ASSESSING THE IMPLEMENTATION STRENGTH OF FAMILY PLANNING PROGRAMS IN MALAWI: METHODS FOR COLLECTING DATA, CREATING COMPOSITE SCORES, AND LINKING TO KEY OUTCOMES

Population growth is a concern for countries around the world, especially in sub-Saharan Africa where growth rates are disproportionally high. In response, many governments have been implementing large-scale family planning (FP) programs. Yet, there are limited ways to assess how strongly these programs are being implemented on the ground. This dissertation develops and tests a tool that assesses the implementation strength of FP programs in Malawi. Paper One tests the validity and feasibility of collecting data for an implementation strength assessment (ISA) tool via phone interviews. Paper Two explores different methods that combine data across the IS domains and health system levels to construct a summary score for IS at the facility catchment area level. Paper Three tests the association between this summary IS score and utilization of modern contraceptives among women in Malawi. This paper links ISA data with outcome data from the 2015/16 Malawi DHS using a new GIS method. Paper One found that it was highly feasible to collect ISA data from health workers in Malawi via mobile phone interviews. This paper also found that the most ISA indicators were above the threshold for sensitivity, but were more issues with specificity. Paper Two found that there was little difference between the methods to combine data across IS domains but significant differences between the methods to combine IS data across health system levels. Paper Three found that a higher dose of FP program implementation across the health system was associated with women in Malawi using modern contraceptives. This dissertation developed a suite of tools and methods that practitioners and researchers can use to rapidly evaluate the dose of implementation delivered to the population. First, it found that phone interviews are valid, feasible alternative to the traditional, costly in-person method. Second, it described different options to construct summary measures of IS that can be used to understand the combined impact of FP interventions across the health system. Third, this dissertation supported the criterion validity of the summary measure when it found that higher doses of IS were associated with increased modern contraceptive use