Scaling Up a Strengthened YouthFriendly Service Delivery Model to Include LongActing Reversible Contraceptives in Ethiopia: A Mixed Methods Retrospective Assessment

Background Donor funded projects are small scale and time limited, with gains that soon dissipate when donor funds end. This paper presents findings that sought to understand successes, challenges and barriers that influence the scaling up and sustainability of a tested, strengthened youthfriendly service (YFS) delivery model providing an expanded contraceptive method choice in one location – the YFS unit – with additional units in Amhara and Tigray, Ethiopia.   Methods This retrospective mixed methods study included interviews with key informants (KIs) (qualitative arm) and analysis of family planning (FP) uptake statistics extracted from the sampled health facilities (quantitative arm). A multistage convenience purposive sampling technique was adopted to randomly select 8 health facilities aligned with respective woredas, zones and regional health bureaus (RHBs). A semistructured interview guide soliciting information on 6 scalingup elements (stakeholder engagement, roles and responsibility, policy environment, financial resources, quality of voluntary FP services and data availability and use) guided the interviews. Fiftysix KI interviews were conducted with policymakers, program managers, and clinic staff. Recurring themes were triangulated across administrative levels and implementing partners. Relevant FP data (acceptor status, age and method uptake) were extracted from the 8 sampled health facilities for a thirteenmonth period. Qualitative findings triangulated with FP service statistics assessed the influence of the 6 scalingup elements with trends in longacting reversible contraceptive (LARC) uptake before and after training.   Results Our findings depict that respondents were knowledgeable and supportive of an expanded method mix. Statistically significant increases in longacting contraceptive uptake were noted at 2 of the 8 health centers. Fidelity to the tested model was operationally constrained; respondents frequently mentioned trained staff absences and turnover as obstacles in offering quality FP services.   Conclusion Despite conducive policy environment, supportive stakeholders, favorable environment, and financial support for trainings, statistically significant increases in LARC uptake occurred at only 2 of the 8 health centers; indicating the influence of weak health systems, poor quality of voluntary FP services and a ceiling effect. Scaleup processes must consider potential bottlenecks of weak health systems and availability of financial resources by addressing these as crucial elements in any systematic scaleup framework.