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.

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.

Key factors to facilitate locally driven family planning programming: a qualitative analysis of urban stakeholder perspectives in Africa and Asia.

BACKGROUND: There has been greater recognition of the importance of country ownership in global health and development. However, operationalising country ownership to ensure the scale up and sustainability of proven interventions remains elusive at best. To address this challenge, we undertook a thematic analysis of interviews collected from representatives of local governments, public health systems, and communities in poor urban areas of East Africa, Francophone West Africa, India, and Nigeria, supported by The Challenge Initiative (TCI), aiming to rapidly and sustainably scale up evidence-based reproductive health and family planning solutions. METHODS: The main objective of this study was to explore critical elements needed for implementing and scaling evidence-based family planning interventions. The research team conducted thematic analysis of 96 stories collected using the Most Significant Change (MSC) technique between July 2018 and September 2019. After generating 55 unique codes, the codes were grouped into related themes, using TCI's model as a general analytical framework. RESULTS: Five key themes emerged: (1) strengthening local capacity and improving broader health systems, (2) shifting mindsets of government and community toward local ownership, (3) institutionalising the interventions within existing government structures, (4) improving data demand and use for better planning of health services, and (5) enhancing coordination of partners. CONCLUSION: While some themes feature more prominently in a particular region than others, taken together they represent what stakeholders perceive to be essential elements for scaling up locally-driven health programmes in urban areas in Africa and Asia.