Leadership in generating transformational change: a review of The Challenge Initiative platform

Introduction

Major challenges continue to persist in the leadership and management of health and development organizations as they strive to implement programs at scale and produce transformational and sustainable results. The Baldridge excellence framework, which is used to assess high-performing health organizations to receive the Malcolm Baldrige National Quality Award, a USA presidential award, describes leadership as one of the critical aspects in successful organizations. One of the core values in the Baldridge excellence framework is visionary leadership, one that “sets a vision for the organization, creates a focus on patients and other customers, demonstrates clear and visible organizational values and ethics, and sets high expectations for the workforce (1)”.

Jim Collins also highlighted the importance of strong leadership to turn good private companies into great ones in his 2001 book, Good to Great: Why Some Companies Make the Leap...And Others Don’t (2). He explained that some good companies become complacent with their strong performance, which then becomes a barrier to their success. Collins discussed the concept of level 5 leaders, those who possess a combination of individual humility and organizational will. These leaders inspire the organization by their modesty and putting the company’s success before their own (2).

Despite the importance of strong leadership, many public health programs face challenges like those expressed by Senge in his book, The Fifth Discipline: The Art and Practice of the Learning Organization (2006) (3). Some organizations are riddled with a learning disability—unable to recognize and act on abundant evidence of issues within the firm. Senge explains seven common learning disabilities in organizations: (I) lack of shared vision and institutional structures that hinder ownership and purpose; (II) fear of individuals to make mistakes; (III) having reactive solutions to problems; (IV) fixation on short-term events; (V) challenge in recognizing gradual forces that contribute to organization problems; (VI) inability to continue learning from past experiences; and (VII) a management team that protects their turf and egos instead of genuinely finding solutions together (3).

These challenges in leadership and management could be further exacerbated in the context of public health programs and organizations that face wicked problems. They are hard to define, difficult to know when they are solved, potential solutions are not plain right or wrong, multiple solutions or approaches are possible, and there is no easy way to test solutions to the problem (4). Wicked problems include the coronavirus disease 2019 (COVID-19) pandemic, climate change, mental health, socioeconomic disparities, the obesity epidemic, reproductive health and population growth, among others (5). Evidence still needs to grow on leadership and management of one of the wicked problems in public health: reproductive health and rights, and family planning. One article that speaks to this is Roper’s (6) seminal 1987 case study on Profamilia Colombia, an organization that shows expanding and continuing success. Roper and colleagues summarized what leadership and management approaches led to the success of the family planning program in Colombia. However, that paper focused on one country’s experience. Thus, an updated study that explores more global programming is needed. Recent studies on reproductive health and family planning focus on leadership at the community or country level, but to the authors’ knowledge, none have focused on a leadership and management perspective for a multi-country program.

It is critical to apply best practices on leadership and management for family planning programs since the United Nations predicts that by 2050, nearly 70% of the world’s population will live in cities—90% of that growth is expected in sub-Saharan Africa and Asia, primarily in poor urban settlements (7). While significant amounts have been invested in rural areas, poor urban women have considerably worse health outcomes when compared to their wealthier urban counterparts and rural women (8,9). These economic disparities, coupled with women’s rights, commodity supplies, and competing priorities of donors and governments, contribute to the wicked problem of meeting the reproductive health needs of this population.

Over the past several decades, the global health community has built a substantial body of knowledge on high-impact practices (HIPs) for family planning programming, especially in sub-Saharan Africa and Asia. Despite the progress made, these practices and interventions have frequently failed to permeate health systems worldwide (9,10). Leaders and managers at all levels—global, national, and local—often struggle to coordinate stakeholders, both within and outside of government, for effective implementation of HIPs. Additionally, the global development community usually invests in small, pilot-based, high-intensity programs that are too expensive to scale for broader and sustainable impact (10,11).

While we acknowledge that leadership and management are unique concepts, we use them together and combine some attributes in this paper. According to Kotter (12), a leader sets directions, and aligns and motivates people; while a manager plans and budgets, and organizes and controls staff. People can excel as leaders, managers, or even both, but each role demands a unique set of skills and abilities (13).

The authors aim to describe how these important concepts were applied to the design of The Challenge Initiative (TCI) model, share key leadership and management lessons that other organizations could learn from, and report continuing challenges and potential future applications. In 2024, Finkle and colleagues published two articles describing the TCI model, its results, and lessons learned with the lens of sustainable scale-up (9,10). This review focuses more on the leadership and management perspective of the TCI platform as part of a case study series on Global Health Leadership and Management.

Description of the program

TCI was envisioned and deployed in 2016 as a global platform that supports local governments in urban areas to scale up high-impact family planning and adolescent and youth sexual and reproductive health (AYSRH) interventions that have been proven successful.

TCI has received independently assessed awards that support the effectiveness of the approach and the success of the program. In September 2024, TCI received the prestigious Public-Private Partnership (P3) Impact Award from the US State Department, Concordia, and the University of Virginia Darden School of Business for the exemplary public-private partnership between TCI, Bayer AG, and the Gates Foundation (14). In 2021, TCI also received the Curve Award in Nigeria, which included judges from Unilever, Harvard University, and the Gates Foundation, for its demonstration of state governments’ inclusion to propel the government towards self-reliance using innovative responsive feedback mechanisms (15).

How does the model work? TCI supports local governments in leading and owning their family planning and AYSRH programs by strengthening their capacity and self-reliance. Local governments co-create the local family planning program design with support from TCI. TCI does not implement programs and instead coaches local staff in implementing HIPs and strengthening their health systems. For example, TCI conducts a master coach training that is then cascaded to other coaches within the city to support health workers in implementing post-partum family planning (PPFP) and other services. TCI then conducts a quarterly quality of implementation assessment of PPFP in select facilities to identify gaps (such as lack of post-partum intrauterine device kits, outdated data recording tools) and corresponding action steps led by local government staff to improve implementation.

Under TCI, cities opt in to join the platform, show their dedication by contributing their resources, and spearhead the execution of impactful practices (8). Since the inception of TCI, $73.1 million has been allocated by local governments to family planning and AYSRH. Health systems allocation and investments by local governments, in parallel to family planning, are estimated to be about three times the direct funding support for family planning. TCI monitors the family planning spending of local governments against their commitments on a quarterly basis and provides needed feedback, which helps improve accountability. Depending on the country context, TCI reviews monthly reports from cities, trackers that serve as cashbooks, and bank statements. In some cities in Nigeria and Francophone West Africa, TCI has supported the addition of family planning as a separate line item in the local budget and the establishment of commercial bank accounts where both local governments and TCI contribute funds to a dedicated account. In return, local governments can access TCI’s Challenge Fund. This seed funding is determined by the city’s program design, which is co-developed with TCI based on the landscaping and root cause analysis in each location.

TCI also provides coaching to support the implementation of HIPs that have been packaged into easy-to-use toolkits with implementation guidance on TCI-University (TCI-U) or TCI-U, a university “without walls” (8,9). TCI-U is divided into global toolkits and regional hub toolkits that have been adapted to the local context. Within each toolkit are service delivery, demand generation, and advocacy interventions that are described in a step-by-step process, including a list of resources required and indicators to track. Users can also take a quiz to receive a certificate for each intervention to signify that they are ready for implementation.

Once a local program is operational, TCI tracks various family planning and contraceptive uptake indicators, conducting quarterly assessments with its management tools. Typically, TCI stays directly engaged with a local government for about three years. As this period draws to a close, TCI coaching and Challenge Fund support taper off as the local government gets ready to “graduate”. Post-graduation, the local government moves towards self-reliance, still having access to TCI-U and on-demand coaching, while TCI continues to monitor for lasting impact (8,9).

TCI is grounded by its four tenets, see Figure 1. TCI postulates that “scaling without impact is an empty scale; impact at scale without being more efficient is not viable; and efficient impact at scale that is not sustainable will not produce lasting change. TCI delivers on all four tenets—recognizing that one without the other three is inadequate to achieve enduring progress” (8).

Figure 1 TCI’s four interlocking tenets (8). AYSRH, adolescent and youth sexual and reproductive health; TCI, The Challenge Initiative.

Led by the William H. Gates Sr. Institute for Population and Reproductive Health (based at Johns Hopkins Bloomberg School of Public Health), TCI has six regional partners or “accelerator hubs” in East Africa, Francophone West Africa, India, Nigeria, Pakistan, and the Philippines. Those partners are, respectively, Jhpiego, IntraHealth International, Population Services International India, Johns Hopkins Center for Communication Programs, Greenstar Social Marketing, and the Zuellig Family Foundation. These accelerator hubs lead the engagement with local governments and have become key in the effective scale-up in 13 countries.

A critical part of TCI’s co-creation is the investors in the platform, which include the Gates Foundation and Bayer AG. Past donors also include the UK-based Comic Relief, USAID, and private philanthropists. TCI’s overall goal is to “support the greater self-reliance of local governments to scale-up family planning and AYSRH high-impact interventions, leading to sustained improvements in urban health systems and increased use of modern contraception, especially among the urban poor” (8).

TCI is described as a platform because it is donor-agnostic, welcoming contributions from investors who align with its vision. Unlike typical health projects, it is not time-bound, offering flexibility and enabling long-term planning and investment to achieve sustainable impact.

Monitoring outcomes

TCI has monitored results across its various outcomes of interest. Table 1 summarizes some key indicators and how, as of June 2024, TCI has exceeded many of its expected levels of achievement for December 2025. TCI has also published a supplement in the Global Health: Science and Practice [2024] that highlights results globally and in different regions of the platform (9,10,16-19).

Key lessons from TCI on leadership and management

Given the success of TCI’s approach in producing results and the independent recognition that it has received, the authors documented key lessons from TCI on leadership and management.

The platform model is a transformative and effective organizational structure for a large-scale family planning program like TCI

Roper’s 1987 case study on Profamilia Colombia posits that organizations’ leadership must develop a strong management structure. Profamilia Colombia demonstrated gradual expansion, which was possible because its management structure evolved closely with its programmatic development (6). The organization also remained relatively small which led to clear lines of authority, promoted a high level of communication, minimized misinformation, and allowed for individual staff members to be identifiable to management and each other (6). Until now, Profamilia Colombia continues to demonstrate success and will be one of the co-hosts of the seventh International Conference on Family Planning or ICFP (20,21).

This has similarities with TCI’s experience. Due to the large scale of the family planning program that TCI was tasked to lead, TCI was designed as a platform model from the beginning. The TCI platform is led by a global aggregator, the Gates Institute, while partnering with multiple south-based organizations as the accelerator hubs. The teams within the aggregator closely mirror those within the accelerator hubs (i.e., senior leadership; program and operations; communications and knowledge management; monitoring, learning, and evaluation).

Additional advantages of the platform model for TCI include: a platform is not a time-bound project, and there are continuous resource mobilization efforts to attract investments from multiple sources. A platform can also accommodate and deliver for other areas outside of the original design—in TCI’s case, health sectors in addition to family planning and AYSRH. TCI also intentionally keeps a horizontal organizational structure, with a minimal number of staff, and has experienced some of the benefits that Profamilia Colombia did, given its staff size.

Leadership principles: management structures, platform model.

Shared vision and transformational leadership are crucial to the success of any organization, especially those with a platform model

To make the platform model work, TCI needed to have visionary and transformational leadership to bring the various components of the platform together. Visionary leadership drives all organizational actions and choices. Senior leaders should motivate and uplift the entire team to participate, grow, innovate, and welcome significant change (1). Meanwhile, transformational leaders “provide vision and a sense of mission, instill pride, gain respect and trust, communicate high expectations, promote intelligence and careful problem-solving, and provide individualized consideration” (22).

TCI senior leaders actively guided the development and promotion of the platform’s shared vision and values. This shared vision allowed TCI to have a clear and compelling description of the future that all stakeholders want to create (23). Bayer AG has commented that what attracted them to TCI is the strong alignment in vision, values, and strategy across the various members of the team. TCI staff consistently used the same language, whether the donors were talking to people from the global aggregator or the regional accelerator hubs. This was also supported by Mathematica’s external program review of TCI in 2021, which described the development and operationalization of a shared vision as one of the Gates Institute’s most critical values for the platform (24).

Leadership principles: transformational leadership, shared vision.

A systems thinking approach is needed to address wicked public health problems like family planning

In his book, Senge identifies the fifth discipline as systems thinking, the integration of the four other disciplines of personal mastery, building shared vision, mental models, and team learning (3). A systems thinking approach considers the whole, its individual parts, and the interactions between them (25).

The TCI platform addresses the needs for family planning with a systems thinking approach, acknowledging the dynamic, complex, interrelated systems that all contribute to the successful implementation of family planning and AYSRH programming by partner local governments. TCI adapted the WHO’s health systems strengthening (HSS) building blocks model in its design, acknowledging the interplay of leadership and ownership, coaching and capacity building, service delivery, domestic public financing, information systems, and supplies in the improvement of local family planning programs. TCI introduced the award-winning Reflection and Action to Improve Self-Reliance and Effectiveness (RAISE) tool, which provides local political and health leaders and the community a structured framework to self-assess and enhance their local family planning programs along the HSS building blocks (8,15).

TCI’s approach to systems thinking included the combination of best practices—the “secret sauce” of service delivery, demand generation, and advocacy activities. To streamline interventions, the model is guided by the Pareto principle, focusing on the 20% of practices that drive 80% of the results (8).

Leadership principles: systems thinking, HSS.

A learning organization cultivates a culture of innovation and continuous improvement

TCI is a continuous learning organization. According to Senge (3), becoming a learning organization is key to successfully solving complex problems efficiently. From the start, TCI leveraged insights and proven methods from the highly successful Urban Reproductive Health Initiative (URHI), which involved four thoroughly evaluated projects in Nigeria, Senegal, India, and Kenya between 2010 and 2015 (9). The successful strategies of URHI informed TCI’s compilation of impactful interventions, formalized in TCI-U. Unlike URHI, TCI was designed from the beginning to help local governments sustainably expand these high-impact interventions (8).

TCI continuously refines its monitoring and evaluation indicators, learning questions, strategy, and operations based on what the platform is learning during implementation. The platform model allows for adaptability and flexibility to apply these learnings.

One notable example is how TCI learned during the COVID-19 pandemic. While there were initial drops in contraceptive uptake given the disruption in services, TCI helped support by advocating for the importance of family planning programming. TCI also supported the integration of COVID-19 services into the interventions, such as mobile outreaches and social behavioral change materials. As an already trusted platform, governments asked for TCI’s support in distributing some personal protective equipment, like masks, during the pandemic. After a few months, cities showed improving trends and have now reached pre-pandemic levels in most cases. This points to the resilience of the platform, which could also apply in situations like climate change challenges and political instability. Additionally, some people who move to urban areas, driven by climate change, go to informal settlements (26), a sub-population which TCI programming heavily focuses on.

Learning organizations consolidate knowledge assets, which are “accumulated intellectual resources that an organization possesses including information, ideas, learning, understanding, memory, insights, cognitive and technical skills, and capabilities–harnessed and stored” (1). TCI documents and disseminates its learnings on the TCI website, global webinars, conferences, peer-review articles, and other mechanisms, such as the quarterly pause and reflect sessions using the “most significant change” storytelling, a qualitative evaluation methodology (27).

Leadership principles: continuous learning, learning organization, knowledge assets.

Near-real-time data the organization’s evidence-based management

Unique among many health and development programs, TCI supports the use of near-real-time data and strengthens the local capacity to use it for problem-solving and better decision-making. TCI balances rigor with relevance and utility, acknowledging inherent constraints such as the impracticality of fielding several rounds of population-based surveys in more than 200 TCI cities. TCI harvests available data on family planning service statistics from the institutionalized yet underutilized local health management information systems or HMIS (8), develops new methods and indicators to address seasonality and noise, and makes these approaches portable so cities can easily adopt and sustainably use them in their decision-making. TCI developed a standard set of key indicators across the platform, while allowing for flexibility in terms of using localized terms and allowing hub partners to add indicators relevant to their regional context. One example is that while TCI measures contraceptive uptake among women of reproductive age across the thirteen countries, regional hubs in India and Pakistan added indicators measured against married women of reproductive age, since this is the population that their local stakeholders prioritize.

The availability of historical and city-level data at a low cost is one of the strengths of HMIS as a data source for a large-scale family planning and AYSRH platform. These near-real-time data are used when coaching local partners in decision-making and course correcting, thus transferring capacity for greater self-reliance and sustainability. The more the data are used by the local governments, the more there is interest and investment in improving their quality. This is in line with high-performing organizations’ ability to demonstrate evidence-based management, the “practice of making decisions in management organizational contexts through the conscientious, explicit, and judicious use of the best available evidence” (28).

Leadership principles: near-real-time data, evidence-based management.

Local program designs should be informed by landscaping and root cause analysis

When TCI first engages a city, landscaping and root cause analysis are performed to inform the program design for family planning (29). This program design process involves the city’s political and health leaders, community representatives, and TCI. It is key that various stakeholders, including community voices, are included for comprehensive programming and accountability. Just like good doctors address root causes and not just the symptoms, good programs are designed to address the root causes of public health problems (23). TCI co-develops program designs with cities that are based on identifying key leverage points within the local governments. TCI advocates for increasing local commitment and spending on family planning, where needed. However, the partnership goes beyond the material resources to also address non-material resources like capacity-building, addressing provider biases, increasing communities’ trust in their local leaders, among others. This supports the systems thinking approach, where nothing is considered outside the system, “transcending organizational boundaries and functions” (25).

Leadership principles: root cause analysis, systems thinking.

Strategy designs should be developed and implemented at different levels of the platform

The strategy design is a path towards the shared vision or desired future of the organization (30). It is one of the critical elements of organizational success, alongside operational effectiveness. A strategy sets the priorities for systems change and establishes the guidelines for how to reach the goals and shared vision. One key challenge is for organizations to develop focused strategies instead of creating a laundry list of desirable outcomes (31). Strategy is also one of the criteria in the Baldridge excellence framework. High-performing organizations are anticipated to create strategic goals and action plans, put them into action, adapt them as needed, and track their progress (1).

TCI applies these various principles at two primary levels. The first is in shaping the platform’s overall strategy, which includes clarifying the roles and priorities of the global aggregator and accelerator regional hubs. The second focuses on engaging with local governments in their implementation of HIPs, supported by strengthening health systems. TCI outlines these relationships in its design and developed a strategy document for 2021–2025 that lists TCI’s key strategic objectives, co-developed with TCI’s partners. The ongoing challenge is to systematically translate this strategy into actionable parts and to regularly review and update as needed, in the context of an implementation science approach.

Leadership principles: strategy design, shared vision.

A digital platform is key to facilitating large-scale online learning, technical and managerial coaching, and a community of practice

Given its scale, TCI developed TCI-U. TCI-U offers customized in-person and online technical and managerial coaching; family planning and AYSRH toolkits with practical guides and tools; and a virtual community of practice for shared learning (9). In the external program review, the independent evaluators referred to TCI-U as a global good, given that it is a vital resource for TCI cities that is also available to the public (24). TCI-U is an example of a knowledge asset, the know-how of the organization (1), and gives TCI a strong comparative advantage.

Ishola et al. [2024] (32) conducted a mixed-methods case study in Nigeria to explore the factors facilitating and hindering state-level adoption, implementation, and scale-up of HIPs. The study found that political and managerial skills, rather than just technical family planning knowledge, are crucial for the successful adoption and expansion of family planning and AYSRH HIPs. Empowering local governments to coordinate, finance, and implement proven health interventions are essential components of health governance (9).

Leadership principles: knowledge assets, coaching, technical capacity, managerial capacity.

Challenges and further refinements

While TCI has shown notable performance in its first eight years of implementation, there are areas for the platform to refine its model and approaches. TCI acknowledges that different styles and types of leadership are needed at different levels of the platform. Given limited resources, only a small number of TCI staff have completed the Johns Hopkins Bloomberg School of Public Health’s course on Strategic Leadership Principles and Tools for Health System Transformation. The platform will further benefit if more staff are trained on this or other similar courses. TCI also encountered post-graduation challenges early in the program—assuming it could be a linear instead of a more complex process, and underestimating the dynamics of changing local government leadership that could affect sustainability (for example, advocacy needed for new mayors that get elected so they continue to support the TCI partnership). However, TCI has been learning from the 100 graduated cities and has applied improvements to the engagement and graduation approach accordingly. As of December 2024, 90% of graduated cities continue to show an increase in additional clients compared to pre-TCI figures. Lastly, TCI, as a platform and not a time-bound project, may be ahead of the family planning community or donors’ traditional practices. It could be challenging for many donors (e.g., bilateral, multilateral, philanthropic) to buy into TCI’s approaches because they think of projects with a specific short-term time frame. However, TCI has found some success in the corporate private sector, when Bayer AG co-funded TCI and received the P3 Impact Award in recognition of their investment in the platform.

TCI’s monitoring outcomes presented in this paper will be complemented by an ongoing external evaluation that includes an interrupted time-series impact evaluation with counterfactuals, a process evaluation with deep-dive studies in select cities and an online survey of coaches in all cities, as well as a cost-efficiency analysis. The results of the evaluation will be available by December 2025.

Application to other areas

While TCI’s current efforts are focused on family planning and AYSRH programming, its model is adaptable to other health areas related to maternal, newborn, and child health (MNCH). TCI is already initiating this expansion in select cities from 2024 to 2025. Early evidence in Nigeria in 2019 showed that in facilities where 72-hour makeovers (3-day improvement of health) facilities led and funded by the local government and community (32) were conducted, there were increases in clients for family planning as well as other primary health care (PHC) interventions. This is an interesting intervention that also highlights community participation before, during, and after the makeover. Local artisans and craftsmen volunteer to help with the facility improvements, and local leaders and celebrities join the unveiling.

TCI is conducting further studies on the model’s contributions to other health outcomes in PHC and MNCH. Starting in 2024, TCI hubs have been conducting a scoping study of applying the TCI model to MNCH in several of the currently supported cities. This is an ongoing effort, results and lessons learned are still being documented. In May 2025, TCI officially launched its toolkit on MNCH to support the further expansion of the model into this health area.

In the last eight years, 17 peer-reviewed journal articles have already been written about the TCI platform and more are in the process of being published. TCI’s “business unusual” approach has been adopted by many organizations to realize their own shared vision and create transformational change.

Conclusions

TCI has demonstrated significant success in scaling up family planning and AYSRH interventions across multiple countries. By employing a platform model, TCI has empowered local governments to lead and sustain their programs, resulting in substantial increases in family planning clients and funding allocations. Key lessons include the importance of transformational leadership, systems thinking, the use of near-real-time data, and continuous learning. TCI’s adaptable model shows promise for application in other health areas, such as MNCH, highlighting its potential for broader impact and sustainability.

Discussion questions

• Which of TCI’s 8 lessons on leadership and management would best apply to your organization? What adjustments would you make as you adapt the lesson to your context?
• Which aspect of TCI-U is most effective as a knowledge management and dissemination tool? Explain your choice.
  • Codification of high-impact best practices into easily understandable and adaptable ideas.
  • Training and certification of master coaches to coach local staff on the adaptation of the best practices.
  • Development of an active and robust community of practitioners learning from each other.
• Will the platform approach, as compared to the more traditional project approach, allow TCI to become a global social good that other investors can use? If yes, how so?

Acknowledgments

This work was supported by the entire TCI team through their various thought contributions—from our staff in the headquarters in Baltimore, in the six regional accelerator hubs, and those in the field. We would also like to acknowledge our local government partners for their meaningful engagement with TCI over the years. This paper was not funded separately but came from the experiences and learnings of TCI, which has been funded by the Gates Foundation, Bayer AG, Comic Relief, and other donors.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mellissa Withers) for the series “Case Studies in Global Health Leadership and Management” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-120/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-120/coif). The series “Case Studies in Global Health Leadership and Management” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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