Boosting Contraceptive Uptake in Urban Uganda: Older Women Benefit When Layering Adolescent and Youth Interventions Onto Existing Family Planning Programming.

INTRODUCTION: Uganda has a large young population with a high unmet need for family planning (FP). Although there have been many efforts to improve access to and uptake of contraception, improvements have been slow. The Ministry of Health Uganda partnered with The Challenge Initiative (TCI) to implement a novel multipronged approach layering adolescent and youth sexual reproductive health (AYSRH) onto a functioning general FP program for women of reproductive age in 3 local governments of Buikwe, Mukono, and Iganga. We describe the approach and aim to determine whether layering AYSRH interventions onto an existing program resulted in increased contraceptive uptake among adolescents and youth aged 10-24 years and among women aged 25-49 years. METHODS: We analyzed service statistics from the Uganda Health Management Information System to assess contraceptive uptake for adolescents and youth (aged 10-24 years) and older women (aged 25-49 years) before and after the implementation of the AYSRH approach in 3 areas (Buikwe, Iganga, and Mukono) compared to 11 areas where only the general FP program was implemented and the Uganda country total. RESULTS: This analysis showed that before the start of TCI's support, levels of contraceptive uptake were similar in all local governments. However, after implementation, there was an increase in uptake for general FP program only areas (1.7-point advantage over country total) and an even greater increase in general FP+AYSRH areas (2.4-point advantage over FP only programming). This was observed in both adolescents and youth aged 10-24 years and among women aged 25-49 years. CONCLUSION: The layering of TCI's AYSRH interventions onto a well-functioning FP platform not only increased contraceptive uptake among adolescents and youth aged 10-24 years but also boosted uptake among women older than age 25 years.

Improving access to family planning services through community pharmacies: Experience from The Challenge Initiative in three counties in Kenya.

Pharmacies play a vital role in improving access to family planning (FP) services in urban areas. They complement the resource-limited public health system and are viewed as key access points for contraceptives among young people (10-24 years) and the general population. The Challenge Initiative East Africa (TCI EA), in collaboration with the health management teams of Mombasa, Kilifi, and the Nairobi counties in Kenya and the Kenya Pharmaceutical Association (KPA) piloted an innovative public-private partnership (PPP) engagement to improve access to quality FP services offered at pharmacies in urban areas. The pilot project built the capacity of pharmacists, strengthened the referral system to public health facilities, and made FP data accessible and visible to drive informed decision-making. This paper describes the strategies employed and the outcomes. The initiative targeted 150 pharmacies across the three counties from June 2019 to December 2020 period. Our assessment shows that this intervention delivered FP commodities to 43,632 FP client visits; 71% for female clients and 21% for males. Adjusting for couple years of protection and seasonality, this translates to about 2,800 annual FP clients obtaining modern contraception in a 12-month period, including 48% injectables, 25% oral contraception, 24% emergency contraception, and 3% condoms. The majority of clients (75%) were older than 24 years, 21% were 20-24 years, 3% were 15-19 years, and 1% were less than 15 years. In addition, 327 clients were referred to a public sector facility for other methods. This intervention demonstrates the potential of pharmacies in contributing to FP uptake and provides a framework for improving access to quality FP services by pharmacies. There is potential to scale such an approach beyond the 3 counties, given the involvement and reach of KPA and the Ministry of Health (MoH) health management teams.

Sustainable financing of AYSRH programs by local governments through the TCI model.

Introduction: Despite the existence of a legal policy framework, financing of adolescent and youth sexual and reproductive health (AYSRH) services has remained weak. External donors are the main financing agents, which has implications for the sustainability of service provision. International development partners have reduced funding for health programs from historically high levels. In Kenya, the health sector's budget allocation has remained below the 15% committed to under the Abuja declaration. With Kenya's devolved government structure, a greater proportion of financial resources are dedicated towards recurrent and structural expenses as opposed to addressing health systems gaps. Objectives: The purpose of this manuscript is to assess the contribution of The Challenge Initiative (TCI) Business Unusual model on AYSRH services in the counties of Kilifi and Migori, as well as to examine the institutionalization of high impact interventions (HIIs) within the annual work plan, budget, and systems of the said counties. Additionally, this study aims to analyse the trend in contraceptive uptake among adolescent and young women aged 15 to 24 in Kilifi and Migori counties. Methods: Migori and Kilifi Counties chose to partner with TCI to implement the Business Unusual model. Interested counties apply for the initiative's support and commit to contributing a portion of the funding needed to adapt and implement high impact interventions (HIIs). Based on the identified gaps, TCI supported the counties to prioritize the HIIs including integrated outreaches, youth fixed days, whole site orientation, youth champions, and youth dialogues. The program was implemented between July 2018 to June 2021 in 60 and 68 public health facilities of Kilifi and Migori Counties, respectively. The county teams identified and selected program implementation team whose key role was to coordinate, review, monitor, mobilize resources and report AYSRH program implementation progress. Results: The results showed a 60% increase in financial commitments on AYSRH programming from 2018 to 2021 in both counties. The average expenditure for committed funds for Kilifi and Migori Counties was 116% and 41% respectively. As the counties continued to allocate and spend funds on the implementation of HIIs, there was a noticeable increase in contraceptive uptake among the young people aged 15 to 24 who visited health facilities for services. There was a 59% and 28% percentage increase in contraceptive uptake among young people (15-24 years) between 2018 and 2021. The proportion of adolescents amongst those presenting for first ANC clinic dropped from 29.4% in 2017 to 9% in 2021 in Kilifi County and from 32.2% in 2017 to 14% in 2021 in Migori County. Using the TCI's Sisi kwa Sisi coaching model of lead-assist-observe-monitor, 20 master coaches were trained. The master coaches cascaded the training to over 97 coaches. The coaches will continue to build capacity of peers in advocacy for resource mobilization and implementation of HIIs. At least nine of TCI's HIIs have been adopted in Kilifi and Migori County strategies and annual work plans, and there is financial support for their sustainability. Discussion: The increase in adolescent contraceptive uptake might have been as a result of the system strengthening through self-financing of AYSRH programs, the institutionalization of HIIs, and the coaching. Local governments can invest in and sustain their own AYSRH programs, which will lead to an improvement in adolescent and youth access to contraceptive services and, as a result, a reduction in adolescent pregnancies, maternal mortality, and infant mortality.

The Tupange Project in Kenya: A Multifaceted Approach to Increasing Use of Long-Acting Reversible Contraceptives.

BACKGROUND: Long-acting reversible contraceptives (LARCs) are safe and highly effective, and they have higher continuation rates than short-acting methods. Because only a small percentage of sexually active women in Kenya use LARCs, the Tupange project implemented a multifaceted approach to increase uptake of LARCs, particularly among the urban poor. The project included on-site mentoring, whole-site orientation, commodity security, quality improvement, and multiple demand-promotion and service-provision strategies, in the context of wide method choice. We report on activities in Nairobi between July 2011 and December 2014, the project implementation period. METHODS: We used a household longitudinal survey of women of reproductive age to measure changes in the contraceptive prevalence rate (CPR) and other family planning-related variables. At baseline in July 2010, 2,676 women were interviewed; about 50% were successfully tracked and interviewed at endline in December 2014. A baseline service delivery point (SDP) survey of 112 health facilities and 303 service providers was conducted in July 2011, and an endline SDP survey was conducted in December 2014 to measure facility-based interventions. The SDP baseline survey was conducted after the household survey, as facilities were selected based on where clients said they obtained services. RESULTS: The project led to significant increases in use of implants and intrauterine devices (IUDs). Uptake of implants increased by 6.5 percentage points, from 2.4% at baseline to 8.9% by endline, and uptake of IUDs increased by 2.1 percentage points, from 2.2% to 4.3%. By the endline survey, 37.7% of clients using pills and injectables at baseline had switched to LARCs. Contraceptive use among the poorest and poor wealth quintiles increased by 20.5 and 21.5 percentage points, respectively, from baseline to endline. Various myths and misconceptions reported about family planning methods declined significantly between baseline and endline. CONCLUSION: Training, commodity security, multiple service delivery models, and demand promotion were the cornerstones of a successful approach to reach the urban poor in Nairobi with LARCs.

From Project to Program: Tupange's Experience with Scaling Up Family Planning Interventions in Urban Kenya.

This paper describes how the Urban Reproductive Health Initiative in Kenya, the Tupange Project (2010-2015), successfully applied the ExpandNet approach to sustainably scale up family planning interventions, first in Machakos and Kakamega, and subsequently also in its three core cities, Nairobi, Kisumu and Mombasa. This new focus meant shifting from a "project" to a "program" approach, which required paying attention to government leadership and ownership, limiting external inputs, institutionalizing interventions in existing structures and emphasizing sustainability. The paper also highlights the project's efforts to prepare for the future scale up of Tupange's interventions in other counties to support continuing and improved access to family planning services in the new context of devolution (decentralization) in Kenya.