Background There has been greater recognition of the importance of country ownership in global health and development. However, operationalising country ownership to ensure the scale up and sustainability of proven interventions remains elusive at best. To address this challenge, we undertook a thematic analysis of interviews collected from representatives of local governments, public health systems, and communities in poor urban areas of East Africa, Francophone West Africa, India, and Nigeria, supported by The Challenge Initiative (TCI), aiming to rapidly and sustainably scale up evidence-based reproductive health and family planning solutions. Methods The main objective of this study was to explore critical elements needed for implementing and scaling evidence-based family planning interventions. The research team conducted thematic analysis of 96 stories collected using the Most Significant Change (MSC) technique between July 2018 and September 2019. After generating 55 unique codes, the codes were grouped into related themes, using TCI’s model as a general analytical framework. Results Five key themes emerged: (1) strengthening local capacity and improving broader health systems, (2) shifting mindsets of government and community toward local ownership, (3) institutionalising the interventions within existing government structures, (4) improving data demand and use for better planning of health services, and (5) enhancing coordination of partners. Conclusion While some themes feature more prominently in a particular region than others, taken together they represent what stakeholders perceive to be essential elements for scaling up locally-driven health programmes in urban areas in Africa and Asia.

Institutionalization of pause and reflect (P&R) sessions as a responsive feedback (RF) mechanism within The Challenge Initiative project in Nigeria has contributed to improved program strategies and applicable lessons learned for replication by others scaling up evidence-based FP/RH interventions. n Initial challenges to institutionalizing P&R sessions can be addressed with advanced planning, use of an experienced facilitator, and application of RF reflections for adaptive management.

The Challenge Initiative (TCI) Nigeria applied the Reflection and Action to Improve Self-reliance and Effectiveness (RAISE) tool as a responsive feedback mechanism to enable all 13 state governments to assess their progress toward selfreliance in family planning/reproductive health programming; identify gaps; and incorporate learning and feedback to make improvements throughout the implementation life cycle. n Adaptation of the RAISE tool to Nigerian and state contexts improved local and state government teams' understanding of adaptive program management, leading to positive changes.

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Strong external champions-both traditional and religious leaders but also media-savvy policy advocates-were a key component of a successful scaling experience by building public understanding and support for FP use and holding government leaders accountable for its provision. n Skilled and empowered state program officers, with support from internal government champions at the highest political but also agency leadership levels, spearheaded the introduction and implementation of the interventions and guided the institutionalization of interventions through existing state mechanisms.