The Challenge Initiative: Lessons on Rapid Scale-Up of Family Planning and Adolescent and Youth Sexual and Reproductive Health Services

INTRODUCTION

Over the past several decades, the global health community has accumulated collective knowledge of what works to expand and improve family planning (FP) programming, including evidence-based interventions to shape the broader enabling environment, service delivery, and social and behavioral change, as well as new contraceptive formulations.^1,2 However, these practices and commodities have often not spread through health systems in countries around the world.^3–5 The challenges of coordinating stakeholders in and outside of government to effectively implement high-impact practices often confound leaders and managers at the local and community levels. Further, the global development community has typically invested in small, pilot-based, high-intensity programs whose design makes scaling to provide expanded and sustained coverage prohibitively costly.

Globally, by 2050, an estimated 7 of 10 people will likely live in urban areas, most in low- and middle-income countries (LMICs), where the pace of urbanization is projected to be the fastest. In this growing urban population, some of the poorest and least well-served are in informal settlements, which have typically lacked infrastructure and received few city resources.⁶ However, while the evidence is limited or mixed, the ongoing trend of political decentralization—shifting the decision-making authorities from the national government to the subnational governments—in LMICs could improve health system performance and outcomes in some settings.^7–9 Helping cities and other subnational governments to achieve sustainable urbanization, and particularly to respond to the health needs of their most marginalized community members, is critical to successful development outcomes.

There is increasing global recognition of the human right to decide whether, when, and how many children to have. At the same time, investing in and scaling upaccess to contraception for women and girls—particularly married and unmarried individuals ages 15–24 years living in Africa and Asia—brings rich social, economic, educational, and environmental returns and proven reductions in women’s, children’s, and infant morbidity and mortality.^10,11

To that end, The Challenge Initiative (TCI) partnered with local governments in various countries to take proven interventions and strategies to scale with local governments taking the lead by not only identifying the interventions that were most needed in their context but also committing human and financial resources from the beginning to enhance the likelihood of sustained impact. Funded by The Bill & Melinda Gates Foundation, Bayer AG, and Comic Relief, TCI covered 106 localities in 10 countries across 4 regions between 2016 and 2021.

The articles in this supplement provide important new evidence, collective experiences, good practices, and lessons learned about the strategies for helping local governments to sustainably scale access to FP for women, youth, and adolescents and to improve access to and use of contraception among adolescents and youth (AY). In this supplement, we present lessons for 2 broad audiences: those interested in the scale and sustainability of FP and other related health and development interventions and those interested in advancing understanding of scaling AY sexual and reproductive health (AYSRH) programming, with a particular focus on contraception.

SCALING AND SUSTAINABILITY OF FAMILY PLANNING INTERVENTIONS

Finkle et al.¹² cite many known challenges to the widespread adoption of FP interventions, including “underestimating the importance of politics and policy, failing to ensure local government ownership from the beginning, misjudging the time and resources needed for successful scale-up with sustainable impact, and the failure to adapt or make portable an innovation shown to be effective in one context to a new context.” The authors note that a growing body of literature on scaling has led to general agreement on the stages of scaling, the importance of adaptive management, the critical role of continuous engagement with local stakeholders, and the need to design for sustainability. However, the need to scale up health interventions for poor urban communities continues to be acute given the rapid pace of growth and gap in our understanding of how best to meet their needs, including for contraceptives, at scale in a sustainable way. The authors briefly summarize TCI’s experiences in and contributions to the field of scale-up theory and practice.

Ishola et al.¹³ describe a mixed-methods comparative case study to determine facilitators and barriers to subnational (state-level) adoption, implementation, and scale-up of high-impact FP/AYSRH interventions. The authors found that among 3 Nigerian states that had received substantive coaching support and financial investment, 2 states were higher performing and one lower performing, as determined by growth in FP client service volume over 24 months of implementation. One of the most important implications of this study is that political and managerial capacity—as opposed to just technical knowledge about FP—are most seen as linked with the successful adoption and scale-up of evidence-based FP/AYSRH interventions. This finding supports the emphasis on working with local governments to build their capacity to coordinate, finance, and implement already proven interventions.

Igharo et al.¹⁴ discuss the threat to development financing in Nigeria posed by declining donor funding, low government accountability, and weak governance. These problems were compounded for FP-related funding due to the limited understanding among policymakers of how investments contributed to the country’s broader health and development goals. These issues were addressed through an innovative, multipronged co-financing model, through which seed money was provided incrementally to Nigerian partner state governments as an incentive to commit and release state government funds for FP. Before the model was implemented, only 4 of 13 states had a dedicated budget line. By 2020, 10 of 13 partner states had budget lines and released funds for FP. The average amount of funds released per state more than tripled from 2018 to 2019, though decreased moderately in 2020. Over the engagement period (approximately 4 years), partner states were expected to increase their share of funds allocated to FP programs as TCI’s share gradually decreased. This intervention built on and strengthened existing state government financial processes and institutions toward increasing domestic financing, resource optimization and leverage, and fiscal accountability and transparency.

Kandji et al.¹⁵ describe how local municipalities and health systems in 5 countries in Francophone West Africa were supported to implement Family Planning Special Days (FPSDs) to reach new contraceptive users. Through FPSDs, municipalities provided free FP services on specific days in poor urban communities. The FPSDs’ management and tracking tools were the same as those already in use by the health system. The intervention strengthened collaboration among and ownership by municipalities and the health system and using existing health system tools strengthened sustainability.

SCALING ADOLESCENT AND YOUTH SEXUAL AND REPRODUCTIVE HEALTH INTERVENTIONS

Globally, levels of contraceptive uptake have increased and unmet need for modern methods has decreased. Despite being slow and uneven in some places, similar trends can be observed for adolescents, whose levels of pregnancy and childbearing have decreased, attributable to increases in adolescent contraceptive uptake.¹⁶ One must appreciate these significant gains in AYSRH to forge ahead in a way that maintains the momentum gained in recent decades and that capitalizes on lessons learned. This must be done while not losing sight of various realities that require continued attention, including considerable regional disparities in modern contraceptive uptake among adolescents and, in some areas, only nominal improvements over time, despite their significance.¹⁶

Indeed, AY in LMICs still face significant challenges related to SRH. These include, among other risks, unintended pregnancies and unsafe abortions, which remain prevalent among this age group.¹⁷ These negative health outcomes affect adolescents by not allowing them to continue their education, pursue employment opportunities, and participate more fully in their communities, limiting their contribution to the overall development and prosperity of their families and communities.^18,19 These outcomes also have broader social and economic implications, including limiting the potential to reap the benefits of a demographic dividend, including workforce growth and improved human capital.²⁰

To mitigate these risks, we must prioritize AY’s access to and use of contraceptives and help them overcome the numerous barriers they face to reproductive health care. These obstacles include limited knowledge, stigma resulting from cultural norms and societal attitudes, lack of sexuality education, and provider bias.²¹ Both married and unmarried adolescents require contraceptive options, but they often struggle to obtain them and are sometimes denied access by providers.²² Other barriers would include the policy framework and laws of countries not explicitly supporting AYSRH.

In response, proven AY-focused interventions that are delivered effectively can help to ensure increased quality of tailored services, greater acceptance of the services among youth, and subsequently increased uptake of contraceptive services.²³ The World Health Organization (WHO) provides official guidance and user-friendly materials to support the design and implementation of adolescent-friendly services, which remain comprehensive in scope.²⁴ For example, the WHO Southeast Asia Regional Office’s supervisory checklist for adolescent-friendly services acknowledges the importance of ensuring that health care structures provide not only services but also information, education, and demand generation that include contraception and sexually transmitted infections.²⁵ In this way, adolescent-friendly services, when delivered in a comprehensive way and aligned with WHO standards, can be effectively poised to address barriers to contraceptive uptake, adolescent pregnancy prevention, and sexually transmitted infections and HIV prevention. Therefore, to address the unique contraceptive needs and preferences of AY, comprehensive strategies appear fruitful for their ability to concurrently target and prevent adolescent pregnancy and other risks for their SRH and well-being.