From a starting point of 188 ideas, we selected the top 24 for further research through an idea sort. This Idea Prioritization Report is the second stage of our research process, and ranks the 24 ideas from most to least promising. Now the top 7 ideas will move to the next stage: 80-hour reports, which we will release in the coming weeks.
To rank the 24 ideas, we spent two hours evaluating each idea using expert interviews. This methodology was selected for this cause area because experts in this field seem to have more cross-agreements, making their judgment more reliable when drawing conclusions. The table below ranks each idea from most to least promising. The final score for each idea takes into account the previous stage of research as well as the linked expert interview. This means that interviewing experts helps us update our views without being the only method we rely on at this stage. Ideas in bold (green background in the table) are our top priorities for research and will be assessed in more depth this year. Below the table, we describe each idea and summarize the main factors that contributed to its place in the ranking. An asterisk (*) denotes that the expert did not want conversation notes to be published. Two asterisks (**) denote that the interview could not be conducted. In this case, the assessment was based on email responses from experts and opinion pieces read on the topic.
Social and behavioral change
Social and behavior change media campaign
Vouchers for contraceptives
Contraceptives provision/ distribution
Targeted delivery of services: postpartum and post-abortion
Contraceptives provision/ distribution
Community health workers (CHWs): contraceptives distribution
Mobile-based interventions to improve contraceptive use
Family planning counseling
Informing parents and girls about future economic opportunities
Social and behavioral change
Social marketing for condoms
Promoting the Standard Days Method
Communication with husbands
Video promotion of contraception
Monitoring health workers
Training health workers
Women and girls/ women’s status and empowerment
Incentives for education/delay of marriage
Lotteries for family planning outcomes
Social accountability of healthcare providers
Relative Risk Information Campaign for students
Conditional cash transfers (CCTs) for family planning outcomes
Promoting the use of evidence in family planning
Contraceptives provision/ distribution
distributionIncreasing supply of long-acting reversible contraceptives (LARCs) in clinic
Contraceptive advertisement/promotion in pornography
SOCIAL AND BEHAVIOR CHANGE MEDIA CAMPAIGN
Social and behavioral change (SBC) media campaigns rely on either mass media (e.g. radio) or other media (e.g. printed materials) to share information and messaging aimed at changing knowledge, attitudes and behaviors towards family planning. Relatively large evidence of its impact on contraceptive use and past successes of programs implementing it at scale make this intervention one of our top priorities for further research. Potential challenges include the lack of data on implementation fidelity, which makes it hard for experts to assess the difficulty of execution. According to experts, the most successful approach combines different media strategies (e.g. radio, TV and pamphlets), and adapts the campaign to the needs in context (e.g. a soap opera approach for social norms change vs a simple informational message for improving knowledge of available services). Although expert impressions were that not much funding has been allocated to this area in the past, awareness about the importance of SBC in family planning programs is growing, and there is space for more actors to work in this area.
Vouchers for contraceptives are a type of subsidy or financial incentive. Usually they take the form of a paper coupon or electronic ticket that can be exchanged at health facilities for a free service or product. Experts affirmed that vouchers effectively increase family planning services use where products are not fully subsidized. Evidence for this intervention seems moderately good. Although implementation cost varies greatly by program, it could be cost-effective given the potentially high effect size on contraceptive uptake among the most disadvantaged populations. The main challenge regarding this intervention is execution difficulty. Experts emphasized the importance of carefully designing the voucher management and subsidy application system. Additionally, the program must be perceived as trustworthy and reliable, the distribution strategy must be well-targeted, and evolution in the quality of the supply side must be carefully monitored. According to experts, some donors are supportive of this kind of program, and because the evidence is recent, there are not many actors implementing it yet.
TARGETED DELIVERY OF SERVICES: POSTPARTUM AND POST-ABORTION
This intervention involves delivering family planning services to women postpartum or post-abortion, to get them to think about and access contraception at a critical time in their reproductive life. Conversations with experts on various topics suggest that this should be a top priority for further research: multiple experts brought it up positively, without prompting. Its main strength is that it targets women who are most likely to need contraception. Post-birth contraceptives use is low compared to the average among women of reproductive age, as women often do not realize the need for it, or struggle to plan for it in time. Similarly, women who undergo abortion did not intend to become pregnant but failed to prevent it, so might be particularly keen for information about contraceptive options. Experts think that more evidence is needed for postpartum family planning (PPFP) than for post-abortion family planning (PAFP), but in both cases the evidence base is growing. Consistent advice on the best approach is to follow women throughout their pregnancy and after childbirth, and before and after their abortion, with multiple reminders about the need to plan for contraceptives, rather than only a one-time meeting. Whether this intervention takes the form of one or multiple meetings with each woman, it seems like costs per person will not be too high, which is another advantage. Finally, we expect PPFP to have positive externalities, as it would lead to more spacing between births, which reduces risks of adverse maternal, perinatal, and infant outcomes.
This intervention is a form of mobile outreach that involves hiring and training local community members to deliver certain health services. There seems to be evidence supporting the delivery of family planning services through CHWs, as well as in other subsectors of health services such as maternal and child health. In general, CHW delivery (and contraceptive use) seems effective at overcoming geographical and social barriers. CHWs can conduct screenings of contraception needs and deliver a variety of contraceptives, including injectables. For such programs to succeed, entrepreneurs should consider: (1) all the elements of the value chain needed to support CHWs in their work (e.g. accreditation, dedicated supervision, payment); and (2) the public sector’s community-based approach, and how contraceptives can be integrated into their package. Countries with existing CHWs programs might be particularly promising geographies to implement this intervention, if we can strengthen existing systems rather than duplicating service delivery infrastructure.
Mobile-based interventions provide information about contraceptives through mobile channels, such as SMS, AVR, or application ads. They can take the form of unidirectional messages, timed reminders, or interactive messaging platforms. A lot of evidence supports their effectiveness at improving knowledge and attitudes towards contraception, and they can have a wide reach. There is less evidence that these interventions improve behaviors, but we expect that the low cost per person reached could nonetheless make a mobile-based intervention cost-effective. The intervention could be particularly promising if we can reach younger people using existing channels and social media. There seems to be both space and money for new actors to enter this space. Although it would be relatively easy to implement, there are limitations. It might be difficult to monitor and evaluate impact; messaging would have to be tailored to the audience; and building a rapport would be challenging but necessary for the intervention to work. In terms of implementation, we were advised to think about issues around literacy and phone ownership, and integrating messaging and ads into existing media rather than creating a new digital platform.
Outreach can deliver family planning services to areas without access to healthcare by going directly to those communities. It can be implemented by either medical or non-medical staff (e.g. community health workers, trained volunteers, peers, etc.). Although we did not conduct an interview about this intervention, reading opinions of experts in the field led us to include outreach as one of our top priorities for further research, as it seems promising from both a cost-effectiveness and equity perspective. The High Impact Practices brief (reviewed by the key experts in the field) suggests that it allows providers to reach the most underserved populations. This increases the choice of different contraceptive methods available among the poorest populations, including LARCs and permanent methods, and improves contraceptive uptake. Some implementation strategies seem to be less resource-intensive, requiring only one dedicated staff member. There seems to be many case studies and substantial historical evidence regarding the contribution of outreach services to modern contraception prevalence rates (e.g. ref and ref), but it is as yet unclear whether rigorous impact evaluations exist on the topic. At least two large NGO actors occupy this space - Marie Stopes International and Population Services International. The brief also emphasizes implementation considerations, like the need for caution to ensure high quality and safe services to women, as well as privacy in the community setting. Entrepreneurs would have to ensure follow-up care once the outreach visit is over.
Health facilities would offer counseling to women who come for a family planning consultation, to provide information about contraception and help women reflect on their contraceptive use. In practice, focusing on this intervention would mean improving existing counseling structures. Even so, this is a top priority for further research. There seems to be a significant number of studies on the topic, and some strategies seem consistently effective at improving continuation of contraceptive use. Aside from the quality of counseling sessions, context significantly affects the effectiveness of counseling. For implementation, we were advised to pay close attention to context-specific barriers and misconceptions; potential unintended consequences of longer counseling sessions (e.g. attention lapses, information overload); and sustainability of the structure without external support. To the best of the expert’s knowledge, not many NGOs currently train health workers to provide better family planning counseling. However, it might be challenging to raise funds for this program. This is because it is dependent on existing systems (i.e. less appealing for funders), and there is no consensus that quality of care is what enables women to meet their contraceptive needs.
This intervention would inform parents about job opportunities available to their daughters if they achieve a certain level of education. By encouraging parents to invest in their daughters’ education, it aims to delay girls’ age at marriage and reduce teenage childbearing. Our conversation with an expert led us to believe that not a lot of evidence supports this intervention, apart from one high-quality randomized control trial (RCT). In this study, a factory had recently opened in the area, so the information provided was valuable to parents in that context. Unfortunately, providing information alone on regular jobs seems ineffective: it seems that this intervention needs a very specific situation to work. Despite lack of generalizability, this is a moderate priority for further research. This is because of potential long-term effects of education and delaying child marriage, and because it would not be very expensive to implement. It also overlaps with the women’s and girls’ education/economic empowerment sector, offering a potentially broader funding base for a scale-up.
This intervention aims to improve contraceptive use through condom marketing campaigns, and assumes that people are more likely to use a product they bought than one they got for free. After our conversation with an expert, this is a moderate priority for further research. Not a great deal of evidence supports the social marketing of condoms specifically (partially because the intervention is challenging to evaluate), although there may be more evidence on marketing other contraceptives or family planning services. However, counter to the social marketing rationale, behavioral economics shows that people do in fact like products distributed for free. We were advised to consider context when deciding the most appropriate contraceptive method to promote. In countries with high HIV prevalence, for example, we would likely emphasize condoms. West Africa seems a promising region, as there is an unmet need for contraceptives and a lower risk of HIV acquisition.
The Standard Days Method (SDM) is a fertility awareness contraceptive method that tracks a woman’s menstrual cycle to identify her fertile days. It can be best promoted using either a necklace-like product called CycleBeads or the CycleBeads smartphone app. According to the expert we spoke with, trials in multiple contexts have proven that the SDM is an effective contraceptive method. Currently, the evidence base is stronger for promoting the SDM through the physical CycleBeads, but preliminary evidence for the app is also strong. Various context-dependent distribution strategies could promote the physical CycleBeads (e.g. through community health workers, at commercial outlets). App use could be promoted through popular social media channels. Although the intervention seems promising, our conversation highlighted some limitations: there may be potential provider bias against this method, for instance, and it is only appropriate for women with regular cycles who are able to communicate with their partners. The expert mentioned that large distribution actors (e.g. UNFPA) do not seem to have invested a lot of resources into this type of contraceptive in the past, but other players are implementing it already in some countries (e.g. USAID, DKT).
COMMUNICATION WITH HUSBANDS
This intervention consists of interpersonal community/group engagement targeted at husbands, to provide information about maternal health risks of repeated pregnancies. Our assessment of this idea was inspired by a recent study (ref). In many contexts, men have higher desired fertility than women, and it seems like opposition by the husband is a key issue preventing married women from using contraception. A lot of qualitative evidence seems to support the idea that women’s contraception is very much influenced by their husband’s attitudes towards it (e.g. here, here and here), but there is limited rigorous impact evaluation evidence on the type of information provided that leads to change. Promising strategies include information focused on socio-economic motivations (ref), and on maternal health risks. From our conversations with experts on other topics and one study (ref), it seems that in some contexts, barriers might be too large to be overcome by a simple information session, because intra-household relationships and approaches to contraception relate to social and cultural norms. Social and behavioral change campaigns such as the soap opera radio campaign appear more promising when it comes to tackling these challenges, according to experts. A range of experts stated that men and boys are not sufficiently involved in family planning, and that they would like to see more programs focusing on them. This suggests that working with husbands might be somewhat neglected.
Video promotion offers information to patients about the benefits of different contraceptives through an easy-to-understand educational video screened at the health facility. According to an expert, one study in Zambia found this to be effective at increasing contraception uptake. Advantages include high coverage and exposure to the content through daily video screenings at the clinic, and that the content is accessible to less educated women. Even so, this is only a moderate priority for further research, as this conversation did not cover the rest of the literature on video promotion, so the assessment of the strength of the idea is inconclusive. An additional limitation to this intervention mentioned by the expert would be the need to purchase hardware (e.g. TVs) to screen the videos, making the intervention less cost-effective. One solution would be sharing the video on Whatsapp or other digital platforms.
This wide range of interventions aims to improve health workers’ performance in delivering a particular service. From the evidence base, several interventions look quite effective. Performance-based incentives for health workers and their managers, along with health worker training and combined with other components, could lead to large positive effects. However, health worker training on its own seems less promising in terms of effect size and duration of effect. The expert mentioned collaborative improvement as a specific example of a promising intervention, but noted that there is substantial variance in these findings, and debate remains around factors influencing effectiveness. To determine potential impact, a closer look at the evidence base in our region of interest and a cost-effectiveness analysis would be necessary. For implementation, entrepreneurs should bear in mind that (1) an iterative approach and close monitoring of results will be necessary to find the right strategy based on contextual problems limiting health services utilization; (2) engaging with existing actors (e.g. through the Quality of Care Network) and integrating the approach into broader health systems would be most impactful; and (3) close attention should be paid to potentially negative knock-on effects on other health areas. A considerable amount of funding seems available for quality improvement interventions, but for specific health conditions.
This intervention would provide a financial or in-kind incentive for educating adolescent girls, thereby delaying the age at marriage and reducing the chance of teenage childbearing. We arrived at this intervention via a conversation about another intervention, which revealed that relatively strong evidence supports conditional cash transfers for education. We are also aware of one rigorous randomized control trial (RCT) on food incentives for marriage delay. The expert believed that these incentives are powerful tools to keep adolescent girls in school for longer. However, this is only a moderate priority for further research, as a second expert suggested that the study incentives are set up such that parents can easily ‘game’ the system and only delay marriage by a short period of time. As such, incentives may not be very effective at reducing unintended pregnancies after all. The expert pointed to the deeper issue: unless social norms and expectations change, incentives may fail to change the number of children women have. Additionally, we expect conditional cash transfers to be moderately difficult to implement, and would require partnership with the government if the incentives were tied to schooling.
Another form of financial incentive, lotteries offer the opportunity to win a prize for those who comply with a behavior or action beneficial to their well-being. Although the evidence base for lotteries is small and mixed, evidence behind financial incentives from other sectors (e.g. education) is pretty strong. However, this intervention has several limitations and is one of our lowest priorities for further research. Ethically, incentives cannot be tied to the outcomes we directly care about (i.e. unintended pregnancies or births), and must instead be tied to an indirect outcome (e.g. education, STIs, contraceptive use). Even then, we would have to be careful to ensure that no coercion is involved. Although the lottery seems more cost-effective than conditional cash transfers (see Conditional cash transfers for family planning outcomes), it still comes at a greater cost than other interventions that directly promote contraceptive use. The implementation strategy will depend on the targeted population (young girls, high STI prevalence populations, etc).
Social accountability supports collective action in communities and enables healthcare providers to tackle issues collaboratively. It can both change how people perceive health services and influence health providers’ practices and attitudes. Talking to an expert revealed that evidence is still limited in the family planning field. As there are a number of ongoing studies investigating cost and impact, the expert recommended we assess this intervention in our next round of research for a more comprehensive picture of its potential. Since this is a complex intervention, the expert suggested we bear in mind that: (1) training facilitators, who act as intermediaries between the community and health workers, is key to the intervention’s success; (2) careful attention to context is necessary to avoid reinforcing existing power dynamics; (3) feedback loops are not quick, so work must take place on a longer timescale; and (4) the long time frame and its political aspect makes it less attractive to donors.
This intervention specifically delivers sexual education in schools. It involves sharing information about the risks of STI transmission among different age groups, making the general risks of sex more transparent, and encouraging safer sexual behaviors. It was inspired by one rigorous study (ref). The expert suggested that sexual education, in general, is important for driving change in adolescent sexual health. We can expect this kind of campaign to have positive externalities outside family planning, in terms of education and reduction in HIV transmission (if implemented in a country with high HIV prevalence). Nonetheless, this intervention is a low priority for further research. Although evidence backing the relative risk campaign is rigorous in terms of internal validity, most studies are implemented on a small scale, and it is unclear whether impact would replicated on a larger scale. Moreover, experts expressed concerns that outcomes from these campaigns are highly context-dependent.
Conditional cash transfers (CCTs) provide cash to individuals who comply with a behavior or action beneficial to their well-being - in this case, safe sex. The expert suggested that the evidence base is small and mixed in the family planning sector, but evidence behind financial incentives from other sectors (e.g. education) seems pretty strong. However, the intervention has several major limitations. Ethically, incentives cannot be tied to the outcomes we directly care about (i.e. unintended pregnancies or births), and would instead be tied to an indirect outcome (e.g. education, STIs, or contraceptive use). Even then, great care would be necessary to ensure no coercion is involved. A further limitation is that the cost per unintended birth averted looks greater than interventions directly promoting contraceptive use. The exception to this is providing CCTs for education, which may have greater benefits in the long term. The implementation strategy depends on the population targeted (young girls, high STI prevalence populations, etc.). To deliver cash, mobile money seems promising when available, as long as it does not exclude people.
This intervention would convince policy makers or NGO leaders to use research and evaluation findings to choose higher impact practices. This could be a promising intervention, categorized as high risk/high reward. However, lack of supporting evidence makes it unpredictable, especially compared to other ‘long-term change’ interventions (e.g. social accountability). A few potentially promising gaps include: (1) helping large and internationally recognized organizations strengthen their use of evidence in country offices; (2) helping smaller and less well funded NGOs build technical capacity to better implement, understand, and use research; (3) running implementation science training to teach decision-makers how to translate evidence into action; and (4) monitoring and evaluating country policy makers’ progress towards goals expressed in Costed Implementation Plans, or helping non-USAID recipient countries who do not yet have them to build these plans. Entrepreneurs should be committed to this idea in the long run, and start off very focused with specific goals and strategies to be tested. Experts were uncertain about funding, but shared the view that there could be a variety of promising funding pathways for this kind of intervention.
INCREASING SUPPLY OF LONG-ACTING REVERSIBLE CONTRACEPTIVES (LARCS) IN CLINICS
This intervention aims to reduce stock-outs and improve access to long-acting contraceptives. The evidence behind the effect of increasing the supply and choice of contraceptives seems strong. In most contexts, family planning actors know people’s preferences and that availability is key. This is one of our lowest priorities for further research, as focusing on it would have some major limitations. The current bottleneck seems practical - dealing with procurement and managing the supply chain is logistically complex. In addition, while the field has focused disproportionately on supply for the past fifty years, there may be low-hanging fruit on the demand side. In most countries, the government and other large players like UNFPA are working on the supply of contraceptives, so the field seems crowded unless we bring a technological disruption. One potential promising area due to its relative neglectedness is providing contraceptive supply to populations in humanitarian settings (e.g. refugees).
Promoting contraception through pornography aims to nudge people to adopt safe sexual behaviors. Adult stars could endorse contraception publicly, or contraception could be advertised on pornagraphic websites. This could be an interesting strategy because pornographic content has a wide reach globally and a default role in sexual education. However, no direct evidence supports the intervention: according to the expert, this has never been done before, and research on pornography is quite rare. Although there is evidence from contraception and family planning advertisements on social media, this evidence may not extend to the context of pornography. There also seem to be major limitations: (1) the industry might be reluctant to include contraceptive advertisements on their website, as evidence suggests that 70% of viewers are men, and would not likely be interested; (2) the industry is poorly perceived because of social stigma and some association with sex trafficking, so working with this sector will be highly controversial and ethically complex; and (3) comments on internet content cannot be controlled, and could distort the original message.
NOTES ON CHANGES TO THE INTERVENTION LIST:
The initial list, after the idea sort process, included 24 ideas. At the end of this prioritization process, we decided to merge some interventions either because they were very similar or because it made sense to combine them from a programmatic perspective. We were also encouraged by an expert to look into a type of intervention that we had excluded, but scored relatively well, in the first stage of the research. Finally, we removed three interventions through merging, and added one intervention, making a total of 22 assessed interventions. Here are the changes:
Family planning counseling and clinic-based family planning education - merged. Although there are slight differences between counseling (interpersonal) and education (structured), they both involve informing women in a clinic setting.
Radio campaigns, pamphlet distribution, and posters - merged. These three different media are often used for social and behavioral change campaigns, and a conversation with three experts on this topic led us to think that media campaigns need to be implemented through a variety of channels to be successful. We will, therefore, look at social and behavioral change media campaigns as a whole, which can include a combination of radio and pamphlets, and even other mass media like TV.
We assessed interventions to incentivize girls’ education, which did not make it to our top ideas, but ranked relatively well in the previous stage and was recommended by an expert.