Key Factors to Facilitate Locally Driven Family Planning Programming: A Qualitative Analysis of Urban Stakeholder Perspectives in Africa and Asia

"When local leaders are in the driver's seat of their health programmes, evidence-based interventions are able to reach more people and have greater impact, especially when communities themselves are empowered and involved in planning and implementation."

Based on the experience of the The Challenge Initiative (TCI), this study explores the perspectives of country-based stakeholders in low- and middle-income countries (LMICs) about the implementation and scale-up of evidence-based family planning and adolescent and youth sexual and reproductive health (AYSRH) interventions. The goal is to understand how TCI effects change through its four regional hubs by listening to local-level ideas about which elements are critical to the sustainable scale-up of modern contraception interventions in urban LMIC settings.

TCI is a Bill & Melinda Gates Foundation (BMGF)-funded project that seeks to work in genuine partnership with local governments across economically poor urban areas. In September 2017, three cities of East Africa self-selected to partner with TCI to implement evidence-based family planning interventions. As of February 2021, TCI had scaled interventions in 104 cities in a total of 10 countries (in East Africa and Francophone West Africa, as well as India and Nigeria). TCI's "business unusual" model for operationalising country ownership is guided by six principles:

1. Demand-driven: Local governments select, and bring their own ideas about how to address, pressing family planning issues to the table.
2. Local ownership and system readiness: Local governments must be ready, willing, and able to address their issues by leading implementation of evidence-based interventions.
3. Right-fitting interventions: TCI works with local governments to ensure evidence-based interventions are adapted and responsive to the particular nuances of local conditions and context.
4. Coaching support: TCI provides support to local governments to design, manage, and implement programmes themselves.
5. Leveraging and activating of existing structures and systems: TCI works within existing government- and community-led systems to harmonise strategies, plans, funding, and technical assistance and avoid duplication, waste, and missed opportunities.
6. Use of near- to real-time data: TCI stresses adaptive management techniques by using data for problem solving and better decision-making.

TCI uses a participatory monitoring and evaluation technique called the Most Significant Change (MSC) as its primary qualitative data collection method in order understand not just what TCI is accomplishing but how. MSC consists of four basic steps: (i) collecting stories of significant change from project beneficiaries or stakeholders, (ii) selecting the most significant stories to surface values about what is important, (iii) feeding back selected stories with all stakeholders to promote ongoing dialogue and learning, and (iv) using the stories to improve the project.

For this study, four members of the research team conducted a secondary analysis of 96 MSC stories collected from representatives of local governments, public health systems, and community stakeholders between July 2018 and September 2019. Of the stories, 49% were from the Nigeria hub, while East Africa and India each contributed about one-quarter of the stories, and Francophone West Africa contributed four stories. After inductively generating 55 unique codes for analysis of the stories, the researchers grouped the codes into five key themes:

• Strengthening local capacity and improving broader health systems: For example, many stories described various capacity strengthening approaches such as coaching, mentoring, and training opportunities that enabled stakeholders to implement, manage, and monitor evidence-based family planning interventions.
• Shifting mindsets of government and community toward local ownership: For example, some stories described how the evidence-based interventions engaged key influencers, such as traditional and religious leaders and community members who served as community health workers (CHWs), to become family planning champions. A religious leader in Plateau state, Nigeria, explained that he was carrying out a door-to-door campaign among his network to talk about the importance of family planning and that he was sharing what he learned from TCI with other religious leaders, which sparked a broader mindset change among the Muslim clerics in his area.
• Institutionalising the interventions within existing government structures: About half of the stories in India illustrated specific examples related to this theme. For instance, the local government, with coaching support, mapped and defined slum catchment areas to better define service needs and allocate resources. All government programmes, including family planning, immunisation, and maternal and newborn health, started using the slum maps to plan urban health interventions.
• Improving data demand and use for better planning of health services: These stories fell into three categories: (i) the use of data as part of advocacy efforts to motivate and inspire local governments to prioritise family planning interventions; (ii) strengthened capacity of local stakeholders to collect, analyse, and use data; and (iii) how this capacity strengthening in data use ultimately led to a culture of data demand by both local government stakeholders and implementers at the facility level.
• Enhancing coordination of partners: For example, stories highlighted improved linkages between the community and service delivery system through activation of community structures. For example, strengthening women's groups was an evidence-based practice in India that aimed to bolster community accountability and facilitate access to family planning services among the urban economically poor.

Per the researchers, these five themes align with all six of TCI's business unusual guiding principles, although the demand-driven and right-fitting principles did not come out as frequently as the other principles in the MSC stories. The researchers indicated that one aspect that emerged from the analysis that could be emphasised more strongly in TCI's guiding principles is community ownership in addition to local government ownership. Subsequent research could explore whether or not perceptions of community ownership change over time, especially as engagement with TCI gradually ends.

The researchers stress that "the cornerstone of successful implementation and scale efforts is coaching of local health systems actors to strengthen their capacity to design, implement, manage, and continually monitor and adapt their own health programmes to changing conditions. Shifting mindsets and fostering local ownership starts with building and cultivating leadership....[T]he specific details on how [TCI] coaching is implemented vary between countries and regions." They are undertaking a study to document the "how" of TCI's coaching approach and to assess the specific outcomes that are associated with coaching.

In conclusion, these results "add to the body of the literature in the scale-up and sustainability fields by providing perspectives from local stakeholders themselves, rather than from public health 'experts' or 'thought leaders,' on important facilitating factors. These stakeholders highlighted coaching to strengthen capacity, alignment of interventions, tools, and approaches with the existing system, the use of data for decision-making, and coordination of partners as significant elements needed to facilitate local ownership and implementation of evidence-based interventions, with the ultimate goal of scale up and sustainability."