The Global Urban Challenge
More than half of the world’s population currently lives in cities and this urbanization is accelerating to 70 percent by 2050, with some of the greatest growth in Africa and Asia. Cities benefit from economic growth, but also struggle to accommodate rising demands for services especially among their growing, underserved poor communities. Like no other project before, the Urban Reproductive Health Initiative (URHI) was designed specifically to address the urban poor and their reproductive health needs. URHI was a Bill & Melinda Gates Foundation-funded multi-country program in India, Kenya, Nigeria and Senegal that aimed to improve the reproductive health of the urban poor by increasing the accessibility, quality and use of family planning services. From 2010-2016, the projects used different interventions, both demand and supply side, to increase use of and access to contraceptives.
Significant Success in Urban Areas
URHI emphasized increasing modern family planning use in urban settings, particularly among the poor. From baseline to endline it achieved increased modern contraceptive prevalence (mCPR) especially amongst the poorest quintiles, improved knowledge around modern methods and saw large increases in use of long-acting and permanent methods including implants, IUDs and, mostly in India, female sterilization. These increases were observed among all women and across the wealth groups.
To determine how the country programs were successful, the initiative was designed with a separate evaluation component, the Measurement, Learning & Evaluation (MLE) Project. MLE followed women and households over the course of the project to determine, using a longitudinal study design, how each programmatic element impacted mCPR.
Although the country programs have common objectives (improving quality of services, integrating FP into maternal and child health services, increasing the role of the private sector, increasing demand for FP and advocating for increased funding for FP at the municipal and national levels), the implementation in each country was tailored to the specific context. Due to this tailoring, the findings were slightly different for each program.
Using statistical methods that took advantage of the data on the same women and facilities over time, the project demonstrated numerous factors associated with increased modern contraceptive use in each of the study contexts. In India, women exposed to brochures, billboards, posters, pamphlets, community health workers and living close to project facilities were more likely to be users. In Nigeria, the key factors driving use were exposure to local radio programs, television programming, outreach activities where family planning was discussed and living close to a program facility. Likewise, in Kenya, local radio programming, as well as exposure to community health workers and exposure to program facilities led to greater modern method use. Finally, in Senegal, among women, the factors that influenced modern method use at endline were exposure to community-based activities and local radio programs. MLE also found that for Senegalese men exposure to religious leaders discussing family planning and a variety of other URHI program activities were associated with increased reported use. The programs were flexible and data driven, which allowed each program to make evidence-based decisions when revising intervention strategies. For example, in Senegal, after the mid-term evaluation showed that some elements of the program were more successful than others, they were able to reduce from 19 approaches to 6, while maintaining the same level of impact.
Program Impacts Reach Further than Intervention Cities
Results from examining the impact of URHI diffusion (the spread and adoption of new information influencing family planning decisions) in Nigeria and Kenya found that exposure to family planning program activities was highest in the program cities followed by other urban areas and then rural areas. This suggests that program impacts spread beyond the target cities.
The Future of Urban Reproductive Health – The Challenge Initiative
URHI was a “proof of concept” to figure out what works where and why. The URHI experience provides sufficient evidence to warrant a next generation of investment for scale-up. The URHI programs demonstrated that significant progress in family planning system strengthening and adoption can be achieved with thoughtful investments and careful programming of various advocacy, demand-generation, service delivery and supply-chain activities that are tailored to each location’s particular circumstances. Together, these various urban-based activities delivered significant increases in the modern contraceptive prevalence rate of 2 to 3.5 percentage points per year, with even more substantial increases for poor women of 2.2 to 4.7 percentage points per year.
This next stage is the Challenge Initiative, an ambitious program to accelerate demand-driven participation, with achievable goals through a highly coordinated and branded marketing approach with regional hubs. The expected outcomes of more urban geographies adapting and using the URHI toolkits and approaches is based in large part on the proven interventions and outcomes of the current URHI programs, upon which the expansion under the Challenge Initiative is built.
Watch The Key to Sustainable Development: Investing in Urban Reproductive Health to understand how we moved from URHI to the Initiative and why investing in urban reproductive health is so important.