TY - JOUR T1 - What Underlies State Government Performance in Scaling Family Planning Programming? A Study of The Challenge Initiative State Partnerships in Nigeria JF - Global Health: Science and Practice JO - GLOB HEALTH SCI PRACT DO - 10.9745/GHSP-D-22-00228 AU - Oluwayemisi Denike Ishola AU - Sarah Jane Holcombe AU - Andrea Ferrand AU - Lekan Ajijola AU - Nneoma Nonyelum Anieto AU - Victor Igharo Y1 - 2022/12/09 UR - http://www.ghspjournal.org/content/early/2023/03/14/GHSP-D-22-00228.abstract N2 - Key FindingsStrong external champions—both traditional and religious leaders but also media-savvy policy advocates—were a key component of a successful scaling experience by building public understanding and support for FP use and holding government leaders accountable for its provision.Skilled and empowered state program officers, with support from internal government champions at the highest political but also agency leadership levels, spearheaded the introduction and implementation of the interventions and guided the institutionalization of interventions through existing state mechanisms.Key ImplicationsEarlier and more in-depth understanding of subnational health systems can enable government stakeholders and intermediary organizations to better target interventions and to sequence support to strengthen health systems and scale up interventions.As political and managerial (political and financial commitment; systems strength; planning and coordination) rather than just technical (knowledge about family planning interventions) capacities are most seen as linked with successful adoption and scale-up, intermediary organizations should prioritize these processes and systems from the start.Introduction:Relatively few studies rigorously examine the factors associated with health systems strengthening and scaling of interventions at subnational government levels. We aim to examine how The Challenge Initiative (TCI) coaches subnational (state government) actors to scale proven family planning and adolescent and youth sexual and reproductive health approaches rapidly and sustainably through public health systems to respond to unmet need among the urban poor.Methods:This mixed-methods comparative case study draws on 32 semistructured interviews with subnational government leaders and managers, nongovernmental organization leaders, and TCI Nigeria staff, triangulated with project records and government health management information system (HMIS) data. Adapting the Consolidated Framework for Implementation Research (CFIR), we contrast experience across 2 higher-performing states and 1 lower-performing state (identified through HMIS data and selected health systems strengthening criteria from 13 states) to identify modifiable factors linked with successful adoption and implementation of interventions and note lessons for supporting scale-up.Results:Informants reported that several TCI strategies overlapping with CFIR were critical to states’ successful adoption and sustainment of interventions, most prominently external champions’ contributions and strengthened state planning and coordination, especially in higher-performing states. Government stakeholders institutionalized new interventions through their annual operational plans. Higher-performing states incorporated mutually reinforcing interventions (including service delivery, demand generation, and advocacy). Although informants generally expressed confidence that newly introduced service delivery interventions would be sustained beyond donor support, they had concerns about government financing of demand-side social and behavior change work.Conclusion:As political and managerial factors, even more than technical factors, were most linked with successful adoption and scale-up, these processes and systems should be assessed and prioritized from the start. Government leaders, TCI coaches, and other stakeholders can use these findings to shape similar initiatives to sustainably scale social service interventions. ER -