Defining Collective Priorities: Research and Learning Agendas for Family Planning Across 6 Countries.

Evidence should be the foundation for a well-designed family planning (FP) program, but existing evidence is rarely aligned with and/or synthesized to speak directly to FP programmatic needs. Based on our experience cocreating FP research and learning agendas (FP RLAs) in Côte d'Ivoire, Malawi, Mozambique, Nepal, Niger, and Uganda, we argue that FP RLAs can drive the production of coordinated research that aligns with national priorities.To cocreate FP RLAs, stakeholders across 6 countries conducted desk reviews of 349 documents and 106 key informant interviews, organized consultation meetings in each country to prioritize evidence gaps and generate research and learning questions, and, ultimately, formed 6 FP RLAs comprising 190 unique questions. We outline the process for consensus-driven development of FP RLAs and communicate the results of an analysis of the questions in each FP RLA across 4 technical areas: self-care, equity, high impact practices, and youth. Each question was categorized as a learning versus research question, the former indicating an opportunity to synthesize existing evidence and the latter to conduct new research to answer the question. Themes emerging from the data shed light on shared evidence gaps across the 6 countries. We argue that similarities and differences in the questions in each FP RLA reflect the unique implementation experience and context, as well as each country's placement on the FP S-curve. Early uses of the FP RLAs include informing the development of FP costed implementation plans and FP2030 commitments. FP RLAs have also been discussed in multiple thematic working groups. For FP stakeholders, these FP RLAs represent a consensus-based agenda that can guide the generation and synthesis of evidence to answer each country's most pressing questions, ultimately driving progress toward increasingly evidence-based programming and policy.

A research utilisation framework for informing global health and development policies and programmes.

A shift in the culture and practice of health and development research is required to maximise the real-world use of evidence by non-academic or non-research-oriented audiences. Many frameworks have been developed to guide and measure the research utilisation process, yet none have been widely applied. Some frameworks are simplified to an unrealistic linear representation while others are rendered overly complex and unusable in an attempt to capture all aspects of the research utilisation process. Additionally, many research utilisation frameworks have focused on the policy development process or within a clinical setting, with less application of the translation process at the programme level. In response to this gap - and drawing from over a decade of experience implementing research utilisation strategies - we developed a simple, four-phase framework to guide global health and development efforts that seek to apply evidence to policies and programmes. We present a detailed description of each phase in our framework, with examples of its relevance and application illustrated through our own case study experiences in global health. We believe the utility of this framework extends beyond the health sector and is relevant for maximising use of evidence to achieve the Sustainable Development Goals.

Evidence-based adaptation and scale-up of a mobile phone health information service.

BACKGROUND: The research base recommending the use of mobile phone interventions for health improvement is growing at a rapid pace. The use of mobile phones to deliver health behavior change and maintenance interventions in particular is gaining a robust evidence base across geographies, populations, and health topics. However, research on best practices for successfully scaling mHealth interventions is not keeping pace, despite the availability of frameworks for adapting and scaling health programs. METHODS: m4RH-Mobile for Reproductive Health-is an SMS, or text message-based, health information service that began in two countries and over a period of 7 years has been adapted and scaled to new population groups and new countries. Success can be attributed to following key principles for scaling up health programs, including continuous stakeholder engagement; ongoing monitoring, evaluation, and research including extensive content and usability testing with the target audience; strategic dissemination of results; and use of marketing and sustainability principles for social initiatives. This article investigates how these factors contributed to vertical, horizontal, and global scale-up of the m4RH program. RESULTS: Vertical scale of m4RH is demonstrated in Tanzania, where the early engagement of stakeholders including the Ministry of Health catalyzed expansion of m4RH content and national-level program reach. Ongoing data collection has provided real-time data for decision-making, information about the user base, and peer-reviewed publications, yielding government endorsement and partner hand-off for sustainability of the m4RH platform. Horizontal scale-up and adaptation of m4RH has occurred through expansion to new populations in Rwanda, Uganda, and Tanzania, where best practices for design and implementation of mHealth programs were followed to ensure the platform meets the needs of target populations. m4RH also has been modified and packaged for global scale-up through licensing and toolkit development, research into new business/distribution models, and serving as the foundation for derivative NGO and quasi-governmental mHealth platforms. CONCLUSIONS: The m4RH platform provides an excellent case study of how to apply best practices to successfully scale up mobile phone interventions for health improvement. Applying principles of scale can inform the successful scale-up, sustainability, and potential impact of mHealth programs across health topics and settings.

Sustainable Cost Models for mHealth at Scale: Modeling Program Data from m4RH Tanzania.

BACKGROUND: There is increasing evidence that mobile phone health interventions ("mHealth") can improve health behaviors and outcomes and are critically important in low-resource, low-access settings. However, the majority of mHealth programs in developing countries fail to reach scale. One reason may be the challenge of developing financially sustainable programs. The goal of this paper is to explore strategies for mHealth program sustainability and develop cost-recovery models for program implementers using 2014 operational program data from Mobile for Reproductive Health (m4RH), a national text-message (SMS) based health communication service in Tanzania. METHODS: We delineated 2014 m4RH program costs and considered three strategies for cost-recovery for the m4RH program: user pay-for-service, SMS cost reduction, and strategic partnerships. These inputs were used to develop four different cost-recovery scenarios. The four scenarios leveraged strategic partnerships to reduce per-SMS program costs and create per-SMS program revenue and varied the structure for user financial contribution. Finally, we conducted break-even and uncertainty analyses to evaluate the costs and revenues of these models at the 2014 user volume (125,320) and at any possible break-even volume. RESULTS: In three of four scenarios, costs exceeded revenue by $94,596, $34,443, and $84,571 at the 2014 user volume. However, these costs represented large reductions (54%, 83%, and 58%, respectively) from the 2014 program cost of $203,475. Scenario four, in which the lowest per-SMS rate ($0.01 per SMS) was negotiated and users paid for all m4RH SMS sent or received, achieved a $5,660 profit at the 2014 user volume. A Monte Carlo uncertainty analysis demonstrated that break-even points were driven by user volume rather than variations in program costs. CONCLUSIONS: These results reveal that breaking even was only probable when all SMS costs were transferred to users and the lowest per-SMS cost was negotiated with telecom partners. While this strategy was sustainable for the implementer, a central concern is that health information may not reach those who are too poor to pay, limiting the program's reach and impact. Incorporating strategies presented here may make mHealth programs more appealing to funders and investors but need further consideration to balance sustainability, scale, and impact.

Who chooses vasectomy in Rwanda? Survey data from couples who chose vasectomy, 2010-2012.

BACKGROUND: Vasectomy is safe and highly effective; however, it remains an underused method of family planning (FP) in Africa. In view of this, three Rwandan physicians were trained in no-scalpel vasectomy with thermal cautery and fascial interposition on the prostatic end as vasectomy trainers in 2010, and this initiative has resulted in over 2900 vasectomy clients from February 2010 to December 2012. STUDY DESIGN: This cross-sectional descriptive study describes vasectomy clients (n=316) and their wives (n=300) from 15 randomly selected hospitals in Rwanda. RESULTS: The vasectomy clients were mainly over age 40, had young children (age <3) and were married and cohabiting. Limited financial resources, satisfaction with existing family size and avoiding side effects from hormonal methods (wives') were key motivators for vasectomy uptake. High rates of previous FP use and high degree of interspousal communication are known correlates of higher FP use. CONCLUSIONS: Future and current Rwandan FP programs and other interested parties will benefit from understanding which couples elect vasectomy, their motivations for doing so and their service utilization experiences. Better integration of vasectomy counseling and postvasectomy procedures will benefit the program. IMPLICATIONS: Until this project, vasectomy projects in sub-Saharan Africa were viewed as unrealistic. This study confirms factors influencing vasectomy uptake identified in earlier research, but does so within a robust sample of vasectomy users and their wives and provides a strong understanding of who likely vasectomy users are in this context. Promotion of vasectomy services should be considered as an essential element of a healthy contraceptive method mix.

Evaluating feasibility, reach and potential impact of a text message family planning information service in Tanzania.

BACKGROUND: The objective of this research was to evaluate the feasibility, reach and potential behavioral impact of providing automated family planning information via mobile phones to the general public in Tanzania. STUDY DESIGN: Data from users of the Mobile for Reproductive Health (m4RH) program were collected during the 10-month pilot period. First, contraceptive methods queried by each user were electronically logged by the mobile phone system. Second, four text questions assessing gender, age, promotion point and potential family planning impact were sent to every user. RESULTS: During the pilot period, 2870 unique users accessed m4RH in Tanzania, resulting in 4813 queries about specific contraceptive methods. Among those responding to text questions, 56% were female and approximately 60% were 29 or younger years in age. A variety of changes in family planning use were mentioned after using m4RH, with reported changes consistent with where users are in their reproductive life cycle. CONCLUSIONS: Reaching younger people, women and men of reproductive age with family planning information delivered via mobile phone is recommended.