Government Ownership and Adaptation in Scale-Up: Experiences from Community-Based Family Planning Programme in the Democratic Republic of the Congo.

A systematic approach to scale-up was applied to expand an integrated package of family planning and primary healthcare services from the Democratic Republic of the Congo's South Kivu province to health zones in Lomami, Lualaba, and Kasai Central provinces. This approach was based on recommendations from the ExpandNet/WHO guide Beginning with the end in mind. The approach emphasized application of three recommendations: engaging government stakeholders, ensuring the relevance of the intervention, and tailoring the innovation to the setting. This approach led to successful scale-up of community-based family planning, increasing access to and uptake of contraception and demonstrating potential for sustainability; 231,566 new acceptors were recruited and 149,826 couple-years of protection were generated. The systematic scale-up approach led to integration of community-based family planning indicators in the national health information system and transferred ownership of the interventions to the government, creating and strengthening government platforms with potential to sustain the interventions.

Beginning with sustainable scale up in mind: initial results from a population, health and environment project in East Africa.

Small-scale pilot projects have demonstrated that integrated population, health and environment approaches can address the needs and rights of vulnerable communities. However, these and other types of health and development projects have rarely gone on to influence larger policy and programme development. ExpandNet, a network of health professionals working on scaling up, argues this is because projects are often not designed with future sustainability and scaling up in mind. Developing and implementing sustainable interventions that can be applied on a larger scale requires a different mindset and new approaches to small-scale/pilot testing. This paper shows how this new approach is being applied and the initial lessons from its use in the Health of People and Environment in the Lake Victoria Basin Project currently underway in Uganda and Kenya. Specific lessons that are emerging are: 1) ongoing, meaningful stakeholder engagement has significantly shaped the design and implementation, 2) multi-sectoral projects are complex and striving for simplicity in the interventins is challenging, and 3) projects that address a sharply felt need experience substantial pressure for scale up, even before their effectiveness is established. Implicit in this paper is the recommendation that other projects would also benefit from applying a scale-up perspective from the outset.

The scale-up and integration of contraceptive service delivery into nursing school training in the Democratic Republic of the Congo.

In Kinshasa, Democratic Republic of the Congo (DRC), modern contraceptive prevalence is low by international standards: 29.6% as of 2020. A 2015 pilot study demonstrated the feasibility and acceptability of using medical and nursing students to administer DMPA-SC (the subcutaneous injection) among other methods at the community level. The more far-reaching discovery was the potential of clinically trained students to increase access to low-cost contraception in the short-run, while improving the quality of service delivery for future generations of healthcare providers. Scale-up involved integrating the family planning curriculum into the training of nursing students, including classroom instruction in contraceptive technology and service delivery, coupled with a year-long field practicum in which students offered a range of contraceptive methods during intermittent outreach events, door-to-door distribution or sales from their homes. Starting in 2015, a multi-agency team consisting of an international non-governmental organizations (NGO), several Ministry of Health directorates and a local NGO used the ExpandNet/WHO framework to guide this scale-up. This article details the nine steps in the scale-up process. It presents results on increases in contraceptive uptake, feedback from participating nursing school personnel and the employment experience of the graduates from this programme. Between 2015 and 2019, the family planning curriculum was incorporated into 30.8% of the 477 nursing schools in 7 of the 26 provinces in the DRC. Students delivered 461 769 couple-years of protection (the key output indicator for family planning programmes). Nursing school personnel were strongly favourable to the approach, although they needed continued support to adequately implement a set of additional interventions related to the service delivery components of the new training approach. Post-graduation, only 40.1% of graduates had paid employment (reflecting the staggering unemployment in the DRC); among those, over 90% used their family planning training in their work. We describe the multiple challenges faced during the scale-up process and in planning for expansion to additional schools.

Strengthening Government Leadership in Family Planning Programming in Senegal: From Proof of Concept to Proof of Implementation in 2 Districts.

Given Senegal's limited resources, the country receives substantial support from externally funded partner organizations to provide family planning and maternal and child health services. These organizations often take a strong and sometimes independent role in implementing interventions with their own structures and personnel, thereby bypassing the government district health system. This article presents findings from the Initiative Sénégalaise de Santé Urbaine (ISSU) (Senegal Urban Health Initiative) that assessed in 2 districts, Diamniadio and Rufisque, the extent to which it was feasible to create stronger government ownership and leadership in implementing a simplified package of family planning interventions from among those previously tested in other districts. The simplified package consisted of both supply- and demand-side interventions, introduced in October 2014 and concluding at the end of 2015. The interventions included ensuring adequate human resources and contraceptive supplies, contraceptive technology updates for providers, special free family planning service days to bring services closer to where people live, family planning integration into other routine services, household visits for family planning education, religious sermons to clarify Islam's position on family planning, and radio broadcasts. District leadership in Diamniadio and Rufisque were actively involved in guiding and implementing interventions, and they also contributed some of their own resources to the project. However, reliance on external funding continued because district budgets were extremely limited. Monitoring data on the number of contraceptive methods provided by district facilities supported by a sister project, the Informed Push Model project, indicate overall improvement in contraceptive provision during the intervention period. In Diamniadio, contraceptive provision increased by 43% between the 6-month period prior to the ISSU interventions (November 2013 through April 2014) and a 6-month intervention period (November 2014 through April 2015), from about 8,000 units to nearly 12,000 units. In Rufisque, contraceptive provision increased by 30%, from more than 17,000 units to more than 22,000 units. Couple-years of protection provided in Diamniadio increased by 82% and in Rufisque by 56%. The experience in these 2 districts in Senegal suggests that it is feasible for districts to play a leadership role in implementing family planning services and mobilizing some of their own resources and that international projects can facilitate capacity building and sustainability within public-sector systems.