health system; manage technical and leadership coaching to build capacity; and lead regional advocacy and knowledge management.

Taken together, the TCI platform performs intermediary functions critical for successful scale-up: strategic planning, fundraising, advocacy and marketing, convening and coordinating of stakeholders, TA, and change management.^25,26 In this way, the TCI platform acts as an intermediary organization (the organization supporting a government to scale and integrate an innovation into its systems, policies, and practices) with local governments as hosts (the organization expected to implement the intervention for the long term, typically governments, nongovernmental organizations, commercial markets, or hybrid combinations). Despite its importance for scaling, intermediary support to a government is frequently overlooked or underestimated by funders.⁶

How TCI Works

TCI’s primary engagement is with city governments, although the initiative also partners with other administrative levels (e.g., county/subcounty in Kenya and districts in Tanzania and Uganda, depending on country context) that have a determining role in the financial, administrative, and service delivery functions of their urban populations. Within an urban area, service delivery support centers on the highest-volume facilities. Under URHI, the implementing partners selected which cities to work in based on size, potential impact, and other criteria. Under TCI, participating governments “self-select” to join, as demand driven is a key guiding principle for TCI (Box 1). They learn about TCI through its marketing efforts, which target subnational governments with large urban populations that are politically committed, able to make a financial contribution, and demonstrate a minimum level of health system capacity (i.e., number of trained providers for all FP methods, status of the supply chain system, supportive supervision structure, and other indicators). Interested governments submit a formal letter of inquiry along with a pledge of funding and political commitment to deliver the FP and/or AYSRH interventions. If approved, they draw from TCI’s “Challenge Fund” for seed funding to supplement their own financial commitments; organize implementation teams; and coordinate with cross-departmental government partners as well as civil society (e.g., youth groups and community gatekeepers) and private sector organizations, as relevant. Throughout this process, governments access TCI-U, which provides tailored in-person and virtual TA coaching (Supplement 1) that tapers off in intensity as local capacity grows and local stakeholders assume full control of implementation; FP and AYSRH toolkits that house the interventions with practical implementation guidance and tools; and a virtual community of practice to enable shared learning. Local governments are also coached to improve the quality of locally generated service statistics data to monitor and improve performance and review and adjust plans each year.

The period of local government engagement with TCI is typically 3–5 years—from the initial planning phase to early implementation, then “surge” (when all elements of an intervention package are being implemented), pregraduation (when TCI gradually reduces its support), and graduation and beyond (when TCI continues to monitor performance and provides coaching “on demand”). The intensity of TA support that TCI provides to local governments throughout these phases is designed to ensure greater self-sustained improvements in urban health systems and increased use of modern contraception, with a focus on low-income urban populations.

Intervention Package

TCI supports local governments to adopt and institutionalize a core package of demand generation, service delivery, and advocacy interventions adapted to the local context and housed in global and hub-specific toolkits on TCI-U. These core interventions align with 10 global HIPs, with hub toolkits also including additional interventions applicable to their regional context (Box 2). A city’s choice of interventions is informed by the key areas of need identified through a rapid landscape assessment conducted in the initial planning phase through a participatory process. TCI-U also includes AYSRH interventions to address provider bias, promote youth-friendly cities, engage pharmacies and drug shops, and use other approaches that enable younger women and men to access contraceptives.²⁷

In addition to technical (intervention-focused) coaching on FP and AYSRH interventions, TCI provides coaching assistance to strengthen a local government’s leadership, management, and coordination functions, financial management and monitoring, adaptation of interventions, and data for decision making—what TCI refers to as “essentials” for successful programming. These essentials have become an increasingly prominent focus of coaching support, based on learnings that coaching at higher levels of the health system—such as state, city, and local government area administrative levels rather than only at the facility/provider level—is required to ensure sufficient capacity to scale and potential to sustain systems level capability to maintain quality FP programming.

Coaching

TCI builds government capacity through targeted coaching on the technical aspects of the intervention package as well as on effective management and health governance to address capacity gaps. TCI coaching is conducted by local and regional master coaches who cascade the evidence-based solutions and guidance to municipal health personnel and managers to strengthen local health systems to implement the selected interventions. Initially, TCI hub staff serve as master coaches but transfer this role to local experts (including from the government) with strong FP and AYSRH experience. In consultation with TCI, city implementation teams identify managers and implementers for training as coaches relevant to specific proven interventions. For service delivery interventions, for example, TCI and local government counterparts review the list of those who currently provide supportive supervision and are considered master trainers of the government as a good starting point for resource persons to be trained as TCI coaches within the public health system. Once coached by TCI, master trainers in turn coach individuals from health system leadership (e.g., political leaders and ministry of health leadership); lower-level managers (e.g., medical officers-in-charge, nurses-in-charge/matrons, FP/RH coordinators, FP officers, urban health officers, health educators, monitoring and evaluation officers, and adolescent health officers); and implementers (e.g., health workers such as FP, health district, and facility-based personnel, and community health workers). As of June 2021, more than 3,300 coaches have been trained across 4 regional TA hubs.

Monitoring and Learning for Scale

TCI’s key outcome measures are anchored in platform scale, contraceptive uptake, health systems strengthening for sustainability, and platform cost-efficiency. Data is triangulated from several sources to collect these measures: the government’s service statistics as captured in its health management information system (HMIS); project records and available surveys; TCI’s RAISE (Reflection and Action to Improve Self-Reliance and Effectiveness) maturity model tool, which uses a participatory approach to self-assess sustainability progress in real time²⁸; the Most Significant Change (MSC) technique,²⁹ which supports adaptive management, routine monitoring, and cross-learning efforts locally and globally; and regular “pause-and-reflect” sessions that generate additional insights and evidence on the scaling pathway. In a large-scale program such as TCI, high-frequency program monitoring is critical to determine where further support is needed and where lessons can be learned, shared, and successfully replicated.

Regularly scheduled monthly data review meetings, quarterly MSC selection meetings, and periodic pause-and-reflect exercises form the backbone of TCI’s adaptive management approach, which aims to continuously track changes, facilitate learning and responsive feedback, and capture program contributions to intended and unintended outcomes.

Platform Scale

TCI monitors 2 main platform-level performance measures monthly: population footprint (the aggregate population of TCI-supported cities) and number of cities engaged. These indicators represent the reach of the platform and how it is distributed across the regional hubs over time. Figure 1 shows the rapid scale that took place over 5 years, with expansion slowing substantially beginning in 2018 to secure additional funding, assess TCI’s progress to date, and then, in response to COVID-19.

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FIGURE 1

The Challenge Initiative Scaling Over Time, 2017–2021, by Population and Number of Cities^a

Abbreviations: EA, East Africa; FWA, francophone West Africa; TCI, The Challenge Initiative.

^a The cumulative number of cities is indicated by the line. Population footprint by hub.

As of June 2021, TCI has partnered with 104 local governments in 11 countries (Benin, Burkina Faso, Cote d’Ivoire, India, Kenya, Niger, Nigeria, the Philippines, Senegal, Tanzania, and Uganda) to implement FP and AYSRH interventions for low-income urban communities.

Contraceptive Uptake

TCI has 3 main indicators for tracking changes in contraceptive uptake: client volume, derived number of additional clients, and net contraceptive uptake. These indicators were developed by reviewing existing data sources—namely, the country’s own HMIS and population census data—and adapting them to meet the needs of local governments to measure and monitor the impact of scaling proven FP interventions.³⁰ TCI’s coaching to strengthen data systems and use helps local government staff provide timely, accurate, and complete reporting of data to HMIS; make more effective use of their own HMIS data for program monitoring and internal decision making; and advocate for continued and increased funding for FP interventions based on data.

A continuing challenge, particularly in francophone West Africa, is weak data systems that jeopardize sustained government use of HMIS data, a challenge noted by an external TCI program review conducted in 2020 (described in more detail in the External Program Review section). Another challenge is disaggregating data to segment youth and the urban poor, identifiers typically not captured in routine data systems.

As of June 2021, overall data showed an increasing trend in FP clients in TCI cities, especially for long-acting reversible contraceptives. An effective number of 2.65 million clients received a modern FP method across 104 TCI cities for the 12-month period ending in June 2021, 44% higher than the baseline period (i.e., the 12-month period before partnering with TCI). Across all cities, this translated to an estimated (derived) number of 2.02 million additional clients from the launch of a city’s partnership with TCI through June 2021 and is equivalent to 2.49 additional clients per 100 women of reproductive age per year (net contraceptive uptake).

TCI has been closely monitoring contraceptive uptake in graduated cities. As of June 2021 (the end date for data in this article), there were 5 graduated cities, all in East Africa, with at least 1 year of data on postgraduation contraceptive uptake. Figure 2 shows a continuing upward trend in additional FP clients from the start of these cities’ engagement with TCI (September 2017) through graduation (June 2020) to 1 year postgraduation. Supplement 2 provides a preliminary analysis of additional FP client trends postgraduation for more cities through February 2022.

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FIGURE 2

Pre- and Postgraduation Trends in Additional Family Planning Clients in 5 East African Cities

Sustainability

TCI identified several predictors of sustainability that helped inform its approach to measuring local government progress toward graduation and greater self-reliance. From these predictors, it developed RAISE, a maturity model tool used by local governments to self-assess progress toward sustainability for implementing the intervention package.³¹ Each quarter, a city’s key health personnel use RAISE to monitor the quality and effectiveness of their activities and implementation strength to identify gaps and make necessary course corrections. RAISE applies a standard set of indicators across TCI’s 4 sustainability domains: (1) political and financial commitment, (2) capacity (knowledge) transfer of FP skills, (3) institutionalization of TCI’s high-impact best practices at all levels of the health system, (4) sustained demand through improved attitudes and behaviors toward FP.

Adapted to the context of the health systems, each of these domains is accorded a maximum score. Based on the results of the self-assessment, an overall score is generated, which RAISE workshop participants then validate using contraceptive uptake data, project records, MSC stories, policy documents, budgets, and expenditure reports. Through discussion of these data, participants work to reach a consensus on scores, which map to different levels of capacity and sustainability (high, moderate, basic, and low). Local health management teams and TCI use RAISE results to track city progress and readiness to graduate and provide inputs into actions required to achieve performance milestones. Quarterly RAISE assessments also provide immediate feedback on what is working well and priorities for coaching support. By the third quarter, local governments typically assume full leadership of the RAISE workshops to monitor their progress.²⁷

Through June 2021, 39 governments have graduated from full TCI support. TCI is monitoring the performance of the graduated cities by continuing to track RAISE scores and contraceptive uptake, which will inform refinements to its coaching approach and time frames of support. TCI also continues to monitor whether interventions are covered in upcoming government budget cycles.

After graduation, cities continue RAISE assessments and avail TCI-U and community of practice resources and coaching by request for a year or more beyond graduation. Graduated cities become TCI “alumni,” with well-performing graduates recognized for their performance and serving as models for newer TCI cities to emulate. Graduated cities that encounter setbacks can be reengaged and offered support, as appropriate.

Figure 3 shows the average RAISE scores of graduated cities in 6 countries. Even after graduation, RAISE scores (represented in the last 1 or 2 rounds in each of the countries in Figure 3) are generally maintained above 85%, the threshold a city must achieve to graduate. The improved scores demonstrate continued or improved capacity to sustain the interventions.

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FIGURE 3

An Average of Graduated Cities' RAISE Scores in 6 Countries Over Time^a

Abbreviation: RAISE, Reflection and Action to Improve Self-Reliance and Effectiveness.

^a The last 1 or 2 rounds occurred postgraduation in India, Kenya, Nigeria, Tanzania, and Uganda. Senegal’s graduated cities had not yet conducted post-graduation RAISE assessments.

Government Political and Financial Commitment

The government’s annual monetary commitment (and spending) is important to affirm government support and is a measurable demonstration of its continued interest and prioritization of FP, given the multitude of other issues needing funding. Government funding is also critical to the ownership and sustainability of the program.

Through June 2021, local governments committed approximately US$28 million to implement the proven interventions, with a large proportion of these funds contributed by India. Overall government commitments exceeded the amount spent (Figure 4). The percentage of funds spent varies across hubs and cities, with some spending even more than what was committed. In Year 4 (July 2019–June 2020), 70% of committed funds were spent across 4 hubs, with Nigeria (88%) and India (72%) leading the way. Average spending as a proportion of total commitments by local governments across Years 2, 3, and 4 stands at 61%.

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FIGURE 4

Local Commitments, Local Spending, and the Challenge Fund Allocations Across TCI Hubs (Years 2–4), in USD

Abbreviations: TCI, The Challenge Initiative; USD, U.S. dollars.

Aside from sustainability at the city level, TCI also seeks to secure sustainability of its overall scaling platform by diversifying its donor base and increasing its operational efficiency. Beyond the initial investment of the Gates Foundation, the platform has attracted investments from Bayer AG, Comic Relief, the U.S. Agency for International Development, and private philanthropists with funding for the platform in place through December 2025. TCI will seek to further diversify funding sources in the coming years.

Cost-Efficiency

TCI monitors the platform’s cost-efficiency over time by tracking the unit cost per engaged city, million population footprint, and additional FP client. These indicators gauge whether the platform is operating more efficiently over time as it partners with a greater number of cities. In its fifth year, TCI’s cost was US$88,080 per engaged city, US$79,675 per million population footprint, and US$25 per additional FP client. Relative to the unit costs recorded in TCI’s second year, these unit costs have declined by 81%, 76%, and 66%, respectively.

While these measures are critical to track and calculate, the cost-efficiency of achieving the qualitative outcomes for sustainable scale-up is also important though more challenging to track; methods are needed to account for hard-to-quantify contributions to health systems strengthening, sustainability, and diffusion that are delivered as part of the same unit cost. TCI is working to strengthen its cost-efficiency measures to better reflect the value proposition offered by a global scaling platform as well as capture the unit cost for each city and each additional client as the platform evolves to demonstrate economies of scale and scope.