The Challenge Initiative

Innovators in global development across sectors have been grappling with how to bring programs to transformative scale with sustainable impact. The Challenge Initiative (TCI), funded by the Bill & Melinda Gates Foundation, is a “business unusual” approach that empowers cities to rapidly and sustainably scale best-practice family planning and adolescent and youth sexual and reproductive health (AYSRH) solutions for the urban poor. Scale, impact, cost-efficiency and sustainability are TCI’s four interlocking tenets as TCI believes scale without impact is empty scale; impact at scale without increasing cost-efficiencies is not viable; and cost-efficient impact at scale that is not sustained will not produce lasting change.

TCI Youth developed an AYSRH toolkit of proven approaches – implemented under URHI as well as from the global literature – designed for the urban context and housed in TCI University. The AYSRH toolkit and other TCI resources support the implementation of AYSRH approaches in those cities that want to include a youth component within their family planning/reproductive health programs.

Local governments in East Africa, Francophone West Africa, India and Nigeria adapt, implement and scale TCI’s youth-focused interventions, drawing on coaching and support from four regional hub partners: Jhpiego, Johns Hopkins Center for Communication Programs (CCP), IntraHealth International, and PSI. TCI is led by the Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health. Over the past four years (2016-2020), TCI has demonstrated proof of scale for its demand-driven model, and is active in 95 cities as of April 2020.

Adolescent & Youth Sexual & Reproductive Health

A GROWING NEED FOR REPRODUCTIVE HEALTH SOLUTIONS FOR YOUNG PEOPLE LIVING IN CITIES As Africa and Asia’s growing youth populations move to cities for better economic, social and educational opportunities, cities have a growing need for adolescent and youth sexual and reproductive health (AYSRH) solutions. The population of adolescents ages 10-19 nearly doubled in the last 25 years in Sub-Saharan Africa – from 127 million in 1994 to 247 million in 2019 – and they are the fastest growing segment of the urban poor, placing them at risk for poor sexual and reproductive outcomes, particularly girls and young women. As the world becomes more urban, and increasingly younger, there is a real need to adapt city structures, institutions and governance to better meet young people’s needs and support their transition into adulthood.

During The Challenge Initiative’s (TCI) early engagement with cities, community and local government leaders voiced a strong interest in helping young people avoid unplanned pregnancies, so that they could stay in school and pursue their goals. Although TCI’s high-impact family planning approaches are designed to reach all women – including young women – TCI responded to cities’ need for more tailored approaches to address AYSRH. With additional funding from the Bill & Melinda Gates Foundation, TCI expanded its portfolio of solutions to include AYSRH approaches for youth ages 15-24 – a program called TCI Youth.

A TCI Technical Brief

Figure 1: TCI Youth is active in 26 cities across four regional hubs.

TCI Youth champions in Migori, Kenya.

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TCI YOUTH: A SYSTEMS-BASED APPROACH TO AYSRH In the first 18 months of TCI Youth’s three-year program, TCI scaled its AYSRH interventions to 26 cities and states across East Africa, Francophone West Africa, India and Nigeria (Figure 1, page 1). The majority of these governments were already implementing TCI’s family planning approaches and valued continued partnership with TCI. The early, promising results of TCI Youth are a testament to how the TCI platform can layer on and scale AYSRH interventions successfully.

A MULTI-PRONGED STRATEGY FOR YOUTH-FRIENDLY CITIES

MAKING DATA ON YOUTH SEXUAL AND REPRODUCTIVE HEALTH VISIBLE

Showing governments how investing in AYSRH can improve outcomes for all women. What is measured, matters. Uganda is currently the only TCI-supported country whose Health Management and Information Systems (HMIS) disaggregates data on contraceptive use by age and method in all cities. TCI has been able to observe early, promising results from its first year of implementation in Uganda (see box, right). The data suggests that governments implementing TCI Youth interventions not only increased uptake among youth ages 15-24, but that they may have a spillover effect, boosting uptake among women above age 25, as well.

Most governments’ HMIS only report on contraceptive uptake for all women ages 15-49 and do not disaggregate data on contraceptive use for youth ages 15-24. This makes it difficult for governments to register the needs of youth as a priority or to adapt interventions to local contexts and monitor their effectiveness. TCI provides financial assistance to local governments to collate data on youth contraceptive use directly from health facility registers,

Mak

ing d

ata on youth sexual and reproductive health visibleAdvocating for youth-friendly cities

Developing engaging messages for youth

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ing provider bias and service quality

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Data visibility: Analyzing and advocating to governments with age disaggregated data on youth sexual and reproductive health.Advocacy: Ensuring separate government budget line-items committed to AYSRH and elevating youth issues at regular multi-sectoral government and community meetings.Demand generation: Developing engaging SRH messages with youth and sharing through edutainment, digital channels, community health workers, and youth movements and associations.Service delivery: Improving the quality of contraceptive care for youth through whole-site orientations and increasing youth-friendly service delivery with unbiased, supportive health providers.

Figure 2: TCI’s strategy for youth-friendly cities.

Uganda Spotlight: AYSRH Interventions May Boost Uptake among All Women

In September 2018, TCI began layering AYSRH approaches in three cities in Uganda that were already implementing TCI high-impact family planning interventions – Buikwe, Iganga and Mukono. Before TCI Youth commenced, HMIS data showed that the percentage changes in contraceptive client volume across three age groups (10-19, 20-24, 25+) were similar between these three cities and the 11 other cities implementing TCI family planning approaches. Since that time, contraceptive client volume across all age groups has increased in all TCI cities. However, in the cities where AYSRH layering took place, the comparable percentage increases in client volume were much higher than in cities only implementing TCI’s family planning approaches. This was true not only for clients aged 10-19 (39% vs. 23%) and 20-24 (40% vs. 13%), but also for clients older than 25 (37% vs. 9%). This suggests that the layering of TCI AYSRH interventions not only increased contraceptive uptake among youth ages 15-24, but that it also had a positive spillover effect, boosting uptake among women above age 25.

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since age-disaggregated data is not reported through HMIS. It then coaches governments on how to use this data to monitor impact and, importantly, advocate with this data to local, state and national government officials to prioritize data collection, funding and programming for youth. In Nigeria, TCI and the Nigerian Urban Reproductive Health Initiative (NURHI) II advocacy efforts contributed to the Federal Ministry of Health deciding to pilot a national HMIS family planning tool for age-disaggregation.

Providing governments with a menu of scalable AYSRH solutions. Historically, AYSRH programs have struggled to bring what works to scale because there is little evidence on how to cost-effectively expand AYSRH interventions to reach larger populations (Nguyen G, 2019). TCI developed an AYSRH toolkit on TCI University of promising and proven approaches designed to increase voluntary contraceptive use among young people living in urban poverty. With financial and technical assistance from TCI, governments adapt these interventions to fit their local context. TCI Youth continually updates the AYSRH toolkit with its learning, providing the global community with the latest insight on what works in scaling AYSRH.

ADVOCATING FOR YOUTH-FRIENDLY CITIESIncreasing government investment and leveraging existing funds for AYSRH. TCI Youth only partners with governments that commit financial resources to addressing teenage pregnancy, and by doing so, catalyzes national, regional and local investments in AYSRH at the start (See box, right). TCI capitalizes on existing national youth policies that have not always been operationalized at the local or state levels, unlocking additional funding for AYSRH. In India, TCI works with city governments to release resources from the National Ministry of Health and Family Welfare’s adolescent health program – Rashtriya Kishor Swasthya Karyakram (RKSK).

Scaling youth engagement through existing systems. TCI supports governments to integrate the participation of young people and youth-focused civil society organizations in regular meetings—such as ministry of health meetings and multisectoral working groups – to ensure a higher profile for youth needs and issues, and to press for further funding of programs.

• In Francophone West Africa, TCI supported Jeunes Leaders Transformationnels (JLT) – or young transformational leaders – are youth ages 15-24 that advocate to government and community leaders about AYSRH issues (see box, upper right).

• In East Africa, TCI supports governments to identify and coach youth champions between ages 15-24, to become community advocates, participate in governance, and partake in demand generation activities (see box, lower right).

• In Nigeria, TCI works with state and local governments to identify and coach a diverse group of young people ages 15-35 as Life Planning for Adolescents and Youth (LPAY) ambassadors. These ambassadors are embedded in regular governance and community structures to elevate youth sexual and reproductive health needs, including in state technical working groups on adolescent health (see box, page 4). They also participate in community outreaches and facilitate intergenerational dialogues.

• In India, TCI plans to engage unmarried youth in its five current cities through government funded, Adolescent Health Days (AHDs) at urban primary healthcare centers.

Institutionalizing multisectoral collaborations on AYSRH. The sexual and reproductive health (SRH) of youth residing in urban environments is shaped by multiple and layered factors. Any

UCOZ Jeunes Leaders TransformationnelsIn UCOZ, Benin, the city’s partnership with TCI Youth sparked youth engagement through its 88 transformational youth leaders (JLT). The President Mayor of UCOZ made the city’s first ever financial commitment to AYSRH, and designated Wednesdays as ‘Youth Fixed Day Services’ – ensuring free access to contraception for youth. One UCOZ government official reported, “Our work focused on awareness raising. Mayors decided that working on this issue is their duty. They took ownership of the matter … decided to allocate funds to the youth project because we believe the youth today are the Benin of tomorrow. … we are planting a seed today to harvest the fruits tomorrow.”

TCI Youth Champion in Kenya Stands Up for Contraceptives

Movinta Akinyi decided to become a TCI Youth champion in Migori County, Kenya after she adopted a contraceptive method from a TCI supported health facility. When a guidance counsellor at her school began telling girls that contraceptives were harmful, she decided to take action. Movinta went to the head teacher at her school to warn her about the guidance counsellor. To her surprise, her head teacher was supportive of contraceptives and decided to work with the Migori County Health Department to sensitize the guidance counsellor and other teachers on contraceptives. “The situation became a blessing. I was given the opportunity to talk to my classmates about the benefits of family planning and encourage them to see a healthcare provider. So far, I have successfully referred 35 classmates to be counselled on their contraceptive options,” said Movinta.

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government attempting to provide SRH services in these complex contexts must build collaborative relationships across sectors. TCI supports health departments and ministries of health to bring together leaders and stakeholders from multiple sectors, government departments and youth organizations to collaborate on AYSRH. In Nigeria, TCI activated State Technical Working Groups on Adolescent and Young People’s Health and Development to ensure coordination and efficiency of all state AYSRH activities (see box, right). In East Africa, TCI Youth catalyzed collaboration between pharmacy associations and government leaders.

DEVELOPING ENGAGING MESSAGES FOR YOUTH AND THEIR INFLUENCERSSegmenting demand generation approaches for the local youth context. Youth living in urban settings have intersecting identities, particularly related to their age, marital status, education attainment, economic status, religion, and parenthood. In all cultures and contexts, these identities impact young people’s SRH behaviors. TCI Youth coaches governments to identify which youth sub-groups are most in need and tailor approaches to most effectively reach them with messages and resources for the greatest impact.

• In India and Niger, TCI Youth is primarily a first-time parent program, aimed at improving contraceptive use among married young women, who have recently given birth. As illustrated in Figure 3, data from India shows the proportion of all IUCD and injectable users that were first-time parents (FTP) or parity 1, was higher in TCI cities layering an FTP focus (41%). compared to TCI cities without the FTP focus (28.9%). In 2020, TCI Youth plans to expand its approaches to reach unmarried youth in India with information about contraceptives.

• In Benin, Kenya, Senegal, Tanzania and Uganda, TCI Youth focuses on unmarried youth, those who have not (yet) had a child. In these contexts, the pregnancy rate among unmarried youth is high, and TCI Youth partnerships aim to support youth in decreasing too-early, unplanned pregnancies that imperil health and derail education and life plans. In Nigeria, TCI Youth and state governments primarily focus on reaching unmarried youth as well, but also recognize the cultural sensitivities to this work in more conservative states.

Connecting youth to accurate information and contraception. TCI Youth cities build the capacity of community health workers (e.g., community health volunteers, Accredited Social Health Activists (ASHAs), community health extension workers) to reach young people with contraceptive information, referrals to health facilities and TCI supported events, and short-term contraceptive methods. TCI supports governments to coach community health workers (CHWs) on how to provide contraceptive counseling to clients based on their age, marital status and parity. In India, ASHAs are coached on how to systematically map eligible first-time parents in their urban catchment area and update their

Nigeria’s Adolescent Technical Working Group

Through TCI advocacy, Plateau State established its first State Technical Working Group on Adolescent and Young People’s Health and Development in December 2019. The technical working group is made up of key stakeholders that meet regularly to ensure the coordination and efficient use of limited resources for adolescent and youth sexual and reproductive health programming, monitor whether or not planned activities are being implemented, and share results with government leadership to advocate for more resources. Following its inauguration, the technical working group developed a 12-month implementation plan to accelerate progress of young people’s health and development in the state.

Young people in Nigeria displaying referral cards.

TCI Youth Cities* TCI Classic Cities**

* Five TCI cities implementing FTP focus ** TCI cities without an FTP focus

Figure 3: Proportion of IUCD and injectable users by parity in TCI Youth cities and TCI ‘Classic’ cities (Jan 2019-Jun 2019)

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Reaching Mothers-in-Law in IndiaLaxmi works as an Accredited Social Health Activist (ASHA) in Firozabad where she organizes community meetings. During one such meeting she met Pooja, a young mother with an infant. Pooja and her husband did not want to have another child for another three years. After the group meeting, Laxmi visited Pooja’s home where she sensed that all decisions in the household were made by her mother-in-law – Pooran Devi. Pooran Devi was against the use of contraceptive methods. Laxmi realized if Pooja was ever going to choose a family planning method, Pooran Devi must be involved. Laxmi ultimately persuaded Pooran Devi to let her daughter-in-law use contraceptives by saying: “You hold such an important position in the family and it is your decisions that have helped your children make wise choices. Family planning is important for the health of your daughter-in-law and your grandchildren, as well as for the financial situation of your family. The best thing you can do is to make the right decision for your son’s family.”

Urban Health Index Registers (UHIR) accordingly. ASHAs then focus their household visits on reaching these first-time parents, counseling them with tailored messages that take into account the constraints they face in making their own contraceptive decisions.

Shifting the mindset of young people’s influencers. An important component of TCI Youth’s advocacy and demand generation work is to engage the audiences that influence – or in some cases, control – young people’s access to contraceptives (see box, below). Such influencers include religious leaders, parents, teachers and male partners. In Nigeria and East Africa, TCI Youth coaches work with local government stakeholders, youth leaders and civil society organizations to host intergenerational and community dialogues for religious and community leaders to discuss AYSRH issues with young people. Government staff and young people help moderate the sessions and hold them leading up to an AYSRH service day in a nearby health facility.

ADDRESSING PROVIDER BIAS AND SERVICE QUALITYAddressing provider bias in a sustainable way. While urban youth typically live closer to health facilities, this does not always translate to access. They may be limited by lack of knowledge, misinformation, cost of services and fear of facing discrimination from health providers. Provider bias against allowing unmarried youth to access contraceptives manifests in many shapes and forms at facilities – from refusing to provide contraceptives to unmarried women, to only informing young women about short-term methods (Beyond Bias, 2017). In many cases, health providers may believe they are helping young people by discouraging their use of contraceptives.

A core component of TCI’s strategy to scale high-impact AYSRH solutions is to support governments in addressing provider bias towards youth contraceptive use, and to do this in a sustainable way. TCI supports ministries of health to conduct technical and values-clarification exercises with health providers, equipping them with the knowledge and tools to provide non-judgmental, supportive care to young people. TCI Youth health facilities hold AYSRH whole-site orientation (WSO) sessions, in which all health facility staff are sensitized to young people’s needs–not just doctors or nurses, but also administrative and security staff. TCI also supports governments to improve the quality of youth-friendly health services through the use of national checklists during routine supervisory visits.

Adapting TCI proven approaches for AYSRH. TCI Youth cities adapt TCI’s high-impact family planning interventions for AYSRH. In East Africa, TCI Youth cities hold youth-focused integrated outreaches (community events) and in-reaches (at facility events) to increase their access to contraceptives. FDS for first-time parents in Allahabad, India

In Francophone West Africa, due to the recognized financial barriers to young people accessing contraceptives, TCI Youth governments support free family planning days for youth, at which young people can access contraceptives for free. In India, ASHAs in TCI Youth cities refer all first-time parents in their catchment areas to monthly Fixed Day Services (FDS) at their urban primary healthcare centers. In addition to holding AYSRH whole-site orientations, the Nigeria team conducts social mobilization events to reach youth with referrals to youth-friendly health facilities.

WHAT’S NEXT FOR TCI YOUTH?In its first two years, TCI Youth scaled rapidly to new locations and focused its efforts on supporting governments to strengthen the quality of service delivery and reduce provider bias. Where data is readily available, the early results are promising and demonstrate that health systems are eager to become youth-friendly. TCI is in the process of triangulating data from HMIS, project records and surveys to sharpen its approaches and improve government data for decision-making. TCI Youth will share its early learning between countries, cities, health facilities, and also health providers. TCI Youth will continue to regularly update its AYSRH toolkit with the latest learning from implementation, and make this available for use by others seeking to scale access to contraception through local governments.

In 2020, TCI is continuing to layer AYSRH interventions in cities where it is currently supporting family planning programs, including in ten more cities in Uttar Pradesh, India and two cities in Francophone West Africa – Niamey, Niger and Ouagadougou, Burkina Faso. In the five cities in India already implementing TCI’s first-time parent approaches, TCI has started to layer an intentional focus on unmarried youth, unlocking additional funding from the National Ministry of Health and Family Welfare’s adolescent health program (RKSK). In all locations, TCI Youth plans to sharpen its youth engagement work and to partner to institutionalize youth participation in government and community systems. The early data from Uganda shows that AYSRH interventions may, in fact, increase contraceptive use for all women. TCI Youth plans to explore this hypothesis in 2020 and beyond, and to use this finding to show governments the value of investing in youth.

Working with youth in Francophone West Africa.