What Underlies State Government Performance in Scaling Family Planning Programming? A Study of The Challenge Initiative State Partnerships in Nigeria

Oluwayemisi Denike Ishola; Sarah Jane Holcombe; Andrea Ferrand; Lekan Ajijola; Nneoma Nonyelum Anieto; Victor Igharo

doi:10.9745/GHSP-D-22-00228

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FIGURE.
Influence of Consolidated Framework for Implementation Research Factors on the Adoption and Implementation of The Challenge Initiative’s Core High-Impact Interventions, by Nigerian State
Abbreviations: CFIR, Consolidated Framework for Implementation Research; TCI, The Challenge Initiative.
^aThe Challenge Initiative scaling strategies that were added.

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TABLE 1

Nigerian States That Implemented TCI’s High-Impact FP and AYSRH Interventions

	Population(Millions)	Total FertilityRate	UnmetNeed, %	mCPR(MarriedWomen), %	CurrentlyMarried WomenAged 15–19Years, %	BirthsAttended bySkilledProviders, %	FemaleLiteracyRate, %	Per CapitaGDP,US$ (2007)	LGAs, No. (%)Supportedby TCI
State A	4.7	7.2	21	5	66	22	26	983	20 (50)
State B	3.2	4.7	20	21	12	43	53	1,587	17 (53)
State C	4.1	4.4	24	13	7	67	77	3,990	25 (52)
Nigeria	206.1	5.3	19	12	29	43	53	2,097	774

Abbreviations: AYSRH, adolescent and youth sexual and reproductive health; FP, family planning; GDP, gross domestic product; LGA, local government area; mCPR, modern contraceptive prevalence rate; TCI, The Challenge Initiative.
Source: Nigeria Demographic Health Survey, State of States factsheet, and National Bureau of Statistics.⁴⁶^–⁴⁸

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TABLE 2
Key Informants Interviewed in Three Nigerian States
Government (State and LGALeaders and Managers) External (CSO,Religious Leaders) TCI Abuja Staff TCI State-LevelCoaches Total
State A 7 1 8
State B 7 1 8
State C 7 1 8
TCI 5 3 8
TOTAL 21 3 5 3 32
Abbreviations: CSO, civil society organization; LGA, local government area; TCI, The Challenge Initiative.

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TABLE 3.

Indicators of Health Systems Strength in Higher- and Lower-Performing States in Nigeria, Through June 2021^a

	CFIR Factors and Subfactors
	ServiceDelivery	Political andFinancialCommitment	Planning andGuidance	Coordination	ExternalChampions	Systems Strength and Readiness
	Growth inFP ClientVolume^b, No. (%)	State BudgetLine Item forFP Disbursed,US$ (%)	HIIs Includedin State AOP^c, No.	State-LedCoordinationPlatforms RegularlyOperating, No.	Advocacy GroupsConstituted, Registered,Operating Independentof TCI	FacilitiesReportingContraceptiveStock-outs, %^d	FacilitiesReportingFP/AYSRH Datain Last 12Months, %(Lowest)^d
State A	+46,923 (+91)	390,385 (79)	9 (SD, DG,Advocacy,and MEL)	7 State TWGs, all includeLGA participation	ACG, IFF^e	>10	70–90
State B	+32,683 (+15)	506,622 (126)	7 (SD, DG,Advocacy)	7 State TWGs, all include LGAparticipation; Partner CoordinationPlatform	ACG, IFF^e	<10	>90
State C	+22,270 (+50)	187,010 (58)	4 (SD, MEL)	1 State Reproductive Health TWGincludes LGA participation; StateTechnical Advisory Committee^e	ACG^e, IFF^e	>10	50–70

Abbreviations: ACG, advocacy core group; AOP, annual operational plan; AYSRH, adolescent and youth sexual and reproductive health; DG, demand generation; FP, family planning; IFF, interfaith forum; LGA, local government area; MEL, monitoring, evaluation, and learning; SD, service delivery; TCI, The Challenge Initiative; TWG, technical working group.
↵^aUnless otherwise noted, all data are from start of states' TCI partnership implementation through June 2021.
↵^bFrom government service statistics (health management information system).
↵^cFrom most recent state Annual Operational Plan/budget: HIIs included are implemented across all state LGAs.
↵^dData from states’ quarterly review of performance.
↵^eNot independently constituted.

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TABLE 4.

Facilitators and Barriers for TCI Intervention Expansion and Institutionalization, by CFIR Domain^a

CFIR Domain	Facilitators	Barriers
1. Intervention Characteristics	• Track record of TCI predecessor (Urban Reproductive Health Initiative) enhanced credibility and attractiveness of TCI partnership, interventions; increased state applications to partner
2. Outer Setting	• Interventions' alignment with national policies (Nigeria's Primary Health Care Under One Roof; task sharing, task shifting, etc.) and with national and state focus on maternal mortality • Appreciation of how TCI results enable states to draw down national results-based financing (Saving One Million Lives)^b	• Weaker tradition of political leader and civil society volunteering for community welfare (undermined by the “resource curse” of plentiful oil revenue) (Idemudia 2012⁵¹); local government leaders' expectation of compensation for activities (State C)^b • Violence and unrest preventing travel to health facilities (especially State B) • Regular shocks to health workforce: government health worker strikes, transfers, attrition (especially State B)^b • Health commodity, particularly contraceptive, supply chain: concern about ability to meet new demand generated^b
3. Inner Setting	• Past donor investments in family planning and health systems strengthening: planning, human resources, state coordination platforms, HMIS (States A and B)^b^,^c • Presence of semi-operational Primary Health Care Development Agency (especially States A and B)^b • Increased financial commitments: creation and size of family planning and AYSRH budget allocations and disbursements (especially States A and B)^b^,^c • Use of prioritized state institutions and processes: state AOPs, TWGs^b^,^c	• Persistent battles to secure release of budgeted family planning funding (especially State C)^b • Weak or absent state health systems and coordinating bodies, requiring establishing and/or strengthening of systems at the same time as expanding implementation of interventions (State C)^c • Reliance on external implementing partners to lead state Health Partners committee^c
4. Characteristics of Individuals	• Commitment to state ownership and leadership of intervention adoption and implementation among state government staff ^b^,^c	• Expectation among some State C stakeholders that TCI staff should spearhead intervention adoption and provide commodities^b
5. Process (of Scale-Up)
Planning and guidance	• Use of state AOPs to adopt and institutionalize interventions: higher-performing states incorporated more and a more comprehensive set of interventions, and accordingly, more are implemented in facilities at LGA levels^b^,c • AOP use triggered implementation through state TWGs, heightened attention to data and outcomes, provided roadmap for advocacy for release of budgeted family planning funding^b • Ready availability of detailed written and coaching guidance to state staff on how to implement high-impact interventions^b
Spread and uptake strategies
Government“point-people”	• Skilled and committed government staff (state program officers) designated as responsible for managing intervention implementation^b • Advocacy to agency heads for funding release, using data on intervention performance, in coordination with external champions^b
Internal champions	• Presence of internal government champions at political, agency leadership, as well as technocratic levels: aided release of budgeted funds and helped programming survive political and other transitions^b^,c	• Gaps in the chain of leadership commitment (agency leadership levels) impeded release of state funding for interventions (State C)^b^,^c
External champions	Institutionalized presence of independent external champions (religious and traditional leaders; ACG), who: • Increased community awareness about family planning and link those interested to services^b • Held state governments accountable for family planning programming through advocacy for funding, formal participation in quarterly review of state programming^b^,^c • Strengthened facilities through quality improvement teams^b	• More infrequent contributions from external champions, more rarely at LGA levels (State C)^b
Executing
Coordination	Step-down and implementation of interventions through existing state coordination platforms (TWGs) helped: • Institutionalize coaching on interventions^c • Synchronize demand generation and service delivery activities^b • Galvanize and better channel local participation at LGA levels (quality improvement teams) - especially in highest-performing state^b^,^c • Coordination advocacy for financial commitments^b^,^c	• Weaker and more limited presence of functioning coordination platforms (TWGs) and advocacy (IFF, ACG) in the lower performing state (State C)^b^,^c
Improvement of data quality and use	• Availability and use of quality data key to strengthening programming; successful advocacy with government leaders for allocation and disbursement of funding^b^,^c
Integration	• Greater popularity and perceived cost-effectiveness and sustainability of integrated interventions; data review; supportive supervision that were more frequently deployed in States A and B^c • Popularity of integrated approaches in framing of family planning messaging, advocacy by religious leaders^b^,^c

Abbreviations: ACG, advocacy core group; AOP, annual operating plan; AYSRH, adolescent and youth sexual and reproductive health; HMIS, health management information system; IFF, interfaith forum; LGA, local government area; TCI, The Challenge Initiative; TWG, technical working group.
↵^aTable format adapted from Callaghan-Koru et al.⁴⁵ who reported on CFIR domains and added World Health Organization/ExpandNet terminology describing scale-up through expansion or institutionalization. If no state specified, points apply to all states.
↵^bScale-up through expansion (horizontal scaling).
↵^cScale-up through institutionalization (vertical scaling).