Facilitators and Barriers for TCI Intervention Expansion and Institutionalization, by CFIR Domaina

CFIR DomainFacilitatorsBarriers
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


• 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

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

• 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).