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Background: The global community has committed to achieving universal access to sexual and reproductive health and rights (SRHR) services, but how to do it remains a challenge in many low-income countries. Capacity development is listed as a means of implementation for Agenda 2030. Although it has been a major element in international development cooperation, including SRHR, its effectiveness and circumstances under which it succeeds or fails have limited evidence. Objective: The study sought to examine whether improvement in team capacity of SRHR practitioners resulted in improved organisational effectiveness and/or improved SRHR outcomes in low-income countries. Methods: The study involved 99 SRHR interventions implemented in 13 countries from Africa and Asia. Self-reported evaluation data from healthcare practitioners who participated in a capacity development international training programme in SRHR was used. The training was conducted by Lund University in Sweden between 2015 and 2019. Logistic regression models were used to examine the association between improved team capacity, improved organizational effectiveness and improved SRHR outcomes, for all the 99 interventions. Adoption of new SRHR approaches (guidelines and policies), media engagement, support from partner organisations and involvement of stakeholders were assessed as possible confounders. Results: Improved team capacity, support from partner organisations and media engagement were positively associated with improved organisational effectiveness. Improved team capacity was the strongest predictor of organisational effectiveness even after controlling for other covariates at multivariate analysis. However, adopting new SRHR approaches significantly reduced organisational effectiveness. Furthermore, support from partner organisations was positively associated with increased awareness of and demand for SRHR services. Conclusions: Successful implementation of capacity development interventions requires an enabling environment. In this study, an SRHR training programme aiming at improving team capacity resulted in an improvement in organisational effectiveness. Support from partner organisations and media engagement were key enablers of organisational effectiveness.
The Swedish International Development Agency Cooperation (Sida) [20] has been supporting an international training programme (ITP) approach to capacity development in low- and middle-income countries for decades. The programme comprises the increment of knowledge and skills for individuals and strengthening of organisational competencies to implement change in different sectors of participating countries. The long-term aim of the ITP approach is to contribute to poverty reduction through the development of effective organisations. Participants in ITP are public servants, civil society organisations and the private sector. Between 2005 and 2018, Sida commissioned Lund University to conduct an ITP in SRHR in low- and middle-income countries [21]. The aim of this ITP was to contribute to the improvement of the living conditions of the poor through improved access to SRHR services. It was founded on the assumption that developing the capacity of key persons in a healthcare system would positively influence organisational capacity and effectiveness to deliver services [22]. The ITP, described in more detail in earlier publications [23,24], had three specific objectives: increasing awareness of and demand for SRHR services, promoting sexuality education, and increasing access to satisfactory SRHR services, which would be achieved through improved organisational effectiveness. Participants in the programme worked in groups (country teams) to address critical gaps in SRHR service delivery through targeted intervention code named ‘change projects’. Participants were guided to design and implement the interventions following a set of principles derived from project design and implementation framework tools such as the Logical Framework Approach (LFA) and Results-Based management (RBM) [25]. The interventions addressed specific SRHR needs of specified target populations in their health systems. The change project themes included youth-adolescent SRH, maternal health, neonatal health, STI/HIV/AIDS/cervical cancer, sexual and gender-based violence (SGBV), sexual minorities/LGBTQ, and commercial sex workers. The change projects were designed and implemented by the participants with support from different stakeholders, partner organisations and Lund University supervisors. The ITP was implemented through five phases (Table 1). The data used in this study were collected at the end of the fifth phase, that is, 6 months after implementation of change projects. Enablers of SRHR interventions in low- and middle-income countries: Phases of the international training programme in sexual and reproductive health and rights (SRHR). The study focuses on change projects as the study population. Change project teams consisted of 3–6 healthcare practitioners from the same country. The projects examined in this study were implemented between the years 2015 and 2019 in Bangladesh, Ethiopia, Uganda, Tanzania, Zimbabwe, Kenya, India, Myanmar, South Sudan, Liberia, Zambia, Cambodia, and Sudan. The healthcare practitioners were of different gender and professional backgrounds, working in various sectors in their respective healthcare systems. They included teachers, nurses, midwives, doctors, managers, and policymakers. Retrospective quantitative data collected using a structured questionnaire consisting of 36–48 items were obtained. The questionnaire was designed by the ITP, and the data were collected as part of ITP outcome evaluation. In the questionnaire, participants reported on different aspects of ITP and their change projects. The data utilised for this study represent participants’ self-reported evaluation of the effects of change projects on organisational effectiveness and SRHR outcomes among target populations and their perceived role of different stakeholders, partner organisations and the media during the implementation of change projects. The data which was collected by the ITP and stored in a secure database at Lund University were retrieved, entered into SPSS software, cleaned and re-coded. One questionnaire was found empty and excluded from the study. Using each participant’s country name at registration, ITP intake number, and change project theme, participants’ responses were linked with their respective change projects. For each variable, a team response was then obtained as the sum of individual responses divided by the number of individuals in each change project, i.e. an average score of each variable was obtained as a group response. Figure 1 illustrates the conceptual relationship between the different components of the ITP intervention, examined using the ‘Inputs-Process-Output-Outcome-Impact’ framework of evaluation [19]. The inputs were the resources used during the training programme including money, materials, and manpower. The processes included the training activities and interactions with stakeholders, partner organisations and target groups, which culminated in the change project outputs. The outputs were the trained ‘change agents’ and the ‘blueprints’ for change projects. The ‘Inputs-Process-Outputs-Outcomes-Impact’ framework used in the evaluation of capacity development interventions implemented in 13 countries in Africa and Asia (N = 99). Change project outcomes were categorised (for each change project) in terms of three outcomes. Outcome 1a and Outcome 1b consisted of self-reported changes in group performance after the training including ‘improved team capacity’, ‘adopted new SRHR approaches’, secured ‘partner support’, ‘stakeholder involvement’ and ‘media engagement’ in change project activities. Outcomes 2 and 3 represented the extent to which the change projects achieved ‘Organisational effectiveness’ and ‘improved SRHR outcomes’, respectively, among the target groups. There were 36–48 items in the questionnaire. Factor analysis was used to reduce the large number of variables into fewer variables that were related by the underlying latent meaning. Items were grouped together if the item had a factor loading of at least 0.4 (Varimax rotation). The ITP in SRHR aimed at improving team capacity to influence organisational change and improve SRHR outcomes. Hence, this study examined ‘improved team capacity’ (having obtained new SRHR knowledge and technical skills) as the main exposure variable. Having ‘adopted new SRHR approaches’, securing ‘partner support’, ‘stakeholder involvement’, and ‘media engagement’ were analysed as covariates. Improved team capacity was defined as the extent to which the ITP intervention led to acquisition of new SRHR knowledge and technical skills and improved preparedness of teams to implement change. It was assessed from the responses to the following six survey statements: ‘ITP provided new knowledge on the subject matter’, ‘ITP improved my technical skills to plan and implement a change’, ‘ITP provided skills regarding how to deal with the change processes within the organisational framework’, ‘ITP had an important impact on value issues that were important for the implementation of the change’, ‘ITP gave me access to a network of colleagues and other individuals of importance for the change implementation’, and ‘ITP made me “think outside the box” which became an important factor for the change implementation’. The responses to each statement were coded on a Likert scale of 1–5, where 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, and 5 = strongly agree. Individuals’ responses were aggregated into group responses for each statement. A composite variable for each change project was obtained by the summation of the six scores provided by the team members. The composite score was then dichotomised based on the median. Scores below and equal to the median meant that the team ‘disagreed’ (reference category) that the ITP intervention had improved team capacity, while scores above the median meant that they ‘agreed’. The following three survey questions were used to assess whether the ITP intervention led to the development and use of new methods, policies, and guidelines in SRHR services: ‘Has your change project led to the development of new guidelines?’, ‘Has your change project led to the implementation of new policy in other organisations?’, and ‘Has your change project led to the implementation of new guidelines in other organisations?’. The responses were coded as 1 = Yes and 2 = No. Individual team members’ responses to each question were aggregated into group responses for each change project. To build a composite variable, the group scores for the three questions were summed up. The variable was then dichotomised into ‘Yes’ for scores below and equal to the median and ‘No’ (reference category) for scores higher than the median. Partners were persons or organisations that had an active role in the ITP intervention. To assess their role, responses to the following survey questions were used: ‘Which critical factors have contributed to the outcome of your change project?’: ‘Support from others in my home organisation’ and ‘Support from course leaders at Lund University’. The responses were coded as 1 = Yes and 2 = No. Individuals’ responses to each question were aggregated into group responses for each change project. A composite variable was obtained by the summation of the group responses to the two questions and then dichotomised into ‘Yes’ for scores below and equal to the median and ‘No’ (reference category) for scores higher than the median. Media engagement was assessed from two items in the questionnaire: Change projects being reported on ‘Radio’ and ‘Media advocacy for the change project’ having been a critical factor that contributed to the outcome of the change project. The responses for both statements were coded as 1 = Yes and 2 = No. Individuals’ responses were aggregated into group responses for each statement. A composite variable regarding ‘media engagement’ for each change project was obtained by the summation of the individual responses of team members on the two items and then dichotomised into ‘Yes’ for scores below and equal to the median and ‘No’ (reference category) for scores higher than the median. Stakeholders were organisations which had an interest in the ITP intervention. To assess change projects’ engagement with stakeholders, responses to the following survey questions were used: ‘Has your team or any member of your team held an oral presentation regarding the results of your change project for any of the following audiences?’: ‘Embassy of Sweden’ and ‘UN-agency’, and ‘Has your team presented a sustainability plan of your change project to’: ‘Your organisation management’, ‘Embassy of Sweden’, and ‘UN-agency’? ‘Has your team submitted a written report concerning the result of your change project to the ministry of education or health?’. The responses were coded as 1 = Yes and 2 = No. A composite variable for each change project was obtained from the individual responses of the group to the six questions. The composite scores were then dichotomised into ‘Yes’ for scores below equal to the median and ‘No’ (reference category) for scores higher than the median.
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