A Platform for Sustainable Scale: The Challenge Initiative's Innovative Approach to Scaling Proven Interventions.

INTRODUCTION: The global health community continues to face barriers in scaling up evidence-based interventions for widespread adoption. Although many effective interventions have been developed over the years, expanding their reach to benefit broader populations has happened slowly or not at all. OVERVIEW: The Challenge Initiative (TCI) is a nontraditional development platform that supports local urban governments to rapidly scale up proven family planning (FP) and adolescent and youth sexual and reproductive health (AYSRH) interventions for the urban poor. TCI prioritizes sustainability and local ownership and uses a health systems approach when planning for and managing scale. TCI strengthens urban health systems with seed funding, coaching, and technical assistance (TA), and TCI University houses "how-to" guidance and tools for implementing the interventions. In turn, local governments commit political will and financial and human resources while using TCI coaching to integrate interventions into routine practice and systems to achieve widespread and sustained impact at scale. RESULTS: As of June 2021, TCI has supported 104 local governments across 11 countries in scaling up effective FP and AYSRH interventions, while also mobilizing about US$28 million from those local governments to facilitate their implementation. TCI has increased capacity and bolstered urban health systems, with 39 local governments "graduating" from TCI support and 2.02 million additional FP clients across 4 regional TA hubs. CONCLUSION: TCI aims to change how local governments coordinate, finance, and implement proven interventions to improve access to quality FP information and services. With built-in incentives for local governments, partners, and donors to participate, TCI is generating significant learning on how local governments can realize sustainable scale and demonstrating how organizations like TCI that facilitate governments to scale up effective interventions can accelerate the scale-up of these interventions across multiple geographies.

Innovations in Public Financing for Family Planning at Subnational Levels: Sustainable Cofinancing Strategies for Family Planning With Nigerian States.

Global declines in donor funding present a substantial threat to development financing in low- and middle-income countries. In Nigeria, the resources required to achieve states' health goals surpass existing government budgets and available donor funding, a shortfall that incentivizes efforts to expand nondonor sources of financing, including public-driven cofinancing models. The Challenge Initiative (TCI) in Nigeria implements a demand-led model wherein 13 state governments requested technical support from TCI to adapt and scale up high-impact family planning and reproductive health (FP/RH) interventions. TCI provides a blend of technical coaching and financial support through the Challenge Fund, a mechanism designed to incentivize domestic funding for FP programming. To qualify as a recipient, states must demonstrate political will, financial commitment, and potential for impact at scale. However, state financial commitments alone are insufficient to guarantee the successful implementation of health scale-up initiatives. For this reason, the TCI Nigeria cofinancing strategy builds positive relations among key actors (donors, implementers, and government) and improves accountability in FP/RH financing. Although there are several donor-led cofinancing primary health care initiatives in Nigeria, such as the Saving One Million Lives Performance for Results project and Basic Healthcare Provision Fund, little is known about the role of government in driving the process specifically for improving domestic FP/RH financing. In Nigeria, state governments, in collaboration with TCI, developed a cofinancing model that helps states meet their FP/RH financing commitments. To promote effectiveness and sustainability, this model operates within an existing state structure, the State Annual Operation Plan. TCI's cofinancing model motivates continuous improvement in state governments' fiscal capacity, using a framework to measure, track, and reward financial and nonfinancial state commitments. Although the model is not a replacement for existing program tracking and monitoring tools, it helps subnational governments better harness their resources to accelerate improvement in FP/RH outcomes.

Engaging Community Health Workers to Enhance Modern Contraceptive Uptake Among Young First-Time Parents in Five Cities of Uttar Pradesh.

INTRODUCTION: Young newly married women and first-time parents (FTPs), particularly those living in slum settlements, have a high unmet need for modern contraceptive methods to limit and space births. We describe an intervention in which adolescents and youth sexual and reproductive health (AYSRH) services tailored to FTPs were incorporated into the government's existing family planning (FP) program in 5 cities of Uttar Pradesh. We examined the effect of this intervention on modern contraceptive use among FTPs aged 15-24 years. METHODS: To assess the effect of this pilot, in 2019, 1 year after the implementation of the program, we analyzed community-based output tracking survey data on 549 married women who are FTPs in the pilot cities. These FTPs were compared with 253 women who were FTPs from other cities where the program was implemented without a specific focus on FTPs. Descriptive statistics and multivariate logistic regression analysis were applied to understand the association between exposure to FP information, either through accredited social health activists or through service delivery points, and use of modern contraceptives. RESULTS: Use of modern contraceptives was higher among FTPs in the 5 pilot cities than non-pilot cities (39% vs. 32%; P<.05). The interaction effect of city type and exposure to the information showed a positive association between modern contraceptive use and program exposure, greater in pilot cities than non-pilot cities. CONCLUSIONS: Higher uptake of modern contraceptives among young women may be achieved when an FTP-focused intervention is layered on the government's existing FP programs. Future studies with a longer duration of implementation, in a wider geography, and with longitudinal design are recommended to provide more robust measures of high impact intervention/practices in urban areas.