How was the TA Mechanism developed?

The review that we began our work with identified only a handful of assessments of TA directed to improving the SRHR of adolescents and young people, although it also identified a number of assessments/evaluations of TA provided on other topics in response to the needs of other population groups. The meetings with the key informants provided an overview of existing mechanisms that governments (including, but not limited to ministries of health), and technical and funding support agencies use to request and provide TA, and an opportunity to synthesize some lessons learned. Put together, these helped identify a number of factors that needed to be taken into consideration during the development of the TA Mechanism and the drafting of the Standard Operating Procedures (SOP).

First, that there are a range of reasons for TA to be requested, or offered, for example to fill staffing gaps, to provide technical inputs on various issues and to strengthen capacity. It may be required for short-term specific programme needs or over the longer-term life of a project/programme.

Secondly, there are different formats and processes through which TA can be provided, all of which have advantages and disadvantages depending on the expectations of the TA and the resources available to carry it out. These include setting up communities of practice to share experiences, expertise, and programme support tools; organizing webinars that provide technical updates and opportunities for questions and answers; facilitating visits by one or more selected staff to other countries where the technical or programmatic issues of concern have been effectively responded to; organizing for individuals from the requesting country to take part in relevant training programmes; or having individuals or teams from within the country requesting the TA, or from outside, provide support, either on a “fly-in fly-out” basis or in ways that provide longer-term support.

Thirdly, there are a number of factors related to the individuals and/or organizations that are responsible for the TA that need to be considered. For example, TA providers are likely to be influenced by their past approaches to providing TA, and by the mandates, structures, priorities and governance of the organizations that they work for (i.e. what they can and cannot do, what they are interested in, how they are able to provide the TA). In addition, the inputs from the global, regional and national levels of organizations need to be considered, in terms of both the selection of the person who will carry out the TA and also processes for reviewing the products of the TA, which may be beneficial, but may also be a source of delays and disagreements.

The review also pointed out that there are a number of other common challenges facing people and organizations providing TA. For example, the Terms of Reference (TOR): are they clear and do they really reflect what it is that the country wants; is there a good match between what the country needs and the expertise and priorities of the organization providing the TA; are there opportunities for the TA provider to work with the country requesting the TA to refine the TOR; and is it likely that there will be a sufficient “dose” of TA to have the desired effects?

Another example of the challenges that those providing TA face is the outputs of the TA: the importance of developing consensus across different providers of TA on the evidence-base for action and the implications of this for programme priorities; and the need to have agreement about what is really useful and likely to be used in relation to any recommendations that might be made. Consideration also needs to be given to the systems that are adopted for monitoring milestones and the quality of the TA that is provided, and for making the links between different but related aspects of the TA, both technical (e.g., HIV and SRH) and programmatic (e.g., focusing on specific outcomes and dealing with the need to strengthen health systems more generally).

These findings were used to draft an SOP for the TA Mechanism setting out the guiding principles, the overall approach and the detailed working methods. This document was tabled and discussed in the co-creation meeting, and led to the development of an agreed modus operandi for moving ahead.

What did the TA Mechanism achieve?

The TA Mechanism was initiated with the following aims:

To provide TA to ministries of health that will help them achieve the goals/commitments that they have defined to improve AYSRHR (with a particular focus on contraceptive uptake);

To provide the TA in ways that are timely, effective, efficient, innovative and contribute to capacity development;

To contribute to overall thinking and lessons learnt about the provision of TA.

A number of principles were identified to guide the TA Mechanism, based on the preparatory activities that were carried out, which were incorporated into the SOP:

What issues would the TA Mechanism address?

Increasing contraception uptake should be a central component of any request, in order for the TA Mechanism to limit the types of requests that it would respond to (i.e., to manage demand and to ensure quality responses). However, the TA Mechanism would also strive to find a balance between the attention that is given to contraceptive uptake and wider AYSRHR problems, to AYSRHR and adolescent and youth health more generally, and to AYSRHR outcomes and their underlying determinants.

Who would provide TA?

Responses to TA requests would be provided through experts working with the TA Mechanism's Partner Organizations, or when such support was unavailable, through national or international consultants - with the support and facilitation of the TA Mechanism Secretariat.

How would the Partner organizations be chosen?

Partner organizations would be selected based on the following criteria: a strong track record of working in the field of ASRHR in LMICs; experience in providing technical support and collaborating with a variety of stakeholders, especially governments, other non-governmental organizations, and youth-led organizations; an interest to be involved with the TA Mechanism, and staff with the experience and flexibility to provide TA as required. At the same time, efforts would be made to ensure that the organizations selected covered a range of expertise and had diverse country-level representation.

How would countries be informed about the TA Mechanism?

Countries would be informed through WHO’s regional offices, through UN partners, notably UNFPA, through funding agencies such as BMGF and USAID, and mechanisms such as FP2030 and the GFF.

How would countries decide what TA to request?

The countries would be self-selected - there would be no pressure on the TA Mechanism to include specific countries. The development of the requests would be led by ministries of health and involve relevant in-country stakeholders (e.g., UN organizations, civil society organizations (CSOs) and young people). The requests would be submitted to the TA Mechanism by ministries of health at national or subnational levels (i.e., the requests would be fully country-led with government buy-in and leadership).

What role would the TA Mechanism Secretariat play?

The T Mechanism Secretariat would play an “honest broker” role in terms of helping to define and clarify the TA requests, as needed; to provide a sounding board for the responses as these are developed; and to play a key role in terms of quality assurance.

The SOP [6] has guided the process of making and responding to requests for TA (see Fig. 1). This process has been added to and modified during the Mechanism’s three years of operation, based on the collective experiences gained through learning-by-doing. In addition, a number of activities were initiated by the TA Mechanism Secretariat in order to manage the process, facilitate collaboration, improve communication and maintain quality assurance. These included monthly meetings with the Partner Organizations; regular meetings with Partner Organizations and WHO Country Offices (WCOs) in countries where TA was being provided; regular meetings with the funders (BMGF), key partners such as FP2030, and WHO colleagues responsible for the overall Accelerator project; and updates for ministries of health about progress and challenges, and their inclusion in the TA plans and budgets.

Fig. 1

Brief overview of the life-course of a TA request and response, and links to the standard operations procedures (SOP)

As of the end of 2022 the TA Mechanism was at various stages of TA provision in 11 countries (Afghanistan, Cameroon, India, Kenya, Liberia, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Uganda), with expressions of interest from an additional 4 countries (Democratic Republic of the Congo (DRC), Pakistan, Tanzania, Zambia). It had rejected requests from only two countries, as these turned out to be more requests for funding than for technical assistance (Colombia and South Africa). Table 1 provides an overview of the range of these TA requests and the responses that are currently being developed and implemented.

Table 1 TA Mechanism support for countries, completed and in progress (end-2022)

In terms of the requests, while they all include a focus on AYSRHR, there was variation in terms of a number of key variables.

The overall focus: The majority of the requests focused on analyzing the current situation with a view to developing and strengthening subsequent activities to increase contraception uptake, to improve AYSRHR and to positively impact adolescent health more generally, using AYSRHR as an entry point. Most of the requests therefore initially involved carrying out situation assessments, including desk reviews and landscape analyses, in order to provide a basis for the subsequent development of strategies and operational plans. Three of the TA requests included the development of specific products: the request from the Ministry of Health and Sanitation (MOHS) in Sierra Leone, to develop national guidance on pregnant adolescents and first-time adolescent mothers; the request from the MOH Liberia, to develop training materials and innovative approaches to training service providers to strengthen their capacity to meet the health needs of adolescents and youth, including ASRH; and the request from India, for TA to support the development of a digital e-learning course for adolescent health service providers in the state of Himachal Pradesh, based on the nationally endorsed training materials for Rashtriya Kishor Swasthya Karyakram (RKSK), the national adolescent health programme.

The target group: Most of the requests for TA have targeted the general population of adolescents and youth. However, the requests from Sierra Leone and Senegal specifically focused on pregnant adolescents and first-time/married adolescent mothers, and the request from Cameroon focused on young people in tertiary education settings.

In terms of the responses to these requests, again there were a number of common elements, in line with the principles outlined in the SOP.

A partnered response: The majority of the requests have involved TA from more than one Partner Organization, something that was proposed by the participants of the initial TA Mechanism co-creation planning meeting. While this has required additional time and effort to plan and coordinate the responses, and is likely to have increased the costs of the TA provided, it has proven to be a positive element of the TA Mechanism, strengthening both the quality of the responses and the collaboration between the Partner Organizations who form the core of the TA Mechanism.

In-country presence: The TA Mechanism always aimed to avoid fly-in fly-out responses to providing TA, and to maximize the contextual relevance, minimize the costs and improve the time efficiency of responses by engaging, when possible, with local partners. This was greatly assisted by the COVID-19 pandemic, which significantly limited travel over the Mechanism’s first two years of operation. It has therefore been essential to have had at least one Partner Organization that has a presence in the country requesting the TA - something that has been important for a range of reasons, from understanding the context to using existing networks to facilitate communication.

A phased approach: In general, the TA that has been provided has been planned in phases. This has been partly related to practical considerations, such as the need to keep the budgets within the limits set by WHO for individual contracts. However, there have also been technical reasons for this phased approach: it has been useful for ensuring that there is a logical progression in what is done, to provide an opportunity to review the appropriateness of the subsequent phases included in the initial plan and to make it possible for other Partner Organizations to be involved in subsequent phases if the skills that they have are more appropriate to the tasks at hand. It has also made it possible to have short-term achievements within the longer-term on-going TA. There are currently four countries initiating or undertaking phase 1 activities (Cameroon, Mali, Liberia and Uganda) and 6 countries planning or providing phase 2 TA (Afghanistan, India, Kenya, Nigeria, Senegal and Sierra Leone). With the exception of Malawi, all countries that completed phase 1 have subsequently moved to phase 2.

An impact model: An impact model was developed that could be adapted for each individual TA request, in order to focus the activities of the TA Mechanism and clarify the expectations for TA responses. By outlining what the TA Mechanism would and would not aim to achieve, and what it could and could not be responsible for doing, the impact model helped to clarify accountability and attribution. In doing so, it also sought to be explicit about those aspects of programme development and implementation for which ministries of health and other partners would be primarily responsible. For these components the TA Mechanism would only be responsible for advocacy and monitoring in relation to the overall intended impact of the technical assistance provided. Table 2 provides an example of the use of the Impact Model for Sierra Leone.

Table 2 The impact model – example from Sierra Leone

An Opportunities Framework: During the course of the three years, a number of tools were developed by the TA Mechanism Secretariat and the Partner Organizations to support the provision of TA. One of these, developed during Phase 1 of the TA response in Afghanistan, was a framework that aimed to synthesize recommendations more strategically - to move beyond the common problem of long lists of recommendations, that can be overwhelming for already overstretched people in-country, to propose activities that build on and strengthen existing programmes and interventions in a structured way (see Fig. 2). This framework will be tested during responses to future TA requests.

Fig. 2

An opportunities framework for TA recommendations – example from Afghanistan

What worked well and what did not, and what are the implications of this for future action?

There have been a number of positive factors that facilitated and strengthened the technical support that has been provided during the first three years of the TA Mechanism, that have helped to ensure that it was timely, effective, efficient and contributed to strengthening capacity, as intended.

In particular, the way that different stakeholders mentioned below have worked together through the collaborative approaches that had been developed, both in the form of multi-person/multi-organizational teams, and also through efforts to build on existing in-country collaborations: ministries of health (in defining the TA requests), Partner Organizations (in working together to provide the requested TA), WHO regional and country offices (in maintaining ongoing communication with ministries of health) and the TA Mechanism Secretariat (in its facilitative and administrative roles) have all been important. The processes and principles included in the SOP similarly played an important role in shaping the day-to-day activities of the Mechanism, notably the development of an integrated TA plan and activities, that included ministries of health; regular meetings and communication, flexibility in terms of timing and approaches to TA, the commitment to involving young people and developing capacity, and the phased/long-term involvement with countries.

However, there have also been a number of challenges, and consequently the TA Mechanism has sometimes not worked exactly as originally planned, or hoped. These included the need for everyone to be clear about the purpose and functioning of the TA Mechanism (e.g., two requests for TA were essentially requests for funding for already-identified national consultants), and about the different roles and responsibilities for providing the TA, if these have not been well defined in the initial integrated TA plans and budgets. Some of the processes were considered to be very time consuming and needed to be further refined, for example the reviewing and commenting on outputs and contracting procedures. And in some cases the expectations for specific deliverables were unrealistic in terms of the time and resources available.

There were also concerns that sometimes insufficient attention was paid to involving national partners/consultants (although there have been encouraging experiences of this in several countries, for example Afghanistan, Malawi and Uganda), to involving young people in a meaningful way and to maintaining the engagement of the ministries of health that requested the TA - due to staff turnover, busy schedules, competing demands for their attention, and/or lack of pre-existing relationships between some TA providers and ministry of health counterparts. This may also have contributed to the finding that the TA Mechanism responses to date have paid too little attention to capacity development, despite the intention to do this.

There have also been several issues related to planning and implementation. Concerning planning, preparatory timelines were often unrealistic and not maintained. There were a number of reasons for this. For example, in several cases it took the TA providers time to fully understand the unspoken dynamics underpinning a request, the key stakeholders and other agencies who might be influencing the TA and the desired outcomes, and the final decision-makers. In addition, the development of tools and methods for data collection, analysis and prioritization took too long; there was sometimes a lack of clarity, or even disagreement about the focus of the TA (e.g. contraceptive uptake, ASRHR or adolescent health more generally); responsibilities and means for quality control were sometimes not adequately specified, including the fact that time for the TA Mechanism Secretariat to review tools and deliverables was not initially built into the timelines of the early TA responses; and the budget guidance was sometimes unclear, and the limited funding ceiling at times made things more complicated and caused some delays.

Concerning implementation, the Partner Organizations felt that there were sometimes too many meetings and processes that were too complex for the limited funding (e.g., to develop expressions of interest, and initial plans/budgets); and in general, not much attention was paid to potential risks and risk-mitigation. It was also found to be challenging to achieve sufficient cross-fertilization when multiple methodologies and partners are involved with the TA, and to define who has the final say when there are differences of opinion/perspectives. Likewise, it was sometimes difficult for both TA providers and people in the requesting countries to complete tasks in a timely way because of competing demands, compounded by individual and organizational changes, including those that took place within ministries of health.

Developing activities to strengthen the engagement of ministries of health has been one of the key changes that have taken place during the three years. This is reflected in the addition of two Annexes to the second version of the SOP, one that provides a structure for regular reports to the MOH and the other that clarifies what the TA Mechanism would (e.g. organizing inception and validation meetings) and would not (e.g. salaries) be willing to include for ministries of health in the overall integrated TA plans and budgets.

Based on the presentations and the subsequent discussions of the Review meeting that took place in June 2021, six issues were identified and discussed in detail. Table 3 provides details about activities that had already been implemented by the TA Mechanism in response to these issues, and outlines selected examples of further responses to these challenges that were proposed during the meeting.

Table 3 Key challenges and solutions [7]

As a result of the experiences and lessons learned from the first two years of the TA Mechanism, the SOP was reviewed and a new version has been drafted