Using data for decision-making in Nasarawa State, Nigeria. Nasarawa graduated from TCI in December 2023.

From the outset of its engagement with urban local governments, The Challenge Initiative (TCI) places a strong emphasis on fostering sustainability and self-reliance, empowering local governments to take the lead in family planning programs that improve the health and well-being of their communities. TCI’s approach is geared towards instituting lasting changes within the health system to ensure that the outcomes remain strong as TCI’s support declines and local government capacity grows. Typically, TCI’s direct engagement takes place over a three-year period, where it strengthens local health systems and individual capacity to effectively implement high-impact family planning practices and other interventions (HIPs & HIIs), while also promoting the use of data for problem-solving and informed decision-making. Upon completion of this period, local governments “graduate” from TCI’s direct support, marking a significant step towards achieving self-reliance in sustaining these efforts. Since 2017, TCI has engaged 198 local governments across 13 countries, with 97 of those graduating from TCI’s direct support. It has also contributed to 4.2 million additional family planning clients.

TCI’s latest annual report for 2023 shows promising signals coming from graduated local governments with more than 864,000 additional family planning clients coming from 94 of the 97 cities that have graduated from TCI (TCI excluded three cities in Senegal due health worker strikes there). Overall, 97% of the local governments met targets that TCI set for graduated cities, however this varied across each of TCI’s six hubs. Local governments in East Africa and India graduated more than two years ago, making this sustained performance even more noteworthy.

Embedding Coaches within Health Systems

Coaching and continually engaging with local leaders were cited as essential factors for sustaining family planning and adolescent and youth sexual reproductive health (AYSRH) programs after graduation. City coordination meetings, in which family planning progress and data are regularly discussed, also helps local governments continue to prioritize their commitments and expenditures towards family planning, as well as guiding action plans and decisions. This collaborative approach not only ensures sustainability but also encourages continued investment in family planning initiatives.

TCI-trained master coaches that help strengthen the local health system’s capacity for scaling up family planning and AYSRH HIPs & HIIs become embedded in the system to withstand any leadership changes.  In 2023, more than 5,800 coaches were trained for a total of nearly 11,000 coaches trained by TCI since 2017. Local government coaches continue to play a pivotal role in ensuring financial resources remain a high priority and these funds are not only mobilized from political and technical local leadership but are also spent on family planning and AYSRH activities, maintaining active and supportive partnerships and collaborations with key stakeholders, continuous use of data-for-decision-making and key HII & HIPs are budgeted into annual work and financial plans.

For example, East Africa found that having a stable pool of coaches was instrumental in sustaining quality family planning and AYSRH services. In 2023,  local coaches in graduated cities continued their efforts towards strengthening capacity, as well as continuing performance review meetings with the goal of sharing HIPs & HIIs implementation and reporting updates and peer-to-peer knowledge exchange. Of the 3,655 master coaches in Francophone West Africa, 22% (804 LG coaches) represent coaches from graduated cities that continue to discuss resource mobilization and expenditure with Advocacy Core Group (ACG) members and monitoring and evaluation challenges, as well as sharing best practices and lessons learned implementing key HIIs & HIPs. FWA continues to intensify and scale up their coaching efforts as they’ve seen how critical coaches are to sustaining interventions.

TCI-trained coaches in Nigeria supported states to be self-sufficient to deal with issues as they emerge, even after graduation from TCI. It was noted that high staff turnover, retirement, frequent changes in leadership and weak succession plans were among the challenges experienced in graduated states. TCI-supported states used coaching to improve and sustain staff capacity and transfer capacity as part of succession planning in cases of personnel retirement. Coaching emerged as a pivotal strategy for graduated cities in India, with master coaches continuing to emphasize data-driven decision-making through regular city coordination committee and data review meetings. India’s most significant achievement regarding institutionalization was ensuring its key HIPs & HIIs are adopted into the government’s Program implementation Plan.

In addition to coaching, maintaining funding for family planning and AYSRH programs is another key factor for sustainability. During direct engagement, TCI coaches advocate for local governments to commit – and spend – funds to implement HIPs & HIIs, as well as making sure family planning funds are ring-fenced with specific budget lines. In 2023, 85% of the funding that local governments committed was spent ($11 million out of $15 million). Sylvain Soubeiga, the District’s chief medical officer in Koudougou, Burkina Faso, noted: 

 We are satisfied with the TCI model because, despite TCI’s financial withdrawal, interventions continue, and this is possible because the mayor’s office has taken the lead and understood the need to support the health system. This is a clear sign of ownership by the players involved, reflecting the institutionalization and sustainability of the TCI model.”

At the end of 2023, 85% of graduated cities across all TCI hubs continued to show positive additional family planning clients since graduation, exceeding TCI’s target of 75% by end of 2025.

Overall, TCI is seeing positive signs of continued contraceptive uptake after graduation. With nearly half of TCI’s cities graduated, staying engaged with the local government after it graduates continues to be fundamental for strengthening capacity and sustaining HIPs & HIIs implementation.