Four Lessons from the “Middle Space”

A former Pathfinder technical director, now CEO of Nigerian NGO the MidSpace, answers the question, “How can we help governments successfully own and scale-up family planning best practices?”

Recently, I was invited to speak at a special meeting of global health professionals. All participants, regardless of country of origin or organization, shared a deep concern about the uneven progress of reproductive health across the globe and a profound commitment to increasing the knowledge and use of approaches for systematic scale-up to ensure services reach everyone who needs them.

They believed—as I believe—sustainable scale-up is a key mechanism for benefitting more people long-term and achieving the Sustainable Development Goal of ensuring universal access to sexual and reproductive health services, including family planning, by 2030.

It felt great to be part of this meeting of the “Global Community of Practice on Systematic Approaches for Scale-Up of Family Planning/Reproductive Health Best Practices,” led by E2A and its partner ExpandNet. Those of us who work on scale-up are a unique sort, and we are fully dedicated to sharing what we learn—to advance the science and practice of scale-up.

We know that we can only achieve our ambitious global family planning goals if we share our successes and challenges with scale-up as widely as possible. With that in mind, here are a few takeaways from my years working in the field that I shared with the group, which I believe are essential for the next generation of high-impact family planning programs:

1. When it comes to effective scale-up, ensuring government ownership and leadership is the single most important factor in sustainable delivery of public health services.

Without strong leadership and robust linkages between the various levels of government, family planning and reproductive health service delivery efforts become hampered by deep-rooted system-wide problems (e.g., commodities or human resources)—which makes even the basic services irregular and unsustainable. This is worsened by inadequately planned donor-supported activities, which frequently institute detrimental parallel systems.

This is why I founded my local organization, MidSpace, which refers to the middle space where we work. We collaborate with the Nigerian government to find ways to mobilize private and NGO-sector resources to meet public sector needs in ways that ensure government responsibility and ownership.

Our sole mission is to strengthen public health service delivery by institutionalizing successful practices using a scale-up mindset.

2. Donor-funded programs should work in tandem with government, not try to replace government.

When donors intervene with short-term, cost-intensive solutions, they can saddle governments with new problems after they leave, such as inadequate public resources to continue services. A balanced relationship among the private/NGO sector and the public-sector is vital in creating an environment that not only encourages government leadership, but strengthens governmental capacity for critical analysis and decision-making. Before implementing a program, governments and donors need to think through the following types of questions together:  What happens when the funding dries up? How can the country continue to provide services without external support? How can they plan for sustainable adaptation?

3. Before an implementer attempts any kind of scale-up, government capacity must be taken into account.

Scale-up relies on a functional system that has the capacity to reach everyone in need of services. If a country government simply does not have the bandwidth to sustain a program or initiative without donor support, scale-up becomes impossible. This is why it is so important for MidSpace and projects like E2A to work to simplify tools and processes to lighten the burden on government officials. To lead effective scale-up, the scale-up plan itself must be realistic and achievable—and this can only be accomplished through beginning with the end in mind.

4. Donor-funded technical assistance, without adequate transfer of skills, is not only unsustainable, but actively harmful—once donors pull out, governments can often be left worse off than before.

While inadequate technical capacity to implement policies and programs is a major issue in public health service delivery, public officials’ capacity to adapt to the changing needs of the system also poses a challenge. Too often, a donor-funded implementer’s technical assistance becomes technical replacement—a lack of adequate skills transfer complicates government ownership by diminishing confidence and authority to adopt and adapt interventions to the wider system.

Support in the wrong areas can be counter-productive and lead to the unnecessary depletion of government resources. Transparency around government and donor expectations can make or break a scale-up effort.




Facilitators and Barriers to Systematically Scaling-up Family Planning Task-Shifting and Task-Sharing of Contraceptive Implants in Cross River State, Nigeria