Facilitators and Barriers for TCI Intervention Expansion and Institutionalization, by CFIR Domaina
| 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 generatedb |
| 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, TWGsb,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 committeec |
| 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 commoditiesb |
| 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 levelsb,c • AOP use triggered implementation through state TWGs, heightened attention to data and outcomes, provided roadmap for advocacy for release of budgeted family planning fundingb • Ready availability of detailed written and coaching guidance to state staff on how to implement high-impact interventionsb | |
| Spread and uptake strategies | ||
| Government“point-people” | • Skilled and committed government staff (state program officers) designated as responsible for managing intervention implementationb • Advocacy to agency heads for funding release, using data on intervention performance, in coordination with external championsb | |
| 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 transitionsb,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 servicesb • Held state governments accountable for family planning programming through advocacy for funding, formal participation in quarterly review of state programmingb,c • Strengthened facilities through quality improvement teamsb | • 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 interventionsc • Synchronize demand generation and service delivery activitiesb • Galvanize and better channel local participation at LGA levels (quality improvement teams) - especially in highest-performing stateb,c • Coordination advocacy for financial commitmentsb,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 fundingb,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 Bc • Popularity of integrated approaches in framing of family planning messaging, advocacy by religious leadersb,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).